Low Back Pain: Diagnosis and Treatment

• The lecture aims to enable students to explain low back pain (LBP) epidemiology and risk factors
• Students should explain lumbar spine anatomy including arthrokinematic motion
• Students should compare patient symptoms with diagnostic imaging findings
• Students should identify non-musculoskeletal LBP sources during patient examination
• Students should be able to explain difficulties establishing a pathoanatomical source of LBP
• Students should analyze findings of patient-reported outcome measures for LBP
• Students should compare patient characteristics of diagnostic classifications using ICF terminology
• Students should develop a plan of care for patients with LBP according to the Clinical Practice Guideline for Low Back Pain: Revision 2021
• Students should discuss a clinical prediction rule used to identify patients who would benefit from lumbar manipulation

Epidemiology of Low Back Pain

• The estimated 1-year prevalence of low back pain is 8-56% in the U.S.
• The lifetime prevalence of low back pain is 40->60%.
• The worldwide prevalence of low back pain was 619 million in 2020.
• Low back pain is the world's leading cause of disability (YLD).
• Low back pain is the 2nd most common reason for symptomatic physician visits.
• More than 50% of all physical therapy(PT) visits are accounted for by low back pain.
• More than $1 billion is estimated to be spent annually managing LBP in the U.S.
• There is a high rate of persistent pain and recurrence of symptoms with low back pain.

Mechanisms of Injury

• Movements such as lifting, bending, and twisting can cause injury
• Combined bending and twisting, especially with a lifting load, can cause injury
• Trauma from falls, motor vehicle accidents (MVA), or direct blows
• Sustained positioning such as slouched sitting or forward bending

Types of Low Back Pain

• Nociceptive pain is associated with facet joints, discs, muscles, and ligaments and manifests as dull, aching local low back pain with a result of nociceptor activation
• Somatic referred pain is associated with facet joints, discs, muscles, and ligaments and manifests as dull, aching pain in the back, buttock, and leg due to nerve root convergence
• Radicular (neuropathic) pain is associated with an inflamed nerve root, such as from herniated nucleus pulposus (HNP), manifests as lancinating, shooting, or burning pain radiating in a 2-3" band down the leg because the nerve is irritated but not compressed
• Radiculopathy involves compression of a spinal nerve root due to HNP or spondylosis, manifests as dermatomal numbness and altered DTRs in the nerve root with or without radicular pain

Risk Factors for an Episode of Low Back Pain

• Prolonged standing or walking
• Occupations requiring heavy or repetitive lifting
• Lifestyle factors such as obesity and smoking
• Depression
• Job dissatisfaction
• Previous episodes of LBP.

Risk Factors for Developing Chronic Low Back Pain

• Genetic factors
• Being female
• Lifestyle factors such as obesity, sedentary behavior, and smoking
• Psychosocial factors such as anxiety, depression, catastrophizing, and kinesiophobia
• Poor coping strategies, including fear-avoidance behavior
• Traumatic mechanisms of injury (MOI)
• Occupational factors such as manual labor and job dissatisfaction
• Secondary gain
• Higher disease burden
• High baseline pain and disability
• Opioid use

Sources of Pain in the Lower Back

• Vertebrogenic pain arises from compression fractures, microfractures, and endplate degeneration
• Treatments targeting the vertebral body nerve supply have shown effectiveness in preliminary studies
• Presentation and affected levels are similar to discogenic low back pain
• In contrast to facet joint and sacroiliac joint pain, discogenic pain is more likely to be bilateral or symmetrical in nature
• Spinal stenosis can be caused by bulging or protruding discs, hypertrophy of facet joints, epidural lipomatosis, or ligamentum flavum buckling or hypertrophy
• Spinal stenosis can be subclassified as central, foraminal, or affecting the lateral recesses.
• More than 50% of people with spinal stenosis could be asymptomatic
• Foraminal stenosis relates to a neuroforaminal diameter of <3 mm.
• Common causes of radicular pain are herniated nucleus pulposus (mechanical and chemical irritation) and spinal stenosis (chronic nerve root compression or ischaemia).
• The pathoanatomic relationship between patients' perceived cause of back pain and the actual cause is often unclear
• Zygapophyseal (facet) joints are susceptible to osteoarthritic changes
• Disc degeneration (without pain) typically precedes and can accelerate facet joint arthropathy
• The pain referral patterns for zygapophyseal joints and discogenic pain are variable,. depending on the level or levels affected and the magnitude of the stimulus

Identifiable Pathoanatomical Source of LBP

• An identifiable pathoanatomical source exists in less than 10% of cases.

Nonspecific Low Back Pain

• It is difficult to determine the tissue causing low back pain
• Many pain-sensitive tissues exist
• It is difficult to isolate the tissues in provocative tests
• There is poor coorelation between the findings on diagnostic imaging and symptoms
• 37% of 20-year-old, 80% of 50-year-old, and 96% of 80-year-old asymptomatic individuals had signs of disc degeneration on MRI

Imaging Abnormalities in Asymptomatic People

• In asymptomatic people, the prevalence of disk degeneration increases with age, ranging from 37% at age 20 to 96% at age 80
• The prevalence of disc signal loss in asymptomatic individuals increases with age, ranging from 17% at age 20 to 97% at age 80
• The prevalence of disc height loss in asymptomatic individuals increases with age, ranging from 24% at age 20 to 84% at age 80
• Disk bulge prevalence rates increase from 30% at age 20 to 84% at age 80 in asymptomatic individuals
• Disk protrusion prevalence rates are between 29-43% for asymptomatic people aged 20-80
• The prevalence of annular fissure in asymptomatic individuals ranges from 19% at age 20 to 29% at age 80
• The prevalence of facet degeneration in asymptomatic people increases with age, ranging from 4% at age 20 to 83% at age 80
• Spondylolisthesis prevalence ranges in asymptomatic people from 3% at age 20 to 50% at age 80

The Lumbar Motion Segment

• The lumbar motion segment consists of three articulations between two adjacent vertebrae
• These articulations include a left zygapophyseal joint, a right zygapophyseal joint, and an intervertebral joint

Lumbar Zygapophyseal Joints

• Characteristics include synovial joints, articular cartilage, synovial membrane/fluid, a capsule reinforced by the multifidus muscle, and meniscoid tissue.
• Orientation is primarily in the sagittal plane but more coronal orientation inferiorly
• Innervated by medial branches of dorsal rami.

Intervertebral Disc

• The intervertebral disc comprises a nucleus pulposus (semifluid gel with hydrodynamic properties) and an annulus fibrosus
• The annulus fibrosis is composed of lamellae: sheets of fibrocartilage arranged in alternating layers
• Fibers run at an inclination of ~65-70 degrees from vertical
• Outer fibers innervated
• The vertebral endplate attaches the IVD to the bodies and allows for diffusion of nutrients and metabolites; includes ring apophysis and Sharpey's fibers.

Superficial Lumbar Musculature

• Acts as global stabilizers
• Controls movement across multiple segments

Deep Lumbar Musculature

• Serves as local stabilizers
• Provides segmental control

Ligaments

• Allow the spine to be flexible while maintaining alignment.
• Provide restraint at end ranges of motion
• Support intervertebral discs and facet joints

Lumbar Arthrokinematics

• Two primary motions of facet joints include translation (sliding) and distraction (gapping).
• Zygapophyseal motion occurs during flexion, extension, lateral flexion, and rotation

Coupled Motions

• In neutral or extension, rotation and sidebending occur in opposite directions
• Left lumbar rotation is accompanied by right sidebending
• In flexion, rotation and sidebending occur in the same direction
• Left lumbar rotation is accompanied by left sidebending

Managing Low Back Pain

• Management of low back pain relies on patient-centered care and shared decision-making
• Utilization of validated outcome measures.
• Screening for patient prognosis factors of poor outcomes informs an appropriate management approach
• Integrates treatment and mechanism-based classifications
• Red flags and mental health comorbidities should be screened for and monitored
• A thorough history and physical assessment should be completed that include neurological deficits and psychosocial factors
• Clinicians should avoid routinely offering imaging procedures

Treatment Recommendations for Low Back Pain

• Should provide self-management strategies
• Should adopt a cognitive-behavioral approach when appropriate
• Should consider referring the patient to an appropriate health professional
• The clinician should foster understanding via education
• A personalized exercise program should be prepared
• Judicious use should be made of manual therapy
• Return to work and usual activities should be promoted

Nonspecific Low Back Pain Prognostic Trajectory

• Recovery: rapid or gradual recovery with little or no pain in most patients
• 70% of patients with acute pain recover and 30% with chronic pain recover
• Ongoing: moderate or fluctuating pain in 39-43% of patients
• Persistent: chronic severe issues with limited recovery in 16-17% of patients
• 40-50% with chronic pain

History & Interview

• Obtain MOI/nature of condition including if it is acute/chronic/insidious, trauma, or ligament testing
• Focus on pain assessment including location and severity
• Enquire about aggravating/relieving factors and functional limitations
• Focus on the patient's values.
• Screen for appropriateness for PT & if there is a need for referral/consultation, particularly regarding red and yellow flags
• Screen for the risk of symptoms/disability becoming chronic

LBP Red Flags: Neoplasm

• Previous history of cancer
• Age >50 or <17
• Constant pain that does not improve with rest
• Night pain
• Unexplained weight loss
• Failure to improve over an expected time period

LBP Red Flags: Abdominal Aortic Aneurysm (AAA)

• Throbbing, pulsing LBP that occurs at rest or when recumbent
• Pulsing mass in the abdomen
• Risk Factors include a history of atherosclerotic vascular disease, HTN, age > 60, being male, Hx smoking, use of statins, and familial Hx of AAA

LBP Red Flags: Infection

• Disc (Discitis) or Bone (Osteomyelitis)
• Prolonged fever >100.4°
• History of IV drug abuse
• Recent infection such as UTI, Pneumonia or cellulitis
• Immunosuppressed patient

LBP Red Flags: Undiagnosed Fracture

• Prolonged use of corticosteroids
• Age > 70
• Mild trauma in patients >50 years old
• History of osteoporosis
• Recent major trauma
• Motor Vehicle Accident (MVA)
• Fall from >5 feet
• Bruising &/or abrasion over the spine post-trauma

LBP Red Flags: Cauda Equina Syndrome

• Caused by HNP, trauma, tumor, fracture, stenosis, infection
• Look for signs and symptoms like LBP +/- LE pain, urinary retention or incontinence, fecal retention or incontinence, paresthesias in saddle distribution, motor or sensory loss in B/L LES, and gait dysfunction
• Immediately refer for medical work-up/imaging if suspected

Screening for Yellow Flags

• Identify pain associated psychosocial factors
• Psychologically informed practice:
• Modify treatment approach to prevent delayed recovery or transition to chronic pain/disability
• Identify modifiable psychological risk factors and address them during care.
• May include cognitive-behavioral approaches during treatment -Modify maladaptive thoughts, emotions, and behaviors -Promote adaptive behaviors- active coping strategies, pacing -Graded activity -Graded exposure

Psychosocial Factors

• Yellow Flags: Emotional distress, pre-occupation with pain, pain catastrophizing, elevated fear-avoidance beliefs, kinesiophobia, low self-efficacy, incorrect beliefs about the best strategies to treat pain, incorrect beliefs about severity of injury & impact of pain.
• Blue Flags: Dissatisfaction in current occupation, conflict in workplace

StarT Back Screening Tool (SBST)

• Allows the stratification of patients based upon risk of developing persistent pain & disability
• Influences management strategy
• Has two scores: Total & Psych sub-score

STarT Back Tool Scoring System

• A low risk score leads to self-management, assurance of findings, education on the natural course of recovery during an episode of LBP
• A medium is score means a course of PT to address impairments, focus on improving function, referral to orthopedic or spine specialist as needed
• A high risk score has Physical Therapy with a greater emphasis on psychosocial factors and active involvement of the patient in their treatment; education on changing unhealthy beliefs about pain and activity

STarT Back Screening Tool Predictive Ability

• Non-formative for discriminating pain outcomes at follow-up, with a pooled AUC=0.59 (0.55-0.63), n=1153
• Acceptable for discriminating disability outcomes, with a pooled AUC=0.74 (0.66-0.82), n=821
• Patient classification can change over time and has been shown to improve in response to physical therapy

Örebro Musculoskeletal Pain Questionnaire

• It involves 25 items (4 descriptive; 21 scored) with a score ranging from 2-210
• Focus on function (Ability to perform ADLs), psychosocial factors (Fear-avoidance, coping strategies), and work experience (Job satisfaction, number of sick days used)
• Scores are grouped according to risk for developing persistent pain & disability Low risk is a score of Low risk 90-105, while a high risk score is >105

Optimal Screening for Prediction of Referral and Outcome Yellow Flag tool (OSPRO-YF)

• Is used to predict 12-month pain intensity, disability, and QoL (physical & mental) outcomes
• It has 17 Items that correctly identified 85% of positive responders 6 are from negative affect, 6 from fear avoidance, and 5 are from positive affect/coping
• Shorter versions of the tool are also effective, with 10 items correctly identified at 81% and 7 items correctly identified at 75%

Lower Quarter Screen

• Used to screen for spinal nerve root radiculopathy vs peripheral neuropathy
• Includes components such as myotomes, dermatomes, and deep tendon reflexes (DTRs)

Postural Assessment

• Observe from anterior, posterior, and side views
• Note the quality of lordotic and kyphotic curves of the spine, including hyperlordosis and hypolordosis
• Note to observe a lateral shift and can be named and observed towards or away from pain

Lateral Shift

• Named according to which side shoulders are deviated toward
• Can be towards or away from pain from patient
• Must be easily visible
• Correlates with the onset of symptoms
• Is unable to self-correct or the patient is unable to maintain correction

Active Motion Assessment

• It is important to assess the quality and quantity of motion
• Note pain during and/or at end-range of movement.
• Be sure to observe for aberrant motion such as flexing knees instead of forward bending at the spine or painful arc or juddering/shaking
• Reference Dutton Tables 28-10 & 28-11 for normative values

Patient Reported Outcome Measures for LBP

• Roland-Morris Disability Questionnaire (RMDQ) and Oswestry Low Back Disability Questionnaire (aka Oswestry Disability Index, or ODI)

Roland-Morris Questionnaire

• Is comprised of 24 items related to pain and function
• Scores range from 0-24 (24 max disability/pain)
• MDC = 5 points (Minimum Detectable Change)
• MCID is dependent upon the initial score (Minimum Clinically Important Difference) 2-3 points for a score less than 9, 5-9 points for a score between 9-16, and 8-13 points for scores greater than 16
• Reference Dutton Table 28-14

Oswestry Low Back Disability Questionnaire

• Comprised of 10 sections related to ADLs and pain with 6 statements per section
• Sections are scored 0-5 (total score x2 = % disability)
• Scores range from 0 - 100 (100 = max disability/pain)
• MCID = 4-10 points; MDC = 5-6 points
• Reference Dutton Table 5-2

Radiology

• Multiple Clinical Practice Guidelines recommend against the use of routine imaging for nonspecific LBP
• Imaging is indicated in the presence of red flags, progressive neurologic deficits, and failure to improve with conservative care.
• Includes types like X-ray, CT, MRI,Bone scan (SPECT), Myelography, and DXA

Low Back Pain with Mobility Deficits

• Associated ICD-10 diagnostic category: Lumbosacral segmental/somatic dysfunction
• Patient characteristics: Central &/or unilateral LBP, decreased lumbar ROM, decreased lumbar segmental mobility, and concordant symptoms reproduced with end-range motions & spring testing

Useful Physical Examination Tests

• Lumbar AROM (Active Range of Motion) and Segmental Mobility Assessment:
• Assessment includes Passive Physiological Intervertebral Motion (PPIVMs), including osteokinematic motion like flexion/rotation. Also includes Passive Accessory Intervertebral Motion (PAIVMs), including the assessment of arthrokinematic motion (gliding)

Passive Physiological Intervertebral Motion (PPIVMs)

• Lumbar motion segments are passively moved via the LEs and pelvis
• The therapist assesses each segment for quantity of motion, quality of motion through range, and end-feel

Passive Accessory Intervertebral Motion (PAIVMs)/ Spring Testing

• Pressure is applied to spinous or transverse processes, or articular pillars via thumbs or pisiform
• The therapist assesses the quantity of motion, tissue response/irritability, and the end-feel
• Can be used to identify concordant pain

Segmental Mobility Assessment

• Has been determined to have questionable validity
• Poor correlation between therapist measure of mobility and vertebral displacement on dynamic MRI
• There is poor inter-rater reliability
• The agreement comes on detecting hypomobility better than hypermobility
• There has been been found to have fair to good intra-rater reliability
• Symptom provocation is more reliable than motion testing

Low Back Pain with Movement Coordination Impairments

• Patient Characteristics: Recurring episodes of LBP, with mid-range pain that worsens at the end-range
• Patients exhibit pain and decreased tolerance to sustained postures, as well as lumbar segmental hypermobility and hypomobility of the thorax and pelvis/hip.
• DEcreased trunk and pelvic strength and endurance cause aberrant motion during trunk AROM & functional tasks, while endrange motions can reproduce symptoms

Useful Physical Examination Tests

• Assessment of aberrant motion during active lumbar motions
• Prone Instability Test
• Trunk muscle power & endurance tests
• Segmental mobility assessment

Low Back Pain with Radiating Pain

• Associated ICD-10 diagnostic categories: Flatback syndrome, lumbago due to displacement of intervertebral disc, and lumbago with sciatica
• Patient Characteristics: LBP + Lower Extremity Symptoms that can be referred or radicular in quality, as well as possible numbness or paresthesias
• Lumbar motion may centralize or peripheralize symptoms, including signs of nerve root compression as well as Neurodynamic tests

Useful Physical Examination Tests

• Includes the Lower quarter screen that assesses weakness of myotome, sensory change in dermatome, and altered DTRS
• Also includes the use of Neurodynamic assessment and the Assessment of symptom response to repeated lumbar movements

Neurodynamic Assessment

• Tests to assess include and SLR, Crossed-SLR, slump, and prone knee bend
• A Test is considered (+) with the reproduction of the patient's concordant symptoms, symptoms change in response to sensitizing maneuvers, and the difference between limbs

Straight Leg Raise Test

• The involved limb is passively moved into hip flexion with knee extended and ankle in neutral dorsiflexion
• Between 30-70 degrees increased tension is placed on spinal nerves and dura of L4-S2, while pain produced from 0-30 degrees may indicate gluteal tumor or abscess, very large HNP, acute spondylolisthesis, dural inflammation, or malingering
• Sensitizing Maneuvers: ankle DF, cervical flexion -High Sensitivity: Sn 0.92

Crossed Straight Leg Raise Test

• Is performed in the same fashion as the SLR, but on the uninvolved LE
• A (+) is test is described as the reproduction of concordant symptoms in the painful LE
• It also has a High specificity: Sp is recorded as 0.90

Slump Test

• The Patient is sitting positioned with their arms behind back
• The Patient assumes slumped posture, and the clinician adds cervical flexion and holds
• The clinician then adds the knee extension and holds it, followed by the ankle DF and holds Sensitizing Maneuvers include cervical extension and the test yields Sp 0.91, Sn 0.91; LR+ 3.03, LR- 0.13.

Low Back Pain with Related Cognitive or Affective Tendencies

• This issue is related to the diagnostic categories of low back pain, low back strain, and lumbago
• Patient Characteristics: Acute or subacute LBP +/- Lower Extremity Symptoms that can be referred or radicular in quality Presence of multiple yellow flags

Useful Physical Examination Tests

• Includes Clinical sensory testing as well includes allodynia and hyperalgesia
• Assess for the presence of yellow flags using OSPRO-YF and FABQ
• Consider the need for multidisciplinary management to prevent transition to chronic pain/disability

Chronic Low Back Pain with Related Generalized Pain

• Associated diagnostic categories of low back pain, low back strain, and lumbago
• Patient Characteristics: LBP +/- Lower Extremity Symptoms present with symptoms that last longer than 3 months and Can be referred or radicular in quality
• Also includes the Presence of multiple yellow flags including Fear avoidance behaviors,Pain catastrophizing, and then depression

Useful Physical Examination Tests

• Clinical sensory testing assessing Allodynia and hyperalgesia
• Presence of yellow flags (OSPRO-YF, FABQ)
• Possible need for multidisciplinary management Individualized to patient's needs, values, & goals

What To Do with managing patients low back pain

• Patient-centered care while utilizing shared decision making
• Consider communicating and educating the patient to support and empower as well have the patient participate in the best managing based on evidence

Base treatment on:

-Symptom behavior and patient characteristics -Pain intensity and tissue irritability -Functional deficits or impairments in Mobility,Strength and Movement Control

Acute Low Back Pain: Interventions

-Exercise that in local low back pain has a Weak Evidence score (C), and pain with Lower Extremity pain has a Moderate Evidence score (B) -Manual therapy that with Thrust/Non-thrust joint mobilization has a Strong Evidence score (A), and Soft Tissue Mobilization has a Moderate Evidence score (B)

• Provide education. has a Moderate Evidence score (B)

Chronic Low Back Pain: Interventions

-Exercise for general lumbosacral and the lower extremity has both Strong (A) and moderate (B) evidence for effectiveness

• Manual therapy, Thrust/Nonthrust joint mobilization has a Strong Evidence score (A), along with STM with a Moderate Evidence score (B)
• Neural mobilization has a Moderate Evidence score (B) and Dry Needling has a Weak Evidence score (C)
• Education to have a combined score between Strong an Moderate between grades A and B.

Key Interventions

• Pain Modulation: Grade I/II Mobilization, Grade V HVLA, Soft tissue mobilization, and Neurodynamics
• Movement Control: Grade III/IV Mobilization, Grade V HVLA, Soft tissue mobilization, and Neurodynamics
• Optimization of Task-Specific Training Activation,Acquisition, and Assimilation includes Therapeutic Exercise (Mid to High intensity) and Patient Education along with PNF and NMES Gait & Functional Training

Lumbar Manipulation CPR

• Symptoms <16 days with no symptoms distal to the knee, along with
• FABQ work subscale <19 that present Hypomobility ≥ 1 lumbar segment and Hip IR >35°at least one side are indicators that variables present at a >4/5=95% probability of success at LR=24.58 with a Success=≥50% reduction on ODI

Lumbar Manipulation CPR Findings

• It is unknown as if one manipulative technique has been found to be better than anothers, that which works best for the therapist and patient -Cavitation is the result of the formation of a gas bubble in a joint along with no relationship between cavitation or the treatment and improvement - that included those 71 w/General lumbopelvic manipulation(Kawchuk et al) -Thrust had met the patient selection criteria similarly to non-thrust mobilization procedures that have been shown to produce equal results

Findings:

• Lumbar Manipulation CPR- It is unknown as to if the there is an improvement from thrust and non thrust as both had criteria with equal results and no pain reduction by means of the thrust

Soft Tissue Mobilization

• Uses pain modulation, and then reduces hypertonicity for short intervals
• Not effective with reducing adhesions in myofascia and requires more than 9075N to compress.

Common Misconception

• It requires 9075N of force (2040 lbs) to produce 1% compression of TFL and STM and release does not break up scar tissue and adhesions in myofascia!!

Neuronal Mobilization

Neuronal Mobilization may aid in reducing treatment for neural mobilization