Download LOWER BACK PAIN

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.


Results from the
following:
 Size and arrangement
of the bones
 Arrangement of the
ligaments and
muscles.
STRENGTH
Results from the
large number of joints
placed so closely
together in series
(typical lordotic
framework).
 Also increases ability
to absorb shock.

FLEXIBILITY
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.
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.

PEDICLES

Components:
1.
2.
3.
POSTERIOR
ELEMENTS
Laminae
Articular processes
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.

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.

INTERVERTEBRAL DISK

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
• Ligamentum flavum
•Joints: zygapophyseal
• Internal annulus
•Disk: only the external annulus
• Disk: nucleus pulposus
and potentially diseased disk
•Ligaments: ALL, PLL,
Interspinous ligament
•Muscles and fasciae
•Nerve root
BIOMECHANICS
Flexion of the lumbar spine
Nucleus pulposus is displaced posteriorly
Herniation thru the posterior annular fibers
(posterolateral disk herniations)

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.

2 sets:
a. Longitudinal
ligaments
1.
2.
Anterior longitudinal
ligament (2x stronger)
Posterior longitudinal
ligament




Muscles with origin on
the lumbar spine
Abdominal
musculature
Thoracolumbar fasciae
Pelvic stabilizers
b. Segmental ligaments
1.
2.
3.
4.
Ligamentum flavum
Supraspinous – resist
flexion
Interspinous
Intertransverse
THE LIGAMENTS
THE MUSCLES
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 factors
 Associated 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. OBSERVATION
 Skin, muscle mass, and
bony structures.
 Posture
 Position of lumbar spine
 Gait

B. PALPATION
 Should begin superficially and
progress to deeper tissues
 Prone stability testing:
○ Pressure over isolated vertebrae
is applied to look for painful
level.

C. RANGE OF MOTION
Quantity of ROM
I.

Single or double inclinometer.
The distance of fingertips to
floor
Schober’s test



II.
DOUBLE INCLINOMETER
 Correlate the closest to
measurements on radiographs
Quality of ROM

D. NEUROLOGIC EXAMINATION
 Look for the following:
a. Weakness
b. Sensory loss
c. Diminished/absent reflexes
d. Special tests – SLR

E. ORTHOPEDIC SPECIAL TESTS TO
ASSESS FOR RELATIVE STRENGTH
 Curl Trunk Sit Up
 Holding the low back flat during lowering

F. ORTHOPEDIC SPECIAL TESTS
FOR LUMBAR SEGMENTAL
INSTABILITY
 Segmental 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 NONORGANIC SIGNS SEEN ON P.E.
 Some patients display symptom out of proportion
to injury
 ILLNESS BEHAVIORS
○ Learned behaviors
○ Are responses that some patients use to convey
their distress.
 Anxiety, panic attacks
 Malingering
 Search 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 nonanatomic 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:
Degenerative disc disease
2. Disc herniation
3. radiculopathy
1.
 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 workup
 Rarely used
 Useful 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 instability
Deconditioning
Abnormal posture
Poor muscle recruitment
Emotional stress
Changes associated with aging and injury
○ Disc degeneration
○ Arthritis
○ Ligamentous hypertrophy

Other names:
 Simple backache
 Non-specific low back pain
 Lumbar strain
 Spinal degeneration

Mechanical low back pain
 the best term to use
 precise
 Suggests that the mechanism of injury is better
than the other terms
 Suggests 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 LBP
Segmental Instability
b. Muscular imbalances and neural
processing problems
c. Lumbar paraspinal abnormalities
a.
a. Segmental Instability
Sufficient joint stiffness: required at the
segmental level to prevent injury and
allow for efficient movement.
 Causes of Instability:

 Tissue damage
 Poor muscular endurance
 Poor muscle control
 A 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 abnormalities
paraspinal muscle atrophy
Multifidi 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 anxiety
Patients 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.
b.
c.
d.
e.

Anatomy and function of the spine
Common sources
Proper lifting techniques
Ergonomics
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 LBP
 Results in positive oucomes
 A combination of strengthening and flexibility
exercises: most common
Specific exercises treatment
for LBP
a.
b.
c.
d.
e.
f.
g.
Postural training
Lumbar stabilization
Awareness of spine position and muscle
contraction in various positions and with different
activities
Obtaining and maintaining mild abdominal
contraction and multifidi activation.
Stabilization exercises to establish motor patterns
and build endurance
Modifications for those in whom exercises
aggravate pain
Flexion exercises
Specific exercises treatment
for LBP
h.
i.
j.
k.
Extension exercises
Aerobic activity
Aquatic exercises
Exercises after surgery
William’s Flexion Exercises
Pelvic tilt.
1.

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
Single Knee to chest.
2.

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.
Double knee to chest.
3.

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.
Partial sit-up.
4.
•
5.
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.
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.
Hip Flexor stretch.
6.

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.
Squat.
7.

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
NSAIDS
2. Muscle relaxants
3. Antidepressants
4. Opioids
5. Anticonvulsants
6. Topical treatments
1.
V. INJECTIONS and NEEDLE
THERAPY
a.
b.
c.
Myofascial and trigger point injections
Acupuncture
Steroid injections
VI. MANUAL MOBILIZATION or
MANIPULATION
Traction
2. Heel lifts and correction of leg length
discrepancy
3. Lumbar supports
4. TENS
5. Massage
6. Complementary movement therapies
1.
Complimentary Movement
Therapies
a.
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:

 Obesity
 Non-insulin-dependent DM
 Cardiovascular disease
DIFFERENTIAL DIAGNOSIS AND TREATMENT
LEG PAIN GREATER THAN
BACK PAIN
Lumbar Spondylosis
b. Lumbar Disk Disease
c. Internal Disk Disruption
d. Disk Herniation
e. Spondylolysis
f. Spondylolisthesis
g. Other Spinal Fractures
a.
I. LUMBAR SPONDYLOSIS