Low Back Pain Stephanie Wetmore, PT PED 596 Adv. Cardiac Rehab Wayne State College.
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Transcript of Low Back Pain Stephanie Wetmore, PT PED 596 Adv. Cardiac Rehab Wayne State College.
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
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
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
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