1. Stephanie Wetmore, PT PED 596 Adv. Cardiac Rehab Wayne State College
Low Back Pain
Stephanie Wetmore, PT
PED 596 Adv. Cardiac Rehab
Wayne State College

2. Epidemiology & Natural History of Low Back Pain
10 million off work daily
$14 billion in missed days per year
Incidence equal in sedentary vs. heavy labor
Truck drivers most common
90% of LBP is recurrent
44% are better in 1 wk
86% are better in 1 mo.
92% are better in 2 mo.
35% with recurrent LBP develop sciatica
Lumbar spine most commonly injured part of human body

3. Anatomy & Physiology of the Lumbar Spine
Multi-jointed rod composed of numerous vertebrae
7 cervical
12 thoracic
5 lumbar
5 sacral (fused)
Normal spinal curves
10x increase strength & resilience than straight spine
Protects spinal cord & provides movement and shock absorption

4. Normal Spinal Curves Cervical spine = lordotic curve
Thoracic spine = kyphotic curve
Lumbar = lordotic curve
Sacral = kyphotic curve

5. Bones & Landmarks

6. Bones & Landmarks (cont.)

7. Ligaments

8. Muscles Flexion – rectus abdominis & obliques
Extension – erector spinae, transversospinalis & interspinalis
Lateral Bending – quadratus lumborum, erector spinae, obliques, intertransversarii
Rotation to same side – int. obliques
Rotation to opp. Side – ext. obliques & transversospinalis
Compression of abdomen – abdominals & obliques

9. Innervation
Muscles are innervated by corresponding spinal nerves and span several levels as do the muscles themselves

10. Pathophysiology Predisposing factors Intradiscal pressure
Poor sitting posture
Frequency of trunk flexion (Burton study)
Intradiscal pressure
Increased with movement toward a kyphotic position
Overstretching of ligaments
Posterior spinal ligaments overstretched by slouched positions

11. Causes of Pain Nocioceptive receptor system
Activated by mechanical forces or chemicals
Located in periosteum, joint capsules of facet joints, muscles, muscle attachments, superficial fascia, skin and outer portion of the disc
Also located in ligaments with PLL having highest density

12. Chemical vs. Mechanical
Mechanical deformation of nocioceptors occurs when force causes physiological stress, deformation and damage, even without pathology (example – hyperextension of index finger)
Can become constant when internal derangement occurs
Chemical irritation occurs with infection, inflammatory diseases and for approximately 20 days following trauma

13. Specific Pathologies Intervertebral disc lesions
Prolapsed (herniated) intervertebral disc
Lumbar instability and spondylosis

14. MRI of disc herniation

15. Spondylosis
Disc degeneration with gradual flattening of the disc and displacement of posterior facet joints
Symptoms due to mechanical derangement and OA of facet joints

16. Spinal Stenosis http://www.spinenet.com/stenosis.html
Narrowing of spinal canal
Caused by disc degeneration or OA

17. Spondylolisthesis Forward shift of spine
Caused by congenital malformation, separation or stress fracture or OA

18. Pharmacology NSAIDs Drugs to protect against NSAID-induced ulcers
Advil, Motrin, Aleve, Relafen
Cox-2 Inhibitors
Celebrex, Vioxx
Drugs to protect against NSAID-induced ulcers
Prilosec, Prevacid
Muscle relaxants
Flexeril, Soma
Anti-depressants
Amitriptyline (Elavil)

19. More Drugs Narcotics Non-narcotic pain meds Oral steroids Injections
Morphine, codeine, demerol, darvocet, vicodin and percocet
Non-narcotic pain meds
Ultram
Oral steroids
Medrol dose pack
Injections
Epidural flood, selective nerve root block, facet joint block and sacroiliac block

20. Epidural Flood

21. Exercise Limitations/Capacity & Modifications
Spondylolisthesis
Avoid heavy labor and vigorous physical activity
Lumbar support to immobilize
Abdominal strengthening and flexion activities
Spinal Stenosis
Lumbar support often helpful
Increase mobility and flexibility

22. Intervertebral disc lesions
Herniated or prolapsed disc
Dependent upon direction of herniation
Dependent on acuteness of condition
Decrease compressive forces and intradiscal pressure
Limit sitting and forward bending for post. herniations
Degenerative Disc Disease
Improve flexibility and mobility
Usually respond better to flexion activities

23. Sample exercises WALKING! Flexion exercises Extension exercises
Strengthening
Pelvic tilt

24. References
McKenzie, R.A. (1981) The Lumbar Spine Mechanical Diagnosis and Therapy. Spinal Publications Limited. Waikenae, NZ
Apley, A.G. and L. Solomon (1989) Concise System of Orthopedics and Fractures. Butterworths. London

25. Web Sites of Interest www.apta.org www.mckenziemdt.org www.aaos.org