1. The Lumbar Spine

2. Introduction Prevalance Diagnosis of lumbar spine Soft tissue/repetitive strain injuries Facet joint injuries OA Disc problems Summary

3. Prevalance 80% of the population will have back pain by the age of 60 By the age of 20, 50% of the population have already experienced back LBP LBP is 2 nd only to the common cold when it comes to symptoms requiring a doctors visit 4% will become chronic 4% represent 80% of the cost to society 1-3% will undergo surgery

4. Back Problems Back problems are not the same thing as back pain and are seldom caused by a single incident but are usually the result of several factors Back problems will be present long before back pain starts and unless the problem is addressed will remain long after the back pain goes This leads to our most common complaint in every physio clinic in the country – recurrent back pain

5. Common cause of back problems Poor posture Faulty body mechanics – leg length discrepancies, pronating feet etc Stressful living and working habits – sitting at computers. Driving Loss of strength and flexibility General decline of physical fitness – weight is an increasing problem

6. Diagnosis of lx spine Patient history often gives us the best clue as to what structure they have damaged. All lumbar pain usually presents with soft tissue inflammation to the tissues in the painful area muscle spasm - this is the muscle guarding the damaged soft tissue restricted ROM – due to muscle spasm scoliosis and decreased lordosis are prime examples of muscle guarding in the lumbar spine What you won’t see is the reduction in metabolism and circulation to these areas!

7. Symptoms and cause These symptoms are rarely the primary cause of the problem however they need treating as whatever the cause, the treatment will always be directed towards getting the patient moving! Physio is particularly useful alongside muscle relaxants and anti-inflammatory/pain killers electrotherapy, acupuncture, ultrasound, supports

8. Injuries to soft tissues or repetitive strain of soft tissues History - overdoing the gardening, driving to Scotland and back in a day, playing rugby, decorating, DIY overuse, Symptoms – usually appear in surgery in slight lumbar flexion, all lumbar movement hurts – therefore they have stopped moving! pain can refer to upper leg

9. Treatment Advise 48 hours rest for an acute muscle spasm with a 10 minute walk every 2 hours will generally heal well after the acute phase during which physio is not always needed when the pain is eased they are given postural and ergonomic advice – computer set up etc lumbar mobility and strengthening exercises to then get rid of their back problem

10. Mobility exercises Leg/s to chest Pelvic tilting Knee rolling

11. Injuries and strains to lumbar facet joints (including SIJ dysfunction) Facet joint

12. Injuries and strains to lumbar facet joints History – either 1) sudden movement leads to acute pain and locking of spine (do not be fooled – there will be an inherent weakness in the lumbar spine that has been there for a while for this to happen) 2) old over use injury has led to this stage due to the tissues tightening up around the facet joints. The patient has stopped moving his spine due to fear and pain and the joint has locked – can be multiple level 3) hyper mobility of spine – particularly young females, pregnancy leads to instability of L5/S1 segment

13. Symptoms pin point area of pain movement in one direction usually painful extension of lumbar spine very uncomfortable lumbar flexion usually more comfortable

14. Treatment of facet joints manipulation of facet joints soft tissue stretching traction (old fashioned but effective) exercise regimes keeping spine in flexion until acute pain has passed

15. Treatment of facet joint Hip hitchingLumbar flexionTraction

16. Prognosis After 2-3 months of facet joint dysfunction the immobility can lead to degeneration and OA of the lumbar spine – this is what most people will eventually present with at the surgery.

17. OA Spine

18. OA spine Symptoms Crepitus Loss of ROM all directions Aggravated by increased levels of activity General stiffness in spine and hamstrings leading to instability either side of the stiff segments Chronic history of recurrent lumbar pain

19. Treatment of OA should be hands off and concentrate on 1) increasing the circulation to the lower vertebrae with mobility exercises eg knee rolling 2) increasing the strength in the lower spine, abdominal and pelvic muscles which are shown to waste even after one incidence of lumbar pain eg Pilates, speed walking

20. Disc problems Prolapsed disc – (herniated/bulge/slipped) only 1% comes from trauma History Under 45 years of age Sedentary occupation Gradual onset

21. Symptoms Severe pain Decreased lordosis – stand in flexion Lateral shift Patient is unhappy sitting and will ease weight with hands on the arm of the chair Pain usually eases walking Peripheral pain and parasthesia Motor weakness Reduced SLR/femoral stretch Extreme cases bladder/bowel disturbance Saddle parasthesia

22. Treatment of prolapsed disc Rest with gentle walks every few hours Anti-inflammatory and pain killers Lumbar support to increase abdominal support and reduce pressure on disc Electrotherapy to ease pain All treatment to centralise pain away from peripheral symptoms Hip glides to correct lateral shift

23. Treatment of prolapsed disc Advice to avoid lifting, prolonged sitting Encourage prone lying and extension exercises Increase exercise tolerance gradually

24. Exercises to encourage lumbar extension Prone lying position Full extension in lying position Prone on elbows

25. After acute disc symptoms have settled Neural stretches Traction Core stability as long term prevention (pilates)

26. Core stability exercises Figure 1: Supine Bent-Knee Raises Figure 2: Quadruped with Alternate Arm/Leg Raises Figure 6: Seated Marching on a Physioball

27. Neural stretches Sciatic nerve stretchFemoral nerve stretch

28. Disc degeneration History over 45 years of age OA spine Recurrent lumbar problems Reduced lordosis

29. Symptoms of disc degeneration Absence of lordosis lumbar flexion increases peripheral pain can also present as only lumbar pain with shooting peripheral pain symptoms as for disc prolapse but patient older and less acute

30. Treatment of disc degeneration Traction Mobility exercises Strengthening exercises

31. Differential diagnosis of mechanical back pain Muscle strain Herniated nucleus pulposus Osteoarth ritis Spinal Stenosis Spondylol isthesis Scoliosis Age20-4030-50>50>602030 Pain location Back (unilatera l) Back, leg (unilatera l) Back (unilatera l) Leg (bilateral) Back Pain Onset AcuteAcute (prior episodes) Insidious StandingIncreaseDecreaseIncrease SittingDecreaseIncreaseDecrease BendingIncrease Decrease Increase SLR_+_+__ Plain X- ray --++++