Low Back Pain PDF

Low Back Pain ‫ ﻋﻠﻲ ﺣﺴﯿﻦ اﻟﺤﺎﻓﻆ‬.‫د‬ low back pain is defined as "pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. Leg pain is a frequent accompaniment to low back pain, arising from diso...

Low Back Pain ‫ ﻋﻠﻲ ﺣﺴﯿﻦ اﻟﺤﺎﻓﻆ‬.‫د‬ low back pain is defined as "pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. Leg pain is a frequent accompaniment to low back pain, arising from disorders of neural or musculoskeletal structures of the lumbar spine. The most common form of LBP is the one that is called "non-specific LBP" accounts for over 90% of patients presenting to primary care and is defined as "LBP not attributed to recognizable, known specific pathology. Those specific pathologies can be defined as:  Radiculopathy  Disc herniation  Lumbar spinal stenosis  Spondylolisthesis  Ankylosing spondylitis  Osteoporosis  Lumbar spine fracture  Skeletal metastases  Cauda equina syndrome  Scheuermans disease  Scoliosis Epidemiology  Low back pain (LBP) is the fifth most common reason for physician visits.  A significant number of 84% adolescents experience back pain.  Some studies have shown that up to 23% of the world's adults suffer from chronic low back pain.  Chronic LBP patients have a high risk of recurrence.  LBP can lead to disability in a substantial portion of the population 11- 12%.  Serious causes 1-2% of LBP cases. (e.g., fracture, cancer, infection, ankylosing spondylitis).  Specific causes 5-10% of LBP cases of back pain with neurological deficits (e.g., radiculopathy, cauda equina syndrome). 1   The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups.  CLBP prevalence varies according to the age being three to four times higher in individuals aged over 50 compared to those aged 18 to 30. Classification Based on duration since onset, LBP can be classified as: Acute low back pain is an episode of low back pain for less than 6 weeks. Sub-acute low back pain between 6 and 12 weeks. Chronic low back pain for 12 weeks or more. Clinical Presentation Pain in the lower area of the back (lumbar and sacroiliac regions) and it may radiate in the lower extremities. Difficulty maintaining the neutral position and/or to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities. Carrying objects in the arms, or bending can also provoke complaints. Daily activities, such as cleaning, sports and other recreational occupations can become a big task for people with CLBP. When pain is generalized, sensory experiences of the patient can also become altered. Chronic low back pain has a significant impact on functional capacity and occupational activities, and can also be influenced by psychological factors, such as stress, depression and/or anxiety. Red Flags: Although uncommon serious spinal conditions may present as LBP: o Cauda equina syndrome o Cancer o Ankylosing spondylitis o Lumbar Spinal Stenosis o Lumbar disc herniation o Lumbar Spine Fracture o Spondylodiscitis o Abdominal Aortic Aneurysm 2 Management Management strategies are typically categorized into conservative and invasive approaches, often starting with the least invasive methods. Recent guidelines recommend advice and non-pharmacological management such as physiotherapy interventions that include exercise, physical activity, education and manual therapy. Assessment 1. Posture and Gait Assessment Assess the patient's overall posture, including any deviations from a neutral alignment: look for signs of hyperlordosis, kyphosis, or scoliosis. Patient's gait for any abnormalities such as: limping, asymmetry, or compensatory movements. 2. Range of Motion (ROM) Assessment  Lumbar spine: assess flexion, extension, lateral flexion, and rotation.  Hip joint: assess flexion, extension, abduction, adduction, internal rotation, and external rotation. 3. Muscle Strength Testing: o Lumbar extensors: Test the strength of the erector spinae muscles by having the patient perform prone extensions. o Hip flexors: Test the strength of the iliopsoas muscles by having the patient perform hip flexion in supine. 4. Neurological Examination:  Sensory testing: assess light touch, pinprick, and temperature sensation in the dermatomes corresponding to the lumbar spine.  Motor testing: Test the strength of the muscles innervated by the lumbar nerve roots (e.g., ankle dorsiflexion, toe extension, plantar flexion).  Reflex testing: Test the knee jerk and Achilles tendon reflexes. 5. Palpation:  Palpate the lumbar spine for tenderness, muscle spasm, and bony abnormalities.  Palpate the sacroiliac joints for tenderness. 3 6. Special Tests:  Straight leg raises: Test for nerve root tension by raising the patient's leg while keeping the knee straight.  Crossed SLR: Test for nerve root tension by raising the opposite leg while keeping the knee straight.  Prone knee extension: Test for facet joint irritation by extending the patient's knee while lying prone. 7. Functional Assessment: o Patient's ability to perform activities of daily living (ADLs), such as bending, lifting, and sitting. o Evaluate the patient's work capacity and any limitations related to their occupation. 8. Outcomes Measures: Use validated outcome measurs to assess the patient's pain intensity, disability, and quality of life.  Oswestry Disability Index  Roland Morris Disability Questionnaire  Numeric Pain Rating Scale. Contraindications to ss Physiotherapy There are few contraindications to physiotherapy interventions for mechanical back pain:  Absolute Contraindications Cauda Equina Syndrome Fracture Infection Malignancy Rheumatological Diseases.  Relative Contraindications o Osteoporosis: While not an absolute contraindication, it may require modifications to treatment techniques to minimize the risk of fractures. Osteoporosis is a contraindication to most manual therapy. o Unstable Spinal Joint: If there is evidence of instability in the spine, certain exercises or manual therapy techniques may be avoided. o Severe Neurologic Deficits: If there are significant neurological deficits, such as complete paralysis, physiotherapy may be limited. o Increasing symptoms or adverse events. 4 Prevention of Low Back Pain The guidelines discuss different possibilities to prevent low back pain. Physical exercises is recommended to prevent consequences of low back pain, such as an absence of work and the occurrence of further episodes. Physical exercise is especially useful in training back extensors and trunk flexors in conjunction with regular aerobic training. There is no specific recommendation of exercise frequency or intensity. Lumbar supports, back belts and shoe insoles are not recommended in the prevention of low back pain. Lumbar supports and back belts have also been shown to have a negative effect on back pain beliefs and are therefore are not recommended in preventing low back pain. Specific mattresses and chairs for prevention have no evidence in favour or against. Medium support mattresses may decrease existing persistent symptoms of low back pain. Ergonomic adjustments regarding the work environment can be necessary and useful to achieve earlier return to work. Physical Therapy Management  Patients with CLBP should receive information about effective self-care options and should be advised to remain active (because muscles that do not move can eventually become hypersensitive to pain).  Assessing the response to therapy is focused on improvements in pain, mood, and function.  A multidisciplinary approach in treating chronic low back pain is advised. Physical Therapy consists of:  Exercise therapy, including strengthening, stretching, and aerobic conditioning, is widely recommended for the management of LBP.  Stretching and flexibility exercises: are used to improve hamstring, quadriceps, piriformis, and hip joint range of motion. The aim is to reduce pain, improve movement, and improve functional limitations of movement.  Strengthening and stabilizing the back and abdominal core muscles: produces small improvements in pain and functioning in patients with chronic low back pain.  Core Stabilization: Core strengthening exercises, which include the muscles of the abdomen, pelvis, and lower back, are crucial for maintaining spinal stability and preventing LBP. Core stabilization 5  exercises are shown to enhance trunk muscle endurance, reducing the likelihood of LBP recurrence  Massage is now recommended in both the acute and chronic stages of back pain.  Physical modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions.  Psychosocial Interventions: Addressing psychosocial factors, such as stress, depression, and work dissatisfaction, is increasingly recognized as part of LBP prevention. These factors can contribute to the onset and persistence of LBP. Cognitive-behavioral therapy (CBT) has been shown to be effective in managing LBP by targeting these psychological aspects.  Manipulative therapy such as spinal manipulation or mobilization to reduce pain and improve functional outcomes when used in combination with exercise therapy.  McKenzie Method: Has been shown to be as effective as other exercise therapy.  Acupuncture is no longer supported by the UK and Belgian guidelines but is still supported by the American guidelines state that acupuncture massage and pressure point massage are minimally helpful for reducing CLBP, with benefits lasting for up to one year.  Pilates: There is inconsistent evidence that pilates is effective in reducing pain and disability in people with CLBP, with a lack of long term follow up information. The use of Pilates was found to improve ongoing (LBP) in patients who received conventional physiotherapy treatment, the improvement was most obvious in the female population group. 6   Yoga: Evidence in recent years has suggested yoga to be an efficacious adjunctive treatment for chronic low back pain. Yoga has had a positive impact on pain and function outcomes in patients with CLBP. Yoga should be considered as an adjunct to usual physiotherapy until further higher quality studies have been produced.  Lifestyle Modifications:  Weight management and smoking cessation are important lifestyle changes that help reduce the risk of developing LBP. Obesity places extra strain on the spine, while smoking affects blood flow to spinal discs, leading to degeneration.  Adequate Sleep: Poor sleep quality and inadequate rest have been associated with a higher risk of developing LBP. Ensuring good sleep hygiene and using appropriate bedding may help mitigate this risk. Exercise Protocols After each type of exercise, the patient should records the level of each exercise for each training session during the eight-week period.  Warm-Up: o Back Awareness: Focus on body posture and alignment. o Pelvic Tilt: Practice anterior and posterior pelvic tilts to engage core muscles. o Lumbar Rotation: Gently rotate the trunk to improve mobility. o Arm Movements: Perform overhead and lateral arm raises to warm up the shoulders and upper body. o Whole-Body Movement: Engage in light cardio, such as walking or jogging in place, to increase heart rate.  Core Strengthening:  Back Extensors: Exercises like back extensions, bird-dog, and superman to strengthen the muscles supporting the spine.  Abdominals: Crunches, planks, and leg raises to engage the core muscles.  Lateral Buttocks: Side planks and hip abductions to target the gluteus medius.  Trunk Rotators: Russian twists and oblique crunches to improve rotational strength.  Posterior Buttocks: Hip thrusts and bridges to strengthen the gluteus maximus. 7   Leg Muscles: Squats, lunges, and calf raises to improve lower body strength and stability.  Well-known exercises targeting the muscles of the back extensors, abdominals, lateral buttocks, trunk rotators, posterior buttocks, leg muscles, oblique abdominals (e.g. the plank, diagonal arm and leg lift).  Flexibility: Hamstring Stretches: Lying hamstring stretch, seated hamstring stretch, and standing hamstring stretch. Quadriceps Stretches: Quadriceps stretch in standing or lying position. Hip Flexor Stretches: Lunge stretch and hip flexor stretch on a table. Calf Stretches: Standing calf stretch against a wall.  Additional Considerations:  Progressive overload: Gradually increase the intensity, duration, or frequency of exercises over time.  Listen to the body: Avoid exercises that cause pain or discomfort.  Proper form: Focus on maintaining correct form to prevent injuries.  Regular practice: Consistency is key for optimal results.  Record progress: Track the progress by noting the level of difficulty for each exercise during each training session. Core muscles The core muscles are involved in maintaining spinal and pelvic stability and can be divided into two groups, according to function.  The first group of muscles is the inner or deep core muscles. This group of muscles is also known as the local stabilizing muscles. The inner core muscles include: o Pelvic floor o Transversus abdominis o Internal Obliques o Diaphragm o Some literature also includes the deep fires of the psoas and the deep hip rotators as part of the inner core. 8   The outer core muscles or the global muscles are also referred to as the "movers" and include:  Rectus abdominis  External obliques  Erector spinae  Quadratus lumborum  Hip muscle groups Typical Core Exercises Bridging Single leg fall out Single Leg Extension in Supine Basic 4 Point Kneeling Advanced 4 Point Kneeling Bridging Progression Onto a Pilates Ball Pilates Ball Plank 9