Functional Assessment and Treatment of Chronic Low Back Pain

ABSTRACT

A case of chronic vertibrogenic low back pain of biomechanical origin characterized by sciatica and trunk and lower extremity muscle imbalances. Initial medical management provided only palliative relief. A four-month program of in-office rehabilitation including gym ball stability exercises, endurance training, proprioception training and work conditioning is administered in conjunction with spinal manipulation and therapeutic modalities. This program proved effective in reducing the patient's low back pain with and early return to work and activities of daily living.

KEY WORDS

Chronic low back pain, Rehabilitation, Chiropractic, Low Tech, Outcome Assessment

INTRODUCTION

Spinal manipulation has been shown to be an effective management tool in the treatment of acute low back pain.(1,2) However, most patients do not seek this type of treatment for their condition.(3) They often depend on other ineffective measures, such as bed rest or medication, to solve their problem.() Unfortunately, 30'X of these patients will become chronic resulting in 90% of the cost of lower back pain.(5) In those cases, where re-occurrence or persistence of lower back pain occurs, decreased strength and lack of flexibility are implicated in its development.(6) This suggests that a comprehensive rehabilitative program including: exercising for spinal mobility, trunk strength, endurance, coordination, and cardiovascular fitness can significantly reduce the risk of functional loss.(7)

The following case demonstrates the value of trunk muscle evaluation and treatment in the conservative chiropractic management of chronic low back pain.

CASE REPORT

A 31-year-old, 5’11”, 135 lbs., female Caucasian presented with a complaint of "left low back" pain radiating down the back of her left leg. She indicated that she felt a “pop” in her lower back when she was lifting her 11-month-old son out of his crib onto a changing table to change his diaper. Her son weighs 25 lbs. The pain was initially described as an "ache", which was worse in the morning and more intense as the day progressed. The pain eventually began to radiate down her left leg. The pain initially radiated into her buttocks then down her leg but above her knee. The patient had difficulty lying on her right side. She stated the pain made it difficult to turn over in bed but was relieved by sitting and relaxing leaning to the right.

The patient was currently taking over the counter medications for pain relief. She slept on the floor on her left side in a fetal position. Her family physician and previous chiropractor had been seen for a history of similar episodes of back and leg pain over the previous three years. The previous episodes were treated by a her family physician who prescribed muscle relaxants and bed rest, and her chiropractor who performed manipulation and therapeutic modalities consisting of ice and massage therapy for pain relief. This resulted in short periods of temporary symptom relief with multiple episodes of acute exacerbation. Other past medical history was unremarkable.

The patient presented with antalgic posture and gait leaning to the right while avoiding weight bearing on her left side. Orthopedic/neurological examination revealed negative spineous percussion, negative Valsalva’s maneuver, negative Farfan’s, positive left Kemps, Elys, Nachlas, Hibbs, Yeomans,  and Bilateral Leg Raise with pain noted in the region of the fifth lumbar vertebra on the left radiating to the left sacroiliac joint. Lumbar range of motion was moderately reduced with pain noted at the fifth lumbar vertebra on flexion, left rotation, and left lateral flexion. The patient was unable to perform functional testing at this time. The patient was totally disabled from work and unable to perform her activities of daily living required to maintain her household. The patient completed the Outcome Assessment forms. The forms were scored demonstrating a perception of moderate disability.

AP & lateral lumbosacral x-rays revealed , mild left lumbar tilting, disc wedging at the fourth lumbar vertebra with spinous rotation to the right. Significant facet syndrome on the left side was noted between the fifth lumbar vertebra and the sacrum with decreased vertical disc height at the fifth lumbar vertebra and sacrum with associated anterior end-plate osteophyte formation. The patient was assessed with a working diagnosis of lumbar sprain/strain with sciatica .

Conservative chiropractic management was implemented to include spinal manipulative therapy, PNF, mobilization, interferential therapy, cryocuff compression therapy, and instructions in activities of daily living and home exercise. The initial manipulation was focused to correct the biomechanics. The physiological effects of manipulation are intracapsular. Mobilization was performed on a motorized kinetic table for muscular  balance and to increase ROM in the lower back. The kinetic table settings were 15 degrees of extension followed by 25 degrees of flexion at 5 cycles per minute for thirty minutes. The physiological effects of mobilization are extracapsular. PNF was performed to balance and stretch the muscles of the lower back and lower extremity. The PNF was performed using 6 repetitions of 6 seconds with 6 second of rest beging at 15 degrees of elevation increasing 15 degrees at a set until reaching a plateau. Cryocuff compression therapy was performed for pain relief and to reduce inflammation. Cryocuff compression was performed using ice in water circulating at 100 percent through a bladder wrapped around and compressing the lower back. Interferential Therapy was performed to reduce inflammation, relieve pain, reduce muscle spasm, increase circulation, and facilitate the healing process. Sequential Interferential Therapy was performed using the setting for muscle spasm for 10 minutes, for enkephan production for ten minutes, ending with the setting for endorphan production for ten minutes. The treatment was performed in the following order. The patient was placed on the kinetic table and received cryocuff compression and interferential therapy. The patient was then manipulated and PNF was performed. This was performed for three weeks.     

As expected, her initial symptoms improved and the magnitude and duration of her pain subsided. The patient completed updated Outcome assessment forms demonstrating markedly improved scores indicating a perception of slight of mild disability. The patient was returned to light duty at her place of employment. She work in a construction materials superstore. Her regular work requirements as described by NIOSH definitions of occupational titles would be “Medium Heavy”. The patient also began performing some of her lighter activities of daily living. However, she seemed very sensitive to an exacerbation of symptoms causing her to express dependency supportive chiropractic treatment to relieve her back discomfort. The patient agreed to a trial of in-office rehabilitation using low tech protocols. The work conditioning program was focused to functional restoration concentrated to proprioception training, endurance training, gymball stability training and band therapy using modified Oxford protocols.

The patient was given a cardiac screening questionnaire and a EMG screening which showed no contraindications for weight training. Range of motion and straight leg raise were normal and the Oswestry Disability Questionnaire was given with a score of 12 noted. Isometric strength testing was performed using computerized dynometric testing with torque curves. The test findings indicated extension/flexion ratio of the thoracic-lumbar spine of .7 as compared to a normal ratio of 1:1 to 1:3.(10) In addition, the patients total strength rating was relatively low when compared to clinic observation of average readings of other patients using the testing device (Myoforce tm).

In-office rehabilitation was scheduled at three session per week for twelve weeks which included: a warm up on the Schwinn Airdyne stationary bicycle; stretching; progressive/ resistance exercise using universal-type equipment with range limiters to include trunk flexion, extension, and rotation; and concluding with additional stretching. Weight training followed; Zinovieff, DeLorme-Watkins, and McQueen protocols with weight adjusted to tolerance starting from an initial base line of one repetition maximum. The Oswestry Disability Questionnaire and muscle testing was performed three times during the course of the program. The initial Oswestry score was 12 which improved to a near normal 4. Muscle testing showed an improvement of the extension/flexion ratio to 1.9. Improvement of lateral flexion ratio were also noted to a near-normal .79.(11) Average strength readings of each motion increased from two to four times the initial testing results. Proper trunk muscle strength hierarchy was reestablished with extension greater than flexion greater then lateral bending.(11) (See chart). Upon release from the rehabilitation center, the patient was given a home program of spinal stabilization exercises to enhance the gains of trunk strength beyond the end of the exercise program.(12) Continuing spinal manipulative therapy on a maintenance basis was recommended to address any joint dysfunction which could reflexively inhibit trunk musculature.(11) Since completing this program, the patient has had fewer exacerbations of pain which were of lesser severity and duration. Over a nine month period, the patient experienced three minor exacerbations, all of which responded favorably to spinal manipulation alone. Patient reached an asymptomatic level and has chosen to return on an "as needed" basis for further care.       

                                                                                                                                                                          
DISCUSSION

It is believed that history, examination, and response to treatment were consistent with a diagnosis of Chronic Biomechanical Lower Hack Syndrome including symptomology consistent with an intravertebral disc disorder.(13) It is further believed that after sustaining her first episode of pain, her condition would have likely responded to a relatively short course of conservative chiropractic therapy and exercise stimulated muscle reconditioning if had she not undergone other treatment (i.e. pain pills and bed rest). Although these other treatments gave symptom relief, they actually may have contributed to the transfer from acute to chronic back pain. (14)

As was true with prior allopathic medical treatment, chiropractic palliative treatment gave some relief but was unable to fully resolve her condition once it became chronic. The addition of chiropractic spinal rehabilitation protocols using progressive/resistance exercise effectively addressed the trunk muscle deconditioning that had occurred which resulted in subsequent improvement in her health relative to her spinal complaint.

CONCLUSION

A case was presented in which chronic, re-occurring low back pain was the predominant complaint. Muscle strength imbalance of trunk was identified and treated using controlled, progressive/resistance exercise. The patient's response was encouraging suggesting that such an exercise program is a useful tool for the chiropractic physician in the management of these often difficult cases.

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