Lx 1 - Mr Ahmed

chronic intermittent LBP

most likely clinical presentation

facet arthropathy/degenerative changes contributing to NSMLBP

differential diagnoses

• Lx spondylosis

• SIJ dysfunction

• myofascial pain

assessment technique + why

SIJ provocation cluster tests

• SIJ 15-30% persistent LBP
• no single test diagnostic
• differentiates Lx disc, FJ, radiculopathy

assessment technique results

positive - reproduces pain/symptoms

• need 3/5 tests indicates positive SIJ dysfunction expect - negative
• rules out DDs therefore confirms WD

assessment technique performance

compression - supine, compress iliac crests down/in distraction - supine, posterolateral pressure to bilat ASIS thigh thrust - supine, hip 90, pressure down femur, change ab/ad Gaenslen - supine, test leg knee/hip full flex, opp leg off side plinth, overpressure both sacral thrust - prone, thrust down over sacrum

management - education

• reduce fear avoid, correct misconceptions, build confidence movement
• changes in spine (stiffness, 'arthritis') very normal for age, don't mean spine is wearing out or fragile
• Movement helps joints stay healthy - lubrication, reduced stiffness, muscles strong
• Pain pattern mech + stable - safe to exercise and gradually build tolerance for activities eg gardening
• Work together to find movements that feel comfy and help stay active w/o flare ups

management - pharmacological

NICE on LBP

• consider oral NSAIDs, consider GI, risk factors, age
• appropriate clinical assessment
• lowest effective dose for shortest possible period of time
• do not offer paracetamol alone

beliefs and disability evidence

Schwab+Silva 2023 - research on how beliefs about damage strongly influence disability

• align with pain principle that fear avoidance and catastrophising increases disability
• education decreases fear and enhances recovery
• addressing and correcting misconceptions essential for improving patient outcomes

education evidence

NICE GL on LBP

• education 1st line management CLBP
• emphasise reassurance, stay active, avoid fear avoidance, encourage normal activities
• self management - advice + info on nature of LBP

management - exercise 1 justification

lumbar mobility - pelvic tilts

• improves Lx segmental mobility
• reduce am stiffness and facet load
• improve lumbopelvic control
• simple, low load, non-threatening, bed/sit/stand, safe

pelvic tilts demo + dose

demo

• sitting
• slow arch flex > slow hunch ext
• smooth, pain free range
• encourage breathing with movement dose - 2x10-15 daily, slow, 3-4secs each direction

pelvic tilts pro/regression

regression

• smaller range
• hands on pelvis for feedback
• performed supine progression
• standing
• progress to cat-camel once confidence improves

pelvic tilt evidence

Hayden et al 2021 - MA of RCTs

• exercise effective for CLBP, improves pain + functional limitations outcomes Sargiotto et al 2016 - MA of RCTs
• MCE similar outcome to manual therapies, not necessarily superior to other forms of exercise
• choice should depend on patient/physio

management - exercise 2 justification

Lx support - glute bridge

• improve posterior chain strength
• enhance pelvic stability
• reduce SIJ strain

glute bridge demo + dose

demo

• supine, knees bent
• lift pelvis by squeezing glutes
• avoid excessive Lx ext
• controlled lowering dose - 3x10 every other day, hold 2 secs at top

glute bridge pro/regression

regression

• hands supporting pelvis
• shorter range progression
• increase 12-15 reps
• resistance band around knees
• single leg

glute bridge evidence

Rekha et al 2026 - observational study, 50pts age 18-45

• glute strength + Lx stabilisation superior therapeutic efficacy to education
• sig greater functional disability decrease, high clinical success
• both interventions have meaningful outcomes - supports conservative management as 1st line treatment for CLBP

exercise evidence

NICE GL on LBP

• support gentle mobility exercises for LBP
• exercise therapy one of most effective interventions for CLBP
• improve segmental Lx movement w/o high load
• improve lumbopelvic control

pathophysiological evidence for exercises

• mobility exercise increases synovial fluid circulation to decrease stiffness
• strength exercise increases load tolerance and decreases strain on FJ/SIJ
• better lumbopelvic stability decreases strain on FJ/SIJ
• regular movement improves pain modulation and decreases sensitivity over time

goal relevance of education/exercise

stay active and help in garden

• movements increase tolerance bending, lifting, standing longer
• more confidence to increase load, can return to helping wife w/o flare up worries
• build strength/mobility - do more for longer w/o pain
• simple and achievable - stay consistent aggs - turn in bed (improve lumbopelvic control) / stiffness (mobility increases synovial fluid)

facet joint arthropathy FJA

synovial joint between vertebrae guide and limit movement especially ext/rot

• part of broader 'age related degen spinal changes', mech pain
• disc dehydrate, less segment mobility, synovial inflam, osteophytes, change load distribution

FJA pain

highly innervated - nociceptors + mechanoreceptors

• typically localised pain
• pain w/ext + side flex
• am stiffness as overnight inflammation

FJA degenerative changes

articular cartilage - thins, less water, more rough

• micro-fissures, less shock absorption, more friction joint space narrows - less cartilage, less joint space
• increased load on subchondral bone (sclerosis/bone thickening) osteophytes - form to stabilise J, contribute to stiff + inflam synovial lining - degen irritates, mild inflam response
• contributes to am stiffness, improves w/movement

FJA mechanical pain generation

local nociception - FJ dense supply, degen increases sensitivity

• pain ext/rot/long standing capsular strain - J capsule less elastic so movements cause pain muscle guarding - paraspinals tighten to protect J, contribute to stiffness

FJA fluctuates, exercise helps

• load varies day to day
• inflam fluctuates
• prolonged static postures increase capsular strain
• movement can increase joint lubrication/syn fluid circulation
• strengthening decreases J load
• mobility reduces capsular stiffness
• exercise improves pain modulation
• PA decreases deconditioning and fear avoidance

NSMLBP

• 90% LBP
• multifactorial - nociception/mechanosensitive, biopsysoc non traumatic - gradual onset, consider load v capacity + age related changes (common >50) LxFJ - 90 sagittal plane, flex/ext allowed

DD SIJ dysfunction

• altered load transfer/irritation of SIJ ligs/J surfaces pain - rich innervation, free nerve endings/mechanoreceptors
• highly variable referred pain patterns - diagnosis challenging can cause mech LBP
• pain typically unilateral around posterior pelvis
• worse w/prolonged standing, asymm loading, turning in bed
• no neuro symptoms

DD SIJ dysfunction mechanism

joint stiff/hypomobility - strain ligs, pain w/transitional movement lig irritation - richly innervated, small positional change can provoke pain altered force closure - reduced muscle support from glutes/pelvic stabilisers inflam irritation - mild synovial irritation can cause local buttock/posterior pelvis pain

DD SIJ why not

• pain mainly R lower Lx, not classic SIJ distribution (buttock, posterior plevis, thigh)
• no reproduction Sx w/tests
• am stiff/painful long stand - more degen spinal structures >SIJ lig irritation

DD Lx spondylosis + why not

• age related degen changes affecting vertebral bodies, discs, FJ why not - more diffuse/radicular features if foraminal narrowing
• no neuro Sx
• pain local - FJ>disc

DD Lx spondylosis mechanism

• disc dehydrate and less height
• less shock absorption and more load FJ/ligs
• osteophytes to stabilise can irritate pain sensitive structures
• lig flavum thickens, causes am stiffness
• FJ degen - cartilage thins, capsular irritation, mild inflam
• pain w/posture + load, less stiff w/movement

DD myofascial pain + why not

• highly innervated, trigger points, muscle overactivity, postural overload
• produces diffuse ache, palpable taut bands, pain reproduction on palpation why not - Sx chronic/mechanical, myo doesn't typically cause am stiffness or intolerance to prolonged standing (both hallmark degen facet signs)

outcome measures

• VAS pain scale - baseline, am stiffness, long stand
• Oswestry Disability Index ODI - gold standard for disability associated w/LBP, assess stand, lift, walk, sleep
• Numeric Pain Rating Scale NPRS - current, worst, am stiff
• Patient Specific Functional Scale PSFS - highly relevant to goals, gardening, prolonged standing, turning in bed -STarT Back Screening Tool - assess psysoc risk factors, useful given belief exercise will 'wear his back out'
• EQ-5D-5L - overall HRQoL, chronic best 3 - ODI, PSFS, NPRS

safety

• no red flags - Sx mech, predictable, stable - reassuring
• exercise safe for degen spine conditions - increases joint nutrition, less stiff, more long term function
• monitor response to loading, ensure exercise within tolerable discomfort, not sharp/worsening pain
• check cv safety before prescribing higher intensity exercises due to age
• no CES Sx - saddle, b/b, bilat etc

fear avoidance

• 'wear spine out' - address as fear avoidance can increase pain and decrease function
• degen changes normal with age, doesn't mean fragile/worn out
• avoiding movement increases stiffness and sensitivity
• graded exercise makes spine stronger and more resilient
• synovial fluid/movement - like door hinge/oil
• set achievable goals - improve tolerance for gardening, build confidence

adherence

• tailor plan to goals - active, garden, meaningful activities
• simple program - 2-3 exercises at home w/o equipment
• agree realistic dosage eg 10-15mins daily
• clear instructions and check technique to boost confidence
• pacing - reduce flare ups or loss of motivation
• schedule follow up to review progress + adjust - accountability

onward referal

not at present - Sx stable, mechanical, no neuro

• CES - saddle, b/b, bilateral leg
• red flags
• new/worse leg weakness
• p+n/numb in dermatomal pattern
• unremitting night pain
• systemic Sx (fever, weight loss)
• sig functional decline
• pain unresponsive to treatment - liaise w/GP for med optimising
• consider imaging if would change management