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.