1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population...
-
Upload
claude-hubbard -
Category
Documents
-
view
214 -
download
0
Transcript of 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population...
![Page 1: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/1.jpg)
1
A Physical Therapy Approach For low Back Pain
![Page 2: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/2.jpg)
2
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
![Page 3: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/3.jpg)
3Steven Stoltz, M.D.
![Page 4: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/4.jpg)
4
Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic
![Page 5: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/5.jpg)
5
Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis
Degenerative Osteoarthritis Spondylosis
![Page 6: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/6.jpg)
6
Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis
Neoplastic Primary Secondary
Prostate Lung Renal Breast Thyroid
![Page 7: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/7.jpg)
7
Referred Pain Gynaecological Renal Other abdominal
Infection TB Osteomyelitis Herpes Zoster
![Page 8: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/8.jpg)
8
Psychological Depression Malingering
Metabolic Osteoporosis Paget’s Osteomalacia
Predisposing factorsPostural stressWork related stressDisuse and loss of mobilityObesityDebilitating conditions
Precipitating factorsMisuseOveruseAbuse or trauma
![Page 9: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/9.jpg)
9
Types of pain Based on source
Mechanical Discogenic
Based on affected region Local Referred
Based on nature Transient Acute Chronic
![Page 10: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/10.jpg)
10
History
Sometimes a clear cause but often not In a young, fit person then usually:
muscle or ligament strain facet joint problem prolapsed disc
![Page 11: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/11.jpg)
11
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
![Page 12: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/12.jpg)
12
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
![Page 13: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/13.jpg)
13
Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes
![Page 14: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/14.jpg)
14
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
![Page 15: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/15.jpg)
15
Back Examination
Nerve tension signs Nerve compression signs
![Page 16: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/16.jpg)
16
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
![Page 17: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/17.jpg)
17
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
![Page 18: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/18.jpg)
18
Straight leg raise (SLR)
Straight leg raised Femoral flexion Adduction Internal rotation Increase in tensile
force On sciatic nerve
Related to ischial tuberosity
![Page 19: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/19.jpg)
19
L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness
Big Toe Foot Dorsiflexion
Sensory Loss Medial foot
![Page 20: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/20.jpg)
20
L5/S1 Prolapse
Straight leg raising reduced Ankle jerk absent Weakness
Plantar flexion Foot eversion
Sensory Loss Lateral foot
![Page 21: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/21.jpg)
21
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
![Page 22: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/22.jpg)
22
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
![Page 23: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/23.jpg)
23
Acute Low Back Pain
![Page 24: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/24.jpg)
24
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
![Page 25: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/25.jpg)
25
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
![Page 26: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/26.jpg)
26
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
![Page 27: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/27.jpg)
27
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
![Page 28: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/28.jpg)
28
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
![Page 29: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/29.jpg)
29
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
![Page 30: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/30.jpg)
30
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
![Page 31: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/31.jpg)
31
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
![Page 32: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/32.jpg)
32
Postural education / body mechanics
![Page 33: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/33.jpg)
33
USING PROPER BODY MECHANICS
![Page 34: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/34.jpg)
34
![Page 35: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/35.jpg)
35
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
![Page 36: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/36.jpg)
36
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
![Page 37: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/37.jpg)
37
- 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
![Page 38: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/38.jpg)
383/4/03 Steven Stoltz, M.D.
![Page 39: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/39.jpg)
393/4/03 Steven Stoltz, M.D.
![Page 40: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/40.jpg)
403/4/03
![Page 41: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/41.jpg)
413/4/03
![Page 42: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/42.jpg)
423/4/03
![Page 43: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/43.jpg)
433/4/03
![Page 44: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/44.jpg)
443/4/03
![Page 45: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/45.jpg)
453/4/03
![Page 46: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/46.jpg)
463/4/03
![Page 47: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/47.jpg)
473/4/03
![Page 48: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/48.jpg)
483/4/03
![Page 49: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/49.jpg)
49
Low Back Stretches
Knee to chest Double knee to chest
Lumbar rotation Lumbar rotation – leg extension – contralateral arm elevation
![Page 50: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/50.jpg)
50
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
![Page 51: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/51.jpg)
51
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
![Page 52: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/52.jpg)
52
Strengthening - TA
Plank – activate TA – elevate on forearms - toes
3-point Plank – raise one foot
2-point plank – elevate opposite arm/leg
![Page 53: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/53.jpg)
53
Bridge – activation of TAPelvis level Bridge with SL extension
Switch legs without lowering trunk or pelvis
![Page 54: 1 A Physical Therapy Approach For low Back Pain. 2 Introduction n Approximately 60-80% of population will have lower back pain at some time in their lives,](https://reader038.fdocuments.in/reader038/viewer/2022110100/56649dce5503460f94ac21f9/html5/thumbnails/54.jpg)
54
Progressing difficulty