Box 373 Example of a motivational component of a physical therapy program for chronic low back pain

• Counseling on the importance of regular and consistent exercise

• Exercise decreases the likelihood of recurrences

• Rehabilitation depends on the patient's behavior

• Problem-solving with the therapist

• Reinforcement techniques used

• A reward strategy can be used

• Oral agreements reinforced in writing

Exercise diary used daily mobilization with impulse referred to in layman's terms as "adjustments" are best known. The goal of this treatment is to restore the full active range of motion to a restricted joint or spinal segment which will secondarily decrease afferent neuronal signals into the central nervous system and consequentially decrease muscle spasm and pain. Most studies on the efficacy of manipulation utilize about two treatments per week for two to three weeks.

In CLBP, manipulation is superior to sham manipulation for pain and functional improvement.108,109,110 [II] It also appears to be about as effective as back school, exercise therapy, or general practitioner care with analgesics.111[II] The risk of serious side effects, such as cauda equine syndrome, disk herniation, or vertebroba-silar accidents (cervical manipulation), range from 1 in 2 million to 1 in 400,000 treatments.112,113[IV] Flexion distraction technique appears to compare favorably with exercise.114[II]

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