Low Back Pain Syndrome and Associated Conditions

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Low Back Pain Syndrome and Associated Conditions

• Developed for OUCOM CORE
• by Craig Warren, D.O.
• Edited by Mindy Ford, D.O.
• and the
• CORE Osteopathic Principles and Practices
  Committee

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Low Back Pain

• Annual US prevalence is 15-20
• 2nd most common symptomatic reason for visits to
  primary care physicians.
• 90 of all episodes will resolve within 6 weeks
  regardless of treatment
• 90 of all persons disabled for more than 1 year
  will never work again without intense intervention

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Low Back Pain

• Most common cause of disability in people younger
  than 45.
• 1 of U.S. population is chronically disabled due
  to back problems.
• 1 of U.S. population is temporarily disabled due
  to back problems.

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Definitions

• Acute LBP Back pain lt6 weeks duration
• Subacute LBP back pain gt6 weeks but lt3 months
  duration
• Chronic LBP Back pain disabling the patient from
  some life activity gt3 months
• Recurrent LBP Acute LBP in a patient who has had
  previous episodes of LBP from a similar location,
  with asymptomatic intervening intervals

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Origins of Low Back Pain

• Referred pain from visceral disease
• Non-activity related
• Inflammation
• Infectious/rheumatic
• Osseous
• Acquired defects
• Intra-spinal lesions
• Metabolic disorders

• Activity related spinal disorders
• Disco dural or disco radicular
• Capsuloligamentous
• Stenotic
• Non-organic causes

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Initial Assessment

• Focused HxCC, PMHx, FMHx, PE
• Be aware of Red Flags
• Findings that suggest a serious underlying
  pathology
• Refer to chart on next slide
• In absence of Red Flags, imaging studies and
  further testing not helpful in first 4 weeks.

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Differential Diagnoses

• Aortic Aneurysm
• Tumors/cancer
• Bony metastasis
• Vertebral Osteomyelitis
• Epidural abscess
• Neurofibromatosis
• Pelvic pathology
• Abdominal pathology
• Herniated disc

• Compression fracture
• Rheumatoid arthritis
• Degenerative joint Disease
• Osteoarthritis
• Ankylosing spondylitis
• Cauda equina syndrome
• UTI
• Strain/ sprain

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Viscerosomatic Considerations

• 10 Medical Cause
• UTI/Cystitis/Nephrolithiasis
• Prostatitis
• Endometriosis
• Dysmenorrhea
• Primary cancer metastatic to bone
• Aneurysm

• 90 Musculoskeletal Cause
• Somatic Dysfunction
• Postural Decompensation

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Symptoms of Benign LBP

• Dull and achy quality
• Diffuse aching with associated muscle tenderness
• Exacerbated with movement
• Relieved with rest in recumbent position

• No radiation, paresthesias
• No dermatomal pattern
• Pt. is able to find a position of comfort
• DTR are within normal limits

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General Considerations

• The history is of vital importance.
• Go slowly, be patient. Listen to the patient.
• Goal is to ascertain the cause for low back pain.
• Somatic dysfunction is not a cause for low back
  pain.

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Important aspects of the history

• Age of patient
• Daily activities
• Symptoms
• Pain, paresthesia, radiation, weakness
• Influence of posture/activity
• Bowel/bladder incontinence
• Saddle anesthesia
• ROS, including constitutional, possibly
  gastrointestinal, gynecologic

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Pain History

• Localization
• Where does it hurt? central, unilateral,
  bilateral
• Does the pain go anywhere? upper lumbar, lower
  lumbar, gluteal, perineal, legs
• Onset
• When did the pain start? days, weeks, months,
  years
• How did the pain start? suddenly, gradually
• Severity
• 0-10 Scale Current? Average? Worst?

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Pain History

• Evolution
• How has the pain changed over time?
• Relationship to activity
• What postures or movements worsen the pain?
• Does it hurt to cough or sneeze?
• Does the pain wake you at night?
• What makes the pain better?

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Osteopathic Exam

• General Impression
• Is there a problem?
• What regions exhibit a problem?

• Diagnostic Characteristics
• What
• What are the specific characteristics of the
  identified segment(s)?

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Screening

• Appropriate screening includes the following the
  regions
• Thoracic
• Lumbar
• Sacral
• Pelvic
• Lower extremities

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Physical Exam

• Standing
• Inspection
• Range of motion
• Flexion
• Extension
• Sidebending
• Toe raise
• One legged Extension

• Inspection for deviation, scoliosis, muscle
  wasting. Skin/hair changes
• ROM range, pain, deviation, painful arc.
• Toe raise neurological testing, motor, S1/2
• One leg extension loading of pars
  interarticularis

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Physical Exam

• Supine
• Muscle strength
• Sensory testing
• Plantar reflex
• Sacroiliac joint
• distraction
• Hip joint
• ROM
• Dural tension signs
• SLR
• Sacroiliac screening
• Hip screening
• Dural tension signs L4-S2

• Seated
• Neurological
• Patellar Reflex
• Achilles reflex
• Muscle strength
• Neurological testing
• DTR L4
• Motor L2-S2
• Sensory L2-S2
• Babinski

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Physical Exam

• Prone
• Dural tension signs
• Femoral stretch
• Palpation
• Spinous processes
• Interspinous ligaments
• Iliolumbar ligaments
• Sacroiliac ligaments

• Neurological testing
• DTR S1/2
• Motor L2/3, S1/2
• Dural tension signs L3 nerve root
• Palpation of osseous and ligamentous structures.
  

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LBP Osteopathic Considerations

• What will be your highest yield regions?
• How does previous trauma influence these regions?
• Which 1 or 2 of the aspects below has the
  greatest influence on the patient complaint?
• Pain
• Hyper-sympathetic influence
• Parasympathetic influence
• Fluid Congestion
• Devise a focused examination based on the
  patients complaint
• What are your expected findings?
• Your expected palpatory findings (TART/STAR) ?
• What are the acute or chronic aspects?

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LBP Osteopathic Considerations

• Propose an appropriate differential diagnosis
• Devise an appropriate treatment plan based on
  musculoskeletal components involved in the
  patient complaint
• What are the dose and frequency considerations?
• What are the OP IP ER considerations?
• Devise an appropriate manipulative approach or
  technique w/indications and contraindications
• How are you going to talk to your patient about
  their complaint?
• How will you communicate your findings,
  diagnosis, and treatment to your preceptor?

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Treatment Sequence

• Leg restrictors
• Pubes
• Superior innominate Upslip (shear)
• Lumbar Spine
• Sacrum
• Innominate
• Iliopsoas

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Sequence Rationale

• Leg restrictor muscle problems will affect the
  bony attachments of the innominate, sacrum, and
  pelvis
• Treatment of the innominate, sacrum or pelvis
  will not be as effective without treating leg
  muscles first
• Articular dysfunction will return more rapidly if
  muscular problem not resolved during treatment

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Treatment Techniques

• Techniques that could be used include
• Direct techniques
• HVLA
• Muscle Energy
• Articulatory
• Indirect techniques
• Strain Counterstrain
• Functional Methods

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Muscle Energy Techniques
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MET Lumbar FRLSLSeated Technique

• Patient seated
• left hand holding right shoulder
• Pts right arm dropped at the side
• Operator
• straddles pts left knee left hand grasping the
  pts right shoulder
• Control the pts left shoulder with the left
  axilla
• Right middle finger monitors the L4-5
  interspinous space
• Right index finger monitors the left transverse
  process of L4
• Localization Trunk Translation Anterior to
  Posterior to introduce L4-5 Flexion

Greenman, English 2nd ed., p.282
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MET Lumbar FRLSLSeated Technique

• Pt side bends left against operator resistance
• Isometric contraction, relax, reposition, repeat
  until sidebending rotation resolution

• Forward bend the pt (to fully open zygapophysial
  joints) while maintaining right rotation
• Pt attempts extension

• Pt cooperation Ask the pt to reach for the
  floor to help introduce right sidebending
  rotation

Greenman, English 2nd ed., p.282-3
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MET Lumbar FRLSLLateral Recumbant Technique
Fine tune extension by moving shoulders posterior
to feather edge of L4 movement
Maintain shoulders perpendicular to table for
right sidebending
Fine tune extension by moving shoulders posterior
to feather edge of L4 movement
Fine tune extension from below via the lower
extremities
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MET Lumbar FRLSLLateral Recumbant Technique

• LE abduction enhances R SB from below sets pt
  up for ME effort adduction
• Repeat

• Pt reaches behind under guidance to grasp side of
  table this enhances right rotation sidebending

• Left hand cephalad translation to barrier
  (for right sidebending)
• Right elbow resists pt attempt to turn left
• Repeat

Greenman, English 2nd ed.,p.292
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Neutral Technique Slide
Neutral SRRL
Notice the physicians right arm under the pts
right axilla allows easy sidebending left.
Physicians Left Thumb palpates the posterior
transverse process.
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• Side bend pt. left using easy control via the
  right axilla
• Rotate right by gently carrying the right
  shoulder backward
• Isometric force 3-5 seconds, reposition, repeat

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Lets discuss and practice other techniques
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References

• Ward, R.C., Foundations for Osteopathic Medicine,
  1997, Williams and Wilkins, Baltimore, MD
  337-345, 591-592, 583.
• Acute Low Back Pain, MCARE Guidelines, 2005,
  http//mcare.org/media/pdf_autogen/cpg_lowbackpain
  _mcare05.pdf