Prof. Eyal Lederman DO PhDProf. Eyal Lederman DO PhD

Why people get back pain and what can we

do about it?

CPDO Ltd / www.cpdo.net / cpd@cpdo.netCPDO Ltd / www.cpdo.net / cpd@cpdo.netAuthorial copyright, distributed by London Osteopathic Society for personal use

Common beliefs about LBPCommon beliefs about LBP

LiftingLiftingInjury by exerciseInjury by exerciseFallingFallingWeak backWeak backWeak absWeak absSpinal curvesSpinal curvesInflexible stiff backInflexible stiff backWear and tear of the spineWear and tear of the spineShort legShort legTwisted pelvisTwisted pelvisFlat feetFlat feetProlong sitting at workProlong sitting at workLack of fitnessLack of fitnessSocio-economic backgroundSocio-economic backgroundPsychological distressPsychological distressDepressionDepression

Physical Genetic factors Previous history of LBP Initial high intensity painReferred pain to LEX

Age 35-55 / Older age

Occupational Frequent heavy lifting

Frequent bendingFrequent liftingUnusual sitting posture

Psychological Depression psychological distress Passive coping strategies Fear-avoidance beliefsCatastrophisingFinancial compensation

Social and socio-occupational factors:Low job satisfactionLow social support

Risk factors for recurrence / Risk factors for recurrence / chronicity / disabilitychronicity / disability

Ramond A, et al Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Fam Pract. 2010 Sep 10Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53

No association between structure, biomechanics and LBP

Trunk asymmetry, thoracic kyphosis and lumbar lordosis in teenagers and developing LBP in adulthood (Poussa MS 2005)Elevation of one shoulder, elevation of one hip, and deviation of the spine from the midline of the body to LBP & neck pain (Dieck GS, 1985)

Low muscle strength, low muscle endurance, or reduced spinal mobility and erector spinea pairs imbalances during extension (Hamberg-van Reenen HH 2007 & Reeves PN 2006)

Lumbar lordosis (Norton BJ 2004).Spinal scoliosis (Christensen ST 2008 syst. rev.)Increased lumbar lordosis and sagittal pelvic tilt on back pain during pregnancy (Franklin ME 1998)Differences in regional lumbar spine angles or range of motion (Mitchell T, 2008)

Pelvic obliquity and the lateral sacral base angle pelvic asymmetry(Fann AV 2002 & Levangie PK 1999)

Inflexibility of the lower extremities or leg length discrepancy (Nadler SF 1998)Hamstrings and psoas tightness (Hellsing, 1988)

Correcting foot mechanics have no effect on preventing back pain (Sahar T, et al, 2007)

For full text and discussion seeLederman E 2010 Fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by LBP. CPDO online journal. www.cpdo.net

No association between structure, biomechanics and LBP

Disc degeneration?

Facet degeneration (n=3529) Spina bifida,

Transitional lumbar vertebra, Tpondylolysis and spondylolisthesis

Disc degeneration?

Facet degeneration (n=3529) Spina bifida,

Transitional lumbar vertebra, Tpondylolysis and spondylolisthesis

Kalichman L, et al Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976). 2008 Nov 1;33(23):2560-5. van Tulder et al 1997, syst. review, Luoma, 2004; Brooks et al 2009

Carragee, E et al 2006 Does Minor Trauma Cause Serious Low Back Illness? Spine. 31(25):2942-2949

Minor trauma does not appear to increase the risk of serious LBP episodes or disability.

Neither the frequency of minor trauma events nor the reported severity of the event correlated with adverse outcomes

Subjects with advanced structural findings were not more likely to become symptomatic

Age and gender, abnormal psychometric testing, smoking, and compensation issues, accurately identified 80% of serious LBP events and 93% of LBP disability events.

N=200 asymptomatic / over 5yrs / check up every 6 months

Does minor trauma lead to chronic back pain / Does minor trauma lead to chronic back pain / disability?disability?

Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events.

Can structure explain the patient’s condition?

Carragee E et al, Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006 Nov-Dec;6(6):624-35

Why spinal degeneration?Why spinal degeneration?

N=116 twins. Study over 5yrs.

Progression of degenerative signs:Genetic and shared environmental influences

47% to 66%

Resistance training and occupational physical loading together

2% to 10%

Videman TDeterminants of the progression in lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine. 2006 Mar 15;31(6):671-8Battié MC 1995 Volvo Award in clinical sciences. Determinants of lumbar disc degeneration. A study relating lifetime exposures and magnetic resonance imaging findings in identical twins. Spine. 1995 Dec 15;20(24):2601-12

Disc degeneration

Disc ageing / degeneration – Disc ageing / degeneration – starts in the first 2 decades starts in the first 2 decades and progress in 5-7and progress in 5-7thth decade decade

Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, Nerlich AG 2002 Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine. Dec 1;27(23):2631-44 Haefeli M, et al 2006 The course of macroscopic degeneration in the human lumbar intervertebral disc. Spine. Jun 15;31(14):1522-31

MacGregor AJ, et al Structural, psychological, and genetic influences on low back and neck pain: a study of adult female twins. Arthritis Rheum. 2004 Apr 15;51(2):160-7Battie MC et al 2007 Heritability of low back pain and the role of disc degeneration. Pain 131 (2007) 272–280 Valdes AM, Hassett Hart DJ, Spector TD. Radiographic progression of lumbar spine disc degeneration is influenced by variation at inflammatory genes: a candidate SNP association study in the Chingford cohort. Spine 2005;30:2445–51.

LBP 41-57%

Neck pain 35-58%.

Heritability for LBP & neck pain

Genes and potential for condition / injury

Posthumus M, et al The COL5A1 gene is associated with increased risk of anterior cruciate ligament ruptures in female participants. Am J Sports Med. 2009 Nov;37(11):2234-40. Epub 2009 Aug 4. Mokone GG, et al The COL5A1 gene and Achilles tendon pathology. Scand J Med Sci Sports. 2006 Feb;16(1):19-26September AV, et al Tendon and ligament injuries: the genetic component. Br J Sports Med. 2007 Apr;41(4):241-6; discussion 246. Epub 2007 Jan 29.

COL5A1 gene associated with cruciate ruptures

The COL5A1 gene and Achilles tendon pathology

Rotator cuff injuries

Battié MC, Levalahti E, Videman T, et al 2008 Heritability of lumbar flexibility and the role of disc degeneration and body weight. J Appl Physiol. 104(2):379-85.

Spinal flexibilitySpinal flexibility

Genetic influences – • Overall flexibility 47%. • Flexion 64%• Extension more environmental and behavioural factors (associated with disc degeneration)

Getting old is not bad after all….

Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. 2009 Pain in the lumbar, thoracic or cervical regions: do age and gender matter? A population-based study of 34,902 Danish twins 20-71 years of age. BMC Musculoskelet Disord. Apr 20;10:39.

Frequency of back and neck pain same at all ages (20-71yrs)Duration slightly longer in older age

Postural-behavioural factors

Lack of association between work-related posture and LBP including: Prolonged standing

Bending, Twisting,

Awkward postures (kneeling or squatting) Sitting posture at work

Prolonged sitting at work / homeRecreational sports activities

(Hartvigsen et al 2000 syst. review; Chen et al 2009 syst. review; Bakker et al 2009 syst. review; Roffey et al 2010 syst. review; Wai et al 2010, syst. review).

Pain hyperexcitability & hyperalgesia

Saline into tib antSaline into tib antSaline infraspinatus muscle Saline infraspinatus muscle

Koelbaek Johansen M. Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain. 1999 Nov;83(2):229-34.Koelbaek Johansen M. Generalised muscular hyperalgesia in chronic whiplash syndrome. Pain. 1999 Nov;83(2):229-34.

DamageDamage PainPain

Central adaptation to painCentral adaptation to pain

Flor H, Braun C, Elbert T, Birbaumer N 1997 Extensive reorganization of primary somatosensory cortex in chronic back pain patients Neurosci Lett 224(1):5-8

Brain areas associated with pain, active during words associated with pain

Flor H, Knost B, Birbaumer N 1997 Processing of pain- and body-related verbal material in chronic pain patients: central and peripheral correlates. Pain, Dec;73(3):413-21

Pain conditionPain condition

Psychosocial factorsPsychosocial factorsCognitions / beliefs / attitudesCognitions / beliefs / attitudesPrevious injury experiencesPrevious injury experiencesCoping strategiesCoping strategiesSelf-help / regulationSelf-help / regulation

Lederman E. 2010 Neuromuscular rehabilitation in manual and physical therapy, ElsevierLederman E. 2010 Neuromuscular rehabilitation in manual and physical therapy, Elsevier

Ability to cope with painAbility to cope with painAbility to cope with functional lossAbility to cope with functional lossSocial interactionsSocial interactionsEmployment consequencesEmployment consequencesActions for recoveryActions for recovery

Pre-injuryPre-injury Post-injuryPost-injury

Narratives..Narratives..

People develop narratives to explain uncertaintyPeople often develop catastrophic narratives to explain their back pain

Reconstructing alternative positive narratives is important

What may helpWhat may help

Helpful Moderate contribution:Functional restoration / multidisciplinary rehabilitation Modest contribution:manual therapy (massage, manips, mobs)All exercise (effective for prevention & CLBP but not acute)

Informative & reassuranceThe spine is strong Emphasise positive attitudes and beliefs Advice to remain activeEarly return to normal pre-pain activities

Don’tDon’t build your part!Medicalisation is detrimentalRestTherapist’s own negative attitudes and beliefs (don’t disable your patients)

What you say is as important as what you do!van Tulder M, Koes B, Bombardier C. Low back pain. Best Pract Res. Clin Rheumatol 2002;16:761–75.van Tulder M, Koes B, Bombardier C. Low back pain. Best Pract Res. Clin Rheumatol 2002;16:761–75.Carragee EJ. Clinical practice. Persistent low back pain. N Engl J Med 2005;352:1891–8. Carragee EJ. Clinical practice. Persistent low back pain. N Engl J Med 2005;352:1891–8. FurlanFurlan AD AD, et al Massage for low back pain: an updated systematic review within the framework of the Cochrane Back Review Group. (Phila Pa 1976). Spine 2009 Jul 15;34(16):1669-84., et al Massage for low back pain: an updated systematic review within the framework of the Cochrane Back Review Group. (Phila Pa 1976). Spine 2009 Jul 15;34(16):1669-84.van van MiddelkoopMiddelkoop M M, et al Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):193-204., et al Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):193-204.LicciardoneLicciardone JC JC, et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005 Aug 4;6:43, et al. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2005 Aug 4;6:43van van MiddelkoopMiddelkoop M M, et alA systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2010 Jul 18. , et alA systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2010 Jul 18. KarjalainenKarjalainen K K, et al Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults Cochrane Database Syst Rev. 2003;(2):CD002193., et al Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults Cochrane Database Syst Rev. 2003;(2):CD002193.

Creating an environment for recovery

TreatmentTreatment

Daily activityDaily activity

General / specific exerciseGeneral / specific exercise

Injury / illnessInjury / illnessBehaviourBehaviour

Patien

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endan

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Therapist

depen

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The back pain lottery

Back pain is Back pain is multidimensionalmultidimensional

RepairRepair

Fluid flowFluid flow

AdaptationAdaptation

PsychologicalPsychological

NeuralNeural

Physical /Physical /

Local Local tissuetissue

NeuromuscularNeuromuscular

DIMENSIONDIMENSION PROCESSPROCESS

Pain / sensitisationPain / sensitisation

Psychological-Psychological-behaviouralbehavioural

Psycho-physiological Psycho-physiological (including pain)(including pain)

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