This case report described the use of a classification system in the evaluation of a patient with chronic low back pain (LBP) and illustrated how this system was used to develop a management program in which the patient was instructed in symptom‐reducing strategies for positioning and functional movement. The patient was a 55‐year‐old woman with a medical diagnosis of lumbar degenerative disk and degenerative joint disease from L2 to S1. Rotation with extension of the lumbar spine was found to be consistently associated with an increase in symptoms during the examination. Instruction was provided to restrict lumbar rotation and extension during performance of daily activities. The patient completed 8 physical therapy sessions over a 3‐month period. Pretreatment, posttreatment, and 3‐month follow‐up modified Oswestry Disability Questionnaire scores were 43%, 16%, and 12%, respectively. Daily repetition of similar movements and postures may result in preferential movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of LBP. Research is needed to determine whether patients with LBP would benefit from training in activity modifications that are specific to the symptom‐provoking movements and postures of each individual as identified through examination. These investigators propose a model for managing nonspecific low back pain (NSLBP) based on the identification of lumbar spinal dysfunction (symptom‐producing motions and alignments) during functional activities. The basis of the management model is the modification of the spinal movements and alignments that are pain producing through clinical education and a home program. The authors sited an example of using this model with a 55‐year‐old female who presented with a 10‐week history of central LBP that worsened with walking and other daily functional activities. The LBP was accompanied by parasthesias and intermittent sharp pain in the (L) lower extremity that was exacerbated by trunk rotation. After concluding that the patient was suffering from a dysfunction in lumbar extension and rotation, she was treated with movement and posture modification, forward flexion in standing and exercises aimed lengthening the hip flexors and improving gluteus maximus function. The patient demonstrated reduced symptoms, improved scoring on the Oswestry Disability Questionnaire, and improvements in pain‐free function. The investigators suggested that the patient's improvements were attributed to the modification techniques incorporated in the patient's home program and that these techniques may prove to be superior to exercise prescription and generic postural instruction. Comment by Phillip S. Sizer Jr., MEd, P.T. This management model may contribute to a patient's recovery and these patient‐specific measures may serve as a symptom‐alleviating concomitant to a multidisciplinary approach to the management of NSLBP. However, readers should approach the conclusions of these investigators with caution. The investigators did not sufficiently address the long‐term conservative management of segmental hypermobility 1 and adjacent segmental hypomobility that so frequently afflicts patients in this age group who suffer from NSLBP. The investigators also reported that extension and rotation increased the patient's symptoms, while forward flexion did not. Although their recommendation to avoid extension and rotation may have served the patient by avoiding the pain‐producing motion, a conclusion to add flexion to the program may not be advised. Forward trunk flexion increases intradiscal pressure, 2 which can be associated with disc degeneration and resultant symptom generation. 3 Respecting the impact of flexion on intradiscal pressure, Snook et al observed a reduction of NSLBP with patients who avoided flexion for the first 2 h of the day. 4 Additionally, symptoms may have been reduced through the influence of the forward flexion on remodeling the adhesions that typically form between the dura mater and the posterior longitudinal ligament 5 and or inter‐transverse ligaments. 6 These benefits could be attained through more force‐friendly techniques, such as neural flossing in a supine position. Furthermore, the patient's improvements may have been fostered by reduced neural sensitization through activation or a reduction her subjective feelings of disability. 7
Relationships between low back pain (LBP) and the hip in patient cohorts have been described primarily in patients with moderate to severe hip osteoarthritis (OA). Less is known about the links of LBP with hip radiographic findings of hip deformity and minimal OA.To describe the incidence of radiographic hip deformity or hip OA; to describe and compare spine- and hip-related pain and function in the subset of patients who were found to have radiographic hip deformity or hip OA; and to compare patients with evidence of radiographic hip deformity or hip OA to patients without hip radiographic findings.Prospective cohort study with cross-sectional design.Tertiary university.A total of 63 patients (40 women, 23 men) with a mean age of 48.5 ± 14 years with LBP and a minimum of one positive provocative hip test.Hip radiographs were assessed by an independent examiner for hip OA and deformity.Comparisons of hip and lumbar spine pain and function were completed for patients with radiographic findings of hip OA or deformity.Moderate to severe hip OA was found in 12 of 60 patients (20.0%). At least one measurement of femoroacetabular impingement (FAI) was found in 14 of 60 patients (23.3%) to 33 of 45 patients (73.3%). At least one measurement of developmental hip dysplasia (DDH) was found in 7 of 60 patients (11.6%) to 11 of 63 patients (17.4%). Greater pain and reduced hip and lumbar spine function were found in the patients with moderate to severe hip OA. Patients with LBP and FAI were found to have significantly greater extremes of pain and reduced lumbar spine function.Links between the hip and the spine affecting pain and function may be found in patients with LBP and hip deformity and before the onset of radiographic hip OA, and may be associated with hip deformity. Further investigation is needed to better understand these links and their potential impact on prognosis and treatment of LBP.II.
The involvement of the primary motor cortex (M1) in chronic low back pain (LBP) is a relatively new concept. Decreased M1 excitability and an analgesic effect after M1 stimulation have been recently reported. However, the neurochemical changes underlying these functional M1 changes are unknown. The current study investigated whether neurochemicals specific to neurons and glial cells in both right and left M1 are altered. N-Acetylaspartate (NAA) and myo-inositol (mI) were measured with proton magnetic resonance spectroscopy in 19 subjects with chronic LBP and 14 healthy controls. We also examined correlations among neurochemicals within and between M1 and relationships between neurochemical concentrations and clinical features of pain. Right M1 NAA was lower in subjects with LBP compared to controls (p = 0.008). Left M1 NAA and mI were not significantly different between LBP and control groups. Correlations between neurochemical concentrations across M1s were different between groups (p = 0.008). There were no significant correlations between M1 neurochemicals and pain characteristics. These findings provide preliminary evidence of neuronal depression and altered neuronalglial interactions across M1 in chronic LBP.
