Week 1 Posture and low back pain

Question 1

advantages and disadvantages of posture

Answer 1

+ve: able to use tools
-ve: increase work against gravity (for heart), reduce base of support = decrease stability

Question 2

postural sway 姿勢搖擺

Answer 2

• even in ‘static’ standing - a slow swaying
• opportunity for joint and intervertebral disc nutrition, unloads and distributes loads across structures 為關節和椎間盤提供營養、卸載和分佈跨結構的負荷的機會

Question 3

erect standing - head, neck, thoracic spine, hip and pelvis, knee, ankle

Answer 3

head:
LoG passes anteriorly, creating a flexion moment

neck:
LoG passes posteriorly, creating extension moment

thoracic spine:
LoG passes anteriorly, creating a flexion moment

hip and pelvis:
LoG passes posteriorly, creating an extension moment

knee:
LoG between the midline of knee joint and patella, creating an extension moment. It is opposed by passive tension in the posterior capsule and ligaments of the knee.

ankle:
LoG passes anteriorly, creating an external dorsiflexion moment. It is opposed by an internal plantarflexion moment (by contraction of soleus)

Question 4

axial spondyloarthritis

Answer 4

Chronic inflammatory LBP
<45yrs old
Family history
Management = medical + exercise

Question 5

cancer (low back pain)

Answer 5

• age >60
• UWL
• unremitting bone pain

Question 6

excessive lumbar lordosis

Answer 6

• weak abdominals
• tight hip flexors
• IR of leg
• protraction of scapula
• forward head posture

Question 7

excessive thoracic kyphosis

Answer 7

• habitual
• poor self-esteem
• compression fracture of thoracic vertebrae

Question 8

ground reaction forces (GRF) and
ground reaction forces vector (GRFV)

Answer 8

GRF: when the body contacts the ground, the ground pushed back on the body

GRFV: equal in magnitude but opposite in direction to the gravitational force

Question 9

‘optimal’ posture

poor posture does not always = low back pain

Answer 9

• hold most joints in mid-range and balancd to reduce ligament strain and muscle activity 將大多數關節保持在中間範圍並保持平衡，以減少韌帶拉傷和肌肉活動
• standing and sitting ‘straight’ may look ideal but if held by highly active muscles or at end of available joint range for that person, it is not energy efficient and therefore not ‘optimal’

Question 10

increased lumbar lordosis and anterior pelvic tilt are associated with

Answer 10

• tight lumbar extensors and quadriceps
• weakness of abdominal and hamstrings

Question 11

lumbo-pelvic rhythm

Answer 11

• allows greater range of motion
• reduce stress
• combined, coordinated lumbar and pelvic activity

Question 12

erect standing: sagittal plane - lumbosacral/ sacroiliac joints

Answer 12

• LoG passes through the body of L5, creating extension moment
• L5 slides anteriorly on S1
• opposed by ALL and iliolumbar ligaments
• facet joints prevent anterior translation
• sacroiliac joint moves into nutation, resisted by passive tension in sacrotuberous and sacrospinous ligaments

Question 13

erect standing: sagittal plane - hip and pelvis

Answer 13

• LoG passes slightly posteriorly to the axis of hip joint, creating extension moment
• opposed by contraction of iliopsoas
• also, passive tension in iliofemoral, ischofemoral and pubofemoral ligaments

Question 14

management of LBP

Answer 14

• education
• exercise
• manual therapy

Question 15

advice for the management of non-specific low back pain

Answer 15

• imaging is not required and will not change management
• avoid using terms such as injury, degeneration
• encourage the patient to stay active and avoid bed rest

Question 16

management of neurocompressive LBP

Answer 16

• education
• exercise
• manual therapy
• surgery if required
• medical

Question 17

neurocompressive LBP

Answer 17

1. Radicular pain
2. Radiculopathy
3. Positive straight leg raise and/or slump test
4. Antalgic gait, spinal list or lateral shift

Question 18

recent onset of LBP
最近出現腰痛

Answer 18

acute LBP 急性腰痛 <6 weeks
subacute 6-12 weeks

Question 19

scoliosis

Answer 19

• leg length differences
• idiopathic
• nerve root irritation
• structural deformity

Question 20

serious pathology of low back pain

Answer 20

• cancer
• spinal stenosis
• axial spondyloarthritis
• spinal fracture
• infection
• cauda equina syndrome

Question 21

spinal fractures

Answer 21

Major trauma (e.g. fall from height, motor vehicle accident)
Age >70
Prolonged use of corticosteroids –> side effect: reduce bone density
Female

Question 22

spinal stenosis

Answer 22

age >65
Spinal stenosis = narrowing of the spinal canal
Acute or degenerative (get history)
Clinical pattern = bilateral leg pain, worse in lumbar extension (e.g. standing) and better in lumbar flexion (e.g. sitting)
pain in walking but relieve in sitting

Question 23

spondylosis,
spondylolysis,
spondylolisthesis

Answer 23

• degeneration of spine
• stress fracture, repetitive hyperextension at pars interarticularis (L5)
• superior articular process of L5 slip forwards with rest of spine
• may progress from spodylolysis if bilateral

Question 24

static erect standing requires relatively

Answer 24

low levels of muscle activity

Question 25

types of LBP

Answer 25

1. specific LBP (serious pathology <5%, neurocompression <10%)
2. non specific LBP (85%+)
   - examples:
   - facet syndrome
   - postural syndrome
   - insability
   - sacroiliac joint pain

non-specific LBP have high incidence of false positive findings with investigations (eg: MRI), so called it non-specific LBP

Question 26

Radicular pain

Answer 26

• Pain (shooting down the leg, can be aggravated by cough / sneeze, highly irritable)
• Leg pain worse than back pain

Question 27

Radiculopathy

Answer 27

• Muscle weakness
• Decreased or absent spinal reflexes
• Paraesthesia (‘burning’, ‘prickling’, ‘pins & needles’)
• Anaesthesia (numbness)

Question 28

SIJ movement, stability and mobility

Answer 28

movement:
nutation: anterior nodding of sacrum;
counter-nutation: opposite movement

stability:
support HAT
role of supporting ligaments

mobility:
allow dynamic function
force dispersal