Low Back PainLow Back Pain

Stephanie Wetmore, PTStephanie Wetmore, PT

PED 596 Adv. Cardiac RehabPED 596 Adv. Cardiac Rehab

Wayne State CollegeWayne State College

Epidemiology & Natural History Epidemiology & Natural History of Low Back Painof Low Back Pain

10 million off work 10 million off work dailydaily

$14 billion in missed $14 billion in missed days per yeardays per year

Incidence equal in Incidence equal in sedentary vs. heavy sedentary vs. heavy laborlabor

Truck drivers most Truck drivers most commoncommon

90% of LBP is 90% of LBP is recurrentrecurrent

44% are better in 1 wk44% are better in 1 wk 86% are better in 1 86% are better in 1

mo.mo. 92% are better in 2 92% are better in 2

mo.mo. 35% with recurrent 35% with recurrent

LBP develop sciaticaLBP develop sciatica Lumbar spine most Lumbar spine most

commonly injured part commonly injured part of human bodyof human body

Anatomy & Physiology Anatomy & Physiology of the Lumbar Spineof the Lumbar Spine

Multi-jointed rod composed of numerous Multi-jointed rod composed of numerous vertebraevertebrae– 7 cervical7 cervical

– 12 thoracic12 thoracic

– 5 lumbar5 lumbar

– 5 sacral (fused)5 sacral (fused)

Normal spinal curvesNormal spinal curves– 10x increase strength & resilience than straight spine10x increase strength & resilience than straight spine

– Protects spinal cord & provides movement and shock Protects spinal cord & provides movement and shock absorptionabsorption

Normal Spinal CurvesNormal Spinal Curves

Cervical spine = Cervical spine = lordotic curvelordotic curve

Thoracic spine = Thoracic spine = kyphotic curvekyphotic curve

Lumbar = lordotic Lumbar = lordotic curvecurve

Sacral = kyphotic Sacral = kyphotic curvecurve

Bones & LandmarksBones & Landmarks

Bones & Landmarks (cont.)Bones & Landmarks (cont.)

LigamentsLigaments

MusclesMuscles

Flexion – rectus abdominis & obliquesFlexion – rectus abdominis & obliques Extension – erector spinae, transversospinalis & Extension – erector spinae, transversospinalis &

interspinalisinterspinalis Lateral Bending – quadratus lumborum, erector Lateral Bending – quadratus lumborum, erector

spinae, obliques, intertransversariispinae, obliques, intertransversarii Rotation to same side – int. obliquesRotation to same side – int. obliques Rotation to opp. Side – ext. obliques & Rotation to opp. Side – ext. obliques &

transversospinalistransversospinalis Compression of abdomen – abdominals & Compression of abdomen – abdominals &

obliquesobliques

InnervationInnervation

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

PathophysiologyPathophysiology

Predisposing factorsPredisposing factors– Poor sitting posture Poor sitting posture – Frequency of trunk flexion (Burton study) Frequency of trunk flexion (Burton study)

Intradiscal pressureIntradiscal pressure– Increased with movement toward a kyphotic Increased with movement toward a kyphotic

positionposition Overstretching of ligamentsOverstretching of ligaments

– Posterior spinal ligaments overstretched by Posterior spinal ligaments overstretched by slouched positionsslouched positions

Causes of PainCauses of Pain

Nocioceptive receptor systemNocioceptive receptor system– Activated by mechanical forces or chemicalsActivated by mechanical forces or chemicals– Located in periosteum, joint capsules of facet Located in periosteum, joint capsules of facet

joints, muscles, muscle attachments, superficial joints, muscles, muscle attachments, superficial fascia, skin and outer portion of the discfascia, skin and outer portion of the disc

– Also located in ligaments with PLL having Also located in ligaments with PLL having highest densityhighest density

Chemical vs. MechanicalChemical vs. Mechanical

Chemical irritation Chemical irritation occurs with infection, occurs with infection, inflammatory diseases inflammatory diseases and for approximately and for approximately 20 days following 20 days following traumatrauma

Mechanical Mechanical deformation of deformation of nocioceptors occurs nocioceptors occurs when force causes when force causes physiological stress, physiological stress, deformation and deformation and damage, even without damage, even without pathology (example – pathology (example – hyperextension of hyperextension of index finger)index finger)

Can become constant Can become constant when internal when internal derangement occursderangement occurs

Specific PathologiesSpecific Pathologies

Intervertebral disc lesionsIntervertebral disc lesions– Prolapsed (herniated) intervertebral discProlapsed (herniated) intervertebral disc– Lumbar instability and spondylosisLumbar instability and spondylosis

MRI of disc herniationMRI of disc herniation

SpondylosisSpondylosis

Disc degeneration with gradual flattening of Disc degeneration with gradual flattening of the disc and displacement of posterior facet the disc and displacement of posterior facet jointsjoints

Symptoms due to mechanical derangement Symptoms due to mechanical derangement and OA of facet jointsand OA of facet joints

Spinal StenosisSpinal Stenosis

http://www.spinenet.com/stenosis.htmlhttp://www.spinenet.com/stenosis.html Narrowing of spinal canalNarrowing of spinal canal

– Caused by disc degeneration or OACaused by disc degeneration or OA

SpondylolisthesisSpondylolisthesis

Forward shift of spineForward shift of spine– Caused by congenital malformation, separation Caused by congenital malformation, separation

or stress fracture or OAor stress fracture or OA

PharmacologyPharmacology

NSAIDsNSAIDs– Advil, Motrin, Aleve, RelafenAdvil, Motrin, Aleve, Relafen– Cox-2 InhibitorsCox-2 Inhibitors

» Celebrex, VioxxCelebrex, Vioxx

Drugs to protect against NSAID-induced ulcersDrugs to protect against NSAID-induced ulcers– Prilosec, PrevacidPrilosec, Prevacid

Muscle relaxantsMuscle relaxants– Flexeril, SomaFlexeril, Soma

Anti-depressantsAnti-depressants– Amitriptyline (Elavil)Amitriptyline (Elavil)

More DrugsMore Drugs

NarcoticsNarcotics– Morphine, codeine, demerol, darvocet, vicodin Morphine, codeine, demerol, darvocet, vicodin

and percocetand percocet Non-narcotic pain medsNon-narcotic pain meds

– UltramUltram Oral steroidsOral steroids

– Medrol dose packMedrol dose pack InjectionsInjections

– Epidural flood, selective nerve root block, facet Epidural flood, selective nerve root block, facet joint block and sacroiliac blockjoint block and sacroiliac block

Epidural FloodEpidural Flood

Exercise Limitations/Capacity Exercise Limitations/Capacity & Modifications& Modifications

SpondylolisthesisSpondylolisthesis– Avoid heavy labor and vigorous physical Avoid heavy labor and vigorous physical

activityactivity– Lumbar support to immobilizeLumbar support to immobilize– Abdominal strengthening and flexion activitiesAbdominal strengthening and flexion activities

Spinal StenosisSpinal Stenosis– Lumbar support often helpfulLumbar support often helpful– Increase mobility and flexibilityIncrease mobility and flexibility

Intervertebral disc lesionsIntervertebral disc lesions

Herniated or prolapsed discHerniated or prolapsed disc– Dependent upon direction of herniationDependent upon direction of herniation– Dependent on acuteness of conditionDependent on acuteness of condition– Decrease compressive forces and intradiscal Decrease compressive forces and intradiscal

pressurepressure» Limit sitting and forward bending for post. Limit sitting and forward bending for post.

herniationsherniations

Degenerative Disc DiseaseDegenerative Disc Disease– Improve flexibility and mobilityImprove flexibility and mobility

» Usually respond better to flexion activitiesUsually respond better to flexion activities

Sample exercisesSample exercises

WALKING!WALKING!– #1 EXERCISE#1 EXERCISE

Flexion exercisesFlexion exercises Extension exercisesExtension exercises StrengtheningStrengthening

– Pelvic tiltPelvic tilt

ReferencesReferences

McKenzie, R.A. (1981) The Lumbar Spine McKenzie, R.A. (1981) The Lumbar Spine Mechanical Diagnosis and Therapy. Spinal Mechanical Diagnosis and Therapy. Spinal Publications Limited. Waikenae, NZPublications Limited. Waikenae, NZ

Apley, A.G. and L. Solomon (1989) Apley, A.G. and L. Solomon (1989) Concise System of Orthopedics and Concise System of Orthopedics and Fractures. Butterworths. LondonFractures. Butterworths. London

Web Sites of InterestWeb Sites of Interest

www.apta.orgwww.apta.org www.mckenziemdt.orgwww.mckenziemdt.org www.aaos.orgwww.aaos.org www.spinenet.comwww.spinenet.com www.spine-health.com/dir/dir01.htmlwww.spine-health.com/dir/dir01.html