BACK PAIN MANAGEMENT

Quoc To Ai Giang D.C.

Statistics

• 75-85% of Americans will suffer from LBP once in their lifetime

• 90% will improve w/out surgery• 50% of those who have an episode will

have a recurrent episode within 1 year• 5.4 million workers will be disabled for 1 or

more years from LBP

– NeuroSurgery Today March 2006

Sacroiliac Joint

• Lumbo-sacral joint complex functions as a self-compensating mechanism which accommodates, mitigates, balances, stores and redirects forces affecting the pelvis and spine.

• Forces: gravity, weight bearing, inertia, rotation, acc/deceleration, ground reactive forces

Sacroiliac Joint

• SI joint is essential for load transfer between spine and legs

• Slight changes in the mobility or stability can be responsible for variety of clinical conditions

Sacroiliac Joint

• Pathology in this joint has been reported in numerous of inflammatory, metabolic, and infective disorders

• Yet mechanical dysfunctions of this joint remains controversial, largely due to our lack of knowledge about the joint

Sacroiliac Joint

• Composed of 2 innominate bones and a sacrum forming 2 SI joints and pubic symphysis

• Ligaments, joint capsule, muscle, fascia, articular configuration

Sacroiliac Joint

• Sacrum– A tilted wedge or

keystone– The weight of the spine

coupled with gravity forces the sacrum to wedge snugly between the two innominates.

• This phenomenon along with other passive anatomical features that provide stability are called form closure.

Form Closure

•Osteoarticulo-ligamentous component

– “Refers to a stable situation with closely fitting joint surfaces, where no extra forces are needed to maintain the state (stability) of the system”

– Vleeming

• Stabilization of the pelvis via ligamentous structures

Ligamentous Structures

Sacroiliac JointSI Joint Surfaces:• Sacrum: The articular

surface, called auricular, is concave, covered in thick hyaline cartilage and is shaped like a plane propeller - wider P-A in the upper aspect and wider A-P in the lower aspect .

• Ilium: Controversy exists as to if the iliac side is fibrocartilage or hyaline. Either way, its convex surface is irregular (rough).

Shape of the SIJ effectively resists flexion.

Sacroiliac Joint

Ligaments - designed to limit the mobility of the SI joint.

• The ligaments must oppose strong forces for long periods of time.

• Simonian noted the strength of the ligaments by cutting through the pubic symphysis and the iliac wings only flared out slightly.

Sacroiliac Joint• Iliolumbar Ligament: limits

axial rotation and anterior glide of L5 on the sacrum.

• Sacrotuberous Ligament: resists sacral movement into nutation, (tightens the ligament). It also has as an important connection to the long head of the biceps femoris.

• Sacrospinal Ligament: see #2• Dorsal Sacral Iliac Ligament:

this large ligament tightens in counter-nutation. It makes up 2/3 of the posterior SI connections and blends with #2, erector spinae and thoracolumbar fascia.

1

2

4

4

3

Sacroiliac Joint

• Anterior Sacroiliac Ligament: opposes axial translation of the sacrum and separation of the SI joints.

• Interosseous Ligament (not shown): fills in the irregular spaces posterior and superior to the joint; resists joint separation.

5

Sacroiliac Joint - Capsule

• Superior portion is a caudal extension of the iliolumbar ligament

• Anterior portion is dense connective tissue and caudally blends with the sacrospinous ligament

• Posterior portion is made up of multiple interwoven bands (interosseous ligaments)

5

Sacroiliac Joint - Innervation

• Anterior superior joint receives info. from spinal nerves L4 & 5

• Anterior inferior joint supplied by S1 & 2 and other sacral nerves

5

Sacroiliac Joint• Muscles: The major muscles and

fascia that are involved in the SI joint are the gluteus maximus and medius, psoas, piriformis multifidus, latissimus dorsi, abdominal obliques, transversus abdominus, biceps femoris, latissimus dorsi, pelvic floor & diaphragm and thoracolumbar fascia.

• The forces created by the muscles acting on SI joint to provide stability is called Force Closure.

Force Closure

•“Force closure refers to a system whereby additional forces are necessary to maintain the joint in place.”

– J. Snijders

Second Interdisciplinary Word Congress on Low Back Pain – San Diego 1995

Force Closure

• Erector Spinali – Extends spine and

pelvis– Contraction creates

sacral nutation (locking) thus ligaments tighten and SI joint locks

Force Closure

• Multifidi– Tendon pass above

interosseous ligament and inserts into sacrum, iliac crest, and sacrotuberous ligament

– Contraction facilitates nutation

Force Closure

• Gluteus Maximus– Hip extensor– Directly compresses

SI joint due to fiber orientation

– Fibers blend with sacrotuberous ligament and thoracolumbar fascia

Form Closure

• Latissimus Dorsi– Extends, abducts, and

medially rotate humerus– Deep fibers: lower T/S

spinous processes and iliac crest

– Superficial fibers: oblique caudal fibers blend with thoracolumbar fascia and then contralateral gluteal muscles

Force Closure

• Biceps femoris– Long head crosses

over the ischeal tuberosity & blends into sacrotuberous ligament

– Contraction increases sacrotuberous tension

Force Closure

• Piriformis– Externally rotates

femur– Crosses SI joint

perpendicular & compresses the joint

Force Closure

• Psoas

• Quadratus Lumborum

Force Closure

• Adominals The Transverse

Abdominals wrap around the spine and goes all the way to the front and when activated it stabilizes the spine and pelvis

Force Closure

• Thoracolumbar fascia– Clinical of

importance in surgery, it blends with the deep cervical fascia which forms a plane for infection to travel

Force Closure

• Abdominals

• Transverse Abdominals– Deepest of the 3

layers– Perhaps the most

functional for core stabilization, spinal stabilization

Joint Functions

• If joint is compressed this will result in restriction

• If joint is not compressed enough this will result in instability or hypermobility

• If joint does not function in a smooth & efficient manner this can result in abnormal firing patterns

Joint Functions

•The Panjabi Model as modified by Vleeming & Lee

Integration

• Joint function requires normal function of the joint & of the muscles – Form Closure – Force Closure

• Joint restriction can be due to muscular and ligamentous elements

•Local stabilizers vs. Global stabilizers & global maximizers

Inner Core

•Tranversus Abdominus•Lumbar Multifidi •Pelvic Floor •Diaphragm

The Tranversus Abdominus

•Pre-Anticipatory

•Damaged by:– Surgery– Overactive

Rectus– Pendulant

Abdomen – The rest of the

inner unit

Lumbar Multifidi

•Shut off after 3 minutes in slumped posture

•Atrophy occurs in most of modern (sitting) society

•Mass is replaced by fatty infiltration

Pelvic Floor

• Damaged by childbirth – a normal vaginal delivery

• Is affected by the other inner unit muscles not functioning

• Puborectalis – a muscle of the pelvic floor can be overactive as a consequence of rectus over-activity which is itself a product of Tranversus Abdominus weakness

3 Phases to LBP Rehabilitation•Phase I: Acute Phase

– Physiatrist and treatment team focus on making a diagnosis, developing an appropriate treatment plan, and implementing the treatment regimen to reduce the initial low back pain and source of inflammation.

– This may include any/all of the items listed above and/or the utilization of ultrasound, electrical stimulation, or specialized injections.

3 Phases to LBP Rehabilitation• Phase II: Recovery Phase

– Once the initial pain and inflammation are better managed, the rehabilitation team then focuses on helping the patient to restore working function of the body.

– This includes returning the patient to normal daily activities while implementing a specialized exercise program that is designed to help the individual regain flexibility and strength.

3 Phases to LBP Rehabilitation

•Phase III: Maintenance Phase– The goal of this phase of low back pain

rehabilitation is two-fold: •Educating the individual on ways to prevent

further injury and strain to the back

•Helping the individual to maintain an appropriate level of physical fitness to help further increase strength and endurance.

Common Causes

• Disc Lesions with/out Radiculopathy– 98% of Disc lesions occur at L4-5 & L5-S1

• Overuse, strenuous activity, or improper use (i.e., repetitive or heavy lifting, exposure to vibration for prolonged periods of time)

• Trauma/injury/fracture• Degeneration of vertebrae (often caused by

stresses on the muscles and ligaments that support the spine, or the effects of instability.

Common Causes

• Infection

•Abnormal growth (tumor)

•Obesity (often caused by increased weight on the spine and pressure on the discs)

•Poor muscle tone in the back

Common Causes

•Muscle tension or spasm•Sprain or strain•Ligament or muscle tears• Joint problems•Smoking (damage to the

vasculatures of discs)•Disease (i.e., osteoarthritis,

spondylitis, compression fractures)

– a term that encapsulates all the

possible causes of joint changes

Movement Dysfunction

– implies some holding element that restricts movement

- possible candidates : muscle, ligament or capsular change due to some past trauma to the tissue

Joint Fixation or Restriction

a. Capsular & Ligamentous Changes following trauma & the inflammatory cascade Clinical Orthopedics, 1987, Akeson, Amiel, Abel, Garfin & Woo (for an overview see

the Aging Body by Morgenthal & Boughie – Chapter 3 b. Trigger Points / Myofascial Changes

Travell & Simons – Myofascial Pain & Dysfunction – the Trigger Point Manual Volume 1 & 2

c. Muscle Imbalances Janda

d. Alterations in the Arthrokinetic Reflex

Cassidy / Mooney

Movement Dysfunction Causes:

Cassidy / Mooney– Based on Hilton’s law, the nerves that innervate

a joint innervate the muscles around the joint. If there's a problem within the joint the surrounding muscles will be weakened or shut off. This has been proposed as a primary mechanism of dysfunction in all areas of the spine. 1.) SI joint dysfunction and glute inhibition,

(Bernard and Cassidy 91) 2.) Lumbar joint dysfunction and multifidus

inhibition, (Hides 96) 3.) Cervical spine and L. coli (longissimus coli

muscle) inhibition, (Wright, Jull 2001) 4.) Vastus medialis inhibition after knee joint

dysfunction, (Richardson PhD thesis)

Alterations in the Arthrokinetic Reflex

Directional InstabilityNutation vs. Counternutation Dominance

• Sacrotuberus ligament Checks Nutation

• Long & Short Sacroiliac ligaments Checks Counternutation

Nutation

Counternutation

Nutation

Counternutation

Assessments

Functionally putting the puzzle

together: We need to be able to assess the

complaints through functional testing.

Orthopedic (Functional) Exams/Assessments

•Acute Vs. Chronic Determine if the problem is an acute

vs. chronic complaint

Gillet’s TestPerformed knee to chest while standing: Pull knees alternately to chest. The PSIS that moves down the furthest in relation to the opposite one is the unblocked side. The blocked side will come very little or appear to move cephalically. Recruitment is from the bottom up. Hip flexion must be at least 90 degrees.

Gillet’s Test

Piedallu’s Sign:

The movement of the posterior superior iliac spines upon forward flexion. A positive Piedallu’s sign is asymetrical movement.

Gaelen’s Test:

The patient lies on the side with the upper leg (test leg) hyperextended at the hip (1st photo). The patient holds the lower leg flexed against the chest. The examiner stabilizes the pelvis while extending the hip of the uppermost leg. The test can also be performed supine (2nd) but this position may limit the amount of hyperextension. Position patient so the test hip extends beyond the edge pf the table. Then draw up both legs onto the chest then slowly lower the test leg into extension. Pain in the sacroiliac joints indicates a positive test.

Gait Analysis

Gait

How can we incorporate static anatomy into functional anatomy?

Gait – Heel Strike

• Prior to heel strike, heel strike becomes active

• Which increases tension of sacrotuberous ligament

• Thus compresses SI joint

• Forces transmitted across SI joint into spine

Gait – Stance Phase

• Innominates begin anterior rotation – counter-nutation begins– Loose SI joint. locking

• Long Dorsal SI ligament tension increases

• Need to stabilize SI joint– Gluteus maximus activates and replaces

Biceps femoris– Contralateral lats dorsi activates

Gait – Swing Phase

• No weight in SI joint. It is suspended.

• Ligamentous control of SI joint

Gait

• With Each Phase of Gait– Opposite arm and “wringing of spine” (it occurs like taking a rubber band and twisting it, when you let go, it “springs”)– Ligaments, discs, and spinal curves maximize

yielding energy storage

Elastic Energy is released in the next cycle —followed by muscular energy

Treatment

Treatment should be inclusive to include all the tissues that can affect movement. Each treatment should be tailor made to fit the patients dysfunction, manipulation, mobilization, rehabilitation, stretching & diet/nutrition should a part of every doctor’s practice regiment.

Treatments

•Activity modification

•Medication

•Physical rehabilitation and/or therapy

•Occupational therapy

•Weight loss (if overweight)

INTEGRATED METHOD OF TREATMENT

The Integrated Model of JointFunction

Form ClosureForce Closure

Function

Motor ControlEmotionsAwareness

Treatments

•Following a prevention program (as directed by your physician)

•Quit smoking

•Surgery

•Assistive devices (i.e., mechanical back supports)

Why Failures?

ApplicationWith all our knowledge in anatomy we need to learn how to apply it to the patient who is having pain after all the treatments they’ve had.•Extensive connections of

sacrotuberous ligaments– Gluteus Maximus– Piriformis– Bicep Femoris– Multifidi– Thoracolumbar Fascia

Application

• SI joint is located in the middle of considerable force streams– Mechanoreceptors

• Dysfunctional of Form/Force Closure can have significant effects locally at the SI joint and far into the lower/upper limbs or cervical spine.– Loss of bracing– Shifting of loads into the lumbar/sacral area

Applications

•Often these connections are incomplete, unilateral or asymetrical– I.E. - Unilateral shorten biceps

•Could these differences cause symptoms in the patient? The answer is YES!

Applications

•Our goal is to find these differences

•Evaluations of:– Trigger Points– Hyper/Hypotonicity – Myofascial bands– Decrease muscle length– Pain

Applications

•These imbalances will change the function of the SI joints and L/S as a UNIT– FAILED SELF BRACING

“Abnormal movement of the sacrum in the SI joints may lead to abnormal stress loads transmitted into the L/S thus abnormal stress on the intervertebral discs and joints.”

- Vleeming

Failed Self Bracing

• Imbalances– Weak erector spinae leads to insufficient

nutation– Weak gluteus maximus leads to insufficient

SI compression– Weak Lats leads to insufficient SI

compression

•Decreased SI joint. compression & poor nutation leads to dysfunction and pain syndromes

Failed Self Bracing

•Sustained counter-nutation leads to:– Absent SI compression therefore

increasing joint shear forces– Lordosis is lost– Load is transferred to L/S and discs…

increasing shear

Failed Self Bracing

• Irritation of the SI joint inhibits the gluteus maximus• Inhibition = weakness

•Hamstring will attempt to increase hip extension and help increase SI joint compression• shorten stride

References• Lee DG, Vleeming A. Impaired load transfer through the pelvic

girdle, a new model of altered neutral zone function. Proceedings from the 3rd Interdisciplinary Word Congress on Low Back and Pelvic pain. Vienna 1998;76-81.

• Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transverse abdominus. Spine 1996;21(22):2640-50.

• Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Physical Therapy. 1997;77:132-44.

• Hungerford B, Gilleard W, Lee D. Alteration of the sacroiliac joint motion patterns in subjects with pelvic motion asymetry. Proceedings from the 4th World Interdisciplinary Congress on low back and pelvic pain. Montreal 2001.

• Lee DG. The pelvic girdle, 2nd Edition. Churchill Livingstone. Edinburgh 1999.

• Lee DG. Treatment of pelvic instability. Movement, stability, and low back pain. Churchill Livingstone, Edinburgh. 1997;37:445-459.

• Panjabi MM. The stabilizing system of the spine. Part I: Function, dysfunction, adaptation, and enhancement. Journal of Spinal Disorders. 1992;5(4):383-89.

References• Deyo RA, Rainville J, Kent DL. What can the history and

physical examination tell us about low back pain? JAMA. 1992;268:760-765.

• Papagerogiou AC, Croft PR, Ferry S, et al. Estimating the prevalence of low back in the general population: evidence from the South Machester back pain survey. Spine. 1995;17:1889-1894.

• Deyo RA, Tsui-Wu JY. Descriptiv epidemiology of low back pain and its related medical care in the United States. Spine. 1987;12:264-268

• Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116.

• Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.

• Jones AK. Primary care management of acute low back pain. Nurse Pract 1997;22:50-56.

• McKenzie RA: The Lumbar Spine. Mechanical Diagnosis and Therapy. Spinal Publications. Waikanae, New Zealand. 1981

References• Travell JG. Simons DG: Myofascial Pain and Dysfunction. The

Trigger Point Manual. Williams & Wilkins. Baltimore. 1983.• Ross, Michael H., Romrell J. Lynn, Kaye I. Gordon: Histology: a

Text and Atlas 3rd Edition. Williams & Wilkins. Baltimore. 1995. • Janda V: Muscles, motor regulation and back problems, p.27. In

Korr IM (ed.): The Neurological Mechanisms in Manipulative Therapy. Plenum, New York. 1978.

• Dvork J. Dvorak V: Manual Medicine: Diagnostics. Georg Thieme Verlag. Thieme-Stratton Struttgart. 1984.

• Kirkaldy-Willis WH. Hill RJ: A more precise diagnosis for low back pain. Spine 4:102. 1979.

• Richardson, C A (1992). Muscle Imbalance: Principles of treatment and assessment. Proceedings of the New Zealand Society of Physiotherapists Challenges Conference. Christchurch, New Zealand.

• Aspden, R M (1992). Review of the functional anatomy of the spinal ligaments and the lumbar erector spinae muscles. Clinical Anatomy. 5. 372-387.

References• Hides. J A, Stokes. M J, Saide. M, Jull. G A and Cooper. D H

(1994). Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acut/subacute low back pain. Spine. 19. 2. 165-172.

• Jull. G A and Richardson, G A (1994). Rehabilitation of active stabilization of the lumbar spine in: Twomey, L T and Taylor. L T (eds) Physical Therapy of the Low Back, 2nd Ed. Churchill Livingstone, Edinburgh.

• Elnaggar IM, Nordin M, Sheikhzadeh A, Parnianpour M, Kahanovitz N. Effects of spinal flexion and extension exercises on low-back painand spinal mobility in chronic mechanical low-back pain patients. Spine 1991;16:967-72.

• Rantanen J, Hurme M, Falck B, Alaranta H. The lumbar Multifidus muscle five years after surgery for a lumbar inververtebral disc herniation. Spine 1993;5:568-74.

• Lehto M, Hurme M, Alaranta H, et al: Connective tissue changes of the multifidus in patients with lumbar disc herniation. Spine 14:302-309, 1989.

• Lindboe CF, Platou CS: Disuse atrophy of human skeletal muscle. Acta neuropathol (Berlin) 56:241-44, 1982.

References• Gardenar-Morse M, Stokes I. The effect of abdominal

muscle coactivation on the lumbar spine stability. Spine. 1998;23:86-92.

• Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N England J Med 1998;339;1021-9.

• Davies J, Gibson T, Tester L. The value of exercises in the treatment of low back pain. Rheumatol Rehabilitation 1979;18:243-47.

• Andersson C, Chaffin D, Herrin C, Matthews L. A biomechanical model of the lumbosacral joint during lifting activities. Journ Biomech 1985;18:578-84.

• Bogduk N, MacIntosh J. The applied anatomy of the thoracolumbar fascia. Spine 1984;9:164-70.

• Magee J D. Orthopedic Physical Assessment 3rd Ed. W.B. Saunders Co. 1997.

• Lieberson C. Rehabilitation of the spine. Williams & Wilkins: Baltimore; 1996