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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
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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
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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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XXV I
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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
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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
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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
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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
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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
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6 1 INTRODUCTON HE LUMBAR S PN E: ECHANCA AGNO & HERAPY
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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
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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)
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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
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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
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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
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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.
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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
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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,
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 .
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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
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30 I CHAPR ONE TH LUMBAR SI N: HANA D AGN & HRAPY
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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