News Category: Lumbar Spine

Low back pain (LBP), a common injury in Western society, has a significant economic impact as well as personal cost. In the United States alone, LBP has a total direct and indirect cost of $50 billion per year.

Researchers have been trying to find ways to lower the economic impact of back injuries. Earlier studies have indicated that early intervention with biopsychosocial education and treatment are more effective in aiding in recovery and maintaining general health than is the mantra of staying active, as is still recommended in some guidelines.

In this cluster, randomized, controlled trial, researchers evaluated if a prevention program for LBP had an effect on economic costs. The researchers recruited 489 workers from nine companies who were randomized to the study group (258) or to the control group (231). The researchers chose a multidimensional LBP prevention program based on integrating three preventative measures for the study group: three back training study sessions, immediate treatment of LBP through physical therapy and the workplace, and workplace visits for advising on ergonomic adjustments or additional training, if needed.

The workers filled out questionnaires regarding their lifestyle and work habits, and the researchers collected data regarding work absences, as well as pain intensity and functional limitations. At 12-month follow-up, results for 360 workers were available.

The researchers found that there was no difference in results from the study participants compared with those in the control group. Although there were fewer sick days due to complaints of pain in the upper body, there were no differences between the two groups regarding LBP in any of the outcome measurements.

Although the early intervention for prevention of LBP remains promising, the results of this study found no evidence supporting adoption of the particular program used. The authors do point out, however, that there are possible reasons that the study may not have found the program effective. They stated that the sample size may have had a negative effect, as did the use of sick days in the analysis. Although the researchers asked if the subject had lost work because of back pain, the answer may not have been truthful. The authors also pointed out that the program of immediate treatment and work-place adjustments may not have been strictly adhered to. Only 10 workers used the services of the in-house physiotherapy while 66 went off-site.

Many people in the Western world experience chronic back pain that affects their quality of life and ability to work. Although researchers have been trying to find the best treatment for chronic back pain, study findings are conflicting about which is better: surgerical or nonsurgical (conservative) treatment.

In this study, the authors searched through medical literature to find studies about surgery versus conservative treatment for non-specific back pain. They compared the different research methods used and study findings to see if they could decide on the best care for chronic lower back pain. They found four studies. The researchers then compared the studies for the types of surgery performed and the nonsurgical interventions, such as physical therapy; information and education; pain relief methods; cognitive and functional training; rehabilitation; and supervised treatment. The success of the treatments was measured by how patients recovered from their back-specific disability, reported pain levels and general function, psychological function, if they returned to work, x-ray results, complications and, finally, how satisfied the patients were with their outcome.

Three of the four studies measured the rate of return to work. The researchers found that the rate of return wasn’t consistent between them. In one study, more patients who had had surgery returned to work, in another, the numbers were just about equal between the surgery and the nonsurgery groups, and in the third, more patients who didn’t have surgery returned to work.

Two studies used patient self-rating reports to measure success. In these two studies, patients who had surgery seemed to be more satisfied than those who didn’t.

Two of the studies followed the patients for two years and the other two studies followed them for one year. In one 2-year study, patients who had surgery were much more satisfied than those who didn’t, but in the other 2-year study, the number wasn’t that much higher in the surgical group. In the 1-year studies, the results were the same: One study had a higher satisfaction rate with surgery, the other study didn’t have such a difference.

The authors concluded that there were limitations to some of the studies that didn’t allow the researchers to draw more definite conclusions about the treatments. While surgery did seem to have a modest advantage over nonsurgical treatment, it could be that it is the type of nonsurgical treatment that is more the issue.

Many people with lower back pain undergo a surgery called a fusion, now considered the gold standard for treatment of certain back injuries. But, researchers still don’t know yet how effective the surgery really is in treating lumbar degenerative disc-disease (DDD).

In this prospective study, researchers followed 99 patients for a least 12 months. The researchers looked results of the surgery, called a total lumbar disc replacement (TDR), to see how the patients with DDD fared. The patients underwent the surgery after trying other nonsurgical methods that didn’t work for them.

Twenty-two of the patients had the disc replacement at the lumbosacral junction, which is just above the tailbone area. Twenty patients had it done in the same area but also a second one at a level just slightly higher at a level called L4-L5. Finally, 22 patients had the surgery only at L4-L5.

When the researchers followed up on the patients, they found that 78.7 percent of patients showed good or excellent results. For the most part, the patients who had the surgery done at the L4-L5 level alone were happiest with the treatment and outcome. The lowest patient satisfaction was among those who had the surgery done at both the lumbosacral junction and the L4-L5 area.

The same pattern followed with return to work. More patients from the L4-L5 group went back to work, the fewest number who went back were those who had the surgery done in the two areas.

The researchers also looked at the complication rates. Fewer patients who had the surgery in the lumbosacral area had complications than those in the other two groups.

The authors concluded that the level in the spine where the surgery is done and number of lumbar disc replacements plays an important role in how the patient recovers. The recommend that more studies be done and they suggest that surgeons be made aware of the lower success rate of the bisegmental replacements.

Drop foot from degenerative lumbar disorders can be a major problem. Drop foot is caused by pressure on the spinal nerve as it leaves the spinal cord in the low back area. When the nerve is impaired, muscle weakness occurs.

A person with drop foot drags the toes when walking. Drop foot causes tripping and falls. Sometimes patients change the way they walk to overcome this problem. The person lifts the knee higher to clear the toes as the foot moves forward. The result is a gait (walking) pattern referred to as steppage gait.

A brace or ankle-foot orthosis (AFO) can help by providing support and keeping the foot from dropping. Shoe wear is limited for people with drop foot. The AFO slips inside a standard shoe and can’t be worn with sandals or slippers. Drop foot is a special problem for people in Japan. Shoes (and braces) are removed indoors.

In this study, surgeons observed 46 patients with drop foot who had lumbar spine surgery. The goal was to find factors that predict who will recover from drop foot. The patients had decompressivesurgery with or without spinal fusion. Decompression takes pressure off the nerve. Part or all of the disc was removed. In some patients, bone around the spinal nerve was cut away too.

Motor recovery after surgery was excellent in 41 per cent of the patients. Another 20 per cent had good results. Results for the rest of the group were rated fair to poor. About one-third of the patients had complete recovery with normal muscle strength restored.

Recovery was best in younger patients who had symptoms for the shortest amount of time. Strength before the surgery was also a factor affecting the outcome. Patients with low strength before surgery had poorer results afterwards. For those patients who made a full recovery, the length of time varied from six weeks to two years after surgery.

Lower back pain (LBP), a common injury in Western society, has a significant economic impact as well as personal cost. In the United States alone, LBP has a total direct and indirect cost of $50 billion per year.

Researchers have been trying to find ways to lower the economic impact of back injuries. Earlier studies have indicated that early intervention with biopsychosocial education and treatment are more effective in aiding in recovery and maintaining general health than is the mantra of staying active, as is still recommended in some guidelines.

In this cluster, randomized, controlled trial, researchers evaluated if a prevention program for LBP had an effect on economic costs. The researchers recruited 489 workers from nine companies who were randomized to the study group (258) or to the control group (231). The researchers chose a multidimensional LBP prevention program based on integrating three preventative measures for the study group: three back training study sessions, immediate treatment of LBP through physical therapy and the workplace, and workplace visits for advising on ergonomic adjustments or additional training, if needed.

The workers filled out questionnaires regarding their lifestyle and work habits, and the researchers collected data regarding work absences, as well as pain intensity and functional limitations. At 12-month follow-up, results for 360 workers were available.

The researchers found that there was no difference in results from the study participants compared with those in the control group. Although there were fewer sick days due to complaints of pain in the upper body, there were no differences between the two groups regarding LBP in any of the outcome measurements.

Although the early intervention for prevention of LBP remains promising, the results of this study found no evidence supporting adoption of the particular program used. The authors do point out, however, that there are possible reasons that the study may not have found the program effective. They stated that the sample size may have had a negative effect, as did the use of sick days in the analysis. Although the researchers asked if the subject had lost work because of back pain, the answer may not have been truthful. The authors also pointed out that the program of immediate treatment and work-place adjustments may not have been strictly adhered to. Only 10 workers used the services of the in-house physiotherapy while 66 went off-site.

Only a very small number of back pain patients have a serious condition such as a fracture, infection, or tumor. More than 90 per cent of patients with low back pain (LBP) have nerve impingement or some other mechanical problem.

Many LBP patients are examined first by a health care professional who is not a doctor. Physical therapists (PTs) are often the first contact for LBP patients.

When examining someone with LBP, physical therapists (PTs) often use questions and physical tests in a process called triage. This clinical exam helps identify the problem. The therapist can then apply the best treatment for the problem at hand.

In this study, researchers measured the reliability of the tests used by PTs in the exam. If the tests aren’t reliable, then the results aren’t valid or helpful. Over 300 patients with acute or chronic back pain were included. Each patient saw two PTs one at a time, an hour apart.

Each therapist conducted a series of 50 questions and tests on the same patient but didn’t know the other therapist’s test results. This is called interrater reliability. The researchers were looking at the interrater reliability to see if the tests were valuable measurement tools.

They found that 86 per cent of the questions and tests had fair agreement or better. Five questions about the pain and other symptoms had poor agreement. Two tests (prone knee bend and myotome testing) had poor interrater reliability.

Refining the initial diagnostic or triage process is important with back pain patients. This study to evaluate the validity of tests often used with LBP patients focused on intertester reliability. Most of the tests were useful but a couple can be tossed out as unreliable.

The next step is to analyze the test results. There may be clusters of signs and symptoms that respond better to one type of treatment over another. Identifying which tests are best for each cluster may help speed up the diagnostic process.

In this case report of a 59-year old woman, MRIs are used to study a condition called chiari malformation. In CM, the lower part of the cerebellum protrudes from its normal location in the back of the head.

The word cerebellum means little brain. It is a separate, smaller part of the brain located at the base of the skull just above the cervical spine. In CM, the cerebellum slides down into the cervical or neck portion of the spinal canal.

Sometimes the patient develops a syrinx in the cervical spine.The syrinx is a cyst that fills with cerebrospinal fluid (CSF), expanding and getting longer. The syrinx can extend over several spinal levels. Over time, this condition can destroy the center of the spinal cord.

Syrinx fluid is forced downward with every heart beat. Anything that blocks the free flow of CSF can keep this fluid from moving normally in and out of the head. Pressure builds in the syrinx until it enlarges and ruptures, damaging normal spinal cord tissue and injuring nerve cells.

This patient did not have a syrinx but the MRI showed that the cauda equina in the lower spine was flattened. Cauda equina means horse tail. It is made up of a group of nerves at the end of the spinal cord.

The authors suggest that even though there was no syrinx, abnormal pressure from the cerebrospinal fluid was causing a sandwiching effect. Every time the heart beat a piston effect sent a wave through the CSF, reaching as far down as the cauda equina.

The patient developed symptoms of neck pain and back pain. She had loss of feeling in her arms and legs and increased muscle tone in all four extremities.

Surgery to relieve pressure on the cerebellum and the spinal cord was done. The patient’s symptoms went away. The large fluid-filled space around the cauda equina went away. An MRI taken a month later showed a normal positioning of the cauda equina.

In this article, surgeons from the University of Washington review and present the evidence for the use of epidural steroid injections (ESIs). ESI is the injection of a steroid and local anesthetic into the spine. The goal is to get temporary relief of back and leg pain (sciatica) until the condition gets better on its own.

There are risks with ESI, and they don’t help everyone. Surgeons are advised to choose patients carefully for this procedure. It should be used when other nonsurgical treatment has failed. Back pain that travels down the leg must be present. ESI is not advised for patients with back pain alone. ESI may be used with spinal stenosis to manage the pain but has no curative value.

Some patients should never have an ESI. For example, anyone with uncontrolled diabetes or spine cancer should not have an ESI. The same is true for anyone on anticoagulation therapy (blood thinners).

Accurate placement of the injection is important. ESI should only be done with fluoroscopic guidance. Fluoroscopy is the use of special X-ray imaging that allows the surgeon to see the needle as it goes into the spine. The authors review specific techniques for both the injection and use of fluoroscopy.

So far studies have not answered the question of how many and how often ESIs can be given. There is no proof that a series of injections is any better than one injection for sciatica.

While some experts argue that ESI should be used early to avoid chronic pain, others say wait at least seven weeks. If the patient did not improve after the first injection, a second injection is not advised.

Surgeons are encouraged to keep up with the latest studies in this area. Patient selection is becoming increasingly important. For best results, careful patient assessment must be done with risk factors identified.

Low back pain from disc degeneration, spinal stenosis, or spondylolisthesis may benefit from new technology. Interspinous process spacers are devices that can be implanted between the spinous processes. to limit spinal motion.

A spinous process is the part of the vertebral bone that protrudes away from the vertebral body. You can feel the tips of the spinous processes as bumps along the back of your spine.

Putting a spacing device between two spinous processes holds the spinal segment in slight flexion. It limits motion in extension without preventing rotation or side bending.

The effect is to stabilize the spine without rigid fusion. By holding the spine in this position, there is less pressure put on the spinal nerves. The facet (spinal) joint cannot slide as far back, thus keeping the space open around the spinal nerves.

Interspinous process spacers aren’t new. They have been around since the 1950s. But the design and technique for implanting them are much improved these days. Currently, only the X STOP spacer is approved by the FDA for patients with spinal stenosis. Two other systems (Wallis Normalization and DIAM) are under being studied.

New implant designs include ways to prevent the device from getting dislodged. They come in many sizes to give the surgeon choices as to how much spinal flexion is allowed while preventing extension. Some are made of titanium while others are polyethylene coated with silicone.

Only very limited results are available after one- to two-year studies with the X STOP. No data has been published on the other implants. There are concerns about the implant causing pain. No one is sure what will happen with their long-term use.

The authors of this update review say that results so far are very promising. For best results, patients must be selected carefully. More study will help tell which device is best for each type of problem. For now, this new technology remains investigational.

Lumbar disc replacements (LDRs) have been used in Europe for years. Long-term results are becoming available now. Results of previous short- to mid-term studies have been wide ranging. Studies will be ongoing until consistent results are reported.

In this study, data is presented on 108 patients with a single-level (L45 or L5S1) LDR. Each patient received an artificial disc and was followed for at least 10 years. Information was collected for some patients for as long as 16 years.

All patients in this study had back and leg pain from degenerative disc disease. Everyone was treated first with physical therapy and medication for at least six months. This is called conservative or nonoperative care. Despite treatment, painful symptoms persisted, so an artificial disc replaced the worn out disc.

Each patient received the same Charité disc device. A single surgeon implanted each one. Everyone was given the same rehab program after surgery. Results were measured using pain levels, work status, and X-rays. Any problems or complications after surgery were also reported.

Most (nearly 90 per cent) of the patients who worked before surgery went back to their former jobs. Patients who had sedentary jobs were more likely to return to work than those whose jobs involved hard labor.

A small number of patients had complications related to the disc replacement. About 10 per cent had to have the LDR removed and replaced or the spine fused. Overall success rate (good to excellent results) was 82 per cent. Only three per cent developed disc disease at the lumbar level next to the LDR segment. This rate is much lower than has been reported in other studies.

The author concludes LDR is safe and effective when used at one level of the lumbar spine. Many improvements over the years have made this possible. Surgical tools are better now. The implants have been changed in size, shape, and design. Knowledge and training programs are available today to help surgeons get better results faster and with fewer problems.

The use of epidural steroid injections for nerve pain such as sciatica has come into question. The injection is given into the area around the spinal cord called the epidural space.

Sciatica is pain and/or numbness and tingling down the leg. It is caused by pressure on the sciatic nerve. The pain may begin in the low back and go into the buttock, then down the leg. It may only go as far as the knee, but can be felt by some patients all the way to the foot.

A review of the results from high-quality studies has been reported. Only marginal pain relief from sciatica was observed. Complications of this treatment are usually minor and don’t last long. The most common problem is a headache after the injection.

The American Academy of Neurology (AAN) has asked for better studies in this area. Are steroid injections safe and effective for chronic pain? How often can they be done? Are there some patients who would benefit more from this treatment than others?

Continued use of epidural steroid injections requires further study. If there isn’t enough evidence to support their use, then insurance companies may not continue paying for them.

What treatment for chronic low back pain (LBP) can deliver reduced pain, less disability, improved quality of life, and a better mood? A large review of many studies showed that psychologic intervention is the answer.

Cognitive behavioral therapy, biofeedback, relaxation therapy, and hypnosis appear to be very effective. If this is true, then why aren’t patients seeking psychologic treatment? And why aren’t insurers paying for them?

Researchers can only guess at the answers right now. They suggest that patients don’t want a psychologic cure. They want a quick and easy cure. They want a physical reason for their symptoms.

Many patients don’t know that psychologic care can make such a difference. That’s because many spine specialists, primary care doctors, and third-party payers don’t know the benefits or don’t advise patients to try this avenue of care.

The most popular treatment options remain the more expensive surgeries, drug use, nerve blocks, and spinal cord implants. With all the evidence pointing to the benefits of psychological care, health care providers must learn more about this treatment option.

The authors suggest that psychological treatment won’t cure patients. But it can make a big difference in pain, disability, and quality of life. It should be considered an important part of the overall care of chronic LBP patients. And insurance companies must be educated about the benefits so that the services are available to all patients.

Minimally invasive surgery (MIS) may be slowly replacing traditional open operations for spinal fusion. Studies show less pain, muscle trauma, and blood loss with MIS. The hospital stay is shorter, thus reducing costs. Patients are able to return to normal activities and get back to work much faster.

In this comparison study, one surgeon looks at the results of posterior lumbar interbody fusion (PLIF) using both methods. All patients had low back pain (LBP) for more than six months. Conservative care during that time was not helpful.

Both procedures were described in detail. A very small incision (less than one inch) was made with the MIS method. A special imaging X-ray called a fluoroscope was used to see inside the spine. For the traditional operation, a three and a half inch incision was used. The muscles were cut and tools called retractors pulled the soft tissues apart.

Removing the disc and placing bone graft and interbody cages in place of the discs was the same for both groups. Data was collected on the patients for at least 12 months. X-rays were taken before surgery and two weeks, three months, six months, 12 months, and 24 months after surgery.

Clinical results were reported as follows:

Many studies have shown increased degenerative changes in the spine after spinal fusion. Most of the research has focused on changes in the next vertebral segment up from the fused segment. This site is called the adjacent segment. The changes are referred to as adjacent segment degeneration (ASD).

In this study, researchers in Spain look at the effects of spinal fusion at other levels. They ask the questions: are there changes in other levels? Are the changes caused by the fusion? Or is there a general pattern of degeneration going on?

They analyzed unfused lumbar segments from 62 patients. Everyone had a posterior, instrumented lumbar spinal fusion. Posterior means the surgery was done from the back of the spine. Instrumented refers to a metal plate and screws used to hold the spine in place until the fusion was solid.

Computer analysis of X-rays taken before and after surgery was the primary measure used in this study. The authors found no difference in disc height before and after surgery. This was true for the first, second, and third segments above the lumbar fusion. Disc collapse or narrowing of the disc space was the same at all levels above the fusion.

The authors conclude that disc narrowing and loss of disc height are not caused by the fusion. These changes were not linked with the length of fusion, fusion level, or the distance away from the fusion. These do not appear to be factors in ASD. The high rate of ASD after spinal fusion is probably the result of normal aging processes.

Spondylolisthesis is a condition in the spine where one vertebra has slipped forward over the vertebra below it. It’s caused by a fracture of the supporting column of the vertebral bone called the pars interarticularis.

When the vertebra slips forward over half of the lower vertebra, it’s called a high-grade spondylolisthesis. Surgery is needed to fuse the spine and hold it in place to keep it from slipping any farther.

But what method of fusion works best for this problem? There are three fusion methods: anterior (front), posterior (back), and circumferential (all the way around). What are the long-term results of the different fusion types? That’s what the authors of this study tried to find out.

They compared X-rays, spinal mobility, function, and trunk strength for patients divided into three groups. The three groups corresponded to the three types of fusion methods. All patients were 20 years old or younger. Lumbar fusion was done at the L5-S1 level for all patients using one of the three fusion methods described.

The authors report that the circumferential fusion had slightly better long-term results than the anterior or posterior methods. For the most past, X-rays and function were the same among the three groups. All fusion methods were successful in stopping further slip of the vertebra.

There’s no miracle cure for spinal stenosis, a narrowing of the spinal canal. Age-related changes cause the opening around the spinal nerves to get smaller, putting pressure on the spinal nerves. The result can be back and leg pain making walking difficult.

Surgery can be done to remove bone and take the pressure off the nerves. But surgery has its own risks and possible problems. And since spinal stenosis is a problem most common in older adults, it may not be worth it to them to consider surgery.

Research shows that using pain relieving medications and exercises gives patients steady improvement. They are more likely to get faster pain relief with surgery but in the end, the results are about the same.

These results were based on a study comparing two groups of patients with moderate spinal stenosis was reported by researchers in Finland. The average age of the patients was 62 years old. They all had chronic low back pain that radiated into the buttocks and down the legs. Symptoms were made worse by walking, a classic sign of spinal stenosis.

Other studies have shown similar outcomes. The results of several studies suggests patients should try at least a six-month trial of conservative care before having surgery. The advantage of surgery disappears after eight to 10 years and may not be worth it to some people.

Spine surgeons rely on the results of the Cochrane Collaboration review to help them keep up to date. The Cochrane Collaboration was started in 1993. It is made up of a group of over 6,000 specialists in health care. These experts review biomedical trials and results of other research.

Only studies of the highest quality are included in the review process. Researchers and clinicians know they can depend on the review for accurate information. In the year 2000, the Cochrane Review published its findings on surgery as a form of treatment for lumbar disc problems.

A new review was published in 2006 with the following updates:

After 50 years of intense research on the origins of back pain, we still don’t know where it comes from. But thanks to Alf Nachemson, M.D. we know much more than we used to. Dr. Nachemson, who died in December, 2006 was a leading researcher in the area of back pain.

In an interview last year, Dr. Nachemson reviewed many of the findings from his 50 years of research on back pain. Working together with many people from other areas, he has discovered:

In this study adult patients with syringomyelia and scoliosis (curvature of the spine) were compared to patients with syringomyelia without scoliosis.

Syringomyelia is a general term used to describe a cyst or tube-shaped cavity that forms within the spinal cord. There is an abnormal collection of fluid within the spinal cord. The cyst or cavity, called a syrinx expands and gets longer. Sometimes it extends over several spinal levels.

Obstruction to the normal movement of cerebrospinal fluid causes it to flow into the spinal cord instead of around it. The syrinx forms and the cerebrospinal fluid collects in these cysts. Over time, this syringomyelia can destroy the center of the spinal cord.

In this study adults with syringomyelia were divided into two groups. The first group had syringomyelia and scoliosis associated with Chiari malformation type I (CM-I). CM-I describes a protrusion of the cerebellum in the back of the head. The cerebellum is a separate, smaller part of the brain located at the base of the skull just above the cervical spine. With CM-I, the cerebellum slides down into the spinal canal. These patients develop syrinx in the cervical spine.

The second group of patients had syringomyelia with CM-I but without scoliosis.
All patients had surgery to take pressure off the cerebellum to correct the problem. The operation is called a foramen magnum decompression procedure.

Using various measurements before and after the operation, the authors found that scoliosis was a predictor of poor results. The patients with syringomyelia and scoliosis had worse neurologic symptoms. They were more likely to have muscle wasting and weakness in their arms. The syrinx spanned a longer length of the spine. The longer they had the two conditions, the worse the prognosis.

The authors suggest that the scoliosis developed as a result of trunk muscle weakness. Patients with longer syrinx spanning more vertebral bodies are at greater risk for scoliosis. Results of surgery are less favorable for those patients with syringomyelia and scoliosis.

Many studies have shown that people with low back pain (LBP) also have less hip rotation motion when compared with people who don’t have LBP. In this study, physical therapists look at the timing of hip and lumbopelvic rotation movement.

They propose that if different movement patterns are linked with LBP, then different treatment may be needed. This study was done in a university-based motion science lab. The therapists measured hip and lumbopelvic rotation in two groups of patients with LBP. One group was more limited in lumbar rotation (Rot). The other group was classified as RotExt because their symptoms occurred when they rotated or extended the spine.

The patients were tested in the prone (lying face down) position. With the knee bent 90-degrees, the leg was rotated inward and hip motion measured. The examiners also recorded if there was any lumbopelvic rotation during the first 50 per cent of hip lateral rotation (HLR) movement.

The purpose of the study was to see if there was equal timing of lumbopelvic rotation on both sides during HLR. All patients were athletes who had LBP for at least one year. Their symptoms were worse during or after sports play. Their sport involved repeated hip and lumbopelvic rotation.

The Rot group had more symmetry in the timing of their HLR compared to the RotExt group. The results show that people in the RotExt group have different timing of low back, hip, and pelvic motion from one side to the other.

This is the first step in understanding how different movement patterns of the hip and pelvis might affect LBP. Asymmetry (more movement on one side compared to the other) may increase the load on one or more lumbar segments. The result may be LBP. The authors suggest that symptoms will come back if the movement pattern is not corrected.