Who Is the Unstable Patient?
The story we tell our patients about their back is a crucial to their wellbeing and self-perception. As patient expectations become more understood and respected in our literature and community – is the word “instability” a fitting one for the low back pain patient?
As discussed previously, patient expectations in the lumbar spine seem to positively reflect on strengthening and stretching techniques to improve their outcomes.1 Thus we know that patients perceive exercise positively as a tool to improve their health. Numerous blog posts and discussions have revolved this month around what are we telling our patients and how are we possibly adding into the chronicity of their symptoms. This brings us to the word – unstable. If patients perceive exercise positively, would they feel as optimistic if they thought their system has instability associated with it? Obviously there is a clinical time and place to discuss instability, but I would question if that is best addressed in a surgeons office, and not the therapist.
The best thing that pain free, graded stabilization can demonstrate to people is that movement is good and exercise is a positive afferent input to their nervous system. If we label this system an “unstable” one, aren’t we setting them up to poorly conceptualize their issue? I have seen too many patients who have been fear stricken into bracing their spine, or the patient who wont let a family member touch her spine even with a hug due to fear of “throwing the unstable back out.” How much of we say in our office feeds this fear beast. Therefore, lets talk about stabilization – but lets talk about it in terms of securing the insecure, comforting the nervous spine, or providing safe feedback to a fearful back. As I tell people, its muscle, bones and nerves – you have to be bigger than that and unfortunately, the word instability sends me into a nervous uncontrollable cycle. So, unless we are talking surgical intervention – maybe it is time to keep it out of the conservative treaters office.
Lets sell function and control
What kind of stabilization does crabby spine enjoy?
Personal treatment tends to start with supine motor control exercises to localize transversus abdominus (TrA) and multifidus with progression in firing complexity transitioning to supine, quadruped, sitting, standing and then back to their functional preference. This week’s review of current literature was an excellent one for me to delve deeper into thought on who is the appropriate person for me to have run this course.
Hicks et al put this concept to the test to identify clinical variables for patients who do well with stabilization. Similar to manipulation CPR studies, predictor of success was a >50% reduction in Oswestry – which is quite significant.2 Items that predicted success was positive prone instability test, aberrant movement, straight leg raise > 91 degrees and younger age (<40 years old). Patients who failed had did not have aberrant motion, negative prone instability test, a FABQ <9 and patients who did not demonstrate hypermobility.2 Unfortunately, the post test probability of success was raised – but to a lesser degree (33 to a 67% success with 3 or more of the above stated criteria.)2
Unfortunately, this CPR was not upheld in the validation study to follow. Regardless – Rabin et al did contribute more food for thought as this study did identify a stronger correlation with success with only the prone instability test and aberrant movement (P = .02).3 Although we would need to re-run through the validation process though to assess its stability it is still useful clinical information. Overall, patients who had a stabilization program had less disability at the end of the treatment compared to the manual therapy group, and as other studies have similarly noted there was changes in the lumbar multifidus after manipulation that was sustained for 3-4 days possibly indicating positive reinforcement for their marriage.3 In any case, of the lack of full validation – these two tests seem to hold weight in assessing who may benefit the most from a stabilization program and allow therapists to weed through interventions and maximize treatment time with patients.
Chronic low back pain has a subset of unique characteristics. It is hypothesized that the central nervous system has complex changes that have altered the sensorimotor integration. Thus, leaving chronic LBP patients with faulty feedback loop and an altered body schema.4 These cortical changes are tied into a package with anxiety, stress, patient beliefs which may explain why patients have poor pain provocative postures and movements.4 Knowing that this system is faulty – do these patients respond similar to our homogeneous groups used to validate the CPR’s? Looking just at the validation study by Rabin et al who had pain average duration 60 days or less – this is rarely the patient that ends up in my office.3 Thus providing steam to the difficulty with this group as the extreme heterogeneity. The complexity to each patient should drive therapists to critically assess what feeds their pain loop – versus simplistic approach of core strength then discharge. Thus the reason I love the nerdy trend of understanding pain, healthy debate on the story we are telling ourselves and patients, and how we can better understand how to narrow our scope to assess who benefits from what exercise.
Once the appropriate patient is ruled in a few questions remain: what types of exercises work?
Stolze et al:9 Established a CPR for identifying patients who would benefit from pilates. Patients who have total trunk flexion ROM of 70 degrees or less, duration of symptoms 6 months or less, no leg symptoms in the last week, BMI of 25 or greater, and hip IR >25 degrees. Three or more of these positive drove successful outcome rates from 54% to a 93%.
Miyamoto et al:10 “We determined that Pilates was not better than other types of exercises for reducing pain intensity. However, Pilates was better than a minimal intervention for reducing short-term pain and disability”
Quick Conclusion: Good supportive evidence
Mayer et al:6 Systematic review suggested that short-term lumbar extensor training improves pain, disability and other “patient-reported outcomes in CLBP.” Although there is no real benefit when compared to other exercise programs.
Moon et al:7 This study compared lumbar stabilization (similar to PT program discussed above) to a MedX program (strengthening back extensors). Both lumbar stabilization and dynamic strengthening exercise strengthened the lumbar extensors and reduced LBP. However, the lumbar stabilization exercise was more effective in lumbar extensor strengthening and functional improvement in patients with nonspecific chronic LBP.
Quick Conclusion: Poor supportive evidence
Specific Motor Retraining:
Hides et al:5 Patients with chronic low back pain who did the lumbar multifidus retraining for 10 weeks had 3 year follow up and re-occurance rates were 75% of the retraining group and 35% of the control
Costa et al:8 As we have studies to show that a lower cross-sectional area and a larger percentage of intramuscular fat lie in the multifidus in patients with low back pain – thus proposed that due to this instability patients guard their spine creating stiffness with superficial musculature. It has been suggested by Hides et al that chronic patients have less re-occurrence rates with motor control retraining this study examined its effect on numerous outcome measures and followed them to 1 year. Results demonstrated that patients improved recovery, activity, and decreased limitations with this plan and this was maintained 12 months after randomization.
Quick Conclusion: Best supportive evidence
Overall, I think the right patient benefits from lumbar stabilization. Although – I want to keep stabilization as the golden child in patients eyes. Therefore, it should address fear avoidance behaviors, be a positive input, and match their expectations. I think it should stay out of telling people there is a perfect alignment, way to move, stabilize your instability, or set up expectations that if they are weak – they will hurt. Lets keep strengthening as the likable guy in the room as I think it has the potential to be the backs good friend – we just have to tear down the co-dependent relationship between the central nervous system and low back pain.
Original post: January 27, 2014
- Mark D Bishop, Joel E Bialosky, and Josh A Cleland. Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions. Journal of Manipulative Medicine. 2011; 19:20-25.
- Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005; 86: 1753-62.
- Rabin A, Shashua A, Pizem J, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients with Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. JOSPT. 2014; 44: 6-33.
- Dabjaerts W, O’Sullivan P. The Validity of O’Sullivan’s Classification System (CS) For A Sub-Group of NS-CLBP With Motor Control Impairment: Overview of a Series of Studies and Review of the Literature. Manual Therapy. 2011; 16: 9-14.
- Dr. Teyhen. Motor Control Training: Who Benefits? Lecture Performed By EIM. January 25, 14.
- Mayer J, Mooney V, Dagenais S. Evidence-Informed Management of Chronic Low Back Pain With Lumbar Extensor Strengthening Exercises. Spine. 2008: 96-113.
- Moon H, Choi K, Kim D, Kim H, Cho Y, Lee K, Kim K, Choi Y. Effect of Lumbar Stabilization and Dynamic Lumbar Strengthening Exercises in Patients with Chronic Low Back Pain. Ann Rehabil Med. 2013; 37: 110-117.
- Costa L, Maher C, Latimer J, Hodges P, Herbert R, Resshauge K, McAuley J, Jennings M. Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial. Physical Therapy. 2009; 12: 1275-1287.
- Stolze L, Allison S, Childs J. Derivation of a Preliminary Clinical Prediction Rule for Identifying a Subgroup of Patients with Low Back Pain Likely to Benefit From Pilates-Based Exercise. JOSPT. 2012; 42: 425-438.
- Miyamoto GC, Costa LO, Cabral CM. Efficacy of the Pilates Method For Pain and Disability in Patients with Chronic Non-Specific Low Back Pain: Systematic Review with Meta-Analysis. Braz J Phys Ther. 2013; 17: 517-32.
- O’Sullican P, Tworney L, Allison G. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylosis or Spondylolisthesis. Spine. 1997; 22: 2959-2967