Stephanie Wetmore, PT PED 596 Adv. Cardiac Rehab Wayne State College Low Back Pain Stephanie Wetmore, PT PED 596 Adv. Cardiac Rehab Wayne State College

Epidemiology & Natural History of Low Back Pain 10 million off work daily $14 billion in missed days per year Incidence equal in sedentary vs. heavy labor Truck drivers most common 90% of LBP is recurrent 44% are better in 1 wk 86% are better in 1 mo. 92% are better in 2 mo. 35% with recurrent LBP develop sciatica Lumbar spine most commonly injured part of human body

Anatomy & Physiology of the Lumbar Spine Multi-jointed rod composed of numerous vertebrae 7 cervical 12 thoracic 5 lumbar 5 sacral (fused) Normal spinal curves 10x increase strength & resilience than straight spine Protects spinal cord & provides movement and shock absorption

Normal Spinal Curves Cervical spine = lordotic curve Thoracic spine = kyphotic curve Lumbar = lordotic curve Sacral = kyphotic curve

Bones & Landmarks

Bones & Landmarks (cont.)

Ligaments

Muscles Flexion – rectus abdominis & obliques Extension – erector spinae, transversospinalis & interspinalis Lateral Bending – quadratus lumborum, erector spinae, obliques, intertransversarii Rotation to same side – int. obliques Rotation to opp. Side – ext. obliques & transversospinalis Compression of abdomen – abdominals & obliques

Innervation Muscles are innervated by corresponding spinal nerves and span several levels as do the muscles themselves

Pathophysiology Predisposing factors Intradiscal pressure Poor sitting posture Frequency of trunk flexion (Burton study) Intradiscal pressure Increased with movement toward a kyphotic position Overstretching of ligaments Posterior spinal ligaments overstretched by slouched positions

Causes of Pain Nocioceptive receptor system Activated by mechanical forces or chemicals Located in periosteum, joint capsules of facet joints, muscles, muscle attachments, superficial fascia, skin and outer portion of the disc Also located in ligaments with PLL having highest density

Chemical vs. Mechanical Mechanical deformation of nocioceptors occurs when force causes physiological stress, deformation and damage, even without pathology (example – hyperextension of index finger) Can become constant when internal derangement occurs Chemical irritation occurs with infection, inflammatory diseases and for approximately 20 days following trauma

Specific Pathologies Intervertebral disc lesions Prolapsed (herniated) intervertebral disc Lumbar instability and spondylosis

MRI of disc herniation

Spondylosis Disc degeneration with gradual flattening of the disc and displacement of posterior facet joints Symptoms due to mechanical derangement and OA of facet joints

Spinal Stenosis http://www.spinenet.com/stenosis.html Narrowing of spinal canal Caused by disc degeneration or OA

Spondylolisthesis Forward shift of spine Caused by congenital malformation, separation or stress fracture or OA

Pharmacology NSAIDs Drugs to protect against NSAID-induced ulcers Advil, Motrin, Aleve, Relafen Cox-2 Inhibitors Celebrex, Vioxx Drugs to protect against NSAID-induced ulcers Prilosec, Prevacid Muscle relaxants Flexeril, Soma Anti-depressants Amitriptyline (Elavil)

More Drugs Narcotics Non-narcotic pain meds Oral steroids Injections Morphine, codeine, demerol, darvocet, vicodin and percocet Non-narcotic pain meds Ultram Oral steroids Medrol dose pack Injections Epidural flood, selective nerve root block, facet joint block and sacroiliac block

Epidural Flood

Exercise Limitations/Capacity & Modifications Spondylolisthesis Avoid heavy labor and vigorous physical activity Lumbar support to immobilize Abdominal strengthening and flexion activities Spinal Stenosis Lumbar support often helpful Increase mobility and flexibility

Intervertebral disc lesions Herniated or prolapsed disc Dependent upon direction of herniation Dependent on acuteness of condition Decrease compressive forces and intradiscal pressure Limit sitting and forward bending for post. herniations Degenerative Disc Disease Improve flexibility and mobility Usually respond better to flexion activities

Sample exercises WALKING! Flexion exercises Extension exercises Strengthening Pelvic tilt

References McKenzie, R.A. (1981) The Lumbar Spine Mechanical Diagnosis and Therapy. Spinal Publications Limited. Waikenae, NZ Apley, A.G. and L. Solomon (1989) Concise System of Orthopedics and Fractures. Butterworths. London

Web Sites of Interest www.apta.org www.mckenziemdt.org www.aaos.org www.spinenet.com www.spine-health.com/dir/dir01.html