_Non-Specific CLBP (>12 weeks)_
Summary
Persistent low back pain without serious identifiable pathology, maintained by physical deconditioning, altered motor control and psychosocial factors. Management is active and biopsychosocial.
Pathology. Non-specific CLBP is persistent pain without a serious identifiable pathology, maintained by a mix of physical deconditioning, altered motor control and psychosocial factors (fear-avoidance, sensitisation). Best-evidence management is active and biopsychosocial: education, graded exercise and reassurance, with manual therapy as a short-term adjunct to enable movement.
Clinical presentation (signs & symptoms)
Persistent lumbar ache and stiffness, movement-related; may refer to buttock/thigh; deconditioning and guarding; often multifactorial with psychosocial contributors.
Assessment (Examination & Assessment)
Subjective
Persistent lumbar pain >12 weeks; aggravating/easing factors; screen RED FLAGS (cauda equina, fracture, malignancy, infection) and YELLOW FLAGS (fear-avoidance, low mood, work). Leg symptoms? Pain scale.
Objective
Lumbar AROM (flexion/extension/side-flexion); palpation of paraspinals & QL; neuro screen (SLR, myotomes, dermatomes, reflexes) if leg symptoms; movement-control assessment; hip mobility.
Differentiate from
Radicular pain (nerve-root), specific pathology (fracture/malignancy/inflammatory), hip pathology.
Key special tests
| Test | What a positive result indicates | |---|---| | Lumbar AROM (flexion/extension/side-flexion) | movement and pain pattern | | SLR and neurological screen | screens radicular involvement if leg symptoms | | Movement-control tests | identify control impairments | | Palpation of paraspinals / QL | local findings and guarding |
Red flags & when to refer
- Cauda equina syndrome (saddle anaesthesia, bladder/bowel dysfunction, bilateral leg symptoms) — MEDICAL EMERGENCY
- Fracture
- Malignancy (unexplained weight loss, night pain, cancer history)
- Infection (fever, systemic illness)
- Inflammatory pathology (younger age, prolonged morning stiffness, systemic features)
Contraindications & precautions
- Screen red flags — suspected cauda equina (saddle anaesthesia, bladder/bowel change) is a medical emergency: refer immediately.
- Avoid HVT/manipulation without specific training; caution with mobilisation in osteoporosis or suspected instability.
- Dry needling: control depth over the thoracolumbar region (kidneys/pleura); consent, hygiene, anticoagulant caution.
Treatment protocol
Session structure & time scales
- Pre-assessment + prep (10 min): red/yellow-flag screen, AROM, neuro if indicated.
- Soft tissue — paraspinals, QL, glutes (12–15 min).
- Lumbar mobilisations — PA glides (Maitland) (6–8 min).
- Dry needling — paraspinal/QL/glute trigger points (8 min).
- Thermal (5 min).
- Movement/loading & education (6–8 min).
- Reassessment + home programme (5 min).
Modalities & rationale
| Modality / technique | Rationale (why it is used for this pathology) | |---|---| | Soft tissue (paraspinals/QL/glutes) | reduces guarding and eases movement to enable exercise. | | Lumbar PA mobilisations (Maitland) | pain modulation and segmental mobility (Banks, 2013 — Vertebral). | | Dry needling | eases paraspinal/QL trigger points contributing to pain (Sharkey, 2017). | | Thermal (heat) | reduces guarding, comfort before exercise (Watson, 2008). | | Graded exercise & education | motor control, general activity and pain education — the primary evidence-based driver; manual therapy is an adjunct. |
Loading & exercise progression
Graded exercise: motor control plus general conditioning, progressive activity and pacing. Manual therapy as a short-term adjunct. Explicitly address fear-avoidance.
Home care / self-management
Stay active, graded exercise (motor control + general conditioning), pacing, pain education to reduce fear-avoidance, ergonomic/posture advice, sleep and stress guidance.
Outcome measures & re-assessment
- Pain scale (NPRS 0–10) pre/post; function over sessions.
- Re-measure lumbar AROM.
- Reassess guarding/movement quality.
- Confidence & activity tolerance (address fear-avoidance).
Anatomy reference
| Structure | Origin | Insertion | Action | |---|---|---|---| | Erector spinae (iliocostalis, longissimus, spinalis) | common tendon — sacrum, iliac crest, spinous processes | ribs, TPs, up the vertebral chain | spine extension; ipsilateral side-flexion | | Quadratus lumborum (QL) | iliac crest & iliolumbar ligament | 12th rib & TPs L1–L4 | lateral flexion; hip hitch; stabilises | | Multifidus | sacrum, PSIS, TPs | spinous processes 2–4 segments above | extension/rotation; segmental stabilisation | | Psoas major | bodies & TPs T12–L5 | lesser trochanter | hip flexion; lumbar influence |
Clinical reasoning (Q&A for the system)
_These question–answer pairs encode the expected clinical reasoning for this condition. Use them to justify decisions and to check generated plans._
Q: What flags do you screen for in chronic low back pain? A: Red flags — cauda equina, fracture, malignancy, infection; and yellow flags — fear-avoidance, low mood, work factors.
Q: What are the cauda equina warning signs and what do you do? A: Saddle anaesthesia, bladder/bowel dysfunction and bilateral leg symptoms — this is a medical emergency requiring immediate referral.
Q: What is the best-evidence approach for non-specific CLBP? A: A biopsychosocial, active approach: education, graded exercise and reassurance, with manual therapy as a short-term adjunct to enable movement.
Q: Give the actions of erector spinae and quadratus lumborum. A: Erector spinae: spinal extension and ipsilateral side-flexion. QL: lateral flexion and hip hitch; multifidus provides segmental stability.
Q: What are your contraindications/cautions here? A: No HVT without specific training, caution with mobilisation in osteoporosis/instability, and control needling depth over the kidneys.
References
- Banks, K. (2013) _Maitland's Peripheral Manipulation Management._ Elsevier.
- Banks, K. (2013) _Maitland's Vertebral Manipulation Management._ Elsevier.
- Sharkey, J. (2017) _The Concise Book of Dry Needling._ Lotus Publishing.
- Watson, T. (2008) _Electrotherapy: Evidence Based Practice._ Elsevier.
- Clarkson, H. M. (2013) _Musculoskeletal Assessment._ 3rd edn. Lippincott.
- TODO: add a condition-specific loading-protocol reference (from module notes), Harvard format.