Article

Classification of lumbopelvic pain disorders - Why is it essential for management

Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth WA 6845, Australia.
Manual Therapy (Impact Factor: 1.71). 09/2006; 11(3):169-70. DOI: 10.1016/j.math.2006.01.002
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Manual Therapy ] (]]]]) ]]]]]]
Classification of lumbopelvic pain disorders—Why is it essential for
management
Peter O’Sullivan
Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth WA 6845, Australia
The majority of lumbopelvic pain disorde rs have no
diagnosis leaving a management vacuum. The classifica-
tion of lumbopelvic pain disorders into subgroups is
considered one of the greatest challenges, so as to enable
the application of specific and effective interventions. It
is well acknowledged that chronic lumbopelvic pain
disorders are complex and multi-dimensional in nature.
These disorde rs are commonly associated with changes
in neurophysiology, altered motor control, psychologi-
cal factors such as fear and anxiety, faulty coping
strategies, social impact and in some cases pathoanato-
mical factors (Waddell, 2004). There is considerable
debate as to the significance of these different factors
and what is cause and effect.
There is a growing focus within physiotherapy to treat
motor control impairments associated with these dis-
orders. Altered motor control in CLBP disorders is
complex, highly variable and individual in nature.
Trunk motor control is influenced by: spinal–pelvic
posture, movement, stability demand, respiration and
continence demand as well as neurophysiological
factors, pathology and various psycho logical factors.
Altered motor control may be adaptive (protective) or
mal-adaptive (provocative). It can result in excessive
spinal stability and increased spinal loading (due to
muscle guarding and splinting) or reduced spinal
stability (inhibition of spinal stabilizing muscles) leading
to pain (O’Sullivan, 2005).
It is proposed that there are three main groups that
present with chronic disabling lumbopelvic pain with
regard to motor control impairments (O’Sullivan, 2005).
1. The first group appears to be represented by subjects
where the movement impairment and motor dys-
function is secondary to an underlying pathological
process such as inflammatory pain disorders, neuro-
genic pain, neuropathic or centrally mediated pain
disorders, severe structural disorders.
2. A second group exists where a dominance of
psychological and/or social (non-organic) factors
are the underlying drive behind the disorder. This
results in altered central processing, amplification of
pain, and resultant disordered movement and motor
dysfunction.
In these two groups, attempts to simply normalize
the motor dysfunction and movem ent impairment
does not result in resolution of the disorder and is
likely to fail.
3. It is proposed that a third group exists where mal-
adaptive movement and motor patterns result in
chronic abnormal tissue loading and ongoing pain
and distress. This group appears to present in two
manners:
(a) Pain disorders associated with movement im-
pairment classification are characterized by
avoidant pain behaviour and are associated with
a loss of normal physiological lumbopevic
mobility in the direction of pain. These disorders
present with abnormally high levels of muscle
guarding and co-contraction of lumbopelvic
muscles. This results in abnormally high levels
of compressive loading across articulations,
excessive stability and hence movement restric-
tion as well as muscle strain and fatique. This is
usually accompanied by fear of moving into the
painful impairment, as well as faulty cognitive
coping strategies and beliefs regarding the pain
disorder. This represents a mal-adaptive re-
sponse to a pain disorder and a mechanism for
ongoing pain and disability.
Management of this group is based on a cognitive
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doi:10.1016/j.math.2006.01.002
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UNCORRECTED PROOF
behavioural model. The aim is to reduce fear of
movement and reduce muscle tone by education
and facilitating graduated movement exposure
into the painful range in a relaxed and normal
manner.
(b) Pain disorders associated with control impair-
ment classification are associated with no
impairment to the mobility of the symptomatic
spinal segment in the direction of pain provoca-
tion. Rather they present with impairments in
the control of the symptomatic spinal segment in
the direction of pain. This is associated with
deficits in motor control with the inability to
effectively control the neutral zone of the motion
segment or fix the spinal segme nt at an end range
provocative positions. This appears to result in
pain secondary to recurrent end range strain an d
non-physiological spinal segment movement and
loading. These patients adopt postures and
movement patterns that are mal-ad aptive, pro-
vocative (not avoidant) and represents a me-
chanism for ongoing pain and disability.
A motor learning intervention based on a cognitive
behavioural treatment model with the aim of changing
faulty movement behaviour that is linked to the pain
disorder is advocated for these disorders.
There is growing evidence to support the presence of
these sub-groups of patients leading to effective targeted
interventions (O’Sullivan, 2000, 2004, 2005; O’Sullivan
et al., 2002, 2003, 2005; Burnett et al., 2004; Elvey and
O’Sullivan, 2004; Dankaerts et al., 2005a, b).
Modern manual therapy, Boyling and Jull. 3rd ed.
References
Burnett A, Cornelius A, Dankaerts W, O’Sullivan P. Spinal kinematics
and trunk muscle activity in cyclists: a comparison between healthy
controls and non-specific chronic low back pain subjects. Manual
Therapy 2004;9:211–9.
Dankaerts W, O’Sullivan P, et al. Towards a clinical validation of a
classification method for non specific chronic low back pain
patients with motor control impairment. Manual Therapy 2005a;
in press.
Dankaerts W, O’Sullivan PB, Burnett AF, Straker LM. Differences in
sitting postures are associated with non-specific chronic low back
pain disorders when sub-classified. Spine 2005b; in press.
Elvey R, O’Sullivan P. A contemporary approach to manual therapy.
Amssterdam: Elsevier; 2004.
O’Sullivan P. Lumbar segmental instability: clinical presentation and
specific exercise management. Manual Therapy 2000;5(1):2–12.
O’Sullivan P. Clinical instability of the lumbar spine. Amsterdam:
Elsevier; 2004.
O’Sullivan P. Diagnosis and classification of chronic low back pain
disorders: maladaptive movement and motor control impairments
as underlying mechanism. Manual Therapy 2005; accepted for
publication.
O’Sullivan P, Beales D, Beetham J, Cripps J, Graf F, Lin I, et al.
Altered motor control in subjects with sacro-iliac joint pain during
the active straight leg raise test. Spine 2002;27(1):E1–8.
O’Sullivan P, Burnett A, et al. Lumbar repositioning deficit in a
specific low back pain population. Spine 2003;28(10):1074–9.
O’Sullivan PB, Mitchell T, Bulich P, Waller R, Holte J. The
relationship between posture, lumbar muscle endurance and low
back pain in industrial workers. Manual Therapy 2005; in press.
Waddell G. The back pain revolution. Edinburgh: Churchill Living-
stone; 2004.
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