PHYSİOPATHOLOGY AND REHABİLİTATİON OF CERVİCAL AND LOW BACK PAİN Dr. Pembe Hare Yiğitoğlu Near East University Faculty of Medicine Department of Physical Medicine and Rehabilitation 2012

Low back and neck pain are second only to the common cold as the most common affliction of mankind. Low back and neck pain are symptoms, not diseases, and they have many causes.

The symptom of axial skeleton pain is associated with a wide variety of mechanical and systemic disorders. Mechanical disorders cause the vast majority of low back or neck pain episodes. Most of these mechanical disorders resolve over a short period of time.

Disorders affecting the low back and neck Mechanical Rheumatologic Endocrinologic/Metabolic Neurologic/Psychiatric Infectious Neoplastic/Infiltrative Hematologic Referred pain

LOW BACK PAİN Low back pain has become a leading cause of disability and loss of productivity. It is extremely common.

About 40% of people say that they have had low back pain within the past 6 months. Studies have shown a lifetime prevalence as high as 84%. Most patients have short attacks of pain that are mild or moderate and do not limit activities.

Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) Back pain in children 55 y History of violent trauma Mild trauma in an aged patient Constant progressive pain at night History of cancer Systemic steroids Drug abuse, human immunodeficiency virus infection

Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) Weight loss Systemic illness Persisting severe restriction of motion Intense pain with minimal motion Structural deformity Difficulty with micturition Loss of anal sphincter tone or fecal incontinence; saddle anesthesia Progressive motor weakness or gait disturbance

Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) Inflammatory disorders (ankylosing spondylitis) suspected Gradual onset <40 y Marked morning stiffness Persisting limitation of motion Peripheral joint involvement Iritis, skin rushes, colitis, urethral discharge Family history

Mechanical disorders of the lumbosacral spine Back strain Lumbar disc herniation Lumbosacral spondylosis Lumbar spinal stenosis Spondylolisthesis Scoliosis

Back strain Back strain is preceded by some traumatic event that can range from coughing to lifting a heavy object. Muscle strain is acute back pain that radiates up the ipsilateral paraspinous muscles, across the lumbar area, and sometimes caudally to the buttocks without radiation to the thigh. No neurologic abnormalities are present.

Lumbar disc herniation The disc's structure is composed of outer annulus fibrosus and inner nucleus pulposus. The nucleus pulposus have regions with highly hydrophilic. The hydrated nucleus within the annulus acts as a shock absorber to cushion the spinal column from forces that are applied to the musculoskeletal system. Nuclear material is normally contained within the annulus, but it may cause bulging of the annulus or may herniate through the annulus into the spinal canal.

Neurologic examination may reveal sensory deficit, asymmetry of reflexes, or motor weakness corresponding to the damaged spinal nerve root. More than 95% of lumbar disk herniations occur at the L4–L5 and L5–S1 levels

Lumbosacral spondylosis Osteoarthritis of the lumbosacral spine may cause localized low back pain. Oblique views of the lumbar spine demonstrate facet joint narrowing, periarticular sclerosis and osteophytes.

Lumbar spinal stenosis The narrowing of the spinal canal that occurs in stenosis results from the degenerative changes. Neurologic claudication is the most common presenting symptom of lumbar stenosis. It is classically described as bilateral leg pain initiated by walking, prolonged standing, and walking downhill (relative lumbar extension). It is typically relieved by sitting or bending forward.

Spondylolisthesis Lumbar spondylolisthesis is the anterior displacement of a vertebral body in relation to the underlying vertebra. Spondylolisthesis usually is secondary to degeneration of intervertebral discs. The most common level affected in a degenerative slip is the L4–L5 level.

Scoliosis Scoliosis is a lateral curvature of the spine in excess of 10°. Most commonly begins to develop in adolescent girls.

Cancer and Low Back Pain The spine is the most common site for bony metastases. Vertebral body metastases are found in more than one third of cancer patients. The most common cancers that involve the spine are – lung, – breast, – prostate, – renal cell.

Spinal Infections Spinal infections include – osteomyelitis, – diskitis, – pyogenic facet arthropathy, – epidural infections.

It is important to diagnose and treat spinal infections quickly – to prevent increased morbidity and mortality, – to prevent complications such as epidural abscesses that can cause paralysis.

Spondyloarthropathies Spondyloarthropathies are a group of diseases associated with the HLA-B27 allele. They include – Ankylosing spondylitis, – Reactive arthritis, – Psoriatic arthritis, – Enteropathic arthritis, – Undifferentiated spondyloarthropathy.

Ankylosing Spondylitis Ankylosing spondylitis is the prototype for the spondyloarthropathies. It generally first presents with morning stiffness and a dull ache in the low back or buttocks.

Rehabilitation Patient Education – Education should include providing as much of an explanation as patients need in terms they can understand. Back Schools – The term back school is generally used for group classes that provide education about back pain. – They include information about the anatomy and function of the spine, common sources of low back pain, proper lifting technique and ergonomic training, and sometimes advice about exercise and remaining active.

Exercise – Exercise results in positive outcomes in the treatment of chronic low back pain. – The most effective exercise for low back pain includes an individualized regimen learned and performed under supervision that includes stretching and strengthening. – Patients who have not tolerated land-based exercises are often able to participate in pool exercises.

Medication Nonsteroidal Antiinflammatory Drugs Muscle Relaxants Antidepressants (Tricyclic antidepressants) Topical Treatments (Lidocaine patches, antiinflammatory creams)

Injections and Needle Therapy for Mechanical Low Back Pain – Myofascial Pain and Trigger Point Injections – Acupuncture – Steroid Injections and Other Spinal Procedures

Lumbar Supports Superficial and deep heat Transcutaneous Electrical Nerve Stimulation – The stimulation of large afferent fibers inhibits small nociceptive fibers, causing the patient to feel less pain.

Lumbar epidural steroid injections have become a common adjuvant for the treatment of lumbosacral radiculopathy. Surgical management of lumbosacral radiculopathy is best reserved for those patients who have – significant persistent symptoms despite 6 to 8 weeks of maximized conservative management, – neurologic progression or – cauda equina syndrome.

CERVİCAL PAİN The prevalence of neck pain with or without upper limb pain ranges from 9% to 18% of the general population. One of three individuals can recall at least one incidence of neck pain in their lifetime.

Mechanical disorders of the cervical spine Neck strain Cervical disc herniation Cervical spondylosis Myelopathy Whiplash

Neck strain Neck strain is rarely associated with a specific trauma. It is typically triggered by sleeping in an awkward position, turning the head rapidly. Physical examination reveals local tenderness in the paracervical muscles, with decreased range of motion and loss of cervical lordosis. No abnormalities are found on neurologic examination.

Cervical disc herniation Intervertebral disc herniation in the cervical spine causes radicular pain that radiates from the shoulder to the forearm to the hand. Neurologic examination may reveal – sensory deficit, – asymmetry of reflexes, – motor weakness corresponding to the damaged spinal nerve root.

Cervical spondylosis Osteoarthritis of the cervical spine As the disc degenerates, the articular structures are brought closer together, the cervical spine becomes unstable. Increased instability results in osteophyte formation. Plain radiographs show the intervertebral narrowing and facet joint sclerosis.

Myelopathy The most serious sequelae of cervical spondylosis is myelopathy. This disorder occurs as a consequence of spinal cord compression by – osteophytes, – ligamentum flavum or – intervertebral disc.

Clinical symptoms include weakness and uncoordination in the hands. In the lower extremities, this disorder can cause – gait disturbances, – spasticity, – leg weakness and – spontaneous leg movements.

Sensory deficits include decreased dermatomal sensation and loss of proprioception. Hyperreflexia, clonus and positive Babinski’s sign are present in the lower extremities.

Whiplash Whiplash injuries are cervical hyperextension injuries of the neck. They are associated with motor vehicle accidents. Regardless of the direction of impact, whiplash is defined by the passive movement of the neck.

Muscular control to stabilize the cervical spine does not react quickly enough to prevent injurious forces from occurring across the cervical functional spinal units.

The anterior disk, anterior longitudinal ligament, posterior disk or annulus, and cervical zygapophyseal joints are all at risk for injury during a whiplash event. Injury also occurs to the cervical soft tissues, resulting in strain and sprain injuries.

The most commonly reported symptoms of whiplash injury include neck pain and headaches, followed by shoulder girdle pain, upper limb paresthesias, and weakness. Less common symptoms include dizziness, visual disturbances, and tinnitus.

Treatment Patient education, activity modification, and relief of pain are the initial treatment steps. Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen (paracetamol) aid in controlling pain.

Adjunct medications are often used in conjunction with antiinflammatory medications. These are: – muscle relaxants, – tricyclic antidepressants, – antiepileptics.

Physical modalities superficial and deep heat, electrical stimulation can be used in the treatment program. Cervical traction applies a distractive force across the cervical intervertebral disk space.

Transcutaneous electrical nerve stimulation (TENS) can also be effective in modulating musculoskeletal pain. Cervical orthoses function to limit painful range of motion and facilitate patient comfort during the acute injury phase. A soft cervical collar can be prescribed to reduce further neck strain.

Surgery – Indications for surgical treatment include intractable pain, severe myotomal deficit (progressive or stable), progression to myelopathy.

REFERENCES Physical Medicine & Rehabilitation DeLisa’s Physical Medicine & Rehabilitation Harrison’s Rheumatology Primer on the Rheumatic Diseases