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no better than general exercise. Both general and motor con-

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trol exercises produce similar results. When one looks at sta-

261

bilization speciﬁc exercises a similar trend appears.

What is interesting is that when one also looks at the evidence for motor control impairments in individuals with cLBP, the literature is also pretty clear; there is good evidence for abnormal motor control. is could indicate one of several possibilities. First, it could indicate that general exercises are equally eﬀective as motor control speciﬁc exercises at restoring proper movement patterns. Alternately, it could indicate that motor control exercises are unable to change motor control patterns in individuals with cLBP, making motor control exercises no more eﬀective than general exercise.

Another common approach to exercise for individuals

with cLBP is through the use of graded activity and graded

262,263

exposure.

ese treatment approaches use a combination of behavioral and cognitive approaches to improve a patient’s tolerance to physical activity. Graded activity uses principles of operant condition to reinforce patient activity levels. On the other hand, graded exposure asks the patient to create a list of feared activities. e patient is then exposed to the least feared activity ﬁrst, and with the help of the therapist, continues going through the list to the most feared activity once the negative associations are overcome. A systematic review completed by

263

Macedo et al in 2010

concluded that both graded activity and exposure techniques were able to reduce pain and disability compared to minimal treatment; a ﬁnding consistent with those of a later separate systematic review by Lopez-de-Uralde-Villa-

262

neuva et al

in 2016. However, the same caveat applies; neither graded activity nor graded exposure were found to be signiﬁcantly more eﬀective than general exercise.

An example of exercise (and evaluative technique) that is frequently used in the clinic is the McKenzie method of MDT. e MDT form of diagnosis and treatment has been used in the clinic since the 1950s and categorizes patients into 1 of 3 mechanical subgroups: derangement, dysfunction, or posture. e most common category, derangement, is typically addressed with the performance of directional preference exercises. e most recent systematic review and meta-analysis performed in

264

2018 by Lam et al

found that MDT was superior to placebo treatment. However, once again, there was evidence that MDT was not superior to general exercise or regular therapeutic exercises performed in the clinic (group exercises, stretching, stabilization/motor control exercises).

Lastly, one additional form of therapeutic exercise that can beneﬁt the patient and is both approachable and aﬀordable is simply walking. Walking, and aerobic exercise at large, has been demonstrated to have large impacts on LBP. For example, a recent meta-analysis assessed 9 studies that included walking as an

265

intervention in patients with cLBP.

ey found that walking was just as eﬀective as other non-pharmacological interventions in reducing pain and disability at up to a 12-month follow-up.

is conclusion was consistent with those of other systematic

266,267

reviews and meta-analysis.

With this in mind, the clinician can conﬁdently prescribe a walking program to the patient who might not yet tolerate other forms of exercise and needs a low cost option of care. While the above studies were not able to determine an optimal dosage, a goal of 150 minutes of walking

268

per week is a good place to start.

e evidence is rather compelling. First, exercise is good for patients with LBP. Guidelines across the world agree with the idea of individuals with LBP receiving some sort of exercise. Second, the type of exercise does not seem to matter. Motor control, stabilization, graded exposure/activity, and MDT are no more eﬀective than general exercise (Table 4). Similar results

269,270

are found for both yoga and Pilates.

is is not meant to be a condemnation of these approaches, but as encouragement to the practitioner that whichever style they are comfortable with and whichever style of exercise the patient prefers, there is good evidence of positive outcomes. If the patient has a preference for stabilization exercises, then the physical therapist can be conﬁdent in prescribing stabilization exercises. If yoga and Pilates ﬁt into the patient’s value system, then the physical therapist can incorporate those approaches into the overall treatment regimen with conﬁdence. e key is to get the patient moving.

Now the question to ask is, “how much should the patient exercise?” Previous commentaries have suggested that low-to moderate-intensity exercise is suﬃcient to decrease symptoms of chronic pain. However, the broader question of timing, frequency, and duration is one that needs to be addressed. Polaski

271

performed a meta-analysis of 75 studies that assessed

et al exercise dosing for chronic pain conditions. Despite enormous eﬀort, they were unfortunately unable to determine the optimal dosage of exercise for cLBP but their work had one interesting ﬁnding: increasing the frequency per week was the most likely cause of pain relief for patients with cLBP. Based on their predictive model, they made the proposition that an exercise program that starts with a shorter amount of daily activity but with a greater weekly frequency might be more acceptable and beneﬁcial to someone experiencing chronic pain. However, future studies need to prove this assertion.

Manual Therapy to the Lumbar Spine can be a Valuable Addition to Exercise

Manual therapy is a routinely used intervention in the

272

management of LBP.

While there is a plethora of diﬀerent techniques available to the physical therapist, this monograph will cover the ones most common to the clinic: spinal manipulation and mobilization. As dry needling has recently become a more commonly used intervention, this author will also include a brief review of the current evidence. However, the mechanisms behind manual therapy are complex and beyond the scope of this monograph. For a better understanding the reader is directed toward the excellent clinical commentary written by

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Bialosky et al in 2018.

Table 4.

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Common Exercise Paradigms Used in Physical erapy and Evidence Regarding Eﬀectiveness

Type of

Description Article Finding

exercise

Motor control Exercises aimed at addressing al-

terations in muscular recruitment and activation

Stabilization Exercises that attempt to increase

the spinal musculature’s ability to stabilize the spine

Graded activity Uses principles of operant

conditioning to reinforce patient activity levels

Graded exposure

Requires the patient to generate a list of “feared activities” that the patient and therapist work through

Directional based exercises

Use of a mechanical based diagnostic approach that incorporates preferred movements into exercise

Walking A simple aerobic exercise that is

both approachable and aﬀordable

Macedo Saragiotto

Coulombe

Macedo

259

260

261

263

Lopez-de-Uralde-Villaneuva

264

Lam

262

Sitthipornvorakul

266

Vanti Lawford

267

Motor control exercises are superior to minimal intervention, but no better than general exercise

Stabilization exercise is better than minimal treatment, but no better than general exercise

Both graded activity and exposure can reduce pain and disability compared to minimal intervention, but no better than general exercise

Directional based exercises are better than placebo treatment, but not superior to general or regular therapeutic exercises

265

Just as eﬀective as other non-pharmacological interventions at a 12-month follow-up

Mobilization and manipulation

For the purposes of this monograph, spinal mobilization for the lumbar spine is deﬁned as a low velocity manual technique with a variable amplitude typically directed at a vertebral body. Spinal manipulation, in comparison, is considered to be a high-velocity, low amplitude thrust (Figure 3). Most clinical practice guidelines recommend the use of spinal manipulation and mobilization in the treatment of aLBP and occasionally

200

cLBP.

Furthermore, authors have suggested that lumbar spinal manipulative therapy (SMT) is generally safe with minimal serious side-eﬀects.

274

Several recent reviews have evaluated the eﬀectiveness and eﬃcacy of spinal manipulation and mobilization. In 2018, Coulter et al

275

performed a systematic review of 51 trials and were able to pool data from 9 of those studies for a meta-analysis that assessed the use of spinal manipulation and mobilization for cLBP. As with most systematic reviews, they found a large amount of heterogeneity in the types and dosage of manipulation and mobilization, but nonetheless were able to draw some valid conclusions. First, based on the reported literature, manipulation and mobilization were safe. Second, both mobilization and manipulation signiﬁcantly reduced pain and disability. Furthermore, from their meta-analysis, the authors found that

manipulation appeared to produce a larger eﬀect than mobilization especially as it relates to reducing disability. erefore, while both techniques having been found to be safe for the pa-

Figure 3.

An Example of Spinal Manipulation to

the Lumbar Region

Academy of Orthopaedic Physical erapy, APTA.

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tient, the clinician might want to consider adopting spinal ma-

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nipulation into the treatment of cLBP if the patient is agreeable. Another systematic review and meta-analysis performed by Ru-

274

binstein et al

assessed SMT speciﬁcally for cLBP. eir general conclusion was that there is moderate evidence to suggest that SMT resulted in similar outcomes as other recommended therapies for short-, intermediate-, and long-term pain relief and improvement in function. eir ﬁnding were generally consistent with those of earlier reviews that found a small to moderate eﬀect for spinal manipulation in the treatment of LBP.

276-278

An additional systematic review and meta-analysis concluded that SMT was an eﬀective treatment in aLBP with only minor musculoskeletal harms (typically as transient pain during the

279

manipulation).

Taking the studies together, the clinician can conﬁdently choose spinal manipulation and mobilization in the treatment of acute and chronic LBP as it has been demonstrated to provide small to moderate improvements in the pain and disability of those with LBP with minimal risk of serious harm.

e logical next question is, “if SMT can provide a positive treatment with minimal risk, which patients are most likely to respond positively to the intervention?” In 2002, Flynn et

280

developed a clinical prediction rule to determine which

al patients would respond the best to spinal manipulation. e rule consists of 5 criteria: (1) no symptoms distal to the knee, (2) pain duration less than 16 days, (3) score of less than 19 on the FABQ work subscale, (4) presence of at least 1 hypomobile segment in the lumbar spine, and (5) 1 or both hips with greater than 35º of internal rotation ROM. e presence of 4 of 5 of these criteria resulted in a +LR of 24.38. is clinical prediction rule was later validated by a study performed by Childs et al in 2004, but was later disputed by Hancock et al

282

281

in 2008. One very large diﬀerence between these 2 later studies was that in the study by Hancock et al, mobilization was used in the majority of the cases, whereas the clinical prediction rule and the validation study by Childs et al both used a high-velocity technique. erefore, the conclusions from the study by Hancock et al limits the eﬃcacy of the clinical prediction rule to the originally intended scope of SMT and not mobilization. Regardless, one could argue that given the bulk of the literature and in the absence of any contraindications SMT should be used as a ﬁrstline treatment for patients with LBP. is is especially true given the safety of the technique, the general eﬃcacy in patients with both aLBP and cLBP, and the fact that the execution of the technique does not require excessive clinic time. However, it is unlikely that the use of SMT in isolation will provide optimal beneﬁt to the patient with LBP and it should therefore be used in conjunction with other therapies.

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Dry needling

Dry needling is another intervention that has gained popularity in the physical therapy clinic over the last several years (Figure 4). is intervention consists of the physical therapist

Figure 4.

Dry Needling Applied to the Lumbar

Paraspinals

inserting monoﬁlament needles into musculoskeletal trigger points and other connective tissues to stimulate the underlying neural and muscular structures in an attempt to decrease pain and improve movement. ese needles can then either be mechanically stimulated through the use of techniques such as “pistoning” or “winding.” ey can be electrically stimulated, or left in situ if the need arises. While trigger point release is a valid outcome and goal of dry needling, it is but one of the many possible mechanisms by which a patient can beneﬁt from dry needling. A full review of the mechanisms behind dry needling is beyond the scope of this manuscript, but the reader is

284

directed to an outstanding overview written by Butts et al in which the details of the peripheral and spinal mechanisms of dry needling are described in detail. However, the eﬃcacy of dry needling has been reported in several recent systematic reviews and meta-analyses. Hu et al

285

reviewed 16 RCTs that assessed the eﬃcacy of dry needling, speciﬁcally trigger point dry needling, in the treatment of LBP. Overall, they found that the studies were of low quality and the authors were reluctant to draw too ﬁrm of a conclusion. However, they found that compared to sham treatment, dry needling was eﬀective in reducing pain and disability. Compared to acupuncture, dry needling was more eﬀective in the short term but equivalent in the long term. Compared to standard physical therapy, however, the diﬀerence in treatment eﬀects were negligible. A separate meta-analysis of 11 RCTs found similar results when comparing dry needling to sham treatment.

286

However, one key ﬁnding was that dry needling seems to work the best when used in conjunction with other therapies.

To help support the argument that the eﬀects of dry nee-

dling go well beyond the resolution of trigger points, several

studies have looked at the central eﬀects of dry needling. For

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example, the study by Kim

110

in 2020, as mentioned above, demonstrated that there was improvements in 2-point discrimination and S1 region GMV after the successful use of acupuncture (a technique similar albeit diﬀerent from dry needling).

287

Dry needling has also been shown to activate supraspinal pain control via the increased activation of midbrain periaqueductal gray area inhibitory control mechanism. dry needling on musculoskeletal trigger points,

288

and through the activation of the diﬀuse noxious

289

While there are clear eﬀects of

285,286

the therapist should not limit themselves to just this single mode of action of trigger point dry needling. Bottom line is that there is evidence that dry needling has a place in the treatment of LBP when used as one part of a multimodal treatment approach.

Educating Patients is Important in Physical Therapy

Almost every guideline on treating LBP includes some

form of education,

200

but the speciﬁc type of education diﬀers depending on the patient population. Traditionally, the pathoanatomical model has been widely popular but new evidence is demonstrating that it might not be as eﬀective as previously thought and another form of education might be more beneﬁcial.

Patients with chronic low back pain beneﬁt from education that is speciﬁc to their condition

Traditional education that is focused on anatomy and biome-

chanics is not the optimal choice for individuals with cLBP. Tr a-

ditional education for cLBP, as is popular in “back schools,”

290

typically focuses on anatomy, biomechanics, and pathoanatomical structures.

291

However, despite the wide adoption of pathoanatomical education, it has limited eﬃcacy in treating cLBP and has the potential to produce harm. For example, a meta-analysis performed in 2001 found that while individuals who went to back schools had learned a lot about correct back posture, movements, and anatomy and biomechanics, there was very small eﬀects on health care utilization and no eﬀects on pain intensity.

292

Essentially, patients knew more about their back but that knowledge did not lead to pain relief. ey concluded that the concept of a back-school program needed to “be improved and systematically re-evaluated.”

As mentioned earlier, most recent guidelines for the treat-

ment of LBP do include education.

200

However, the education in the guidelines revolves around reassuring the patients that they have a good prognosis and to resume their typical activities. Finally, there is some evidence that teaching individuals about their pathoanatomy might in fact be detrimental. It has been suggested, although not directly proven, that using a biomedical educational model can increase patient fears, anxiety, and stress.

293-295

Clearly, at the very best, teaching someone in pain with the pathoanatomical model has no eﬀect on their pain and disability and at the worst has the potential to increase psychosocial factors of fear and anxiety.

Pain neuroscience education is a valid addition to the overall

treatment of cLBP. Pain neuroscience education (PNE) was de-

veloped as an alternative to traditional education models that had a heavy focus on anatomy, biomechanics, and pathoanat-

291

omy.

For the purposes of this monograph, the terms PNE, therapeutic neuroscience education, and pain neurophysiology education will be used interchangeably. According to Louw et

294

al,

PNE “aims to explain to patients the biological and physiological processes involved in a pain experience and, more importantly, defocus the issues associated with the anatomical structures.” Essentially, it attempts to teach the patient who has pain about their pain, not their back anatomy. Since its inception in the late 1990s, multiple studies and systematic reviews have evaluated the eﬃcacy of PNE. Moseley et al

295

studied the eﬀect of an intensive PNE session and compared it to a traditional education session that focused primarily on anatomy and physiology. ey found that compared to the traditional education group, the people in the PNE group demonstrated statistically signiﬁcant improvements on disability, pain beliefs, pain catastrophizing, and surprisingly, both straight leg raise (increase from a mean of 37±13º to 43±13º) and forward bending (cm from ﬂoor, 25±13 to 22±9). So not only did the psychosocial aspects of the participant’s health improve in this study, but the improvement translated to physical gains as well. Since then, several systematic reviews and meta-analysis have been performed to evaluate the eﬃcacy of PNE. A systematic review performed by Louw et al

294

assessed 13 published RCTs. One very interesting addition this systematic review provided was an assessment of the content provided in the PNE. Some of the topics commonly covered in PNE included neurophysiology of pain, nociception and nociceptive pathways, synapses, action potentials, spinal inhibition and facilitation, central and peripheral sensitization, plasticity of the nervous system, and psychosocial factors and beliefs that contribute to pain. Quite intentionally, there was a noticeable lack of content that covered anatomic or pathoanatomic models. In their conclusion, they found that PNE was able to signiﬁcantly improve a patient’s psychosocial health (pain catastrophizing and fear avoidance), but also aspects such as pain ratings, disability, and very importantly, decreased health care utilization. However, one important caveat that they include is that PNE in absence of other interventions may not be enough for improvement. It is when PNE is combined with exercise and other physical interventions that signiﬁcant reductions in pain can occur. is sentiment was largely echoed in a 2019 systematic review and meta-analysis performed by Wood et al.

296

Patients with acute low back pain require a diﬀerent type of education

While education is still important in the treatment of aLBP, the content needs to diﬀer. Like for cLBP, traditional pathoanatomical models of education should be eschewed. A recent Cochrane Review attempted to assess the eﬀectiveness of

Academy of Orthopaedic Physical erapy, APTA.

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back schools to improve pain and disability for individuals with

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297

aLBP.

While the data were too heterogeneous to pool into a meta-analysis, their results found that there was no evidence that back schools were more eﬀective than a placebo in treating pain and disability. In addition, for this population with aLBP, PNE does not seem to be as eﬃcacious. A recent investigation

298

performed by Traeger et al

assessed the eﬀects of 2, one-hour sessions of PNE compared to placebo education for patients with aLBP who were likely to develop chronic symptoms. ey found no diﬀerence in pain or disability between those who received the intervention and those who received the placebo. However, they do note that one limitation of the study was that each group received basic patient education as part of their initial care, potentially limiting the observed between-groups differences. is led the authors to conclude that “adding complex, time-consuming treatments to primary-care based advice and reassurance is likely to be unnecessary for most patients with aLBP.”

So, to summarize, traditional anatomy and physiology education seems to have at best no eﬀect on an individual’s pain and might in fact make it worse. For those with cLBP, PNE when combined with active physical interventions has the potential to improve not just the anxiety, fear, pain, and disability of a patient with cLBP, it also has the potential to reduce overall health care utilization. For those with aLBP, PNE does not seem to be warranted and the current guidelines seem to focus on education that reassures patients and promotes a return to normal

200

activity in lieu of a biomedical approach.

With this in mind, one could argue that physical therapists should stop teaching their patients about “jelly donuts” and instead teach patients about their pain and positive likelihood of recovery.

Take Home Messages

• Physical therapy can be just as eﬀective as invasive care for the patient with cLBP.

• Exercise is good. What is more, the type of exercise does not (currently) seem to matter. Physical therapists can conﬁdently employ whichever form of exercise they and their patient are most comfortable with to get them moving.

• When used in conjunction with exercise, manual therapy can be a useful tool in the treatment of LBP. is includes mobilization, manipulation, and dry needling.

• Eﬀectively educating the patient with LBP is important. Education based on the pathoanatomical model may worsen a patient’s outcome. However, when combined with exercise, education based on pain neurophysiology has been demonstrated to be beneﬁcial for the patient with cLBP. For the patient with aLBP, evidence-based guidelines recommend reassurance and encouragement to resume normal activity.

The Environment in Which Physical Therapists Provide Treatment can be a Powerful Factor in Rehabilitation

In the previous sections this author discussed how many diﬀerent options that a physical therapist has in treating a patient. Exercise, be it motor control, graded exposure/activity, or just general exercise have all shown to be beneﬁcial in the treatment of LBP. Manual therapy, including dry needling, mobilization, and manipulation, can be a powerful tool when used in conjunction with exercise; and education, especially PNE, can help a patient with cLBP manage fear and catastrophization. Furthermore, the overall risks to physical therapy are minimal, especially when compared to pharmacologic or surgical approaches making physical therapy an attractive cost-risk-beneﬁt

299-301

for the patient with LBP.

However, the literature consistently demonstrates that the overall eﬀect size of improvements following physical therapy (or any medical provider for that matter) is modest at best. erefore, a reﬁnement and improvement in the application of these eﬀorts may be needed to best serve the patient. e following segment will focus on aspects in which a physical therapist could potentially improve the impact that their interventions might have, not by means of reﬁning the technique, but rather by changing the environment in which the treatment is delivered.

Factors we cannot control: e impact of the built environment and the health care setting in which one works

While the intent of this section is not to fully examine the role that built environment plays in LBP rehabilitation, it is important to recognize that there are several factors that we as physical therapists have little control over. A recent viewpoint

302

by Rethorn et al

discussed how social determinants of health (factors such as economic stability, education, and neighborhood and built environment) plays a large role in overall health and recovery. In fact, they surmised that only about 20% of health and recovery can be attributed to the actual health care provided, whereas the remaining 80% is attributed to the remaining social determinants. While physical therapy cannot directly inﬂuence these broader categories of social determinants of health, one that might be of keen interest to the physical therapist is the neighborhood environment and the walkability of said environment. As discussed earlier, general exercise such as walking can have an enormous impact on LBP.

265-267

Evidence has shown that neighborhood environment can play a large role in determining who is able to participate in walking and receive the beneﬁts. ose who live in environments that have decreased walkability and poor social cohesion have a lower odds of meeting physical activity recommendations.

303

More speciﬁc to LBP, studies have shown that people who live in neighborhoods with good walkability have a lower prevalence

304

of LBP.

With this in mind, the physical therapist should pay

special attention to the living environment of their patient and

take into consideration the walkability level prior to prescribing

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a walking program. Or, conversely, think of alternatives such as mall walking or other public places if transportation is available to the patient.

While there are arguably some factors of control that a physical therapist might have in the clinic setting, it is largely dependent on where one ﬁnds a job. As such, for the purposes of this section, the clinic environment will be considered a factor that a physical therapist in a non-management role cannot control. Beattie et al

305

reviewed the records of more than 70 000 patients receiving outpatient physical therapy for an orthopedic problem to better understand the impact the health care setting had on the diﬀerences in number of visits, treatment units, and billing for physical agents. ey found that the patient management strategy was based largely upon the business model and clinical ownership rather than individual patient factors. For example, after controlling for ICD-9 classiﬁcations, they found that utilization of physical therapy treatment was signiﬁcantly diﬀerent among the settings; patients who went to a corporate or private physical therapy clinic had higher utilization rates and overall units of treatment compared to other settings (eg, hospital based). However, those patients who went to a corporate or private physical therapy clinic were more likely to receive treatment in line with evidence-based treatment guidelines, eg, therapeutic exercise instead of physical agents, as opposed to patients who received care at an occupational medicine clinic or physician oﬃce. While this study exposed some disturbing practice patterns among various clinical settings, it did not provide any information on the diﬀerences, if any, in outcomes in the diﬀerent settings. It could easily be forgiven if private practices and corporate owned physical therapy clinics used more resources if they provided better outcomes.

One study that did attempt to determine the inﬂuence of

the practice setting on outcomes was performed by Childs et

306

in 2014. ey assessed pre- and post-data of more than 138 000 patients in both private practice and hospital-based clinics. ey found that for patients who received care in a hospital-based clinic they had almost 3 fewer visits per episode while also having greater improvements in functional status. While they could not conclude anything deﬁnitively regarding the cost-eﬀectiveness of hospital-based clinics (due to greater reimbursement for these settings), they did support and expand on the ﬁndings of Beattie et al

305

in that use rates were greater in private and corporate owned physical therapy clinics with no better outcomes. Clearly, neither of these studies intended to or did measure the skill or quality of the physical therapist working in either one of these clinics. It would be reasonable to assume that in both settings the physical therapists are equally dedicated to the care and improvements of their patients. However, what these 2 studies do highlight is that the environment in which the physical therapy treatment is delivered, with all the externalities that are impossible to fully measure, clearly impact the overall care.

Factors we can control: therapeutic alliance can play a key role in a patient’s rehabilitation

Integral to physical therapy is the interaction between the patient and the therapist. is relationship is best described by the term, “therapeutic alliance” and can be deﬁned as the “working relationship or positive social connection between the patient and the therapist and established between therapist and client through collaboration, communication, therapist empathy, and mutual respect.”

307

It can be broken down into 3 primary components: (1) agreement on goals between the therapist and patient, (2) agreement on the intervention between the therapist and patient, and (3) the aﬀective bond

308

between the therapist and patient. by the “Working Alliance Inventory,” has shown to be a strong predictor of outcomes for cLBP.

Most commonly measured

307

the therapeutic alliance

309,310

One fascinating study that evaluated the eﬀects of therapeutic

311

alliance was performed by Fuentes et al.

In this study, the authors evaluated the eﬀect enhanced versus limited therapeutic alliance had on patients receiving either active or sham interferential current therapy. e “enhanced” therapeutic alliance group received care in which the therapist was actively engaged with the patient, inquiring about their symptoms, lifestyle, and causes of the condition. e therapist also performed active listening strategies and expressed empathy to the patient. For those in the “limited” therapeutic alliance group, the therapist was restricted to a 5-minute interaction during which they described the interferential current intervention but was otherwise not allowed to converse with the patient. Surprisingly, or maybe not so surprisingly, the group that received the sham treatment but “enhanced” therapeutic alliance demonstrated greater improvements in pain and beneﬁt (as measured by the global rating scale) when compared to the active treatment but “limited” therapeutic alliance group. Essentially, the beneﬁt of having a relationship with the therapist outweighed the beneﬁt of having an active interferential current treatment.

It is tempting for some to write oﬀ the therapeutic alliance as a “placebo” eﬀect. However, there is a growing consensus that placebo eﬀects are not fake reactions to an inert stimulus, but can be an active treatment that results in actual physiological events. Several studies have demonstrated positive eﬀects of placebo intervention even when the patients are intentionally told

312,313

that they are receiving a placebo.

312

randomized individuals with cLBP to receive either treat-

For example, Carvalho et

ment as usual or an open-label placebo, meaning that they were told the substance that they were about to receive was a placebo with no medicinal properties. e researchers found that at the 3-week follow-up, those in the open-label placebo group demonstrated signiﬁcantly greater improvements in pain reduction and disability when compared to the treatment as usual group. At the end of the 3-week follow-up, those in the treatment as usual were allowed to transfer over to the open-label placebo group. After switching, those in the treatment as usual group showed signiﬁcant reductions in pain and disability.

Academy of Orthopaedic Physical erapy, APTA.

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So, even when the participant knows they are receiving a placebo,

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they can exhibit a signicant positive eect. is study, along with previous work, has led to a reconceptualization of how placebos should be thought of. As an example, the traditional model would subtract the placebo eﬀect from the overall outcome to determine the “true” eﬀect of a treatment. Instead, a reconceptualized model looks at the “placebo” eﬀect as an additive factor in determining the overall value of the treatment (Figure 5).

314

is provides strong evidence for the practitioner to really engage with their patients to achieve the best outcome possible.

of Massachusetts Medical Center,

to non-judgmentally appraise dynamic and automatic stimulus

while allowing thoughts and feelings to be acknowledged. An

MBSR program typically runs for 8 weeks with a single day of

silent retreat.

kin et al

(CBT) to usual care. According to their study, the focus of the

CBT group was to change pain-related thoughts and behaviors

while the MBSR training focused on mindfulness meditation

and yoga. ey recruited a total of 342 patients with cLBP from

multiple cities to participate in the study. At the conclusion of

Novel Interventions that are Gaining Popularity

In the previous 2 sections, common physical therapy treatments and the importance of the context in which therapists perform said interventions were discussed. Basically, the what and the how of LBP interventions. However, with the exception of PNE, the interventions mentioned above target the biological structures. As we are now ﬁrmly in the biopsychosocial model of health care, it is important that we treat the “psychosocial” aspect as well as the “bio” aspect. For patients who experience stress as a comorbidity, one technique physical therapists have at their disposal to treat the “psychosocial” aspect is a technique called Mindfulness Based Stress Reduction (MBSR). Originally developed in the 1970s by Dr. Jon Kabat-Zin at the University

Figure 5.

Reprinted with permission from Beattie PF. Current Concepts of Orthopaedic Phys-

e Additive Eﬀects of Placebo

their study, they found that both CBT and MBSR were able to relieve pain to a similar extent with no statistical diﬀerence between them, and both groups improved more than with usual care. is study helped to demonstrate that for those patients who need some form of psychosocial intervention, MBSR can be used in lieu of CBT if it is not available. is is advantageous to the therapist as CBT requires extensive training to be appropriately administered, whereas the process of becoming certiﬁed in MSBR is much simpler, thus improving the accessibility of MBSR for patients.

With more and more interest in MBSR, there has been great progress in determining the mechanisms behind how it works. Functional MRI studies have provided evidence for sev-

315

MBSR teaches individuals

316

To assess the eﬀects of MBSR on cLBP, Cher-

317

compared MBSR and cognitive behavioral therapy

eral mechanisms including deactivation of the thalamus (which would reﬂect a “cognitive gating” and inhibition of sensory information); alterations in the activation of the perigenual anterior cingulate cortex, orbitofrontal cortex, and anterior

318,320

insula;

and deactivation of the

periaqueductal gray area (Figure

320

However, one fascinating study

6). of particular interest to clinicians treating patients with cLBP was per-

321

formed by Zeidan et al.

e goal of the study was to determine if pain reduction via MBSR was mediated through endogenous opioids. e researchers used functional MRI to evaluate the brain activation resulting from a heat-evoked pain stimulus during meditation in 2 groups: one with a saline injection and another with an opioid antagonist naloxone injection. e hypothesis was that if the pain reduction was due to endogenous opioids, then the naloxone injection should decrease the eﬀects of mindfulness meditation. e researchers found that this was not the case and concluded that pain reduc-

318-320

Figure 6.

283-285

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of Mindfulness-Based Stress Reduction

Changes in Activation Across Diﬀerent Regions of the Brain as a Result

283-285

Blue arrows indicate increased activation in these regions in individuals who practice mindfulness-based stress reduction. e red arrow indicates decreased activation.

tion via MBSR was not mediated through endogenous opioids. e reason this is so impactful in the treatment of individuals with cLBP is that many of these patients develop a tolerance to opioids. If MBSR works outside of opioid pathways, it remains a potential intervention even in population who are tolerant to opioids.

While studies have demonstrated the eﬀectiveness of

322

MBSR in treating LBP,

the clinician might be reluctant to either go through the training to become a certiﬁed MBSR teacher or lack the time or resources to do so. One solution to this is through the widely available commercial smartphone applications for MBSR. Several RCTs have evaluated the eﬃcacy of app-based MBSR and showed good results. While the eﬀects of electronic MBSR on LBP are unclear, it seems to be

323,324

beneﬁcial for stress reduction.

erefore, easily accessible smartphone applications, both fee-based and free, can be good alternatives for the patient if a trained MBSR practitioner is not available.

As mentioned above, another component of physical therapy that seeks to address the cognitive inﬂuences on cLBP is through the use of PIPT. In their description of PIPT, Main

221

and George

in 2011 position PIPT on a continuum between standard physical therapy that address the physical impairments based on a biomechanical approach, and mental health practices that were initially developed for the treatment of mental illness. e PIPT approach recognizes that treatment is not only directed toward the biomechanical causes of cLBP but also considers the patient as a whole, the contextual factors, and addresses the

325

combined contribution to the problem.

325

evaluations that use the PIPT approach seek to identify

olas,

According to Nich-

FUTURE DIRECTIONS AND ADDITIONAL THOUGHTS

In the previous sections, the eﬃcacy of common physical therapy interventions, the importance of the context in which those interventions are performed, and also some new interventions that are gaining popularity were reviewed. However, there are some key knowledge gaps that still need to be addressed. One of the primary knowledge gaps is that, despite major advancements, there is still a lack of understanding of the mechanisms behind which our interventions work. For example, study after study has demonstrated that individuals with LBP move diﬀerently and exhibit altered motor control. However, when one looks at the interventions that are geared towards addressing this deﬁcit, physical therapists end up making no more improvements than general exercise. How might physical therapists improve our motor control interventions to address this apparent gap in the literature? Or, as another example, physical therapists know that manual therapy has both central and peripheral mechanisms to aﬀect change in patients. An exemplary model of this was put forth by Bialosky et al 2018, but in their publication they address the need to better understand how provider and patient preference and expectations can modulate the eﬀects of manual therapy. Furthermore, they highlighted the need for studies examining outcomes outside the domain of pain reduction and to explore how manual therapy might improve emotional function, sleep, and patient satisfaction.

Another key knowledge gap that needs to be addressed is in what other domain can physical therapists support and help

what the patient is seeking for consulting physical therapy and what the patient’s expectations are. Additionally, the physical therapist will assess the patient’s beliefs about pain and develop a way to communicate that meets the patient where they are. As far as diﬀerent treatment approaches are concerned, the PIPT model embraces PNE to help not just explain pain but also to address faulty beliefs. Education should be given that reduces fear and encourages patients to resume normal activity, and graded exposure and graded activity are also advocated in the PIPT model. As is evident, the PIPT model does not eschew traditional physical therapy, but supplements it with meaningful interactions with the patient and attempts to reframe it in a way that best suits a patient with psychological comorbidities.

273

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For personal use only. No other uses without permission.

their patients? One area that is largely overlooked in the phys-

https://t.me/med1917

ical therapy clinic is how important quality sleep is for cLBP. Sleep disturbance has been directly correlated with chronic

326,327

pain intensity and patient function.

Furthermore, a recent meta-analysis has suggested that sleep interventions such as CBT and pharmacological interventions can improve cLBP symptoms.

328

An excellent recent paper by Nijs et al

329

reviewed diﬀerent interventions physical therapists can provide their patients to improve sleep quality and decrease pain. Some of those interventions include education regarding the importance of sleep, maintaining consistent bedtimes, limiting amount of time spent awake in bed, and daily self-monitoring of time in bed. e reader is encouraged to review the paper to develop a fuller understanding of the diﬀerent ways in which a physical therapist can have a positive impact on sleep quality.

Take Home Messages

e environment in which we provide care is important,

• and the role of the therapeutic alliance should not be undervalued.

• Mindfulness-based stress reduction, even when administered via an app on a phone, is a potential avenue by which a physical therapist can help the psychosocial aspects of a patient’s pain.

• Psychologically informed physical therapy provides an avenue for the physical therapist to address the psychological inﬂuences a patient might have on musculoskeletal pain.

SUMMARY

Low back pain continues to be an enormous burden on

the health care system and our economy. Despite an extensive amount of research, the prevalence and severity of LBP continues to rise. As the literature has demonstrated, aLBP has a generally favorable condition with “ﬂare-ups” being common. However, for individuals who go on to develop cLBP, they can have debilitating symptoms that are both physical and psychological. is condition is further confounded by the fact that it is largely unknown what speciﬁc anatomical pathology, if any, is contributing to the condition. Multiple studies have demonstrated that asymptomatic populations routinely have pathological anatomical features on radiographs, indicating that many degenerative changes are a simple consequence of age. As such, the implications of having a bulging disc or end-plate change are unclear.

While serious medical conditions can mimic mechanical

LBP, the incidence is relatively low. erefore, physical therapists should rightly use red ﬂags to screen for serious pathology, but it should be understood that the presence of a single red ﬂag is not likely to be meaningful. Lumbar MRI is very sensitive and as the strength of the MRI ﬁeld improves, the rate of

incidental ﬁndings increases. Regardless, physical therapists are good at determining who needs to be screened by physicians and do not often miss serious diagnoses.

Yellow ﬂags in LBP need to be considered. Depression, fear, catastrophization, and stress all play a large role in the development and persistence of LBP and should be addressed by the physical therapist. A PIPT approach could certainly help the physical therapist feel more comfortable in addressing these concerns. Additionally, the evidence to date gives the physical therapist a lot of freedom to practice in a manner in which they are comfortable, but more importantly, they should also adhere to the beliefs and preferences of the patient. Motor control exercise, directional preference, graded activity/exposure, walking, or even general exercise have all been shown to be beneﬁcial to the patient. ese exercises, combined with education that is focused on explaining pain, addressing fears, and supporting the patient to resume normal activities, can have a positive impact. Taken together, the physical therapist can have an impact on a patient’s pain that is equivocal to that received from surgery. Additionally, physical therapy care is less likely to be associated with adverse eﬀects and is cost-eﬀective. is positions physical therapists as a health care provider who can signiﬁcantly help the patient with aLBP and cLBP.

CASE SCENARIOS

Case Scenario 1

e patient is a 28-year-old male with the diagnosis of aLBP. Almost 2 weeks ago, the patient was working on his car when he felt a “pop” in his low back. He indicates that his pain was mild to begin with but has progressed to a 7/10 when it is at its worse. Aggravating factors include forward ﬂexion of the lumbar spine. e patient notes that he has not had any medical care to this point for his LBP, however this is not his ﬁrst incidence of LBP. ree years ago, he had a similar incident of LBP and went to a chiropractor to receive a manipulation. He noted that he did not receive any beneﬁt from the manipulation and if anything felt worse afterwards. He denies any radicular pain and no motor/sensory disturbances.

1. During history intake, the patient also mentioned that he

had some increased pain at night but no other sign of serious pathology. Because of this, your next course of action should be:

a. Immediately refer the patient to a primary care physician

because of the presence of a “red ﬂag.”

b. Inform the patient that they need to have imaging as soon

as possible to rule out serious pathology.

c. Continue to evaluate the patient but wait for him to

follow-up with his primary care physician prior to any strenuous treatment.

d. Continue to perform an evaluation and treat the patient,

while encouraging him to return to normal activities.

e correct answer is d. Continue to perform an evalua-

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tion and treat the patient, while encouraging him to return to normal activities. e presence of a single red ﬂag is very

rarely associated with any serious pathology and with an otherwise healthy individual an immediate referral to a physician is unwarranted. Imaging would not be appropriate for this patient and early intervention that includes exercise and education could help the patient reduce his pain and return to normal function.

e patient was given the Fear-Avoidance Back Questionnaire (FABQ) and scored a total of 12 points. On the objective examination, you note his range of motion was within normal limits for the spine and both hips. e correct course of action is to:

Perform a spinal manipulation as the patient meets 4 of the 5 criteria of the clinical prediction rule for a positive outcome.

Focus solely on therapeutic exercise to regain motion into

lumbar ﬂexion.

c. Focus solely on education, with speciﬁc focus on pain

neuroscience education.

d. Approach the patient with a treatment paradigm that in-

cludes exercise, manual therapy as needed (with the focus on mobilizations), education, and reassurance.

e correct answer is d. Approach the patient with a

treatment paradigm that includes exercise, manual therapy as needed (with the focus on mobilizations), education, and reassurance. While the patient does meet the criteria for

the clinical prediction rule for spinal manipulation, he has had a negative experience with the technique in the past. Evidenced-based medicine includes, in one of its pillars, patient preference and in this particular scenario a manipulation is not likely to produce beneﬁts. Both therapeutic exercise and education are great choices for this patient but have their best eﬀects when used in conjunction.

3. Upon assessment of the spine, the physical therapist feels as if there is some hypermobility in the L3 region. Furthermore, the passive lumbar extension test and prone instability test (2 tests which are purported to assess for motor control of the lumbar spine) are both positive. In addition, while spinal ﬂexion seems to aggravate the symptoms, extension seems to alleviate some of his pain. erefore, the best course of action would be:

a. Focus on motor control exercises exclusively until the

hypermobility improves.

b. Focus on directional preference exercises exclusively until

lumbar ﬂexion is no longer an aggravating symptom.

c. Perform a combination of motor control and direction-

al preference exercises, along with other general exercises the patient feels would be beneﬁcial.

Refer the patient to a primary care physician due to the

lumbar instability.

e correct answer is c. Perform a combination of mo-

tor control and directional preference exercises, along with other general exercises the patient feels would be beneﬁcial.

Remember, currently there is no conclusive evidence that directional preference, stabilization, or motor control exercises are any better than general exercises. ey all can help the patient improve. erefore, the therapist should feel conﬁdent in their choice if the patient is included in the decision process and is comfortable with the exercises.

Based on the information provided in this case, in addition to the exercise approaches listed above, what other interven-

tion is appropriate given the patient presentation? a. Graded activity/exposure. b. Dry needling.

Mindfulness.

c. d. Psychologically informed physical therapy.

e correct answer is b. Dry needling. is patient has few yellow ﬂags and is not exhibiting excessive psychosocial symptoms. e best additional intervention that might be appropriate is dry needling, as it has been preliminarily suggested to be beneﬁcial when used in combination with exercise.

Case Scenario 2

Your patient is a 68-year-old female who comes via direct access to your clinic with complaints of LBP. She has a long history of LBP that will occasionally ﬂare up like it is now. e most recent episode of LBP came when she was working in her garden. Other than gardening she enjoys an occasional walk but otherwise has no consistent exercise. She has seen her primary care physician for her previous episodes of LBP but has always just been referred to physical therapy. is time she has decided to try physical therapy ﬁrst without seeing her physician. To date she has had no imaging for her LBP.

1. Based on the information above, your ﬁrst step should be to: a. Refer the patient to her primary care physician for radio-

graphs due to the patient’s age and female sex.

b. Initiate a gentle exercise program that the patient can

progress from.

c. Recommend bed rest during the “ﬂare up” and a reduction

of activity.

d. Screen for any red ﬂags or indications in the patient’s his-

tory and presentation that might suggest a more serious pathology.

e correct answer is d. Screen for any red ﬂags or indi-

cations in the patient’s history and presentation that might suggest a more serious pathology. While the patient is older

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