The Lumbar Spine Mechanical Diagnosis & Therapy

8/10/2019 The Lumbar Spine Mechanical Diagnosis & Therapy

1/400


2/400

T Lr Dgss & Tr

Vlume One

Ro bi cKziZ BE F (on FZ (on ip

Stph May ip c

Sp b w Z k w Z


3/400

e Lumbar Spine: Mechacal Daosis Theapy

Fs Edton s publshed i 98 by Spna Pubicaons New Zealad d

Secod Edion firs pubished in March 3 by Spa Pubcaos

New Zeaand Ld

PO Box 93 Waikaae, New Zealad

Ema [email protected]

Roin McKenzie 3

A rghts eseved. No pa of this pubicaion may be epoduced stoed

n a retrieva syste or ansmted i ay fom o y ay meas

eecroc, mechacal ncuding phoocopyg, ecodg o ohewse

wihou he prior wren pemsso o the copygh holde

ISBN 8347

Desgn by Ne Communicaions

Eded y Wes'

Phoogaphy y John Cheese

lustations by Pau Pugh

Ped ad oud y Asta Prin


4/400

dc

To dear oy whom I loe so dearly wo thogh

thc ad t, has aety alowed my osesso

to feey fow ad wo as eer oce compaed

ao he ors, days ad mohs o asece

my seach o he fal goal


5/400

vl Frwrd

Wen it frs appeared Luba Spin was a sm ediion hat

anounced a new cocept. I postuated wat migh be happening

n paients wt low back pain and it provided a system of assessmet

and treatment.

Since t s incepo, the McKeze system has grown ino a movement .

Te system captured he imaginaion of herapists ad ohes who

adoped i. Ter umbers grew o fom a neatona ogansaonha offes rainig progammes ad postgraduae degrees n several

coues around te wold Te sysem also atraced the attetion

o oppoens, critcs and nonalgned nvestigaors.

Over te years, ensions ave developed as the McKenie system has

ed to keep pace w advances n spne scence but aso as spine

sciece has ied to keep pace wt advances i McKene. I basic

scieces, ou undersadng o the sructue , uncio ad pathoogy

of e umbar itervetebral dsc as increased enormously In cinical

scieces te advent of evdecebased medcine has demanded hat

terventos have evidence o eiab ty vadty and eficacy These

developmets have challeged the McKenze system bu ave ot

hreatened Indeed, in many respects, the McKezie movemet

has ed the way n udeakng research nto its precepts ad as

impcitly caed upon oter concepts in physica therapy to catch

up o other sysem in pysica theapy as aaced as uch

eseac boh from among its poponets and from s detactos

s ew edon o Luba Spin as become a tome I sl

descbes he origina concept albe updaed and evised bu he

edon povides sudents ad ote eades wt a compedum o

all the lieratue petang o he lumba teveebra disc and te

massve eraure tat ow perains o the McKenze sysem

Readers receive a upodae review of inomaton on he structuead unction o e disc s pahoogy, ad ew data on s pao

biomecanics. Relaed etites , suc a zygapopysal on pai and

sacoiliac oint ae compehesivey evewed

As befitting a text o ts subect Luba Spn conas a

complete coecon of all sudies tat have examined he McKeze


6/400

system These sudes hae sought he edence for ts reablty

ady and effcac

Is reaby s ow beyod doubt Whereas reseach has show

ha ohe ethods ofassessmen lack relabty McKene assessmet

has moed ro sregh to stregh Its relablty howeer s

cotget up o tranng Whe anyoe can assess accodng to he

system cao be asteed by hearsay or assupto

Some seps hae bee taken owards esabshng adt The early

studes hae been encouagngly poste bu perhaps seffullng

The crtca sudes hae ye to be peroed ad deped on

establshng the ecacy o the treate

The ub Spine prodes a exhauste bu hoest ad esponsble

apprasa of sudes o the effcacy of McKenze eaen Much o

the wold fds the edece nsucety compelg but the

treatent has o been efued Proponets retan he prospect o

stl ndcang the treatent f ad once putaely confoundng

actors can be eaed or cotroled

To soe obserers McKee therapy ay seem to be a gorfed

system of speca manoeures ad exercses bu such a ew sakes

ad udersaes ts rtues Throughout ts hstory McKeze

teae has ephassed educatng paes and empowerg them

to ake chage of ther ow management Not only dd ths approach

preept cotemporary conceps of best practce t has bee

ndcaed by the edece. Empowerg he pae s semnal othe success of y prograe o anageet

Athough a not a McKeze dscpe or enhusast we hae our

ow research boowed ro he McKene system I studyg the

efcacy o eidencebased practce fo acute low back pan prm

care 1 we talked to ou pates and we addressed her ears but o

copeet tha we eeded somethng ore fo the paten ts to ake

wth he For th s purpose we dew o soe of the spler exercses

descbed The uba Spn Not ha we beeed that hese wereherapec n he own ght but hey epoweed he pat ens wh

sesble thgs tha hey could do o cope wth the pan ad a

f no poe ther oby ad ucton Ths approach a no too

dsan cous of what McKenze prootes was o oly successful

a ccal sese bu receed great approa ro he consuers


7/400

The pahoaaoic coceps ad he echaical aspecs o

McKeie herapy ay o ay o be absoluely aera. hey ay

or ay o e idcaed ie Bu wha s aleady cearly edece

based s he ceral hee o McKeie heapy: o eabe paescodely t cae o hesees

koai Bogduk MD PhD DSc

Proesso o Pai Medicie

Uiesiy o ewcasle

Roya ewcasle Hospial

ewcasle , Asalia

IMcGuik B, Kng W, GovndJ Lowry J Boguk . The safety effiay and osteffeveness of eviene-based guidelines o te managent o ate low akpan i iay ae. Spine 200; 26265-2622


8/400

Akwdgs

I wuld like t give special thanks t y cauthr and clleague

Stephen May, MA, MCS Dip MDT, MSc, wh has prvded the

necessary epertse t ake hs secnd editn an evidenceased

et f iptance al heath pressinals nvlved n nn

peratve care the lwer ack.

I am als greatly ndeted t the any facuty f the McKenie

Insitue Inteanal wh have either diecty r ndrectly inluencedthe efineents tha ave een ade he descrptins the

prcedures f assessment and eainatin Te value f these

cnriutns is ieasurae

I wuld als ke t epress my gatitude t Kathy Hy a funder

te Instue in the United States, and Helen Clare f Austraa, the

Inst tutes Directr f Educatin, wh gave s uch f their tie t

read the manuscrpts and pvide invaluae centary andcitics

T ert Mney, wh pened s any drs Rn Dnelsn fr

his cninued suppt the syse and the I nsitue, and t thse

mebes the Inernatinal Scety f he Sudy f he ua

Spne wh have encuaged and supprted y wk, I give y

hanks

Fnaly, t Jan, my daughter, wh reganised e and cdinatedthe varius specaliss required t successfully cpee ths a

task, I gve my heatfelt lve and thanks

Robin McKnzi

M 200

V


9/400

A Ars

Rob McKezie was bor Ackad New Zealad, i 93 ad

gadaed fom he New ealad Scool o Physioteay 952

He commeced ae ractce i Welgto, N ew Zeaad 1953,

seciasg te diagosis ad teame of sa dsordes

Dig e 960s , Rob McKeze deeoed ew coces o

dagoss ad reatmet dered rom a systematic aaYis o aiets

w boh acte ad croc back obems This system is ow

actised gobaly by seaiss Yoteay, medice ad

cioracic

The sccess of he McKeze cocets of dagosis ad teatmet

o sia robems as ataced teest fom esearches wodwide

e imoace o he diagosic system is ow recogsed ad the

extet o te teaec e fcacy of he McKezie Mehod is sbec

to ogoig esigao

Rob McKezie is a Hooary ie Membe o te Amerca Physical

Theray Associato "i recogito o dstgshed ad metoios

sece o he a ad scece of hyscal teay ad to e weare

o makd He s a membe o he Iteratoa Siey for the

Sdy o e mba Sie , a Feow o f he America ack Society

a Hooay Fellow o te New Zealad Socety of Pysiotheasts

a Hooray fe Member of he New Zeaad Malatie Theaiss

Associaio ad a Hooary Fellow o he Cartered Socety ofPysoheass i he ied Kigdom I e 990 Qees

hday Hoos, he was made a Ocer of e Most Ecele

Order o e ish mre 1993, e receed a Hooary

Docoae from te Rssa Academy o Medical Sceces I the

2000 New eas Hoos ist, Her Maesty he Qee aied

Robi McKeze as a Comao o te New Zeaad Ode oMert

I 2003, e iesty o Otago, i a o ere wi e McKezie

Istte Iteaioa, stted a Pos Gradate Dloma Mastes

ogramme edosed i Mecacal iagosis ad Thea Rob

McKeze has bee made a Feow Physioheay at Oago ad

w be lecrig dg he ogamme


10/400

Robin McKene as atored or books Trat Your Own Bac;

rat Your Own Nc Th Lumbar Spin: Mchanical Diagnosis and

hrapy and Th Crvical and Thoracic Spin Mchanical Diagnosisand Thrapy. With the blcation o Mcanical Diagnosis

Thrapy of th Human Extrmitis, Robin McKene n collaboraion

wih Stehen ay describes te acaon of s mehods o he

management o mscloskelea dsoders in geneal As wit his

blications dealing wh sinereated roblems te emhass n

ths tex is direced at ovding seeatmen straegies for an

and dsabiliy among te general olaion

Seen May was born n Ken England n 958 His irst degreewas in Engish iterare rom Oxod Universit He ained to be a

hysoherais a eeds and gradaed in 990. Snce qafying

e as woked o the aiona Heah Sevce n Engand rncay

in imay Care In 00 he became a Senior ecrer at Shefed

Haam Univesity

He deveoed a seial inerest n mscloskelet a medcine eary in

his caeer and as aways maintaned a dlgent inees n teierae One of he esls o tis was a ega sy of aices

and reviews o he McKenie newsletter (UK n 995 Stehe n

comleed e McKenzie diloma rogamme n 998 e comleed

an Sc n Heath Servces Research and Technoogy Assessment at

Shefied Uni versi ty

Steen s ato o coahor of several aricles blished n

inernatonal jonals He has reviosly collaborated wit Robin

Mc Kene on h Human Extrmitis Mchanical DiagnosisThrapy


11/400


12/400

Cs

CHAPTER ONE

CHAPTER TWO

CHAPTER THREE

VOLUME ONE

Introduction .. . . . . . . . . . . . . 1

The Problem of Back Pain .

Inroducion

Prevalence

Natua hisoryDisabty

7

7

8

. 9 13

Cost 6

Heath care 18

Teaten . . . 2

fectveness 23

Concusions 28

Risk and Prognostic Factors in Low Back Pain 31

Inroducion . 31Risk facors . . 31

Individual risk facors

oechanical risk factos

Psychosocia isk actos

A risk facors

. 3

33

35

36

Onset .. ... ..........3 7

Individual and c nica prognostic facors 39

oechancal pognosic actos

39Psychosocia pognostc actors . . 41

A pognosic actos .... . .. .. 42

Conclusions .. . 44

Pan and Connective Tissue Properties ... 45

. 45

. .46

Intoducion

ocicepton and pain

Souces o f back pain and sciaica . . 47

Types of pain ... 49Acivaton o nocceptos . .. 52

Mechanical nocicepion 52

Cheica nocicepton 54

Traua as a cause of pa n . . 54

x


13/400

CHAPTER FOUR

CHAPTER FIVE

CHAPTER SIX

Disgsig ceical ad ecaica ai . 5

sse eai pocess 56

aie o emode eai sse ..... 6

Croc pa saes ... 62Coclsos 65

The ntervertebral Disc . . 67

Irodcio . . . . . . .. .. 67

Srcal cages . .. .. .. . . . 67

evaio . . . 69

Mecaical o cecal pa . . . 69

Dagosg a a fl disc . . 71

e mole disc 7

Discogenc pai . ...

Rada sses .

7

75

Disc eao

Sess roomery

. . . . . . . .. ... .. .. .. .. 77

. . . ...... 83

Cocsos . ................. . .... .. .. 84

Disc Pathology - Clinical Features . . 87

Iodco .

. . 8 7Dscogeic a - revaece

Dscogeic a clica eaes

Scaca - prevaece

Scaca - cica eaes

Sae of e ala wal . .. ..

Nara sory of disc eaio ..

Cocsios

.87

88

90

91

95

97

0

Biomechanics . . 03Iodco . . . 03

Movees a e ar sie 0

Rage o ovee .. . . 0

ar odoss 105

oadig saegies ad sypos 106

Efec o osres o lmar crve 108

Bioecacs of e lar sie 10

ie faco ad cree loadg Cree i e ar sie 3

Opial sg osre . . . 15

Eec o e of day o ovemes ad ioecas 17


14/400


15/400

xvlCHATER

ELEVEN

CHATER

TWELVE

CHATER

THRTEEN

Literature Review .. . 18

Introducion . 18

Sysemaic eiews and gdelines . . . . . . ... 181

Conrolled as and randoised controlled rias . 85Oter eicacy trials . ...... . 193

Sudies n to directiona preerence . . . . 198

Reliability sudies . .... .......... 201

Reliability o palpation sudies . . . . . . . 207

Studies nto e prognostc and diagnostic utity of centraisaton 20

Concusons . ..... .. .. ... . . . .. 25

Serious Spinal athology 27

Int roducion . . . . . .. . . . .. .. . 217

Cancer 28

nectons . 220

Fractures . 222

Osteopoross . 223

Cauda equina syndrome . . . . . . . .. .. . . . . . . . . 22

Cord sgns ... . . . . . . .. . .. . . .. .. . .. . .. . . . .. .. 226

Anylosing spondyliis

Conclusons

. .. . . . . . . 227

. .... 232

Other Diagnostic and Management Consideratons 233

I ntoduction .. . . . . . . .. 233

Spna stenoss 23

r

. . . . .:!Zygapopysea oin poblems ... 254

SpondylolYi and sponyolisesis . . 257

Instabili ty .. . ... . . . 267

Mecancay nconcluse Surgery

ostsurgica status . . . . . . . . .

... . 2 70

.. 2 7

. .. . 275

Cronic pain . .. ... . . . .. .. . . 276

adels nonoganc signs an symptoms .279

Teating cronic bacs - te McKenzie Instute Internatona

Reabaion rogramme 283Concusions

Appendix

Reerences

.. . . . . . . . 288

.... 289

. . . . 297


16/400

CHAPTER

FOURTEEN

CHAPTER

FIFTEEN

CHAPTER

SXTEEN

xvGlossary of Terms . 55

Index .. .. .. . .. 6 7

VOLUM TWO

The Hstory . . . . . .. . . . . 75

trocto . . . .. . .... . . ... . . .. . 75

Aims of historytag . . .. 76

tere . . 76

Paie . . . . . . . . .. . . . 77

Symptoms 79Peios hstory 89

Speciic questos 90

Coclusios 9

Physical Examination 95

troctio ........ .......... 95

Ams of physica eamatio . 96

Sitg posture a its effect o pai 97

Staig postre .... . . .. 99

eurologica tests . . 401

Moemet loss . .. ... . ... 404

Repeate moemes 408

Eamiato of repeae moemets .. ... 41

Eamato of ssaie postures . 48

estig coclsie 4

Other eamatio proceres . . 421

Cocusios .. . ..... 422

Evaluation of Clinical Presentations 427

Irouctio . . . ... . . . . . . . . . 4 27

Sympomaic preseaio . . .. ... . . 428

Assessmet of sympomatic respose . 43

Use of sympom respose to guie loag strategy

Mechaical pesetato . . . . 45

Assessmet of mechacal presetatio 46

Use of mechacal respose to gie oag strategy 440

Symptomatc a mechaica preseatios o ietify mechaical

syromes 441

Chroc pa erpreaio of sympomatc resposes 442

Cocusos .... 444


17/400

CHAPTER

SEVENTEEN

CHAPTER

EGHTEEN

CHAPTER

NINETEEN

CHAPTER

TWENTY

Procedures of Mechanical Therapy for the

Lumbar Spine .5

Itodcto 5

Foce progressio . . . ... . . .. .Force ateatves .. .. . . . . . . . 8

Repeated movemets or sstaied postres 8

Pocedres

Eteso pcipe - static

tesio prcpe - dyamc

. .9

... 5

... 58

Eteso pcipe wih atera compoet - dyami 71

atera pricipe descptio of atera procedes 77

Feo pcpe

. 87Feo picipe wih atera compoet . . 91

Patient Management ..........

Iodcto

dcatio compoet of maagemet

dcaioa terveios fo bac pai

.. . .. . . . . . 99

99

. .. . . . . . .. . . . . . 500

. .. . . .. .. 501

Edcatig paies . .. . .. . .. . .. . . . . .503

Active mechaica theapy compoe . 50

Compiace or heapeic aiace? . .. .......... 507To trea or ot o tea? 508

Commcatio . . . .... . . .... . 509

Pate saisfacio . . .. . . 51

Cocsos

ollowup Evaluations

Itodcto

Reacg a cocsio

52

513

513

.513

Review process . 5

Impicatos 57

Cocsios . . . . . .. . . .. .. . . . . . . ... ... .. .. . . . . . . 518

Clinical Reasoning . .. ... . . . . . . . . . .. . .. . . . . . . . . . . . 521

Irodcio . 521

Cica reasog . . 522

Eemes th at form the cica easog pocess . 523

ata gatheg

. . . . ... . . ... . . . . .. .. . . 523Kowedge base . . . . . ..... .... 52

Ciica epeiece . 52 7

Errors i cica easoig . . .. . . 528


18/400

CHAPTER

TWENTYONE

CHAPTER

TWENTYTWO

CHAPTER

TWENTYTHREE

CHAPTER

TWENTYFOUR

CHAPTER

TWENTYFVE

Eample of clical easoig pocess .. 59

536Coclsios

Recurrences and Prophylaxs .. 537

Itocio

Preeaie stategies

. .. .. .. . ... .. . ... . 537

Pates perspecie

. . . . . . . . . . . . . .538

. . . . . . . .51

Coclsos . .. .. . .. . . .. .. 53

Derangement Syndrome - Characterstcs 55

toctio .. .. 55

Caracestcs o erageme syrome ....... 56Cocsos . . . . .. . 552

Derangement Syndrome Presentaton and

Classication . .. . .. .... 553

tocto

Cca preseao

Treamet pricples

Cocsos

. ... . .. . ... 553

.. . .... .... . . 55

. 560

562

Derangement Syndrome - Management Principles 565

Itrocto .. . . . . .... 565

Stages of maagemet 565

reamet pricples

Irrecie eragemes

Cocsos

... . . .. . . . . . .. .. .. . . .. . . . 57

.. .. . ... ... 58

58

Management o Derangements Central Symmetrical

(Previously Deangements 1,2 7) 587Irocto . ... ...... . ... 587

Treame paways i eageme 587

Maageme of eagemes - cetasymmetrica pa 589

tesio pcpe hisory a physical eamiato 589

tesio prcpe - maageme gees . 592

tesio pcpe eew .59

Fleio prcple - hisoy a physical eamiato 596

Fleo prcple - maageme gees 597Feio prcpe - eew . 598

xv


19/400

xv CHAPTR

TWNTYSIX

CHAPTER

TWENTY SVN

CHAPTER

TWNTYIGHT

CHAPTR

TWENTYNIN

Management of Derangements - Uniateral

Asymmetrical Symptoms to Knee

(Peviouy Deanement 4, 7) . . 601

Assessment - determinng he appopae sraeg 602Identicaton o laeal componen . .. .. . . . . .609

anagement laeral component, no latera shift 610

anagement laeral pinciple so ft o hard latea shif 615

Fexion princple 620

Management of Derangements Unilateral

Asymmetrical to Below Knee

(Peviouy Deanement 5 6) 623ntroducion . . . 623

Dffeeal diagnosis .. .. . 624

anagement o derangeme - nla tera asmmerca

elow knee . ....... .. .. . . . .626

anagement - rst twee weeks or three months 627

Differenta dagnoss between reducile deangeme nee ro

enrapmen and adherent nee oot 642

Repeaed moemens . 642

Dysfunction Syndrome

Introducion

Categores of dsfuncton .

. . . .. . . . . . . . 647

. 647

. 648

Pain mechanism ... 649

Clinical picure ........ .... 652

Phsica examinato 654

Managemen of dsfunction sndrome 655

Instrctons a patens wh dsfunction sndome 657

iteraure on stecig 658

Managemen of exension dsfunLon 660

Management of flexion dsfuncton ..... .662

Conclusions ..... ... 667

Dysfunction of Adherent Nerve Root (ANR) 669

I nroduction . ..... 669

Deelopment of adherent nere r 669

Clnical presenaionstor ...... . .

Phsica examinaton

anagemen

.. . 67..673

.. 674

. . 675


20/400

CHAPTER

THRTY

Postural Syndrome . ...... ... 681

ntodcton . .... ... . . . ....... . .. 681

Pan mchanism

.. . .. .. .. .. . 68Ec o f posr on sympoms in normal popaon 683

Cnca pcur .. ....... .. . ... .685

Pyscal xaminaion .... ... . .. . 686

Poss invovd ..

Managmn o posal sydrom

Pos syndom - aggavaing actor st ng

..688

. . 688

689

... 695Pos syndom - aggavaing acor sanding

Pos sydom - aggavaing actor yng ........... ...... 696

Concsons

Appendx

Gossary of Terms

ndex

. . . . . . .. . .. ... . . . .. .. . . . .. . 697

701

. .. ... . ... . . .. 709

......... .. . ...... 71

xx


21/400

xxi Ls f Fgrs

1.1 The assumed ad rea atua hstor of bac a 13

1 Th e dect ad drect costs of bac a . 17

3 Ratos of bac sugey ates to bac suge rae e U

(1988 - 989

31 Matc g th e stage of th e codo to maagemet 61

4 Commoly foud fssures of the auu s brosus 68

4 Grades of radal ssues accordg o dscogra . 76

4 3 Four stages of dsc eatos - eat ee w bemay substages . . . . . . . . 78

4 4 Routes ad extruso pots o f heraos 80

45 At 4 5 a atera dsc herao (e ft) a fects te ex g

eve roo ( 4) a oseroatea dsc eato g)

aec s e descedg eve oo (5) . . . 81

5 1 Recovery om severe scatca

5 Recover from scaca frst hree oths

98

. 99

6 1 T e eec o f dere ostues o t e lumbar cuve . 108

8 Mechacal ad omecacal dagoss relatve roles 46

8 Classcao agorthm 47

9 Cetalsa to o a - t e ogressve abol o o da

pa . . . . . . . . . 56

9 Cocetua mode ad rocedues; eatg rocedures o

drecto of deagemet . . . . 64

10.1 Cetrasao of a the rogressve reduco dabo o of dsta a . . 168

3 Bac a durg regacy ... . 50

15.1 Tyca l aeas o a ad sesoy loss 4 , 5, 1 403

15 Prces of maageme meca ca thea 43

15.3 Casscao agorthm .. . .... 46

51 eageme - maagemet cosderaos (elevat

chaper) . . . . . . ... . . 5885. erageme treamet cpes ad smtos 589

7.1 Casscao pathway fo scatca 67


22/400

Ls f Ts

. Prevece of bck pn n seece ge popuon

1.2

13

1

15

6

2.

22

23

3

3 2

33

3

2

3

5 1

5 2

bsed sudes .. 9

Repse e nd pessen symptoms n seece sues 11

Dsbty n wok oss due o bck pn n gene

popuon . . . .. .. . . . .. . . . . . . .... . 1

rng o conc bck pn .. . . 15

The ynmc se o chronc bck pn 6

Poporon o bck p populton who seek e cre 9

Three mjo clsses o sk fctors for bck pn 32

ggrvng n eevng mechnc cos n Lose

wh bck pn .... .. . .. .... 0

cors ssocted wth coc bck pn n sby 3

Pn poucon on ssue smulon n 93 ptents n

orer o f sgnfcnce 8

Bsc pn types .. .. . . .. 9

Te segmen nnervon of he owe lmb muscuure 50

Pngenerng mechnsms . .. . .. . 66

rdng of rl fssues n nnulus brosus 75

sc erntons: ers nd phoogy used n hs tex 79

Herno roues/fssues n ses o n ernon 79

Deconl eento o sc exrusons on MRI 81

Crer for denyng sympomtc sc hernon wt

neve oot nvovement

. 9Dsrbuo of nge nerve oo nvolveme n sc

hernons . . ... 92

53 Typc sgns n symptoms ssoce w t 4

nerve oos 92

5 Dffereces beween scc ue o prouson o n

exrusosequestron .......

55 Recovery om neuologcl efc

.. .. 96

. 100

61 Efect o ffeen posues on the spn curve

086.2 Fcors th ffec e spn cuve n st ng 09

63 Proposed vnges n sdvges o kyphot nd

7

oroc stng posures 116

QT csscon of bck pn 126

xx


23/400

xxi7 2

91

92

9 . 3

101

102

10

10

11

112

n ial anageen paway key caegories esiae

prevalence in back pain poplaion 18

Peoperaive pa in isrbon an operaive fngs 155

Pevalence of laeral sh 160

Sieness of laera sifs 161

Prognostic sgnicance o [ centralisaon 175

Occrence o cenrasaon n ace sbace a

conic back pain 175

Occrence of centrasaon accoring o se o[ reerre

pan 177

Characesics o f cenralsatio 178

Coparson of etho scoes o e sae trals 182

Man otcoes ro pblishe ranoise corole

trials sing etension eercises or prporing to se

Mcenie egie 190

1 Oher lite atre - absracts nconroe rias ec 97

114 Sties ino ireciona preerence 200

115 Sties evaang he reliaby of feret aspects of

te Mcenie syste 206

16 Reability o f palpaton eainaton proceres n e

lbar spine copare o rel ab ty o[ pa behaors 208

17 Stes invesgaing cenralisaon 214

12 Sgnfcan history n ieniicatio o cance 220

122 Sgnifca hisory n iencaion o spna infeco 222

12 Sgnifcan history n ienicaion o copesson

fractre 222

12 4 Signcant sory an eainaion inngs i

ient ifcaton of caa eqina synroe 225

125 Signfican sory an eainaion in ings i

ientificaon o f pper oor nerone lesions 22 7

126 Mofie New ork criteria [or iagnoss o[ ankyosg

sponyli 20

27 Te clnica istory as a sceening est o ankylosng

sponylii 21

11 eares o[ history an eainaion n spnal seos s 26

12 Distingsng spina steosis fro eangeen wh

eg pain 27

1 Significan history an eainaion finngs i

ient ifcaon o[ spinal senos s . . 29


24/400

1. an stes in hi p stearthrtis 240

1 Signica hstry ad examan fidigs in hp jin t

prems . . . . .. 241

1 6 Reli y f examian prcedes he saciliac

jin (S . . .. ... . . 244

7 The staged deretia l diagsis fr S prlems 247

.8 Sgn fican examinati dings in ideni fcatin

J prlems . . .... ... . 247

.9 Distngshig eates f lw ac pain and pserir

pelvic pai . 2

0 Geeral gdenes maageme f wmen with ac

ai rig egnacy 24 ssle chaacerisics f paies w h chrc

nactae pai 277

. 2 ey factrs i ident icati chrnic pain pa tens 279

Inapprprate signs 279

1 4 Inapprpate symptms ....... .. . ..... 280

4 Sym p m patterns reevan t managemet decsns 79

142 Deintns ac e , sacte an d chrc .. . . 8

4 Ctea r dening sas f cndin 8244 Feates f hisy (red lags that may idicae ses

spinal pahgy . . . . 9

1 Cteia r a elevat atea l sh f 400

2 Criteria fr cndcting a nerlgical examinain 402

. Typcal sigs ad symptms assciaed with 4 - l

eve ts . . . . . .. . .. .. . .. . .. 40

4 Citera fr a elevant atera cpnet 418

6 Dimensns syptmac presentai mitr

pogess 428

6 2 Ceia y whch paraesthesia ay e ip vng .. . 40

6 Traffc igh Gide symp respse efe drng

and after repeaed mvement testing . .. .. . 4

6 4 Diensns mechanical presentatin y whch t

assess change . . . .... 46

6. Se cmmny sed ac dsailty qestnnaes 440

66 eanc a esses lading straegy .. . .. . . 44 6 7 Characeisic sympmaic and mechancal presenatns

the mechanica sydrmes 44

7 Fre prgessin 448

xx


25/400

xxvl72

173

7 4

81

19 1

192

211

22 1

231

232

233

241

242

243

24 4

24

246

247

24 8

249

Force aerates 448

Treatmet pcples 40

Procedures 4 0

Dimesos tha paets coside importa i a epsoeof physoheapy 11

D ere ehods o carifyg sypo respose 14

Mai elees of reiew pocess 7

Key pots to patets i popyais 41

Caraceristcs of deagemet sydroe 4

Deagemet sydroe - ceria 60

Dmesios i aayss o deragemes 61

Mai eae prciples or deragee sydroe by

rec ioa pefeece 62

Stages of maagemet of deragemet 66

Recoery of fucio - esuig stability of derageet 72

Treate of eragemet sydome by diectona

pefeece 7

Cles as o the eed fo etesio prciple - o al wil

be prese 76

Foce progessos ad fore aeraies etesio

priciple 78

Idcators for cosieato o laera copoe 79

ateral shift deitos 80

Cu es as o te eed fo ateal prciple ot a wi bepeset a oce 80

Procedres se d whe a releat atera copoet is

pese

240 Cues as to te eed o eio pricipe81

83

241 Foce progessos ad force alterates i leio

pcipe 83

242 Clues o ieducibe deageets ot all eed be

peset .

26 Respose o etesio oces i uatera asymetrcal

84

ad m pcatos 603

26 2 Ceria for a eea latea sht 61

2 71 Maagee of sciaica 626

272 Distigsig bewee sciaica de o a potrsio or a

extrsioseesrato - feates are ariabe 633


26/400

273 Dfrntiaing twn a rducil drangmnt an

irrduci drangmnt/nrv rt ntrapmnt (NRE)

and adhrnt nrv rt ANR) n patns wth psstn

g pai . . .. ........... .. .... 6

28.1 Aticular dysunctn syndrm - cra (all will apply . 65

282 Instucins t pat n ts wth dysunct in sdrm . . . 657

2.1 Adhn nrv clincal prsnatin (all w apply) 673

2.2 Criria dnitn fr adhrn nr t (all w apply .675

23 Prcdurs fr traing adhrnt nrv r .. . 67 7

301 Pstural syndrm crita (a wil appy ..

30.2 Managmn pstur sydrm

.. 687

. . . 68

xxv


27/400

XXV I


28/400

Ird

Many yeas ae passed since te plcation of he is edition of

y onogap The uba Spne Mechanca Dagnss and

heap nce 98 , wen te oo was fis released te concepa

odes fo e idenifcaion o sgrops in he nonspecific

specL of ac pan and the meLhods o eatment recoended

ae ernaonally eceied wide accepance

The eXen o e accepLance for wha 1 cose o ca Mecancalagnosis and Terapy (MT) was nee ant icpated did nL as a

es of dissaisfacon w exist ing ehods delierately consct

a new syse o diagnoss and eaen o anage comon

ecanica ac proles. Rather fom eeyday oseration and

coac wit age nmes of paients 1 eaned fo em

nconsciosy a fs sspect a dfeen patiens wit h appaenly

siia symptos eacLed qite difeeny when sjected to te

same ecanical oadings On gopng togete a hose wose

sypoatc and echanical esponses o oadng wee idenical

tee consienL pae ns emerged and ecame n n e syndomes

wose idenifcaLon and manageen are desed wihin tese pages

Becase o e sale polaion in te ciy o Welington in ew

ealand many paents wiL ecren and chronic prolems rened

or ep oe Lie Ts I had te oppotnity o osere in many

indidals e passing specr of mecanical and sypomaic

canges ta pogressed ding two o een thee decades of lifeFro Lis expeience leaned ow to make te changes n

anagemenL Lha were dictated y the gradal scral canges

esng ro e naal ageing pocess Te eental refineent

of y oseraions and echniqes of oading wee hs eely a

ncton of eotion

ae econted e sLory of M Smi descied ate n ts

olme on many coses and a any conferences arond e world.

do so ecase descies an acal een tat has ad an enomosipacL on my e and as and conines o ae , an impac on the

way eat poeionals wodwide in ao and manage te spine

and scloseeal polems n genea


29/400

2 NTRODUCTIO H E L U M B A R S P N : E C A N C A A G O & A 'YOccasionally am asked "Was there reay a Mr Sth or you

inven hi to pove an amusng story o go wh he efecs of

extension? I can onl y rep y tha t yes t is a true stoy an d no 1 did

not make it up, bu his rea nae is long fogoten

Po to he encounte wih M Smh , aong wt a few oher

physotherapsts at that time was exporng and maserng the

mutitude o manipulatve techniues and t he phosophes ha ay

behi n hem Cyiax, Men nel l Sodard an the ch opracors were

the avour of that perod. Mai an and Katenbon were ye L appear

In y min the only ationa expanaion o accoun or the

centrasation of M Smiths syptoms was to be found in the frs

volume (95) wren by one ames Cyriax MD.

Cyrax abute suden and sow onseL back pain especvely to

earng of the annulus and bulg ng or dsplacement of he nucleus. If

he buge was a ge enoug , copresson o f e root wou follow

Thus it suggested to me that Mr Smith centralisaton occurre because

he pressure on hs scatc neve was reove Extenson toughL

was herefore a good thing to apply n these cases L ight even be

moe e ffective han he manipulaions we practised which soet esdi - and many tmes d not produce a benefi fo the paien

Follng the encouner wit M Smith he hypotesis o explan

he vayng responses to oa ng crystallised an foe he basis of

the concepua oels upon which the reatents wee deveope

Withou the concepual model o f dsplacement and is sequelae I

doub that could have deveope he expanatons and evenualy

provided he solutions for many of the echancal disorders

presenng n ay pacce

Beef in he concepua model povded an explanation and bete

understanng of cenalisaion and perpheraisaion I expaine

the changes in pan locaton and ntensy that foow prolonge o

repeiive saga oa ng and led to he scovery haL o fset oang

hps off centre) was required when sympos wee unaea or

asymetrica. The moe suggested that coul be posse by

applying latea forces, o enice ow back and cevical pains L changeses. That phenomenon is now cnicay epeaable n ceran

seected patents


30/400

INTRODUCO

en caon o h e mos eecte recon o appyg herapeu c

exercse he use o pologe postog a repeat e raher han

ge moeens n assessme; the progressos o orce ereaonbeween he pan o spaceme, rom he p a o coracure, a

pan arsng rom orma tssue the thee syromes erentato

o l pan cause y oo aherence, entapmet o sc pouso

all arose ecly or n recly rom the cocepual mo e.

The sc oe, he heoes a cca outcomes reate o

mechanca agnoss a therapy are ue estgao wolwe

The oes e as ye unproe cefcally e e so they proe a

sou ass o he maageme o ospec soers o he lowebac. uch o my tense satsaco, the expemens , he

conclusons an he esuls I ecoe hae successully een

repcae y others

To ths ay, ee he concepual moel, actg o ts suggestos

an oeyg s wags ge me he maageet o the pat et

Many hngs recy arose om he moel. Mr Smh was he

caalys. e no loger hae o manpulae all paes n orer o

eer he proceue o he ey ew requrg We o oge hae

o appy anpuaon o our pates o eteme retrospectely

t was ncate I woul eer e whout the moel a M r Smth

s nee ar ro my houghs

echancal Dagoss a herapy s ow oe o the most commoly

use eame appoaches u lse y phYoheapsts the Ute

Kngo, New eala a he Ute S tates t s a ap poach aso

se an recommee by chopacors, physcans a surgeonsThe ceasng ees s efecte n he sustatal oy o reseach

ha has een conuce no aspecs o "The cKenze Meho , as

has coe o be kow The ery naure o MDT es tsel to

easurement

Thee hae een umerous sues no cetasao, sympto

espose an reaty as we as stues to he e fcacy o MDT

ore sues ae eee , u much research aleay sogy enorses

aspecs o hs system o assessme an maagee Futhe ecet

enorseent o MDT has ee ge y s cuso aonal

back pan gue nes rom Demak a sysematc muscuoskeleal

guelnes ro he Ute Saes

O C O 1 3


31/400

4 NT U T N LM A E A N A AG NO & HE RA Cenasatio as ee sow to ae cea ogostc as we as

agostc sgcance lL s one o he ew clcal acos ha ae

een oun o hae oe ognosic caons ta sycosocal

acos. Suy ae suy as assee he oo elalty o assesseth at is ase on aaon o oseaton, we symto esose

consistent y shows goo elaility

ucaon in DT has now een stuctue o enale e oalse

eachng o clncas an oVie a ase uon wc goous

scen c iuy ay ocee. ucaona ogaes ae oe

une e ausces o te cKenzie Istitue Ineaoa a s

ac es a ae conuce a connens an aee annually

y ousans o clinicans Soe aeciatio o te exe o e

aoo o DT ca e see o the eques y e Deco o he

Chnese nsy o Hea , Deaet o Reail ato o oe

te Istutes eucatio ogae o Cnese yscans a

sugeons ole i te aageent o ac isoes ougou

he wol's os oulous couy

It is now comon nowlege a aageent o uscuoselea

oles mus ole a et unestanng, nclug a nowlegeo he ole a oee souon Paes us e acey

oe n teaen Ts was a essage st stae oe wenty

yeas ago in he s eo o s e Say sees w e

cotnue usage o uasoun a o he asse eae oal es

y clincians, ese clea eiece o ac o ecacy; ts s a

essage that ealth oessoals ae s o cealy hea. How

any anoise cotolle tals oes ae o connce c cans

aou he lack o ecacy o utasou an oe asse teaens

Nacheson 200

Te clnica uilty a woth o the syse s aese o y he

housas o suies o oe coucte y lncas on he at es

hougout he wol eey yea. lL s use a connues o e use

ecause t is eecie

Ultmatey, o we wis to make e aet ee ete ', ale e y

o o we wis to oe he aten a eas o seeae anuesanig so ha ee s a sog ossily ey wi ee

o ou seces te loge e we ceating ae

eenece on heay, o og a cance o eenece


32/400

R O U O

ough semaageme ey oe for as ms e as

eaos raer ha he aes'

Te seo eon of hs le s esee o he eae w e

nowege a hsg of exeree gae se he oo

of he rs In e fs eo o 98 , here were ew, f ay, eeees

o uoe suor o e mehos a eors I ooe Por

esos o he use of eee eage moo a s e ffes

o an oaon a esy; he eomeo o laly ue

eal sao a eea sao he rogos ale o

ea saon a oera sao e heorea moels

e ao o sugou syomes e ogressos o eaeu foes a os morany seleame a manageme

sraeges o exs he eaue of e ay oraey ha s

o e ase oa

eee ha w he oeme o Sehe a e w g of

hs eo he meeos a ao my frs exrso o

he erary wo ae ee emae. See's ersag o

Keze omne wh s eay aes a goal famlary

wh he se leraure, hae ough o s eo a qualy

ha far exees my ow aaes s eome aare o

he eae o aag hrough e haers w

e hae oVe for you hs seo e o a moogah ha

eses ex ea wha e Keze eho s, how o

ay a he eee a ssaaes a j sfes s use for

e maageme of ose ow a a

I eee ese aes wll allow eer uesag a more

aroae esgao of D oe all I us ll see s

rme urose eg ou aes

R obin McKenzie

Ru Beh

New Ze nd

NTROUTON s


33/400

6 1 INTRODUCTON HE LUMBAR S PN E: ECHANCA AGNO & HERAPY


34/400

1 The Problem of Back Pain

Introduction

It is imptt undestnd te eXen wic ny elt bem

imcts upn te ppultin Ths pvides n undestding f

t t bem s well s suggesis s t w i t suld be ddessed by

heh ce vides Cey i s inpppite helt pfessis

t del wih beign se lfim ig d endem c blem suc s e

cm cld n e sme wy t hey ddess ssiby le

theteg dsdes suc s e tcs he s udy nd desc i

the sed disese in pulin is nwn s pidmioo

de cnicl epidemlgy s cncened w te dstbuin

tu hsy d clnic cuse f disese s fcts sscted

wit i he helth eeds i pduces d te deemini f e

mst efecive meds f etmen nd mngement (S ene d

996) Eidelgy hus ffes vus nsg s h e

cc udstndig ny he le ndess 99 ces 2000 I vides infmt bu e exte f

pbem nd e esul demd n sevices n undestndng

e ntu isy inms pen cunselling but pgnsis

d helps detemine e effects f tement sscitins beween

sympms d idvidu nd extenl fcts lw he de fict

d mdiicin is fcts utcmes m studies bu

teveis sud vde he evdece f the mst effective

ngeme stegies.

Te secs i s cpe e s ws

evence

nu sy

disbity

el ce ement

effectveness

R 7


35/400

AP T H UMA P HA A AI & TH Y

Rs nd pgnstic cs e dscussed n the next chpLe. Ths

infmtn pvides bcgund udesnding h shud

influence the mngement h eh pfessnls pde

Pevaence

Tying t mesue the fequency f bc p in its cl n cuse

te te f ce-seeing elted t bc pi n is nt sLight fwd

ee s cnsdeble vibil ity n he wy dt hs bee gheed

in diffeent cunties diffeent mes, empyng dieen

den tins s ing sight ly d fee questins nd us ng fee

meds t ghe ts n fm Thee s ten c f becemesuemenL he pbem s fequenly ntemtet nd ec c

be pgued by bis Tus hee is pblem with the ly nd

elibliy f te dt nd the figues ffeed shud be seen s

estmtns e thn exct cs Andessn 99 ; Ncemsn

2000 Nneteless, cetin figues ppe cnsisenLly enugh

t give esnby elible vell pictue f e extent te pblem

nd iL nu histy

Despie mehdlgc d ficu te s it n be sLed Lht bc pis but the mst peent pn cmpin pssibly ng wh edes

Rspe 993 ) I n dults beween nel f nd t heequtes the

pputn wl expeience bc pi sme pnt in thei l ife Abut

40% wi expei ence n episde f bc pn in ny ne ye nd

but 5 -20% e expeenng bc pn t ny gen tme Smi l

figues e gve n evews nd pmy esech m dee

cuties und he wld Cf 99; Klbe t

995; vs nd Rchds 996; Wddell 994; Shee 99

Ppgegu nd Rgby 99; Ppgegu 995

998; Bwn 998; ebeu-Yde 996; cKinn

99; Spsi 995 ; Heliv 989 Tpsv

995 Cssidy 1 998) Appenty ny 0 - 20% f the u

pputin seems ve neve hd bc pblems Rspe 993)

Tbe cntins smple f nteL studes tht he been

cnducted in ge numbes f the geel pput ge

epesetve suveys e the bes evdence pblem Lgee ppun Nchems 2000 Cmmny hese sueys

descbe te pptin f pepe wh ept bc p L e ime

thL mnt pnt pevence) n ye ye peence)

bc pin eve lifeime p evlece)


36/400

T RM F K

Table Prevaence of back pain in seected age

popuation-based sudes

Ye LfemeR1 Cunt rvne revene .rvn

ll 1996 UK 9% 39% 59%

Ppoou 995 UK 39%

ow 984 Canada 42%p

o 989 F 20% 75%

oopso I 995 Russ % 3% 48%

o-Yd 996 No 50% 66%

cousv

O I 998 Sw 66%

Mo ] 99 K 6% 48% 62%

Soo 994 33% 59%

sh 992 UK 36% 58%

Do 997 UK 5% 40%

x 2000 UK 4% 59%

ver res f 44

seeced sudies

Tese gss gues dsguse difeences n te ccteistcs f

difeen episdes bc pn eltive t dutin seveiy nd e fect

n esn's lestyle

Cley bc pin s n endemic pblem widesped thughut

the cmmunity It is blem t w ffec the mj iy f du lts

sme nt in thei lives Bc pi s nm

Natura hstory

Te tdi inl cncept f bc pin ws he cutechnic dchtmy

n wic i ws tugt tht ms ptients hve bi e finte ep isdes

nd ny few pgess t chnic pblem It is fequeny stted

tht f ms peple the pgnss is gd (Klbe fet t a1 1995

Evns nd Rcds 996 Wdde 1994) " - o ck o

ow bck in rcovr in bou wk egdess f te t etmentpd c f t Wddell 98 Hweve ctue f the ntu

isy bc n tht suggests the mjity w ve bief sef

lmit ng episde denies ecen epidemilgcl evidence nd pints n

e-pimistic summ f mny individuls expeience f this pblem

PR [9


37/400

I P E TE L UM B N D I & T P

t is ctanly tr tat a grat nmr of ac p isos of ac pan

so qicy an sponanosy (ost l. 994 ay L

995a) ost l. (994) ollow 03 ac paints n pimary

ca for r monts an fon a 90% a co n twows an at ony wo lop conic ac pain owr

t is sty sampl conan pa ins wit a ry i isory of ac

pain (lss t an o s), no rfrra of pain ow t ga fo

an cl tos wo a princ a prios piso in

las t r monts all caactrstics wit a goo prognosis

an l. ( 96 6) rport at aion o t piso in or

90% o os wo s i GP wit ac ac pain was ss

an o ws ow raton was in as im

twn frst an as consaion wt octo An piso

of ac pain canot fn n s wa Aog pains may

sop attn ing tir mical pactitonr, s os not ncssary

man tat i ac pain as rsol or rcnly i was on

tat w most pa ins only isi ir GP onc o twic cas

of prolm on ya a 5% o m w si not sympom

r (roft l 99)

O stis at a loo a natra stoy o nw pos

o ac pain n primay car stngs also pan a mor pssimisc

pictr, atog ocom pns party o n wat is ng mas

(ary l. 995a in l. 1996a) Sis a fon ta

only 3 0 40% of tir sampl a comply sol at ao two

o r mons itt rtr mpomnt a si or wl

mons (rin l. 996a Pps an Grant 99 Klnman

l. 995) omas l (999) ntw patns wo a

prsnt o primay car wit n w pisos of ac pain 4%

still rport saling symptos a tr mons 4% a on yar

an 34% w cassi as aing prsistn isaling ac pain a

ot rportg ims

Rcrrncs in t fo owing yar aftr onst a r tmly common,

por in ao r-artrs o sampls (Knran . 995

an n oogn l. 99) n a larg grop o patin s n pmay

ca s (on Kor l 993) on yar afr sng mcaltramn o ac pan, majority wit o cn an non

rcn ons of ac polms pot pa in in pos mont

(69% an 2% spctily) n tos wos prom a star

rcnly, ony 2 % wr pain-fr in t pos mon n tos


38/400

RBM N

whose obem was o a longe aion on 1 % wee ain-fee in

e peos o nh

able 1 ges a see ton o stes ta hae esibe elase aes

an esistent smptoms. Relapse aes ee o those n e ba pan

oaon who epo moe tan one epsoe in a ea an pesisene

efes to ba an ha as aste o seea monts o moe Exa

einions a eween ifeen s ies b a h sto o eenes

an nonesong sptoms is eal a e ommon expeiee

Tabe 12 Reapse ae and pessten symptoms in seeced

stdiesefeence

Lnon t. 99

t 998

Szpalski 995

Heiovaara t. 989

Tooptsoa t 995

Hilman t 996

Phips and Gan 99Kenea t 995

hoas l 999

Van den Hoogen 998

Miedea 998

Cof 99

Caey t 999

Waxan . 2

elape ae Peen p

5% 43%

55%

5%

65%

%

6%

39%

36%

23%

%

%

48%

35%

8%

9%

42%

v s o sd ss 4

h mssag m h fiurs i s ha i n any on ya; rcu rrncs

xacrbaions and prsisnc domina xpinc of ow back

pain in h communiy (ot 99, 1 4)

t s ea hat o man inas, eoe from an ae epsoe

of baae is not en of he a pain exeene he stongest

nown s fao fo eeoing ba pa in is a so of a peios

episoe (of 99 Sheee 99 Smee 199 heane of haing a eene o ba pan ate a s epsoe s

geate an 50% an eenes ae ommon an moe han

one-ti o he ba pan poaton ae a ong-tem poem

(o 1 99 Eans an Rias 1 996 Wael 99

J A R N 1


39/400

P M P I DI G & PY

apageorgiou and gby 99 nton 998; Brown 998

Szpask a 1 995 Heiovaaa 1989 oopsova 1995)

here is aso the suggesion fom one popuation study tat hose

with persistent or episod pain may graduay deteorate engigniiany moe ikey to epo hon low ba pain and

assoiated disabiity a t a aer date (Waxman a 000) However,

the risk of eurene or pesistene of bak pain appears to essen

wit he passage of tme sine he as episode (BiengSoensen 983a)

he i nferene from hese igues is ear an indiv idual's exerene

of bak pain may we enompass hei fe histoy he hgh ate of

reurenes episodes and persistene of sympoms seiousy

haenges he my th of an aue/hron dhoom Ba pa is "acun c ondi ion Jo wh ic h dJi ni ions o acu and ch nic pain

basd on a Sing pisod a inadqua chaacisd by vaiaion

and c hang ah han an acu sJ i mi i ng pisod Choni c bac

pain dfind as bac pain psn on a as ha h days duing an

xndd p iod is Ja Jom a . " (Von Koff and Saundes 996)

t woud appea fom te evidene tat he mu-uoed speedy

eovey of bak pan does not onfom to many peop es exeieneand ha he dvision of he bak pain populaton nto oni and

aute ategori es pesents a fase dhotomy (igue 1 ) h is is not

to deny that many peope have brief aute episodes tha resove n

days nor ha here is a sma group of seriousy disabed honi

suffeers ut tat for age numbes "o w bac pain sho ud b vi wd

as a chnic pbm wih an unidy pa of gumbing sympoms

and p ods o ai v fdom Jm pain and di sabi i y i n spsd

wih acu pisods xacbaions and cuncs (Cof 998)

Bak pain shoud be vewed from the perspeve of the suffeesifeime and gven suh a pespetive the og o f se fmanagement

is ovewheming.


40/400

RBM AC A N

Fgue he assue an eal natual istoy o back painA

B

ACle

. "

Sma percentage becoe chri,

Tie

i

Recurrene oexcerbn

Assud crs cu w bc i Rl cu bck pn

Reprduced wilh pemon om Crfl Papageogo A MNy R (7) w h In: A Sevens J Rfer (s) Heth re ees Assessme. eod ees Rdfedc r xfod

sua a episodes of ba pain are bref and se-iting

howeve a ignfan proporon o indviduas wil experene

persisLe sptos, while a io develop hroni pain. he

naa oeen ae sabses ae e s ew ons, and

afLer th is Lie resout ion is uh le ss ke p to one-t hid o f new

episodes esult in poonged periods of sptos Ha o those

hvng an iiLa epsode of ba pan wi experiene reaps es. ak

of liia oowup reaes the istaken ipession ha thee s

oo resou to n o probes whh s no oned b oesneL eseah ethods

Disabity

L all bak pain s the sae hee is variabii t between indivdua ls

the pessene of spos i seveit and in funtional dsabi

(von Korf 1990) One review o the i erature found hat between

7% ad 18% of popuaLio sapes that have been studed are aeted

feuel ai or onsan t b bak pain aspe 993. Pessen

spLos have been epoed b about 40% and logstanding

disabng baahe b abou 0% of a hose who suffer fro the

probe Croft 1997; vans and Rihards 996 Forde 995

H P E 13


41/400

4 R N H MBR N D I N &

Waddell 99 inton 998 Spalski 995 Heovaaa

989 oropsova 995 Carey 2000. evels o disabii ty,

even aong hose wi th pers sent syptos, vay widey.

Musuoskeleal disordes ae te ost omon ause of hroni

inapaity, wh bak pain aounting for a signifiant poportion of

ths ota Bennett 995 Badey 994 Bak pa n s L us

one of he ost omon auses of disability, espeally duing he

produtive dde yeas of i fe t has been estiae Waddel 994)

tat 0% of te adult populaion or 30% o tose wit bak pan,

repo some iitation o their nora aivity i te past ont

beause of Work oss due to bakahe ous fo 2% of he alult

populaton ea ont, ust ess han 0% eah year and 25 -30% of the working popua tion aross the i l fetimes Waddel 99

Heoaaa (989 epoed fr a popu aion s vey ta 0%

of h ose wh bak pan had been fored to redue ei sure ativiies

pemanenty, 20% had arked mitat on of daily aLies and 5%

had seere lima ons. n a oneyear period, 22% o tose wit bak

pain who were employed went on sik leae beause of i epresenting

a peaee ate in e adult popuaion o6%

Ha 996

Aording o one sudy seous disabiity and wok loss afes 5 0%

o the population in any year, and in a li feime oer one-uarter of the

popua tion take ime of wok due to bak pan Was 992

Tabe 13 Disabiity ad work loss due o back pai i

geea popuatio

Men Men WomenOn yar Liltim On ya

l 5% % 45%W loss % 3% 7%

W

WomenLfti

3%

23%

sability due o bak pain has vaed over tme n te UK during

the 980s, he payment of skness and inald iy bene ose by 208%

ompaed to an aerage rse of 5% fo a napaiLes Wadde

994 hee is no evidene o f an nreased prevaene o bak pain

ove reen deades ahemson 2000 eboeuf-Yde 996

he neased napa y s thougt to reate to hange attudes and

expeatons, hanged medial ideas and manageen, and hanged

soal povision Waddell 99 ight also be see to ee a

ie o hgh unempoyent and soial hange withn e Indeed,


42/400

RBM CK

or rn vdn ro t US rorts ha ra h r tan bn g on

h nras, th sta of anna oaiona bak an for whih

workrs ad onsaton aay dind by34%

btwn987 an 995 (Mrhy an Voinn 999

t s ioran Lo b awar tha ains with hron bak ain

rrsn a dvrs gro, not a of wo ar fa to a oor

rognosis Whn n intyfor nividas with roni bak a in wr

siond abo wor an soa sabiity, ss tan 8% ndiatd

an intrrtion o nora av is ovr a six-onth r iod (MGory

2000 ALts av bn ad to assify hroni ain sas

raLv to svrity and ssoiatd isabiity, whi ina haovr hf o tos w hroni ain rort a o w v o f rstrion

on hr fsLyl an ow vs o rsson .

Svra arg oatonbasd sts of hroni an and bak a n

(von Korff 990 992 Cassiy 998 and a stdy o

hron bak ain atins (Kaow 993 rva rasonaby

onssn vs o iitaton of atvity d to rsstnt ain

robs Abo a f of tos w h roni ain rort a ow v o

dsabi ty and a good vl of ong Abot a artr rort odrat

vs of disabiy, and anothr arr ror svr inaaiy d

to h rob (s b .. n hos at ning riary ar or

ba ain, abo 60% ha ow dsaby an abo 40% ad hig

disabiiy at rsnat ion (vo n Kor 993 Afr on yar, ss

han 20% wr ainfr, 65% had ina disabiiy and bwn

% and 20% had igh sabiy, so vn in hos wi h rsistnt

syos h svry and disabi ity is variab , wi t t ajorit y

roring in a ri on o nton

Tabe 14

Gade

Gading o chonic back pain

von Koff l 992( 2)

Low iy ow ny 35%

Low iiiy d high ntity 28%

gh bty 37%

(Moderate 20%;Sve 17%)

Klapow Cassd l 99 l 998( 96) ( 0)

49%

25%

26%

48%

2%

%

hr was onsdrab htrognity in anifstations of ain

ysntion aong rsons wi singy oarab ain

xrn. A onsidrb roorion of rsons wh svr and

H E R N 1 5


43/400

6 AP LUM BA P I HA A D AGI & APY

ersistet a i ot eviee sgia airelaed dsailt

Some ersos wth severe ad ersise a i o evidee

syhoogia iarmet , ahogh may d Vo Korff l 1

he a stas of d vials is o sa , yami ale 5)

Symtoms a assoiate dsaity fae ove e a may

a et s eave he ool o f ersste ai sferers if foowed over a

ew years he overa oo of hose w hro a ears o

say ao he sae a ooro leave ha g ad e he

eome a- ee o are ess severey afeed , while a s la mer

jo i over a eod of a year or more Cedrasi l Crof l

17 o l 187 vo Ko l 1 rry l

Table 15 The dynaic sae of chonic back pain

ot 99

ashi l 999

op l 98

oo l 99

h wh beme r

8%

% pain clinc)

% pimary ar

LBP = ho low a pa

ISQ = saus quo

whmr

%

5%

9%

whm Q

%

%

%

Ba a s a symtom ha des es a heeogeeos ad dya

sate. ivials vary i he exeriee of akahe reave o

e sevey a dsail t ay idivdas ave ersise

oems ost hroi ak ai s of low iesy ad ow

isaiiy hig eves o f severy a disal y a ffe oy e o t

Soe of hose w h o i aahe do eoe ai-ee oweve,

ease o high evaee raes, ak a rodes exesive

isaity ad wor oss ad hs imas osderably o dividals

ad o soe

Cost

ve hogh ot eveyoe wih ak a sees healh ae, he

revalee of he oem s so gea ha g mes of aesare eterg the hea th serves A mao oe is he CO assoiated

with ak a , athogh ths s d fi o ala e I s ade of

h e ret ost of heah are ore y soey o y he ae ad


44/400

M K

he n d ret osts assoaed wh absene om wo n the UK osts

o he HS aone n 992/3 have een esimated at between 265

and 383 on wh onstes 0 .65 0. 93% of oa HS

sendng (Kae Mo et l 1 995 ) A more een esmate o he

dret heat are osts of ba a n n he U K o 998 p t the os

at 632 on (Manadaks and ay 2000). n he S meda

ae oss have ee esated a etween $8 and 1 8 bion Sheee

l 995)

h e meda oss o ak an owever are ony a art o e woe

ost o e pobe that soe y ays d ret oss sh as dsa y

or oensaion aymens prodton osses at wokpaes andinfoa ae, dwar he amo ha s spent drey on paien

ae he tota soea ost o ak an n t e S has een estm aed

at $75 1 00 b o n 990 (Fymoyer and Cas-Bar 1 99) Cos

daa fo nsane opanes o wo separae s des shows ha

eda ae represens aot 34 % o f he o a oss we nd

oss mae abo 66% (Webser and Snoo 1990; Wams

998a) oa emomet-eaed oss n the K have been

esated a between 5 and 1 0 on (Manadaks and ay 2000)

whh means hat det oss ony aont for be tween 1 3% and

24% of he oa osts (Fgre 1 2 ) . n he eherands he d re

heat ae oss ave bee esated as ony 7% of he toa os

wth the oa os repeseng 17% of the gross natona od

(van der l. 995)

Fgur l2 T dc and indct coss of ack pan000

,

'c

1t-

tMcal ss Maual Thpy

Indirect OSI5,low stmat

t co,pe etat

Sourc: Miks nd Gy 2

Meda oss nde ednes and x-ays; aa heray ndes

hysoherapy osteopathy ad hroprat; dre oss nde

odo osses and oa are. Some o f these oss an oy e

estaed e de and n det osts o a a n ae so gea tat

R N 7


45/400

8 A R N H E LUMBA : AN IA D I A & A '

the eonomi burden is arger than for any other disease or whih

eonomi anaysis was avaab le in t he UK in 998 anadaks and

Gray 000 is more osty han oronary heart disease and he

ombned oss of heumaoid ahis espatoy ifeosAzhemer's disease stroke dabetes ahrtis, multipe serosis

hromboss and emboism depression diabees shaeia a epeps

A minorty of patients onsume the maoriy of heah are and

nd iret osts for low bak pain. Combinng data fom mutpe sudes

suggests that abou 5% of the bak pain populaion aout or

about 70% of osts Spitzer 987 Webser and Snook 990

Wiiams 998a inton 998

hus not ony s the ost of bak pan huge but the ajoity of hs

money s not spent ey on patien are bu on iet soietal

osts' Fuhermoe it is the hroni few who onsue he agest

proportion o hs expese.

Heah care

o eveybody wit h bak pan seeks professiona hep os surveysrevea tha t about a uarte o a ha of a peope wi th bak pain wi

onsu their media pratoner Crot 997 apageorgou

and igby 99 Kinnon 997 Caey 996 A survey

in Begium found tha 6% o those with bak pain had see a heath

professona fo the most reent episode Szpalski 1995 Where

hiroprati are is avaiabe % of bak pain suffees seek heir

hep nton 998 Caey 996 Seeking are appears to

vary widely; one survey n th e U K found those seeking onsuation

wih oa physiians to range from - 59% of hose with bakpain in d ieren areas Wash 99 Caeseeking among hose

with honi bak pain may be sghty highe Carey 995b

000 Man y peope wit h ow bak pa n ope independenty in he

ommunity and do not seek hep whether edia or aeaive


46/400

M A A I

Tabe 16 Prprtn f back pan ppuatn wh eek

heah care

% who% who % who % who osuu osu osu physio-

Rc

Co GP ooph haor heas

Do 997 K 38% 6% 3% 9%

Wh a. 99 UK 40%

ll 996 UK 37% 4% % 0%

o 998 Swn 8% 3% %

996 US 4% 3%

Kino U 4%997

So-Eggin Sw- % 000 n

I the UK Waell (994 estmae a populaton prevalence of

5 m io people ih ack pai i n 993 Of hese he esimae

ha 8 % cosul teir 0% aten a hospital oupatent

epame % are see y S physoeapss % y oseopas

ess La % each y pivae physoteapiss an chropactos 0.2%

ecome paies an 0 % go o surge

Eve tough may people ith ack pa o not ate a eah

prfessioal ecause o te arge pevaence rae in he comm uy

he umers acualy seekng hea care are consierale a

costue a sgnifica uen primary cae For insance i the

S t is estimate that i is the reaso fo 5 mi lon vss o physicians

anuay te ftarges reason o aenace represeing nearly

3% o all vsis (a 995 n a ura pmary care seing nFa a pacices in he UK, lo ac pan paens mae up

aout 5 % o a consultatios (Reola 993 acke

993 Waell 994 he UK i as ee esimae ha onetr

of Lhose atteig primary cae ih ac pain ill presen i a

e episoe onehr l pesen ith a recurrence an o ne-ir

il pesent it a perssent saling prolem (Crof 997

here ae o cea clica feaues a singuis ose paiens

o seek eat care om tose o o o man (996ou LhaL ose ho consu te e to repo ge leves o pain

geae saility a loger epsoes u also a some i viuals

ith te same characerisics i o seek healt cae Caey l.

(999 fou that ecurences of ack pain e pesence of sciaca

A P 9


47/400

I APR LMBAR P I HA A D AGN & TH RAP

a geae isabiiy ere associae ih cae-seekg onger

uao of an epsoe of back pai s more ikely o cause peope o

cosu (Saos-Eggma l 000 a failue o mpoe s

assocae i seek g cae from up le roies o ea cae(Sunaarajan l. 998

hose ho ae eiary care en o be a e moe seere e of

e specrum of sympoms Hoeer oe-ffh of oosuers ha

consa pain a neee beres oneir a ha pai fo oer

hree mos e peious year a eay half ha eg pai a

esrc e ac y (Crof l 997.

I e S Caey l. 996 ou a ose ho soug cae eemore likey o ae pa o oger ha o eeks ha aae io

e leg a a come o a ok Hoeer coserale umbers

of hose o seeking care aso ha hese chaacerscs Szpalsk

l. 995 fou a back pa fequecy hea beefs

sococulual faos ifuece eah care-seekig. Ohe suies

hae also fou ha psycosoca l aors ae some mpa o cae

seeking for back pan (Wg l. 995 Vngar l 000. he

ype o hea proer a paes frs see may hae a efec osubsequen cosuao aes ih ose o see a chropraco

be g ice as l ikely o seek urer he p compre o hose o sa

a mea ocor (Carey l 999

e message e epem ioogica ieaure a may peope

ih back pa cope ie peney fom professioa help s

e oce by eience om ualae reserch usng iees o

peope ih back pan Skeo l 996 he K ou a arge

number o is sample o be aciely oking o heir prblem yao ping arious preenie sraegies. ese iclue use of ceai

boy posues hen being sng a ifg akg lgh exercse

resing oing back an abom na exercises a fo some consa

aaeness of a back problem ayoay aies I os a

smaller group of paies repoe akg a mimas approac o

se-maagemen espe ag some koege aou peee

measues I beee ese o exremes ere a fe ho repore

a ey ere n e process o recogsng a ee o o someh gabo u he problem a ee begiig o pecee e nee o aop

self-maageme sraeges


48/400

RBM A AN

oa (995) a o o patie aopt g a age o

iteectua a ehaioua tategie that ee eigne to miimie

pai or maie uct o normat o aou ack care i a commoepetaio o toe o o eek poeioa he p (zpa rick al

197) .

e than ha o hoe i t e comuny ith ac pai actay

ee hea care t i thu cear that emanagement o ack

proem i oth at aae an pacie y ma Some o toe

ho o ot ee heah are ae cona peritet an reerre

pai ith reuce uto e majority o peope it ac pan

maage iepeenty o eat proeiona. O hoe o o ee ep ay are ookng or thig tat hey can o to he p theee

o aage thei proe eter. The re are ohe ho are negec u

o aop ig he eceary raegie, u ho may e coice o

he ecety o og o they are uienty i ome Noe thee

ecaue o te high preaence rae ack pai coti tue a

coierae ure to priary care

Teatment

he rage o reatmet oee to patient it ack pai arie

coiea Thee i o coneu o n he e ype o teatet or

ack pai a o te teatmet gie i choen on the ic ia ion o

e pracitoer It epen more on hom the patient ee ha

eir nica preeao (Deyo 993)

A ac pai patient i t he Unite Stae i e me more iey to

e a gca aiate ta they ee a paie in Ega orScoa (igure 1 3 rom Cheki al. 994a) ac rgery rate

increae amot i eary it he oca uppy o orthopaeic an

eurourgeo

A R N 12


49/400

HAP T E UMA PN AN A DAG & E Y

Fig l3 Ratios o back sgy ats o back sgy at in

th (1988 - 19891.2

.g0.8

" 0.6

04

02

o

Country

oue hkn el al 1994.

In he S nonsurgica hospiasaion an surgery raes vary

conseray oh oer me an place For insace paies are

ice as iely o e hospalise in he souh han i he es an

eeen 979 an 199 here as a % increase n he rae o

usio operaons (aylor a 994) .

In he eheras a escrpive suy o genera raciioersapproaches o chroni ac pan paes has shon a here is

i le consisency eee cinicans (an Tuler a 997a). Cher

a (99) oun here as lile cosensus among physicas

aou hch agnosic ess shoul e use o ac pain paiens

h cerain l ca presenaons a concue ha or he paie

ho you see s ha you ge .

Equa y, n physica herapy here is no sanarise maagemen o

ac pan Sureys o repoe managemen syles ave ee

conuce n he S (ae a 994 Je e a 99; Jee a n

Delio 997 ; elen a 997) he Neherans (an aar a

99) an n he K (Foser a 999) . These surveys sho a a

ie range o he rmal an elecroherapy moaes massage

moilisaon an manpuaion exercises an mixe reame

regimes are use Exercses are commony use u hese are

requeny comne h he use o passive reamen moalies

such as ulrasoun hea o r elecrca smu laion a es s requenyih he use o manua l herapy assive reamen moaliies en o

e use y some cni can s haever he u raio o sympoms


50/400

H RB M A A N

I a sure n he S e McKenzie Me ho as eeme he mos

usefu approac fo maaging ac pain alough n pracce

cl cias ee le l o use a ae o eamen approaces (ae

99 In te UK an Irelan e Malan an McKenie

appoaches ere epoe use mos oe o anage ac

poes aough e ecoheap moal es ( inerferen ia

u rasou S an s or-ae iahem) an passe seching

a aoa eecses are aso common use (Fose 999.

Ienaional phsoherap pracce s ececc a apparenl e

uece e moemen oas eence-ase pracice

ack care regimes are clearl eclecc an non-sanaise Wenso much ae o eamen is on ofe ha paiens ge is moe

le o efec he clicians' ases rahe a o e ase on he r

clca peseat o o te es eience ne r ese ccumsances

ere us e occasons en he managemen ofee s suopima

a s not he est ong-erm ineres of he paen

Effecveness

ortuae seeg eah care oes no o an sole their

ac prole (Vo Kof 993 ion . 1998 an en

Hooge a 99 C 998 De spe e as numes ho

are reate o s conion iferen eal poessionas e

uneing ep emolog of ac pan i s h gh pealence a

ecurence raes eas ucange (Wael l 994) . nee he e

s een he accusaio ha raional meos o care iolng

es a passe reamen moaes rahe ha ac hae een

pal impicae i he alamig se o hose sale ac pain(Wael 198

Some sues ae calege h e oio a oucomes ae necessai

eter those ho are reae i phsioeap or cropacc

(Ia 1995 an e Hooge 99 Fo i nsance I na

s su 9 9 5 foloe ear paiens ho e re

anomse eer o orma care or o a group ho ee gie a

hoough epanaon of he mpoance o ac an e negae

efecs o eng oo careful A 2 as 6% o he nomal care

goup ere st on sc leae compae o 3% o hose insuce

to eep ace hose n he nomal care group 62% receie

psica herap an 42% chiopracc o c 9% a %

AP 13


51/400

4 R N T E LUM BR : ECN C D GN & TH RPY

rspctvy rpord hat tatmnt mad h si tua ion wors o had

tl o no ffct

Vaous rvws an sysmac vws av bn unta nontvntons sd n h tratmnt o bac pain Ts vrsay

only incld prospctv ranoms contod trials whc, wit

hr spposd adnc t o stict mthodoogical critra ar sn

as th go standad by whch to j udg intrvntons Ts ahrnc

to spcific stuy dsigns is rary achiv, b th focus o study

dsg nds o israc fom th itrvnio tslf Rstrict

rcrmnt and foowup may limit gnasablty; ntrvtos

may no c cnica practc baus mosty y a v i a

sandarisd way wh no atmpt at assssn of val

su tab ty o tat atmn gim t h outcom masurs ay not

b appropriat for t conito

Nonthlss h un yng mssag s mpossbl to va no

nrvntion to dat ofrs a sraigtorwa curatv rsoluto of

bac pobms (Sptr 1 987 AHCPR 1 994; Evans an Rcards

1 996; Cof 1 997 ; van Tulr a 997b) Ths a a o

viws concd in las dca o r so ta qusto t cacyo a wi rang of commoly usd ntrvnons

"Rsch o d hs bn i nsuffici n y rigo us o giv r

i ndi cions of h v u of mn for non spcific LBP pins No

m n h s bn sh ow n byond d oub o b ffciv h is

n o c i ndi ci on of h vu of mns compd o n o mn

o of h iv bnfi of diffn mns (vans a Rcas

996 pp 23)

Spcfic systmac viws av bn condc o nvual

n t v n t i o s u s o a s o n d i h a m o

musclosta probms in gnal as bn sriousy challng

by all copnsiv systmac rvws to at, whc rport hat

aciv u rasound s no mo ffctiv than pacbo (va Wt

1 999; Ga an ohanns 1 995 ; Robrtson an Ba 2001 )

Tr i s n o car vnc for fctvnss o as tapy

B 1 998)

A systmatc rvw ond th vic cocrning taco to b

conc usv van ijn a 1 995a ) so a raos sa

controld a was consuc avoing ari stdy faws Dspit


52/400

TH E RB M OF ACK A N

faouae esults n a po study (an de Heijden t l. 1995 ,

lage ues and shot a d long-em foow-up eealed la of

eiay o lua ao (Beusens l 1 9 9 5 1 9 9 7

Results of aohe systeati eew show thee was o eidene

ha aupuue s moe effetie han no eae and some

edee show i is o moe efetie han plaeo o sham

aupuue o hoi a pa n (an Tude t l. 1999

A eent systea eew of he use of TNS o honi a a n

ound no d ffeene n outomes eween atie and sha teamets

(e e . 2001. Thee would appea to e ltte oe in temanagee o a pa fo su h assie theaes

"No con tr d st ud is hv provd t h JJic cy oj phys i gn ts in

th trtmnt oj pti nts w ho hv cut, subcut, o ch ni c ow

bck pin Th ct oj us ing pssi v o d i ty i s qu to or wo rs

th n pcbo JJc t (Nodin and ampeo 1 999, p 80

The la o fay of asse theapies s enfoed y sysema

eews of eds omaed o eep ng ae . hee is a onsse fdng tha ed-est has no alue, u ay auay dela y eoey

in aue a ai . Ade stay ate and esume noma aiites

as soon as possile esuls n faste eun to wo, ess ho

dsal ad fewe euent poems pat ents ae foed o es

the aue sage, this shou d e mited o wo o thee days (Koes

and a den Hooge 1 994 ; Waddell t l. 997 Hage l 000

en o saa he same ules app ly (Voome l 1999

hee is soe edee ha nonsteoida antiamaoy dugs

(SADs ght pode shottem sypomat ele ases o

aue a pan ut hese ae no lealy ete han odinay

aagess ad o NSAD s ette han aohe. Thee s o edene

o sugges a NSADs ae hep u i oni a pan o n siata

(Koes l 997 ; a ulde t l. 000

Seeal syseat eews foud lte edene fo the eay of

goup eduaon o a shoos (D ao 995 ; ohen l 1994 ion and Kawedo 987 , ut hee was some eidene o enet

to hon a a aes, espeally an oupatoa setng

(an ulde l 999b

P E R 125


53/400

6 l A R N E T i l LUM BAR : ECHA IA D AGNOS S & T ERAPY

Srl mo rcnt rnomis co ol tris wo sggs

t s rol for cio mngmnt o bc p (I

998; Bto 999 o Korff [ 998; Moor 000

Ron ixon 989) Ts ss s i o mtos topo ppop nfomtion bo oml cii smngn

n rmo o fr of mom, fct s

bfs of s pints s wll s fcon n bor

n n w t h mrgnc o t concpt of ptits ts n

bifs ning ilnss bio, r mps to

rc croc isb tog t moifct on o f nv om

conngcs pits' cogv procsss sig biol

p Ssmi c riws sggst t b iol hp c ffct whn compr o no trmn t, b is lss cl so w

compr o o ct nrn os (Mor 999 n Tr

000c) Comp to rmn s s grop, on cogi

bior inntio poc g of imp ov ocoms of

cicl impotnc, clng rg t ris o log- sc

l b hrfo (no n Rbrg 00)

Thr bn mlpl ws o mnpton o bc p;hr mo rws thn ls (Assnlt 995) Som

rws sggst tht m po n s fct (Ason 99

Shl 99 ; Bronfor 999) b ohrs sggst h s cc

s npron bcs o con cto sts (Kos 99 , 996)

En wn th conclsio fors mnpo , thr r m os

o s Mos ws o bit of mplo is

sho -m ol n lso gl conin o sbc gop w

bc pn on T l of mpo in oth sb-gops o

th bc pin poplio s cl If ls xmin t s so ppr t rmt fc w

prst is mos th ril, wit cliicl n mpon ffcs

bwn th trmnt gops Frmo, mn o f t ris iw

s big bo mnpion i fc nc no- rs mobilson

s p o f h rtm otn s cl xcl wic of s

i rions s bng g

Som sstmt rws sggs c o spcifcxciss os o t r ffct (Kos 9 9 ; vn

l 000a). Ths riws icl hrognos colcon

of frnt ps of xrcss from whch s gls

int pr io of ll xrcis Mos s i to pscb xcs


54/400

RB M AK A

ata m o sitbl pat ts, b a xciss a gi in

a stas wa ws sw gat ccn [o moogca

ctss, b spa lss stang itns a sg g tis tat s xtnsion xcss a cos

b sg cKnz ppac. H an 1998) a t

ac a coc s gaing t o xcis in coc bac pai n

Ot iws a b mo psiti, spcial l ccning

xcss s ing t sbact a conic pass Faas 1 996

Haig a 999; a et 1 999; Non an ampo

999) a e 999) col at ac bac pats so

b as a b-s an o omal actit n apgss wa an at t is bsc app oac co b sppmt

wt mipat o cKz ap. F conic bac patts

s stg nc t ag ntnsi xciss

s bi iw t iat mas o sobg aing

cg mal poap pacc Fo a wi ag

pass aps stl bing sps b cinicians o a ga basis

s sc spptg o t tins a

c s sppo fm t a aml mpat,

xis baoa tap omaon posio t is

somms tact o i mt inc

Im b b ts inc an b tat pscoscial

ats a i acing coc sab t, t ot ns o a opt mal

maagmnt appoac bgi mg:

a bst a agm to noma

att

ma im a maig pat nts ss a

sng nlnc som ats an bli s abt pa

asg pi ts w t ca manag wat ma b a o ngog

cnt poblm

mng pats a t acti paticpat s ia in

stng nc

cgng smagm , xcis an a ct

p g patns wit t mans to ac smpms a ts

ga s cnt o i pobm.

H A R N 17


55/400

8 A T M R P N C N C D & A

Tese ou appea o e e mai emes a sou e i fomg

i a maageme of a pa

Concusions

Or uesaig o e poem o o a pa s e ge

erai ir euae us

ak pa is so ommo t a e sai to e oa e a

o oer eem poes su e ommo o or ea

giee proems essae o e measa o of a oa

expeee sou e ae o a seaagee appoa

pesoa respos s egeee Te ouse of ak pa i s eue o epsoes

pesisee are-ups eourrees a oi t s

impo r a o ememer s i e a eo ue

aageme mus am a og-e eefs o sorerm

smpomai reie

a peope ak pai mage iepee a o o

seek ea ae e o s usg exeises a postua o

egoom sraegies Some paes te aopio of ispersoa esposii iu a ma ee eoagee

Suessu se-maageme ioes te aopo o ea

eeua a eaoua sraegies a m ise pa a

maimse uo

e os o a pa o e ea is a soie as a

oe is as e soea' osts asor e maor of s

speig e ire meia oss are omae speig

o e ro a pa popuao Teefore aageesou e ee o g o eue e isa a ee

or ae-seeig s goup eouagig a se -ea a

opg ae

a pai is o aas a uae isoer a fo ma s a

feog poem No eeio as ee so to ae e

ue g pea ee i ee o reuree a es

Coseue maageme mus a sho aas e

oerg oe s o se-maageme a pesoa resposi to e patet .


56/400

T M A A N

e mie er he e he mngeme

i Tee me eee r exece

mip n frmn priin n beh he

Gvn ts sps o b pn pps t so b v n gt

oj ot n sss n ngnt t tn tv

tp s on o t pt n on t n s to qp t s

t ong-tm s-mngnt sttgs s s sott

mss ojsmptomt pvnt It so b sggst tt

to o ots nd t t ptn ts t so tt pssv o t s

o np to n, bt no t qp t t not on n st tgs

o smngmnt, s -onv n s not n t ptnts' bstntsts I onton s v omon, psstnt otn pso n

sst nt to s m, t s t m pt nts f po to

t ts pobs n n opt n s t fs on As

n ns , so b of ng ts po nt t o o pt n ts

H A N 129


57/400

30 I CHAPR ONE TH LUMBAR SI N: HANA D AGN & HRAPY


58/400

2: Risk and Prognostic Factors

n Low Back Pain

Introducion

Aeiologicl fo are varae reag eye ccpa

geec va caracerc a a ae acaed w

a ge r [ evepg a ecfc ea e. Tee ac

Documents

The Lumbar Spine Mechanical Diagnosis & Therapy