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
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
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.
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
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 Origins of Low Back Pain
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. Initial Assessment
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 Differential Diagnoses
10% Medical Cause UTI/Cystitis/Nephrolithiasis Prostatitis Endometriosis Dysmenorrhea Primary cancer metastatic to bone Aneurysm 90% Musculoskeletal Cause Somatic Dysfunction Postural Decompensation Viscerosomatic Considerations
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 Symptoms of Benign LBP
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.
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
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?
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?
General Impression Is there a problem? What regions exhibit a problem? Osteopathic Exam • Diagnostic Characteristics • What • What are the specific characteristics of the identified segment(s)?
Screening • Appropriate screening includes the following the regions • Thoracic • Lumbar • Sacral • Pelvic • Lower extremities
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 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 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. Physical Exam
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?
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?
Treatment Sequence • Leg restrictors • Pubes • Superior innominate Upslip (shear) • Lumbar Spine • Sacrum • Innominate • Iliopsoas
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
Treatment Techniques • Techniques that could be used include: • Direct techniques: • HVLA • Muscle Energy • Articulatory • Indirect techniques: • Strain Counterstrain • Functional Methods
MET – Lumbar – FRLSLSeated 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
MET – Lumbar – FRLSLSeated Technique • 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 • Pt cooperation: Ask the pt to reach for the floor to help introduce right sidebending & rotation Greenman, English 2nd ed., p.282-3
MET – Lumbar – FRLSLLateral Recumbant Technique Fine tune extension by moving shoulders posterior to feather edge of L4 movement Maintain shoulders perpendicular to table for right sidebending Fine tune extension by moving shoulders posterior to feather edge of L4 movement Fine tune extension from below via the lower extremities
MET – Lumbar – FRLSLLateral Recumbant Technique • LE abduction enhances R SB from below & sets pt up for ME effort – adduction • Repeat • Pt reaches behind under guidance to grasp side of table; this enhances right rotation & sidebending • Left hand cephalad translation to barrier; (for right sidebending) • Right elbow resists pt attempt to turn left • Repeat Greenman, English2nd ed.,p.292
Neutral Technique Slide Neutral SRRL Notice the physician’s right arm under the pt’s right axilla – allows easy sidebending left. Physician’s Left Thumb palpates the posterior transverse process.
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
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