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Running head: INNOVATIVE TREATMENT STRATEGIES FOR CHRONIC LOW BACK PAIN 1

Innovative Treatment Strategies for a Female Patient with Nonspecific Chronic Low Back Pain and Fear-Avoidance Beliefs: A Case Report

Andra J. MindlingCleveland State University

INNOVATIVE TREATMENT STRATEGIES FOR CHRONIC LOW BACK PAIN 2

Abstract

Background and Purpose: Low back pain (LBP) is one of the most common patient complaints

treated by outpatient physical therapists. Development of chronic LBP involves numerous

influences, including psychological factors. These psychological factors can include fear-

avoidance, which have been shown to play a significant role in the progression of LBP into a

chronic problem. While many treatment options have been proposed, limited research is available

regarding the practical application of fear-avoidance interventions in the clinical treatment of

chronic LBP. The purpose of this case report is to describe the unique interventions utilized in

the management of a LBP patient with significant fear-avoidance beliefs.

Case Description: The patient, a 47-year-old female, presented with chronic LBP, extremely

limited lumbar range of motion (ROM), and inability to perform numerous functional tasks

secondary to pain and fear of spinal instability. Outcome measures included the physical activity

subscale of the Fear-Avoidance Beliefs Questionnaire (FABQ-PA) and the Oswestry Low Back

Pain Disability Index (ODI). Therapeutic interventions focused on spinal motion in the frontal

plane in order to increase the patient’s spinal motion without exacerbating her fear while bending

forward.

Outcomes: With intervention, FABQ-PA decreased from 24 to 13, ODI decreased from 42% to

16%, and pain decreased from 10/10 to 0/10. In addition, the patient’s fingertip-to-floor forward

bend test improved from 22 inches from the floor to 11 inches from the floor.

Discussion: This case report demonstrated the unique use of frontal plane exercises to assist in

decreasing fear of forward bending while simultaneously enhancing spinal ROM. Further studies

are needed to determine cause and effect for this intervention in a larger population with LBP.

Manuscript word count = 3500


Introduction

Low back pain is one of the most common patient complaints treated by healthcare

professionals,1 with nearly 80% of adults experiencing low back pain at some point in their life.2,3

Low back pain can be defined as “pain, muscle tension, or stiffness localized below the costal

margin and above the inferior gluteal fold, with or without leg pain.”4 Numerous structures have

the potential to contribute to low back pain, including nerve roots, muscles, bones, joints, fascia,

and intervertebral discs (IVDs).5 In addition, back pain may be referred from viscera in the

abdominal cavity.5

It has previously been reported that up to 85% of those who seek treatment for their low

back pain are classified as having “nonspecific low back pain” – a diagnosis that offers little

substance regarding the specific structure causing the patient’s pain.6,7 Furthermore, nonspecific

low back pain has been established to have a recurrence rate of up to 87%, adding considerably

to the financial burden of both the individual patient and the health care system as a whole.8 With

the likelihood of recurrence so high, the development of chronic low back pain might seem only

a natural progression for this diagnosis. However, development of chronic pain is often

extremely complex, involving multiple biopsychosocial factors.3 Psychological factors in

particular, including fear-avoidance, have been shown to play a significant role in the

progression of the initial onset of low back pain into a chronic problem.9 In fact, fear-avoidance

beliefs have been shown to significantly increase disability,3,9,10 reduce sagittal-plane lumbar

motion,3 and hinder overall patient recovery.11 Limited information regarding the practical

application of fear-avoidance interventions in the treatment of chronic low back pain can be

found in the scientific literature, despite a recent increase in interest regarding the topic of fear-

avoidance.


By contrast, numerous treatment methods are included in the literature regarding

strategies for the general therapeutic management of patients with low back pain. Treatments

commonly utilized include bracing, thermotherapy, cryotherapy, traction therapy, electrical

stimulation therapy, biofeedback, manual therapy, therapeutic exercise, acupuncture, mattresses,

spinal cord stimulators, oral medications, topical medications, spinal injections, and surgery.12,13

During physical therapy treatment, traditional interventions for low back pain routinely consist

of manual therapy and therapeutic exercises aimed at strengthening and restoring muscular

function, supporting the spine, and preventing recurrence of low back pain.1,14

Unfortunately, despite the numerous studies reporting on physical therapy interventions

for low back pain, the overwhelming absence of concrete diagnoses to isolate the underlying

causes of a patient’s pain often results in ineffective treatment outcomes.15 In fact, the most

recently published Journal of Orthopaedic and Sport Physical Therapy (JOSPT) clinical practice

guidelines reported that efforts to ascertain effective interventions for patients with low back

pain have been largely unsuccessful due to the fact that low back pain is treated as a

“homogeneous entity” after nerve root compression and medical red flags have been ruled out.15

Because of the homogeneous nature of treatment in much of the research regarding low back

pain, little consensus exists regarding the best strategy for therapeutic management of

nonspecific low back pain.14,16

Consequently, although numerous studies have reported on possible intervention

techniques for nonspecific low back pain and many other studies have provided research

regarding the presence of fear-avoidance beliefs in low back pain, no research was found upon

review of the literature that depicted possible physical therapy interventions to treat nonspecific

low back pain with the added complexity of fear-avoidance beliefs. With that in mind, the


purpose of this case report is to describe the unique interventions utilized in the management of a

female patient with fear-avoidance beliefs and a diagnosis of chronic nonspecific low back pain.

Patient History and Review of Systems

The patient in this case was a 47-year-old Caucasian female referred by her physician to

the physical therapy clinic with a diagnosis of chronic bilateral low back pain without sciatica.

The patient, a stay-at-home mom with two children under the age of 15, reported that she had

been experiencing intermittent low back pain for 9 years with an increase in painful episodes

over the last 3 weeks. During the initial encounter, the patient’s chief complaints included aching

pain across her sacral base and lumbar spine, limited lumbar flexion range of motion (ROM),

muscle spasms in her low back, and frequent episodes of her back “giving out” with bending

forward. Although the patient had previously sought treatment numerous times with physical

therapy and chiropractic adjustments, the patient felt that treatments had failed to reduce her pain

or solve her instability, stating that she believed the treatments had actually only further

exacerbated her symptoms. The Numeric Pain Rating Scale (NPRS)17 was utilized during the

interview with the patient rating her average pain as 5/10, with “good days” characterized by

0/10 pain and “bad days” characterized by pain “well above 10/10.” Functional limitations

included: needing assistance dressing her lower body due to inability to bend forward; inability

to lift heavy objects; inability to sit, walk, or stand for a prolonged period of time due to

increased pain; difficulty going up and down steps; inability to exercise due to increased pain;

difficulty participating in energetic activities with her children due to increased pain; and

inability to perform housework that involves bending forward, such as unloading the dishwasher,

picking up toys on the floor, or gardening. The patient’s past medical history included 2 cesarean

section births, a rectus diastasis repair, and asthma. Results from both magnetic resonance


imaging (MRI) and radiographs of the spine included in the patient’s chart revealed no

significant or pathological findings. No information was noted during review of the patient’s

chart or intake documentation that would preclude the patient from physical therapy examination

or treatment. Upon completion of questioning regarding her chief complaints and medical

history, the patient reported that her primary goals for physical therapy treatment included

increasing her overall strength and flexibility, decreasing her back pain, and improving her

ability to bend over without the sensation of instability in her low back.

Clinical Impression 1

Following the interview to obtain any patient-identified problems (PIPs),18 the initial

clinical impression of this patient was that she likely would demonstrate poor core stability and

hypermobility of at least 1 spinal segment, leading to instability of the lumbar spine and the

sensation of her back “giving out.” It was believed that her reports of “muscle spasms” were her

body’s attempt to maintain stability in the absence of active deep lumbar stabilization. With this

in mind, the physical therapy diagnosis was initially thought to fall under the classification of

“chronic low back pain with movement coordination impairments” as described in the low back

pain clinical practice guidelines.15 However, with the addition of the patient’s stated fear-

avoidance and the chronicity of her pain, the category of “chronic low back pain with related

generalized pain” was also considered.15 Following this mental assessment, it was determined

that a thorough examination of the patient’s lumbar ROM should be performed, along with

examination of the patient’s abdominal muscle stabilization with active movement. In addition,

segmental mobility would be assessed to determine the presence of hypermobility at any specific

segment(s).


Examination

An examination of the patient’s lower extremity dermatomes, myotomes, and reflexes

noted no abnormalities. Observation of standing posture revealed forward head position,

increased thoracic kyphosis, increased lumbar lordosis, anterior pelvic tilt, and a bilaterally

flexed sacral position. Observation of the patient’s gait on a level surface showed a decrease in

hip extension bilaterally and a maintained anterior pelvic tilt throughout the gait cycle. The

patient presented with tenderness to palpation at the sacral base, sacral apex, generalized lumbar

region, right gluteal region, and the right tensor fascia latae. Muscle flexibility was measured

with the patient demonstrating limited 90-90 hamstring flexibility bilaterally in supine, limited

hip flexor flexibility bilaterally during the Thomas test, limited gluteal flexibility bilaterally in

supine, and limited gastrocnemius flexibility bilaterally in supine.

Active ROM measurements were taken for the lumbar spine using a standard goniometer,

revealing 20 degrees flexion, 30 degrees extension, and 20 degrees lateral flexion both to the left

and right. Further measurements of lumbar active ROM were noted using the fingertip-to-floor

test for forward bending and side bending. This test resulted in measurements of 22 inches from

the floor for flexion, right lateral flexion, and left lateral flexion. Additionally, hip active and

passive ROM was assessed with all motions found to be within normal limits. Strength testing

was performed on the patient’s hip abductors, hip extensors, and abdominal muscles with results

as follows: hip abduction strength 3-/5 right and 4-/5 left, hip extensor strength 4-/5 bilaterally,

and trunk flexion 2/5. In addition, deep abdominal stabilization was assessed using the bent knee

fall out technique. Using this technique, the patient demonstrated the ability to control the lower

extremities through 50% of her hip external rotation range on the left and 20% of her hip

external rotation range on the right.


Special tests administered included Ober’s test, the slump test, and the prone instability

test. Both Ober’s test and the slump test were positive bilaterally, while the prone instability test

did not reveal the presence of spinal instability. Pelvic asymmetry was observed based on

palpation and visual inspection with an elevated right anterior superior iliac spine, an elevated

left posterior superior iliac spine, and an inflare of the right ilium. Joint mobility was assessed in

prone using passive intervertebral movements (PIVMs) for the thoracic spine and lumbar spine

with limited segmental mobility noted throughout. Motion at the sacrum was assessed in prone

with deep breathing and demonstrated limited sacral extension. The Oswestry Low Back Pain

Disability Index (ODI)15 and the physical activity subscale of the Fear-Avoidance Belief

Questionnaire (FABQ-PA)15 were both administered with scores of 42% and 24, respectively.

Table 1. Validity and reliability of examination tests and measures

Tests and measures Test validity Test reliability

Hamstring 90-90 test Moderate to strong statistical and clinical support19

Intratester: ICC = 0.90 – 0.9920

Lumbar goniometry r = 0.8521 Intratester: r = 0.9220

Fingertip to floor test ICC = 0.6720 Intratester: r = 0.9120

Trunk flexion manual muscle testing

Not established22 Test-retest: ICC = 0.97 – 0.9822

Bent knee fall out (BKFO) No measurements of validity identified

Intratester: r = 0.6423

Segmental mobility assessment

“Validity has been established with correlation to radiographic lumbar segmental instability.”15

“Reliability for presence of hypomobility or hypermobility during intervertebral motion testing demonstrated moderate to good agreement.”15

Ober’s test Minimal statistical and some clinical support19

Intratester: ICC = 0.9420

Thomas test Minimal statistical and some clinical support19

Intratester: ICC = 0.83 – 0.9820

Prone instability test Minimal statistical and some clinical support19

“Good to excellent reliability reported.”15

Slump test Moderate to strong statistical and clinical support19

Intertester: k = 0.83 – 0.8915

ODI r = 0.11 – 0.7524 Test-retest: ICC = 0.78 - 0.9824


FABQ - PA r = 0.9525 Test-retest: ICC = 0.84 - 0.8815,25

Clinical Impression 2

While initially it was thought that the patient would simply demonstrate poor core

stability leading to segmental instability in the lumbar spine, the physical examination

illuminated the presence of the patient’s overwhelming fear-avoidance tendencies, significantly

limiting her willingness (either conscious or unconscious) to perform lumbar ROM. In addition,

it was clear that pelvic and sacral impairments were likely contributing to her pain and

dysfunction. While it was obvious that the patient demonstrated multiple impairments, there was

a noticeable disconnect between the PIPs and the clinical impairments noted in the physical

examination. With this in mind, it was felt that the examination had confirmed our physical

therapy diagnosis of chronic low back pain with related generalized pain, and that the patient’s

fear-avoidance beliefs were a significant barrier that served to further intensify her pain and

exacerbated her functional limitations. At this point, it was determined that the patient would be

an excellent candidate for a case report due to the magnitude of her fear-avoidance and her

obvious motivation to participate in physical therapy despite the severity of her fear.

Following completion of this assessment, the patient was deemed to be a good candidate

to continue with physical therapy intervention, and a plan of care was created in coordination

with the patient. Under recommendation from the physical therapist, the patient agreed to be seen

2 times a week for at least 10 weeks with the possibility for extension of the episode of care,

dependent on progress. Formal re-examination and re-administration of outcome measures

would be performed every 10th visit, in accordance with the outpatient clinic’s policy. Outcome


measures would include the ODI, FABQ-PA, the Global Rating of Change Measure (GROC),

and the NPRS.

Interventions

The patient was seen 20 times over a 10-week period by a licensed physical therapist and,

during the last 8 of those 10 weeks, a 3rd year doctorate of physical therapy student. Sessions

consisted of 30-45 minute treatments, with on-site interventions comprised of manual therapy

techniques and therapeutic exercises. Intervention strategies generally followed the JOSPT

clinical practice guidelines,15 techniques of Patrick Hoban of Great Lakes Physical Therapy

Seminars,26 as well as the clinical expertise of the supervising PT. Each treatment session

followed a typical course of events, including:

1. the patient’s subjective report of pain using the numeric pain rating scale, changes in

mobility and function from the previous session, and adherence to interventions

prescribed for use at home.

2. Assessment of the patient’s pelvic, sacral, and lumbar alignment.

3. Manual therapy techniques to correct structural alignment issues and impairments noted

each visit.

4. Instruction in therapeutic exercises focused on increasing mobility without exacerbating

the patient’s pain or fear, enhancing deep lumbar stabilization, and strengthening

musculature to assist in maintenance of structural alignment.

This general course of events for treatment sessions differed slightly early on in the course of

care as the therapeutic interventions consisted largely of manual therapy techniques aimed at


reducing the patient’s pain and increasing her confidence in and comfortability with the physical

therapists.

Visit 1

Following the initial examination, performed by the licensed physical therapist, the

patient was educated regarding the exam findings and how her impairments contributed to her

chief complaint. The patient was instructed in a home exercise program (HEP) following

completion of the exam and was provided pictures and descriptions of each exercise, including

the frequency, duration, and repetitions prescribed for each exercise (Appendix I). Due to the

patient’s high fear-avoidance, the initial HEP consisted entirely of gentle stretching exercises

focused on increasing mobility and acclimating the patient to gentle movement. The patient

expressed and demonstrated understanding of the HEP provided.

Visits 2-3

Due to the high level of pain reported and early patient aversion to significant movement,

initial treatment sessions consisted of manual therapy interventions to manipulate pelvic and

sacral alignment abnormalities, mobilize lumbar segments, enhance patient relaxation, improve

tissue extensibility, and increase ROM.26,27 It was felt that these manual interventions would also

assist in gaining the patient’s trust and would subsequently enhance participation in therapeutic

exercise techniques as the course of care progressed. Manual therapy techniques provided

included muscle energy (MET) inflare correction, sacral respiratory mobilizations, leg pull

manipulation technique, pubic clearing technique, and lumbar posterior to anterior (PA)


mobilizations.26,27 Descriptions of manual techniques provided throughout the course of care can

be found in Table 2.

Table 2. Manual therapy (MT) interventions performed throughout the plan of careMT technique Description Rationale for useInflared ilium correction MET26

With the patient in supine, the involved hip is flexed to 90 degrees. The therapist places one hand on the patient’s opposite ASIS to stabilize and the other hand on the lateral knee of the involved side. The involved leg is brought into external rotation and abduction. The patient then pushes into the therapist’s hand with their knee to fire the gluteus medius.26

To correct alignment of the pelvic girdle.

Sacral respiratory mobilization26

With the patient in prone, the therapist places one hand on the sacrum with fingers pointing toward the head. As the patient inhales, the therapist allows their hand to move with the sacrum into extension and maintains pressure to prevent the sacrum from flexing on the exhale. As the patient continues to breathe, the therapist takes up the slack with each breath and maintains pressure in the new position.26

To improve extension mobility of the sacrum and increase lumbar flexion.

Leg pull manipulation26

With the patient in supine, the therapist grasps the leg above the ankle and positions the leg into slight hip flexion and external rotation. The therapist takes up the slack and provides a quick, firm pull through the long axis of the leg. 26

To correct alignment of the pelvic girdle and correct for apparent leg length discrepancy.

Pubic clearing technique26

With the patient in supine in the hooklying position, the therapist places their hands initially on the lateral aspect of both knees. The patient is asked to gentle abduct their legs against the therapist’s hands (laterally). The therapist then moves their hands to the medial side of the knees and the patient is asked to gentle adduct against resistance.26

To correct alignment of the pelvic girdle.

Thoracic PA mobilization27

With the patient in prone, the therapist places the pisiform bone of one hand over a spinous process of the patient’s thoracic segment to be mobilized. With the therapist’s elbows fully extended, a gentle oscillatory force is applied from posterior to anterior through the spinal segment.27

To improve thoracic segmental mobility.

Lumbar PA mobilization27

With the patient in prone, the therapist places the pisiform bone of one hand over the spinous process of the patient’s lumbar segment to be

To improve lumbar segmental mobility.


mobilized. With the therapist’s elbows fully extended, a gentle oscillatory force is applied from posterior to anterior through the spinal segment.27

Soft tissue mobilization of the erector spinae26

With the patient prone, the therapist places one hand on top of the other and pushes gently into the erector spinae where the tissue tension is felt, holding the position until the muscle releases.26

To decrease pain and increase extensibility of paraspinal musculature.

Piriformis manual release26

With the patient in prone, the therapist places one hand on top of the other and pushes gently into the piriformis where the tissue tension is felt, holding the position until the muscle releases.26

To decrease pain in gluteal region due piriformis tightness.

Psoas manual release26

With the patient in supine, the therapist locates the ASIS and places one hand on top of the other. The therapist then gently applies pressure into the abdomen and moves in a medial and superior direction until a rope-like structure is felt. Once the location of tissue tension has been located, the position is held until the muscle releases.26

To decrease tissue tension and enhance lumbar mobility.

Lumbar side bending mobilization with finger block27

With the patient prone, the therapist grasps the patient’s leg with one hand just above the knee. With the other hand, the therapist places their 2nd

and 3rd fingers along the side of the spinous process of the superior vertebra of the segment being mobilized. With the hand grasping the patient’s leg, the therapist moves the leg into abduction until movement is felt at the segment being mobilized. Force is localized by providing a finger block to the superior aspect of the target segment. Oscillations are performed by moving the patient’s leg back and forth against the blocked segment.27

To enhance facet joint gapping of the lumbar spinal segments.

Visits 4 - 10

As the patient began to demonstrate trust in the physical therapists, therapeutic exercise

techniques were introduced into the patient’s on-site treatments. Therapeutic exercises focused

on the following: increasing gluteal muscle activation; decreasing hip flexor tightness;

decreasing tightness of the TFL; activation of deep lumbar stabilizers (transversus abdominis and


multifidi); and increasing thoracic, lumbar, and pelvic mobility through gentle sagittal plane

exercises. Descriptions of exercises provided in visits 4–10 can be found in Table 3.

Table 3. Therapeutic exercises performed throughout the plan of careExercise Description Rationale for useTall kneel with gluteal muscle activation

While in the kneeling position on a foam pad or towel, squeeze the buttocks to push the hips forward/up, moving the body into a tall kneel position.

To increase activation of the gluteal muscles and stretch the hip flexor muscles.

Cobra stretch While the prone position, push hands into table to slowly arch the back, focusing on extending one spinal segment at a time until full extension of the spine is reached with the hips still in full contact with the table.

To increase spinal mobility.

Hip flexor eccentric lowering

While lying on back near the edge of the bed, bend one leg with foot flat on bed. Attach an ankle weight around the other ankle. Flex the hip of the weighted leg to approximately 90 degrees and then slowly lower the leg down to the table, taking at least 10 seconds to complete the motion.

To enhance elongation of the iliopsoas muscles.

Posterior pelvic tilt

While in the hooklying position in supine, flatten the low back against the table by tightening the stomach muscles and rotating the pelvic girdle backwards.

To enhance proprioception of the pelvis while facilitating gentle initiation of flexion mobility.

Drawing in maneuver with biofeedback

In supine, place the biofeedback unit in the lumbar lordosis and pump the unit to 40 mm Hg. While lying on back with knees bent and feet flat on the floor, tighten the stomach by “bringing your belly button to your spine.” The dial of the biofeedback should remain at 40 mm Hg.

To enhance deep lumbar stabilization.

Hip flexor stretch

While lying on back near edge of bed, bend one leg with foot flat on bed. Hang the other leg over edge, relaxing with thigh resting entirely on bed. Allow the muscle to hang heavy until a gentle stretch is felt in the front of the hip.

To improve hip flexor flexibility.

TFL stretch While standing, cross one leg over the other, then lean to the opposite side until a stretch is felt over the outside of the hip.

To improve TFL flexibility.

Seated theraball roll-outs with breathing

While seated in a chair, place hands on an inflated therapy ball in hand-over-hand position in front of torso. While exhaling, push the ball forward, allowing the spine to bend forward.

To facilitate gentle initiation of flexion mobility coupled with breathing.


Birddogs While in the quadruped position, tighten the stomach and simultaneously raise leg and opposite arm. Perform the movement without allowing the trunk to twist.

To enhance stabilization of deep lumbar musculature.

Visits 11 – 20

Following re-evaluation on the 10th visit, it was noted that the patient’s sagittal plane

spinal motion remained significantly limited, despite good HEP adherence. The patient reported

continued fear while bending forward, causing the therapists to hypothesize that this was likely

still the major limitation to her sagittal plane motion. Because of this, the treating therapists

modified the therapeutic interventions to focus on spinal motion in an alternate plane,

specifically the frontal plane, in an attempt to increase the patient’s spinal motion without

exacerbating her fear of bending forward. Interventions added to the patient’s therapeutic

program to accomplish this task included lumbar side bending mobilization in prone, active side

bending exercises while seated in a chair, active side bending exercises while seated on a

theraball, active side bending exercises while standing, and active side bending with posterior

pelvic tilt in standing. Following manual therapy interventions, these exercises were performed

actively to each side with the patient stopping if she felt uncomfortable or if there was an

increase in her fear. The patient was instructed to bend to each side as far as possible, focusing

on moving at her lumbar spine, 10 times in each direction. Each exercise was progressed only if

the patient expressed feeling comfortable in the current ROM. A combination of these exercises

was used during each session, along with the previously described exercises and manual therapy.

The patient’s forward flexion was assessed after each session with the fingertip-to-floor forward

bend test to determine improvement in forward flexion following interventions.


Outcomes

Over the course of the episode of care, the patient reported a decrease in pain to 0/10 on

the NPRS and an overall improvement in daily functional mobility. A significant improvement

was noted in the patient’s outcome assessments, as noted in Table 4 and figure 1. Perhaps the

most notable of these changes was the improvement of the patient’s ODI and FABQ-PA to 16%

and 13, respectively. Lumbar AROM improved to 71 degrees flexion, 35 degrees extension, and

25 degrees lateral flexion to both the left and right. The patient’s fingertip-to-floor forward bend

test also revealed an improvement to 11 inches from the floor. Hip abduction strength and hip

extension strength both improved to 4+/5. Abdominal strength improved to 3/5 and BKFO test

demonstrating control through 50% of the hip external rotation range bilaterally. Tightness of

bilateral hip flexors and TFL were still noted during the Thomas test and Ober’s test,

respectively. Improved pelvic symmetry was noted upon palpation and visual inspection. The

patient reported no tenderness to palpation at the sacrum, the gluteal region, or the right TFL. No

pain was elicited with palpation of the lumbar spine or with PIVMs. The patient reported

significantly decreased fear of moving overall, but continued to experience occasional instances

of increased fear with bending forward, despite the absence of further episodes of her back

“giving out” since commencing physical therapy. The patient additionally reported a change in

her belief that physical activity had been the cause of her pain and felt that she could now

perform physical activity independently without additional visits.

Table 4. Patient outcomes across the episode of careInitial exam Visit 10 Discharge

NPRS 5/10 4/10 0/10GROC n/a +4 +6FABQ-PA 24 20 13ODI 42% 32% 16%Fingertip-to-floor 22’’ from floor 19.5’’ from floor 11’’ from floor


forward bend testLumbar flexion active ROM

20 degrees 39 degrees 71 degrees

FU = Follow up; NPRS = Numeric pain rating scale; GROC = Global rating of change; FABQ-PA= Fear-avoidance beliefs questions physical activity subscale; ODI = Oswestry disability index; ROM = Range of motion

NPRS (10-point scale)

GROC FABQ-PA ODI (%) Forward Bend Test (inches from

floor)

Lumbar flexion ROM (degrees)

0

10

20

30

40

50

60

70

80

50

24

42

22 20

4 4

20

32

19.5

39

0

6

1316

11

71Outcome Measures

Initial Visit 10 Discharge

Figure 1. Graphic representation of the patient’s progress across the episode of care

Discussion

The purpose of this case report was to describe the unique interventions utilized in the

management of a 47-year-old patient with a diagnosis of nonspecific chronic low back pain, fear-

avoidance tendencies, and extremely limited sagittal plane motion. It was hypothesized that the

patient’s limited ROM was largely due to her fear-avoidance beliefs, causing her limited ROM

and fear of forward bending to remain largely unaltered at the re-evaluation performed during the

10th treatment session. The limited change persisted despite the use of interventions consistent


with clinic practice guidelines for low back pain and good patient HEP adherence.15 Following a

change in treatment strategy to focus on frontal plane exercises for the remaining 10 treatment

sessions, the patient demonstrated a clinically important change in the results of her ODI and

FABQ-PA.8,24,25 In addition, the patient’s lumbar ROM measurements improved in all planes of

motion, with the most significant improvement being noted in lumbar flexion. The patient’s

lumbar flexion goniometric measurement progressed from 20 degrees to 71 degrees, an

improvement well above the necessary 5-15 degrees improvement needed to determine that a

true change occurred.28 This improvement significantly enhanced the patient’s ability to

participate in normal everyday activities that require nearly full lumbar ROM, such as putting on

her own socks and bending to unload the dishwasher.29

Because there is limited information regarding what precise interventions should be

utilized with patients diagnosed with nonspecific low back pain and fear-avoidance, the

interventions used in the treatment of this patient were rationalized from the therapists’ clinical

expertise and knowledge of human anatomy, along with direct consideration for the preferences

of the patient. The problem-solving strategy for this intervention utilized basic principles of

lumbar kinematics, specifically the concept of upgliding or downgliding of spinal segments with

specific motions. During lumbar flexion, the superior spinal segment glides anteriorly on the

inferior segment, producing a bilateral upglide and opening of the facet joints.27 During lumbar

side bending, there is an ipsilateral downglide of the superior spinal segment on the inferior

segment and a simultaneous upglide of the contralateral superior spinal segment on the inferior

segment.27 It was felt that instructing the patient in side bending exercises would allow for

improved unilateral upglide of the spinal segments, and would subsequently enhance the

patient’s ability to upglide the facet joints bilaterally when bending forward. This strategy


allowed the patient to participate in physical activity in a pain-free manner, decreasing her

overall aversion to physical activity, and thus addressed her fear-avoidance beliefs in a

therapeutic manner.

Research has previously shown that decreasing fear-avoidance beliefs has a significant

impact on a patient’s recovery from chronic low back pain.9,10,30 While previous research has

supported the use of fear desensitizing as a way of reducing fear-avoidance, little information is

available regarding specific exercises to accomplish this task.11 Because of this, the mechanisms

of the treatment interventions utilized in this case are largely hypothetical.

While causality can certainly not be inferred from the improvement of one patient, the

intervention strategy utilized in this case may be useful in the treatment of other patients who

present similarly with nonspecific chronic low back pain and significant fear-avoidance beliefs

where conventional treatment strategies were unsuccessful. Further research is needed to

determine the presence of a cause and effect relationship between lumbar frontal plane exercises

and improvement of sagittal plane mobility. In addition, further research would certainly be

needed to link the use of these interventions to the reduction of fear-avoidance beliefs.


References

1. Ali S, Sajjad A, Keramat K, Darian H. Effects of lumbar stabilization exercises on pain, range of motion, and functional disability in the management of chronic low back pain. Professional Medical Journal [serial online]. April 2017; 24(4):526-533. Available from: Academic Search Complete, Ipswich, MA. Accessed May 26, 2017.

2. Low back pain fact sheet. National Institute of Neurological Disorders and Stroke Web site.https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Published December 2014. Accessed May 20, 2017.

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http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1200




APPENDICES

Appendix I – Home exercise program (HEP)




Appendix II – Site permission form



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andrajmindlingdpt.files.wordpress.com€¦ · Web viewManuscript word count = 3500. Introduction. Low back pain is one of the most common patient complaints treated by healthcare