What is Back Pain ? Most disc herniations occur at L5-S1 At least 30% of the healthy symptomless population have clinically significant disc protrusions (Stadnik et al., 1998).
What is Back Pain ? Several studies have shown that there is no correlation between MRI findings and patients’ low back symptoms. 1. Wittenberg et al., 1998 2. Smith et al., 1998 3. Savage et al., 1997
What is Back Pain ? There are many more joints in the back than discs. There are many more muscles than joints. The most common cause of low back pain is when one or more muscles “forget” to relax. We call this a somatic dysfunction.
Common Sources of LBP Somatic dysfunction Muscle in “spasm” Nerve root In somatic dysfunction, some muscles become overactive (“spasm”) and other muscles become inactive.
Common Sources of LBP Any dysfunction involving the thoracic or lumbar spine, the sacroiliac joint or the hip can create low back pain.
Common Sources of LBP Disc 1. posteriorly - sinu vertebral nn. 2. laterally - gray rami communicantes a. branches of ventral rami 3. various types of nerve endings up to ½ annulus depth Targets for dorsal primary ramus 1. facet joints 2. interspinous ligaments 3. back muscles GRC VPR SVN DPR
piriformis sciatic nerve Common Sources of LBP Long dorsal si ligament sacrospinous ligament sacrotuberous ligament
Role of the sacroiliac joint The coxal bones consist of a thin shell of cortical bone (1-2 mm) over trabecular bone. Muscles play an important role in helping the pelvis resist stress. When muscles can’t work due to pain, the risk of injury increases.
Introduction • COMMON, 2ND only to URTI • Tx is symptomatic • HISTORY is critical to ruling out serious issues. • Conduct a Physical Exam to confirm and assess functional status
What Causes Acute Low Back Pain • Muscle strain? • DJD or OA? • Disc disease? • Who cares? • Initially they are all treated same for the most part. • Most all get better with conservative treatment. • Beware of the serious causes!
Evaluate for “Red Flags”: May Signal Serious Causes of LBP • Cancer • Infection • Fracture • Sciatica • Cauda Equina syndrome • Ankylosing spondylitis
Sciatica • The sciatic nerve is the longest nerve in your body. It runs from your spinal cord to your buttock and hip area and down the back of each leg. The term "sciatica" refers to pain that radiates along the path of this nerve — from your back down your buttock and leg. Source: Mayoclinic.com
Cauda Equina Syndrome: • Caused by massive midline disc herniation or mass compressing cord or cauda equina. • Rare (<.04% of LBP patients). • Needs emergent surgical referral. • Symptoms: bilateral lower extremity weakness, numbness, or progressive neurological deficit. • Ask about: • Recent urinary retention (most common) or incontinence? • Fecal incontinence?
Ankylosing spondylitis • Ankylosing spondylitis is one of many forms of inflammatory arthritis, the most common of which is rheumatoid arthritis. Ankylosing spondylitis primarily causes inflammation of the joints between the vertebrae of your spine and the joints between your spine and pelvis (sacroiliac joints). Source: Mayoclinic.com
Evaluation of the Patient With LBP • Start with a detailed history – your best diagnostic tool. • Get an idea of the severity. • Look for the “red flags” of serious causes. • Use the physical exam to confirm what you suspect based on history. • Keep in mind: • Most of the time you won’t have a definitive diagnosis. • Imaging rarely changes initial treatment. • Most patients get better with conservative TX.
What Was the Mechanism of Injury or Overuse? • Was there an acute trauma or injury? • Sudden severe pain with bending. • Motor vehicle accident or fall. • Was there a recent history of excessive lifting or bending?
About 85-90% of LBP sufferers will get better in 3 days to 6 weeks • Most back problems are not surgical cases • Of the remaining 10-15%, most will never get completely well
Treatment ApproachesSurgery Spine Surgery Outcomes Success Rate (%) Risk Factors
Mechanisms of Injury • Congenital abnormalities • Poor body mechanics • Back trauma
Pathology of Low Back Pain • Causes: • Herniated disks, facet pathology, spinal stenosis, stress fractures (spondys), compression fractures, ligamentous sprains, adaptive shortening, and muscle strain • Do spinal abnormalities always cause low back pain? • MRIs on 98 people with no back pain • Dr. Maureen Jensen, Hoag Memorial Hospital, Newport Beach, CA. (1995) • Nearly 2/3 had spinal abnormalities including bulging or protruding discs
Musculature Superficial Thoracic group Abdominal group Erector Spinae group Spinalis Longissimus Iliocostalis Deep Transversospinal group Multifidus Rotatores Intertransversarius Trunk Musculature
Spinal Nerves and Plexi 31 spinal nerves 4 Plexi Cervical Brachial Lumbar (T12-L5) Femoral, Obturator Sacral (L4-S5) Sciatic Tibial and Common Peroneal Nerves
Neural Testing Dermatomes -correspond to an area of skin that is innervated by the cutaneous neurons of a single spinal nerve or cranial nerve. Myotomes -correspond to groups of muscles innervated by a specific nerve root.
Classify patient • Determine cause of problem • Postural • Inflammation of soft tissues • Dysfunctional • Adaptive Shortening • Strain or Sprain • Derangement • Disk • Facet joint • Stress Fracture
Lumbar Spine Conditions • Low Back Muscle Strain • Acute (Overextension) and Chronic (Faulty posture) • Facet Joint Dysfunction • Dislocation or Subluxation (Acute or Chronic) • Low Back fracture • Compression, Stress, or Spinous and Transverse Processes • Herniated Disc • Protrusion, Prolapse, Extrusion, and Sequestration • Local and Radiating Pain • Classic term “Sciatica”
Lumbar Spine Conditions • Spondylolysis • Unilateral defect in the pars interarticularis • Spondylolisthesis • Bilateral defect in the pars interarticularis which causes forward displacement of vertebra. • Spina Bifida Occulta • Congenital condition – spinal cord is exposed = delays in development.
Sacroiliac Joint Conditions(note this is advanced) • Sacral torsion • Forward or Backward torsion • Ilium torsion, upslip, downslip, outflare, inflare • Piriformis strain/trigger points
Unique risk factors for athletes • High impact trauma: • football, rugby • End range loading: • gymnastics, diving • Overuse trauma: • impact loading: distance running • rotational loading: golf, baseball • prolonged sitting: travel
Evaluation Techniques • HOPS/HIPS • History, Observation/Inspection, Palpation, Special Tests • Your first priority! • Establish the integrity of the spinal cord and nerve roots • History and several specific tests provide information (Dermatomes, Myotomes, Reflexes)
Assessing the Low Back • On-Field Assessment • Primary Survey • ABCs • Level of consciousness/Movement • Neurological system intact? • Secondary Survey • Pain, Dermatomes, Myotomes • ROM – only if no motor or sensory decrements • Further assessment on sidelines
Assessing the Low Back • Off-Field Assessment • HISTORY!!!! • Observation and Palpation • The Triad of Assessment • Asymmetry, ROM alteration, Tissue texture • Special Tests • Begin to be selective in you choices. • Classify tests as to their main findings • Use results of key tests to determine further testing
Triad of Assessment • Asymmetry • ASIS, PSIS, iliac crests, malleoli, feet • Range of motion alterations • Standing and seated flexion tests • Single leg stance test (Stork) • Springing of facet and sacroiliac joints • Guarding of certain positions • Tissue texture abnormalities • Muscles – “tootsie roll”
Kinetic Chain • Why do we need to assess the pelvis, hip and lower extremity?
Over-pronation Hip flexion Anterior pelvic tilt Pelvic rotation/Tilt Over-supination Hip extension Hip external rotation Pelvic rotation/tilt Foot conditions