Lumbar Spine Lecture

Burden of Low Back Pain

  • The prevalence and burden of low back pain (LBP) continues to rise significantly.

  • Approximately 65% of the population will experience at least one episode of LBP in a year.

  • The experience of LBP varies by race, sex, and socioeconomic status.

  • Structural changes in the lumbar spine occur over time.

  • Intervertebral discs (IVDs) are crucial as shock absorbers and are affected by degenerative disc disease (DDD).

  • Central nervous system (CNS) changes can occur alongside LBP.

  • Motor control patterns differ in patients with LBP.

  • Many individuals with LBP also suffer from psychological comorbidities.

Red Flags Associated with LBP

  • Cancer

  • Fracture

  • Infection

  • Abdominal Aortic Aneurysm (AAA)

  • Urinary/Kidney disorders

  • Cauda Equina Syndrome (herniated nucleus pulposus (HNP) or stenosis, affecting bowel and bladder)

  • Vascular Claudication

  • Ankylosing Spondylitis (often presents in young individuals, insidious onset, buttock pain, morning stiffness, and decreased pain with exercise)

Yellow Flags – Psychosocial Factors

  • Depression

  • Stress

  • Fear

  • Anxiety

  • Catastrophizing

  • Sleep deprivation

  • Low expectation for recovery

Outcome Measures for LBP

  • Roland Morris Disability Questionnaire

  • Oswestry LBP Disability Index

  • Modified Oswestry

  • Patient-Specific Functional Scale

  • Global Rate of Change Scale

  • Fear Avoidance Beliefs Questionnaire

Factors to Consider with LBP

Youth

  • Rapid growth spurts (ages 12-15) may predispose children to LBP.

  • Scoliosis and heavy backpacks can contribute to LBP in younger individuals.

  • Involvement in activities such as athletics, dance, or music can also impact back health.

Adults

  • Ages 30-60 represent the highest likelihood for a new episode of LBP, particularly in the 30s.

  • Factors such as activity level and occupation are significant contributors.

Older Adults

  • Reduced activity and functional decline are prevalent issues.

  • Psychosocial factors, along with degenerative factors (e.g., osteoarthritis, spinal stenosis), can lead to LBP.

  • Socioeconomic factors also play a role, with lower education correlating with increased duration, persistence, and poorer outcomes from LBP.

LBP Classifications & Stages

Acute, Subacute, Chronic, Recurrent

  • Acute: 0-4 weeks

  • Subacute: 2-6 months

  • Chronic: >3-6 months

  • Recurrent: episodes of LBP with or without symptoms in between episodes

Lumbar Joint Mechanics

  • Facet joints orient medially and laterally impacting movement.

  • Opening/Gapping

    • Occurs during flexion, contralateral side bending, and ipsilateral rotation.

  • Closing/Compressing

    • Occurs during extension, ipsilateral side bending, and contralateral rotation.

Lumbar Intervertebral Disc

  • Bulging: Fairly even, at least 1/4 of circumference, degenerative changes noted.

  • Herniation or Prolapse (HNP): Can be small and focal.

  • Other terms include “ruptured” and “slipped”.

  • Extrusion and Sequestration categories defined.

  • Mechanisms of injury often include flexion and rotation with or without load.

Herniated Nucleus Pulposus (HNP)

Clinical Manifestations

  • Right lateral shift may occur due to left HNP.

  • Patients typically shift away from the painful side and may have reduced weight-bearing on the painful side.

Lateral shifts

  • Prone self or manual assist for lateral shift correction:

    • A) Physical Therapy (PT) assists to shift hips to the non-painful side.

    • B) PT keeps hips off-center during mobilizations.

Lumbar Classifications

Five Major Classifications

  1. LBP with Mobility Deficits (requires Mobilization/Manipulation)

  2. LBP with Movement Coordination Impairment (need Stabilization or Immobilization)

  3. LBP with lower extremity radicular or referred pain (Direction Specific Exercise (DSE) - with 3 subgroups).

  4. LBP with lower extremity related pain (utilizes Traction).

  5. LBP with Symptomatic Stenosis (LSS).

Additional Classifications

  • LBP with Related Leg Pain (LBPRLP) categorized by predominant pain mechanisms (central sensitization, peripheral sensitization, denervation, musculoskeletal referred pain).

  • LBP with Related Generalized Pain, often associated with depression, fear-avoidance, and pain catastrophizing.

  • Conditions may relate to cognitive and affective tendencies, chronic LBP/lumbopelvic pain related to motor control, pelvic girdle pain (PGP), and pregnancy-related PGP.

  • It's important to note that a patient may not fit precisely into one classification or could fit into more than one classification.

  • Classifications can be acute, subacute, chronic, or recurrent.

  • Example: Chronic LBP with movement coordination impairments, which may or may not exhibit related cognitive and affective tendencies.

ICD-10 Codes for LBP Diagnoses

  • Low back pain

  • Flat back syndrome

  • Spinal instability

  • Lumbosacral segmental dysfunction

  • Lumbar radiculopathy

  • Lumbago with sciatica

  • Low back strain

  • Pain in buttock

  • Lumbago due to intervertebral disc displacement

Goals of the Physical Exam

  1. Reproduce the patient’s symptoms.

  2. Determine the impact of posture, movement, work, and recreational factors as causes or contributing factors to the patient’s problem.

  3. Establish the treatment threshold by identifying a cluster of signs and symptoms for diagnosis/classification.

  4. Establish a baseline for evaluating and progressing interventions alongside outcome measures.

Lumbar Exam Components

  • Observation: Evaluate gait, balance, function, and posture to assess for lateral shifts.

  • Neuro Screen (as needed): Assess neurological function.

  • Palpation: Look for pelvic asymmetry, areas of pain, and assess muscle tone.

  • Range of Motion (ROM): Examine in all planes, observing combined motions, quality, and aberrant movements.

  • Lumbar Quadrant Test: Testing for pain and dysfunction.

  • Repeated Motion Testing: To determine movement responses.

  • Joint Mobility Testing (PPIVMs & PAIVMs): Evaluating passive range of motion in functional activities.

  • Muscle Strength & Length Testing: Including core stability evaluation.

  • Special Tests: Details of these tests to be covered later.

Exam by Position

  • Standing: Assess posture, palpation, lateral shift/correction, repeated testing, active range of motion (AROM), quadrant test.

  • Sitting: Look for posture, rotational range of motion, conduct neuro screen, assess slump posture.

  • Supine: Perform various tests including straight leg raise (SLR), palpitations, and muscle length assessments.

  • Prone: Include specific tests for motor function and joint mobility.

  • Sidelying: Assess specific movement capabilities and muscle responses.

Joint Play and Mobilizations

Types of Joint Motion Testing

  • PPIVMs: Passive physiological intervertebral motions, including flexion, extension, side bending, rotation (performed in sidelying).

  • PAIVMs: Passive accessory intervertebral motions (performed in prone):

    • Central PA

    • Unilateral PA (facets ~2-3 cm lateral to spinous process)

Repeated Motion Testing

  • Better, Worse, or the Same: To assess how movement affects symptoms through activities in varying positions.

  • Flexion Exercises:

    • Standing and lying exercises to test functional range with repeated motion (e.g., standing 10 times without stopping).

  • Extension Exercises:

    • Similar analysis for extension actions, including variations in setup (e.g., prone on pillow, elbow positions).

  • Lateral Shift Correction Exercises:

    • Standing or prone side glide movements aimed at minimizing pain.

Lumbar Quadrant Test Procedure

  • Patient stands and actively moves into extension, side bend towards the painful side, and rotation towards the painful side while being cued to reach.

  • This test assesses lumbar spine loading and can indicate facet dysfunction, degeneration, and nerve root compression through observed symptoms.

Spring Test

  • Conducted to assess local mobility dysfunction.

Prone Instability Test

Steps for Assessment

  1. Patient starts with feet on the floor while PT performs central PA at the suspected level of instability, noting any experienced pain.

  2. Patient lifts feet off the floor (less than 6 inches), while PT performs the central PA again. If the pain decreases in the second part of the test, it may indicate instability.

Slump Test (Sitting) Procedure

  • Patient sits with thighs fully supported and knees together, hands behind back.

  • The test progresses through a 'slump' position, then neck flexion followed by active knee extension and ankle dorsiflexion, assessing symptoms.

Sciatic Nerve Tests

  • Straight Leg Raise Test (SLR):

    • Passively lifts the lower extremity, maintaining hip neutrality and extension, recording the angle at which symptoms appear. Sensitization through ankle dorsiflexion or neck flexion can influence outcomes.

  • Femoral Nerve Test (Prone or sidelying):

    • May involve knee flexion while in a prone position or sidelying; symptoms noted and assessed through various movements to establish tension and release dynamics.

Baseline Core Stability Testing

  • Abdominal Brace (AB):

    • Aims for a 5-10% maximal isometric contraction with no motion in the spine or pelvis.

  • Abdominal Drawing In Maneuver (ADIM):

    • Focuses on drawing the navel toward the spine at 15% contraction while maintaining a relaxed state, emphasizing tension control without displacement.

  • Importance of both techniques for comprehensive core stabilization development:

    • AB for dynamic stability using global and local muscles

    • ADIM for focused motor control and segmental stabilization.

LBP Classifications and Interventions

LBP with Mobility Deficits

Key Exam Findings

  • No symptoms distal to knees.

  • Recent onset (< 16 days).

  • Active range of motion (AROM) limited.

  • End range pain with repeated motion showing no change.

  • Joint play reveals hypomobility, with hip internal rotation > 35 degrees.

Interventions

  • Mobilization/manipulation, muscle energy techniques, soft tissue mobilization, passive range of motion (PROM), followed by AROM and stabilization exercises, and pelvic tilts multiple times a day.

Clinical Prediction Rule for L/S Manipulation

  • Pain duration < 16 days.

  • Symptoms primarily proximal to knee.

  • Hip internal rotation > 35 degrees.

  • Hypomobility found in one or more lumbar segments.

  • Fear Avoidance Beliefs Questionnaire (FABQ) work subscale < 19.

  • Achieving 4 out of 5 criteria indicates a 95% success rate for improvements observed through the Oswestry index.

Joint Mobilization/Manipulation Techniques

Focus Examples

  • Central PA for sacrum and lumbar spine

  • Unilateral PA for sacral and lumbar mobilizations

  • Sacral inferior glide/distraction for L5-S1

  • Side lying rotations with flexion, extension, or side bend incorporated.

  • Manual traction permitted in various positions emphasizing flexion or extension per comfort and requirement.

LBP with Movement Coordination Impairment

Key Exam Findings

  • Age < 40.

  • Multiple prior LBP episodes indicating increased frequency.

  • High general flexibility noted.

  • Aberrant motion patterns with active range of motion assessments.

  • Mid-range and end-range pain present, with hypermobility evident in central PA testing.

Interventions

  • Stabilization exercises targeting deep core stabilizers; a combination of strengthening and motor control strategies.

LBP with Lower Extremity Pain (Radicular/Referred)

Direction-Specific Exercise

  • Extension subgroup characterized by:

    • Symptoms extending past the knee.

    • Nerve root compression markers identified.

    • Responses indicate centration via repeated extension or peripheralization through repeated flexion.

Interventions

  • Extension-promoting exercises, mobilizations to facilitate extension, and initial avoidance of flexion, with gradual reintroduction possible post asymptomatic periods.

Flexion Subgroup Interventions

Key Exam Findings

  • Symptoms beyond the knee.

  • Nerve root compression experienced.

  • Responses indicating centration with flexion, while extension leads to peripheralization markers.

Interventions

  • Focus on flexion exercises, mobilizations that foster flexion, unweighted ambulation, and careful monitoring of symptoms.

Lumbar Spinal Stenosis

  • Characterized by narrowing that often becomes degenerative, resulting in various symptoms relating to spinal or nerve root compression.

Key Exam Findings

  • Increased pain with standing/walking, alleviated in sitting positions.

  • Demonstrates reduced AROM, with exacerbated pain during extension and relief during flexion.

  • Core and hip strength/endurance decline noted, along with altered neurodynamics.

Interventions

  • Mobilization techniques for lumbar and thoracic segments, promoting AROM and hip mobility exercises, emphasized core stabilization, neurodynamic assessments, and low-intensity functional activities (aquatic exercise, treadmill walking with incline) to aid pain control.

Low-Back Related Leg Pain (LBPRLP)

Pathomechanics Subgroups

  1. Central sensitization: characterized by allodynia and hyperalgesia.

  2. Peripheral nerve sensitization with nerve trunk inflammation present.

  3. Denervation marked by axonal damage causing sensory and motor deficits.

  4. Musculoskeletal referred pain emerging from non-neural structures.

Treatment Considerations

  • No clearly defined treatment;

  • Focus is on patient education regarding pain perceptions and management.

  • Manual therapy, aquatic exercises to manage anxiety/fear avoidance, and neurodynamic techniques may offer relief.

Biopsychosocial Approach

  • Addressing biological (physical therapy for pain science education), psychological (referrals as needed), and social aspects through community support.

Managing LBP

  • A comprehensive algorithm exists to guide clinical decision-making for efficient assessment and treatment protocols in troublesome low back pain cases.