The addition of manipulation to an extension-oriented intervention for a patient with chronic LBP

Abstract

Objective and importance: There is a paucity of research investigating the combined interventions of direction-specific lumbar exercise and manipulation for individuals with low back pain (LBP) who exhibit centralization or a directional preference. The purpose of this report was to describe the management and outcomes of a patient with chronic LBP who met two categories of the revised treatment based classification (TBC) approach initially described by Delitto and colleagues.

Clinical presentation: A 55-year-old female with a 15-year history of right LBP/leg pain demonstrated centralization of symptoms with repeated extension and met four out of five criteria on the clinical prediction rule for thrust manipulation.

Interventions: The patient was treated for seven physical therapy sessions, once a week for seven weeks. Lumbar thrust manipulation and extension-oriented interventions were combined throughout the course of care. The patient experienced a decrease on the modified Oswestry disability index score from 26 to 8%, an increase in the patient-specific functional scale score from 5.6 to 9.4, and patient-report of full return to pain-free activity at discharge.

Conclusion: A patient with chronic LBP reported a clinically meaningful improvement after seven visits of manipulation and extension-oriented interventions. Further research should compare the effectiveness of combining interventions for individuals who meet the two TBC groups of manipulation and extension-specific exercise compared with performing either intervention alone.

Keywords: Chronic low back pain; Clinical decision making; Directional preference; Extension specific exercise; Motor control; Thrust manipulation; Treatment based classification.

Figures

Figure 1

Patient’s body chart. PC = Cervical pain, PB = Buttock pain, PL = Leg pain, N/T = numbness and tingling, C/V = constant varying, I/M = intermittent, check marks indicate no pain reported in region.

Figure 2

: ODI = Modified Oswestry Disability Index, Eval = initial physical therapy evaluation, DC = discharge from physical therapy. Graph on the left shows improved function over time, graph on the right shows decreased disability over time.