Low Back Pain

By Kyle Schultz & Sarah Hoover

Patient Case

42 y.o. male construction worker who

sustained a low back sprain/strain

injury on the job while lifting and

twisting a 60 lb load.

(the 3rd injury to his back)

His medical history is NEGATIVE for

any contributing factors including the

absence of any known spinal disease.

Patient Case (cont’d)

SUBJECTIVE 10/10 back pain initially, reduced

to 6/10 (max) – 2/10 (best)

Avg. pain (w/ pain meds): 3-4/10

Pt. reports occasional pain shooting down his R leg to his toes, but no loss of sensation

Pt. reports that he does not do any regular exercise

Pt. stated he did not receive lifting training (except 5 minute verbal instruction “years ago”)

OBJECTIVE Pt. is slightly overweight and

presents with a slightly foreword flexed posture

Lumbar spine shifted to the left

Significant tenderness and edema in bilateral lumbar paraspinals (right > left), and R gluts

Multiple trigger points in R gluts Palpation of trigger points reproduces

radiating pain down R posterior leg

Unable to test core muscles due to pain Pt. only able to isometrically contract

rectus abdominus

Patient Case (cont’d)

OBJECTIVE (CONT’D)

Myotomal and neuro screens of LE are negative

Slump and SLR tests are positive for reproducing pain

Tight hamstrings noted during SLR test: L LE: 0 – 40 degrees of hip

flexion R LE: 0 – 50 degrees of hip

flexion

Lumbar AROM:

FF: -7 17 degrees Limited by pain and

deviates to the L

Ext: +7 0 degrees (neutral) Limited by pain

SB L: 15 degrees

SB R: 5 degrees (pain)

RR: 15 degrees

RL: 5 degrees (pain)

Question #1:

Paraspinal muscular hypertrophy & acute inflammation (poor lifting technique + lack of abdominal bracing) Poor lifting technique, exponentially

increases the force exerted on the spine Rotation of the spine under this force

caused a lumbar strain/sprain Inflammation radiating pain down sciatic

nerve root

Left AIC Pattern

Shelly

Alex

What do you think are the most likely anatomical causes of his back and RLE pain based on his clinical exam? Why?

Question #2:

E-Stim

Thermotherapy

Traction

Myofascial Release

Trigger Point Dry Needling

Active Release Techniques

Shelly

Alex

What modalities would you choose and what settings/parameters to reduce edema, pain, or both?

E-Stim/Thermotherapy

IFC Pain Edema

Heat Pain Relaxing muscles and

supportive structures

Traction

Form of decompression therapy that relieves pressure on the spine

Can be done manually or mechanically

Myofascial Release (MFR)

MFR Highly specialized stretching technique used for a

variety of soft tissue problems

Trigger Point Dry Needling (TDN)

What is dry needling?

What is a Trigger Point?

Active Release Techniques (ART)

ART

Similar to deep tissue massage but uses the patient’s natural body mechanics to break up adhesions and to stretch tissue

Question #3:

Contraindication: Acute Inflammatory Phase Redness, edema, warmth of skin Wait at least 72 hours post-injury

Traction could be beneficial for this patient and reduce his pain by: Soft Tissue Stretching Muscle Relaxation

Ryan

Jesse

What traction setting would you use and why? If you decide not to use traction, then why would you not use it?

Traction (Tx)

Settings: Static traction (inflammation) Supine w/ hip flexion 25% pts body weight (initially)

Increased distance between vertebral bodies/facet joints Increases length of soft tissues

in the area Increases spinal ROM

Relaxation of the paraspinal muscles Decreases pain

Comparison of Two Methods for Interpreting Lifting Performance

P: 130 people (20-60 years of age) with chronic nonspecific LBP that were referred for fitness-for-work evaluation to measure their physical ability to safely engage in work-related activities

I : Waddle signs (Questionnaire) 8 physical signs to assess psychological factors that could negatively affect

performance of lifting activities C: Functional Capacity Evaluation (FCE)

Determined the level of effort utilizing predetermined observational criteria 3 FCE lifting tests (floor to waist, waist to shoulder, horizontal lifting)

O: 53%-63% of participants who exhibited submaximal effort during FCE tests also presented with Waddell signs. The contribution of submaximal effort to an unsafe performance was greater than that of Waddell signs, with a 20%-29% higher explained variance. Therefore, Waddell signs should not be used independently to analyze an individuals ability to safely engage in work-related activities.

Question #4:

Poor Lifting = Low Back Pain

Types and Causes

How to avoid these injuries

Proper lifting techniques and proper body mechanics

Compressive forces on the disc

Ryan

Jesse

What would you teach him initially about lifting and body mechanics? Write out a brief script.

Types & Causes

Types Muscle Strains Ligament Sprains Radiculopathy Disc Pathologies

Causes Poor Physical Condition Poor Posture Extra Weight Stress Over working

(“pushing it”) Poor body mechanics

How to avoid these injuries

Place objects higher

Raise/lower shelves

Body management/conditioning

Reduce weight

Use straps

GET HELP!!

Proper lifting mechanics!

Mechanics of Lifting

Load

Lever

Lordosis

Legs

Lungs

Compressive Forces

Standing: 100% of BW

Supine: < 25%

Side-lying: < 75%

Standing and bending forward: ~ 150%

Supine with both knees flexed: < 35%

Seated in a flexed position: ~ 85%

Bending forward in a flexed posture and lifting: ~ 275%

Question #5:

Myofascial Release

Active Release Technique

Dry Needling for trigger point release

Ice cup massage to paraspinals Good for small area Decrease Pain and edema

SLR with distraction Stretch soft tissues of the acetabulo-femoral

joint, as well as the hip extensors

Josh C

Rene

What manual therapy techniques could or would you use to address the pain, edema and trigger points? Why did you choose these techniques?

SLR with Distraction

Patient Position: supine, close to edge of table. Hip is flexed to loose-packed position, keeping knee extended (decrease hip flexion if symptoms reproduced)

Therapist Position: staggered stance, applying force to increase dorsiflexion and to maintain knee extension

Mobilization: therapist applies a force away from the patient’s hip for traction/distraction (Grade III)

(Hensley, C.P. & Courtney, C.A, 2014)

Question #6:

SF-36 / SF-12

Roland-Morris Questionnaire (RMQ)

Oswestry Low Back Paid Disability Questionnaire

Patient-Specific Measures

Functional Capacity Evaluations (FCEs)

ROM

Manual Muscle Testing (MMT) scores

Josh C

Rene

What outcome measures/tools could you use to follow his care and why could you use them?

SF-36 / SF-12

Subdivided into 2 separate health constructs

Measures 8 different health concepts

Self-administered

SF-12 is an abbreviated version

Roland-Morris Questionnaire (RMQ)

Most widely tested of all disease-specific measures

Consists of 24 questions

Scored on a scale of 0-24

Oswestry Low Back Pain Disability Questionnaire

Self-administered

Takes 5 mins to complete

Includes 10 sections

Sections scored from 0-5

First developed in 1980

Patient-Specific Measures

Patient selects up to 5 main activities which they find difficult

Asked to rate ability to complete the activity on an 11 point scale

Takes about 15 mins

Functional Capacity Evaluations (FCEs)

Highly specific to individual’s job tasks

To identify risk factors associated with a particular job or activity

Administered to a patient recovering from injury before returning to work

Range of Motion (ROM)

To identify and set goals based on measurements

Identify where limitations are

Puts a reproducible number that can be used to evaluate progress

Manual Muscle Testing (MMT)

Identifies which muscles are weak

Identifies compensatory patterns

Sets up interventions for muscles with limitations

Reproducible evaluation to track progress

Question #7:

SLR stretch Nerve glides Stretch HS

Balance exercises To increase abdominal

strength and control Tandem & single leg

stance (advanced with airex)

Stretching on Foam Roll Decrease kyphosis of

thoracic spine, retract shoulder girdles, PPT

Add marching = balance exercise

Erica

Monique

Describe at least three exercises in detail that you would teach him early on in his therapy. Why did you choose these three exercises?

Patient Progression …

He is cleared for full duty but you sense he is

not ready and have the supervising PT do a

reevaluation which shows continued core

weakness, that the patient still does NOT know

his lifting techniques without prompting, and he

still needs reminders about what exercises to

do. The PT gets the doctor to order a few more

sessions.

Question #8:

Advanced Exercises “Proximal Stability for Distal Mobility”

Stabilization Training

Flexibility

Cardiovascular conditioning

Postural Restoration Institute (PRI) exercises

Erica

Monique

What advanced exercises would you choose at this point? Describe them and the rationale for using them.

Stabilization Training

Hamstring Stretch

Pelvic tilt

Arm/leg raises

Exercise ball bridges

TA activation / exercises

Flexibility

Neck and shoulder stretches

Back exercise stretches

Hip and Gluteus stretches

Cardiovascular Conditioning

Low-impact aerobic exercises

Benefits of aerobic exercise for back pain

To PRI or Not to PRI

P: 42 y.o. male with low back sprain/strain and history of mild back pain

I: Standard physical therapy integrated with PRI exercises

C: Standard physical therapy with IFC, Aquatic Therapy

O: Using the Oswestry Disability Index for comparison: IFC = 2.5% improvement, Aquatic = 11% improvement, Standard with PRI = 40% improvement

PRI

90/90 Hip Lift With hip shift

Right side lying left adductor pull-back

Left side lying knee-toward-knee

Postural Restoration Institute (PRI)

Factors Associated with Paraspinal Muscle Asymmetry P: 101 sets of monzygotic (identical) twins (202 men, avg. age = 49.35)

with a history of LBP

I : Behavioral, environmental, and constitutional factors leading to paraspinal asymmetry

C: Genetic Link of paraspinal asymmetry

O: 57.92% of participants had erector spinae muscle asymmetry. This asymmetry was found to be associated with handedness and the greater CSA was found on the dominant side (usually the right). Greater asymmetry was not always associated with greater LBP and there was a lack of statistically significant data linking asymmetry and/or LBP with specific factors that were investigated. The results did suggest that greater exercise and sports participation may decrease the likelihood of paraspinal asymmetry. It is unclear what accounted for the large portion of unexplained variance in muscle asymmetry, but some degree of asymmetry may be a naturally occurring phenomenon in human anatomy

Basic Concepts

The human body is not symmetrical Ex: Asymmetry of the diaphragm

PRI recognizes anatomical imbalances and typical patterns associated with system disuse, or weakness that develops because of dominant side overuse (usually Right)

When these imbalances are not regulated, a strongly favored pattern emerges (Left AIC = most common) Structural weaknesses Instabilities Musculo-skeletal pain syndromes Gait/Postural Deviations

Left Anterior Inferior Chain (AIC) Pattern

Difficulty rotating to one or both sides

Elevated anterior ribs on the LEFT Influencing breathing patterns

Lowered, depressed shoulder and chest on the RIGHT

LEFT pelvic is anteriorly tipped and forwardly rotated

Excessive hypertrophy of right lower back muscle

References

White, J.D., Norkin, C.C. (2009). Measurement of Joint Motion: A Guide to Goniometry (4th Ed.). Philadelphia, PA: F.A. Davis

Hilsop, H.J., Avers, A., Brown, M. (2014). Daniels and Worthingham’s Muscle Testing: Techniques of Manual Examination and Performance Testing (9th Ed.). St. Louis, MO: Elsevier Saunders.

Shankman, G.A., Manske, R.C. (2011). Fundamental Orthopedic Management for the Physical Therapist Assistant (3rd Ed.). St. Louis, MO: Elsevier Mosby.

Kisner, C., Colby, L. A., (2012) Therapeutic Exercise (6th Ed.) foundations and Techniques. Philadelphia, PA: F. A. Davis

Cameron, M. H. (2013). Physical Agents (4th Ed.) In Rehabilitation. St. Louis, MO: Elsevier Sanders

Pedro, A.B., Artero, E.G., Arroyo-Morales, M. (2014). Aquatic Therapy Pain, Disability, Quality of Life, Body Composition and Fitness in Sedentary Adults with Chronic Low Back Pain. A Controlled Clinical Trial. Clinical Rehabilitation. Vol. 28(4), 350-360. http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=b6665e00-0105-4a19-bb1c-071c7d2d60d5%40sessionmgr113&vid=5&hid=118

References (cont’d)

Miller, L. (2013) Back Safety. Retrieved from http://ehs.okstate.edu/modules3/back/index.htm

Cole, A. J. (2001) Lumbar Spine Stabilization Exercises. Retrieved from http://www.spine-health.com/wellness/exercise/lumbar-spine-stabilization-exercises

Watson, T. (2014) Interferential Therapy. Retrieved from http://www.electrotherapy.org/modality/interferential-therapy

Manheim, C. J. (2003) Myofascial Release. Retrieved from http://www.myofascial-release.com/

Neurosport Physical Therapy. (2013) Dry Needling: Trigger Point Release. Retrieved from http://www.neurosportphysicaltherapy.com/services/dry-needling

Kranzler, M. (2008) Active Release Techniques as an Alternative for Soft-Tissue Injuries and Ailments. Retrieved from http://healthpsych.psy.vanderbilt.edu/2008/ART.htm

Stubblefeild, H. (2014) Spinal Traction. Retrieved from http://www.healthline.com/health/spinal-traction#Overview1

Lara-Palome, I. C., Encarnacion, M. A., Mataran-Penarrocha, G. A. (2012) Short-term Effects of Interferential Current Electro-massage in Adults with Chronic Non-specific Low Back Pain: A Randomized Controlled Trial. Clinical Rehabilitation. Vol. 27(5), 439-449. http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=c18fca3c-9d95-4240-86d5-68c05c476551%40sessionmgr115&vid=8&hid=118

References (cont’d) Coenen, P., Kingma, I., Boot, C. R., (2012) Cumulative Low Back Load at Work as a Risk

Factor of Low Back Pain: A Prospective Cohort Study. Journal of Occupational Rehabilitation. Vol 23, 11-18. http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=53d2daf5-03b8-4236-bc0e-ecb0d0c6371d%40sessionmgr110&vid=5&hid=110

Boyle, K. L. (2011) Managing a Female Patient with Left Low Back Pain and Sacroiliac Joint Pain with Therapeutic exercise: A Case Report. Physiotherapy Canada. Vol. 63(2). 154-163. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076916/

Resnik, L., Dobrzykowski, E. (2014) Guide to Outcomes Measurement for Patients with Low Back Pain Syndromes. Journal of orthopedic and Sports Physical Therapy, Vol. 33(6), 307-318. http://www.jospt.org/doi/pdf/10.2519/jospt.2003.33.6.307

Hensley, C.P., & Courtney, C.A. (2014). Management of a Patient With Chronic Low Back Pain and Multiple Health Conditions Using a Pain Mechanisms-Based Classification Approach. Journal of Orthopedic & Sports Physical Therapy. 44(6), 403-414.

Oesch,P., Meyer, K., Bachmann, S., Hagan, K.B., & Vollestad, N.K. (2012). Comparison of Two Methods for Interpreting Lifting Performance During Functional Capacity. Physical Therapy Journal of the American Physical Therapy Association, 92(9), 1130-1140

Fortin, M., Yuan, Y., & Battie, M.C. (2013). Factors Associated With Paraspinal Muscle Asymmetry in Size and Composition in a General Population Sample of Men. Physical Therapy Journal of the American Physical Therapy Association, 93(11), 1540-1550.

Rundell, S.D., Davenport, T.E. & Wagner, T. (2009). Physical Therapist Management of Acute and Chronic Low Back Pain Using the World Health Organization’s International Classification of Functioning, Disability and Health. Physical Therapy Journal of the American Physical Therapy Association, 89(1), 82-90.