통증 물리치료학 및 실습

Gachon University

Department of Physical Therapy Hwi-young Cho, PT, PhD

CH 13. 요통 재활 - 1

• 70~80 % of adults experience at least once

during their lifetime (Andersson , 1998; Frymoyer , 1988)

• Low back pain (LBP)

– Intervertebral discs : 39 %

– Facet joints : 15 - 40 %

– Sarcoiliac joints : 30 % (Schwarzer ,1995)

http://doctormurray.com/magnesium-for-chronic-low-back-pain/

• Spondylosis (=spinal arthritis)

• Spinal stenosis

• Spondylolisthesis

• Scoliosis

• Kyphosis

• Whiplash injury

• Hyperlordosis

• Paget`s disease

• Specific cognitive (Apkarian, 2004)

– ↓ decision making

• Brain chemical (Grachev, 2000)

– ↓ N-acetyl aspartate & glucose in the dorsolateral

prefrontal cortex

• Morphologic abnormalities (Apkarian, 2004)

– ↓ neocortical gray matter volume : brain atrophy

Cortical changes reflecting maladaptive reorganization

Functional changes

- CLBP patients have significantly lower increases in blood flow in the periaqueductal gray than controls when exposed to equally painful stimuli.

(Giesecke et al., 2006)

- Enhanced cortical responses have been noted with noxious subcutaneous stimulation of the back and acute experimental muscle pain.

(Flor et al., 1997a ; Diers et al., 2007)

Functional changes

• Activation of a more expansive network of pain-related brain regions with peripheral noxious input.

(Giesecke et al., 2004,2006; Kobayashi et al., 2009)

• Raised motor thresholds have been reported for the lumbar back muscles of CLBP patients

- deceased corticospinal drive to these muscles

(Strutton et al., 2005)

[Pain subtype]

• Musculoskeletal pain

– Muscles, bones, tendons, ligaments, fascia

• Neuropathy

– Parasthesia

– Radiculopathy

– Pinched Nerve

• Discogenic pain

– Pain from an intervertebral disc(IVD)

• Mechanical factors

• Inflammatory factors (= chemical factor)

[Changes in the interior of the body]

• Loss of vertebral structure (mechanical factor)

– Intervertebral disc (IVD)

– Facet joint

– Sacroiliac joint

– Ligament & muscles

– Spinous process (SP)

• Release of mediators (chemical factor)

– TNF-α in NP (Weiler, 2005)

– Cytokine genes (IL-6) (Noponen-Hietala, 2005)

– ↑bFGF & TGF- 1, macrophages & mast cells (Peng, 2006)

Mechanical theory

Chemical theory

Anatomy of Spine

architecture

http://legacy.owensboro.kctcs.edu/gcaplan/anat/notes/api%20notes%20h%20skeletal%20vertebrae.htm

http://www.visualphotos.com/image/1x6008301/intervertebral_disc_light_micrograph

http://b-reddy.org/2014/06/16/my-second-visit-to-washington-university-in-st-louis/

(Hariharan S et al., 2009)

http://www.novaorthospine.com/neck_pain.html

http://www.darrellkilcupdc.com/2011/10/herniated-disk-fixed-without-harmful-addictive-drugs-and-surgery/

ANATOMY of DISC

http://www.youtube.com/watch?v=btqHRxwQlYY

Inner annulus : Type 1 collagen fiber – Compression stress

Outer annulus : Type 2 collagen fiber – Tensile stress (more dense)

Distraction of vertebral bodies closes oblique angels and Radial fissures

http://www.medscape.com/viewarticle/543611_2

http://www.sonsa.org/spine-anatomy.html

• Location – The back of the spine on each

side

• Role – Stability & control motion

between the vertebrae (Backward bending & rotation)

• Facet joint block – An anesthetic & steroid are

injected on facet joint or facet capsule

http://www.spineuniverse.com/anatomy/facet-joints-spines-anatomy

Innervation of the spine & IVD

http://www.netterimages.com/image/4642.htm http://www.medscape.org/viewarticle/756736_transcript

http://www.dynamicdiscdesigns.com/shop/custom-neurology/

http://4.bp.blogspot.com/_ZqNxIxdLa1A/TJze7nxXtsI/AAAAAAAAAs0/shltmhYJQEg/s1600/IVD+innervation.jpg

http://medical-dictionary.thefreedictionary.com/dermatome

Pathology of LBP

- The source of LBP -

Loss of normal structure &

weight bearing properties

Disc degeneration &

deterioration

Disc

herniation

Stimulation of the

nocicepotor in the AF

Nerve & vessel

supply

changes

Abnormal

motions

Influence other structure

(Facet joint, lig,

muscles)

↑ inflammatory & signaling

substances (TNFα, IL-6, IL-8,

IL-1β) in DRG neurons or

primary afferent neurons)

Discogenic pain

Adjacent nervous system

structure (DRG, nerve

roots) affected

Macrophage

Mechanical factor (Kawakami M (1994) Spine. 19:1780-94) (Olmarket K (1995) 20:665-9.)

Mechanical factor

• Is this one and only factor to make the LBP?

• How about the aging people?

– They show the degeneration of spine architecture

• In many cases asymptomatic (Boden SD, 1990)

• Is there an another factors of LBP?

–Chemical factor, such as Proinflammatory

cytokine and cytokine

• In human

– ↑ pro-inflammatory mediators (IL-6 & 8) in disc

tissue from discogenic pain pt. (Burke , 2002)

– ↑ cytokine genes (IL1A, IL1B, IL1RN, TNF-α, IL2,

IL4, IL4R, IL6, IL10, IFNG) (Noponen-Hietala, 2005)

– ↑ SP, VIP -ir nerve fibers in painful disc (Peng , 2004)

– ↑ IL-6, IL-8, & PGE2 in scoliosis, lumbar

radiculopathy & discogenic pain pt (Burke , 2003)

– ↑ TNF-α in adults nucleus purposus (Weiler , 2005)

• In rat

– Iinfliximab (TNF-α inhibitor) : ↓pain, induced immobility (Olmarker , 2003)

– ↑ CGRP, IB4-ir by CFA-inj. on L5-6 disc (Aoki, 2004)

– ↑ Apoptotic change & TNF-α, IL-1, MMP-1, TIMP-1 & PGE2,

6-K-PGF1α, IL-1α following mechanical imbalance (muscle &

ligaments incision) (Wang, 2006)

– ↑ NGF & BDNF-ir by NP application on DRG (Obata, 2002)

– ↑ SP-ir in L2 DRG by L2 ramus cut (Chen, 2008)

– ↑ FOS-ir in lamina Ⅰ-Ⅴof L5 in cutaneous pain that were

induced formalin injection at corresponding L5 dermatome (Ohtori, 2000)

The degenerative process of Spine

associated with LBP

http://www.horst-chiropractic.com/wp-content/uploads/2012/12/spinal-degeneration.jpg

Phase 1

• The early stage of spinal degeneration

• No symptoms, and therefore few patients seek treatment for it.

• In many cases, the first phase of spinal degeneration begins in the patients 20s or 30s. However, most do not realize that the spine is misaligned because these vertebral subluxations do not cause any pain for the first few years.

• At this stage, which can last between 10 and 20 years, the spine loses some of its natural curvature and the joints, discs, and nerves experience some stress that causes them to age at an accelerated rate. Regular chiropractic care is ideal at this stage, as the body responds best to chiropractic adjustments in the early stages of spinal degeneration.

http://www.horst-chiropractic.com/wp-content/uploads/2012/12/spinal-degeneration.jpg

Phase 2

• In phase two of the spinal degeneration process, which can last for another 20 years, patients begin to experience increased neck pain and back pain.

• During this stage, the discs are thinner, the spinal cord has narrowed, and bone spurs have formed.

• The patient’s posture is typically affected by now. PT or Chiropractic care is still effective for many patients at this point, and patients suffering from signs of spinal degeneration should schedule regular chiropractic adjustments to improve spinal balance and relieve spinal stress.

http://www.horst-chiropractic.com/wp-content/uploads/2012/12/spinal-degeneration.jpg

Phase 3

• By the time spinal degeneration has progressed to stage three, more invasive treatment may be needed to address spinal problems; however, regular PT or chiropractic appointments can still be beneficial and help to delay the degeneration process.

• In this stage, patients experience a change in posture, nerve damage, more serious disc problems, and deformation of the bones.

http://www.horst-chiropractic.com/wp-content/uploads/2012/12/spinal-degeneration.jpg

Phase 4

• By the time degenerative spinal disease has hit stage four, patients’ quality of life is impacted. Chronic pain, reduced range of motion, numbness or paralysis, and poor balance can make it difficult for patients to attend to daily tasks.

• In phase four, many patients will require a more aggressive treatment plan, which may include routine chiropractic adjustments to provide some relief of symptoms. However, at this stage, spinal degeneration is irreversible and our main goal is keeping patients as comfortable as possible.

http://www.horst-chiropractic.com/wp-content/uploads/2012/12/spinal-degeneration.jpg

Radiological analysis

• Criterion

– Decrease of disc height

– Irregular disc contour with bulging due to

deterioration of the annulus fibrosus

– Abundant presence of gas

– Osteophyte formation (Gruber , 2002)

– End-plate erosions (Gruber , 2005)

– Vascularization (Gruber , 2005)

CT

http://www.nytimes.com/health/guides/symptoms/back-pain-low/diagnosis.html

Rehabilitative ultrasound imaging

http://www.rehabpub.com/2014/11/use-rehabilitative-ultrasound-imaging-treat-low-back-pain/

http://comstockpt.com/2011/04/29/working-core-back-pain-injury-muscles/

Digital thermography

http://www.breastthermographync.com/thermograms-for-breast-faq-north-carolina

Disc burging

Gas

Disc

herniation

Disc herniation (MRI) http://wubifo.pev.pl/mri-pictures-of-herniated-cervical-disk.php

Disc herniation (MRI) http://www.painmanagementatlantaga.com/herniated-disc.html

Disc height narrowing

http://www.coloradospineinstitute.com/subject.php?pn=cond-cervical-degen-disc-11

Degenerative changes at the Facet joint

Spinal disease

http://mandevillehigh.stpsb.org/teachersites/laura_decker/disk_problems1.JPG

1. Herniated Nucleus Pulposus

Herniated Nucleus Pulposus

• 원인 ① 진행적으로 퇴행성 변화

를 나타냄 (=progressive IVD degeneration)

② 외상

– 두 원인에 의하여 결국 NP 를 적절하게 contain 할 수 없게되어 증상이 나타남

• = herniated disc

http://blog.planetc1.com/herniated-discs-getting-on-your-nerves/

Herniated Nucleus Pulposus

• Symptoms – Pain that travels into one or both legs

– Numbness or tingling in areas of one or both legs

– Muscle weakness in certain muscles of one or both legs

– Loss of the reflexes in one or both legs

http://umm.edu/programs/spine/health/guides/lumbar-herniated-disc

Herniated Nucleus Pulposus

• 다양한 손상 정도

1. Disc bulge (붓기) – 양호한 정도 (Mild)

• Usually go away with nonoperative treatment

– 드물게 수술하는 경우도 있음

2. Prolapse (탈출) – AF를 탈출하지는 않음

3. Extrusion (탈출) – = herniation = AF를 탈출함

– Moderate/severe symptoms • Nonoperative treatment

• http://www.spine-health.com/video/herniated-disc-video

http://www.vibrosoundtouch.com/docs/id151.html

http://www.darrellkilcupdc.com/2011/10/herniated-disk-fixed-without-harmful-addictive-drugs-and-surgery/

Herniated Nucleus Pulposus

• 진단 – MRI

– Physical exam = Special test

• 비수술적 치료법

– 초기: 침상 안정

– Physical therapy • Pain management

• Strengthening

– Steroid injections

– Nonsteroidal anti-inflammatory (NSAID) medication

http://www.spine-health.com/conditions/herniated-disc/whats-a-herniated-disc-pinched-nerve-bulging-disc

Herniated Nucleus Pulposus • 수술적 중재법

– 시기: 비수술적 중재법으로 중재가 실패할 시(최후의 보류)

• 최소 6주 이상의 비수술적 중재를 시행한 후 결정

• 가급적 비수술적 중재 기간을 최대로 적용 후 결정

– Discectomy (추간판 절제술)

• IVD 제거

• 최대한 절제를 (incision)를 작게 시행함.

• 높은 성공률을 보임

http://3dprecisiondiagnostics.com/anterior-lumbar-discectomy-and-fusion-10005702xr.aspx

1. Herniated Intervertebral Disc · HIVD

(a) Normal 수핵 : 섬유륜에 감싸져 있음

(b) Bulge·protrusion 수핵 : 섬유륜에 충돌

(c) Extrusion 수핵 : 섬유륜을 뚫고 나옴, 후종인대에 의해

감싸져 있음

(d) Sequestration 추간판 일부분이 이탈, 경막공간에서 유리체가 됨

1. Herniated Intervertebral Disc · HIVD

• 20 ~ 30 years : activity

• Approximately70% : parasthesia

• Lateral and posterior protrusion

• Sharp, fast, severe pain + radiating pain

• Hot spot : L4,5

• Pain : activity (↑), rest (↓)

• Deep tendon reflex – L3-4 : knee DTR ↓

– L5-S1 : ankle DTR ↓

Test

1. Straight Leg Raise (SLR) test

2. Kernig test

3. Milgram test

4. Naffziger test

5. Valsalva test

• Straight Leg Raise test

–목적: back과 하퇴의 동통 재현으로 요통의 원인을 결정하는 검사

–방법

• Supine에서 환측 하지 80°(정상 ROM) 거상

• 대퇴 후부 통증 : 슬괵근 단축에 의함

• 하퇴 연관통 : 좌골신경의 압박에 의함 (이때 다리를 약간 내린 후 족배측굴곡시 통증이 나타나면 좌골신경 의한 통증 확실)

• http://www.youtube.com/watch?v=4ik29RwqA3s

• Kernig test –목적: 척수를 신장시켜 동통을 재현하는

검사 –방법

• Supine에서 머리뒤로 깍지끼고 머리 가슴쪽으로 굴곡

• 경추 통증, 요부와 하퇴의 방사통 : 뇌막자극, 신경근 압박, 신경근의 경막피개의 자극에 의함

• 검사자는 통증 시작 위치 정확하게 평가 • http://www.youtube.com/watch?v=Evx48zcKFDA

• http://www.youtube.com/watch?v=6B-SXLRkoMQ

• Milgram test

–목적: 경막 내·외의 병변, 척수를 싸고 있는 수막 자체 압박 여부 검사

–방법

•슬관절 완전 신전 상태로 하지를 5cm정도 들어올려 약 30초 유지

•통증 유무 확인

•장요근·전복부근 긴장 → 척수내압 상상

• http://www.youtube.com/watch?v=ukM1cSVZFqg

• Naffziger test –목적: 아랫배에 힘을 주게 하여 척수강 내압을 상승시키는 검사

–방법 • supine에서 경정맥을 10초정도 가볍게 누른후 기침을 하게 함

•통증 : 경막에 병적인 압박에 의함

• http://www.youtube.com/watch?v=kCYPjIohPqs

• http://www.youtube.com/watch?v=1Xy2ArkVX3k

• Valsalva test

–목적: 경막 내·외의 병변, 척수를 싸고 있는 수막 자체 압박 여부 검사

–방법

•통증(허리, 다리의 방사통) : 내경막의 압력 증가나 경막자체 손상에 의함

• http://www.youtube.com/watch?v=RDNmY

Op3TWM

• http://www.youtube.com/watch?v=XAzcdkI

cmc4

2. Segmental Instability

2-1. Spondylolosthesis 2-2. Retrolisthesis 2-3. Lateral listhesis 2-4. Axial and rotational displacement

Segmental Instability

• Spondylolisthesis

– 척추전방전위증

– 척추의 전방전위

• Retrolisthesis

– 척추후방전위증

– 척추의 후방 전위

• Lateral listhesis

– 척추의 측방 전위

• Axial and rotational displacement

– Segmental hypo- and hyper- kyphosis

or lordosis http://www.doctorpinchback.com/backpain2.html

2. Spondylolysis (척추분리증) &

spondylolisthesis (척추전방전위증)

http://orthoinfo.aaos.org/topic.cfm?topic=a00053

http://www.youtube.com/watch?v=DtEmmcMd7ec

Spondylosis VS Spondylolysis VS Spondylolisthesis

• Spondylosis is a term referring to degenerative changes of the

spine. When the degenerative changes extend to the spine’s

facet joints the proper term would be Spondyloarthrosis.

• Spondylolysis refers to a defect in a specific part of the facet

joint called the pars interarticularis or just “Pars”. This

defect can cause potential instability in the vertebra.

Unilateral defect in the pars interarticularis.

• Spondylolisthesis is an anterior slipping or displacement of

one vertebra on another. Bilateral defect in the pars

interarticularis which causes forward displacement of

vertebra.

Spondylolisthesis

• Gradation of spondylolisthesis

– Meyerding’s Scale

• Grade 1 = 1 – 24 %

• Grade 2 = 25 – 49 %

• Grade 3 = 50 – 74 %

• Grade 4 = 75 – 99 %

• Grade 5 >100%

(complete dislocation,

spondyloloptosis)

http://www.celebrationmisi.com/spondylolisthesis

Evaluation of the Patient With LBP

1. Start with a detailed history – your best diagnostic tool. – Get an idea of the severity.

– Look for the “red flags” of serious causes.

2. Use the physical exam to confirm what you suspect based on history.

• Keep in mind: – Most of the time you won’t have a definitive diagnosis.

(진단이 제일 중요함)

– Imaging rarely changes initial treatment.

– Most patients get better with conservative TX.

Spondylolisthesis

• Symptoms

– Back or buttock pain.

– Pain that runs from the lower back down one or both legs.

– Numbness or weakness in one or both legs.

– Difficulty walking.

– Leg, back, or buttock pain that gets worse when you bend over or twist.

– Loss of bladder or bowel control, in rare cases.

http://www.webmd.com/back-pain/tc/spondylolisthesis-topic-overview

Spondylolisthesis

• Diagnosis – Plain radiographs

– CT, in some cases with leg symptoms

• Nonoperative Care – Rest

– NSAID medication

– Physical therapy

– Steroid injections

– http://www.youtube.com/watch?v=vCWYsF3_9Ig

http://www.summitmedicalgroup.com/media/db/relayhealth-images/xspondyl_3.jpg

Spondylolisthesis

• Surgical care – 비수술적 중재가 실패 시 시행됨

– Decompression and fusion

• Instrumented

• Posterior approach

• With interbody fusion

https://www.pinterest.com/pin/173036810657944436/

Spondylolysis

• Spondylolysis – Pars의 defect가 생김

– Spondylolisthesis가 동반도리 수도 있고 아닐 수도 있음

– Single Pars fracture에 의해 발생

http://www.sonsa.org/spondylolysis.html

Spondylolysis

• Symptoms – Low back pain/stiffness

– Forward bending increases pain

– Symptoms get worse with activity

– May include a stenotic component resulting in leg symptoms

– Seen most often in athletes • Gymnasts at risk

• Caused by repeated strain

http://radiology-anatomy.blogspot.kr/2013/04/scotty-dog-x-ray-anatomy.html

Spondylolysis • Diagnosis

– Plain oblique radiographs

– CT, in some cases

• Nonoperative care

– Limit athletic activities

– Physical therapy

• Most fractures heal without other medical intervention

• Surgical care

– Failure of nonoperative treatment

– Posterior fusion

• Instrumented

• May require decompression