1 a physical therapy approach for low back pain. 2 introduction n approximately 60-80% of population...
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A Physical Therapy Approach For low Back Pain
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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
3Steven Stoltz, M.D.
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Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic
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Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis
Degenerative Osteoarthritis Spondylosis
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Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis
Neoplastic Primary Secondary
Prostate Lung Renal Breast Thyroid
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Referred Pain Gynaecological Renal Other abdominal
Infection TB Osteomyelitis Herpes Zoster
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Psychological Depression Malingering
Metabolic Osteoporosis Paget’s Osteomalacia
Predisposing factorsPostural stressWork related stressDisuse and loss of mobilityObesityDebilitating conditions
Precipitating factorsMisuseOveruseAbuse or trauma
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Types of pain Based on source
Mechanical Discogenic
Based on affected region Local Referred
Based on nature Transient Acute Chronic
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History
Sometimes a clear cause but often not In a young, fit person then usually:
muscle or ligament strain facet joint problem prolapsed disc
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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
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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
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Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes
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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
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Back Examination
Nerve tension signs Nerve compression signs
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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
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Passive hip flexion
Hip hyperflexed Lumbar spine flattened
Over 900 of flexion
Force transmission To extensor of hip
Posterior rotary movement on ilium
Spinal flexion
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Straight leg raise (SLR)
Straight leg raised Femoral flexion Adduction Internal rotation Increase in tensile
force On sciatic nerve
Related to ischial tuberosity
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L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness
Big Toe Foot Dorsiflexion
Sensory Loss Medial foot
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L5/S1 Prolapse
Straight leg raising reduced Ankle jerk absent Weakness
Plantar flexion Foot eversion
Sensory Loss Lateral foot
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Investigations For simple backache, age 20-50 <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
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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
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Acute Low Back Pain
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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
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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
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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
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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
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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
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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
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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
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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
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Postural education / body mechanics
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USING PROPER BODY MECHANICS
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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
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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
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- 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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Low Back Stretches
Knee to chest Double knee to chest
Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation
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Supine Hamstring – knee extended90 deg – normal length
Periformis stretch – pressing outward on crossed knee
Hip Flexor stretch – front kneeat 90 degrees
Deeper stretch – elevate arm on same side of extended leg
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ROM/Localizing/Strengthening
Prone on elbows Prone Press-ups pain free only
Multifidus engagement – activate TAExtend leg 2-3 inches off surface
Swimmers (Multifidus)Extend opposite arm/leg
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Strengthening - TA
Plank – activate TA – elevate on forearms - toes
3-point Plank – raise one foot
2-point plank – elevate opposite arm/leg
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Bridge – activation of TAPelvis level Bridge with SL extension
Switch legs without lowering trunk or pelvis
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Progressing difficulty
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