Multidimensional manual therapy model for managing patients with chronic non-specific low back pain

Abstract

Low back pain (LBP) is regarded as a major health and economic problem in western industrialised countries even at this time in the twenty-first century. Researchers estimate that it has increased to affect about 45% of the population in 2011. This increase creates a major burden on the health care services, social structures and the economy in terms of absenteeism from work. CNSLBP is still poorly understood. Main reasons for the poor understanding of CNSLBP discussed in this study are the limited understanding of the effect of the spine as kinetic chain which includes the head and pelvic girdle and with its attachments to the scapulae . The process of development of ISMS dysfunction are discussed as a combination of abnormal spinal loading, soft and neural tissue plasticity that result in biomechanical malalignment, adaptive and maladaptive movement patterns, pain processing integrated with psychosocial factors that influence the biomechanical, pain processing and psychological responses are discussed as possible mechanisms in the development of CNSLBP. The researcher developed a multidimensional manual therapy model to manage patients with CNSLBP based on metacognitive reflection on her clinical reasoning over a period of 40 years as the research methodology. The metacognitive reflection has been performed within the interpretive paradigm The model that resulted from the metacognitive reflection is dialectic in nature because it entails the understanding of the patient‘s problem from an interpretive as well as from an empirico-analytical perspective. The model is conceptualised in three stages: Firstly the conceptualisation of the integrated spinal movement system (ISMS), to indicate that the spine, head, shoulder and pelvic girdles function as a closed kinematic chain. Secondly the process of the development of ISMS dysfunction as a major concept in the clinical picture of patients with CNSLBP is based on functional anatomy of the ISMS and the researcher‘s clinical observation in clinical practice. The researcher indicates how the development of ISMS dysfunction and characteristic adaptive behaviour are integrated components of the patient‘s complex heterogenic clinical picture. The underlying process for the development of ISMS dysfunction as a possible mechanism for CNSLBP is described as plasticity of soft and neural tissues (including the brain) which result in chronicity over time. Thirdly a multidimensional manual therapy model to manage patients with CNSLBP‘s heterogenic condition is discussed. The model indicates how the mechanisms underlying the development of ISMS dysfunction is addressed in a multidimensional approach to patient management. Finally the multidimensional manual therapy model is discussed in relation to other relevant intervention approaches. The model finally serves as a point of departure for planning and conducting appropriate research in basic and clinical sciences. The multidimensional manual therapy model for the management of patients with CNSLBP has been developed in clinical practice and is presented as a practicetheory in the form of a model.