Low Back Pain: Isolated or Degenerative Problem - What are the Implications?
Shirley Sahrmann, PT, PhD, FAPTA
Ninety percent of people are expected to experience low back pain during their life. The prevailing pattern for treatment of low back pain is to intervene during an acute episode of pain with the intention of alleviating the symptoms through application of various modalities or techniques designed to provide immediate relief. In some instances a program of exercise is provided but often with a rationale that is highly variable or poorly defined. The recurrence rate of low back pain is known to be high, having been reported to range from 36 to 80%. This raises several questions about both the pattern of management and the emphasis of treatment. The high incidence and the recurrence rate are consistent with low back pain being associated with the degenerative process. Characteristic of the degenerative process is temporary dysfunction and 4 stages of hypermobility before the final stage of hypomobility and spinal stenosis. If the “acute episodes” are part of the pattern of temporary dysfunction associated with segmental hypermobility then treatment should be directed toward control and prevention of the progressive hypermobility that at a minimum should slow the degenerative process. Other investigators have suggested that that “loading” of the spine is an important factor in the degenerative process. The presence of hypermobility and/or abnormal loading as causative factors is consistent with the need for long-term monitoring of movement patterns and appropriate recommendations for correction. This would mean that physical therapists should be periodically but continually monitoring the pattern of movement of the low back, designing and appropriately instructing the patient in corrective exercises and movement strategies rather than just providing episodic short-term treatment.
This presentation will describe the best-available evidence regarding low back pain as part of the degenerative process and for the presence of segmental hypermobility. The exam to detect segmental hypermobility and treatment will be described. Evidence will be presented that detection of the movement direction associated with modification of symptoms can be used to classify the patient. Such a classification system provides a specific strategy for treatment rather than a generic, generalized stability program. Excessive loading associated with abdominal muscle overdevelopment will also be discussed as a contributing factor to low back pain.
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