The Core: Prevention and Treatment of Low Back Pain...therapy and normal medical treatment.” J...
Transcript of The Core: Prevention and Treatment of Low Back Pain...therapy and normal medical treatment.” J...
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The Core: Prevention and Treatment of Low Back Pain
Joshua Fischer, DO and Sibyl Knight, DO
Family Practice/Neuromuscular Medicine PGY3 Larkin Community Hospital
South Miami, FL
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Goals of this presentation
Discussion of possible causes of Low Back Pain To educate about the essential role of “The
Core” in examining a patient with Low Back Pain
Provide tools for the physician in educating his/her patients about prevention and treatment of Low Back Pain
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Low Back Pain
Massive topic This is not an all-encompassing discussion of
every possible cause of Low Back Pain Instead, it is designed to increase awareness
of causes that the physician may not have in the forefront of their mind
As Osteopathic Physicians, we have more in our toolbox then we realize!
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Case presentation:
35 yo male presents with 2 weeks of low and mid thoracic back pain. Pt reports pain is a dull ache, non radiating, and worse near the end of the day. Reports no pain relief with NSAIDS and pain seems to be exacerbated with exercise.
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PMH: None
PSH: Appendix @ 12 yo
FH: Maternal Hx: Diabetes
All: NKDA
SH: Current smoker- 1ppd, No ETOH
Case presentation:
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Case Presentation:
PE: Gen: NAD, A&Ox3 CV: RRR S1 S2 Resp:CTA Bilaterally Abd: NT ND +BS no CVA tenderness Ext: +2/4 Bilateral DP, Moves all equally, Straight leg negative , + L Thomas Test
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Case Presentation:
C2 FSRl C5FSRr T3FSRr T5ESRL L5ESrRl
Osteopathic Examination:
Thoracic Diaphragm: inhalation restriction Hamstrings Bilaterally: Hypertonic
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Case Presentation:
+L Standing Flexion test +L Seated Flexion test Springing present at left Sacral Sulcus Restricted springing at Left ILA Sacrum: Left Sulcus Deeper, Left ILA inferior
and Posterior
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Case Presentation:
Hip Extension Movement Pattern Test: Flexion of the knee during hip extension
Hip Abduction Movement Pattern Test: Flexion at hip during hip abduction
Trunk curl up test: Limited kyphosis of upper trunk
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Case Presentation:
Labs:
88 14
.6
136
4.3
105
26 8.7
15.1
45.7 284
Ca: 9.0
Total Protein:6.8
Albumin: 4.2
Globulin 2.6
TBili: .5
Alk Phos: 46
AST: 31
ALT: 35
Trigs:87
Cholesterol:184
HDL: 65
LDL: 102
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Diagnosis:
Unilateral Sacral Shear (unilateral flexion) Somatic dysfunction of L5 Lower cross Syndrome
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Treatment: Muscle Energy to Sacrum Muscle Energy to L5 Seated Muscle Energy to Cervical and
Thoracic Vertebra Muscle energy to Psoas Thoracic Diaphragm release
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Treatment
Home Exercise Prescriptions: Lower Crossed syndrome corrective exercises
Yoga poses Physical Therapy
We will talk more about this stuff later...
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Low Back Pain - for the physician, the pain is a little lower...
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From Greenman’s Principles of Manual Medicine: Disability from lower back pain continues to be a major societal problem. The cost of care to the patient with industrial back pain continues to escalate and frustrates the health care delivery system, the insurance industry, and employers.
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World Health Organization
States that LBP is responsible for an estimated 149 million work days lost in the United States every year. That works out to be approximately $100 to $200 billion a year.
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So how do WE help our patients?
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Differential Diagnosis Medical: Cauda Equina,Urolithiasis, Renal Colic, Ectopic Pregnancy, Renal Cyst -Bleeding, Aortic Aneurysm, Cholecystitis, Posterior Wall Renal Infarction, Pelvic thrombophlebitis, Renal Embolism, Addison's Disease, Female Urethral Syndrome, Pelvic Congestion syndrome, Hemolysis, Sickle Cell Crisis, Myoglobinemia, Hypervitaminosis A, Stress, Shingles, Psychiatric
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Differential Diagnosis Structural: Lumbar Herniated Disk syndrome, , Piriformis Muscle Entrapment Syndrome,Spinal Cord Compression, Slipped Capital epiphysis, Kyphoscoliosis, Leg Length Discrepancy, Lumbar Spinal Stenosis, Facet Syndrome, Lumbosacral Instability, Spondylosis, Compression Fracture, Sacroiliitis, Allen Masters Broad Ligament Syndrome
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And don’t forget!!!!!
SOMATIC DYSFUNCTION
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Greenman’s Dirty Half Dozen
183 pts (79 men and 104 women) with an average age of 40.8 years who were disabled for an average of 30.7 months
53% working less than halftime 42% were not working 5% totally disabled
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Greenman’s Dirty Half Dozen
84% found to have FRS or ERS in lumbar spine at L4-L5
75% had unleveling of the pubic symphysis 48.6% anterior nutation of the posterior sacral
base 60% of surgical had posterior sacral base
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Short - leg, Pelvic Tilt syndrome: 63% Only 2.7% of pts failed to demonstrate any of
the dirty half dozen Following Tx: 75% returned to full
employment Greenman Principles of Manual Medicine: p488
Greenman’s Dirty Half Dozen
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Greenman”s Dirty Half Dozen 1.Non Neutral Dysfunction within the lumbar
spine (FRS dysfunctions) in Lower Lumbar 2.Dysfunction at Symphysis Pubis 3.Restriction of anterior nutation movement
of the sacral base (Torsion or Extended Sacrum)
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Greenman’s Dirty Half Dozen
4. Innominate shear dysfunction 5. Short leg, Pelvic tilt syndrome 6. Muscle imbalance of the trunk
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So why is the CORE so
important?
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The Core as we define it
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http://shaungent.deviantart.com/art/Vitruvian-Man-Da-Vinci-Tribute-152194742
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http://abduzeedo.com/da-vincis-vitruvian-man- Storm Trooper - Dacinci
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The Core
For us, this includes the skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements from approximately the thoracic diaphragm to the mid thigh
This, however, does not exclude structures that originate or insert elsewhere
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Major Players
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Thoracic Diaphragm
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Thoracic Diaphragm
Primary muscle of respiration Aids in the pumping of lymph and blood
throughout the body Origin: Xiphoid process, inner surface of the
7th-12th ribs; anterior surfaces of the L1-3 vertebrae; fascia over quadratus lumborum; psoas major muscles via the medial and lateral arcuate ligaments
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Thoracic Diaphragm
Insertion: Central tendon of the diaphragm Inferior vena cava, Abdominal Aorta,
Esophagus, Azygos Vein, Thoracic Duct, Sympathetic trunk all pass through the diaphragm
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Arrangement of abdominal wall muscles and rectus sheath
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Pelvic Diaphragm
Very important - especially in women There is a lot of trauma that can occur to this
area Function plays an essential role in abdominal
muscle strength and stability of the lumbar spine
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Frequently there is reduction in available active motion due primarily to myofascial shortening.
From Greenman’s Principles of Manual Medicine:
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Linea Alba
Flat band of connective tissue where rectus abdominus, the internal and external oblique, and transverse abdominis join into a single tendinous band
Attaches superiorly from the xiphoid process, inferiorly to symphysis pubis
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Inner abdomen
Where many major organs reside The organs have movement, too! Peritoneum allows sliding of the organs along
the inner surface of the abdominal wall
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The SI joint
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So how do we prevent low back pain?
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“Stressed myofascial structures undergo sustained changes
in length.… New collagen forms with a half life of 10-12
months, realigns the connective tissue in response to
vectors of stress and perpetuates postural problems.”
Foundations of Osteopathic Medicine
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“When stressed some muscles become tight and facilitated
and others become weak and inhibited.”
Vladimir Janda (1928- 2002)
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Muscle Imbalances
Upper cross syndrome Lower cross syndrome Middle cross syndrome Layered Syndrome
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Normal Active
Posture
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Active Rigid Posture
Passive Slumped Posture
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Lower Crossed Syndrome
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Anterior Pelvic Tilt
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Lower Crossed Syndrome Postural Changes:
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Lower Crossed Syndrome
Common Dysfunction: L4-L5 L5-S1 SI joint Hip Joint
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So how do we diagnose Lower Crossed Syndrome ?
Hip Extension movement pattern test
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Hip Abduction Test
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Trunk Curl Up Test
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Upper Crossed Syndrome
Tight: Upper Trapezius/Levator Scapulae and Suboccipitalis Weak: Cervical Flexors, Rhomboids, and Lower Trapezius
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Upper Crossed Syndrome Posture: Forward Head Posture Increased Cervical lordosis Thoracic kyphosis Elevated and Protracted shoulder Abduction/Winging of the Scapula
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Upper Crossed Syndrome
Dysfunction: OA C4-C5 Cervicothoracic junction T4-T5
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Upper Cross Syndrome Cervical Flexion Movement Test
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Push up Movement Test
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Push Up movement Test
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Shoulder Abduction Test
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Layered Syndrome
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Middle Crossed Syndrome Dysfunction of the Anterior and Posterior Oblique Slings which lead to imbalance of the system.
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So what are these Slings?
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Middle Crossed Syndrome
Anterior Oblique Sling:
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Thoracolumbar Fascia
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Middle Cross Syndrome
Assessment: Gait Analysis: Weak anterior oblique sling will result in deviation of the umbilicus towards the weak shoulder
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Middle Cross Syndrome and implications for mechanics
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Middle Cross Syndrome
Active Straight Leg Raise:
http://www.coachkaehler.com/new/2009/01/20/hamstring-stretching-flexibility-and-strength/
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Middle Cross Syndrome
Treatment: Anterior Sling ASLR in 2 to 1 ratio Posterior Oblique Sling: Bird Dogs
It's Easy!
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OMT treatment plan
Important to both relax the tight muscles as well as strengthen the weak ones
Can use muscle energy to Isometrically engage weak muscles
Also pay attention to myofascial aspects of the core
Thoracic and pelvic diaphragms
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5 minute treatment plan
Thoracic diaphragm release Pelvic diaphragm release Muscle Energy for the Sacrum Muscle Energy for L5
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So we treat them, now what do we give our patients?
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Exercises!
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Yoga - my personal favorite Quickly becoming
popular Beneficial for patients
and providers if done correctly
Corrects some of this core imbalance we have been talking about
Quick shoutout to Ray Long, MD, Orthopedic Surgeon who has contributed greatly to my yoga anatomy knowledge and is responsible for this neat image:
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Studies about yoga and low back pain
Study published in the Journal of Back Musculoskeletal Rehabilitation in 2015 shows that yoga is safe and effective for those with pain from bulging discs and/or sciatic pain
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Yogis think that
Light contraction of the abdominal wall muscles at the same time as pelvic floor contraction = the “Airbag Effect”
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The “Airbag” Effect
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Airbag, Abdominal Press, Same thing...
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Abdominal Press
Simultaneous contraction of thoracic diaphragm, abdominal muscles, and pelvic floor muscles
Important for raising intra-abdominal pressure in order to expel things
Also important in order to stabilize the spine - reduces pressure on the spine (especially the lumbar spine)
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Bandhas
Bandhas are considered to be an energetic lock in yoga
Mula Bandha corresponds to contraction of the pelvic floor
This action helps support the inner organs as well as the spine
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4 poses to fix Upper Crossed Syndrome
Bolster supported corpse pose Upward facing plank Cow-faced pose Warrior 2
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4 poses to fix Lower Crossed Syndrome
Triangle pose Downward-facing dog Bridge pose presses Plank pose on forearms
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And if all else fails...
Have the patient do Kegels and BREATHE
deeply
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To revisit our patient...
Pt was seen for follow up 2 weeks later He reported decrease pain in his low back and
cited feeling stronger from doing his prescribed exercises as well as Physical Therapy
Re-examination revealed resolution of Somatic Dysfunction at Lumbo-Sacral Junction
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Broad, William. “The Healing Power of Yoga Controversy.” 6thfloor.blogs.nytimes.com. Accessed August 29, 2015. Destefano, Lisa. “Greenman’s Principles of Manual Medicine.” 4th ed. Baltimore, MD 2011. p488, Advancedballstriking.com Essential Anatomy 5 iPad application Lasater, Judith Hanson. “Yogabody: Anatomy, Kinesiology, and Asana.” Berkeley, California: Rodmell Press; 2009. Lee, Diane. “The Pelvic Girdle.” 3rd Edition. Churchill Livingstone, 2004. P 52. Long, Ray. “Fix the slouch: 4 poses for upper crossed syndrome.” YogaJournal.com. Feb. 6, 2015. Accessed August 30, 2015. Long, Ray. “Fix the slump: 4 poses for lower crossed syndrome.” YogaJournal.com. Feb. 6, 2015. Accessed August 30, 2015. Long, Ray. “The Key Muscles of Yoga: Scientific Keys Volume 1.” Bandha Yoga Publications, LLC. 2006. Monro, L et al. “Disc extrusions and bulges in nonspecific low back pain and sciatica: Exploratory randomised controlled trial comparing yoga therapy and normal medical treatment.” J Back Musculoskelet Rehabil. 2015;28(2):383-92. PubMed ID: 25271201
Page, Phillip. “The Janda Approach- Assessment and treatment of muscle imbalance. Chicago, IL 2010 Schuenke, Michael, et al. “Thieme Atlas of Anatomy: General Anatomy and Musculoskeletal System.” New York, NY: Thieme New York; 2010. Speece and Crow. “Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body.” Eastland Press, Inc. Seattle, WA. 2001.
Resources
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OMT LAB
First we will do some Upper, Lower, and Middle Crossed Syndrome testing
Then we will learn some quick office treatment techniques
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5 minute treatment plan
Thoracic diaphragm release Pelvic diaphragm release Muscle Energy for the Sacrum Muscle Energy for L5
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Thoracic Diaphragm release
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Pelvic Diaphragm release
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Muscle Energy for the Sacrum
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Muscle Energy for L5