Musculoskeletal Physical Therapy: Medical-Surgical Conditions of the Spine PDF

MUSCULOSKELETAL PHYSICAL THERAPY LECTURER: Prof. Yu, PTRP 17 January 2024 MEDICAL-SURGICAL CONDITIONS OF THE SPINE OUTLINE A. Cervical Spine a. Neck Pain b. Neuroanatomy of the Spine c. Bloo...

MUSCULOSKELETAL PHYSICAL THERAPY LECTURER: Prof. Yu, PTRP 17 January 2024 MEDICAL-SURGICAL CONDITIONS OF THE SPINE OUTLINE A. Cervical Spine a. Neck Pain b. Neuroanatomy of the Spine c. Blood Supply of the Cervical Spine d. Nerves of the Cervical Spine e. Pain Generators of the Cervical Spine f. Patterns of Pain in the Zygapophyseal Joints B. Lumbar Spine a. Anatomy and Biomechanics b. Pain Generators of Lumbar Spine c. History and PE of the Lower Back d. Different Conditions of the Lumbar Spine e. LBP in Different Populations Cervical Segment Motion AO joint (C0-C1) innervated by: C1 ventral ramus 10 deg flex, 25 deg ext CERVICAL SPINE AA joint (C1-C2) Innervated by: C2 vental ramus lat. 45 deg B rotation NECK PAIN C2-C3 Lat flex., coupled c ipsilateral rotation TYPES OF NECK PAIN C3-C4 & C4-C5 Greatest lat bending ○ Cervical axial pain C4-C5 & C6-C7 C5 - C6 Greatest amount of flex Pain in inferior occiput to superior inter C3-C7 Have uncovertebral joint / capsular region, localizing in the midline or joints of Luschka, located between rheumatoid uncinate paramidline process ○ Cervical radicular pain Uusally develop osteoarthritic Involves shoulder girdle and/or distal areas changes, which can narrow diameter of IV foramina and (e.g Upper limb) cause nerve impingement limb pain is greater than axial pain NEUROANATOMY OF THE SPINE Cervical zygapophyseal joints (facet joint) ○ allow motion within the cervical spine ○ Connects each vertebral segment ○ Innervated by medial branches from the cervical dorsal rami UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 1  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE IV foramina ○ are widest at C2 - C3 & decreases caudally IV disc - ○ are thicker anteriorly which explains NERVES OF THE CERVICAL SPINE cervical lordosis Dorsal and ventral nerve roots contains the BLOOD SUPPLY OF THE CERVICAL SPINE spinal cord ○ Dorsal root ganglion - Primary sensory Anterior spinal artery afferent fibers ○ supplies blood to cervical spinal cord ○ Ventral root ganglion - primary motor Upper cervical spinal cord - efferent fibers supplied by anterior spinal artery from vertebral arteries Midcervical spinal cord - supplied by 2 - 3 anterior radiculomedullary arteries Lower cervical and upper thoracic spinal cord - anterior small nerve root radiculomedullary artery from deep cervical artery ○ Radiculomedullary arteries - supplies blood to spinal cord, if penetrated, can induce cord infection ○ Radiculopial artery - pial network and INNERVATION OF IV DISC posterior spinal arteries ○ Anteriorly - supplied by afferent branches of sympathetic trunk ○ Posteriorly-posterolateral disk - sinuvertebral nerve UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 2  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE PATTERNS OF PAIN IN THE ZYGAPOPHYSEAL JOINT Cervical level Area of pain C1 - C2 & C2 - C3 Rostral to occiput pain from IV disc C3 - C4 Occiput PAIN GENERATORS OF THE CERVICAL SPINE Includes the IV Disc, Zygapophyseal joint, C3 - C4 & C4 - C5 Posterior neck posterior longitudinal ligament, muscles can produce somatic referral of pain into upper *SUPRASPINATUS limb C5 - C6 Supraspinous fossa of ○ Somatic pain pain from skin, muscle, bones scapula pain produced w/o irritation of the neural tissue ○ Mesodermal structure (muscle, ligament, joint capsule, IV disc, or C6 - C7 Caudal scapula periosteum) is stimulated leading to pain in another mesodermal tissue of the same origin COMMON CLINICAL DISORDERS Convergence muscles ligaments ○ theory when afferent fibers from cervical CERVICAL STRAIN & SPRAIN spine and distal upper limb converge on 2nd order neurons/dorsal root ganglion Strain "nasobrahan" within spinal cord, leading to the spine ○ musculotendinous overload injury thinking that the pain is from the limbs ○ Most commonly caused by motor vehicular instead of the cervical area accidents (MVA) ○ Diagnosis: History of trauma? MVA? Sports? Sharp/dull headaches that localize to shoulder girdle Aggravated by passive/active motion Decreased ROM - due to muscle guarding and splinting Tender Most commonly (MC) involved areas: Trapezius and SCM ○ Diagnostic testing not included unless neurologic or motor abnormalities UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 3  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE X-ray - If ever diagnostic testing is included AFFECTED or required, X-rays are initially done ○ Treatment: C5, C6, C7 Medial scapular edge C5 or C6 Superior trapezius Precordium Deltoid and lateral arm C6 or C7 Anterolateral forearm C7 or C8 Posterior forearm C7, C8 or T1 Posteromedial arm C6 - 8 or T1 UE digits It is important to differentiate the two due to different NSAID & Paracetamol management Muscle relaxants for 5 - 7 days, but not Peak incidents occur at ages 50 - 54 yrs old always In order of decreasing frequency: C7>C6>C8>C5 Tizanidine or TCAs antidepressants Massage -> sedatives, reduction of adhesions, muscle relaxation, Superficial and deep heat -> analgesia, muscle relaxation ES TENS Soft cervical collar -> restrict to the first 72 hours post injury Gradual return to activities by 2-4 weeks compression on cervical nerve roots Pathophysiology: CIDH CERVICAL RADICULOPATHY & ○ MC: Cervical IV disk herniation & Spondylitic RADICULAR PAIN changes Pathologic process involving neurophysiological dysfunction of the nerve root Radicular pain ○ hyperexcitable state of affected nerve root ○ Dull ache or sharp, lancing pain Cervical radiculopathy Exacerbating factors ○ reflex and strength deficits marking a ○ are those that increase subarachnoid pressure: hypofunctional nerve root Coughing ○ Axial cervical pain followed by explosive onset of Sneezing UE pain Valsalva maneuver ○ Patients may present: If not addressed properly, cervical stenosis can pins & needles Paresthesia / sensory disturbance happen if severe Depressed muscles / stretch reflex Physical exam: ○ Inspection: NERVE ROOT LOCATION OF PAIN Ask pt to Tilt head towards the side of herniated disk UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 4  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE Check for atrophy AVOID deep heating (utz) because ○ MMTs are more specific than sensory deficits / increased metabolic response leads to reflex loss inflammation, aggravating the nerve root ○ Check for Sensation light touch, pinprick, injury vibration TENS ○ Special tests: Cervical orthoses -> limits painful ROM Spurling’s test + pain upon compression - Soft cervical coolers -> kinesthetic Lhermitte’s test + sharp pain =UMNL reminders Abduction relief test + if relief upon abd - Narrow segment should be positioned Root tension test /Straight Leg Test, +radiating tinglin pain at back of thigh anteriorly - Worn 1-2 weeks Cervical traction - 25lbs of force 25 mins at an angle of 24 degrees Medications: ○ NSAIDs - 1st line ○ Muscle relaxants - used for 5-7 days to aid in sleep ○ TCAs - amitriptyline/notriptyline 10-25 mg ODHS ○ Antiepileptics Gabapentin 300-900 mg/day max 3600 mg/day Imaging/diagnostics: Anteroposterior, Lateral View Pregablin, tiagabine, zonisamide, ○ X-ray - APL, open mouth, flexion and extension oxcarbazepine ○ CT myelography - gold standard for ○ Opiates image: white/light borders THERAPUETIC EXERCISES: degenerative cervical spine conditions ○ MRI - modality of choice in investigating cervical Stabilization and functional restoration includes: radiculopathy image: darker borders ○ Biomechanical correction ○ EMG - nerve function, prognosis ○ Physical conditioning Treatment: ○ Strength training ○ Objectives: Start with pain free ROM → increase ROM by Resolution of pain addressing any restriction → restore proper cervical Improvement of myotomal weakness biomechanics → strengthening Avoidance of spinal cord complication Prevention of recurrence Diagnostic selective nerve root block (SNRB) ○ Definitive indication for cervical management: Therapeutic selective nerve root injection (SNRI) progressive neurological deficit ○ Corticosteroids ○ Patient education Percutaneous discectomy / disc compression ○ Proper posture, biomechanics, utility of Nucleoplasty- uses coblation energy to vaporize ergonomic evaluation nuclear tissue into gaseous elementary molecules ○ Repetitive and heavy lifting must be avoided Surgery ○ Modalities: ○ Indications: intractable pain, severe myotomal Thermotherapy -> increase muscle deficits (progressive or stable), myelopathy relaxation ○ Difference between conservative and surgery Cold compress 15-30 mins 1-4x a day equalizes in 1 year Superficial heat 30 mins, 2-3x a day UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 5  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE CERVICAL JOINT PAIN ○ Transition begins when there is reduction of pain from acute injury MC symptomatic level: C2-3 → C5-6 → C6-7 Interventional spine care Usually only 1 joint is symptomatic, rarely 2 Diagnostic zygapophyseal joint blocks Cervical zygapophyseal joints are a common source ○ Definitive means to which to target symptomatic of chronic posttraumatic neck pain joint Associated with headache Therapeutic zygapophyseal joint injections Pxs with Whiplash injury who complain of posterior Percutaneous radiofrequency ablation medial branch headaches usually have C2-3 zygapophyseal joint neurotomy pain ○ Objectives: If traumatically induced lower cervical usually Resolution of pain involves C5-C6 Resolution of pain History NEUROANATOMY OF CERVICAL SPINE ○ Ask for neck position at the time of impact/accident CERVICAL INTERVERTEBRAL DISC INJURY ○ Traumatic C2-C3 joint pain can unilateral occipital headaches Internal disruption ○ Can present unilateral paramidline neck pain w/ ○ Derangement of internal architecture of nucleus or w/o periscapular symptoms and is more pulposus and/or annular fibers with little or painful than associated headaches external modification ○ Px (patient) can pinpoint a localized spot of maximal pain Physical Examination ○ Assess neurologic function and cervical ROM ○ Tenderness posterolaterally over a joint ○ Focal suboccipital pain that occurs or is exacerbated with 45 degrees of cervical flexion and sequential axial rotation suggests a painful C1-2 joint Imaging ○ X-rays ○ CT scans - better delineate joint fracture Cervical Internal Disc Disruption History/PE Treatment: ○ Can present with: ○ Medications: Posterior neck, occipital, suboccipital, upper NSAIDs trapezial, inter and periscapular that is non Opiates radiating to the arm Physical Modalities Vertigo, tinnitus, ocular dysfunction, ○ Cryotherapy is preferred over superficial heat → difficulty in swallowing dysphagia, facial pain and anterior chest 20 mins (3-4x a day) wall pain Soft tissue mobilization and massage Usually with history of trauma Soft cervical collars up to 72 hrs after injury Symptoms can be sudden, gradual, or explosive Main symptom: axial pain associated with Restorative phase encompasses stabilization and nondescript upper limb symptoms functional restoration (ROM, soft tissue length, strengthening) UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 6  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE Exacerbated by prolonged sitting, coughing, and sneezing or lifting Physical Examination Relieved by lying supine ○ Weakness LE > UE ○ Intrinsic hand muscle weakness Imaging studies ○ Pain and temp. disturbances - spinothalamic ○ X rays - hyperostosis and disc space collapse ○ Proprioception and vibratory deficits - posterior ○ MRI - decreased intradiscal signal, but not column useful in detecting symptomatic cervical discs ○ UMN signs (Babinski, Hoffman) ○ Provocation discography - functional diagnostic testing to diagnose painful disc level Imaging studies ○ X-rays Treatment ○ MRI ○ NSAIDs - check kidney function 6 weeks after ○ EMG-NCV initiating NSAIDs then after 12 months ○ TCAs can be adjunct Treatment: ○ Opioids - short time ○ Non operative - PT, cervical orthoses ○ Superficial heat modalities and TENS ○ Surgery ○ Traction - but be cautious CERVICOGENIC HEADACHES Treatment: F>M are affected ○ Cervical collars but only within 72 hrs post injury Convergence theory then discontinue ○ Cranial symptoms occurs because of cervical ○ Cervical spine stabilization, stretching and spine pain generators strengthening C2-C3 zygapophyseal joint → primarily implicated as ○ Interventional spine: sources of cervicogenic headache Provocation discography Transforaminal Epidural Steroid Injection History (TFESI) ○ Hx of trauma ○ Surgery ○ Unilateral and stemming from the posterior compression on spinal cord occipital region CERVICAL MYELOPATHY AND ○ Refers toward vertex of scalp, ipsilateral MYELORADICULOPATHY anterolateral temple, forehead, midface, or compression on spinal cord and nerve roots ipsilateral shoulder girdle Cervical spondylotic myelopathy ○ Can involve the contralateral side inflammation ○ Most common cervical cord lesion AFTER ○ Deep ache to sharp and stabbing middle age but less common than radiculopathy ○ Initially intermittent then progresses to persistent ○ Average onset is AFTER 50, M>F ○ Usually non throbbing in character ○ Autonomic complaints are less apparent than History: migraines but can still occur ○ Insidious onset develops gradually, hndi halata ○ CC: cervical axial pain 70% complaints Physical Examination: ○ Numbness and parasthesia in distal limbs ○ Reduced ROM due to muscle guarding, arthritic ○ Weakness lower > upper limbs, and intrinsic changes or soft tissue inflexibility hand muscle wasting ○ Localized pain with one finger ○ Course: initial deterioration then static period ○ Axial rotation or cervical extension can that can last several years aggravate ○ Bladder symptoms nerve Sx ○ Spurling's maneuver does not reproduce upper ○ If with radicular symptoms, it’s called cervical limb radicular symptoms but usually aggravates spondylitic myeloradiculopathy axial pain UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 7  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE ○ Pain reproducible by deep palpation over the Each vertebral segment can be thought of as 3 involved joint joint complex ○ 1 intervertebral disk with vertebral end Imaging plates ○ Radiographs ○ 2 zygapophyseal (facet) joints ○ CT scan - if suspicious of fracture ○ MRI - intervertebral discs of desiccation, VERTEBRAE decreased disc height and frank herniation ○ Functional diagnostic tests and treatment 5 lumbar vertebrae Diagnostic blockade Vertebral body (VB) increases in size as you go caudally WHIPLASH SYNDROME Lower 3 are wedge shaped (taller anteriorly) Happens when car abruptly stops which explains lumbar lordosis PASSIVE Hyperflexion - hyperextension Pedicles - connect posterior elements to VB 3 components: ○ Resist bending ○ Whiplash event ○ Transmits forces between VBs and ○ Whiplash injury- impairment/injured structure posterior elements resulting from whiplash injury Posterior elements ○ Whiplash syndrome - set of symptoms arising ○ Laminae from injury ○ Articular processes Rear end collisions represent the most common ○ Spinous processes pattern of whiplash related injury (movement of head forward and back) Can present with neck pain, headache, shoulder INTERVERTEBRAL DISK (IVD) girdle pain, upper limb paresthesias and weakness IVD and its attachment to the vertebral end plate Can also present with dizziness, visual disturbances are considered a secondary cartilaginous joint or and tinnitus symphysis Recovery within the first 2-3 months after the injury, Consists of: after 2 years, the pt. becomes symptom free ○ Internal nucleus pulposus ○ Gelatinous inner section LUMBAR SPINE ○ Composed of water, proteoglycans and Largest predictors of persistent disabling back collagen pain are: ○ 90% water at birth ○ Maladaptive pain coping behaviors Outer annulus fibrosus ○ Presence of psychiatric disease ○ Concentric layers of fibers at oblique ○ Low physical function angles to each other this gives its ○ Low general health structural integrity Low socioeconomic status ○ More collagen, less proteoglycans and Obese, smokers and physical and mental water then inner fibers comorbidities ○ MAIN shock absorber If you have a pt. c LBP, the following mentioned above Main function: shock absorption will help screen the pt. C these factors to give you an ○ Flexion loads anterior disk → displaces idea whether this pt. Can recover in the long run or not. nucleus posteriorly ○ Lateral fibers of the posterior ANATOMY & BIOMECHANICS longitudinal ligaments are the thinnest making posterolateral disk herniations The spine protects and supports spinal canal most common contents and gives us inherent flexibility UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 8  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE ○ There is no substantial difference in disk Paraspinals (iliocostalis, pressure when lifting with the legs vs. longissimus and spinalis) - chief lifting with the back extensors Lift load closer to the body will Rotators decrease load on lumbar spine Multifidi Control lumbar flexion Sensory organ for proprioception ABDOMINAL MUSCULATURE ○ Superficial Rectus abdominis External obliques ○ Deep Internal obliques Transversus abdominis FACET JOINTS Thoracolumbar fascia Paired synovial joints with synovium and ○ Lumbar brace when lifting capsule Majority of spinal flexion and extension occurs at Pelvic Stabilizers L4-L5 and L5-S1 → high incidence of disk ○ Core muscles problems ○ Gluteus medius - stabilizes the pelvis during gait LIGAMENTS Weakness can cause pelvic instability → introduces lumbar 2 main sets: side bending and rotation ○ Longitudinal - disruption of either creating increased shear or ligament occurs with rotation torsional forces on the lumbar Anterior - resist extension, disks. translation and rotation Piriformis - hip and sacral Posterior - resist on flexion rotator, can cause excessive ○ Segmental external rotation of the hip and Ligamentum flavum - pierced sacrum when it is tight when performing lumbar punctures Nerves Supraspinous ○ Conus medullaris ends at ~L2 Interspinous ○ Cauda equina below L2 Intertransverse PAIN GENERATORS MUSCLES IVD ○ External annulus - innervated by Origins on the lumbar spine Sinuvertebral nerve ○ Anterior - accentuates lumbar lordosis ○ Nucleus pulposus and internal annulus Psoas Flexion and lat. rotation of hip fibrosus - insensate Quadratus lumborum lateral trunk flexion Facet joints ○ Posterior muscles ○ Medial branch of the dorsal primary Latissimus dorsi ramus innervates facet joints and UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 9  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE interspinous ligaments, lumbar fear-avoidant-type beliefs may multifidus be an effective therapy Spinal ligaments Multidisciplinary pain programs ○ Posterior longitudinal ligament have been proven effective in innervated by Sinuvertebral nerve decreasing fear-avoidant beliefs ○ Anterior longitudinal ligament innervated and catastrophizing by gray rami communicans Vertebral body HISTORY AND PE OF LOWER BACK ○ Anterior VB innervated by sinuvertebral History branch Pain history ○ Posterior CB innervated by dorsal Features: primary ramus ○ Location, character, severity, timing, onset, duration, and frequency, PAIN CAUSED BY DEGENERATION alleviating aggravating factors, Tears in the annulus - first anatomic sign of associated signs and symptoms degenerative wear Segmental dysfunction Red flags signs - pt. c these signs may need special ○ A segment = disc + vertebrae, muscles attention/immediate action and ligaments Yellow flag signs - help you manage a pt. c chronic back ○ Is too stiff or pain and determine how long you will be treating this pt. ○ If too mobile, it is termed as functional instability Physical Examination (PE) ○ In general, only ~ 10% of maximal ○ Observation: posture, gait, muscles, contraction of muscles is needed to bones provide segmental stability BUT strength ○ Neurological Examination reserve is important for falls, sudden ○ Orthopedic special tests to assess for load to the spine or quick movements relative strength and flexibility Abdominal strength see fig Pain is caused by differences in muscular Braddom 6ed 33.15-17, pp activation and neuronal control of segment 663-664 ○ Examining the are above and below the PSYCHOSOCIAL lumbar spine ○ Depression, anxiety and anger Check ROM of hip, knee and 30-40% of those with chronic ankle joints back pain have depression Thoracic joint - ROM and Linked to pain intensity, duration palpation and disability ○ Patient belief and fear avoidance Illness Behavior and Nonorganic signs seen on Fear avoidance PE Movement or activity will be ○ Waddell signs if ⅗ are present, a associated with further injury nonorganic contribution to the patient’s More extreme: catastrophizing presentation Fear avoidance and Inappropriate tenderness that is catastrophizing are more widespread or superficial predictive of pain related Pain on testing that only disability tan the level of pain stimulates loading the spine Treatment addressing (e.g. light pressure applied to self-control and limiting the top of the head) UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 10  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE Inconsistent performance when ○ Low calcium intake testing the same thing in ○ Smoking different position ○ Alcohol use ○ Younger age at puberty DIAGNOSTICS Presents with acute axial pain Imaging ○ X Rays CANCER AND LOW BACK PAIN ○ MRI Spine is the most common site of bony ○ CT metastases ○ Scintigraphy Thoracic spine - most commonly involved ○ EMG Lumbar spine - for colorectal cancer Constant ache, not exacerbated by movement LUMBAR SPONDYLOSIS History: Usually for older patients with back pain ○ Back pain unrelieved by bed rest Zygapophyseal joint pain typically refers to the ○ New onset of back pain after 50 years buttock old Imaging studies are not useful because ○ Pain worse in supine position asymptomatic patients can have spondylotic ○ History of cancer changes Treatment: SPINAL INFECTIONS ○ Lifestyle and activity modification Vertebral Osteomyelitis - can occur from ○ Medications hematogenous spread via spinal arteries ○ exercises mc source: UTI by E coli and other enteric bacili *SPONDYLOLYSIS mc location: lumbar spine SPONDYLOSIS mc symptom: back pain Defect of the pars interarticularis Fever is present only 50& of the time SPONDYLOARTHROPATHIES HLA-B27 (i.e., genetic mutation) Seronegative spondyloarthropathies Ankylosing spondylitis ○ M>F ○ Late teens or 20s ○ Morning stiffness and a dull headache in Once you have spondylosis, pt. can present the low back or buttocks (that can be spondylolisthesis relieved c movement) Reactive arthritis (Reiter syndrome) SPONDYLOLISTHESIS Psoriatic arthritis Anterior displacement of one vertebra above the sub adjacent vertebrae DISK HERNIATION Most pars fractures occur early in childhood and are asymptomatic Most typically seen in adolescent athletes OSTEOPOROTIC COMPRESSION Fx Risk factors: ○ Female gender ○ Lower levels of physical activity UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 11  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE ○ Results from central canal narrowing ○ Back and bilateral leg pain initiated by walking, prolonged standing, and walking down hill (relative lumbar ext) ○ Relieved by sitting or bending forward (grocery cart sign) (+) GROCERY CART SIGN LUMBAR SPINAL STENOSIS Venous engorgement theory: ○ Spinal veins with stenosis dilate → venous congestion and stagnating blood flow → inc epidural and intrathecal pressures → ischemic neuritis → neurogenic claudication MC lumbar disk herniations occur at: L4–L5 and L5–S1 Arterial insufficiency ○ Arterial dilation during LE exercises Most common: L4-L5 and L5-S1 > L3-L4 > (lack of blood flow to lumbar spine) L2-L3 Goals of conservative management: Most common lumbosacral radiculopathies: L5 ○ Pain control *POSTEROLATERAL - MC DISK HERNATIONS and S1 ○ Reducing functional limitation MC: posterolateral disk herniation - because Tx: annulus fibrosus is weakest posterolaterally ○ Exercise ○ Posterior longitudinal ligament is also ○ Flexion based lumbar stabilization weak in this area ○ Strengthen abdominals, pelvic girdle Pain generators: stabilizers ○ Inflammatory response ○ Improve hip mobility (iliopsoas and ○ Mechanical compression rectus femoris) ○ Axial pain ○ Aerobic conditioning Mainstay Tx: conservative TREATMENT OF LBP LUMBAR RADICULOPATHY Depends on etiology Mechanical compression of a nerve root OR Reassurance and pt. education chemically mediated process Back schools contain information about: MC cause: inflammation due to nearby disk ○ Anatomy and function of spine herniation ○ Common sources of LBP For compression alone to be painful, the dorsal ○ Proper lifting techniques root ganglion must be involved ○ Ergonomic training Lancinating, shock-like or electrical ○ Exercise MC: L5-S1 > L4-L5 (common nerve root Exercise benefits affectation) ○ Modest amount of pain relief Trua cauda equina syndrome: bowel, bladder, ○ Inc strength, flexibility, endurance, and and sexual dysfunction muscle mass and cardiovascular ○ Large postvoid residual of urine benefits ○ Decompression should be done within ○ Improves behaviors on pain 48 hours ○ 30 mins of moderate aerobic exercise 5x a week LUMBAR SPINAL STENOSIS ○ Needs to be every day Neurologic claudication ○ Exercise first deep stabilizers (multifidus ○ MC symptom of lumbar stenosis and transversus abdominis) UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 12  MUSCULOSKELETAL PT | MEDICAL-SURGICAL CONDITIONS OF THE SPINE ○ McKenzie Exercises for back pain Idiopathic scoliosis - can be classified based on accompanied by radicular leg pain age when diagnosed (e.g., infantile, juvenile, Other Tx adolescent) ○ Aquatic exercises ○ Not painful ○ Traditional exercises and ○ Spinal curves exceeding 10 degrees complementary movement therapies ○ Usual: R thoracic, L lumbar Yoga, tai-chi, pilates ○ Main problem is spine mobility, and if ○ Massage severe, it can restrict pulmonary and ○ Manual mobilization/manipulation cardiac function ○ Lumbar support Tumors ○ Traction ○ Osteoid osteoma - nocturnal pain that ○ TENS and other modalities responds to aspirin, most frequent is ○ Medication Ewing sarcoma ○ Osteoblastoma, aneurysmal bone cyst PROGNOSIS OF LBP Depends on complex cultural, psychological, social support, and economic factors that REFERENCES influence pain and rehab outcomes Rapid improvement within 1 mo. 1. Cifu, D. X. (2020). Baddom’s Physical Medicine Still c improvement up to 3 mo. and Rehabilitation 6th Ed. Elsevier, Philadelphia, 3 mo. - 1 yr. little change PA. LBP IN SPECIAL POPULATIONS LBP IN PREGNANCY Pelvic girdle pain: pain below the iliac crest LBP can occur any time during pregnancy, but peak at 36 wk. then decreases and improves by 3 mo. postpartum Could be caused by hormones Tx: individualized PT, water aerobics, acupuncture, and massage therapy LBP IN PEDIATRICS Prevalence of LBP has greatest inc during puberty and the time of maximum growth spurt Sitting - main cause of exacerbation Recommendation for child’s backpack weight is limited to 10% of body wt. Scheuermann disease - painless exaggerated thoracic kyphosis ○ Ant. wedging of at least 3 adjacent vertebrae ○ End plate irregularities ○ Schmorl nodes ○ Disk space narrowing ○ Brace is recommended UERMMMCI - BSPT BINAG | DIEZ | LAAG | NETHERCOTT 13