Low Back Pain

Question 1

epidemiology

Answer 1

back pain happens a whole lot.

Mostly to 45-60 y/o caucasians.

fitness level is correlated, not much else is.

Question 2

resolution of back pain

Answer 2

most episodes of LBP or sciatica resolve spontaneously within the first 2 weeks and a relative minority take 6-12 weeks.
only 1-2% require evaluation for surgical procedures.
interestingly, herniated disc intervention has better 3 month symptom relief but no difference at 1 year with non-surgical intervention.

Question 3

acute low back pain definition

Answer 3

Acute LBP is defined as activity intolerance due to back-related symptoms less than 3 months duration

Question 4

Risks for chronic disability

Answer 4

Clinical Factors:
previous episodes of back pain
mult previous msk complaints
Psych history
ETOH, drugs, cigarettes

Pain Experience:
Rate pain as severe
Maladaptive pain beliefs (pain will not improve; needs invasive)
Legal issues or compensation

Premorbid Factors:
Rate job as physically demanding
believe they will not be working in 6 months
Do not get along with co-workers or supervisor
near to retirement
FamHx of depression
enabling significant other
mutliple marriages or single
low socioeconomic status
troubled childhood

Question 5

Important parts of the history

Answer 5

Is the pain reproduced in a specific anatomic structure?
Is there a neurologic deficit?
Are there any clues to a dangerous systemic disorder?
What is the extent and appropriateness of the patient’s pain behavior?
Is there an associated headache?

Question 6

red flags

Answer 6

History:

 - Cancer
 - unexplained weight loss
 - immunosuppression
 - chronic steroids
 - IVDA
 - UTI
 - pain inc/unrelieved by rest
 - fever
 - significant trauma for age
 - bladder/bowel incontinence
 - urinary retention w/ overflow incontinence

PE:

 - saddle anesthesia
 - loss of sphincter tone
 - major motor weakness in LE
 - vertebral tenderness
 - limited spinal range of motion
 - neurological findings beyond a month

Question 7

Clinical clues from history and exam

Answer 7

aching/throbbing suggests mechanical
worse with movement; improves rest
long sitting/flexion aggravates disc
shooting/stabbing suggest radicular
Specialized testing
Reflexes
Waddell’s signs

Question 8

Sacroiliac Joint

Answer 8

up to 30% LBP (way higher in pregnancy)
L- shaped articulation
1-2 mm wide
Diarthroidial and Synovial joint
hyaline cartilage
Fibrocartilage
anatomic variability
Changes in 3rd decade
gravitational stress
increased size and number of ridges
thickened capsule
accessory articulations

Question 9

Functional Anatomy of sacroiliac joint

Answer 9

self locking
Form closure: “keystone” anatomy
Force closure: ligaments/muscles

Question 10

variations in the sacroiliac joint

Answer 10

bigger transverse process on one side or other or both, can have articulation on one or both sides
one bigger transverse process can bridge and fuse with sacrum (sacralization- L5 functions as first sacral segment)

Question 11

Disc bulge/ herniation with pain findings

Answer 11

Back pain only- disc dengeneration
back pain + leg pain- prolapse
LBP + LP + hard neuro findings- extrusion
Mostly leg pain- sequestration

Question 12

Herniation

Answer 12

for both cervical and lumbosacral disc herniations the nerve root involved usually corresponds to the lower of the adjacent two vertebra.

Question 13

Cauda Equina Syndrome

Answer 13

Compression to multiple lumbosacral nerve roots and/or spinal cord within spinal canal
May occur due to herniated lumbar intervertebral disk, lumbosacral fracture, spinal canal hematoma (following lumbar puncture), compressive mass/tumor
Produces low back pain, leg weakness/areflexia, saddle anesthesia and loss of bladder/bowel control

Always ask about a loss of bladder/bowel control when evaluating patient with low back pain!!!!
Surgical emergency-need to undergo surgical decompression within 6 (up to 48?) hours to prevent permanent neurologic injury

Question 14

Spondylolysis

Answer 14

The majority occur at L5
Frequently seen with activities involving repetitive axial spine compression, extension, rotation or bending
Seen in gymnasts, dancers, divers, football lineman and linebackers, competitive divers, weight lifters, pole vaulters and anyone who repetitively jumps
May be present unilateral or bilateral
Associated with pain near midline of back
Increased pain with extension and rotation
Positive one-legged hyperextension test (STORK sign)

Question 15

What to do for spondylolysis

Answer 15

Treated like a fracture
Discontinue aggravating activity
Rehabilitative exercise to improve core function
Gentle OMM – counterstrain and indirect myofascial release work well for symptomatic relief. Avoid HVLA!
Bracing used if no response to 1 month of above treatment
Occasionally surgery

Question 16

Spondylolisthesis

Answer 16

Sliding (usually anterior) of one vertebrae over another
May be congenital or acquired
Acquired
Traumatic due to bilateral spondylolysis
Degenerative due to apophyseal joint degeneration
Diagnosed via x-ray
Tx: conservative to surgery

Question 17

L4 neurologic level

Answer 17

Quads/Tibialis Anterior
Patellar reflex
Sensory Great toe and medial leg

Question 18

L5 neurologic level

Answer 18

Strength of Ankle and great toe dorsiflexion
Extensor Hallucis Longus
Sensory to dorsum of foot

Question 19

S1 neurologic level

Answer 19

Ankle reflexes and sensation of posterior calf and lateral foot
Peroneals/Gastroc
Achilles reflex
Sensory to lateral and plantar foot

Question 20

Straight leg raise test

Answer 20

= Lasegue Test, = Bragard Test

raising up leg, looking for discomfort and symptomology between 30 and 70 degrees –> indicative of herniation

meta analysis for herniation:
sens 91%
spec 26%

opposite leg:
sens 29%
Spec 88%

Question 21

Femoral stretch test

Answer 21

prone, lift up bent leg.

pain
anterior thigh = L2-3 protrusion
medial leg=L3-L4

Question 22

goals of treatment

Answer 22

Treat segmental upper lumbar dysfunctions
Improve hip extension (iliopsoas tension)
Improve asymmetry/alignment of the innominates
Treat any pubic dysfunction
level the sacral base
Improve cranial motion
Improve abdominal and pelvic diaphragm motion
Resolve anterior or posterior lumbar tenderpoints
Obtain a negative seated flexion test

Question 23

treatment sequence

Answer 23

generally the greatest area of restrictions, if not acutely injured. Leave sacral issues last.
otherwise, there are some different philosophies

Question 24

Dr. Kappler model

Answer 24

Pelvis and Lumbar 1st
Psoas included here
any thoracolumbar areas
Lower extremity imbalance

Question 25

VanBuskirk “Still technique”

Answer 25

Pelvis and lumbar 1st

if done appropriately, then all that should be left is oblique sacrum dysfunctions

Question 26

Greenman’s Dirty Half Dozen

Answer 26

For failed Low Back Syndrome
Muscle imbalance of the trunk and LE (90%)
Nonneutral (Type II) dysfunction of lumbar spine, primarily FRS in the L4-L5 area (85%)
Dysfunction of symphysis pubis (76%)
Short-leg, pelvic-tilt syndrome (63%)
Restriction of anterior movement of the sacral base (49%)
Innominate shear dysfunction (15%)

Question 27

Anterior Lumbar Tender Points

Answer 27

L1- medial to ASIS
L2- medial to AIIS
L3- lateral to AIIS
L4- inferior to AIIS
L5- anterior aspect of pubic symphysis

Patient Position: Supine
Initial Position: Hips and knees in flexion, rotation and sidebending of pelvis as needed
Involved muscles: internal obique, external oblique, rectus abdominis, iliacus

Question 28

Quadratus Lumborum

Answer 28

Origin:
Post iliac crest and iliolumbar ligament
Insertion:
12th rib 
transverse process L1-4
Action:
lateral side bends and fixes 12th rib
Innervation:
subcostal nerve and ventral primary rami of spinal nerves of L1-4

Question 29

Quadratus Lumborum - ME

Answer 29

QL dysfunction side up
have patient flex and hold the down side knee to body.
Adduction of upper leg with some mild extension off table and physician stabilizes leg btw their legs
pt raises lesion side arm above head
ME technique is to have patient ‘hitch’ iliac crest up while physician has an inferior force to counteract.

Question 30

(Ilio) Psoas

Answer 30

Psoas Major muscle
originates on the vertebral bodies, disks and transverse processes of lumbar vertebrae
inserts on lesser trochanter of femur
Innervation L2-L4
Actions
flexing thigh and trunk and sidebending lumbar spine

Question 31

Psoas Syndrome

Answer 31

may occur when patient sits for a long time, leaning fwd for a long time, lifting while leaning fwd and doing sit-ups with hips and knees extended (legs straight)
produces pain that may radiate to the anterior thigh (via irritation of lumbar plexus)
on exam, may find increased tension in one or both psoas major muscles. Frequently find decreased hip extension
Frequently Type II dysfunction at L1 and/or L2 that is flexed, sidebent and rotated toward the side of the tighter psoas major muscle.
may be assoc with innominate and sacral dysfunction
may see assoc piriformis irritation (sacrum) on the side opposite the tight psoas
responds to OMM and exercise

Question 32

Psoas ME technique

Answer 32

Acute
pt flexes hip and knee on opposite side.
have affected side limb pushed towards the floor (extending into barrier)
have patient flex the affected side hip

Chronic of Subacute
prone and pull up on affected side knee/thigh monitoring psoas/upper glut
have pt pull leg down to table

Question 33

Anterior pelvic tender points

Answer 33

x

Question 34

Piriformis

Answer 34

Originates on anterior surface of sacrum
Inserts onto greater trochanter of femur
Innervation L5, S1-S2
Action
Extended hip - externally rotates thigh
flexed hip – abducts thigh

Question 35

Piriformis syndrome

Answer 35

Buttock and/or posterior thigh pain due to dysfunction (spasm) of the piriformis muscle and irritation of the sciatic nerve.
+/- trauma
may be induced by prolonged sitting, esp on a wallet
Frequently associated with sacral/innominate dysfunction
responds well to OMM

Question 36

Piriformis ME

Answer 36

cross affected leg over other leg and engage ext rotator with further int rotation/adduction
have pt abduct knee

Question 37

Iliolumbar ligament

Answer 37

runs between the transverse processes of L4 and L5 and the ilium
continuous with the anterior sacroiliac ligament

Question 38

Iliolumbar ligament syndrome

Answer 38

May become irritated due to rotation and sidebending of L4 and L5 to the side opposite to the tight and tender ligament
Example-left sidebending and rotation of L4 or L5 will tend to irritate right iliolumbar ligament
May also become bilaterally irritated due to anterior translation of L4 and L5 due to spondylolisthesis
May be associated with pain in the sacroiliac area, posterior thigh and/or inguinal regions (may mimic an inguinal hernia)
On palpation, commonly find a tenderpoint 1-inch superior and lateral to the PSIS
Responds well to counterstrain. Don’t forget to treat associated dysfunction in the lumbar spine, sacrum and innominates
Consider trigger point injection if nonresponsive

Question 39

iliolumbar ligament CS

Answer 39

prone
affected leg abduct to barrier
then extend hip/leg to point

Question 40

Sacrum

Answer 40

should be an oblique dysfunction (if any) at this point but check pubic area first

ME: Forward Torsion = UUU or DDD
Backward Torsion = DUD
where……axis, face, force of DO is order