Assessment and Treatment of Low Back Pain

Steven Stanos, DO

Medical DirectorCenter for Pain Management

Rehabilitation Institute of ChicagoAsst. Professor, Dept. PM&R

Northwestern University Medical School Feinberg School Of Medicine

Goals• Individualized yet

comprehensive• Efficient• Comfortable for patient• Comfortable for clinician• Build rapport• Educate and prepare patient for

treatment• Monitor for inconsistencies

Physical Exam Overview

– Pain behavior– Gait– Motor strength– Muscle stretch reflexes– Dural tension testing– Sacral iliac joint testing– Myofascial assessment– Kinetic Chain considerations

Anatomy of LumboSacral Spine

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.

Annulus Fibrosis

Lumbar Facets: zygapophysial joints “z-joint”

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.

Degenerative Cascade

Definitions• Somatome: field of somatic and

autonomic innervation based on embryologic segmental origin of somatic tissues

three basic elements:1. Dermatome: cutaneous structures

2. Myotome: skeletal musculature

3. Sclerotome: bones, joints, and ligaments8

Inman VT, Saunders J. J Nerv Ment Dis 1944;99:660-67.

Spinal “stability”

Neural

Control Unit

Spinal Column Spinal Muscles

Vertebral Position

Spinal Loads

Spinal Motions

Muscle

Activation Patterns

Panjabi MM. J Electromyography Kinesiology 2003:12:371-9

“Core” muscle groups

– Abdominals (Front)– Paraspinals and gluteals (Back)– Diaphragm (Roof)– Pelvic floor and hip muscles (Bottom)

Richardson C, et al .Therapeutic exercise for spinal stabilization and low back pain. Edinburgh (Scotland): Churchill Livigstone1999.

Abdominals

Local muscles

(Slow twitch)• Transversus

abdominus• Multifidi• Internal oblique • Pelvic floor

Global Muscles

(Fast-twitch)• Erector spinae• External oblique• Rectus abdominus

MULTIFIDIERECTOR SPINAE

Panjabi MM. J Electromyography Kinesiology 2003:12:371-9

the “15 minute rotisserie special”

Pain Behaviors

• Grimace• Groan• Guarding• Overreaction• Inconsistencies• Give-way weakness• Shaking

• Equipment• Cane• Ice-packs, • Heating pads• Braces: collars

Gait

• Balance

• Base of support

• Arm swing/ trunk and shoulder rotation

• Cadence

• Leg: cicumduction, stance time, position

• Pain behavior

Static Stance Assessment

(J. Rittenberg. Photos from practice & personal files used with permission)

L4-L5

PSIS

Flexion Based

Muscular

Ligamentous

Compression Fracture

Discogenic

Extension Based

Stenosis

Facet

Spondylosis

Central Disc

Transitional

Spondylolisthesis

Sacroiliac

Facet

Differential Diagnosis

Facet Arthropathy

• Zygapophyseal (z-joint)

• Poor correlation with history and exam1

• Commonly pain with extension & rotation

• Referral patterns2

1. Schwarzer AC, et al. Spine 1994;19:1132-7.

2. Slipman, C. Arch PM&R 81:334-338, 2000.

Myofascial Assessment

Myofascial Trigger Points

Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2. Williams & Wilkins, Baltimore, 1992.

“Muscle pain is not skin pain”

Jay Shah, MD

Myofascial Trigger Points (MTrPs)

Active – cause a clinical pain complaint or other abnormal sensory symptoms

Latent – show all the other characteristics of active MTrPs, except that they’re pain free

Muscle Pain

• Aching and cramping

• Difficult to localize and refers to other deep somatic tissues (fascia, muscle, joints)

• Muscle nociceptive activity is processed differently in the CNS

• Inhibited more strongly by descending pain-modulating pathways than cutaneous pain

Symptoms• Local & referred pain• Pain with iso

contraction• Stiffness, limited

ROM• Muscle weakness• Paresthesia &

numbness• Propriocpetive

disturbance• Autonomic

dysfunction

Physical Findings• Local Tenderness• Single or multiple

muscles• Palpable nodules• Firm or Taut Bands• “twitch response”

(LTR)• Jump sign• Muscle shortening• Limited joint motion• Muscle Weakness

Motor Strength Testing

• 5 = Normal, full ROM vs. gravity, max resistance

• 4 = Good, full ROM vs. gravity, moderate resistance

• 3 = Fair, full ROM vs. gravity,

no resistance• 2 = Poor, full ROM,

gravity eliminated• 1 = Trace• 0 = No activity

Core Stabilization Testing

Muscle Stretch Reflexes

Lower Limb

– Patella (L2, L3,L4)

– Medial hamstring (L5,S1)

– Achilles (S1, S2)

Muscle Stretch Reflexes

4 + = hyperactive with clonus

3 + = more brisk

2 + = normal response

1 + = decreased with facilitation

0 = no response

Radiculopathy

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.

• Sitting• Standing• Walking• Bending• Valsalva or cough

Dural Tension Signs

• Straight Leg Raise (SLR)

• Slump Seated

• Femoral Nerve Stretch

(J. Rittenberg. Photos from practice & personal files used with permission)

Straight Leg Raise:

Epidural Space• Contents:

– Loose areolar connective tissue

– Semiliquid fat– Lymphatics– Arteries– Extensive plexus of veins– Spinal nerve roots

• Segmented and discontinuous

Transforaminal Approach

Injection Techniques

S1 Transforaminal Epidural

Dr. Stanos’ personal files.Nelemans PJ, et al. Spine 2001;26:501-15.

Caudal Approach

Axial Low Back Pain

• Degenerative disc disease (DDD)

• Internal disc derangement (IDD)

• Facet dysfunction

• Myofascial dysfunction

© 2005 Rehabilitatio Institute of Chicago

Dorsal Rami Anatomy

Sacroiliac Joint and Pelvis

Integral Components of SIJ motion

• Form closure: joint surfaces congruently fit together

• Force closure: muscles & ligaments provide force to withstand load

• Motor control: timing & sequencing of muscle activation & release

• Emotion & awareness: emotions can influence motor control

Vleeming A, et al. Spine 1990;15:133-5

Sacroiliac Joint Pain Referral Zones

Buttocks 94%

Thigh 48%

Lower leg 28%

Foot / ankle13%

Groin 14%

Abdomen 2%

Dreyfuss D, J Am Acad Ortho Surg 2004, 12.

SIJ Assessment

(J.Rittenberg. Photos from practice & personal files used with permission)

Sacroiliac Joint Provocative Tests:

• SIJ border tenderness

• Patrick’s test

• Gaenslen’s test

• Prone hip extension

• Compression testing

Fortin J, et al, Spine 1994;19:1475-82.

Sacroiliac Joint Injections

Bogduk N, MJA 2004;19:79-83.

Lumbar Spinal Stenosis: Posture

Akuthota, V. Pathogenesis of lumbar spinal

stenosis pain. Phys Med Rehab Clin N Am 14:17-28, 2003.

With permission.

J. Rittenberg. Used with permission.

BI-Level Central

Neurovascular Claudication

Porter RW. Spine 1996;21:2046-52.

• Onset with walking

• “Heavy” sensation

• Variability

• Attempt to increase flexion

• Stooped posture

Lumbar Spinal Stenosis: Simian Stance

• Posterior pelvic tile

• Hips, knees flexed

• Hands face backwards

• Hip and psoas tight

• Gluteus and

piriformis inhibited

• Gait: lumbar flexion

Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission.

Weak and Inhibited Muscles

Finding Balance

Underactive Overactive Shortened

Stabiliser Synergist Antagonist

Glut Medius TFL, QL, Piriformis Thigh adductors

Glut Maximus Iliocast, Hamstring Iliopsoas, Rec Fem

Lower Trapezius Levator Scapulae Pectoralis Major

Upper trapezius

Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports Musculoskeletal Med; Aspen Publishers,1998. With permission.

trapezius and cercival spine

Cervical & Scapular Dysfunction

(Janda 2002)

APS: LBP Guidelines

• Categorize the condition– Nonspecific low back pain?– Back pain associated with neurologic deficits,

radiculopathy or spinal stenosis?– Back pain associated with an alternate

cause?

• Identify patients who require urgent surgical evaluation

Chou R, et al. Ann Intern Med. 2007;147:478-491.

Acute Low Back Pain ‘Red Flags’

• Cauda equina syndrome?

• Cancer?

• Infection?

• Fracture?– Confirmation of red flag conditions may require

• Lab testing [complete blood count (CBC)/erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP)/urinalysis (UA) and PSA when appropriate]

• Medical imaging [lumbosacral (LS) radiographs/computed tomography (CT)/magnetic resonance imaging (MRI)]

• Test results may indicate need for emergent surgical referral

Chou R, et al. Ann Intern Med. 2007;147:478-491.Chou R, et al. Lancet. 2009;373:463-472.

Pharmacologic InterventionsAcute Low Back Pain

Drug Net benefitLevel of evidence

Acetaminophen Small to moderate Fair

NSAIDs Moderate Good

Skeletal muscle relaxants

Moderate (for acute LBP only) Good

Chou R, et al. Ann Intern Med. 2007;147:504-514.

Guideline Highlights

Chou R, et al. Ann Intern Med. 2007;147:478-491.

Guideline Highlights1. Conduct a focused history and physical

examination– Assess severity of baseline pain and

functional deficits

2. Evaluation of psychosocial risk factors is essential to predict the risk for chronic, disabling low back pain

3. Limit use of diagnostic imaging and testing– Except in patients with signs of severe or

progressive underlying disease or those with neurologic deficits

Recommendation 6ACP/APS Guidelines 2007

• Clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess the severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy. For most patients, first-line medication options are acetaminophen or NSAIDs.(Strong recommendation, moderate-quality evidence)

Chou R, et al. Ann Intern Med. 2007;147:504-514.

Pharmacologic InterventionsDrug Net benefit Level of evidence

Acetaminophen Small to moderate Fair

NSAIDs Moderate Good

Skeletal muscle relaxants

Moderate (for acute LBP only) Good

Tricyclic antidepressants

Small to moderate (for chronic LBP only)

Good

Opioids and tramadol Moderate Fair

Benzodiazepines Moderate Fair

Antiepileptic medications

Small (for gabapentin in patients with radiculopathy only)

Unable to estimate topiramate

Fair for gabapentin to poor for topiramate

Systemic steroids No benefit Good

Chou R, et al. J Pain. 2009;10:113-130.

Summary

• Comprehensive, but focused• Efficient• Exam should be easy on you and the

patient• Great opportunity to initiate a therapeutic

relationship and dialogue• Use a “good” exam to improve outcomes

and identify deficits or impairments

Thanks