Table 1

Intermittent back pain under prolonged, static end-range postures (usually flexion); no loss of movement, absence of deformity.

Patient education and postural correction.

Patient adopts the posture that produces their symptoms. Physiotherapist instructs patient how to abolish symptoms by correcting the posture and provides explanation on the mechanism that produces pain of postural origin. Attainment of the corrected posture is taught through the use of the "slouch-overcorrect" exercise. Patients are taught how to maintain the corrected posture through the use of a Lumbar roll and actively when a lumbar roll can-not be used. Consequences of postural neglect are discussed.

Dysfunction Syndrome

Intermittent back pain at premature end-range; radiation only in the case of the dysfunction of an adherent nerve root; partial loss of movement.

Patient education, postural correction, and stretching of contracted structures.

Posture correction and repeated end-range movements towards the direction of dysfunction (e.g. extension exercises for extension dysfunction). Ten to 15 stretches are repeated at 2/3-hourly intervals, until the movement loss is restored. Treatment progression may include clinician overpressure and/or mobilisation.

Derangement Syndrome

Clinical picture

Constant or intermittent back pain and/or leg pain that moves proximally or distally during repeated movements; variable degree of loss of movement; deformity, paraesthesia, numbness and myotomal weakness may be present. A rapid change in the location of symptoms and in the range of movement is seen.

Reduction of derangement and maintenance of reduction, recovery of function and prophylaxis.

Reduction of derangement is achieved with sustained positions and/or repeated end-range movements. The treatment principle (extension, flexion or lateral) is selected according to the movements that abolish, decrease or centralise symptoms, as well as those that restore mobility and function (e.g. extension principle is adopted when extension centralises symptoms). Patient generated forces are used as the procedure of first choice. The exercises are repeated at home at 2-hourly intervals or as necessary for pain relief. Forces are progressed when the progress plateaus including over-pressures and therapist mobilisation. To ensure the maintenance of the reduction the patient is instructed to avoid aggravating postures or movements. Lumbar supports are used where necessary for the maintenance of lumbar lordosis.