Mechanical Low Back Injuries[1]

8/4/2019 Mechanical Low Back Injuries[1]

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Mechanical Low Back

Injuries

An Integrated Approach ofFunctional Movement


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Objectives

To identify the underlying causes andmechanisms of mechanical low back pain

To understand some of the physical,biomechanical and psychosocial impairments

/ approaches associated with mechanical lowback pain

To integrate the approaches into a clinicalmodel and incorporate treatment strategiesinto the approach


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Epidemiology

Leading cause ofdisability in those underthe age of 45

3rd major cause ofdisability in generalfollowing heart diseaseand arthritis

About 70% of all adultshave low back pain(LBP) at some time intheir life

Most episodes of LBPresolve in 2-3 months(80-90%)

Recurrence rates areabout 50% in thefollowing 12 months

5-10% of people with

LBP develop chronicLBP (>3 months)

(Mannon et al, 2002; OSullivan, 2000)


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Epidemiology (contd)

Upto 85% of low back clients cannot begiven a definitive diagnosis

It is assumed that these injuries are dueto (1) musculoligamentous injuries or (2)degenerative changes

(Mannon et al, 2001)


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Causes of Low Back

PainRheumatologic

Endocrine /

MetabolicNeoplastic Disease

Vascular /

Hematologic

Infections

Referred Pain

PsychologicalMechanical

(Swenson et al, 1998)


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Mechanical Low Back

PainMechanical Low Back Paincan bedefined as pain that appears to have

been caused by a mechanical event(eg. Lifting, twisting, etc), and isaggravated by movement

(Gallagher, 2002)


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Mechanical Causes of

LBPFacet

Disc

Paraspinal MusclesInstability

Ligaments

Sacroiliac JointSpondylolysis / spondylolisthesis

Spinal stenosis


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Facet Joints

Degeneration of facet joints as a cause of lowback pain was first postulated in 1933

Theory continues to be controversialSuggested that accounts for upto 15-20% ofclients with low back pain

Nocioceptive nerve fibres have beenidentified in facet-joint capsules and insynovial and pericapsular tissue

(Hanley et al, 1999;Swenson,1998)


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Intervertebral Disc

Easily imaged on MRI; however degeneration andprotrusion may be seen in upto 64% of asymptomaticadults

Innervation of the disc has been well characterized

The meningeal nerve branches supply the PLL &outer layers of the annulus fibrosus (AF)

The outer 1/3 of the AF is innervated with paintransmitting free nerve endings

Evidence suggests that severely degenerated discshave more extensive innervation than normal discs

(Hanley et al,1999)


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Disc (contd)

Two most common causes of disc pain

are annulus fibrosus tearsand disc

herniationHerniated discs cause compression onpain sensitive structures such as the

outer 1/3 of the annulus, PLL, anteriordura, nerve root & sinuvertebral nerve

(Hanley et al, 1999)


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Ligaments

6 main ligaments Anterior longitudinal ligament (ALL),Posterior longitudinal ligament (PLL), Interspinous,Supraspinous, Ligamentum flavum & Intertransverse

Ligamentumflavumnot sensitive to mechanicalstimulation

PLLsensitive to stimulation similar to that of theannulus fibrosus

? Injury to other ligaments cause pain due to stresson other pain sensitive structures that arises fromligament laxity

(Hanley et al, 1999;)


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Lumbar Spine Muscles

Trunk muscles have been categorizedinto localand globalmuscle systems

Localrefers to deep muscles of thetrunk (eg. Multifidus, QL, transversusabdominis, interspinales)

Global refers to larger, more superficialmuscles (eg. Other abdominal muscles,longissimus)

(Bergmark, 1989)


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Muscles (contd)

Muscles can be acutely injured or bedue to overuse injuries

A typical inflammatory response takesplace when a muscle is injured


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Instability

Defined as an abnormal response to applied loads,

characterized by motion in the motor segmentbeyond normal constraints or motion quality

abnormalities

Basic concept is that abnormally large intervertebralmotions cause either compression and/or stretchingof the neural elements or abnormal deformations of

ligaments, joint capsules, annular fibres and end-plates, which all have a significant density ofnocioceptors

(Panjabi,1992)


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Sacroiliac Joint

Controversial source of low back pain

Constant debate regarding the amount

of movement, the location of the axesand the vulnerability of the joint todysfunction

Certain authors believe that instability ofthe pelvic girdle can lead to low backpain


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Sacroiliac Joint (contd)

Instability again refers to a loss of thefunctional integrity of a system that providesstability

In pelvic girdle, 2 systems that contribute tostability, the osteoarticularligamentousandmyofascial

These 2 systems have been referred to asform closure and force closure

Together they provide a self lockingmechanism

(Vleeming, 1990;1995)


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Spondylolysis /

SpondylolisthesisSpondylolysisrefers to a defect / fracture inthe pars interarticularis of arch

Spondylolisthesisrefers to a forwarddisplacement of one vertebrae over another(with or without a fracture)

Tissue of origin of pain is unknown

Places many back tissues under stressincluding discs, facets, ligaments

Fracture / defect itself could be source of pain(Swenson, 1998)


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Classification of LBP

Many authors have attempted toclassify LBP into categories to aid in

treatment and clinical decision making

4 classifications appear in the literature

that are widely used and thoroughlydescribed


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A Review of the Literature

of Classification Systems(Riddle, 1998) reviewed classification systemsdesigned for the majority of patients with low backpain

MEDLINE searchSystems reviewed were those most relevant tophysiotherapists

4 (of 11 found) were found to be most relevant and

reviewed criticallyMost appropriate because most thoroughlydescribed; used in continuing education courses andpractice;use diagnostic terms familiar to physios


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4 Approaches

1 developed by an orthopaedic surgeon

2 by physiotherapists

1 (Quebec Task Force Classification) bymany medical and non-medicaldisciplines


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Classification System of

Bernard & Kirkaldy-

Willis (1987)Developed by an orthopedic surgeon

Pathology based system

Purpose is to determine the pathologycausing the problem

23 categories in 3 groupsStrongly based on radiologic findings


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CategoriesGroup A

Herniated disc

Central Stenosis

Lateral StenosisSpondylolist-hesis

Segmental Instability

Group B

SI Joint Syndrome

Muscle Syndromes

Posterior JointSyndrome

Maigne Syndrome

Group C

Chronic Pain

Pseudo-arthrosis

Anky SponInfection

Tumour

Post fusion stenosis

ArachnoiditisFemoral nerveentrapment


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Classification System by

Delitto et al. (1995;1997)Developed by a physiotherapist

Clinical guideline index

Purpose is to guide treatment

Has 3 levels involving different types ofclinical decisions


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Classification Scheme

Physio ReferralConsultation

Stage II Stage IIIStage I

Extension

FlexionLateral Shift

Immobilization

Traction

Mobilization

Flexibilty

Deficit

StrengthDeficit

Cardio Deficit

Coord. Deficit

Body Mech.

Deficit

Activity

Intolerance

Work

Intolerance


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McKenzie Classification

Developed by a physiotherapist

Clinical guideline index

Purpose is to guide treatment

Has 13 categories


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Patients with low back pain who do not haveserious pathology, severe sciatica or

neurological deficits

PosturalSyndrome

4DysfunctionSyndromes

7DerangementSyndromes

Hip JointOr

SI JointProblem


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Quebec Task Force

Developed by experts in many fields

Judgement Approach

Purpose is to guide clinical decisionmaking, establish prognosis, for qualitycontrol and research

Designed for patients with low back painrelated to work injuries

1LBP without radiation of pain below gluteal folds,


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Work RelatedDisordersOf theSpine

1

2

34

5

6

7

8

9

10

11

LBP without radiation of pain below gluteal folds,No neurological signs

LBP with radiation not beyond the knee,No neurological signs

LBP with radiation below the knee,

No neurological signs

LBP with lower extremity radiation andNeurological signs

Presumptive compression of nerve roott based onRadiographic tests (eg.instability, fracture)

Compression of nerve root confirmed by imagingTests (eg. CT scan, MRI)

Spinal stenosis confirmed with radiologic tests

Post surgical status, 6 mos following surgery

Chronic pain syndrome, treatable active disease hasBeen ruled out

Other diagnoses (eg. Metateses, visceral disease)

A - < 7 daysB 7 days-7WeeksC - > 7 weeks

SymptomDuration

W WorkingI - Idle

WorkStatus

For Categories 1-4

For categories 1-4, 10, 11


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What System is Being

Used?No studies availablethat indicate clinicaluse / preference

2001 study didexaminephysiotherapistsreportedmanagement ofacute and subacuteLBP in Ontario

274 Ontario PTssurveyed whose weeklyworkload included more

than 10% of people withLBP

3 areasassessment,treatment, beliefsregarding treatment

3 scenarios andquestions related toassessment andtreatment

(Li & Bombardier, 2001)


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Results

Most respondentsassessed to rule outred flags

Assesment includedobservation,palpation, ROM,SLR, LE strength,reflexes, abdominalstrength, extensorstrength

>50% of the PTsreported would useother assessment

techniques such asMcKenzie, lumbar scan,SI testing, LE scan

No mention ofclassifying based on a

system (other thanMcKenzie)

Treatment was also notbased on a system

(LI & Bombardier, 2001)


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Risk Factors for Onset

of LBPAge 25-45

Male Sex

Physical Work Factors such as heavyphysical work (esp. lifting)

Psychosocial Work Factors such as lowworkplace social support and low job

satisfactionPrevious back pain

Low fitness level, obesity

Smoking(Hoogendoorn et al,2000;Bombardier et al,1994)


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Developmental


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Age Related Changes

As individuals age, their lumbar spinesundergo changes that are fairly uniformly

reflected by the populationThere is a natural biological process of agingin the lumbar spine

A natural process occurs but things we do

over the course of our lives can affect theprocess (eg. Exercise and osteoporosis)


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Discs

Becomes more fibrous,nucleus pulposusbecomes drier /

granularTherefore, less able toexert fluid pressure andtransmit weight directly

A greater share of thevertical load is borne bythe anulus fibrosus andis subject to greaterstresses

Previously thought thatdiscs loose their heightas we age, now know

height increases(10%for females and2%for males)

Loss of trunk stature is

due to decreases invertebral body heights

(Twomey & Taylor,1985;Bogduk & Twomey,1991)


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Vertebral Body

An overall decrease inbone density and bonestrength in vertebral

bodiesRelated to changes intrabeculae

A loss of horizontaltrabeculae removes the

bracing effect of thevertical trabeculae andthe load bearingcapacity of the centralportion of the vertebralbody weakens

Vertebrae then have torely more on corticalbone which fails sooner

than trabeculae boneThis reliance on corticalbone puts the vertebralbody at greater risk for

deformation and injury

(Bogduk & Twomey,1991)


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Facet Joints

Cartilage exhibits cell hypertrophy

Osteophytes often form

(Bogduk & Twomey, 1991)


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Clinical Implications

The older spine is less flexible and compliantand reacts more slowly to conditions ofsustained loading

Extensive research exists pointing to effect ofexercise on bone, education is our key rolewith regards to this

Smoking affects the integrity of the disc asdiscussed earlier, again our role as educatorsis emphasized

Education with regards to posture and body

mechanics


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Biomechanics


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Biomechanical Function

of the Spinal SystemTo allow movements between bodyparts

To carry loadsTo protect the spinal cord and nerveroots

(Panjabi,1992)


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A Biomechanical Theory

Proposed by Panjabi in 1992

Based on in vitro experiments of the

spineAttempts to explain the mechanics ofspinal motion

(Panjabi, 1992)


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Neutral Position

Neutral Positionthe posture of thespine in which the overall internal

stresses in the spinal column and themuscular effort to hold the posture areminimal

(Panjabi,1992)


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Neutral Zone

Neutral Zone (NZ)that part of thephysiologic range of motion, measured

from the neutral position, within whicheach spinal motion meets with minimalinternal resistance

(Panjabi,1992)


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Elastic Zone

Elastic Zone (EZ)that part of thephysiologic range, measured from the

end of the neutral zone up to thephysiologic limit within the EZ, spinal

motion is produced against a significant

internal resistance

(Panjabi,1992)


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Important Points

When spinal movement begins from neutral,spinal motion occurs first in the NZ, where itmeets with minimal stiffness

Movement is then through the EZ whichdisplays an increasing amount of resistanceto motion; the ligaments develop the greatestamount of tension

At this point these definitions only apply to theosseoligamentous spine (no muscles)

Therefore stiffness only refers to ligamentstiffness

(Panjabi,1992)


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Importance of Neutral

ZonePanjabis experiments revealed that changes

in the size or amplitude of the neutral zone

were more dramatic than were changes inoverall ROM as progressively greater loadswere applied to the spine

He noted that changes in neutral zone

provided a more sensitive indication of theonset of spinal injury


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Panjabis Experiments

Documented the load at which the NZ andROM increased & how they correlated withinjury

At a load of 6.3 kg dropped from 1 metre andaligned to produce compression/flexion, theNZ increased markedly while no significantchanges was seen in overall ROM

Thus when ligaments begin to fail, the NZ isthe first parameter to increase instability isseen in the NZ, not in overall ROM


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Effect of NZ

CompromisePanjabi noted injuries at the onset of NZinstability / laxity

Included: ligament tears, disc injuries,ligament avulsion tears, compressionfractures, torn facet joint capsules

(Panjabi,1992)


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Types of NZ

NZ is described as being of 2 typesactiveandpassive

Passivecan only be observed in experiments where

muscles have been removedActiveis seen in living or in vivo spine

The size of the NZ is likely to be of smaller amplitudeas the spinal muscles provide greater stiffnessthrough this portion of the ROM

Thus depending on the extent to which a personsmusculature is working optimally, their spine mayexhibit more or less movement in the NZ

(Panjabi,1992)


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Neutral Zone Summary

Overall spinal ROM is composed of motionthrough the NZ and EZ

NZ is a region of low stiffness or laxity

EZ is a region of high stiffness, whichincreases in a non-lonear fashion

Increases in the amplitude or size of the NZ

correlate with the onset of osseoligamentousinjury in the in vitro spine

The in vivo spine displays greater controlover size of NZ through the stabilizing effect

of muscles


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Biomechanical Study

In vivo experiment by McGill (1998)

Trained powerlifters

Video fluoroscopy, EMG (surface &indwelling)

Recording muscle action while subjects

lifted heavy loads


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Stabilizing Systems of

the Spine

ControlSubsystem

Neural

PassiveSubsystem

SpinalColumn

Active

Subsystem

SpinalMuscles


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Passive System

Ligaments do not provide stability to the spine interms of motion within the NZ; in this range theyfunction as proprioceptors

Ligaments likely provide stability only as movementapproaches limit of the EZ

Dysfunction of the passive system which could affectbiomechanics include overstretching of the ligaments,annulus tears or fissures, endplate microfractures,

disc extrusion into vertebral bodiesAll these factors decrease the load bearing andstabilizing capacity of the passive system

(Panjabi,1992)


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Active System

Muscles and tendons serve 2 functionswithin this model:

To provide stiffness or control of spinalmotion through the NZ

Proprioceptive feedback via GTOs andmuscle spindles

(Panjabi,1992)


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Neural System

The CNS is provided with input from a variety ofproprioceptors (GTOs, muscle spindles, jointmechanoreceptors)

With this input the neural control subsytem

determines specific reqirements for spinal stability,and causes the active system to achieve the stabilitygoal

The neural system monitors ligament stretch andmuscle tension to assess the position and load ofindividual spinal motion segments and the column ingeneral; with this feedback, the control subsystemcan alter the muscle forces acting across a spinal

joint to affect an appropriate stability response(Panjabi,1992)


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Motor Control


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Motor Control Issues

Has been a growing amount of research inthis area in the last decade

Studies have identified a number of motorcontrol issues which affect the overall stabilityof the lumbar spine

Research is now starting to reveal how thecentral nervous system prepares andmodulates the muscle system to support thelumbar spine and its segments for functionalactivity and load


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Transversus Abdominis

The deepest of the abdominal muscles

A cylinder like muscle with attachments to the

lumbar vertebrae via the thoracolumbarfascia

When it contracts bilaterally it produces adrawing in of the abdominal wall, resulting in

an increased pressure within the abdominalcavity and an increase in tension in thethoracolumbar fascia (Richardson et al, 1999)


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Main Deficits

3 main motor control problems identified in theTransversus Abdominis

These muscles appear to lose their normal

anticipatory function in patents with low back pain,exhibiting delays in activation & thus a loss of normalpreprogrammed function for support

In contrast to patients without low back pain, themuscle appears to be unable to function

independently of the other abdominal muscles inpatients with low back pain

Demonstrates phasic activity rather than the tonicactivity required for its supporting role

A Motor Control


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A Motor Control

Evaluation of

Transversus AbdominisStudy

Hodges etal, 1996

Subjects

N = 30

15 patientswith LBP

15 controls

Protocol

Subjectsperformedrapidshouldermovementsin responseto visual

stimulusMuscleactivity wasmeasured

Measures

Surface andindwellingEMG

Outcome

Trunkmuscles incontrolscontractedbefore orshortly afterdeltoid

T.A.delayed inLBP with allmovements


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Multifidus

Most medial of the lumbar muscles

Unique arrangement of predominantly

vertebra-to-vertebra attachmentsPredominantly Type I fibres (tonic role)

Contributes to the support and control of

the orientation of the lumbar spine andthe support of the lumbar segments


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Main Deficits

Appears to react by inhibition at asegmental level in acute episodes of

low back painSlower activation/recruitment renderingthe muscles too slow to meet the

demands of joint protection

(Hodges,2000)


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Exercise

Physiology


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Inactivity Changes

Low back pain leads to a variety ofdegenerative changes associated withinactivity

This is further compounded if there is anextended time span between injury andadmittance to rehab programs

Changes can include muscular atrophy,decreased flexiblityandcardiovasculardeconditioning

(Robert et al,1995)


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Muscle AtrophyDysfunction of the lumbar muscles in LBP patientshas been demonstrated using imaging modalities thatallow assessment of muscle size or cross sectionalarea and muscle consistency

Atrophy in terms of decreased size of the paraspinalmuscles has been demonstrated using imagingtechniques

Decreased muscle density, which can be a sign ofmuscle atrophy, is caused by fatty infiltration or actual

fatty replacement of fibresFatty degeneration of the multifidus and erectorspinae has been found in chronic LBP patients andpost operative patients

(Alaranta et al,1993;Richardson et al,1999)


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In addition changes in the internal structure ofthe type I fibres of the multifidus have beendemonstrated in LBP patients

The fibres have been described as moth

eaten in appearance

Changes in the internal structure of type Ifibres occur quickly (in biopsy specimens of

subjects with a symptom duration of only 3weeks)

(Richardson et al,1999)

Effects of Exercise on CSA


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of Multifidus in LBP

PatientsStudyHides et al,1996

Subjects

41 patientswith acuteLBP (< 3

weeks)

1st episodeof LBP

Protocol

2 groups

10 weeks ofRx

1.MedicalRx

2.MedicalRx + Ex

Measures

VAS, RMQ,US,Habitual

activity levelquestionnairre

Reax

weekly x 4wks + @ 10weeks

Outcome

Multifidusrecoverynot

spontaneous onremission ofsymptomsin group 1

Mmrecoveryrapid &morecomplete in

group 2

Effects of Work Hardening on


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g

Cardio Fitness & Muscle

StrengthStudy

Robert etal,1995

Subjects

31 LBPpatients

Acute &chronic

Protocol

Singlegroup

6 weeks of

cardio,wt.training,

Stretching& work sims

Measures

Sub maxcycleerg,Arcon

staticstrengthtestingdevice

Pre test and

post test

Outcomes

Markedimprovement in cardio

& muscularfitness

Nodifference

bt fitnesslevels forthose whoreturned towork & whodidnt


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Motor Learning


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Motor Learning

A set of internal processes associatedwith practice or experience leading to a

relatively permanent change in motorskill

(Schmidt & Lee,1999)


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Motor Learning & LBP

Very few, if any studies that look directly atmotor learning principles

Are studies that investigate body mechanicstraining and performance as well as studiesthat look at practice and ability to performcertain exercises

In addition there are studies that investigatefunctional training vs. non functional physioand how this affects RTW and functionalrestoration


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Motor Learning &

StabilityStage 1 The Cognitive Stage

Stage 2 The Associative Stage

Stage 3 The Autonomous Stage


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Stage 1- Cognitive Stage

A high level of awareness is demanded of subjects inorder to isolate the co-contraction of specific muscles

Aim of first stage is to train the specific isometric co-

contraction of transversus abdominis and multifidusat low levels of maximal voluntary co-contraction

Also to cease contraction of other muscle subsitution

Training is suggested 1x/day(10-15 mins)

Incorporate into functional tasks once achieved

At this stage a degree of pain control is expected withpostures = a biofeedback for client

(OSullivan,2000)


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Stage 2Associative Stage

Focus is on refining a particular movementpattern

Aim is to identify 2 or 3 faulty or painprovocative movement patterns and break

them down into component movements withhigh reps

Patient does this while maintaning co-contraction of local muscles

Can be performed for sit to stand, lifting, etcPatients do on a daily basis and increasespeed and complexity

(OSullivan,2000)


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Stage 3-Autonomous Stage

A low degree of attention is required for thecorrect performance of the motor task

The third stage is the aim of the exerciseintervention, whereby patients candynamically stabilize their spinesappropriately in an automatic manner during

the functional demands of daily living

(OSullivan,2000)


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Effects of Practice on

Stabilization ExsStudy

Hagins etal, 1999

Subjects

44asymptomaticvolunteers

(No LBPwithin 3mos ofstudy)

Protocol

2 groups

1.Ex

2.No Ex

Pretest of 7exercisesfor muscle

controlmeasured,pass/fail

Measures

Pretest of 7exs formusclecontrol witha pressuretransducer

Pass/fail

Measuredagain @ 4weeks

Outcome

Level of exattainmentincreasedfor ex groupwithinstructions& testing

F ti l R t ti


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Functional Restoration

vs. Regular PhysioStudies in the USA on the efficacy of FRare very positive regarding RTW rate

Studies in Canada and Finland do notdemonstrate as strong results

Hypothesized difference could be due tolower economic benefits during sick

leave in USA lead to favourable resultsfrom FR programs


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Review of LiteratureOverall the programs are effective in returning agreater percentage of individuals to the workplaceand in a more efficient manner (between 21-52%improvement in the rate of RTW vs control groups)

A review of the literature reveals the programs areeffective for chronic and acute LBP

1 study examining reinjury reported that 48% of Rxgroup and 79% of control group had a reoccurencewithin 1 year

Only 1 cost analysis study. The program resulted inan increase cost of $400/subject but there was asaving of $2000/subject in WCB costs, resulting insavings of $1600

(Lechner,1994;Bendix,2000)


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Motor Learning Summary

Few studies exist in the LBP literature directlyrelated to motor learning

Studies / information is available thatdiscusses different treatment methods thatinclude aspects of practice

Points to a need to research in motor learning

in this area and to investigate what motorlearning principles are being used in clinicalpractice


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Psychosocial

P h i l F t &


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Psychosocial Factors &

LBPPsychosocial factors play a crucial rolein low back pain clients

They play a particular important role inthe transition from an acute injury to achronic injury

Seems to be personal and work

psychosocial factors that affect LBPclients

P h i l F t @


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Psychosocial Factors @

WorkOne,psychosocial work characteristics candirectly influence the biomechanical loadthrough changes in posture and movement

Two,these factors may trigger physiologicalmechanisms, such as increased muscletension or increased hormonal excretion, that

may lead to organic changes or influencepain perception

(Hoogendoorn,2000)


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Three,psychosocial factors may changethe ability of an individual to cope with

an illness which could in turn influencethe reporting of symptoms

Four, the association may be

confounded by the effect of the physicalfactors at work

(Hoogendoorn,2000)

P h i l F t t


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Psychosocial Factors at

WorkA 2000 review of the literature found 6reported psychosocial factors at work thatinfluence LBP

Work Pace

Qualitative Demands

Job Content

Job Control Social Support in the Workplace

Job Satisfaction(Hoogendoorn,2000)


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Work Pace

3 high quality studies1 found no significant effect

1 found a statistically significant effect of ahigh work pace on back related shortabsenteeism

1 found a statistically significant effect of ahigh work pace on sciatic pain

When rated the studies showed there isinsufficient evidence of an effect of high workpace on the risk of pain, due to inconsistentfindings

(Hoogendoorn,2000)


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Qualitative Demands

Include conflicting demands, interruption oftasks, and intense concentration for longperiods

1 high and 1 low quality study

1 study found that high conflicting demandshad a statistically significant effect on shortand long absences from work due to pain

When rated there is insufficient evidence ofan effect of high qualitative demands on therisk of LBP

(Hoogendoorn,2000)


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Job Content

Includes monotonous work and workwith few possibilities to learn new skills

4 high quality studiesNo statistically significant effect wasfound

(Hoogendoorn,2000)


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Job Control

Includes aspects such as autonomy andinfluence

2 high quality studiesBoth found no significant effect

(Hoogendoorn,2000)

Social Support in


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Social Support in

WorkplaceIncludes social support of coworkers andsupervisors, relationships at work andproblems with coworkers and supervisors

5 high quality studies4 of 5 showed that low support had astatistically significant effect

Rating system showed that there is strongevidence for low social support in theworkplace as a risk factor for back pain

(Hoogendoorn,2000)


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Job Satisfaction

7 high and 2 low quality studies

Researchers in 5 high quality studies

found that low job satisfaction had astatistically significant effect

Strong evidence for low job satisfaction

as a risk factor for low back pain

(Hoogendoorn,2000)

Personal Psychosocial


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Personal Psychosocial

FactorsThe same review in 2000 examined the studiesavailable on the effect of psychosocial factors inprivate life and there effect on LBP

Only 1 high and 2 low quality studies were foundFactors studied included family support, presence ofa close friend, social contact, social participation andemotional support

In general, no significant effect was found

Application of the rating system found there isinsufficient evidence of an effect of psychosocialfactors in private life

(Hoogendoorn,2000)

P h l i l F t i th


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Psychological Factors in the

Development of Chronic LBP

Psychological factors in addition to being riskfactors for LBP also appear to play a role inthe development of chronicity in LBP

A systematic review of the literature done byPincus et al (2002) reviewed studies thatinvestigated psychological factors as

predictors of chronicity/disability inprospective cohorts of LBP


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Method

6 studies met inclusion criteria

Inclusion criteria :prospective cohortsconcerning LBP;subjects with acute or

subchronic LBP;measurement of at least 1psychological variable at baseline

Rated on 3 main criteria (methodologicquality, quality of measurement of

psychological factors and quality ofmeasurement of psychological factors)


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Results

4 psychosocial factors are identified inthe literature

Psychological distress/Depressive Mood Somatization

Personality

Cognitive Factors

(Pincus,2002)

P h l i l Di t /


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Psychological Distress /

Depressive Mood

Due to tools used in studies difficult todifferentiate between psychological distress,depressive symptoms & depressive moods

Authors therefore used distress to representa composite of all terms

Distress is a significant predictor ofunfavorable outcome

This effect was independent of clinicalfactors, such as pain and function @ baseline

(Pincus et al,2002)


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Somatization

I high quality study and 1 acceptablestudy

Somatization scales predict unfavorableoutcomes

(Pincus et al, 2002)

P lit d C iti


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Personality and Cognitive

Factors

Personality Minnesota

Multiphasic

Personality Inventory(MMPI) subscale ofhysteria wasreported to be apredictor of RTW in 1

study Overall quality rated

low

Cognitive Factors Dealt with coping

strategies, fearavoidance,catastrophizing

Studies had a low qualityrating

(Pincus et al,2002)


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Summary

Distress and somatization are confirmed as having arole in the progression to chronicity in LBP

2 areas of psychological risk are surprisinglyunderrepresented: fear avoidance and

catastrophizingAuthors commented that although it is felt that painrelated fear and avoidance appear to be an essentialfeature of the development of chronicity, support fromprospective studies is sparse

Research regarding catastrophizing predictingdisability is based on cross sectional studies or basedon groups with different disorders

(Pincus et al,2002)


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Functional Self Efficacy

Refers to confidence judgments regarding theability to execute or achieve tasks of physicalperformance

Suggests that those having higher levels ofFSE and believing they could performfunctional tasks could be expected to reachhigher levels of physical performancebecause they invest more effort and

persistence and, consequently are less likelyto become preoccupied with expectations offurther pain and injury

(Lackner et al,1996)

FSE & Chronic LBP


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FSE & Chronic LBP

StudySome interesting conclusions made bythe authors

A link between FSE and disability FSE has a predictive power

Individuals with high FSE may be lessprone to thoughts of future harm and mayapply coping skills more effectively

(Lackner et al,1996)


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An Overview of

Treatment Approaches

used in LBP


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Interventions

A wide range of interventions exist forthe treatment of LBP

These include Exercise

Modalities

Manual Therapy

Education Functional Restoration Programs


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Efficacy

With the exception of exercise andfunctional restoration no evidence exists

that substantiates effectiveness of theother interventions in a low backpopulation

Lack of evidence is mostly due to (a)lack of studies and (b) lack of high levelstudies


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Exercise

Literature seems to be divided into 2groups

General Exercise (stretching,strengthening, aerobic, McKenzie)

Stabilization Exercise (specific to deeptrunk muscles)


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General Exercise

A review was published in 2001 undertaken by thePhiladelphia Panel

The review evaluated 9 rehab interventions for LBP1 being exercise

Studies were eligible if they were RCTs,nonrandomized controlled clinical trials (CCTs), casecontrol and cohort studies

Studies had to evaluate exercise in nonspecific LBP

and included post surgerySummarized exercise studies according to acuteLBP, subacute LBP and chronic LBP


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Exercise & Acute LBP

Acute defined as < 4 weeks

4 RCTs

Exercises included McKenzie, back extension,

strengthening exsNo efficacy was demonstrated

Therapeutic exercises were no better than control forimproving function, ability to work and pain

Clinical Recommendations: poor evidence to includeor exclude stretching or strengthening exs alone asan intervention for acute LBP

Exercise & SubAcute


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Exercise & SubAcute

LBPSub acute defined as 4-12 weeks3 RCTs included

Exercises included McKenzie, Flexion Exs,strengthening exsClinically important benefits found withregards to pain relief, patient assessed globalcondition & functional status

Recommendations: good evidence to includeflexion, extension and strengthening exs asinterventions for subacute LBP


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Exercise & Chronic LBP

Chronic defined as > 12 weeks

8 RCTs

Exercises included: flexion, extension,stretching, circuit training and strength exsClinically important benefit was demonstratedfor pain relief & functional status

Recommendations: good evidence to includestretching, strengthening and mobility exs asinterventions for chronic LBP


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Stabilization Exercises

A review was done by Gallagher (myself) in2002

Identified and reviewed literature available onexercise studies that incorporated the use ofstabilization exercises

Stabilization exercises was defined as

exercises that incorporated training of themultifidus and transversus abdominismuscles


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Summary of Literature

5 studies reviewed

3 RCTs and 2 single group designs

Included studies of acute and chronic clients

Clinically important benefits included painrelief, decreased disability and decreasedmuscle atrophy

Recommendations: Stabilization exs arerecommended for acute and chronic clients toaddress pain, disability, muscle atrophy andpossibly motor control issues


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An Integration of

Approaches in Clients

with LBP

Biomechanics: Clinical


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Biomechanics: Clinical

Implications

As therapists we should:

Be aware of the neutral zone and factors

that affect it Maintain neutral zone with stability exs

Protect the joint with proper exercises andeducation on posture and ergonomics

Help maintain muscle strength

Motor Control: Clinical


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Motor Control: Clinical

Implications


Be aware of muscles most affected in LBP

Provide exercises relevant to theseaffected muscles

Measure outcomes as closely as possible

Attempt to have patients minimize use ofinappropriate muscles

Motor Learning: Clinical


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Motor Learning: Clinical

Implications


Provide practice and feedback for clients

Encourage practice outside of treatmentsessions

If work related injuries, provide tasks /treatment that is specific to tasks they have

to return to

Exercise Physiology:


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Exercise Physiology:

Clinical Implications


Be aware of effects of inactivity in the LBP

client Enhance cardiovascular fitness of LBP

clients

Address muscle atrophy with specific

exercise training

Psychosocial: Clinical


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Psychosocial: Clinical

Implications


Be aware of the factors that affect LBP and

chronicity of LBP Identify factors that may be affecting a

clients treatment / return to work

Identify If work psychosocial factors are

affecting treatment

Attempt to increase functional self efficacy


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An Integrated Model to

Address Function in

Low Back Pain Clients

Group Activity

Obj ti


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Objectives

To identify the underlying causes andmechanisms of mechanical low back pain

To understand some of the physical,biomechanical and psychosocial impairments

/ approaches associated with mechanical lowback pain

To integrate the approaches into a clinicalmodel and incorporate treatment strategiesinto the approach

Documents

Mechanical Low Back Injuries[1]