LOWBACK PAIN

8/10/2019 LOWBACK PAIN

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LOW BACK PAIN

REVIEW OF ANATOMY AND PHYSIOLOGY

The vertebrae increase in size distally in the spine. Vertebrae are most massive in the

lumbar region, which constitutes 25% of the height of the vertebral column. The shoc

absorbers! of the spine are the intervertebral dis. "n young person, they constitute 25% of

the height of the spine, but this percentage decreases signi#cantly with age, as the discs

lose water and collapse. The orientation of the facet $oints varies at di erent levels of the

spine. The superior and inferior articular facets are in frontal planes in the mid&thoracic

regions. The lumbar facets are almost in sagittal planes, allowing the facet $oints to glide

anteroposteriorly and facilitating most of the 'e(ion and e(tension movements of the lower

spine. The contribution from thoracic vertebral segments to these movements is negligible.

)eventyve percent of lumbar 'e(ion and e(tension occurs in the lumbosacral $oint, 2*% at

+ to +5, and the remaining 5% at the other levels.

The lumbar vertebrae are composed mainly of cancellous bone that is susceptible to

collapse under trauma or from osteoporosis. The thin but dense cortical layer may

proliferate with aging at the sites of ligamentous attachments and lead to osteophyte

formation. The vertebral body is attached to the neural arch, which is composed of pedicles,

superior and inferior facets and lamina. The superior facet $oint is smaller than the inferiorone. "t has a concave cartilaginous articular surface and forms the roof of the lateral recess.

This is where the nerve root leaves the central canal to enter the neural foramen. -edicles

form the 'oor and roof of the neural foramina. The lamina unite posteriorly to complete the

neural arch which then protect the neural elements and are the sites of paraspinal muscle

attachments. owever, the lamina contributes little to the stability of the spinal column, and

unilateral fracture or surgical removal of the lamina does not cause spinal instability. The

pedicle facet comple( normally bears only 2*% of the intervertebral vertical load/ the

remaining 0*% is absorbed by the intervertebral disc. The posterior longitudinal ligament is

attached to the lumbar discs and vertebral body margins. This ligament is attached to the

periosteum that can e(pand with purulent material, tumor, or hematoma. The posterior

longitudinal ligament, along with the anterior longitudinal ligament, helps maintain the a(ial

stability of the vertebral column.

"ntervertebral discs are remnants of the notochord that act as cushions between

vertebral bodies and are composed of #bro cartilaginous elements. The nucleus pulposus is

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?isc herniation in lumbosacral spine usually occur posteriorly so usually only have

signs of nerve root compression

E#a!ple$ %& Di'eren(ial Dia)n%$i$ &%r Cervical * L !"ar Pa(+%l%)ie$

Cervical an, L !"ar Face( -%in( Pr%"le!$

)imilarities8

;cute episodes of lumbar @ cervical facet $oint pain are typically intermittent,

generally unpredictable, and occur a few timesAmonthAyearBost patients will have a persisting point of tenderness overlapping the in'amed

facet $oints and some degree of loss in the spinal muscle 'e(ibility mm guarding6 Typically there will be more discomfort while leaning bac ward than while leaning

forward

?i erences8

-ain from lumbar facet $oint problem often radiates down the bac of the into the

buttoc s @ down the bac of the upper leg, pain is rarely present in front of the leg,

or rarely radiates below the nee=ervical facet $oint problems may radiate pain locally or into the shouldersAupper

bac @ rarely radiates below the nee3acet $oint problems in the lumbar area may indicate that standing may be somewhat

limited but sitting @ riding in a car is worst.

Cervical * L !"ar Sp%n,.l%$i$

)imilarities8

)ensory @ motor disturbances such as severe pain in the nec , shoulder, arm, bac

and or leg accompanied by muscle wea nessCoth refers to spine degeneration, natural wear @ tear brea s down the spinal

anatomy, which can result in a loss of 'e(ibility @ mobility, sti ness @ mm aches @

painsCoth can lead to poor re'e(es

?i erences8


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=ervical spondylosis may result to myelopathy, characterized by global wea ness,

gait dysfunction, loss of balance @ loss of bowelA bladder control=ervical spondylosis patients may e(perience a phenomenon of shoc s paresthesia

in hands and legs because of nerve compression and lac of blood 'ow+umbar spondylosis only a ects the lower limb, cervical spondylosis may a ect the

limbs @ head=ervical spondylosis has a more worse prognosis+umbar spondylosis can cause sciatica

Cervical * L !"ar Di$c Hernia(i%n

)imilarities8

Coth are the same spine degenerative disorders which may both easily lead to

neuralgiaCoth condition may be due to trauma, lifting in$uries or idiopathic causes

?i erences8

+umbar dis herniation signs and symptoms are more easily overloo ed by patients

and mostly misdiagnosed by doctors+umbar disc herniation usually a ects + &+5A between +5&)1, symptoms may a ect

the lower bac , buttoc s, thigh, analAgenital region and may radiate to foot Atoe.

)ciatic and femoral nerve are usually a ected3or cervical disc herniation, it usually a ects =5 @ =D or =D@ = , symptoms would

a ect bac of s ull, nec , shoulder girdle @ scapula, shoulder, arm @ hand, nerves

commonly a ected are cervical @ brachial ple(us

Muscles supporting the spine and their unction

M $cle Gr% p$

3our groups of muscles provide support to the spine8 the e(tensors, the 'e(ors,

lateral 'e(ors, and rotators of the spine. 9ormally the e(tensors and rotators are the main

supportive muscles of the spine. The massive musculotendinous bul over the upper sacral

and lower lumbar vertebrae are the origin in of the erector spinae muscles, which e(tend thevertebral column. ?eep to the erector spinae lie the semispinalis muscles. The interspinal

muscles are between spinous processes. The main role of the bac muscles in erect posture

is to resist gravity. Ehen a movement of the spine is initiated, and once the vertebral

column is bent far enough in any direction, the muscles of the bac that resist their

movement must actively contract to provide smooth and controlled movements and also to

prevent falling. )ome muscles that have no vertebral attachments also participate in


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movements of the spine. The abdominal muscles are signi#cant 'e(ors and lateral 'e(ors of

the trun and also participate in rotation.

L !"ar Spine

Re$(in) P%$i(i%n 8 Bidway between 'e(ion and e(tension

Cl%$e pac/ p%$i(i%n 8 4(tension

Cap$ lar pa((ern 0 )ide 'e(ion and rotation, e>ually limited e(tension

DEFINITION

+ow bac pain is a symptom that can be caused by various disease entities and can

be a ected by various psychosocial factors

1Bra,,%!

CLASSIFICATION

There are many di erent system available to classify +C- into any of several categories.

The general categories or classi!cation o L"# b$ origin are:

Mec+anical1 it includes non speci#c musculos eletal strain, herniated dis , a compressed

nerve root, degenerative dis A $oint disease @ vertebral fracture6

N%n1!ec+anical $pinal pr%"le!$ &includes neoplastic disease, in'ammatory conditions

such as spondyloarthritis infection

Re&erre, pain &these is a classi#cation where pain felt is from internal organs use such as

F" diseases, and renal failure6

L"# ma$ be classi!ed based on signs and s$mptoms:

N%n1$peci2c 3!%$( c%!!%n4 G di use pain that does not change in response to particular

movements @ is localized to the lower bac without radiating into the buttoc s

Ra,ic lar1 pain which radiates down the leg below the nee, located in 1 particular side in

case of dis herniation6 or bilateral spinal stenosis6 and changes in intensity in response to

a particular positionAmovement

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5r)en(6 Speciali7e, a((en(i%n1 pain that is accompanied by certain red 'ags such as

trauma, fever, a history of cancer or signi#cant muscle wea ness may be indicative of a

more serious underlying problem

There is general agreement o the chronicit$ o L"#: it ma$ be classi!ed b$ the

duration o s$mptoms as ollows 0

Ac (e1 pain lasting less than D months

S "1ac (e1 pain lasting D&12 wee s

C+r%nic1 more than 12 wee s

SOME COMMONLY ENCO5NTERED PAINF5L DISORDERS OF THE SPINE

Mechanical Low "ac% #ain

Bechanical low bac pain is a descriptive term commonly used for non& discogenic

pain that is provo ed by physical activity and relieved by rest. The mechanism of in$ury may

be an episode of trauma or continued mechanical stress of postural or occupational type. "t

does not point to one to a single or particular cause. This type of pain is usually often due to

stress or strain of the bac muscles, tendons and ligaments and is usually attributed to

strenuous daily activities, heavy lifting, or prolonged standing or sitting. The pain usually

worsens during the day because daily physical activities such as bending, twisting, lifting,prolonged sitting and standing often aggravate the pain. There are no associated

neurological symptoms or signs, nor a cough or sneeze e ect on the lower limbs.

The lumbosacral $oint, situated at a critical level between movable and immovable

portions of the spine, is particularly liable to in$ury from forces applied in an obli>uely

anteroposterior direction, as in violent 'e(ion or hypere(tension of the spine, falls on the

buttoc s, and gravitational stresses associated with e(cessive lordosis. The lower lumbar

area is especially susceptible to in$ury from torsion. +umbosacral sprains are therefore

fre>uently encountered. The sacroiliac $oints in the other hand are large and are protected

by strong ligamentous structures/ little motion can be demonstrated in them 5 degrees in

young women6. They may nevertheless be in$ured by occasional violence applied to the

blowbac in a rotatory or obli>uely lateral manner. ?uring pregnancy, temporary rela(ation

of the ligaments of symphysis pubis and the sacroiliac $oints occurs normally and sometimes

may be suHcient degree to play a part in causing bac pain

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&cute and Chronic mechanical strains o the low bac%

Acute low back pain syndrome

also called acute low back strain or acute lumbosacral strainis the most common a ectation of the lower bac , usually associated with some form

of trauma, which may be ma$or, as in lifting a very heavy ob$ect, or minor, as in

simple act of bending forwardup to wee s of symptoms

Chronic low back pain syndrome

;lso called as chronic low bac or lumbosacral strain)ymptoms are less severe and the physical #ndings less obvious although repeated

acute e(acerbations with #ndings of acute strain may occur"n ma$ority of instances, the underlying pathologic processes are degenerative dis

disease and secondary changes in the facet $oints and supporting structures7ften necessitates change in patientIs occupation and lifestyle

Lesions o the Lumbar Intervertebral Dis%

Bost commonly causes pain in the lower lumbar region8 degenerative $oint diseaseBost common cause of sciatica8 erniation of "V?


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Degenerative 'oint Disease

?egenerative $oint disease ?J?6 occurs with aging and can begin during the third decade of

life. +umbar ?J? can remain asymptomatic. "f the disease is symptomatic, the associated

pain is centered in the lower bac and is often increased with movement of the spine.

)ti ness, morning sti ness, and sti ness after having been in one position for an e(tended

period of time are common. Kange of motion of the spine may be limited and is often

relieved by rest. "mprovement of spinal muscle support through proper strengthening

e(ercises can alleviate pain.

Degenerative Disease o (acet 'oint

?egenerative arthritis of the facet $oints results in localized spine pain, which is often

episodic, that sometimes e(tends to the limb and can mimic radicular pain. The onset of

each attac is usually abrupt. Kange of motion especially with e(tension, is often limited. "n

some instances, facet $oint ?J?, more di use ?J? and even degenerative disc disease may

coe(ist. -ain is increased with activity and relieved by rest.

Disc )erniation

7verall, the mean age of patients with lumbar disc herniation is the early *s. ?isc

herniation may occur in the midline, but it often occurs to one side. The cause is usually a

'e(ion in$ury. Kepetitive in$ury results in degeneration of the posterior longitudinal ligaments

and annulus #brosus. ?i erent types and degrees of disc herniation may occur. BacnabIs

classi#cation is useful, and correlates well with BK" #ndings as follows8

De)enera(e, ; bulge and conve(ity of disc beyond the ad$acent vertebral disc margins,

but with intact annulus #brosus and )harpeyIs #bers

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Pr%lap$e, Di$c8 The disc herniates posteriorly through an incomplete defect in the annulus

#brosus

E#(r ,e, Di$c8 The disc herniates posteriorly through a complete defect in the annulus

#brosus

Se9 e$(ere, Di$c . -art of nucleus pulposus is e(truded through a complete defect in

annulus #brosus and has lost continuity with the present nucleus pulposus.

The most common levels of lumbar disc protrusion, herniation, or e(trusion, in

decreasing order of fre>uency are +5 to )1, + to +5, +< to + , and +2 to +


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ii4 De&ec($ %& (+e La!ina 3$pina "i2,a %cc l(a4

=lefts are fre>uently found in the vertebral lamina and may be associated with

underdevelopment of supporting ligaments. -artial or complete lac of fusion between the

laminaof the last lumbar vertebra or of the #rst sacral segment is common. There is little

evidence of any causal relationship between mild degrees of spina bi#da and mechanical

low bac pain.

iii4 Varia(i%n$ %& (+e $pin% $ pr%ce$$e$

Ehen the neural arch has failed to fuse, the spinous process may be attached to only

one lamina. "n other instances a spinous process associated with normal lamina maybe so

large and elongated that it touches the spinous process of the vertebra above or below.

"ncreased lumbar lordosis and narrowed intervertebral dis s tend to increase such contact

between the spinous processes, which may lead to the formation of painful bursa. The

symptoms can usually be relieved by 'e(ion e(ercises without resort to surgical treatment.

iv4 Varia(i%n$ %& (+e l !"%$acral an)le

"ncrease of the lumbosacral angle is often associated with a so&called horizontal

sacrum and lumbar lordosis. "n such bac s the lumbosacral $oint may be especially

sub$ected to strain and degenerative changes, with subse>uent formation of small bony

spurs about the margins of the vertebral bodies. "n treatment, 'e(ion e(ercises are helpful.

v4 Varia(i%n$ in (+e ar(ic lar &ace($

Variations in the size and plane of these small but important $oint surfaces are

common. The facets between +5 to )1 are susceptible to such variations. ;symmetricallyaligned facets may contribute to the torsion stresses that are a cause of dis degeneration.

)agitally aligned facets probably contribute to the development of the degenerative form of

spondylolisthesis.

vi4 C%n$(i( (i%nal Varia(i%n$ )hort, stoc y individuals8 sometimes with only lumbar vertebrae Tall, thin persons8 sometimes with +D vertebra

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+) $oint lac s the support of strong iliolumbar ligaments

Spond$losis

;N; )cotty dog 9eural arch defect in the continuity of pars intercularis commonly involving +5 @

occasionally + vertebra 3( of -ars interarticularis +eads to spondylolisthesis if bilateral =ommonly a ects ballet dancers @ athletes, males:females

Spond$lolisthesis

;N; decapitated dog3orward slipping of a vertebra@ superincumbent spinal column on the vertebra aboveBost commonly at +) level followed by + on +5

Gra,in) %n (+e a!% n( %& $ "l #a(i%n1O forward displacement of P 25%

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2. Isthmic, the commonest form of spondylolisthesis, in which a lac of normal bony

continuity in each pars interarticularis or isthmus, the narrowest part of the neural

arch, permits the displacementuel of deforming or destructive bone

disease a ecting the articular facets

Spond$lol$sis

Kefers to a bony defect in the pars intercularis;N; )cotty dog with collarCilateral isthmus defect without forward displacement of the vertebral body due to

narrowing "V?, degenerative changes in the dis and proliferative changes about the

intervertebral foramina

Spinal Stenosis

+ocalized narrowing of the spinal canal from a structural abnormality of its bony

componentsKeduction in the transverse diameter, ;- diameter or both of the spinal canalBay lead to compression of the cauda e>uine if the narrowing is at the lumbar level&

: +C- and pain in the +4 chie'y on wal ing=ongenital or ac>uired local bony deformities

;chondroplasiaO short pedicles @ decrease interpediculate space -agetIs diseaseO bony thic ening

?egenerative spinal diseaseO most common cause

Di'eren( &%r!$ %& Spinal S(en%$i$ 3Bra,,%! 6

I8 Pri!ar.;. =ongenitalC. ?evelopmental

II8 Sec%n,ar.;. ?egenerative spondylolysisC. +ate se>uelae of fracture=. +ate se>uelae of infection

?. )ystemic bone disease -agetIs ?isease of Cone6III8 Mi#e,;. )pinal )tenosis due to degenerative $oint disease

L%; Bac/ Pain in Pre)nanc.

?evelops at some point during pregnancy

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1. ?egenerative ?egenerative Joint ?isease, 7;, +umbar

)pondylolysis3acet $oint disease, facet ?J??egenerative )pondylolisthesis?egenerative disc disease?i use "diopathic s eletal hyperostosis

2. "n'ammatory non

infectious6

)pondyloarthropathies an ylosing spondylitis

Kheumatoid ;rthritis


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uency in patients with

chronic bac pain0. )mo ing appears to increase ris for bac pain maybe because of the increased

incidence of osteoporosis with smo ingM. -hysical #tness and conditioning appears to have a preventive e ect on low bac pain

PATHOPHYSIOLOGY

N%n Ra,ic lar L%; Bac/ Pain Dia)ra!

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e a v y + i f t i n g

e a v y + i f t i n g

T o r s i o n o f t h e ) p i n e

T o r s i o n o f t h e ) p i n e

- o o r b o d y B e c h a n i c s

- o o r b o d y B e c h a n i c s

E h i p l a s h " n $ u r y

E h i p l a s h " n $ u r y

?iagram for Kadicular +owbac -ain

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The pathophysiology of nonradicular low bac pain is usually indeterminate. "n fact,

one of the de#ning features of this disorder is its nonspeci#c etiology. -ain can arise form a

number of sites, including the vertebral column, surrounding muscles, tendons, ligaments,

and fascia. )tretching, tearing, or confusion of these tissues can occur after such sudden

une(pected force applied to the spine from events such as heavy lifting, torsion of the spine,

and whiplash in$ury. Ehether muscles spasm is a signi#cant etiology of lumbar spine pain,

either as cause or e ect is of bac in$ury has not been proved.

The pathophysiology of radicular spine pain and lumbosacral radiculopathy is usually

more obvious. ?is herniation through the annulus #brosus does not in itself produce pain,

but compression by dis of the dural lining around the spinal nerve is one li ely e(plaination

for the bac pain associated with acute dis herniation. This is also li ely to contribute to the

pain from spinal nerve root compression from arthritic spurs at degenerated facet and

uncovertebral $oints. =ompression can directly stretch nociceptors in dura or nerve root

tissues, but ischemia from compression of vascular structures, in'ammation, and secondary

edema is also li ely to play a role in some cases.

CLINICAL MANIFESTATION

&cute Low "ac% #ain s$ndrome

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On$e(0 sudden or gradual Pain0

catching, usually severe and often incapacitating pain localized to the

lumbosacral area or spread di usely across the lower bac and the buttoc s,

and may radiate to the posterior thighs, occasionally as far as the nees the radiation is a deep aching, somatic type of pain in contrast to the sharp

lancinating radicular pain of sciatica characteristic of lumbar dis lesions pain i$ $ all. a))rava(e, by any movement of the bac such as bending

or twisting and relieve, ". rec !"enc. , but it is often diHcult to #nd a

comfortable position patient on physical e(amination are often seen to hold the bac >uite rigidly,

paravertebral mm are taut, in spasm, and normal lumbar lordosis is 'attened,

when patient is as ed to bend forward, patient does it in hip $oints and the

thoracolumbar area with most of the lumbar spine rigid attempts with forward 'e(ion are accompanied by 'e(ion of the nees, and

patient usually places hands on the thighs for support, patient wal s with

cautious gait to avoid $arring the bac , but no limping can be observed when patient is in supine, movements of the hip are normal until the e(tremes

are reached, when motion transmitted to the pelvis and spine causes pain )+K is painless until pull by the hamstring muscles transmits movement via

the pelvis to the lumbosacral $oint, usually beyond D* degrees of elevation neurologic #ndings including re'e(es, motor, and sensory tests are normal palpation of the spine with the patient in prone usually demonstrates

tenderness at the lumbosacral or lower lumbar levels tenderness may also be present over the paravertebral muscles but not over

the sacroiliac $oints

Chronic Low "ac% #ain / *0 months

istory of several previous attac s of acute bac pain=hronic aching, tired feeling in the lower bac;ggravated by prolonged standing or sitting, by bending, twisting, or lifting"mproved by recumbency-ain predominantly +5 but often radiates to the sacrum and buttoc s, occasionally to

the posterior thigh

Lesions o the lumbar intervertebral dis%s

1 degree complaint, pain in low bac @ leg istory of previous attac s of non&radiating +C- 7nset8 abrupt or gradual, may be associated with

"mmediate snapping sensation in the low bac when lifting a heavy ob$ect =atching sensation in the bac while stooping +eg pain a few days to several wee s after the onset of bac pain8

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?eep, aching pain e(tending to the thigh and leg )harp, lancinating pain shooting down the limb to the lateral side of the leg

and an le and even into certain toes+eg @ bac pain aggravated by spinal motion @ by activities that increases

intraspinal pressure e( coughing or sneezing

9umbness of foot or toes @ occasional wea ness @ instability of feet @ an le+oss of bladder or bowel control and decrease sensation in the perianal region )


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Ehen radiculopathy occurs, several features, including distribution of pain, re'e(

changes, distribution of wea ness and sensory alterations, provide reliable information that

enables the clinician to localize the level of disc protrusion or root irritation as follows8

Ta"le =0 Clinical Mani&e$(a(i%n$6Fea( re$ %& L !"%$acral Ra,ic l%pa(+ie$3Bra,,%!4

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L"# in #regnanc$

22

R%%

(

Di$(ri" (i%n %&

Pain

Pare$(+e$ia

%r Sen$%r.

L%$$

Wea/ne$$ Decrea$e, %r

A"$en( Re>e#e$

+1 +ower

abdomen, groin,

or upper

anterior medial

thigh

+ower

abdomen,

inguinal

region

"liopsoas

R,&6

ypogastric and

=remasteric

+2 Froin, ;nterior

or Bedial Thigh

;nterior and

medial thigh

"liopsoas or adductors of

thigh or both+< ;nterior thigh or

nee

;nterior thigh

and nee

Suadriceps and

thigh adductors

Suadriceps

+ =an e(tend

below nee,

often to innerleg or medial

malleolus

"nner leg Suadriceps and thigh

adductors and Tibialis

;nterior R,&6

Suadriceps and

medial hamstring

+5 -osterolateral

thigh, lateral

calf to dorsum

of foot

7uter leg and

dorsum of

foot to great

toe

Tibialis ;nterior, toe

e(tensors, and e(tensors,

hallucislongus therefore

impaired heel&wal ing6,

hamstrings, perinea, and

tibialis posterior, gluteus

medius

Bedial hamstring,

an le $er often

normal, sometimes

decreased but not

absent because

only +5 root lesion

)1 -osterior thigh,

calf, and lateral

malleolus

-osterior leg,

lateral foot,

last two toes

Fastrocnemius&)oleus and

toe 'e(ors therefore

impaired toe&wal ing6,

hamstring, gluteus

ma(imus

;n le Jer and

lateral hamstring

)2 -osterior thigh

and

occasionally calf

Variable

posterior

thigh, saddle

area

"ntrinsic foot muscles R,&6,

rectal sphincter R,&6

;nal

)uently in the absence of low bac pain =ommonly in buttoc , lower abdomen, groin, and anteromedial or posterior thigh 9on&dermatomal paresthesia, vague heaviness in the buttoc or leg, and sub$ective

numbnessAtingling )ymptoms may be in sciatic distribution -ubic symphysis pain may occur in a severe sacroiliac problem -atient may report sharp catches, clic ing, deep clun ing and may state that the hip

or bac feels out of place!

DIAGNOSIS

#h$sical e4amination

In$pec(i%n

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+oo for deformities, paraspinal spasm, birthmar s, unusual hair growth, listing to one

side, cor screw deformity, decrease or increase in lordosis, presence of scoliosis, muscular

atrophy, or asymmetries.

Palpa(i%n an, Perc $$i%n

?etermine whether there are tender or trigger points, local tenderness or pain on

percussion, spasm, or tightness of the paraspinal muscles. 7bserve patientIs reaction to

pain.

Ran)e %& M%(i%n

K7B should be determined for 'e(ion, e(tension, lateral bending and rotation. Values for

normal K7B of the lumbar spine are as follows8

3le(ion 8 * degrees

4(tension 8 15 degrees

+ateral bending 8 ues and instruments can be used for measurement of K7B of the spine as

follows8

A8 Tape Mea$ re Me(+%,

7riginally described by )chober, this method is a simple and practical way to determine

the amount of 'e(ion in the lumbar spine. ; line is drawn that connects the dimple of

Venus!. Then, two mar s are made along a line that perpendicularly bisects the #rst line.

7ne mar is 5 cm below and the other is 1* cm above the point of bisection, with the

distance between these two mar s being 15 cm. The patient is then as ed to bend forward

ma(imally. The measured distance beyond the original 15 cm gives an estimate of the

degree of spinal 'e(ion.

B8 Inclin%!e(er$

These were initially introduced by ;smussen and eeboll&9ielsen and further developed

by +oebl. This method however fails to separate hip motion from spine motion. ; double&

inclinometer method8 zero starting position. The inclinometers are aligned over T12 and the

sacrum and their gauges are set at * degrees. The sub$ect then positions the spine in

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ma(imal 'e(ion. The degrees recorded on the sacral inclinometer are subtracted from the

degrees recorded on the inclinometer positioned over the T12 spinous process

9eurological e(amination

Gai(: S(a(i%n an, C%%r,ina(i%n

7ne should loo for antalgic gait, foot drop, and functional or hysterical features. The

patient should do toe&wal ing, and tandem gait. "t should be determined whether the patient

can stand on either one foot or can s>uat and rise. ;lternate motion rates are to be done

rapidly and regularly. They depend on an intact sensory motor system. These can also be

a ected by pain, diseases of $oints, insuHcient e ort, poor cooperation and functional

factors

M $cle S(re(c+ Re>e#e$

;n increase, decrease, or absence of muscle stretch re'e(es should be recorded. ; patientIs

re'e(es must be compared with other muscle stretch re'e(es, particularly of the

corresponding opposite side. Ke'e( asymmetry, however, is most often signi#cant

M $cle B l/

"nspect for muscle atrophy. =omparison of the circumference of the lower limbs, determined

with a tape measure, at di erent levels such as mid&calf level6 is sometimes useful. 7ne

should also loo for muscle fasciculations.

M $cle $(ren)(+

"t is important to determine whether the muscle wea ness is genuine or whether it is a

giving&way as the result of pain, functional factors, or poor e ort. "t should be noted whether

the distribution of the wea ness corresponds to as single root or multiple roots or toa

peripheral nerve or ple(us, or whether the wea ness is of upper motor neuron type.

Laborator$

Plain Ra,i%)rap+.

2D


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-lain radiography is a >uic and less costly screening study/ it is helpful in detecting

fractures, dislocations, degenerative $oint disease, and spondylolisthesis, narrowing of

intervertebral disc space, and many bony diseases and tumors of the spine.

Ra,i%i$%(%pe B%ne Scannin)

Kadioisotope scanning is a valuable test for screening the entire or a large part of the

s eleton. "t is useful for the detection of tumors, particularly bony metastases. Fallium

scanning is used if infection is suspected.

CT an, MRI

Coth =T and BK" are useful in detecting disc disease, herniated, or e(truded disc, or tumors

vertebral, epidural, meningeal, intradural, or cord6. 7verall, BK" is superior to =T. BK" can

image the entire lumbar spine in a single scanning session and shows the soft tissues better

than the =T. "t is an e(cellent method for detecting epidural, intradural, and some of the

intra a(ial spinal cord lesions, such as tumor, cyst or even demyelinating pla>ues. =T can

de#ne or demonstrate bony lesions better.

M.el%)rap+.

)till used by many surgeons before a #nal decision is made regarding lumbar surgery. =T

myelography remains the most accurate imaging method for the diagnosis of disc

herniations and e(trusions.

Elec(r%!.%)rap+.

4lectrodiagnostic studies are useful for detecting neurogenic changes and denervation, as

well as the e(tent of these changes and level of involvement.

Special Tests

The various maneuvers can be classi#ed based on the potential cause of the bac pain as

follows8

Nerve R%%( C%!pre$$i%n

)+K +asegueIsNernigIs CraggartIs=rosssed )+K ooverIs

2


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A8 Sacr%iliac Pa(+%l%).-atric Is 4ric sonIsFaenslenIs -elvic Koc

B8 Hip -%in( Pa(+%l%).

-atric IsC8 In(ra(+ecal Pa(+%l%).

BilgramIs9a zigerIsValsalvaBaneuver

D8 Ti)+(ne$$ %& M $cle$ Thomas 7berIs

?8 S(rai)+( Le) Rai$in) Te$(S(ar(in) P%$i(i%n0 )upinePr%ce, re 8 Kaise the leg of the patient by lifting the heel while eeping

the nee e(tended

N%r!aL (e$( 8 leg can be raised up to 0* degrees without painP%$i(ive (e$( 8 pain in the raised leg, usually following the distribution of the

sciatic nerve ;nywhere between


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8 Mil)ra!@$ Te$(S(ar(in) P%$i(i%n 8 supinePr%ce, re 8 as patient to eep both feet raised about two inches from the

table, with nees ept straight for


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??8Br ,7in)$/i@$ Si)n)tarting position 8 supine

Testing position8 e(aminer places his hand behind the patientIs head and 'e(es the

nec forward-ositive test and interpretation Gpatient is malingering/ he is not at all trying tolift the leg

?


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?8 L !"ar C%!pre$$i%n Frac( re

)imilarities between +C- and +umbar =ompression 3racture

)imilarities of +C- and )pondylosis

Boderate to severe bac pain that is made worse by movement Tenderness on lower lumbar area

?i erences between +C- and +umbar =ompression 3(

Bay lead to deformity such as dowagerIs hump+oss of height=rowding of internal organs+oss of mm @ aerobic conditioning


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Tenderness on lower lumbar area

?i erences between +C- and erniated disc

+C- usually has localized pain while herniated disc has unde#ned pain in thighs,

muscular wea ness, paralysis, paresthesia and a ectation of re'e(eserniated disc usually comes with sciatica+C- does not cause se(ual dysfunction but herniated disc in +


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compression fractures present/ orthosis for stabilization/ surgical

decompression and stabilization in selected areas

Ta"le 0 S%!e Ca $e$ %& C+r%nic L%; Bac/ Pain an, Trea(!en( 3Bra,,%!4

Ca $e Trea(!en(7;/ ?J?

+umbar )pondylosis

"mprove muscular bac

support, corset

Eeight loss3acet -ain )yndrome

3acet ?J?

;void lumbar hypere(tension

"mprove muscular support

=onsider "n$ection

?ynamic, )tatic posture

principles

)pondylolisthesis)table

3le(ion e(ercise program)pinal 7rthosis

;ctivity precautions-rogressive neurological de#cit ?ecompression and fusion)pinal )tenosis

-seudo claudication

+ateral recess syndrome

)pinal 'e(ion e(ercises

Eeight reduction

=orrection of posture

?ecompressionBetabolic bone disease

7steopenia7steoporosis

"sometric bac e(tension

program

Treat underlying disease

;void heavy lifting 5 to 1*

lbs6=hronic "n'ammatory ?isease

;n ylosing )pondylitis, =hronic

)pondyloarthropathies63ibromyalgia =onservative Treatment

Ciofeedbac

Kela(ation

=orrection of posture=hronic -ain )yndrome Bultidisciplinary behavioral

approach

-sychological Testing

)tretching

)tretch Banagement to


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consider antidepressants

4lectromyographic

biofeedbac


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&cute Low "ac% #ain

Me,ical

;nalgesics with acetaminophen, sedative mm rela(ants can be used

Cetter to avoid codeine and its derivatives because constipation induced by theseagents aggravates bac pain as a result of straining intraspinal pressure-atient is instructed to use a #rm matress"n very acute and painful phase, rest in bed may be needed by-atient in semi&3owler position

S r)ical

;cute low bac pain does not re>uire surgical procedures unless the pain lingers and

further evaluation had been done

PT Re+a" Mana)e!en(

=old pac s ( 2* mins during #rst 0 hrs after strain or sprain on lower bac&for reduction of edemaot Boist -ac ( 2* mins thereafter on lower bac&for pain reduction"nfrared heat lamp ( 2* mins on lower bac

T49) ( 1* mins on lower bac&for pain relief BcNenzie for e(tension bias patient or EilliamIs e(ercise for 'e(ion bias patients

Typical McKenzie Back Extension Exercises

1. Pr%ne l.in)8 +ie on your stomach with arms along your sides and head turned toone side. Baintain this position for 5 to 1* minutes.

2. Pr%ne l.in) %n el"%;$8 +ie on your stomach with your weight on your elbowsand forearms and your hips touching the 'oor or mat. Kela( your lower bac . Kemain in this position 5 to 1* minutes. "f this causes pain, repeat e(ercise 1, thentry again.


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pillow. "f this does not hurt, add a third pillow after a few more minutes. )tay in thisposition up to 1* minutes. Kemove pillows one at a time overseveral minutes.

8 S(an,in) e#(en$i%n8 Ehile standing, place your hands in the small of your bac

and lean bac ward. old for 2* seconds and repeat. Lse this e(ercise after normalactivities during the day that place your bac in a 'e(ed position8 lifting, forwardbending, sitting, etc.

H%; (% Per&%r! Willia!@$ Fle#i%n E#erci$e$

?8 Pelvic (il( . +ie on your bac with nees bent, feet 'at on 'oor. 3latten the

small of your bac against the 'oor, without pushing down with the legs. old

for 5 to 1* seconds.

2. Sin)le Knee (% c+e$( . +ie on your bac with nees bent and feet 'at on the 'oor.)lowly pull your right nee toward your shoulder and hold 5 to 1* seconds. +ower the

nee and repeat with the other nee.


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3N%(e 8 Di'erence "e(;een McKen7ie an, Willia!@$ >e#i%n e#erci$e

,i$c $$e, in A,,en, !4

Byofascial release for low bac

Per&%r!in) Direc( M.%&a$cial Relea$e

+and on the surface of the lower bac area with the appropriate UtoolU nuc les, or

forearm etc.6.

)in into the soft tissue.

=ontact the #rst barrierArestricted layer.

-ut in a Uline of tensionU.

4ngage the fascia by ta ing up the slac in the tissue.

3inally, move or drag the fascia across the surface while staying in touch with the

underlying layers.

4(it gracefully

H%; (% Per&%r! In,irec( M.%&a$cial Relea$e

+ightly contact the fascia with rela(ed hands.

)lowly stretch the fascia until reaching a barrierArestriction.

Baintain a light pressure to stretch the barrier for appro(imately


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strain usually results from overuse involving prolonged, repetitive movement of the

muscles and tendons.; sprain often results from a fall or sudden twist, or a blow to the body that forces a

$oint out of its normal position. ;ll of these conditions stretch one or more ligaments

beyond their normal range of movement, causing in$ury."n addition, there are several factors that put a person at greater ris for a bac strainor sprain, including e(cessively curving the lower bac , being overweight, having

wea bac or abdominal muscles, andAor tight hamstrings muscles in the bac of the

thighs6. -laying sports that involve pushing and pulling such as weightlifting and

football also increases the ris of a low&bac in$ury.Lse good body mechanics when sitting, standing and lifting. 3or e(ample, try to eep

your bac straight and your shoulders bac . Ehen sitting, eep your nees bent and

your feet 'at on the 'oor. ?onIt over&reach, and avoid twisting movements. Ehen

lifting, bend your nees and use your strong leg muscles to help balance the load.

4ducate patient on proper body mechanics Pr%per "%,. !ec+anic$"f prolong sitting is re>uired for an occupation, one should get up every 2*

minutes3or driving a car, the seat should be brought close to the steering wheel so

that the nees are slightly higher than the hips)tomach muscles should be tightened before coughing or sneezingCegin a progressive low bac isometric strengthening e(ercise program and

perform stretching e(ercises to increase 'e(ibility for performing daily

activities3orward bending increase intradis al pressure, therefore neeling is advisable

when pic ing an ob$ect from the 'oor or ma ing a bedEhen getting into bed, one should sit on the edge of the bed, turn and roll

slightly to one hip, bring the nees up with the feet hanging over the edge of

the bed, slowly recline, pushing up with the arms on the bed to support the

body. 3or getting out of bed, one needs to reverse this procedure)oft Tissue Bobilization&can help rela( muscles of lower lumbar area Banipulation&rotating the pelvis on the trun or by 'e(ion Kole of Banual Therapy 1Bobilization and manipulation in )pine pain

)tandard grades of mobilization used for pain control or to generate motion8Frades " and ""& oscillation/ low velocity forces applied repetitively within

resistance free K7B of a $oint/ used manily for pain controlFrade """ and "V& stronger forces that move $oint into its restricted range and

are useful in producing motionFrade V& called manipulation/ includes small amplitude, high velocity thrust at

or $ust beyond the normal physiologic range of the $oint without e(ceeding its

anatomic integrity


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Kesults of studies have shown that spinal mobilization and manipulation may

be bene#cial but only to small subgroups of bac pain patients, the patients

who are more li ely to bene#t from manipulation are8;cute low bac pain of P < wee s durationBinor or absent +4 neurologic signs

9o evidence of dural tension signs

Chronic Low "ac% #ain

Me,ical

Ehen symptoms are pronounced and incapacitating, a period of 1 or 2 wee s of

complete bed rest may be necessaryLse of analgesics

S r)ical

)pinal fusion if unrelieved by conservative measure

PT Mana)e!en(

Lse of a #rm matress and bed board especially for patients whose bac pain is worse

after a nightIs sleep;cute recurrent 'are&ups treated as +C-;d$ustment in chair height and inclination may help patients whose bac pain get

worse after prolong sitting4(ercise programs designed to build up abdominal and gluteal muscles, including

hamstring stretching and general postural e(ercises-atient education on proper body mechanics1&2 wee s of complete rest when symptoms are pronounced and incapacitating

Traction to the pelvis or legs

Dis% )erniation

Me,ical

-ain relieverCed rest/ semi&fowler position

S r)ical

-artial laminectomy "ndications of dis surgery


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)evere symptoms that fail to improve by ade>uate conservative program-rogressive neurologic involvement, especially if bladder or sphincter

function is becoming impaired?isabling symptoms with inade>uate response to non&operative treatment

=hemonucleolysis& in$ecting the 9- with the enzymes chymopapain which causes

hydrolysis of the glycoproteins of the nucleus

PT Mana)e!en(

Traction to the legs or pelvis4(ercises to strengthen abdominal muscles and decrease lumbar lordosisCilateral forced 'e( of hips and nees on the pelvis with accompanying rotatory

movement=old pac s ( 2* mins during #rst 0 hrs after strain or sprain on lower bac&for reduction of edemaot Boist -ac ( 2* mins thereafter on lower bac&for pain reduction"nfrared heat lamp ( 2* mins on lower bac

T49) ( 1* mins on lower bac&for pain relief BcNenzie for e(tension bias patient or EilliamIs e(ercise for 'e(ion bias patientsByofascial release for low bac4ducate patient how to get in and out of bed properly4ducate patient on bac precaution no bending on trun , no twisting @ etc.64ducate patient on proper body mechanics)oft Tissue Bobilization&can help rela( muscles of lower lumbar area Banipulation&rotating the pelvis on the trun or by 'e(ion

Low "ac% #ain in #regnanc$

Me,ical

;cetaminophen&the analgesic of choice for management of +C- during pregnancy

PT Mana)e!en(

-rophyla(is Keducing the load of the spine by appropriate changes in lifestyle and wor

environment ;voidance of e(cessive weight gain during pregnancy 4ducating the patient regarding proper posture

-roper techni>ues for lifting, wor ing positions and resting positions

Lesions o the or Intervertebral Dis%s

Me,ical


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)alicylates, acetaminophen, @ non&steroidal anti&in'ammatory drugs7piods for acute pain not for chronic patients6Cenzodiazepines, methocarbamol and cyclobenzaprine for muscle rela(ants"buprofen, 'urbiprofen, napro(en

S r)ical

-artial laminectomy, e(posure of the protruding mass and e(cision of the mass as

well as nuclear material remaining in the dis , indications for dis surgery are as

follows816 )evere symptoms that fail to improve with treatment by an ade>uate

conservative program26 -rogressive neurologic involvement, especially if bladder or sphincter function is

becoming impaireduate response to non&operative therapy

PT Mana)e!en(

Traction applied to the legs or hips4(ercises to strengthen the abdominal muscles and decrease lumbar lordosisCilateral or unilateral )+K and hypere(tension of the spine or hips

Isthmic spond$lolisthesis

Me,ical

"mmobilization of the spine in a 'e(ed position by means of a plaster cast e(tending

from the lower part of the thighs to above the costal margins, will relieve most of the

acute painCac brace;nti&in'ammatory medications4pidural in$ection-rednisone for severe radicular symptoms

S r)ical

)urgical fusion of the last two lumbar vertebrae to the sacrum in cases of severe or

progressive slipping+aminectomy in cases of pressure on the cauda e>uina

PT Mana)e!en(

4(ercises to decrease pelvic tilt and lumbar lordosis4lectrical stimulator+umbar traction&can help with reactive mm spasm


42/50

K7B4&to help maintain $oint motion

De)enera(ive Sp%n,.l%li$(+e$i$

Me,ical

;nalgesics+ow bac corsets3racture boards;de>uate rest

S r)ical

?is replacement involves removing the dis and replacing it with arti#cial parts

similar to replacements of hipA nee6

?ecompressive laminectomy)pinal fusion

PT Mana)e!en(

T49) M hertz ( 1* minsB-&can help increase $oint mobility=ryotherapy&can reduce pain and edemaL))tretching 4(ercises with sec hold ( 1* reps

-K4s ( 1* reps Traction


43/50

ADDEND5M

Overvie; %n McKen7ie * Willia!@$ Fle#i%n E#erci$e$

5illiam-s (le4ion 64ercises

Eilliams lumbar 'e(ion e(ercises are set of system related to physical therapy

intended to enhance lumbar 'e(ion, avoid lumbar e(tension @ strengthen the

abdominal @ gluteal musculature in an e ort to manage +C- non&surgically"t was devised devised by ?r -aul =. Eilliams 1M**&1M 06 then a ?allas orthopedic

surgeon"t is a cornerstone in the m( of +C- for many years for treating a wide variety of bac

problems regardless of diagnosisA chief complaints"n many cases, it is usually used when the causeA characteristics of the disorder were

not fully understood by -TA -hysician


44/50

"t is a standard in non&surgical +C- treatment

Mc7en8ie 64tension 64ercises

?evised by Kobin BcNenzie

"n contrast to EilliamIs 'e(ion e(ercise, it suggests that all spinal pain can beattributed to alteration of the position of the discIs nucleus pulposus, in surrounding

to annulus, mechanical deformation of soft tissue caused by postural stressBcNenzie concluded that a continually 'e(ed lifestyle may cause the nucleus to

migrate more posteriorly, resulting to +C-

General Principle$ %n E#erci$e$ &%r L%; Bac/ Pain

9b ectives

?ecrease painKestore normal function-revent recurrence

?8 Willia!@$ E#erci$e$0 $e, &%r an(eri%r ,i$c pr%(r $i%n

I

-osterior -elvic Tilt 5 sec hold, 1* reps

II

Lnilateral, alternate nee to chest 5 sec hold, 1* reps

II

Cilateral nee to chest 5 sec hold, 1* reps

I

)traight +eg Kaising 5 sec hold, 1* reps

V

-artial curl ups 5 sec hold, 1* reps

V

urdleIs position 5 sec hold, 1* reps

V

Eall slides 5 sec hold, 1* reps


45/50

?

+ie face down with arms on sideead turned to one side 5

ues in its shortened position


49/50

?osage is criticalKesistance is minimalLse only enough to generate a setting contraction

c. Fentle oscillating motion

d. ;dapt the environment

G5IDELINES FOR MANAGEMENT OF IMPAIRMENTS WITH A NON1

WEIGHT BEARING BIAS

A8 Mana)e!en( %& Ac (e S.!p(%!$1. Traction2. arness


50/50

REFERENCES

Crashear Jr., Han,"%%/ %& Or(+%pe,ic S r)er.: ? (+ e,i(i%n

Craddom, P+.$ical T+erap. Me,icine an, Re+a"ili(a(i%n

Bagee, Or(+%pe,ic P+.$ical A$$e$$!en(: (+ e,i(i%n

)antos Kamona, PT1OT Revie;er: < n, e,i(i%n

NPTE Man al

Prepare, ".0

C+err. Ann Sevillen%1Ban)%.-T "V"loilo ?octors =ollege

S "!i((e, (%0

Mr8 Fernan,% Pa,illa -r8: PTRP=linical "nstructor

Mr8 Ar!el Al(iller%: PTRP=linical "nstructor

Documents

LOWBACK PAIN