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Amadio PC, Feldsher SB, Shin EK, eds. Rehabiliation of the
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Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
NOTES
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Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
67
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Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
The Lumbar Spine:
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Evidence-Informed Physical
Therapy Patient Management
Independent Study
Course 31.2.8
Max Jordon, PT, DPT, PhD
Assistant Professor
Department of Physical Therapy
College of Health Education and Professional Studies
University of Tennessee at Chattanooga
Chattanooga, Tennessee
The Lumbar Spine:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Guy G. Simoneau, PT, PhD, FAPTA—Editor
Gordon Riddle, PT, DPT, ATC, OCS, SCS, CSCS—Associate Editor
Cover Illustration by Joseph Kinstler
Dear Colleagues,
I am pleased to welcome you to e Lumbar Spine: Evidence-Informed Physical erapy Patient Management monograph written by Max
Jordon, PT, DPT, PhD. is work is part of the Academy of Orthopaedic Physical erapy Independent Study Course series 31.2, Cur-
rent Concepts of Orthopaedic Physical erapy, 5th Edition.
Dr. Jordon graduated with his Doctor of Physical erapy degree from the University of South Carolina in 2011. After working as a fulltime clinician in an outpatient orthopedic practice, he returned to the University of South Carolina to work on his PhD in Rehabilitation
Sciences. His predoctoral work focused primarily on the interactions between pain and motor control using functional magnetic resonance imaging in individuals with chronic low back pain. While he was working on his PhD, he continued to work in the clinic where he
started to specialize in chronic pain and low back pain management. Dr. Jordon completed his PhD in 2019, at which time he joined the
University of Tennessee at Chattanooga as an Assistant Professor of Physical erapy. At the University of Tennessee at Chattanooga, he
is part of the orthopedic faculty with a focus on teaching spine and upper extremity disorders. He continues to see patients in the student
pro bono clinic and is actively engaged in research as it relates to motor control in the lumbar spine.
In this monograph, the author provides a contemporary, evidence-based perspective on the management of acute and chronic low back
pain. e monograph begins with practical information on screening for red and yellow flags. Incorporated in the discussion of yellow
flags are the limitations of the pathoanatomical model for the treatment of low back pain and strategies to manage these patients efficiently within a biopsychosocial context. e author then presents factors that contribute to the transition from acute to chronic low back
pain, with a particular focus on preventing that transition. A discussion of the physical examination follows, in the context of the limited
ability to make a pathoanatomical diagnosis for most people with acute or chronic low back pain. An overview of evidence-based treatment options for low back pain, differentiating between acute and chronic conditions, is then provided. For additional clinical context,
the monograph concludes with pertinent clinical scenarios.
I am confident that readers will find value in this monograph, which summarizes the management of a common yet complex
condition in a practical manner.
My sincere thanks to the author for his contribution to the Current Concepts series.
Sincerely,
Guy Simoneau, PT, PhD, FAPTA
Editor
2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Office 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965
TABLE OF CONTENTS
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ACRONYM LIST ................................................................................................................................................................................................................5
ABSTRACT
LEARNING OBJECTIVES
BACKGROUND
..........................................................................................................................................................................................................................7
..............................................................................................................................................................................................7
................................................................................................................................................................................................................7
Prevalence and Chronicity ............................................................................................................................................................. 7
e economic and health burden of low back pain is still on the rise .................................................................................... 7
e burden of low back pain is not borne equally in our society ............................................................................................ 8
Take home messages .............................................................................................................................................................. 8
Pathophysiology ............................................................................................................................................................................ 8
Acute and chronic low back pain are very different ................................................................................................................8
e natural history of acute low back pain ............................................................................................................................. 8
e natural history of chronic low back pain ......................................................................................................................... 9
Structural changes associated with low back pain ................................................................................................................... 9
e lumbar intervertebral discs are integral to the spine ......................................................................................................... 9
Disc degeneration occurs naturally and does not always result in pain .................................................................................. 10
How do we differentiate an asymptomatic degenerative disc from a symptomatic one? ........................................................ 10
A disc by any other name… ................................................................................................................................................. 11
What role does a herniated (or bulging) disc play in low back pain? ..................................................................................... 11
Herniated discs get better with time ..................................................................................................................................... 12
e potential role of endplate changes in low back pain ....................................................................................................... 12
Structural changes in the central nervous system can occur with low back pain .................................................................... 12
Changes in gray matter volume can reverse with treatment .................................................................................................. 13
Wrapping it up: What are the structural causes of low back pain? ........................................................................................ 13
Non-structural changes occur in individuals with low back pain .......................................................................................... 15
People with low back pain commonly suffer from psychological comorbidities ....................................................................17
Predictors for transition from acute to chronic low back pain...............................................................................................18
Take home messages ............................................................................................................................................................ 20
EVIDENCE-BASED GUIDELINES ..........................................................................................................................................................................20
What Makes the “Best Evidence”? ............................................................................................................................................... 20
e Benefits of Evidence-Based Guidelines ................................................................................................................................. 20
Limitations of Evidence-Based Guidelines ................................................................................................................................... 21
Take Home Message ................................................................................................................................................................... 21
PHYSICAL THERAPY EVALUATION ....................................................................................................................................................................21
Physical erapist Screening Flags ............................................................................................................................................... 21
Red flags and their use to screen for serious medical conditions ........................................................................................... 21
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
3
Yellow flags can help with patient prognosis ......................................................................................................................... 22
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Components of the Assessment ................................................................................................................................................... 23
e challenge of using special tests to diagnose pathophysiology in the spine ....................................................................... 23
Neurological examination .................................................................................................................................................... 24
Physical examination............................................................................................................................................................ 24
Take Home Messages .................................................................................................................................................................. 25
Movement-Based Classification Systems ......................................................................................................................................25
PHYSICAL THERAPY INTERVENTIONS ............................................................................................................................................................ 26
Physical erapists are Effective in Treating Low Back Pain ......................................................................................................... 26
e Evidence (For Once) is Conclusive: Exercise is Good ...........................................................................................................26
Manual erapy to the Lumbar Spine can be a Valuable Addition to Exercise ............................................................................. 27
Mobilization and manipulation ............................................................................................................................................ 28
Dry needling ........................................................................................................................................................................ 29
Educating Patients is Important in Physical erapy ................................................................................................................... 30
Patients with chronic low back pain benefit from education that is specific to their condition ..............................................30
Patients with acute low back pain require a different type of education ................................................................................ 30
Take Home Message ................................................................................................................................................................... 31
e Environment in Which Physical erapists Provide Treatment can be a Powerful Factor in Rehabilitation ........................... 31
Factors we cannot control: the impact of the built environment and the health care setting in which one works .................. 31
Factors we can control: therapeutic alliance can play a key role in a patient’s rehabilitation ................................................. 32
Novel Interventions that are Gaining Popularity ........................................................................................................................33
FUTURE DIRECTIONS AND ADDITIONAL THOUGHTS ............................................................................................................................34
Take Home Messages .................................................................................................................................................................. 35
SUMMARY ....................................................................................................................................................................................................................... 35
CASE SCENARIOS ........................................................................................................................................................................................................ 35
Case Scenario 1 ........................................................................................................................................................................... 35
Case Scenario 2 ........................................................................................................................................................................... 36
Case Scenario 3 ........................................................................................................................................................................... 37
Case Scenario 4 ........................................................................................................................................................................... 38
REFERENCES..................................................................................................................................................................................................................39
Opinions expressed by the author are his own and do not necessarily reflect the view of the
Academy of Orthopaedic Physical erapy. e author declares no conflict of interest.
e publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
© 2021, Academy of Orthopaedic Physical erapy. For personal use only. No other uses without permission.
Course content is not intended for use by participants outside the scope of their license or regulations.
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
ACRONYM LIST
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aLBP: acute low back pain
CBT: cognitive behavioral therapy
CI: confidence interval
cLBP: chronic low back pain
CPM: conditioned pain modulation
CS: comparable sign
DD: disc degeneration
DDD: degenerative disc disease
DLPFC: dorsal lateral prefrontal cortex
DNIC: diffuse noxious inhibitory control
EMG: electromyographic
FABQ: Fear-Avoidance Beliefs Questionnaire
GM: gray matter
GMV: gray matter volume
HIZ: high intensity zone
HR: hazard ratio
IVD: intervertebral disc
LBP: low back pain
MBC: Movement Based Classification
MDQ: Modified low back pain Disability Questionnaire (Oswestry)
MDT: Mechanical Diagnosis and erapy
MBSR: Mindfulness Based Stress Reduction
mPFC: medial prefrontal cortex
MRI: magnetic resonance imaging
NA: nucleus accumbens
-LR: negative likelihood ratio
NPRS: numerical pain rating scale
NSAIDs: non-steroidal anti-inflammatory drugs
OMPQ: Orebro Musculoskeletal Pain Questionnaire
OSPRO: Optimal Screening for Prediction of Referral and Outcome
OSPRO-ROS: Optimal Screening for Prediction of Referral and Outcome – Review of Systems
OSPRO-YF: Optimal Screening for Prediction of Referral and Outcome – Yellow Flag
PCC: posterior cingulate cortex
PCS: Pain Catastrophizing Scale
PIPT: psychologically informed physical therapy
PNE: pain neuroscience education
+LR: positive likelihood ratio
RCT: randomized controlled trial
RMDQ: Roland Morris Disability Questionnaire
rLBP: recurrent low back pain
ROM: range of motion
SBT: STarT Back Screening Tool
SES: socioeconomic status
SMT: spinal manipulative therapy
TBC: Treatment-Based Classification
TENS: transcutaneous electrical nerve stimulation
TMS: transcranial magnetic stimulation
TSK: Tampa Scale for Kinesiophobia
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