# A Research Guided Algorithm to Solving your Low Back Pain!

### Introduction

Written by Dr. Chad Kuntz, PT, DPT, OCS, SCS, CSCS, CISSN, TPI-1

Back pain impacts up to 84% of people throughout their lifetime and has a 67% one year prevalence rate ( meaning at any one point in time in a year, up to 67% of people can have low back pain). While 90% of people actually get better within the next 2 weeks, low back pain patients still take over 50% of the visits in physical therapy clinics ( versus knees, shoulders, etc). In addition, surprisingly the onset is largely due to an insidious onset, meaning “it came out of nowhere,” where nothing happened and no trauma preceded it. This monstrosity costs the USA around 50 billion dollars in healthcare to sustain it and even that number came out around 10 years ago, so the healthcare cost is probably much higher. Lastly, research has shown that only 7% of people actually utilize physical therapy when they could benefit from it. That means 93% of people either tough it out, don’t know about the services of physical therapy, or, I guess, rub some dirt on it’ and move on.

For the 93% out there, I’d like to reach out to you with this article for the purpose of giving you an idea of how to manage your back pain.

### Research

There has been a ton of research performed on low back pain and although not perfect, some light has been shed on some categorization of low back pain for the purpose of improving the efficacy of treatment. I’d like to share it with you and make it practical to help get you on the right track.

Not that you have to memorize this chart or even understand all of the fancy words, what I want you to take away from it is that there are three main categories that you can fall into. Specific Exercise, Manipulation, and lastly, Stabilization.  I’d like to explain how you determine which group you fall into and the exercise that correlates with that subgrouping. In an algorithmic model, we will first start with Specific Exercise. We’ll determine if you fall into either a flexion bias or an extension bias. If you don’t fall into either of those categories, we will move onto the Manipulation category. Lastly, after determining if you do or don’t fall into Manipulation, we will move onto the Stabilization category.

## Specific Exercise

This one is quite simple. First, you will stand up and provide a numerical rating for your pain level while standing with 0 being no pain and 10 being so bad that you’re going to go to the hospital. Then, after determining your number, as seen in the videos below, you will bend forward and touch your toes ( or at least attempt to) and then back backwards. Please take a look at the flow chart linked here. It will help you understand the algorithmic process for Specific Exercise.

### Specific Exercise –  Flexion bias

Start standing. After you touch your toes and come back up, determine if your pain level changed at any point in time during that movement or immediately after upon returning to standing. If you noticed that it substantially got worse, stop. Since bending forwards got worse, please feel free to move onto the next section titled “Specific Exercise -Extension Bias.” The following exercises most likely will not apply to you.\]

If you noticed it didn’t change or seemed to get better, perform up to 10 repetitions. After 10 repetitions, again, make a decision as to what your pain level is. If your pain level decreased, then you can perform the exercises below listed as “Specific Exercises for Flexion.” If your pain stayed the same throughout the 10 repetitions and you don’t feel any better, you can now move onto the next section titled ” Specific Exercise- Extension Bias.”

### Specific Exercise for Flexion

1. Single Knees to Chest- This exercise helps stretch out your lower back and hips in hopes of opening up your low back to find relief. If you notice you have pain in the front of the hip when bringing your knee to your chest, allow the knee to move to the outside as this can decrease hip impingement, yet still do the job of opening up the low back. Hold for 5 seconds and perform 10 times on each side. This exercise will be a prerequisite to the next exercise.

2.  Supine Marching- This second exercise reinforces the flexion bias on your lower back and helps engage in your core musculature. Although it appears simple, most will actually find this quite difficult. As shown below, the towel helps keep you honest that you are indeed, keeping your back flat. While the video shows me pulling the towel only at the top of the movement, this can be performed throughout the entire range of motion. Most will actually have the greatest difficulty keeping the back flat as you slowly return your heel to the ground. Perform 10 times x 2 sets if possible. If you notice you are losing your form, rest until you can properly perform the exercise again.

### Specific Exercise –  Extension Bias

You will again, start in a standing position and determine your pain level again from 0-10 ( this may have changed from performing the previous standing lumbar flexion movements). Then, you will bend backwards as shown in the video. After performing this movement, determine if your pain level changed at any point in time during that movement or immediately after upon returning to standing. If you noticed that it substantially got worse, stop. Since your pain got worse, you can move onto the next section titled “Manipulation.”If you noticed it didn’t change or seemed to get better, perform up to 10 repetitions. After 10 repetitions, again, make a decision as to what your pain level is. If your pain level decreased, then you can perform the exercises below listed as “Specific Exercises for Extension.” If you pain was unchanged, please feel free to move onto the next section titled “Manipulation.”

### Specific Exercise for Extension

1. Prone Press Ups – This exercise simply helps increase the range of motion into extension. Since you noticed that bending backwards helps your pain, this movement will only continue to improve the range of motion for your lumbar spine in the same direction. Keys are to point your toes inwards, keep your pelvis on the ground, and use your arms to help your chest fully off of the ground. Perform these 2 sets x 10 repetitions.

2. Prone Extension Holds –  Now that you’ve improved some range of motion and flexibility into extension, it’s time to use your musculature to further cement in that favorite direction of yours. Lay on your stomach to start. While keeping your feet on the ground, lift your head and chest away from the ground. Keep your eyes looking at the ground so that you don’t tamper with your neck. Hold for 3-5 seconds and perform 10x.

### Manipulation

After assessing your fit to the Specific Exercise categories, it’s time to assess your fit with the notion of receiving or performing mobilizations/manipulations to your lumbar spine.  This one’s quite simple but lets make sure we get it right.

Only if you do not fit into the category of Specific Exercise (either flexion or extension) AND you meet the two qualifications below, do you fit into the Manipulation category.

Qualifications:

1. Have had a recent, worsened flare of symptoms of familiar or chronic symptoms and/or your pain first started < 16 days ago.
2. No symptoms related to your back pain go below your knee ( such as tingling, burning, numbness, etc.)

If you do meet the criteria, I’d like you to try your own version of a self mobilization or self manipulation that can be very successful. In fact, the position and movement itself represents a manipulation technique frequently performed by manual therapists.

If you don’t meet the criteria of Self Mobilization or Manipulation, move onto Stabilization.

### Self- Manipulation

Technique: To be honest, this technique could be performed on either side, not depending on what side you have pain on. Keys are to make sure you have the bottom leg straight, the top leg hooked right behind it and to gently pull down on the knee toward the ground. Set up next to a wall so that the top arm can push into the wall providing more force into the spine to help mobilize and loosen it up. You may or may not hear a “pop,” however more importantly you feel better after performing them. Shoot for 20 gentle pulls, each lasting around 1-2 seconds.

### Stabilization

Last but not least is the Stabilization category. Remember, this category is essentially ruled in by exclusion, meaning you have not fit into either of the two previous categories ( Specific Exercise or Manipulation). However, you still need to ‘fit’ to have a higher chance of success with the exercises. Lets refresh our memory on the criteria.

1. Straight Leg Raise > 91 degrees
2. Positive Prone Instability Test
3. Positive Aberrant Movements
4. Age < 37

First off, remember you only need 3 out of 4 to officially fit this categorical grouping. Before we can say yes or no, we need to know how to score a positive or negative.

#### Straight Leg Raise

Grab a belt, dog leash, or anything that can extend to your foot and does not have an elastic component to it ( like a workout band). Loop it around your foot and simply pull the leg toward the ceiling. Make sure that your other leg is flat against the bed because if it’s bent, you may score a false positive. If you notice your leg goes >91 degrees from the table and is closer to your head than it is your other foot on the table, than this test is positive.

*** For clarification, you’ll see that I do not meet the criteria as I am < 91 degrees.

#### Prone Instability Test

Now this test is typically performed by a health professional or physical therapist. That being said, there is still a way to mimic the test on your own to get a pretty good insight if you are positive for the test or not. Basically the test is determining if you have instability in your lower back and if it is better or not with muscular activation. Muscles, via something known as force closure, can provide stability to the Sacroiliac joint and/or lumbar spine and minimize pain if it is an instability problem upon contraction. To perform the Self-Prone Instability test, lay on your stomach and prop up on your elbows. Maintain this position for 30 seconds. After holding it for 30 seconds, slowly take away your elbows  and lift up your legs at the same time. Hold it for a 3-5 seconds using your back and legs.

If you had an increase in pain during the 30 seconds of the initial position and it got better when using your musculature, it is a positive test. See below for the positioning and an example of the test ( brief example).

#### Aberrant Movements

Aberrant what? Basically what this means to you is the fact that as you are touching your toes from a standing position, that you have pain only at one particular moment throughout the full range of motion.  In other words, when you are standing and go to touch your toes, you feel a small arc of pain only at one point in time of the full range. The video below is an example showing when you may experience this ‘hitch’ like pain.

### Age <37

Uhh pretty self explanatory I hope. Basically the younger you are, the more flexible you are. This increased flexibility can be pathological and yield instability and thus pain.Thus the younger you are, the more likely that clinical instability is a source of your pain.

### Exercise – Stability

First and foremost, understand that there are a LOT of different exercises to choose from when it comes to stability. That being said, I’ve picked a traditional exercise called the bird-dog because I like its attention to the quality of movement you need to exude to successfully complete it. In addition, there are three progressions within the exercise eventually building up to the complete Bird-Dog exercise, so it allows you to find the level of difficulty that’s right for you. Feel free to watch the video below to learn more.

Shoot for 3 sets of perfection x 20 for each step up until you’ve proven that you can move both your arms and legs in an alternating fashion without pain and with sufficient core control.

## Summary

Phew that was a lot information. Let’s review what we discussed.

Back pain has become a leading cost for healthcare due to the numerous amounts of people with back pain. An excessive amount of people with back pain elect MRI’s and utilize the emergency room prior to seeking a physical therapist. This increases the burden on the healthcare system. In addition, most people who have back pain don’t know that they could benefit from skilled physical therapy.

Physical therapy’s progress in research has been substantial over the course of the past few years. Subgrouping classifications have been formed and are largely accepted by the physical therapy community.

This subgrouping follows an algorithmic model that can help improve outcomes. That being said it is not perfect and leaves some people wondering where they fit, if at all. It’s not all that uncommon that a patient will actually fit more than one category with varying degrees of success within each grouping. If you find yourself lost, you can actually try a little bit of all of them and find what feels best. That’s what you’re looking for here anyways, it may just be the long road in.

While this is not intended to be a substitute for a health professional or physical therapist, it is intended to help you learn a little bit about your current pain generator and help mitigate pain. It can help propel you on the right track so that your physical therapist can further help you excel toward your health and fitness goals!

My name is Chad Kuntz and I am physical therapist that believes in reaching into the community to provide education and support to help improve the public’s ability to get them on the right track. Feel free to e-mail me if you have any questions and feel free to check out my social media!

Chad Kuntz, PT, DPT, OCS, SCS, CSCS, CISSN, TPI-1

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