Prevalance

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The Lumbar Spine
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Introduction

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

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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

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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

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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

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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 wont see is the reduction in metabolism
  and circulation to these areas!

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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

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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

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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

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Mobility exercises
Pelvic tilting
Leg/s to chest
Knee rolling
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Injuries and strains to lumbar facet joints
(including SIJ dysfunction)
Facet joint
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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

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Symptoms

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

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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

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Treatment of facet joint
Hip hitching
Lumbar flexion
Traction
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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.

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OA Spine
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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

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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

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Disc problems

• Prolapsed disc (herniated/bulge/slipped) only
  1 comes from trauma
• History
• Under 45 years of age
• Sedentary occupation
• Gradual onset

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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

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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

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Treatment of prolapsed disc

• Advice to avoid lifting, prolonged sitting
• Encourage prone lying and extension exercises
• Increase exercise tolerance gradually

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Exercises to encourage lumbar extension
Prone lying position
Prone on elbows
Full extension in lying position
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After acute disc symptoms have settled

• Neural stretches
• Traction
• Core stability as long term prevention (pilates)

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Core stability exercises
Figure 2 Quadruped with Alternate Arm/Leg
Raises
Figure 1 Supine Bent-Knee Raises
Figure 6 Seated Marching on a Physioball
Figure 6 Seated Marching on a Physioball
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Neural stretches
Sciatic nerve stretch
Femoral nerve stretch
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Disc degeneration

• History
• over 45 years of age
• OA spine
• Recurrent lumbar problems
• Reduced lordosis

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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

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Treatment of disc degeneration

• Traction
• Mobility exercises
• Strengthening exercises

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Differential diagnosis of mechanical back pain
Muscle strain Herniated nucleus pulposus Osteoarthritis Spinal Stenosis Spondylolisthesis Scoliosis
Age 20-40 30-50 gt50 gt60 20 30
Pain location Back (unilateral) Back, leg (unilateral) Back (unilateral) Leg (bilateral) Back 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 _ _ _ _
Plain X-ray - -