A Physical Therapy Approach For low Back Pain

Introduction Approximately 60-80% of population will have lower back pain at some time in their lives, and one –half will have recurrences. 2nd most common cause for P-T visit Potent cause of absence from work 60% of LBP suffers experience functional limitation or disability as a result of their pain 90 % of cases of LBP resolve without treatment within 6-12 weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6 months

Steven Stoltz, M.D.

Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic

Musculoskeletal Degenerative Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis Osteoarthritis Spondylosis

Rheumatic Neoplastic Primary Secondary Prostate Lung Renal Breast Rheumatoid Arthritis Ankylosing Spondylitis Primary Secondary Prostate Lung Renal Breast Thyroid

Referred Pain Infection Gynaecological TB Renal Osteomyelitis Other abdominal TB Osteomyelitis Herpes Zoster

Psychological Metabolic Osteoporosis Depression Paget’s Malingering Osteomalacia Depression Malingering Predisposing factors Postural stress Work related stress Disuse and loss of mobility Obesity Debilitating conditions Precipitating factors Misuse Overuse Abuse or trauma

Types of pain Based on source Based on affected region Based on nature Mechanical Discogenic Based on affected region Local Referred Based on nature Transient Acute Chronic

History Sometimes a clear cause but often not In a young, fit person then usually: muscle or ligament strain facet joint problem prolapsed disc

Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped by rest Facet Joint - Sudden backache with a simple movement “I was just picking up a coin off the floor” - Often flexion with rotation - May have heard a click Prolapsed Disc -Shooting pain -Pain radiating down the leg below the knee -Aggravated by coughing/sneezing -Usually sudden onset and often no trauma

Red Flags in the History Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes

Forward bending Hands are pushing in opposite direction Tissues from skin to central core Elongate posterior Compress anterior Assessing lumbo-pelvic congruency Palpation from cervical spine to pelvis

Back Examination Nerve tension signs Nerve compression signs

Examination of back pain Supine Testing Passive hip flexion Faber position Straight leg raise (SLR) Force is directed to right femur Posterior to anterior force directed to femur In flexed and vertical position Passive knee flexion in a prone position Passive internal and external hip rotation knee at 900 of flexion

Passive hip flexion Hip hyperflexed Force transmission Lumbar spine flattened Over 900 of flexion Force transmission To extensor of hip Posterior rotary movement on ilium Spinal flexion

Straight leg raise (SLR) Straight leg raised Femoral flexion Adduction Internal rotation Increase in tensile force On sciatic nerve Related to ischial tuberosity

L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness Big Toe Foot Dorsiflexion Sensory Loss Medial foot

L5/S1 Prolapse Straight leg raising reduced Ankle jerk absent Weakness Plantar flexion Foot eversion Sensory Loss Lateral foot

Investigations For simple backache, age 20-50 <4 weeks duration,no red flags - no x-rays necessary. Patients expect one. X-ray: recent significant trauma recent mild trauma over 50 prolonged steroid use osteoporosis age over 70

Investigations Plain x-ray with FBC and ESR to rule out tumour, infection if red flags suggest likely If red flags present and plain x-ray normal then bone scan, CT or MRI may still be indicated

Acute Low Back Pain

Nerve Root Pain Unilateral leg pain worse than low back pain Radiates to foot or toes Numbness and paraesthesia in same distribution SLR reproduces leg pain Localised neurological signs - reflexes and power

Possible Serious Spinal Pathology Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

Cauda Equina Syndrome Sphincter disturbance Gait disturbance or widespread motor weakness involving more than on nerve root or progressive motor weakness in the legs Saddle anaesthesia of anus, perineum or genitals Needs emergency referral

Red Flags (again) Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness - weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use

What to tell the patient Increase physical activity progressively over a few days or weeks Stay as active as possible and continue normal daily activities Stay at work or return to work as soon as possible as beneficial

Who to Refer Nerve root pain not resolving after 4 weeks (Orthopaedics) One or more red flags leads to credible evidence of serious pathology Cauda equina syndrome Can have manipulation as long as no progressive neurology

Phases of Treatment Treatment of pain Modalities Medication Support the region Biomechanical counseling / rest Continue support Begin non-destructive movement Decrease destructive behavior Discontinue support Begin proprioceptive and kinesthetic strength training Neuromuscular efficiency Dynamic stabilization Establishment of limits Movement Loads Positions Frequencies

Treatment Options Cryotherapy Thermotherapy Superficial heating Deep Heat Injection Therapy & Soft tissue injections Electrotherapy Transcutaneous electrical nerve stimulation (TENS) Manipulation Traction Massage Physical therapy and exercises Acupuncture Corsets and braces Surgerical treatment

Postural education / body mechanics

USING PROPER BODY MECHANICS

Back Exercises Strong evidence that back exercises do not produce any significant improvement in acute back pain Moderate evidence that exercise programmes can improve pain and function in chronic low back pain

Exercises Many programs available, but difficult to make any scientific recommendations for one type versus another Goals of exercises: Improves pain and function Decrease mechanical stress Increase strength and flexibility Improve posture and mobility

Two main practical Exercises are used in P-T clinics 1- Williams exercises: Strengthening exercises for the lumbar flexors with stretching the musculature and ligamentous structure of the extensors. Flexion exercises are used to open the intervertebral foramina and facet joint. 2- McKenzie Exercises: Strengthening exercises for the lumbar extensors to reduce the derangement and centralise the pain

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Lumbar rotation – leg extension – contralateral arm elevation Low Back Stretches Knee to chest Double knee to chest Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation

Supine Hamstring – knee extended 90 deg – normal length Periformis stretch – pressing outward on crossed knee Deeper stretch – elevate arm on same side of extended leg Hip Flexor stretch – front knee at 90 degrees

Prone Press-ups pain free only ROM/Localizing/Strengthening Prone on elbows Prone Press-ups pain free only Multifidus engagement – activate TA Extend leg 2-3 inches off surface Swimmers (Multifidus) Extend opposite arm/leg

Plank – activate TA – elevate on forearms - toes Strengthening - TA Plank – activate TA – elevate on forearms - toes 3-point Plank – raise one foot 2-point plank – elevate opposite arm/leg

Bridge – activation of TA Pelvis level Bridge with SL extension Switch legs without lowering trunk or pelvis

Progressing difficulty