the lumbar spine. introduction prevalance diagnosis of lumbar spine soft tissue/repetitive strain...

The Lumbar Spine

Introduction

• Prevalance• Diagnosis of lumbar spine• Soft tissue/repetitive strain injuries• Facet joint injuries• OA• Disc problems• Summary

Prevalance

• 80% of the population will have back pain by the age of 60

• By the age of 20, 50% of the population have already experienced back LBP

• LBP is 2nd only to the common cold when it comes to symptoms requiring a doctors visit

• 4% will become chronic• 4% represent 80% of the cost to society• 1-3% will undergo surgery

Back Problems

• Back problems are not the same thing as back pain and are seldom caused by a single incident but are usually the result of several factors

• Back problems will be present long before back pain starts and unless the problem is addressed will remain long after the back pain goes

• This leads to our most common complaint in every physio clinic in the country – recurrent back pain

Common cause of back problems

• Poor posture• Faulty body mechanics – leg length

discrepancies, pronating feet etc• Stressful living and working habits

– sitting at computers. Driving• Loss of strength and flexibility• General decline of physical fitness

– weight is an increasing problem

Diagnosis of lx spine• Patient history often gives us the best

clue as to what structure they have damaged.

• All lumbar pain usually presents with soft tissue inflammation to the tissues in the painful area

• muscle spasm - this is the muscle guarding the damaged soft tissue

• restricted ROM – due to muscle spasm• scoliosis and decreased lordosis are prime

examples of muscle guarding in the lumbar spine

• What you won’t see is the reduction in metabolism and circulation to these areas!

Symptoms and cause

• These symptoms are rarely the primary cause of the problem however they need treating as whatever the cause, the treatment will always be directed towards getting the patient moving!

• Physio is particularly useful alongside muscle relaxants and anti-inflammatory/pain killers

• electrotherapy, acupuncture, ultrasound, supports

Injuries to soft tissues or repetitive strain of soft

tissues• History - overdoing the gardening,

driving to Scotland and back in a day, playing rugby, decorating, DIY overuse,

• Symptoms –• usually appear in surgery in slight

lumbar flexion, • all lumbar movement hurts – therefore

they have stopped moving!• pain can refer to upper leg

Treatment

• Advise 48 hours rest for an acute muscle spasm with a 10 minute walk every 2 hours

• will generally heal well after the acute phase during which physio is not always needed

• when the pain is eased they are given postural and ergonomic advice – computer set up etc

• lumbar mobility and strengthening exercises to then get rid of their back problem

Mobility exercises

Leg/s to chest Pelvic tiltingKnee rolling

Injuries and strains to lumbar facet joints

(including SIJ dysfunction)

Facet joint

Injuries and strains to lumbar facet joints

History – either • 1)    sudden movement leads to acute pain and

locking of spine (do not be fooled – there will be an inherent weakness in the lumbar spine that has been there for a while for this to happen)

• 2)    old over use injury has led to this stage due to the tissues tightening up around the facet joints. The patient has stopped moving his spine due to fear and pain and the joint has locked – can be multiple level

• 3)    hyper mobility of spine – particularly young females, pregnancy leads to instability of L5/S1 segment

Symptoms

• pin point area of pain• movement in one direction usually

painful• extension of lumbar spine very

uncomfortable• lumbar flexion usually more

comfortable

Treatment of facet joints

• manipulation of facet joints• soft tissue stretching• traction (old fashioned but

effective)• exercise regimes keeping spine in

flexion until acute pain has passed

Treatment of facet joint

Hip hitchingLumbar flexion Traction

Prognosis

• After 2-3 months of facet joint dysfunction the immobility can lead to degeneration and OA of the lumbar spine – this is what most people will eventually present with at the surgery.

OA Spine

OA spine

Symptoms • Crepitus• Loss of ROM all directions• Aggravated by increased levels of activity• General stiffness in spine and hamstrings

leading to instability either side of the stiff segments

• Chronic history of recurrent lumbar pain

Treatment of OA

should be hands off and concentrate on • 1)    increasing the circulation to the

lower vertebrae with mobility exercises eg knee rolling

• 2) increasing the strength in the lower spine, abdominal and pelvic muscles which are shown to waste even after one incidence of lumbar pain eg Pilates, speed walking

Disc problems

Prolapsed disc – (herniated/bulge/slipped) only 1% comes from trauma

• History • Under 45 years of age• Sedentary occupation• Gradual onset

Symptoms• Severe pain• Decreased lordosis – stand in flexion• Lateral shift• Patient is unhappy sitting and will ease

weight with hands on the arm of the chair• Pain usually eases walking• Peripheral pain and parasthesia• Motor weakness• Reduced SLR/femoral stretch• Extreme cases bladder/bowel disturbance• Saddle parasthesia

Treatment of prolapsed disc

• Rest with gentle walks every few hours• Anti-inflammatory and pain killers• Lumbar support to increase abdominal

support and reduce pressure on disc• Electrotherapy to ease pain• All treatment to centralise pain away

from peripheral symptoms • Hip glides to correct lateral shift

Treatment of prolapsed disc

• Advice to avoid lifting, prolonged sitting

• Encourage prone lying and extension exercises

• Increase exercise tolerance gradually

Exercises to encourage lumbar extension

                                                                                 Prone lying position

Full extension in lying position

Prone on elbows

After acute disc symptoms have settled

• Neural stretches• Traction• Core stability as long term

prevention (pilates)

Core stability exercises

Figure 1: Supine Bent-Knee Raises

Figure 2: Quadruped

with Alternate Arm/Leg Raises

Figure 6: Seated Marching on a Physioball

Figure 6: Seated Marching on a Physioball

Neural stretches

Sciatic nerve stretch Femoral nerve stretch

Disc degeneration

History • over 45 years of age• OA spine• Recurrent lumbar problems• Reduced lordosis

Symptoms of disc degeneration

• Absence of lordosis• lumbar flexion increases peripheral

pain• can also present as only lumbar

pain with shooting peripheral pain• symptoms as for disc prolapse but

patient older and less acute

Treatment of disc degeneration

• Traction• Mobility exercises• Strengthening exercises

Differential diagnosis of mechanical back pain

Muscle strain

Herniated nucleus pulposus

Osteoarthritis

Spinal Stenosis

Spondylolisthesis

Scoliosis

Age 20-40 30-50 >50 >60 20 30

Pain location

Back (unilateral)

Back, leg (unilateral)

Back (unilateral)

Leg (bilateral)

Back Back

Pain Onset

Acute Acute (prior episodes)

Insidious Insidious Insidious Insidious

Standing Increase Decrease

Increase Increase Increase Increase

Sitting Decrease

Increase Decrease

Decrease

Decrease

Decrease

Bending Increase Increase Decrease

Decrease

Increase Increase

SLR _ + _ + _ _

Plain X-ray

- - + + + +