LOW BACK PAIN Flashcards
Definition
Low Back Pain (LBP) is generally described as pain between the costal margin and the gluteal
folds.
Relevant Anatomy
x The spine supports and protects the spinal canal contents at the same time contributes to the inherent flexibility of the trunk.
x The five lumbar vertebrae have distinct components, which include the vertebral body, the neural arch, and the posterior elements.
x The large bodies and the intervertebral disks of the lumbar vertebrae bear most of the weight of the head, neck and trunk in erect posture.
x Pedicles - resist bending and transmit forces back and forth from the vertebral bodies to the posterior elements.
x Intervertebral disk – acts as shock absorber.
x Zygapophyseal joints – allow flexion, extension, some lateral bending, and very little rotation.
x Anterior longitudinal ligament - resist extension, translation, and rotation.
x Posterior longitudinal ligament - resist flexion.
x The posterior muscles, which include the latissimus dorsi and the paraspinals act as the chief extensors of the spine.
x The anterior muscles include the psoas and the quuadratus lumborum.
x Lumbosacral junction – subjected to a great deal of anterior shear by the superimposed body weight.
x Thoracolumbar fascia - decreases some of the shear forces that other muscles and lumbar motions create.
x Pelvic stabilizers – ―core‖ muscles
x Nerves – The connus medullaris ends at about bony level L2, and below this level is the cauda equine.
Etiology
- The Degenerative Spine Cascade – The process is described as follows:
x Zygapophyseal Joints – synovial hypertrophy, cartilage degeneration and destruction, capsular laxity, joint instability, bony joint hypertrophy, narrowing of central canal, potential impingement of nerve roots.
x Disk degeneration – repetitive microtrauma producing excessive shearing forces, annulus tear, disk herniation, foraminal narrowing, potential nerve root impingement.
- Pain of Spinal Stenosis
a. Venous engorgement theory:
x The spinal veins dilate causing venous congestions and stagnating blood flow.
x This pooling of blood causes increase intrathecal and epidural pressure leading to neuroischemic insult which in turn leads to the neurogenic claudication symptoms of spinal stenosis.
b. Arterial Insufficiency theory – the reflex arterial dilatation of lumbar vessels during lower extremity exercise which provide increased circulation and nourishment to nerve roots is defective.
- Radiculitis and Radiculopathy
- Segmental Dysfunction can occur when either a segment is too stiff or too mobile caused by arthritic or ligamentous changes, tissue damage, poor muscular endurance, or poor muscular control.
- Muscular Imbalances and Neural Procession Problems can occur with strength ratio abnormalities and muscle endurance deficits.
Epidemiology
x Studies have shown lifetime prevalence as high as 84%.
x Most patients have short attacks of pain that are mild to moderate and do not limit activities.
x A small percentage of low back pain becomes chronic and causes significant disability.
x Over 1% of adults in the US are permanently disabled by back pain, and another 1% is temporarily disabled.
Pathophysiology
- Mechanical Low Back Pain – multifactorial axial backache. The causes may include deconditioning, poor muscle recruitment, emotional stress and changes associated with aging and injury.
- Sacroiliac Pain:
a. Nociception from articular cartilage and posterior joint capsule and ligaments. b. Peripartum period increases incidence of SI joint pain
c. Innervation of posterior rami of S1 and S2 and L5 dorsal rami. - Disk Herniation – disk material that extends beyond the intervertebral disk space.
a. Protrusion – nuclear material is contained by the outer layers of the annulus and
supporting ligamentous structures
b. Prolapse – frank rupture of the nuclear material into the vertebral canal
x Extrusion – extension of the nuclear material beyond the confines of the posterior longitudinal ligament or above and below the disk space but still in contact with the disk.
x Free sequestration – the extruded nucleus has separated from the disk and moved away from the prolapsed area. - Spinal Stenosis – any type of narrowing of the spinal canal, causing compression of its content.
- Spondylolisthesis – anterior slippage of one vertebra on another which can result from many causes.
a. Isthmic slip – results from a stress fracture of the pars interarticularis.
b. Dysplastic spondylolisthesis – congenital slip caused by dysplasia of the facet joints of
the upper sacrum leading to an inability to resist shear stresses and forward slippage.
c. Degenerative spondylolisthesis – related to long-standing intersegmental instability related to degeneration of facet or disk disease.
d. Traumatic spondylolisthesis – caused by acute fracture.
e. Pathologic spondylolisthesis – due to generalized or local bone disease that decreases
bone strength.
f. Postsurgical spondylolisthesis – due to instability from an extensive decompression.
Clinical Manifestations
Clinical Manifestations
x Acute Low Back Pain(no more than one month):
o Can appear suddenly or with significant physical effort
o Can start insidiously or can arrive at the complete lumbar blockage
o Can start on one side and move to the other or remain fixed
o Last from several minutes to several weeks
x Subacute Low back Pain (more than one month but less than six months)
o Not very different from the acute
o With psychological and/or social disturbances
x Chronic Low Back Pain (More than six months)
o With or without functional limitation
o Fear-avoidance behavior
o Non-use syndrome or Deconditioning syndrome leading to progressive loss of physical
abilities
- Mechanical Low Back Pain:
a. Cyclic pain
b. LBP referred to the buttocks and thighs c. Morning stiffness
d. Start Pain (i.e. when starting movement)
e. Pain on forward flexion and often on returning to the erect position
f. Pain aggravated by extension, side flexion, rotation, standing, walking, sitting, and exercise in general
g. Pain becomes worse over the course of the day h. Pain is relieved by change of position
i. Pain is relieved by lying down, especially in the fetal position - Sacroiliac - pain does not radiate above the lumbosacral junction but can radiate into the groin, thigh, and even below the knee, with significant overlap of lumbosacral radicular pain patterns.
- Disk Herniation
a. Can cause an inflammatory response which affect the nerve root and can cause radicular pain.
b. Can cause solely axial pain.
c. Bandlike and exacerbated by either lumbar flexion or extension, depending on the site of disk pathology.
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- Stenosis
a. 65% of patients have decreased walking ability b. Leg symptoms due to radiculopathy
c. Both lower limbs are involved more often than one.
d. Neurogenic claudication most often experienced in both lower extremities e. Occasional bladder dysfunction and sexual difficulties
f. Typically relieved by sitting or bending forward. g. Can lead to significant hip flexion contracture.
h. Back may appear normal or may show spasm or stiffness. i. Diminution or loss of ankle jerk.
j. Advanced cases – sensory loss - Spondylolisthesis - nonspecific LBP and sciatica are the most frequent clinical presentations
a. Isthmic – more often bilateral than unilateral; pain may be severe, slight or entirely absent; often well localized in the lumbosacral junction but may radiate down one or both legs along the course of the sciatic nerve; stiffness of the back
b. Degenerative – typical patient is a woman aged 5o years or more who complains of long-standing pain in the low back, buttocks, or thighs; rarely incapacitating pain; long remissions; relieved by sitting or reclining; lower limb pain is often unaccompanied by significant neurological signs.
Diagnosis/Differential Diagnosis
- Mechanical Low Back Pain – No specific diagnostic tests but tests and images are used to exclude other diagnoses.
- Sacroiliac – The gold standard for diagnosing sacroiliac joint pain is a fluoroscopically guided injection of local anesthetic into the sacroiliac joint to help delineate the sclerotomal referral of pain emanating from the SI joint.
a. Pain after 70° during unilateral straight leg raising. - Disk Herniation – Diagnosing diskogenic pain is a challenge because asymptomatic patients can have disk herniations present on MRI. Discography is controversial and is typically used as a presurgical screening tool.
a. Straight leg raising – positive if pain is primarily back pain
b. Neck flexion component of SLR – Brudzinski‘s sign: Increased pain
c. Well leg raising of Fajersztajn – pain of opposite side of raised leg
d. Compression test – patient in hook lying. The hips are flexed until PSIS start to move
backward (usually about 100° hip flexion). The examiner then applies direct pressure
against the patient‘s feett or buttocks applying axial compression to the spine. Radicular pain is produced into the posterior leg. - Stenosis – Electrodiagnostic studies are used to fully characterize the stenosis.
Grading lumbar stenosis on Magnetic Resonance Imaging
Grade Percentage of the AP Canal Dimensions at a Normal level Mild 75-99 Moderate 50-74 Severe <50 5. Spondylolisthesis: a. One-leg Standing (Stork standing) Lumbar extension test – The patient stands on one leg and extends the the spine while balancing on the leg. A positive test is indicated by pain in the back and is usually associated with pars interarticularis stress fracture (spondylolisthesis).
b. Oblique view on plain film radiography: ―scottie dog decapitated‖
c. lateral flexion-extension films
Meyerding‘s grading system for Spondylolisthesis Grade Percentage Slip 1 <25 2 25-49 3 50-74 4 75-99 5 >100 (spondyloptosis)
Prognosis/Complications
x Most LBP patients improved within a month.
x Others have continuous pain decrease until about 3 months.
x Risk of recurrence within 3 months varies between 19% and 34%.
x Risk of recurrence with 1 year varies between 66% and 84%.
Medical/Pharmacologic Management:
Mechanical Low Back Pain
Medications:
x Nonsteroidal Anti-inflammatory Drugs prescribed at regular intervals provide pain relief for both acute and chronic low back pain.
x Short-acting opioids are used to treat acute low back pain.
x Anticonvulsants, particularly gabapentin and pregabalin, are widely used for neuropathic pain. One study of topiramate showed small improvement of Chronic Low Back Pain.
x Tramadol has been shown to be helpful for short-term treatment of chronic low back pain with a low rate of side effects.
x Topical Treatments such as Lidocaine (lignocaine) patches have been found effective by some patients for the treatment of back pain.
x Herbal Medications for LBP
x Muscle Relaxants – benzodiazepines, nonbenzodiazepines, antispasticity medications
x Antidepressants – for chronic low back pain
Myofascial Pain and Trigger point Injections
Acupunture – has effects on the endogenous opioid peptide system, sympathetic nervous system and alterations in pain processing in the brain and spinal cord.
Experimental Injection Procedures – Botox and Prolotherapy are increasingly being used to treat low back pain.
Steroid Injections
Sacroiliac Pain – A corticosteroid and anesthetic mixture is usually injected until capsular resistance is encountered(0.8 to 2.5mL)
Disk Herniation: If leg pain >> Axial pain i. Epidural Steroid Injections ii. Percutaneous disk decompression procedures 1. Ozone Chemonucleolysis 2. Thermal Laser 3. Mechanical a. Automated devices b. Radiofrequency nucleoplasty iii. Surgery 1. Microdiskectomy
If Axial pain»_space; Leg Pain
i. Intradiskal steroids ii. Annuloplasty
iii. Lumbar fusion
iv. Disk Arthroplasty
Stenosis
Oral Medications
Transforaminal epidural steroid injections
Laminectomies – the most common decompression procedure
Spondylolisthesis – Fusion surgery
PT management
PT management
- Mechanical Low Back Pain a. Objective of care
i. Patient Education ii. Decrease Pain
iii. Improve alignment and posture
iv. Strengthen muscles that support the spine
Intervention Rationale
Stretching exercises Stretch tight areas caused by postural faults
Lumbar stabilization and core strengthening exercises To strengthen the muscles that support the spine
Aerobic exercise (Aquatic exercises for those who cannot tolerate land-based exercises) Increase endurance
Relevant health teachings to patient and family
x Small doses of exercise that are not sufficient to cause physiologic change have been found to decrease pain and increase function.
x Activity levels should be increased in planned, fixed increments based on realistic goals rather than on symptoms.
- Sacroiliac
a. Objective of care
i. Patient Education ii. Decrease Pain
iii. Improve alignment and posture
iv. Strengthen muscles that support the spine
Intervention Rationale
Stretching exercises Stretch tight areas caused by postural faults
Lumbar stabilization and core strengthening exercises with drawing-in maneuver as prerequisite activity To strengthen the muscles that support the spine
Drawing-in maneuver develops the pattern of setting the abdominal and multifidus muscles in a feedforward pattern and then trains their holding capacity in coordination with the global muscles. Aerobic exercise (Aquatic exercises for those who cannot tolerate land-based exercises) Increase endurance
- Disk Herniation
a. Objective of care
i. Patient Education ii. Decrease Pain
iii. Improve alignment and posture
iv. Strengthen muscles that support the spine
Intervention Rationale
McKenzie Approach Mobilize the spine and symptomatic disk without causing pain;
it could facilitate immediate washout of inflammatory agents
Patient Education and Cognitive behavioral counseling Reducing the risk of symptoms and increasing self care
Traction May relieve the symptoms from a disk protrusion. Separating the vertebral bodies have a flattening effect on the bulge and
it may also decrease the intradiskal pressure.
Extension Approach x Prone on elbow x Prone press-ups x Standing back-bend Extension motions and positions relieve the symptoms by moving the fluid to reverse the stasis.
Relevant health teaching to patient and family
x Let the patient know what to do and what to avoid to decrease risk of exacerbation
x In case of neurologic damage, the patient must clearly understand the timing of recovery and what it can mean to his/her everyday life.
x Following any flexion exercises, perform extension exercises.
x If being in a prolonged flexion posture is necessary, interrupt the flexion with backward bending at least once every hour. Also, perform intermittent pelvic tilts.
x If symptoms of a protrusion develop and are felt, immediately perform press-ups in a prone position, anterior pelvic tilts in a quadruped position or backward bending while standing to prevent progression of the symptoms.
- Spinal Stenosis
a. Objective of care
i. Patient Education
ii. Decrease Pain and avoid/delay development of symptoms iii. Improve alignment and posture
iv. Strengthen muscles that support the spine
Intervention Rationale
Manual therapy, Mobilization techniques, exercises Increase ROM, neuromuscular control, proprioception, strength, endurance
Postural Education Provide more space for neural tissues; Renormalize the pathoanatomic situation
Aerobic training Increase peripheral uptake of oxygen; increase patient‘s
maximum walking distance
Traction Widens the intervertebral foramina
Relevant health teaching to the patient and family:
x Key messages should include knowledge of the pathology, its main symptoms, and its prognosis in terms of pain and the ADL. Particularly, the possible evolution of the flexed posture must be explained with the aim of avoiding it.
- Spondylolisthesis
a. Objective of care
i. Control Pain
ii. Strengthen trunk stabilizing muscles iii. Improve posture
Intervention Rationale
Rigid brace Control worsening of the listhesis and sometimes also a reduction
Lumbar support Help spine support itself
Aerobic conditioning Increase endurance
Lumbar stabilization exercises Improve motor control skills
Drawing-in action or abdominal hollowing, 10 minutes ten times a day while maintaining a normal breath Facilitates neutral lordosis and a sensation of transversus abdominis contraction
Joint stability exercises, Balance training, Proprioception training Achieve neuromuscular control
Relevant health teaching to patient and family:
x Inform them to avoid heavy and sudden loads, avoid extreme flexion and extension movement of the spine.
x Patients must know the risk factors for worsening (hyperextension movements, high physical activity)
General Spinal PT management
x Apply to all spinal problems in the acute, subacute and chronic settings for both nonoperative and surgical patients:
Acute phase:
Intervention Rationale
Superficial cold for 20-30 minutes Decrease spasm, pain, and capillary blood flow
Superficial heat Decreases spasm and pain but increases ar5terial and capillary blood flow
Deep heat Decreases spasm and pain, increases collagen distensibility (helping to improve flexibility)
Therapeutic electricity Decrease spasm, edema, pain, inflammation, and atrophy; increases circulation to help remove inflammatory byproducts.
Low energy Lasers Affect tissue healing
Manual therapy techniques Modulate pain; provide early controlled motion; stimulate mechanoreceptors and nociceptors
Mechanical therapy – traction Pain relief by intervertebral distraction, stretching muscle and other
soft-tissue structures, and providing period or relative rest
Corsets Control ROM; provide proprioceptive feedback and warmth; decrease intradiscal pressure
Therapeutic exercise
x Extension bias
x Flexion bias x Reduce intradiscal pressure; allow anterior migration of nucleus pulposus; increase mechanoreceptor input
x Reduce facet joint compression and provide stretch to lumbar musculature, ligaments, and myofascial structures
Kinesthetic training: Pelvic tilts, Neutral spine Awareness of spine position and movement
Core activation techniques: Drawing- in, Multifidus contraction, basic stabilization To initiate neuromuscular activation and control of stabilizing muscles
Subacute Phase:
Goal: to achieve full, pain-free ROM
Intervention Rationale
Manual soft—tissue techniques
x Massage
x Fascial-tendon stretching
x Traction
x Joint mobilization Increase soft-tissue distensibility along lines of physiologic stress to promote proper alignment of collagen fibers during remodeling and
healing
Myofascial Release techniques Improve elasticity and freedom of movement and decrease pain
Mobilization Restores optimal joint mobility
Exercise: Dynamic lumbar stabilization training Control pain, Gain dynamic control of segmental spine and kinetic chain forces; optimize tissue repair and regeneration
Home exercise program; Ergonomic adaptation of work or home
environment Educate patient in self-management and how to decrease episodes of pain
Practice posture correction and active spinal control in pain-free positions and
with all exercises and activities Progress awareness and control of spinal alignment
Low to moderate intensity aerobic exercises; emphasize spinal bias Develop cardiopulmonary endurance
Lumbar Stabilization Exercise:
1. Drawing-in maneuver for Transverse Abdominis Activation
2. Abdominal Bracing – setting the abdominals and actively flaring out laterally around the waist.
Braced position is held while breathing in a relaxed manner.
3. Posterior Pelvic Tilt – activate the rectus abdominis which is primarily used in trunk flexion activities.
4. Multifidus activation and training
- Lumbar Stabilization with progressive loading - emphasis on abdominals a. Lift bent leg to 90° hip flexion
b. Slide heel to extend knee c. Lift straight leg to 45° - Lumbar stabilization with progressive limb loading – emphasis on trunk extensors a. Quadruped position
i. Flex one upper extremity
ii. Extend one lower extremity by sliding it along the exercise mat iii. Extend one lower extremity and lift 6-8 inches off exercise mat
iv. Flex one upper extremity and extend contralateral lower extremity
b. Prone lying position-near end range of motion requiring greater control of neutral spine i. Extend one lower extremity
ii. Extend both lower extremity
iii. Lift head, arms, and lower extremity
Chronic spinal problems/Return to Function Phase
Intervention Rationale
Practice active spinal control in various transitional activities that challenge balance Emphasize spinal control in high-intensity and repetitive activities
Joint mobilization/manipulation, muscle inhibition, self-stretching Increase mobility in tight muscles/joint/fascia
Progress dynamic trunk and extremity exercises emphasizing functional goals Improve muscle performance; dynamic trunk and extremity strength, coordination, and endurance
Progress intensity of aerobic exercises Increase cardiopulmonary endurance
Engage patient in all activities and healthy exercise habits For self-maintenance; maintaining fitness level and safe body mechanics
Relevant health teachings to patient and family:
Patient education for Body mechanics:
x Position the body close to and facing the task, which avoids twisting and bending the trunk and limits excessive loading from upper extremity reaching.
x Use both legs to turn the body to face the activity, which avoids muscular stress on the spine caused by twisting the body
x Maximize lower extremity flexibility and reduce the stress on the lumbar region by using the hip flexors and extensors to lower and raise the body
x Take micro-breaks and walk briefly or stretch every hour, interrupting sustained periods of static sitting or standing
x Balance activity with rest to facilitate endurance, good body mechanics, and safety by incorporating rest periods into the course of the activity or alternating between two work patterns that each challenge different muscle groups.
