low back pain

CORE OMM Curriculum

for Students, Interns, & Residents ©2006

Low Back Pain Syndrome and Associated Conditions

Developed for OUCOM CORE by Craig Warren, D.O.

Edited by Mindy Ford, D.O. and the

CORE Osteopathic Principles and Practices Committee

CORE OMM Curriculum


Low Back Pain

• Annual US prevalence is 15-20%• 2nd most common symptomatic reason for visits

to primary care physicians.• 90% of all episodes will resolve within 6 weeks

regardless of treatment• 90% of all persons disabled for more than 1 year

will never work again without intense intervention

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Low Back Pain

• Most common cause of disability in people younger than 45.

• 1% of U.S. population is chronically disabled due to back problems.

• 1% of U.S. population is temporarily disabled due to back problems.

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Definitions

• Acute LBP: Back pain <6 weeks duration• Subacute LBP: back pain >6 weeks but <3

months duration• Chronic LBP: Back pain disabling the patient

from some life activity >3 months• Recurrent LBP: Acute LBP in a patient who has

had previous episodes of LBP from a similar location, with asymptomatic intervening intervals

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Origins of Low Back Pain

• Referred pain from visceral disease

• Non-activity related:– Inflammation

• Infectious/rheumatic

– Osseous– Acquired defects– Intra-spinal lesions– Metabolic disorders

• Activity related spinal disorders:– Disco dural or disco

radicular – Capsuloligamentous – Stenotic

• Non-organic causes

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Initial Assessment

• Focused HxCC, PMHx, FMHx, PE• Be aware of Red Flags

– Findings that suggest a serious underlying pathology

– Refer to chart on next slide• In absence of Red Flags, imaging studies and

further testing not helpful in first 4 weeks.

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Cauda Equina

Fracture Cancer Infection

Progressive neuro deficit X

Recent bowel or bladder dysfunction

X

Traumatic Injury X

Steroid use history X X

Women age > 50 X

Men age >50 X

Male with osteoporosis X X

Cancer history X

Diabetes Mellitus X

Insidious onset X X

No relief at bedtime or worsens when supine

X X

Constitutional Symptoms X X

Hx UTI/other infection X

IV Drug Use X

HIV X

Immune suppression X

Previous surgery X

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Differential Diagnoses

• Aortic Aneurysm• Tumors/cancer• Bony metastasis• Vertebral Osteomyelitis • Epidural abscess• Neurofibromatosis• Pelvic pathology• Abdominal pathology • Herniated disc

• Compression fracture • Rheumatoid arthritis• Degenerative joint

Disease • Osteoarthritis• Ankylosing spondylitis• Cauda equina syndrome• UTI • Strain/ sprain

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Viscerosomatic Considerations

• 10% Medical Cause– UTI/Cystitis/

Nephrolithiasis– Prostatitis– Endometriosis– Dysmenorrhea– Primary cancer

metastatic to bone– Aneurysm

• 90% Musculoskeletal Cause– Somatic

Dysfunction– Postural

Decompensation

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Symptoms of Benign LBP

• Dull and achy quality• Diffuse aching with

associated muscle tenderness

• Exacerbated with movement

• Relieved with rest in recumbent position

• No radiation, paresthesias

• No dermatomal pattern

• Pt. is able to find a position of comfort

• DTR are within normal limits

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General Considerations

• The history is of vital importance.

• Go slowly, be patient. Listen to the patient.

• Goal is to ascertain the cause for low back pain.

• Somatic dysfunction is not a cause for low back pain.

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Important aspects of the history

• Age of patient• Daily activities• Symptoms:

– Pain, paresthesia, radiation, weakness– Influence of posture/activity– Bowel/bladder incontinence– Saddle anesthesia– ROS, including constitutional, possibly

gastrointestinal, gynecologic

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Pain History

• Localization:– Where does it hurt? central, unilateral, bilateral– Does the pain go anywhere? upper lumbar, lower

lumbar, gluteal, perineal, legs

• Onset:– When did the pain start? days, weeks, months, years– How did the pain start? suddenly, gradually

• Severity:– 0-10 Scale: Current? Average? Worst?

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Pain History

• Evolution: – How has the pain changed over time?

• Relationship to activity:– What postures or movements worsen the

pain?– Does it hurt to cough or sneeze?– Does the pain wake you at night?– What makes the pain better?

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Osteopathic Exam

• General Impression

• Is there a problem?– What

regions exhibit a problem?

• Diagnostic Characteristics

• What―What are the

specific characteristics of the identified segment(s)?

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Screening

• Appropriate screening includes the following the regions– Thoracic– Lumbar– Sacral– Pelvic– Lower extremities

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Physical Exam

• Standing:– Inspection– Range of motion

• Flexion• Extension• Sidebending

– Toe raise– One legged Extension

• Inspection: for deviation, scoliosis, muscle wasting. Skin/hair changes

• ROM: range, pain, deviation, painful arc.

• Toe raise: neurological testing, motor, S1/2

• One leg extension: loading of pars interarticularis

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Physical Exam

• Supine– Muscle strength– Sensory testing– Plantar reflex– Sacroiliac joint

• distraction– Hip joint

• ROM– Dural tension signs

• SLR– Sacroiliac screening– Hip screening– Dural tension signs L4-S2

• Seated– Neurological

• Patellar Reflex• Achilles reflex• Muscle strength

– Neurological testing• DTR L4• Motor L2-S2• Sensory L2-S2• Babinski

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Physical Exam

• Prone– Dural tension signs

• Femoral stretch

– Palpation

• Spinous processes

• Interspinous ligaments

• Iliolumbar ligaments

• Sacroiliac ligaments

• Neurological testing– DTR S1/2– Motor L2/3, S1/2

• Dural tension signs L3 nerve root

• Palpation: of osseous and ligamentous structures.

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LBP – Osteopathic Considerations

• What will be your highest yield regions?– How does previous trauma influence these regions?

• Which 1 or 2 of the aspects below has the greatest influence on the patient complaint?– Pain– Hyper-sympathetic influence– Parasympathetic influence– Fluid Congestion

• Devise a focused examination based on the patient’s complaint– What are your expected findings?– Your expected palpatory findings (TART/STAR) ?– What are the acute or chronic aspects?

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LBP – Osteopathic Considerations

• Propose an appropriate differential diagnosis

• Devise an appropriate treatment plan based on musculoskeletal components involved in the patient complaint– What are the dose and frequency considerations?– What are the OP – IP – ER considerations?

• Devise an appropriate manipulative approach or technique w/indications and contraindications– How are you going to talk to your patient about their complaint?– How will you communicate your findings, diagnosis, and

treatment to your preceptor?

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Treatment Sequence

• Leg restrictors

• Pubes

• Superior innominate Upslip (shear)

• Lumbar Spine

• Sacrum

• Innominate

• Iliopsoas

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Sequence Rationale

• Leg restrictor muscle problems will affect the bony attachments of the innominate, sacrum, and pelvis

• Treatment of the innominate, sacrum or pelvis will not be as effective without treating leg muscles first

• Articular dysfunction will return more rapidly if muscular problem not resolved during treatment

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Treatment Techniques

• Techniques that could be used include:– Direct techniques:

• HVLA• Muscle Energy• Articulatory

– Indirect techniques:• Strain Counterstrain• Functional Methods

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Muscle Energy Techniques

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MET – Lumbar – FRLSL

Seated Technique

• Patient seated:– left hand holding right shoulder– Pt’s right arm dropped at the side

• Operator:– straddles pt’s left knee & left hand grasping

the pt’s right shoulder– Control the pt’s left shoulder with the left axilla– Right middle finger monitors the L4-5

interspinous space– Right index finger monitors the left transverse

process of L4

• Localization: Trunk Translation Anterior to Posterior to introduce L4-5 Flexion

Greenman, English 2nd ed., p.282

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Seated Technique

• Pt cooperation: Ask the pt to reach for the floor to help introduce right sidebending & rotation

Greenman, English 2nd ed., p.282-3

• Pt side bends left against operator resistance• Isometric contraction, relax, reposition, repeat until sidebending & rotation resolution

• Forward bend the pt (to fully open zygapophysial joints) while maintaining right rotation• Pt attempts extension

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Lateral Recumbant Technique

Fine tune extension by moving shoulders posterior to feather edge of L4 movement

Fine tune extension from below via the lower extremities

Maintain shoulders perpendicular to table for right sidebending

Fine tune extension by moving shoulders posterior to feather edge of L4 movement

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Lateral Recumbant Technique

• Pt reaches behind under guidance to grasp side of table; this enhances right rotation & sidebending

• LE abduction enhances R SB from below & sets pt up for ME effort – adduction• Repeat

• Left hand cephalad translation to barrier; (for right sidebending)• Right elbow resists pt attempt to turn left• Repeat

Greenman, English 2nd ed.,p.292

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Neutral Technique Slide

Notice the physician’s right arm under the pt’s right axilla – allows easy sidebending left.

Neutral SRRL

Physician’s Left Thumb palpates the posterior transverse process.

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• Side bend pt. left using easy control via the right axilla

• Rotate right by gently carrying the right shoulder backward

• Isometric force 3-5 seconds, reposition, repeat

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Let’s discuss and practice other

techniques

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References

• Ward, R.C., Foundations for Osteopathic Medicine, 1997, Williams and Wilkins, Baltimore, MD: 337-345, 591-592, 583.

• Acute Low Back Pain, MCARE Guidelines, 2005, http://mcare.org/media/pdf_autogen/cpg_lowbackpain_mcare05.pdf

http://mcare.org/media/pdf_autogen/cpg_lowbackpain_mcare05.pdf

http://mcare.org/media/pdf_autogen/cpg_lowbackpain_mcare05.pdf

low back pain

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