Acute Lumbar Sprain / Chronic Low Back Pain

«Understanding the condition (definition, symptoms, epidemiology, stages, absolute surgical indications)» slot — content in preparation.

«How surgery and SART complement each other» slot — content in preparation.

These are the evidence candidates assigned to this topic. The citations to be used are finalised by the author when the page is published.

• EV-071★★★★★L1 · Systematic review / meta-analysis

  Spinal manipulative therapy produces effects comparable to other standard care in chronic low back pain, and is safe

  A Cochrane systematic review found spinal manipulative therapy (SMT) to produce effects and safety comparable to other recommended treatments for chronic low back pain.

  Rubinstein SM (2019) · Benefits and harms of spinal manipulative therapy (BMJ 2019, Cochrane)

  Limitation — This is evidence for SMT in general, not a validation of any specific SART technique.

• EV-050★★★★L2 · Randomised controlled trial / prospective cohort

  In low back pain the anticipatory (feedforward) activation of the deep stabilisers is delayed or lost

  Normally transversus abdominis and multifidus activate in advance of limb movement (feedforward) to lock the spine. In low back pain that anticipatory activation is delayed and the deep muscles become inhibited and atrophic.

  Hodges PW (1996) · Inefficient muscular stabilization of the lumbar spine (1996) and related work

• EV-051★★★★L2 · Randomised controlled trial / prospective cohort

  Chronic low back pain is often a problem of maladaptive movement, cognition and fear rather than tissue damage

  Cognitive functional therapy classifies and treats chronic low back pain in terms of maladaptive movement patterns driven by pain avoidance, alongside fear and belief. Pain may be a product of behaviour and cognition more than of tissue.

  O'Sullivan P · Diagnosis and classification of chronic low back pain; RESTORE trial and related work

  Limitation — CFT takes a different (non-structural) approach from SART. Cite it only as shared ground in pain science; do not press it into SART conclusions.

• EV-069★★★★L2 · Randomised controlled trial / prospective cohort

  There is data showing that active self-correction (exercise) genuinely improves curve and function

  Randomised clinical evidence that active self-correction exercise improves curve and disability in scoliosis and low back pain.

  Monticone M (2014) · Active self-correction (2014) and related work

• EV-079★★★★L2 · Randomised controlled trial / prospective cohort

  Much discogenic pain centralises and improves with movement in a specific direction (extension)

  In discogenic low back pain, repeated extension movements draw pain radiating into the leg back towards the midline (centralisation) and improve it — the concept of directional preference, developed into a self-treatment system (MDT).

  McKenzie R · Treat Your Own Back; the MDT research literature

• EV-004★★★L3 · Retrospective cohort / case-control / cross-sectional

  In spinal pain the deep stabilising muscles are neurologically inhibited and undergo structural change

  In low back pain patients the deep stabilisers such as multifidus show reduced cross-sectional area, fatty infiltration and neurological inhibition. Under fixation the brain's protective command drives the deep muscles into hypertonicity or loss of function (segmental facilitation).

  Korr IM; Hodges P et al. · Korr IM (segmental facilitation); Hodges P et al. (core stability, multifidus); MRI studies on multifidus fatty infiltration

  Limitation — Quantitative recent imaging papers (with PMIDs) on multifidus fatty infiltration still need to be added.

• EV-070★★L4 · Cadaveric / biomechanical model / basic experiment

  Lumbar lordosis must be maintained for disc pressure to be distributed evenly

  A load-distribution model showing that when lumbar lordosis is maintained, pressure is spread evenly across the disc, and that when lordosis is lost, pressure concentrates in particular regions.

  Müller A (2021) · Load distribution in the lumbar spine

• EV-002★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Fixation of one segment drives compensatory hypermobility in the adjacent segment, and the neutral zone expands asymmetrically into pain and deformity

  Spinal stability is maintained by three cooperating systems: passive (bone, ligament, disc), active (muscle) and neural control. After injury or degeneration it is the neutral zone — the early range that moves with little resistance — rather than total range of motion that enlarges abnormally, and that loosened zone becomes the pain generator. When a fixated segment stops moving, adjacent or vulnerable segments over-compensate and their neutral zones widen.

  Panjabi MM (1992) · The stabilizing system of the spine I·II (1992); Clinical spinal instability and low back pain (2003)

• EV-020★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Fascia is the body's largest sensory organ, and when gliding between its layers is blocked, pain and dysfunction follow

  Fascia is layered, with hyaluronic acid allowing the layers to glide over one another. When that lubrication dries out (fixation), gliding is blocked and pain and altered sensation result. Anatomical work established fascia as a sensory organ with rich sensory innervation.

  Stecco C (2015) · Functional Atlas of the Human Fascial System

• EV-021★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Breathing does more than exchange gas — it supports the spine through intra-abdominal pressure

  Intra-abdominal pressure (IAP), generated by the diaphragm, abdominal wall and pelvic floor, acts as an internal column supporting the spine (developmental kinesiology, DNS). When breathing patterns break down, that support is lost.

  Kolar P · Clinical Rehabilitation of the Locomotor System (DNS)

• EV-029★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  The lumbar spine is damaged by repeated flexion and torsion, and neutral must be preserved

  An injured lumbar spine is made worse by repeated flexion and extension and by cumulative load (spine sparing). The combination of flexion and torsion is central to annular damage.

  McGill S (2002) · Low Back Disorders

• EV-031★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Fixation of a spinal segment leaves the nervous system of that segment hyper-excitable (facilitated)

  Joint dysfunction holds the corresponding cord segment in a state of sustained hyper-excitability (segmental facilitation), so that even mild stimuli produce exaggerated muscular and autonomic responses. This is the mechanism behind viscerosomatic and somatoautonomic reflexes.

  Korr IM (1947) · The Neural Basis of the Osteopathic Lesion

• EV-049★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Sensitisation of the nervous system amplifies pain, and pain is not proportional to tissue damage

  Introduced mechanical sensitivity of the nervous system and central sensitisation into clinical practice. Pain is a product of the nervous system's threat appraisal rather than of the quantity of tissue damage.

  Butler D (2000) · The Sensitive Nervous System

• EV-077★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  The pressure borne by the disc varies markedly with posture (sitting exceeds standing)

  Direct in vivo measurement of lumbar intradiscal pressure across postures. Sitting — and especially sitting in forward flexion — raises disc pressure substantially above standing.

  Nachemson A (1960) · Lumbar intradiscal pressure

• EV-086★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Function (movement) can fail even when imaging is normal

  Functional diagnosis established that segmental dysfunction — restricted or excessive movement — can exist even when structural imaging such as radiographs is normal.

  Dvorak J & Dvorak V · Manual Medicine: Diagnostics

• EV-091★★L4 · Cadaveric / biomechanical model / basic experimentfoundational

  Low back pain is a problem of the spine and equally of the person's life (psychological and social)

  The biopsychosocial model treats low back pain as produced jointly by tissue damage and psychosocial factors, with non-organic factors such as fear and avoidance weighing heavily in chronicity.

  Waddell G (2004) · The Back Pain Revolution

  Limitation — SART works on the structural axis, but this model warns that pain cannot be reduced to structure alone — cite it as a guard against over-structuralism.

• EV-015★L5 · Expert opinion / classical theory / mechanistic hypothesisfoundational

  The vulnerable segment beside a fixated one compensates by moving too much (relative flexibility)

  Rather than moving a stiff segment, the body moves the adjacent flexible segment excessively, and damage accumulates there (movement impairment syndromes, relative flexibility).

  Sahrmann S · Diagnosis and Treatment of Movement Impairment Syndromes

• EV-055★L5 · Expert opinion / classical theory / mechanistic hypothesisfoundational

  Pain arises from loss of control in a specific direction (uncontrolled motion)

  Identifies the direction in which movement is uncontrolled and retrains stability in that direction, distinguishing the roles of global and local muscles.

  Comerford M (2001) · Functional Stability Re-training

• EV-078★L5 · Expert opinion / classical theory / mechanistic hypothesisfoundational

  Joints have accessory play that cannot be produced voluntarily, and its loss constitutes dysfunction

  Identified the fine accessory motion (joint play) essential to normal joint function. When that play disappears (fixation), pain and dysfunction follow.

  Mennell JM (1964) · Joint Pain

• EV-083★L5 · Expert opinion / classical theory / mechanistic hypothesisfoundational

  Real treatment happens in active rehabilitation outside the treatment room

  A spinal rehabilitation system that goes beyond passive treatment, preventing recurrence through the patient's own active exercise and self-management.

  Liebenson C (1996) · Rehabilitation of the Spine