Use of a classification to guide nonsurgical management of a patient with chronic low back pain. (Washington University School of Medicine, St Louis, MO) Phys Ther 2000;80:1097–1111.
Authors: Maluf K. S. , Sahrmann S. A. , Vandillen: L. R. 
Published: March 2003

This case report described the use of a classification system in the evaluation of a patient with chronic low back pain (LBP) and illustrated how this system was used to develop a management program in which the patient was instructed in symptom‐reducing strategies for positioning and functional movement. The patient was a 55‐year‐old woman with a medical diagnosis of lumbar degenerative disk and degenerative joint disease from L2 to S1. Rotation with extension of the lumbar spine was found to be consistently associated with an increase in symptoms during the examination. Instruction was provided to restrict lumbar rotation and extension during performance of daily activities. The patient completed 8 physical therapy sessions over a 3‐month period. Pretreatment, posttreatment, and 3‐month follow‐up modified Oswestry Disability Questionnaire scores were 43%, 16%, and 12%, respectively. Daily repetition of similar movements and postures may result in preferential movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of LBP. Research is needed to determine whether patients with LBP would benefit from training in activity modifications that are specific to the symptom‐provoking movements and postures of each individual as identified through examination.

These investigators propose a model for managing nonspecific low back pain (NSLBP) based on the identification of lumbar spinal dysfunction (symptom‐producing motions and alignments) during functional activities. The basis of the management model is the modification of the spinal movements and alignments that are pain producing through clinical education and a home program. The authors sited an example of using this model with a 55‐year‐old female who presented with a 10‐week history of central LBP that worsened with walking and other daily functional activities. The LBP was accompanied by parasthesias and intermittent sharp pain in the (L) lower extremity that was exacerbated by trunk rotation. After concluding that the patient was suffering from a dysfunction in lumbar extension and rotation, she was treated with movement and posture modification, forward flexion in standing and exercises aimed lengthening the hip flexors and improving gluteus maximus function. The patient demonstrated reduced symptoms, improved scoring on the Oswestry Disability Questionnaire, and improvements in pain‐free function. The investigators suggested that the patient's improvements were attributed to the modification techniques incorporated in the patient's home program and that these techniques may prove to be superior to exercise prescription and generic postural instruction.

Comment by Phillip S. Sizer Jr., MEd, P.T. This management model may contribute to a patient's recovery and these patient‐specific measures may serve as a symptom‐alleviating concomitant to a multidisciplinary approach to the management of NSLBP. However, readers should approach the conclusions of these investigators with caution. The investigators did not sufficiently address the long‐term conservative management of segmental hypermobility1 and adjacent segmental hypomobility that so frequently afflicts patients in this age group who suffer from NSLBP. The investigators also reported that extension and rotation increased the patient's symptoms, while forward flexion did not. Although their recommendation to avoid extension and rotation may have served the patient by avoiding the pain‐producing motion, a conclusion to add flexion to the program may not be advised. Forward trunk flexion increases intradiscal pressure,2 which can be associated with disc degeneration and resultant symptom generation.3 Respecting the impact of flexion on intradiscal pressure, Snook et al observed a reduction of NSLBP with patients who avoided flexion for the first 2 h of the day.4 Additionally, symptoms may have been reduced through the influence of the forward flexion on remodeling the adhesions that typically form between the dura mater and the posterior longitudinal ligament5 and or inter‐transverse ligaments.6 These benefits could be attained through more force‐friendly techniques, such as neural flossing in a supine position. Furthermore, the patient's improvements may have been fostered by reduced neural sensitization through activation or a reduction her subjective feelings of disability.7