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

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

183
184 Manual Therapy
reluctant to seek further treatment as they are
concerned that their symptoms will be exacerbated.
The practitioner therefore, needs to employ strategies
that will minimize the aggravation of the symptoms
and facilitate the rehabilitation of the patient. 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. 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. (Comerford &
Mottram 2001b; Sahrmann, 2002). This masterclass
article will examine the effects of hip stiffness, lower
limb loading and thoracic spine restriction as a
precurser to lumbar spine dysfunction (instability)
and pain. Some new directions in treatment will also
be offered.
NEUTRAL ZONE, INSTABILITY AND
SYMPTOM PRODUCTION
Spinal stability requires the interaction of three
systemsFpassive (the vertebrae, ligaments, fascia
and discs), active (the muscles acting on the spine)
and neural (central nervous system and nerves
controlling the muscles) (Panjabi 1992a). Theoreti-
cally, the most vulnerable area of the spine (the
neutral zone) occurs around the neutral position of a
spinal segment, where little resistance is offered by the
passive structures (Panjabi 1992b). If decreased
passive stability occurs, the active and neural systems
can compensate by providing dynamic stability to the
spine. Stability around the neutral zone can be
increased by muscle activity of as little as 1–3%
(Cholewicki et al. 1997). Uncompensated dysfunc-
tion, however, will ultimately cause pathology
(Panjabi 1992a).
How long will it take before uncompensated
movement causes symptoms? The answer to this
question is probably best determined by Dye’s model
of tissue homeostasis of a joint (1996). Dye contends
that symptoms will only occur when an individual is
no longer operating inside his/her envelope of
function (see Fig. 1), reaching a particular threshold
thereby causing a complex biological cascade of
trauma and repair which is manifested clinically as
pain and swelling. The threshold, which varies from
individual to individual, depends on the amount and
the frequency of the loading (Dye 1996; Novacheck
1997; Schache et al. 1999). Breaching the threshold
will diminish the patient’s envelope of function, so
that activities that initially were not painful for a
patient become painful. Four factors (anatomic,
kinematic, physiologic and treatment) are pertinent
in determining the size of the envelope of function
Manual Therapy (2002) 7(4), 183–192
Fig. 1FHomeostasis of a joint (adapted from Dye’s Homeostasis
of the Knee, 1996).
(Dye, 1996; 1999). The anatomic factors involve the
morphology, structural integrity and biomechanical
characteristics of tissue (Panjabi’s passive subsystem).
The kinematic factors include the dynamic control of
the joint involving proprioceptive sensory output,
cerebral and cerebellar sequencing of motor units,
spinal reflex mechanisms, muscle strength and motor
control (the active and neural subsystems described
by Panjabi). The physiological factors involve the
genetically determined mechanisms of molecular and
cellular homeostasis that determine the quality and
rate of repair of damaged tissues. Treatment factors
include the type of rehabilitation or surgery received.
The therapist can have a positive influence on the
patient’s envelope of function by minimizing the
aggravation of the inflamed tissue and can even
increase the patient’s threshold of function by
improving the control over the mobile segments
(O’Sullivan 2000), and the movement of the stiff
segments.
JOINT STIFFNESS AND STARTING POSITION
Therapists often consider joint stiffness and soft
tissue tightness, be it muscle, fascial or neural, as
restricting range of motion, but the amount of joint
mobility in any one direction needs to be carefully
interpreted as often the joint is not in its neutral
position when the assessment is made. A conclusion
is therefore made about the overall range of move-
ment (either hyper or hypomobility) regardless of
where the movement started. An obvious example
would be the patient with a ruptured posterior
cruciate ligament, when an anterior draw test is
performed, would demonstrate an increased draw
movement. In this situation, the therapist would not
conclude that the anterior cruciate ligament is
ruptured, but would examine the resting position of
the tibia before deciding that the increased anterior
# 2002 Elsevier Science Ltd. All rights reserved.

movement was a consequence of the starting position
rather than a pathological increase in movement.
HIP INVOLVEMENT IN SPINE MOVEMENTS
During forward bending of the trunk not only does
the spine flex, but the hips must flex and internally
rotate (see Fig. 2). A patient who has internally
rotated femurs often demonstrates a decrease in
forward bending because the femurs are at the end of
range of rotation at the beginning of movement and
cannot rotate further during the forward bending.
Movement will have to increase elsewhere (usually in
the lumbar spine), if the forward bending range is
going to be maintained. This contention has been
supported in part by the work of Hamilton and
Richardson (1998), who found that individuals with
low back pain used more lumbar spine movement
than individuals with no low back pain during
forward leaning in sitting, indicating an increase in
relative spinal flexibility in these individuals.
It has been observed clinically that a large number
of low back pain sufferers have internally rotated
femurs. Internal rotation of the femurs not only
Fig. 2FForward bending, notice the internal rotation of the
femurs.
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Recalcitrant chronic low back and leg pain 185
affects forward bending of the spine but also reduces
the range of hip movement into extension and
external rotation. This causes an increase in the
rotary movement required in the lumbar spine when
the patient walks. The internal rotation in the hip
also causes tightness in the iliotibial band (ITB) and
diminished activity in the gluteus medius posterior
fibres (Sahrmann 2002). The patient will therefore
demonstrate diminished pelvic muscular control. This
lack of control around the pelvis may further increase
the movement of an already mobile lumbar spine
segment. It has been established that excessive
movement, particularly in rotation is a contributory
factor to disc injury and the torsional forces may
irrevocably damage fibres of the annulus fibrosis
(Farfan et al. 1970; Kelsey et al. 1984;). Therefore, an
excessive amount of movement about a lumbar spine
segment because of limited hip movement and
control, in combination with poor abdominal sup-
port and diminished load dissipation in the lower
extremity, may possibly be a significant factor in the
development of low back pain, particularly if the
repetitive nature of the loading is considered. It has
been estimated that if an individual walks for about
80 min in a day, then each limb will go through 2500
stance and swing cycles per day, which equates to one
million cycles per year (Dananberg 1997). By age 30
then, 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.
SHOCK ABSORPTION DURING GAIT
Lumbopelvic movement is further increased during
gait if adequate shock absorption has not occurred at
the knee or the foot, or if dorsiflexion of the great toe
is inadequate at push off, reducing the available ankle
range of plantarflexion and hip extension (Dananberg
1997).
Initial shock absorption occurs with knee flexion of
10–151, because the foot is supinated when the heel
first strikes the ground (Perry 1992). As soon as the
heel hits the ground, the foot rapidly pronates and
the lower leg internally rotates. If the knee is
hyperextended or the subtalar joint is stiff, there will
be increased rotation and/or lateral tilting of the
pelvis which will manifest as excessive motion in the
spine. If the patient has an anteriorly tilted pelvis,
then an increase in pelvic rotation occurs during
walking, because that individual lacks hip extension
and external rotation. If the patient has a posteriorly
tilted pelvis, he/she presents with a ‘trendelenberg-
like’ gait, indicating weak gluteal musculature. The
individual with a sway back posture walks with a
combination of increased tilt and rotation. The
optimal amount of pelvic movement is reported to
Manual Therapy (2002) 7(4), 183–192
186 Manual Therapy
be 101 for rotation, 41 for lateral tilt and 71 for
antero-posterior tilt (Perry 1992).
Saunders and colleagues (1953) described six
components essential to normal gait. These were
pelvic rotation, pelvic tilt, lateral pelvic displacement,
hip flexion, knee flexion and knee and ankle
interaction. They felt that when an individual lost
one of these essential gait components, compensation
was reasonably effective, with exaggerated motions
occurring at the unaffected levels to preserve as low
a level of energy consumption as possible. This
contention has been supported in a recent study
examining the long-term effect of hip arthrodesis on
gait in adolescents. All subjects showed excessive
motion in the joint above and below the arthrodesis,
that is the ipsilateral knee and the lumbar spine,
which the authors hypothesized led to the high
incidence of low back pain in these individuals (Karol
et al. 2000). Further evidence of the interrelationship
of hip muscle control and lumbar spine function has
surfaced recently where it was found that hip muscle
imbalance was predictive of the development of low
back pain in female athletes (Nadler et al. 2001).
It has been postulated that the sacroiliac joint (SI)
also has a role in the control of locomotion and body
posture (Indahl et al. 1999). Indahl and colleagues
(1999) have found that stimulation of the porcine SI
joint capsule elicited activity in the Multifidus muscle,
whereas stimulation of the anterior aspect of the joint
elicited responses in Quadratus Lumborum and
gluteus maximus. Interestingly, it has been found
that the activity of the Gluteus Maximus is shorter in
duration in back pain patients during trunk flexion
and extension than in controls. However, activitation
patterns in the lumbar paraspinals and Biceps
Femoris muscles were similar in both order and
duration in back pain patients and controls (Leino-
nen et al. 2000).
To further understand the effect over time of
repetitive torsional forces at one or two lumbar
segments, some relevant anatomy and biomechanics
must be explored.
ANNULAR MECHANICS
During twisting movements all points on the lower
surface of one vertebra will move circumferentially in
the direction of the twist, this has a unique effect on
the Annulus Fibrosus. Because of the alternating
direction of orientation of the collagen fibres in the
annulus, only those fibres inclined in the direction of
the movement will have their points of attachment
separated. Those in the opposite direction will have
their points of attachment approximated. Thus, at
any one time the annulus resists twisting motion with
half of its complement of collagen fibres. This is one
of the major reasons why twisting movements are the
Manual Therapy (2002) 7(4), 183–192
most likely to injure the Annulus. The maximum
range of rotation of an intervertebral disc without
injury is about 31(Bogduk & Twomey 1991). Beyond
this the fibre will undergo micro injury. After 121 of
rotation overt failure occurs. The disc contributes
35% resistance to torsion, the remainder (65%)
comes from the posterior elements (Bogduk &
Twomey 1991). As the distance between the Zyga-
pophyseal Joint (ZAJ) and the axis of rotation is
about 30 mm, for every 11 of rotation 0.5 mm of
compression must occur. The articular cartilages of
the ZAJ are about 2 mm thick and articular cartilage
is about 75% water, so to accommodate 31 of
rotation the cartilages must be compressed to about
62% of their resting thickness and must lose over half
of their water (Bogduk & Twomey 1991).
The Annulus is therefore protected from injury
by the ZAJ. ZAJ impaction occurs before the fibres
of the annulus undergo more than 4% strain (Bogduk
& Twomey 1991). However, it is possible that the
excessive movement at one lumbar segment occurring
with every step an individual takes may cause a
permanent elongation of the annular fibres so these
fibres are unable to provide adequate restraint when a
sudden twisting motion occurs. Alternatively, the
excess mobility of a particular lumbar segment may
affect the recovery from compression of the ZAJ and
hence hysteresis. Passive structural changes will affect
the neutral zone and hence the stability of the lumbar
segments.
Hysteresis is a phenomenon in which there is a loss
of energy when a structure is subjected to repetitive
load and unload cycles (White & Panjabi 1978).
Restoration to the initial length of a collagenous
structure occurs at a lesser rate and to a lesser extent
than the original deformation. When a structure is
deformed the energy applied to it goes into deforming
the structure and straining the bonds within it. For
collagenous tissues, some of the energy goes into
displacing proteoglycans and water, and rearranging
some of the bonds between collagen fibres. Once used
in this way, the energy is not immediately available to
restore the structure to its original shape. Displaced
water for example does not remain in the structure
exerting some sort of back pressure attempting to
restore its original form. It is squeezed out of the
structure and the energy used is no longer available to
the system. If chemical bonds are broken, they cannot
act to restore the form of the structure. The tissue is
therefore vulnerable to injury during this restoration
period (White & Panjabi 1978).
MECHANICAL FINDINGS IN CHRONIC LOW
BACK PAIN
Patients with chronic low back and leg pain who lack
hip extension and external rotation in gait, will
present with tight anterior hip structures, particularly
# 2002 Elsevier Science Ltd. All rights reserved.

Fig. 3FTesting the flexibility of the anterior hip joint structures.
Fig. 4FReleasing the adductor trigger point. Leg is supported in
external rotation.
the adductor muscles. Adductor Longus and Brevis
activity will increase flexion and internal rotation of
the hip whereas the posterior fibres of Adductor
Magnus will encourage extension and external rota-
tion (Basmajian & De Luca 1985). Although the
adductors forcibly adduct the thigh, this is not a
common activity, so they are essentially synergists
supporting the pelvis during gait (Williams &
Warwick 1980; Basmajian & De Luca 1985). When
the Adductor Longus is tight, there seems to be an
associated painful trigger point which if palpated,
often reproduces posterior buttock pain.
Anterior hip tightness is tested in prone with the
patient in a figure of four position (see Fig. 3).
Ideally, the pelvis should be flat on the table. Usually,
the hip on the painful side is higher off the plinth than
the non-painful side. As the patient’s condition
improves this hip lies closer to the plinth. If the
adductors are tight and painful, the patient cannot
get into this position until the trigger point in the
adductor is released (see Fig. 4).
Additionally, many patients with chronic low back
pain have associated stiffness in the thoracic spine.
The thoracic spine is inherently stiff as it is
# 2002 Elsevier Science Ltd. All rights reserved.
Recalcitrant chronic low back and leg pain 187
constrained by the ribs and possesses long spinous
processes. Increased stiffness in the thoracic region
may result in compensatory changes in the passive
and active structures in the regions above and below,
in this case the lumbar spine, which may in turn cause
an increased stiffness in the thoracic region, thereby
increasing the segmental mobility in the lumbar spine
and so forth. Increased mobility (instability) in the
lumbar segment, which can be examined using
accessory or physiological movements, is often in a
non-physiological direction/s.
If the palpation is being performed in prone and
the patient has an increased lumbar lordosis, the
segment may actually feel stiff, unless the spine
has been placed in a neutral position prior to the
commencement of palpation. Thus, the starting
position of the joint is critical in the decision-making
process.
Increased lumbar spine mobility is often accom-
panied by poor segmental muscle recruitment/control
(Hodges & Richardson 1996; Richardson et al. 1999).
A variety of strategies are used to control spinal
stability at different levels. The deep intrinsic muscles
of the spine are recruited to control translation and
rotation at the intervertebral level, enabling spine
stiffening, while the long multisegmental muscles
prevent buckling of the spine (Bergmark 1989).
However, in low back pain sufferers, changes in the
recruitment pattern of the local muscles of the trunk
have been found, compromising intervertebral stabi-
lity(King et al. 1988; Hodges & Richardson 1996;
Wilder et al. 1996). In contrast, a delayed offset of
activity when a load is released from the trunk has
been found in the global muscles such as the Oblique
Abdominals and Erector Spinae, possibly indicating
an attempt by these superficial muscles to compensate
for poor deep muscle function (Radebold et al. 2000).
It has not yet been established whether the muscle
control problem causes the back pain or whether the
back pain triggers the muscle control problem
(Hodges 2000).
The situation may be quite different with chronic
pain as some of the alteration in motor control may
be due to the neuroplastic changes which have
occurred in the nervous system (Coderre et al.
1993). Changes may occur because of altered
proprioceptive input, either locally, by damage to
receptors and surrounding structures, or centrally, by
changes in the interpretation of proprioceptive input,
where non-noxious stimuli are perceived as pain (Flor
et al., 1997). In this situation, the normal proprio-
ceptive input is either misinterpreted so it does not
elicit the appropriate motor response, or the internal
motor planning model is faulty (Hodges 2000).
Motor performance may also be affected by changes
in attentional demands, whereby people with chronic
pain perform poorly in tasks demanding attention
(Kewman et al. 1991; Eccleston 1994) and are less
Manual Therapy (2002) 7(4), 183–192
188 Manual Therapy
able to be focus away from pain (Dufton 1989).
Therefore, there is a need to decrease the pain input
from the periphery so that treatment does not
aggravate the condition.
UNLOADING PAINFUL STRUCTURES
The concept of minimizing the aggravation of
inflamed tissue is certainly central to all interventions
in manual therapy. Therapists have a number of
weapons in their armoury to manage pain and reduce
inflammation. It is in the chronic state that pain is
more difficult to settle and sometimes symptoms seem
to be increased by the very treatment that is designed
to diminish them. The patient with chronic back and
leg pain who can only flex to his knees is often given a
slump stretch as part of his treatment, but if the pain
is increased there is an adverse reaction to treatment.
This patient is then reluctant to have further
treatment, limits his movement even more, becomes
stiffer and has increases in pain. Key to the success of
management of this patient is to unload the inflamed
soft tissues so that the clinician can address the issues
of lack of flexibility and poor dynamic control
(McConnell 2000). Unloading the soft tissue struc-
tures, particularly the neural tissues will allow the
Fig. 5F(a) Unloading the buttock to decrease leg symptoms. The tape must be sculptured into the gluteal fold. (b) For S1 distribution of
pain, the posterior thigh is taped, with the skin being lifted to the buttock. If the proximal symptoms worsen, the tape diagonal should be
reversed. (c) Unloading the calf to further decrease S1 symptoms.
Manual Therapy (2002) 7(4), 183–192
physiotherapist to mobilize the appropriate stiff
segments without inadvertently stretching mobile
tissues.
The principle of unloading is based on the premise
that inflamed soft tissue does not respond well to
stretch (Gresalmer & McConnell 1998; McConnell
2000). For example, clinical experience has demon-
strated that if a patient presents with a sprained
medial collateral ligament, applying a valgus stress to
the knee will aggravate the condition, whereas a
varus stress will decrease the symptoms. The same
principle applies for patients with an inflamed nerve
root, producing leg pain. The inflamed tissue needs to
be shortened or unloaded. Tape can be used to
unload (shorten) the inflamed neural tissue, which
will in turn decrease the pain. Initially the buttock is
unloaded, which should decrease the proximal
symptoms but may increase the distal symptoms
(see Fig. 5a). Next a diagonal strip of tape is placed
mid-thigh over the appropriate dermatome (posterior
thigh for S1; lateral aspect of the thigh for L5 and so
forthFFig. 5b). The soft tissues are lifted up towards
the buttock. The direction of the tape is dependent on
symptom responseFif there is a local increase in
symptoms then the direction of the diagonal should
be reversed. Another diagonal piece of tape is
commenced mid calf/shin (following the dermatome),
# 2002 Elsevier Science Ltd. All rights reserved.

again lifting the skin towards the buttock (see Fig.
5c). The patient should experience an immediate 50%
decrease in symptoms. 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.
EFFECT OF TAPE
The effect of tape on pain, particularly patellofemoral
pain, has been fairly well established in the literature
(Conway et al. 1992; Bockrath et al. 1993; Cushnagan
et al. 1994; Cerny 1995; Powers et al. 1997; Gilleard
et al. 1998; Cowan et al. 2002). Although there have
been no studies investigating the effect of tape on low
back pain, it could be surmised that there would be a
similar measurable pain reduction effect. The me-
chanism causing pain reduction for patellofemoral
patients is still debated in the literature. It has been
found that taping the patella of symptomatic
individuals such that the pain is decreased by 50%
results in an earlier activation of the vastus medialis
oblique (VMO) relative to the vastus lateralis (VL) on
ascending and descending stairs (Gilleard et al. 1998;
Cowan et al. 2002). Patellar taping has also been
associated with increases in loading response knee
flexion, as well as increases in quadriceps muscle torque
(Conway et al. 1992; Powers et al. 1997; Handfield &
Kramer 2000). Whether taping the back causes a
change in the timing in the spinal musculature,
enhancing segemmental stability, is still speculative.
As far as the effect of the unloading tape is
concerned, the mechanism is yet to be investigated.
Clinically it works. The tape on the posterior thigh
could be inhibiting an overactive hamstrings muscle,
which is a protective response to mechanical provo-
cation of neural tissue (Hall et al. 1995). It has been
found that firm taping across the muscle belly of VL
of asymptomatic individuals significantly decreases
the VL activity during stair descent (Tobin &
Robinson 2000). The tape could have some effect
on changing the orientation of the fascia or could just
have a proprioceptive effect, affecting the gating
mechanism of pain (Garnett & Stephens 1981; Jenner
& Stephens 1982). The unloading tapes does however,
enable the patient to be treated without an increase in
symptoms, so in the long term, treatment is more
efficacious.
TREATMENT
Once the soft tissues have been unloaded, treatment
should be directed at increasing hip and thoracic
spine mobility (Fig. 6) as well as improving the
stability of the relevant lumbar segments. The patient
may need to practise walking with the knees slightly
# 2002 Elsevier Science Ltd. All rights reserved.
Recalcitrant chronic low back and leg pain 189
Fig. 6FMobilizing a stiff thoracic spine in sitting. The lumbar
spine is stabilized with the towel.
bent to improve the shock absorption through the
lower legFsmall range eccentric quadriceps control
is needed for stability around the knee. Shock
absorption can also be improved by mobilizing a
stiff subtalar joint. If there is a problem with push off
the first metatarso-phalangeal joint may need to be
mobilized to minimize the possibility of compensa-
tory lumbar spine movement.
At the same time as increasing the mobility of
adjacent areas, the therapist needs to commence
stability work on the unstable areas. Segmental
stability training involves muscle control of the
Multifidus, Transversus Abdominus and the poster-
ior fibres of the Gluteus Medius. Specific exercises for
these muscles must be carefully supervised by the
therapist, so the appropriate muscles are recruited
during the exercise. If there has been habitual disuse
of the muscles, activation will be difficult. Feedback
to the patient must be precise to achieve the desired
outcome (Sale 1987). Precise training of the trans-
versus abdominis and multifidus has been quite
adequately described by Richardson et al. (1999),
O’Sullivan (2000) Comerford and Mottram (2001a)
and others. As the multifidus, transversus abdominis
and gluteus medius muscles all have a stabilizing
function, endurance training should be emphasized in
treatment. Decreased activity of the obliques and trans-
versus abdominis has been reported when subjects
perform rapid ballistic sit up exercises (Richardson
et al. 1991). Thus, exercises should be performed in a
slow, controlled fashion. The number of repetitions
performed by the patient at a training session will
depend upon the onset of muscle fatigue. The long-
term aim is to increase the number of repetitions
before the onset of fatigue. Patients should be taught
to recognize fatigue so that they do not train through
fatigue and risk exacerbating their symptoms.
Muscle training to control mobile segments dyna-
mically may take many months to achieve. O’Sullivan
(2000) has described a three-stage model for training
local trunk muscles. The training process may be
accelerated by the addition of firm tape across the
Manual Therapy (2002) 7(4), 183–192
190 Manual Therapy
Fig. 7FStabilizing an unstable lumbar segment.
lumbar mobile segment, minimizing the amount of
movement and enhancing the proprioceptive input to
the stabilizing muscles (Fig. 7). It has been found that
taping is effective in preventing ankle sprains and
improving proprioception in the ankle (Robbins et al.
1995; Verhagen et al. 2000), as well as preventing the
lateral shift of the patella that occurs with exercise
(Larsen et al. 1995), so there could be a similar
proprioceptive effect on an unstable segment in the
spine.
Pelvic stability training should not be overlooked,
as poor pelvic control can undermine the progress of
the muscle training of the spine. If possible Gluteus
Medius training should be performed in weight
bearing, simulating the stance phase of gait (Fig. 8).
This can be done with the patient standing with the
foot and hip of the exercising leg parallel to the wall
and the knee slightly flexed. The other knee is flexed
to 601 and is resting on the wall for balance. The
patient externally rotates the standing knee without
moving the hips or the feet. This contraction is held
for 15 seconds and should be repeated often to effect
an automatic change in the motor programme. If the
patient experiences pain or has poor ‘core’ stability
then a more stable position such as sidelying or prone
should be chosen initially. However, muscle training
is very specific to limb position, joint angle, velocity,
type and force of contraction (see Herbert (1993) and
Sale & MacDougall (1981) for excellent reviews on
specificity of training), so for training to be effective,
a return to functional positions should occur as soon
as possible.
Manual Therapy (2002) 7(4), 183–192
Fig. 8FTraining posterior gluteus medius. Knee slightly flexed,
weight back through the heel, hips and foot facing the front,
external rotation of the standing leg thigh.
CONCLUSION
Management of chronic low back and leg pain
requires a multifactorial approach. The therapist
needs to examine the way the patient walks so the
effect of any uneven loading through the lower
extremity on the lumbar spine can be observed.
The inflamed soft tissue should be unloaded so the
symptoms are not increased when there is an attempt,
in treatment, to gain range. Flexibility needs to be
gained in the anterior hip structures and thoracic
spine, while stability is required at the mobile lumbar
segment/s and pelvis. There is also a need in the
management of chronic pain problems in general, for
therapists to review patients every 6 or 12 months to
ensure patients still know how to manage their
symptoms, as chronic problems are never cured, only
managed. If patients are empowered to manage their
own symptoms, the burden of chronic musculoskele-
tal problems on the health-care system could possibly
be reduced.
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