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Manual Therapy (2002) 7(4), 183–192

# 2002 Elsevier Science Ltd. All rights reserved.
doi:10.1054/math.2002.0478, available online at http://www.idealibrary.com on

Masterclass

Recalcitrant chronic low back and leg painFa new theory and different approach
to management

J. McConnell
McConnell & Clements Physiotherapy, Mosman, NSW, Australia

SUMMARY. The management of chronic low back and leg pain has always provided a challenge for therapists.
This paper examines the influence of a repetitive movement such as walking as a possible causative factor of chronic
low back pain. Diminished shock absorption and limited hip extension and external rotation are hypothesized to
affect the mobility of the lumbar spine. These compensatory changes can result in lumbar spine dysfunction.
Treatment must therefore be directed not only at increasing the mobility of the hips and thoracic spine, but also the
stability of the lumbar spine. Sometimes however, the symptoms can be exacerbated by treatment, so the neural
tissue needs to be unloaded to optimize the treatment outcome. This can be achieved by taping the buttock and down
the leg following the dermatome to shorten the inflamed tissue. r 2002 Elsevier Science Ltd. All rights reserved.

INTRODUCTION back pain, but as highlighted in the literature, the
majority of low back pain sufferers will sponta-
Low back pain is a major problem in our society, neously recover within a month of the episode,
costing millions of dollars per year. Eighty per cent of regardless of the type of treatment. However, it has
the population will suffer a disabling episode of low been found on MRI that multifidus muscle atrophy
back pain at least once during their lives and at any was present in 80% of patients with low back pain
one time 35% will be suffering from low back pain (Kader et al. 2000) and the multifidus seems to
(Waddell, 1987; Frymoyer & Cats-Baril 1991). Risk remain atrophied even though spontaneous recovery
factors for first time low back pain sufferers have from low back pain has occurred (Hides et al. 1996).
recently been investigated in a prospective study of Chronic low back pain seems to be a quite different
403 health-care workers over a 3 year period (Adams scenario. It has been described as a ‘complex disorder
et al. 1999). Over 85% had reported having some that must be managed aggressively with a multi-
back pain with 22% experiencing serious back pain. disciplinary approach that addresses physical,
The most consistent predictors were decreased lateral pyschological and socioeconomic aspects of the
flexion range, a long back, reduced lumbar lordosis, illness’ (Wheeler 1995). In fact, all the recent
increased psychological distress and previous non- literature examining chronic low back pain has
serious low back pain (Adams et al. 1999). Despite attributed this condition to primarily psychosocial
extensive research in the area of prevention and factors (Cats-Baril & Frymoyer 1991; Feuerstein &
management of low back pain, the effectiveness of the Beattie 1995; Zusman 1998; Andersson, 1999; Ken-
treatment has, on the whole, been quite poor. dall, 1999; Lundberg, 1999; Hadjistavropoulos &
Treatment success is more common with acute low LaChapelle 2000; Maras et al. 2000). This is probably
because chronic low back pain usually does not
Received: 20 May 2002
respond to treatment directed locally at the site of
Accepted: 26 July 2002 symptoms, so the patient is often blamed for
treatment failure. Physiotherapists examine spinal
Jenny McConnell, BAppSci(Phty), Grad Dip Man Ther,
MbiomedE, Private practice, McConnell & Clements, movements in detail, but often fail to examine other
Physiotherapy, 4 Bond St, 2088 Mosman, NSW, Australia. dynamic activities such as walking, getting out of a
Visiting senior fellow, School of Physiotherapy, University of chair and lifting the arms. Patients with chronic back
Melbourne.
and leg pain frequently complain of increasing pain
Correspondence to: JM. not only with prolonged sitting, but also with walking
Tel.: +61 2 9968 4766; Fax: +61 2 9958 3042;
E-mail: jennymcconnell@bigpond.com and standing. In many situations, patients are

183

INSTABILITY AND The kinematic factors include the dynamic control of SYMPTOM PRODUCTION the joint involving proprioceptive sensory output. needs to employ strategies that will minimize the aggravation of the symptoms and facilitate the rehabilitation of the patient. and the movement of the stiff (Cholewicki et al. The anatomic factors involve the morphology. so performed. which varies from ment (either hyper or hypomobility) regardless of individual to individual. Some new directions in treatment will also be offered. Uncompensated dysfunc. 183–192 # 2002 Elsevier Science Ltd. 1997). Sahrmann. Breaching the threshold cruciate ligament. An obvious example the frequency of the loading (Dye 1996. lower Fig. If decreased patient’s envelope of function by minimizing the passive stability occurs. ligaments. 1996. Spinal stability requires the interaction of three spinal reflex mechanisms. Chronic low back and leg pain could therefore be seen as the result of habitual imbalances in the movement system where a spinal level/s develops increasing mobility as compensation for restrictions in adjacent areas. The practitioner therefore. Treatment factors neutral zone) occurs around the neutral position of a include the type of rehabilitation or surgery received. 1999). physiologic and treatment) are pertinent ruptured. spinal segment. In this situation. muscle strength and motor systemsFpassive (the vertebrae. The threshold. How long will it take before uncompensated JOINT STIFFNESS AND STARTING POSITION movement causes symptoms? The answer to this question is probably best determined by Dye’s model Therapists often consider joint stiffness and soft of tissue homeostasis of a joint (1996). conclude that the anterior cruciate ligament is kinematic. 2002). structural integrity and biomechanical characteristics of tissue (Panjabi’s passive subsystem). the active and neural systems aggravation of the inflamed tissue and can even can compensate by providing dynamic stability to the increase the patient’s threshold of function by spine. when an anterior draw test is will diminish the patient’s envelope of function. 1999). Theoreti. the most vulnerable area of the spine (the rate of repair of damaged tissues. reaching a particular threshold interpreted as often the joint is not in its neutral thereby causing a complex biological cascade of position when the assessment is made. (Dye. tion. This masterclass article will examine the effects of hip stiffness. however. the therapist would not patient become painful. Stability around the neutral zone can be improving the control over the mobile segments increased by muscle activity of as little as 1–3% (O’Sullivan 2000). depends on the amount and where the movement started. would demonstrate an increased draw that activities that initially were not painful for a movement. will ultimately cause pathology (Panjabi 1992a). 1). NEUTRAL ZONE. Novacheck would be the patient with a ruptured posterior 1997. active (the muscles acting on the spine) by Panjabi). Dye contends tissue tightness. . 1996). 1FHomeostasis of a joint (adapted from Dye’s Homeostasis limb loading and thoracic spine restriction as a of the Knee. but would examine the resting position of in determining the size of the envelope of function the tibia before deciding that the increased anterior Manual Therapy (2002) 7(4). but the amount of joint no longer operating inside his/her envelope of mobility in any one direction needs to be carefully function (see Fig. where little resistance is offered by the The therapist can have a positive influence on the passive structures (Panjabi 1992b). fascia control (the active and neural subsystems described and discs). All rights reserved. It may be difficult for the clinician to determine the cause and origin of the back pain as there may be confounding hyper/hypomobility problems of the surrounding soft tissues. be it muscle. cellular homeostasis that determine the quality and cally. A conclusion trauma and repair which is manifested clinically as is therefore made about the overall range of move- pain and swelling. Four factors (anatomic. (Comerford & Mottram 2001b. The physiological factors involve the and neural (central nervous system and nerves genetically determined mechanisms of molecular and controlling the muscles) (Panjabi 1992a).184 Manual Therapy reluctant to seek further treatment as they are concerned that their symptoms will be exacerbated. as that symptoms will only occur when an individual is restricting range of motion. precurser to lumbar spine dysfunction (instability) and pain. cerebral and cerebellar sequencing of motor units. Schache et al. segments. fascial or neural.

All rights reserved. the range of hip movement into extension and external rotation. there will be increased rotation and/or lateral tilting of the pelvis which will manifest as excessive motion in the spine. in combination with poor abdominal sup- low back pain used more lumbar spine movement port and diminished load dissipation in the lower than individuals with no low back pain during extremity. then each limb will go through 2500 femurs. or if dorsiflexion of the great toe is inadequate at push off. Therefore. factor to disc injury and the torsional forces may Movement will have to increase elsewhere (usually in irrevocably damage fibres of the annulus fibrosis the lumbar spine). 1970. but the hips must flex and internally demonstrate diminished pelvic muscular control. indicating weak gluteal musculature. reducing the available ankle range of plantarflexion and hip extension (Dananberg 1997). if the forward bending range is (Farfan et al. 1984. This contention has been excessive amount of movement about a lumbar spine supported in part by the work of Hamilton and segment because of limited hip movement and Richardson (1998). repetitive nature of the loading is considered. 183–192 . particularly if the relative spinal flexibility in these individuals. Initial shock absorption occurs with knee flexion of 10–151. The individual with a sway back posture walks with a Fig. The patient will therefore the spine flex. As soon as the heel hits the ground. then an increase in pelvic rotation occurs during walking. particularly in rotation is a contributory cannot rotate further during the forward bending. he/she presents with a ‘trendelenberg- like’ gait. The internal rotation in the hip HIP INVOLVEMENT IN SPINE MOVEMENTS also causes tightness in the iliotibial band (ITB) and diminished activity in the gluteus medius posterior During forward bending of the trunk not only does fibres (Sahrmann 2002). Recalcitrant chronic low back and leg pain 185 movement was a consequence of the starting position affects forward bending of the spine but also reduces rather than a pathological increase in movement. because that individual lacks hip extension and external rotation. each limb has performed almost 30 million cycles so if there is any asymmetry in the system there will be a greater propensity for tissue overload and hence pain. Internal rotation of the femurs not only stance and swing cycles per day. because the foot is supinated when the heel first strikes the ground (Perry 1992). If the patient has an anteriorly tilted pelvis. The femurs. Manual Therapy (2002) 7(4). SHOCK ABSORPTION DURING GAIT Lumbopelvic movement is further increased during gait if adequate shock absorption has not occurred at the knee or the foot. This rotate (see Fig. A patient who has internally lack of control around the pelvis may further increase rotated femurs often demonstrates a decrease in the movement of an already mobile lumbar spine forward bending because the femurs are at the end of segment. If the patient has a posteriorly tilted pelvis. 2FForward bending. Kelsey et al. may possibly be a significant factor in the forward leaning in sitting. This causes an increase in the rotary movement required in the lumbar spine when the patient walks. an going to be maintained. indicating an increase in development of low back pain.). which equates to one million cycles per year (Dananberg 1997). 2). optimal amount of pelvic movement is reported to # 2002 Elsevier Science Ltd. who found that individuals with control. It has It has been observed clinically that a large number been estimated that if an individual walks for about of low back pain sufferers have internally rotated 80 min in a day. the foot rapidly pronates and the lower leg internally rotates. notice the internal rotation of the combination of increased tilt and rotation. It has been established that excessive range of rotation at the beginning of movement and movement. By age 30 then. If the knee is hyperextended or the subtalar joint is stiff.

All subjects showed excessive rotation the cartilages must be compressed to about motion in the joint above and below the arthrodesis. the posture (Indahl et al. in this way. the energy is not immediately available to restore the structure to its original shape. 41 for lateral tilt and 71 for most likely to injure the Annulus. some relevant anatomy and biomechanics some of the bonds between collagen fibres. The disc contributes hip flexion. pelvic tilt. 2000). . Those in the opposite direction will have BACK PAIN their points of attachment approximated. at any one time the annulus resists twisting motion with Patients with chronic low back and leg pain who lack half of its complement of collagen fibres. only those fibres inclined in the direction of the movement will have their points of attachment MECHANICAL FINDINGS IN CHRONIC LOW separated. If chemical bonds are broken. it is possible that the surfaced recently where it was found that hip muscle excessive movement at one lumbar segment occurring imbalance was predictive of the development of low with every step an individual takes may cause a back pain in female athletes (Nadler et al. Indahl and colleagues excess mobility of a particular lumbar segment may (1999) have found that stimulation of the porcine SI affect the recovery from compression of the ZAJ and joint capsule elicited activity in the Multifidus muscle. This compression must occur. These were this the fibre will undergo micro injury. Because of the alternating therefore vulnerable to injury during this restoration direction of orientation of the collagen fibres in the period (White & Panjabi 1978). When a structure is duration in back pain patients and controls (Leino. It is squeezed out of the During twisting movements all points on the lower structure and the energy used is no longer available to surface of one vertebra will move circumferentially in the system. Alternatively. Interestingly. lateral pelvic displacement. Passive structural changes will affect whereas stimulation of the anterior aspect of the joint the neutral zone and hence the stability of the lumbar elicited responses in Quadratus Lumborum and segments. this has a unique effect on act to restore the form of the structure.186 Manual Therapy be 101 for rotation. The tissue is the Annulus Fibrosus. However. ZAJ impaction occurs before the fibres et al. compensation Twomey 1991). They felt that when an individual lost comes from the posterior elements (Bogduk & one of these essential gait components. For To further understand the effect over time of collagenous tissues. 1999). activitation Restoration to the initial length of a collagenous patterns in the lumbar paraspinals and Biceps structure occurs at a lesser rate and to a lesser extent Femoris muscles were similar in both order and than the original deformation. After 121 of pelvic rotation. and extension than in controls. 2000). and rearranging segments. knee flexion and knee and ankle 35% resistance to torsion. Beyond components essential to normal gait. All rights reserved. some of the energy goes into repetitive torsional forces at one or two lumbar displacing proteoglycans and water. As the distance between the Zyga- was reasonably effective. Displaced water for example does not remain in the structure ANNULAR MECHANICS exerting some sort of back pressure attempting to restore its original form. deformed the energy applied to it goes into deforming nen et al. it has been found Hysteresis is a phenomenon in which there is a loss that the activity of the Gluteus Maximus is shorter in of energy when a structure is subjected to repetitive duration in back pain patients during trunk flexion load and unload cycles (White & Panjabi 1978). of their water (Bogduk & Twomey 1991). 2001). hence hysteresis. particularly Manual Therapy (2002) 7(4). rotation overt failure occurs. Further evidence of the interrelationship of the annulus undergo more than 4% strain (Bogduk of hip muscle control and lumbar spine function has & Twomey 1991). The maximum antero-posterior tilt (Perry 1992). annulus. they cannot the direction of the twist.5 mm of a level of energy consumption as possible. Thus. for every 11 of rotation 0. gluteus maximus. range of rotation of an intervertebral disc without Saunders and colleagues (1953) described six injury is about 31(Bogduk & Twomey 1991). so to accommodate 31 of gait in adolescents. permanent elongation of the annular fibres so these It has been postulated that the sacroiliac joint (SI) fibres are unable to provide adequate restraint when a also has a role in the control of locomotion and body sudden twisting motion occurs. will of the major reasons why twisting movements are the present with tight anterior hip structures. which the authors hypothesized led to the high The Annulus is therefore protected from injury incidence of low back pain in these individuals (Karol by the ZAJ. the structure and straining the bonds within it. the remainder (65%) interaction. 62% of their resting thickness and must lose over half that is the ipsilateral knee and the lumbar spine. with exaggerated motions pophyseal Joint (ZAJ) and the axis of rotation is occurring at the unaffected levels to preserve as low about 30 mm. Once used must be explored. 183–192 # 2002 Elsevier Science Ltd. This is one hip extension and external rotation in gait. However. The articular cartilages of contention has been supported in a recent study the ZAJ are about 2 mm thick and articular cartilage examining the long-term effect of hip arthrodesis on is about 75% water.

the starting position of the joint is critical in the decision-making process. whereby people with chronic pain have associated stiffness in the thoracic spine. All rights reserved. either locally. the normal proprio- improves this hip lies closer to the plinth. the Fig. It has not yet been established whether the muscle tion (Basmajian & De Luca 1985). The deep intrinsic muscles of the spine are recruited to control translation and rotation at the intervertebral level. by damage to patient in a figure of four position (see Fig. enabling spine stiffening. the pelvis should be flat on the table. unless the spine has been placed in a neutral position prior to the commencement of palpation. in this case the lumbar spine. Increased mobility (instability) in the lumbar segment. A variety of strategies are used to control spinal stability at different levels. in low back pain sufferers. 1997). Changes may occur because of altered Anterior hip tightness is tested in prone with the proprioceptive input. Hodges & Richardson 1996. 1993). Although the control problem causes the back pain or whether the adductors forcibly adduct the thigh. Wilder et al. while the long multisegmental muscles prevent buckling of the spine (Bergmark 1989). 1991. which can be examined using accessory or physiological movements. adductor is released (see Fig. In this situation. 1988. there seems to be an be due to the neuroplastic changes which have associated painful trigger point which if palpated. As the patient’s condition et al. In contrast. 1996). 2000). pain perform poorly in tasks demanding attention The thoracic spine is inherently stiff as it is (Kewman et al. changes in the interpretation of proprioceptive input. Fig. segment may actually feel stiff. Magnus will encourage extension and external rota. 3FTesting the flexibility of the anterior hip joint structures. If the ceptive input is either misinterpreted so it does not adductors are tight and painful. often reproduces posterior buttock pain. possibly indicating activity will increase flexion and internal rotation of an attempt by these superficial muscles to compensate the hip whereas the posterior fibres of Adductor for poor deep muscle function (Radebold et al. this is not a back pain triggers the muscle control problem common activity. the hip on the painful side is higher off the plinth than where non-noxious stimuli are perceived as pain (Flor the non-painful side. thereby increasing the segmental mobility in the lumbar spine and so forth. many patients with chronic low back in attentional demands. Recalcitrant chronic low back and leg pain 187 constrained by the ribs and possesses long spinous processes.. If the palpation is being performed in prone and the patient has an increased lumbar lordosis. compromising intervertebral stabi- lity(King et al. so they are essentially synergists (Hodges 2000). Eccleston 1994) and are less # 2002 Elsevier Science Ltd. Leg is supported in external rotation. Manual Therapy (2002) 7(4). 3). occurred in the nervous system (Coderre et al. Increased stiffness in the thoracic region may result in compensatory changes in the passive and active structures in the regions above and below. Thus. Richardson et al. 4FReleasing the adductor trigger point. the patient cannot elicit the appropriate motor response. supporting the pelvis during gait (Williams & The situation may be quite different with chronic Warwick 1980. or centrally. receptors and surrounding structures. Usually. which may in turn cause an increased stiffness in the thoracic region. When pain as some of the alteration in motor control may the Adductor Longus is tight. However. 183–192 . 1999). Adductor Longus and Brevis Abdominals and Erector Spinae. or the internal get into this position until the trigger point in the motor planning model is faulty (Hodges 2000). changes in the recruitment pattern of the local muscles of the trunk have been found. 4). Increased lumbar spine mobility is often accom- panied by poor segmental muscle recruitment/control (Hodges & Richardson 1996. a delayed offset of activity when a load is released from the trunk has been found in the global muscles such as the Oblique the adductor muscles. is often in a non-physiological direction/s. by Ideally. Motor performance may also be affected by changes Additionally. Basmajian & De Luca 1985).

Next a diagonal strip of tape is placed This patient is then reluctant to have further mid-thigh over the appropriate dermatome (posterior treatment. The principle of unloading is based on the premise that inflamed soft tissue does not respond well to stretch (Gresalmer & McConnell 1998. be reversed. McConnell UNLOADING PAINFUL STRUCTURES 2000). becomes thigh for S1. All rights reserved. physiotherapist to mobilize the appropriate stiff Therefore. . Tape can be used to to be increased by the very treatment that is designed unload (shorten) the inflamed neural tissue. but if the pain symptoms but may increase the distal symptoms is increased there is an adverse reaction to treatment. The inflamed tissue needs to more difficult to settle and sometimes symptoms seem be shortened or unloaded. there is a need to decrease the pain input segments without inadvertently stretching mobile from the periphery so that treatment does not tissues. Initially the buttock is leg pain who can only flex to his knees is often given a unloaded. Manual Therapy (2002) 7(4). If the proximal symptoms worsen. 5a). For example. (c) Unloading the calf to further decrease S1 symptoms. the posterior thigh is taped. Unloading the soft tissue struc. which to diminish them. whereas a in manual therapy. producing leg pain. Therapists have a number of varus stress will decrease the symptoms. It is in the chronic state that pain is root. applying a valgus stress to inflamed tissue is certainly central to all interventions the knee will aggravate the condition. (see Fig. Another diagonal piece of tape is tures. Fig. The patient with chronic back and will in turn decrease the pain. aggravate the condition. Key to the success of forthFFig. The tape must be sculptured into the gluteal fold. The soft tissues are lifted up towards management of this patient is to unload the inflamed the buttock. (b) For S1 distribution of pain. clinical experience has demon- strated that if a patient presents with a sprained The concept of minimizing the aggravation of medial collateral ligament. The same weapons in their armoury to manage pain and reduce principle applies for patients with an inflamed nerve inflammation. 183–192 # 2002 Elsevier Science Ltd. particularly the neural tissues will allow the commenced mid calf/shin (following the dermatome). limits his movement even more. lateral aspect of the thigh for L5 and so stiffer and has increases in pain. which should decrease the proximal slump stretch as part of his treatment. 5F(a) Unloading the buttock to decrease leg symptoms. the tape diagonal should be reversed. with the skin being lifted to the buttock. 5b). The direction of the tape is dependent on soft tissues so that the clinician can address the issues symptom responseFif there is a local increase in of lack of flexibility and poor dynamic control symptoms then the direction of the diagonal should (McConnell 2000).188 Manual Therapy able to be focus away from pain (Dufton 1989).

activation will be difficult. Powers et al. O’Sullivan spine mobility (Fig. 1991). Specific exercises for change in the timing in the spinal musculature. 1994. et al. treatment Muscle training to control mobile segments dyna- should be directed at increasing hip and thoracic mically may take many months to achieve. Handfield & Multifidus. so the appropriate muscles are recruited As far as the effect of the unloading tape is during the exercise. All rights reserved. 183–192 . Segmental flexion. 2002). The training process may be may need to practise walking with the knees slightly accelerated by the addition of firm tape across the # 2002 Elsevier Science Ltd. 1997. If there is a problem with push off individuals such that the pain is decreased by 50% the first metatarso-phalangeal joint may need to be results in an earlier activation of the vastus medialis mobilized to minimize the possibility of compensa- oblique (VMO) relative to the vastus lateralis (VL) on tory lumbar spine movement. et al. As the multifidus. so in the long term. 1993. Whether taping the back causes a ior fibres of the Gluteus Medius. 5c). of the muscles. The long- term aim is to increase the number of repetitions before the onset of fatigue. 1998. Shock patients is still debated in the literature. The lumbar et al. 1995). Manual Therapy (2002) 7(4). The patient local trunk muscles. endurance training should be emphasized in on changing the orientation of the fascia or could just treatment. affecting the gating versus abdominis has been reported when subjects mechanism of pain (Garnett & Stephens 1981. Although there have been no studies investigating the effect of tape on low back pain. Gilleard spine is stabilized with the towel. Powers et al. Transversus Abdominus and the poster- Kramer 2000). If there has been habitual disuse concerned. versus abdominis and multifidus has been quite cation of neural tissue (Hall et al. is still speculative. these muscles must be carefully supervised by the enhancing segemmental stability. therapist. Patients should be taught TREATMENT to recognize fatigue so that they do not train through fatigue and risk exacerbating their symptoms. Cerny 1995. treatment is more performed by the patient at a training session will efficacious. EFFECT OF TAPE The effect of tape on pain. Bockrath et al. 1992. Cowan et al. The tape could have some effect function. ascending and descending stairs (Gilleard et al. 1998. The patient should experience an immediate 50% decrease in symptoms. At the same time as increasing the mobility of Cowan et al. depend upon the onset of muscle fatigue. the therapist needs to commence associated with increases in loading response knee stability work on the unstable areas. found that firm taping across the muscle belly of VL O’Sullivan (2000) Comerford and Mottram (2001a) of asymptomatic individuals significantly decreases and others. Cushnagan Fig. (1999). It has been absorption can also be improved by mobilizing a found that taping the patella of symptomatic stiff subtalar joint. transversus abdominis the VL activity during stair descent (Tobin & and gluteus medius muscles all have a stabilizing Robinson 2000). it could be surmised that there would be a bent to improve the shock absorption through the similar measurable pain reduction effect. It has been adequately described by Richardson et al. particularly patellofemoral pain. The me. 6FMobilizing a stiff thoracic spine in sitting. The unloading tapes does however. 1992. as well as increases in quadriceps muscle torque stability training involves muscle control of the (Conway et al. Decreased activity of the obliques and trans- have a proprioceptive effect. has been fairly well established in the literature (Conway et al. Feedback Clinically it works. The tape is kept on for a week before it is renewed and usually only needs two or three applications before the symptoms have settled sufficiently. Once the soft tissues have been unloaded. The number of repetitions symptoms. exercises should be performed in a enable the patient to be treated without an increase in slow. Recalcitrant chronic low back and leg pain 189 again lifting the skin towards the buttock (see Fig. outcome (Sale 1987). Jenner perform rapid ballistic sit up exercises (Richardson & Stephens 1982). controlled fashion. Precise training of the trans- which is a protective response to mechanical provo. the mechanism is yet to be investigated. 1997. Patellar taping has also been adjacent areas. 6) as well as improving the (2000) has described a three-stage model for training stability of the relevant lumbar segments. lower legFsmall range eccentric quadriceps control chanism causing pain reduction for patellofemoral is needed for stability around the knee. The tape on the posterior thigh to the patient must be precise to achieve the desired could be inhibiting an overactive hamstrings muscle. 2002). Thus.

Mannion AF. References type and force of contraction (see Herbert (1993) and Adams MA. Knee slightly flexed. 1995). 7FStabilizing an unstable lumbar segment. 8FTraining posterior gluteus medius. simulating the stance phase of gait (Fig. This contraction is held own symptoms. . patient experiences pain or has poor ‘core’ stability then a more stable position such as sidelying or prone should be chosen initially. Management of chronic low back and leg pain 1995. hips and foot facing the front. segment/s and pelvis. weight back through the heel. joint angle. The inflamed soft tissue should be unloaded so the Pelvic stability training should not be overlooked. muscle training is very specific to limb position. Verhagen et al. for foot and hip of the exercising leg parallel to the wall therapists to review patients every 6 or 12 months to and the knee slightly flexed. 2000). the burden of chronic musculoskele- for 15 seconds and should be repeated often to effect tal problems on the health-care system could possibly an automatic change in the motor programme. If the be reduced. spine. Spine 24(23): 2497–2505 specificity of training). 183–192 # 2002 Elsevier Science Ltd. to gain range. 354(9178): 581–585 a return to functional positions should occur as soon Basmajian J. Williams & as possible. The other knee is flexed ensure patients still know how to manage their to 601 and is resting on the wall for balance. However.190 Manual Therapy Fig. There is also a need in the This can be done with the patient standing with the management of chronic pain problems in general. as well as preventing the requires a multifactorial approach. The symptoms. Fig. 5th edn. Dolan P 1999 Personal risk factors for Sale & MacDougall (1981) for excellent reviews on first time low back pain. If patients are empowered to manage their moving the hips or the feet. velocity. 7). Baltimore Manual Therapy (2002) 7(4). symptoms are not increased when there is an attempt. De Luca C 1985 Muscles Alive. The therapist lateral shift of the patella that occurs with exercise needs to examine the way the patient walks so the (Larsen et al. as chronic problems are never cured. It has been found that CONCLUSION taping is effective in preventing ankle sprains and improving proprioception in the ankle (Robbins et al. 8). so there could be a similar effect of any uneven loading through the lower proprioceptive effect on an unstable segment in the extremity on the lumbar spine can be observed. minimizing the amount of movement and enhancing the proprioceptive input to the stabilizing muscles (Fig. All rights reserved. so for training to be effective. as poor pelvic control can undermine the progress of in treatment. external rotation of the standing leg thigh. Lancet 14. If possible Gluteus gained in the anterior hip structures and thoracic Medius training should be performed in weight spine. Flexibility needs to be the muscle training of the spine. Andersson GB 1999 Epidemiological features of chronic low back pain. while stability is required at the mobile lumbar bearing. lumbar mobile segment. Wilkins. only patient externally rotates the standing knee without managed.

Winter: 39–44 Conway A. Zilvold G Journal 308(6931): 753–755 1999 Distribution of psychological aspects in subgroups of Dananberg H. Esch O 1998 Torsional injury resulting in disc becoming disabled because of low-back pain. Spine. 21(22): Cushnaghan J. Vienna Austria spine posture. Dieppe P 1994 The effect of taping 2640–2650 the patella on pain in the osteoarthritic patient. Manual Therapy 6(1): 3–14 243–253 Comerford MJ and Mottram SL 2001b Movement and stability Hodges PW Richardson CA 1996 Inefficient muscular stabilization dysfunctionFcontemporary developments. Katz J. Malone T. Melzack R 1993 Contribution perceived pain and knee extensor torques during isokinetic of central neuroplasticity to pathological pain: Review of exercise performed by patients with patellofemoral pain clinical and experimental evidence. Stephens JA 1982 Cutaneous reflex responses and their Dye S 1996 The knee as a biologic transmission with an envelope of central nervous system pathways studied in man. 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