Transcript Prevalance - Goodson Parkbury

The Lumbar
Spine
Introduction
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Prevalance
Diagnosis of lumbar spine
Soft tissue/repetitive strain injuries
Facet joint injuries
OA
Disc problems
Summary
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 2nd 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
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
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
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!
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
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
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
Mobility exercises
Leg/s to chest
Knee rolling
Pelvic tilting
Injuries and strains to lumbar facet
joints (including SIJ dysfunction)
Facet joint
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
Symptoms
• pin point area of pain
• movement in one direction usually
painful
• extension of lumbar spine very
uncomfortable
• lumbar flexion usually more
comfortable
Treatment of facet joints
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manipulation of facet joints
soft tissue stretching
traction (old fashioned but effective)
exercise regimes keeping spine in
flexion until acute pain has passed
Treatment of facet joint
Lumbar flexion
Hip hitching
Traction
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.
OA Spine
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
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
Disc problems
Prolapsed disc –
(herniated/bulge/slipped) only 1%
comes from trauma
• History
• Under 45 years of age
• Sedentary occupation
• Gradual onset
Symptoms
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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
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
Treatment of prolapsed disc
• Advice to avoid lifting, prolonged
sitting
• Encourage prone lying and extension
exercises
• Increase exercise tolerance gradually
Exercises to encourage lumbar
extension
Prone lying position
Prone on elbows
Full extension in lying position
After acute disc symptoms
have settled
• Neural stretches
• Traction
• Core stability as long term prevention
(pilates)
Core stability exercises
Figure 1: Supine
Bent-Knee Raises
Figure 6: Seated Marching on a
Physioball
Figure 2:
Quadruped with
Alternate Arm/Leg
Raises
Neural stretches
Sciatic nerve stretch
Femoral nerve stretch
Disc degeneration
History
• over 45 years of age
• OA spine
• Recurrent lumbar problems
• Reduced lordosis
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
Treatment of disc
degeneration
• Traction
• Mobility exercises
• Strengthening exercises
Differential diagnosis of mechanical back pain
Muscle
strain
Herniated
nucleus
pulposus
Osteoarth
ritis
Spinal
Stenosis
Spondylol
isthesis
Scoliosis
Age
20-40
30-50
>50
>60
20
30
Pain
location
Back
(unilatera
l)
Back, leg
(unilatera
l)
Back
(unilatera
l)
Leg
Back
(bilateral)
Back
Pain
Onset
Acute
Acute
(prior
episodes)
Insidious
Insidious
Insidious
Insidious
Standing
Increase
Decrease
Increase
Increase
Increase
Increase
Sitting
Decrease
Increase
Decrease
Decrease
Decrease
Decrease
Bending
Increase
Increase
Decrease
Decrease
Increase
Increase
SLR
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Plain Xray
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