Combining spinal adjustments, postural stabilization, and rehabilitative exercise
can result in a successful care program for chronic low back pain
Low back pain is a common health care and social
problem associated with disability and absence from work. One 2005 medical
study of chronic spinal pain stated that the “lifetime prevalence of
spinal pain has been reported as 54% to 80%, with as many as 60% of
patients continuing to have chronic pain 5 years or longer after the
initial episode.”1 The long-term and disabling conditions of chronic and
recurrent low back problems are of major concern, from both cost and
morbidity aspects.
Chiropractic care has been shown to compare favorably
to medical care with respect to long-term pain and disability outcomes in
many cases,2 but the chiropractor should carefully consider the optimum
treatment plan for each patient on an individual basis. For most cases of
chronic low back pain, I recommend a three-step program of spinal
adjustments, postural stabilization, and rehabilitative exercise.
Combining these three elements can make the difference between a
successful care program and a lingering, recurring low back condition.
Spinal Adjustments
As far back as 1985, medical research was reporting
that “a 2- to 3-week regimen of daily spinal manipulations by an
experienced chiropractor” brought significant improvement in 81% of
totally disabled patients with chronic low back and referred leg pain.3 The patients in the
study were from a university back-pain clinic for patients who had failed
to respond to previous conservative or surgical treatment. The
researchers stated that, “in our experience, anything less than 2
weeks of daily manipulation is inadequate for chronic back-pain
patients.” In addition, several chiropractic research studies
published between 1979 and 1993 have described various procedures that
assisted patients in regaining lumbopelvic structural function and
alignment.4–6
Postural Stabilization
A significant factor in reducing excessive
biomechanical forces on the lumbar spine—the use of external supports
to decrease external forces—is frequently overlooked by
practitioners. Positioning aids such as sitting postural supports (examples
are postural backrests or ischial lifts for chairs and car seats), standing
postural supports (such as foot orthotics and heel lifts), and sleeping
postural supports (such as mattresses and pillows) can all greatly assist
in the long-term management of painful lumbar spine conditions.
During standing and walking (not to mention running in
athletes) the lumbar spine and pelvis balance on the lower extremities. If
leg or foot asymmetries or alignment problems are present, abnormal forces
are transmitted along the closed kinetic/kinematic chain, interfering with
spinal function.7 When excessive pronation and/or arch collapse is present, a
torque force produces internal rotation stresses to the leg, hip, and
pelvis.8
These forces can be decreased significantly with the use of custom-made orthotics, which help to stabilize the spine and pelvis. In patients with degenerative
changes in the lumbar disks and facets, the external force of heel strike
may aggravate and perpetuate low back pain and is easily reduced with the
use of shock-absorbing orthotics.9,10
Rehabilitative Exercises
Corrective exercises done at home to strengthen
supporting muscles are recommended as an adjunct to chiropractic
adjustments and postural stabilization. Active involvement of the chronic
low back patient in an appropriate exercise program has been found to be
very beneficial,11 even for patients with herniated disks.12 Flexibility and strength
exercises can bring about rapid improvements in lumbar spinal function as
well as decreases in pain levels.13 Activity should focus on developing strength in the
abdominals and supporting pelvic and low back muscles. This can also
enhance the tissues’ shock-absorbing properties.
Specific exercises must develop “dynamic control
of lumbar spine forces in order to eliminate repetitive injury to the
intervertebral discs, facet joints, and related structures.”14 Recommending
specific exercises is not easy, as some research supports the need for
abdominal strengthening,15,16 others advise pelvic tilts,17 and other reports focus on the importance of strengthening
the lumbar extensor muscles.18,19 The bottom line is that patients’ needs vary,
and exercises that worked for one will not necessarily work for another.
The first step toward a solution is to use clinical
testing and, in particular, postural evaluation to identify the most
appropriate and effective lumbopelvic exercise routine. By evaluating the
patient’s three-dimensional posture in a reference frame and noting
any specific deviations from the ideal intrinsic equilibrium, the doctor is
able to identify the sources of excessive biomechanical stress and give
specific corrective exercise recommendations. Of course, a general
conditioning and flexibility program will complement the specific
corrective postural exercises.
Kim D. Christensen, DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at
PeaceHealth Hospital in Longview, Wash. He has participated as team
chiropractor to high school and university athletic programs. He is also a
postgraduate faculty member at numerous chiropractic colleges, past
president of the ACA Rehab Council, and a lecturer and author of many
musculoskeletal rehabilitation texts. Contact him at
kchristensen@peacehealth.org.
References
1. Boswell MV, Shah RV, Everett CR, et al.
Interventional techniques in the management of chronic spinal pain:
evidence-based practice guidelines. Pain
Physician. 2005;8(1):1–47.
2. Nyiendo J, Haas M, Goldberg B, Sexton G.
Pain, disability, and satisfaction outcomes and predictors of outcomes: a
practice-based study of chronic low back pain patients attending primary
care and chiropractic physicians. J Manip
Physiol Ther. 2001;24(7):433–439.
3. Kirkaldy-Willis WH, Cassidy JD. Spinal
manipulation in the treatment of low back pain. Can
Fam Phys. 1985;31:535–540.
4. Mierau D, Cassidy JD. A comparison of the
effectiveness of spinal manipulative therapy for low back pain patients
with and without spondylolisthesis. J Manip
Physiol Ther. 1987;10:49–55.
5. Cassidy JD, Potter GE. Motion examination of
the lumbar spine. J Manip Physiol Ther. 1979;2:151–158.
6. Cassidy JD, Thiel HW, Kirkaldy-Wills WH. Side
posture manipulation for lumbar intervertebral disk herniation. J Manip Physiol Ther. 1993;16:
97–103.
7. Keane GP. Back pain complicated by an
associated disability. In: White AH, Anderson R, eds. Conservative Care of Low Back Pain. Baltimore, Md: Williams & Wilkins; 1991:307.
9. Light LH. Skeletal transients on heel strike
in normal walking with different footwear. J
Biomechanics. 1980;13:477–480.
10. Fauno P. Soreness in lower extremities and back is
reduced by use of shock absorbing heel inserts. Int
J Sports Med. 1993;14:288–290.
11. Mayer TG, Gatchell RJ. Objective assessment of
spine function following industrial injury: a prospective study with
comparison group and one-year follow-up. Spine. 1985;10:482–493.
12. Saal JA, Saal JS. Nonoperative treatment of
herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine. 1989;14:
431–437.
13. White AA, Panjabi MM. Clinical
Biomechanics of the Spine. 2nd ed.
Philadelphia, Pa: JB Lippincott Co; 1990:429.
14. Saal JA, Saal JS. Rehabilitation of the patient.
In: White AH, Anderson R, eds. Conservative Care
of Low Back Pain. Baltimore, Md: Williams &
Wilkins; 1991:31.
15. Williams PC. Lesions of the lumbosacral spine:
chronic traumatic (postural) destruction of the lumbosacral intervertebral
disc. J Bone Joint Surg. 1937;19:690.
16. Schmidt GL, Herring T. Assessment of abdominal and
back extensor functions. Spine. 1983;11:19–27.
17. Partridge MJ, Walters CE. Participation of the
abdominal muscles in various movements of the trunk in man: an EMG study. Phys Ther Rev. 1959;39:
791–800.
18. Mayer TG, Smith SS. Quantification of lumbar
function: sagittal plane trunk strength in chronic low-back pain patients. Spine. 1985;10:
765–772.
19. Beinborn DS, Morrissey MC. A review of the
literature related to trunk muscle performance. Spine. 1988;13:655–660.
Low back pain is a common health care and social
problem associated with disability and absence from work. One 2005 medical
study of chronic spinal pain stated that the “lifetime prevalence of
spinal pain has been reported as 54% to 80%, with as many as 60% of
patients continuing to have chronic pain 5 years or longer after the
initial episode.”1 The long-term and disabling conditions of chronic and
recurrent low back problems are of major concern, from both cost and
morbidity aspects.
Spinal Adjustments 
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