The Lumbar Spine. Introduction Prevalance Diagnosis of lumbar spine Soft tissue/repetitive strain...
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Transcript of The Lumbar Spine. Introduction Prevalance Diagnosis of lumbar spine Soft tissue/repetitive strain...
The Lumbar Spine
Introduction
• 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 Pelvic tiltingKnee rolling
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
• 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
Hip hitchingLumbar flexion 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• 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
Full extension in lying position
Prone on elbows
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 2: Quadruped
with Alternate Arm/Leg Raises
Figure 6: Seated Marching on a Physioball
Figure 6: Seated Marching on a Physioball
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
Osteoarthritis
Spinal Stenosis
Spondylolisthesis
Scoliosis
Age 20-40 30-50 >50 >60 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
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