reported by: felvee m. basibas, ptrp md rehabilitation medicine philippine orthopedic center

Reported by:

FELVEE M. BASIBAS, PTRP MD

Rehabilitation Medicine

Philippine Orthopedic Center

LOW BACK PAIN A symptom, not a disease Generally described as pain

between the costal margin and the gluteal folds.

Extremely common The leading cause of disability

and loss of productivity.

LUMBAR SPINE

Has a dichotomous role in terms of function;Strength Flexibility

Performs a major role in support and protection of the spinal contents

Gives us inherent flexibility.

STRENGTH FLEXIBILITY

Results from the following:Size and arrangement

of the bonesArrangement of the

ligaments and muscles.

Results from the large number of joints placed so closely together in series (typical lordotic framework).

Also increases ability to absorb shock.

The LUMBAR SPINE Five lumbar vertebrae Small percentage has four

(sacralization of L5) or six (lumbarization of S1).

LUMBAR VERTEBRA Components:

1. Vertebral body

2. Neural arch

3. Posterior elements

The vertebral bodies increase in size caudally.

Lower 3 are more wedge shaped (taller anteriorly): creates normal lumbar lordosis.

Serves as weight-bearing function.

PEDICLES

Sides of the bony neural arch

Thick pillars that connect the posterior elements to the vertebral body

Resist bending Transmit forces back

and forth from the vertebral bodies to the posterior elements.

POSTERIOR ELEMENTS

Components:1. Laminae

2. Articular processes

3. Spinous processes

Zygapophyseal joints: created by the superior and inferior articular processes of adjacent vertebrae

Pars interarticularis: a part of the lamina between the

superior and inferior articular processes.

The site of stress fractures (spondylosis), because it is subjected to large bending forces.

INTERVERTEBRAL DISK

IV Disk and its attachment to the vertebral end plate are considered secondary cartilaginous joint, or symphysis.

Main function: shock absorption

Annulus fibrosus: acts as the primary shock absorber.

NUCLEUS PULPOSUS: Geletinous inner section of the disk Consists of water, proteoglycans and

collagen. At birth- 90% water Desiccate and degenerate as we age.

ANULUS FIBROSUS: Consists of concentric layers of fibers

at oblique angles to each other Withstand strains in any direction Outer fibers: more collagen and less

proteoglycans and water○ Acts more as a ligament to resist

flexion, extension, rotation and distraction forces.

POTENTIAL PAIN GENERATORS OF THE BACK

Innervated Structures Non-Innervated Structures

• Bone: vertebrae

•Joints: zygapophyseal

•Disk: only the external annulus

and potentially diseased disk

•Ligaments: ALL, PLL,

Interspinous ligament

•Muscles and fasciae

•Nerve root

• Ligamentum flavum

• Internal annulus

• Disk: nucleus pulposus

Flexion of the lumbar spine

Nucleus pulposus is displaced posteriorly

Herniation thru the posterior annular fibers(posterolateral disk herniations)

BIOMECHANICS

The posterolateral portion of the disk is most at risk, with forward flexion accompanied by lateral bending (i.e. bending and twisting).

Increase in torsional shear forces once the zygapophyseal joints can no longer resist rotation of the lumbar spine; most risky for lumbar disks.

THE LIGAMENTS THE MUSCLES

2 sets:

a. Longitudinal ligaments

1. Anterior longitudinal ligament (2x stronger)

2. Posterior longitudinal ligament

b. Segmental ligaments1. Ligamentum flavum

2. Supraspinous – resist flexion

3. Interspinous

4. Intertransverse

Muscles with origin on the lumbar spine

Abdominal musculature

Thoracolumbar fasciae Pelvic stabilizers

Biomechanical Lifting in Relation to Muscular Activity and Disk Loads When the muscles contract, there’s associated rise in

disk pressure. These change in pressures depend on the spine posture

and the activity undertaken. There is no significant difference in disk pressure when

lifting with the legs (i.e. with the back straight and knees bent) versus lifting with the back (i.e. with a forward-flexed back and straight legs.)

What decreases the forces on the lumbar spine is lifting the load close to your body, as the farther the load is from the chest, the greater the stress on the lumbar spine.

HISTORY

85% of patients- no specific cause for LBP. 85% of a diagnosis is made using history

alone Know the following:

Features (location, character, severity, timing)

Alleviating and aggravating factorsAssociated signs and symptoms.

RED FLAGS of LBP

Back pain in children <18 years old with considerable pain, or onset in those >55 years old.

History of violent trauma Constant progressive pain at night History of CA Systemic steroids Drug abuse, HIV infection Weight loss Systemic illness

RED FLAGS of LBP

Persisting severe restriction of motion Intense pain with minimal motion Structural deformity Difficulty with micturation Loss of anal sphincter tone or fecal incontinence, saddle

anesthesia Widespread progressive motor weakness or gait

disturbance Inflammatory disorders (ankylosing spondylitis) suspected

RED FLAGS of LBP

Gradual onset, <40 years Marked morning stiffness Persisting limitation of motion Peripheral joint involvement Iritis, skin rashes, colitis, urethral discharge Family history

YELLOW FLAGS of LBP

Signs that the patient who is experiencing low back pain needs further psychologic evaluation.

That the clinician should proceed with caution. Psychosocial factors

YELLOW FLAGS of LBP

The presence of catastrophic thinking Expectations that the pain will only worsen with work or

activity Behaviors such as avoidance of normal activity, and

extended rest. Poor sleep Compensation issues Emotions such as stress and anxiety Work issues such as poor job satisfaction Extended time of work

PHYSICAL EXAMINATION

A. OBSERVATIONSkin, muscle mass, and

bony structures.PosturePosition of lumbar spineGait

B. PALPATIONShould begin superficially and

progress to deeper tissuesProne stability testing:

○ Pressure over isolated vertebrae is applied to look for painful level.

C. RANGE OF MOTIONI. Quantity of ROM

Single or double inclinometer. The distance of fingertips to

floor Schober’s test

DOUBLE INCLINOMETER Correlate the closest to

measurements on radiographs

II. Quality of ROM

D. NEUROLOGIC EXAMINATIONLook for the following:

a. Weakness

b. Sensory loss

c. Diminished/absent reflexes

d. Special tests – SLR

E. ORTHOPEDIC SPECIAL TESTS TO ASSESS FOR RELATIVE STRENGTHCurl Trunk Sit UpHolding the low back flat during lowering

F. ORTHOPEDIC SPECIAL TESTS FOR LUMBAR SEGMENTAL INSTABILITYSegmental instability – responds to specific

stabilization treatment.○ SPECIAL TESTS:

1. PASSIVE INTERVERTEBRAL MOTION TESTING

Prone position Pressure over spinous process Assess: amount of vertebral motion and if pain

was provoked.

2. PRONE INSTABILITY TEST prone position Torso on the table; legs over the edge of the table; feet

on the floor Passive IV motion testing to provoke pain Patient then lifts legs off the floor Positive Test: pain disappears when the legs are lifted off

the table Reason: the back extensors are able to stabilize the

spine in this position.

G. Examining the area above and below the lumbar spine

H. ILLNESS BEHAVIOR AND NON-ORGANIC SIGNS SEEN ON P.E.Some patients display symptom out of proportion

to injuryILLNESS BEHAVIORS

○ Learned behaviors○ Are responses that some patients use to convey

their distress.Anxiety, panic attacksMalingeringSearch for Waddell’s signs

Waddell’s Signs a group of physical signs first described by Waddell et al in 1980 may indicate non-organic or psychological

component to chronic low back pain. Historically they have been used to detect "

malingering" patients with back pain. One or two Waddell's signs can often be found even

when there is not a strong non-organic component to pain.

Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory.

Waddell's signs are:

1. Superficial tenderness – skin discomfort on light palpation.

2. Nonanatomic tenderness – tenderness crossing multiple anatomic boundaries.

3. Axial loading – eliciting pain when pressing down on the top of the patient’s head.

4. Pain on simulated rotation - rotating the shoulders and pelvis together should not be painful as it does not stretch the structures of the back.

5. Distracted straight leg raise - if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated (e.g. when checking the Babinski reflex).

6. Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.

7. Regional weakness - Weakness that is jerky, with intermittent resistance (such as cogwheeling, or catching). Organic weakness can be overpowered smoothly.

8. Overreaction - Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.

1. Superficial and Widespread tenderness or non-anatomic tenderness. (It's "one" sign)

2. Stimulation tests: Axial loading and pain on simulated rotation. (It's another "one" sign)

3. Distracted straight leg raise.

4. Non-anatomic sensory changes: Regional sensory changes and regional weakness.(It's another "one" sign)

5. Overreaction.

If there are more than 3 of 5 present then there is high probability that patient has non-organic pain.

A. PLAIN RADIOGRAPHY Very low sensitivity and

specificity AP-Lat views – common Oblique view

Spondylolysis Pars interarticularis “ Scottie dog” appearance

Lateral flexion/extension views Check for dynamic instability

Most helpful in surgical screening for spondylolisthesis

B. MRI The imaging study of choice for LBP

and radiculopathy Pre-eminent imaging method:

1. Degenerative disc disease

2. Disc herniation

3. radiculopathy With contrast enhancement:

Identify structures with increased vascularity

In the evaluation of the following: Tumor/infection Determination of scar tissue (vascular)

versus recurrent disk herniation (avascular)

C. CT MYELOGRAPHY More useful than MRI in evaluating bony

lesions. Useful in the post-surgical patient with

excessive hardware and in patients with implants.

D. SCINTIGRAPHY (RADIONUCLEAR BONE SCANNING)

Fairly sensitive but not specific Can detect occult fractures, bony

metastases and infections. SPECT ( Single Photon Emission CT)

Increase anatomic specificity Used to obtain bone scans with axial slices

E. EMG Provides a physiologic measures for detecting

neurogenic changes and denervation with good sensitivity and high specificity.

F. MYELOGRAPHY Contrast dye is injected into the dural sac Then plain x-rays are performed

Blood workupRarely usedUseful as an adjunct in diagnosing

inflammatory disease of the spine and some neoplastic disorders○ ESR○ C-reactive protein○ Serum protein electrophoresis and urine

protein electrophoresis.

DIFFERENTIAL DIAGNOSIS AND TREATMENT

MECHANICAL LOW BACK PAIN 85% of those who seek consult due to lower

back pain do not receive a specific diagnosis. Multifactorial cause:

Functional instabilityDeconditioningAbnormal posturePoor muscle recruitmentEmotional stressChanges associated with aging and injury

○ Disc degeneration○ Arthritis○ Ligamentous hypertrophy

Other names: Simple backacheNon-specific low back painLumbar strainSpinal degeneration

Mechanical low back painthe best term to use preciseSuggests that the mechanism of injury is better

than the other termsSuggests that, by changing biomechanics,

improvement can occur.Does not imply permanence

One of the goals of rehabilitation is to categorize faulty alignment and abnormal movement patterns so that specific treatment can be given.

PHYSICAL FACTORS associated with LBPa. Segmental Instability

b. Muscular imbalances and neural processing problems

c. Lumbar paraspinal abnormalities

a. Segmental Instability Sufficient joint stiffness: required at the

segmental level to prevent injury and allow for efficient movement.

Causes of Instability:Tissue damagePoor muscular endurancePoor muscle controlA combination of the three factors

Muscles: provide the most critical component of spinal stability.

In normal situations, only a small amount of muscular coactivation, about 10% of maximal contraction, is needed to provide segmental stability.

Muscular endurance- more important than absolute muscle strength for most patients.

b. Muscular Imbalances and Neural Processing Problems

c. Lumbar paraspinal abnormalitiesparaspinal muscle atrophyMultifidi atrophy“ It is unclear whether these muscular

abnormalities are the result of back pathology that leads to pain, or the cause of back pain.”

PSYCHOSOCIAL FACTORS AND LBP

Pain is an individual experience The biomechanical factors alone do not

explain much of the variance seen clinically in patients with low back pain.

Multiple psychosocial factors that have been found to play a role in LBP:Depression and anxietyPatients beliefs about pain and pain

cognition.

DEPRESSION and ANXIETY

30-50%of patients with chronic low back pain also have depression.

Depression, anxiety and distress are strongly related to pain intensity, duration and disability.

PATIENT’S BELIEFS ABOUT PAIN AND COGNITION

Affect outcomes FEAR AVOIDANCE BELIEFS PAIN CATASTROPHIZING KINESOPHOBIA Treatment:

1. Multidisciplinary pain programs

2. Cognitive behavior treatment program

I. Reassurance and Patient Education Should be adequate “There’s a strong evidence that the

advice to continue ordinary activity as normally as possible fosters faster recovery and can lead to less disability than the advice to rest and let the pain be your guide”.

II. Back Schools A term generally used for group of

classes that provide education about pain.

Information about the following:a. Anatomy and function of the spine

b. Common sources

c. Proper lifting techniques

d. Ergonomics

e. Exercises

Effective in reducing disability and pain of chronic LBP.

III. Exercise Exercise in ACUTE LBP:

No studies have shown that it is effective for the treatment of ACUTE low back pain.

Rationale:1. To prevent deconditioning

2. To reduce chance of recurrence

3. To decrease the risk of the development of symptoms of chronic pain and disability.

Exercises in CHRONIC LBPResults in positive oucomesA combination of strengthening and flexibility

exercises: most common

Specific exercises treatment for LBPa. Postural training

b. Lumbar stabilization

c. Awareness of spine position and muscle contraction in various positions and with different activities

d. Obtaining and maintaining mild abdominal contraction and multifidi activation.

e. Stabilization exercises to establish motor patterns and build endurance

f. Modifications for those in whom exercises aggravate pain

g. Flexion exercises

Specific exercises treatment for LBPh. Extension exercises

i. Aerobic activity

j. Aquatic exercises

k. Exercises after surgery

William’s Flexion Exercises

1. Pelvic tilt.   Lie on your back

with knees bent, feet flat on floor.  Flatten the small of your back against the floor, without pushing down with the legs.  Hold for 5 to 10 seconds

William’s Flexion Exercises

2. Single Knee to chest. Lie on your back with knees bent

and feet flat on the floor.  Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds.  Lower the knee and repeat with the other knee.

3. Double knee to chest.   Begin as in the previous exercise.  After

pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds.  Slowly lower one leg at a time.

4. Partial sit-up.  • Do the pelvic tilt (exercise 1) and,

while holding this position, slowly curl your head and shoulders off the floor.  Hold briefly.  Return slowly to the starting position.

5. Hamstring stretch.   Start in long sitting with toes

directed toward the ceiling and knees fully extended.  Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched over the legs, and eyes focus ahead.

6. Hip Flexor stretch.  Place one foot in front of the other

with the left (front) knee flexed and the right (back) knee held rigidly straight.  Flex forward through the trunk until the left knee contacts the axillary fold (arm pit region).  Repeat with right leg forward and left leg back.  

7. Squat. Stand with both feet parallel, about

shoulder’s width apart.  Attempting to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet flat on the floor, the subject slowly lowers his body by flexing his knees.

IV. MEDICATIONS

1. NSAIDS

2. Muscle relaxants

3. Antidepressants

4. Opioids

5. Anticonvulsants

6. Topical treatments

V. INJECTIONS and NEEDLE THERAPY a. Myofascial and trigger point injections

b. Acupuncture

c. Steroid injections

VI. MANUAL MOBILIZATION or MANIPULATION1. Traction

2. Heel lifts and correction of leg length discrepancy

3. Lumbar supports

4. TENS

5. Massage

6. Complementary movement therapies

Complimentary Movement Therapiesa. YOGA

Both an exercise system and philosophy that promotes relaxation, acceptance, and breathing techniques while various stretching and strengthening exercises are done.

b. PILATES A form of core-strengthening exercises that

stress alignment and proper form.

c. ALEXANDER TECHNIQUE An educational approach to posture and

normalizing movement patterns.

d. FELDENKRAIS A combination of classes and hands-on work

with therapeutic exercise to promote natural and comfortable movement patterns and improve body awareness.

VII. MULTIDISCIPLINARY PAIN TREATMENT PROGRAMS Goal: Functional restoration Helpful for severe chronic pain

VIII. TREATMANT of COMORBIDITIES Depression Anxiety Sleep disturbances Unhealthy and Sedentary Lifestyle:

ObesityNon-insulin-dependent DMCardiovascular disease

DIFFERENTIAL DIAGNOSIS AND TREATMENT

LEG PAIN GREATER THAN BACK PAINa. Lumbar Spondylosis

b. Lumbar Disk Disease

c. Internal Disk Disruption

d. Disk Herniation

e. Spondylolysis

f. Spondylolisthesis

g. Other Spinal Fractures

I. LUMBAR SPONDYLOSIS