1. A Physical Therapy Approach For low Back Pain

2. 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

3. Steven Stoltz, M.D.

4. Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred
Infection
Psychological
Metabolic

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

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

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

8. 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

9. 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

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

11. 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

12. 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

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

14. 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

15. Back Examination
Nerve tension signs
Nerve compression signs

16. 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

17. 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

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

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

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

21. Investigations
For simple backache, age <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

22. 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

23. Acute Low Back Pain

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Postural education / body mechanics

33. USING PROPER BODY MECHANICS

35. 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

36. 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

37. 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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49. 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

50. 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

51. 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

52. 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

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

54. Progressing difficulty