LOW BACK PAIN

REVIEW OF ANATOMY AND PHYSIOLOGY

The vertebrae increase in size distally in the spine. Vertebrae are most massive in the
lumbar region, which constitutes 25% of the height of the vertebral column. The shock
absorbers of the spine are the intervertebral dis. In young person, they constitute 25% of
the height of the spine, but this percentage decreases significantly with age, as the discs
lose water and collapse. The orientation of the facet joints varies at different levels of the
spine. The superior and inferior articular facets are in frontal planes in the mid-thoracic
regions. The lumbar facets are almost in sagittal planes, allowing the facet joints to glide
anteroposteriorly and facilitating most of the flexion and extension movements of the lower
spine. The contribution from thoracic vertebral segments to these movements is negligible.
Seventy-five percent of lumbar flexion and extension occurs in the lumbosacral joint, 20% at
L4 to L5, and the remaining 5% at the other levels.
The lumbar vertebrae are composed mainly of cancellous bone that is susceptible to
collapse under trauma or from osteoporosis. The thin but dense cortical layer may
proliferate with aging at the sites of ligamentous attachments and lead to osteophyte
formation. The vertebral body is attached to the neural arch, which is composed of pedicles,
superior and inferior facets and lamina. The superior facet joint is smaller than the inferior
one. It has a concave cartilaginous articular surface and forms the roof of the lateral recess.
This is where the nerve root leaves the central canal to enter the neural foramen. Pedicles
form the floor and roof of the neural foramina. The lamina unite posteriorly to complete the
neural arch which then protect the neural elements and are the sites of paraspinal muscle
attachments. However, the lamina contributes little to the stability of the spinal column, and
unilateral fracture or surgical removal of the lamina does not cause spinal instability. The
pedicle facet complex normally bears only 20% of the intervertebral vertical load; the
remaining 80% is absorbed by the intervertebral disc. The posterior longitudinal ligament is
attached to the lumbar discs and vertebral body margins. This ligament is attached to the
periosteum that can expand with purulent material, tumor, or hematoma. The posterior
longitudinal ligament, along with the anterior longitudinal ligament, helps maintain the axial
stability of the vertebral column.
Intervertebral discs are remnants of the notochord that act as cushions between
vertebral bodies and are composed of fibro cartilaginous elements. The nucleus pulposus is

an ovoid, yellowish, gelatinous, and Para centrally located middle portion of the disc made of
mucous protein. This is surrounded by a firm, concentric meshwork of collagenous fibers
called the annulus fibrosus. The lumbar disc is normally thicker anteriorly, a shape that
partly explains the normal lordosis. Tiny blood vessels enter and exit the disc in the early
decades of life, but these are obliterated during the first three decades. Thereafter, the disc
nutrition is supported only through the lymphatics and by extracellular fluid osmosis. This
lack of support may be responsible, atleast in part, for lost of water from discs with
advancing age. The water content of the disc in young persons is 88%, but it is reduced to
less than 70% in the elderly.
Functionally, the spine is composed of a series of mechanical units. Each unit consists
of an anterior segment (two adjacent vertebral bodies and the intervertebral discs between
them) and a posterior segment (neural arches0). The anterior segment is primarily the
weight bearing and shock absorbing component, whereas the posterior segment protects
the neural structures and directs movements of the units in flexion and extension. The
amount of force exerted on the spine varies depending on activity and posture.
Other Important features of the lumbar spine include the following:

Orientation of facet joints is in the vertical plane starting at T12-L1 thus allowing

greater flexion and extension

Nerve root at lumbar level will escape through the foramen adjacent to the bony
body-> therefore the posterolateral displacement of a given lumbar disc will not
involve the root escaping at that numbered level, but will affect the one exiting

below
An angle is formed between L5 and S1 called the lumbosacral angle; in an adult

this is normally 30-40 degrees

Posterior longitudinal ligament is incomplete posteriorly below L2

Table 1: Important Differences between the Lumbar and Cervical Spine

Posterior
ligament
Location
pulposus
Thickness

Cervical Spine

Lumbar Spine

Complete and wide, two

Narrowed

nucleus

layered
Anterior

starting L2
Central

annulus

Thicker posteriorly

Thicker anteriorly

longitudinal
of
of

and

incomplete

fibrosus
Partly explains higher frequency of herniations in lumbosacral area
Disc herniation in cervical spine usually occur anteriorly and thus, are more often
associated with cord compression

Disc herniation in lumbosacral spine usually occur posteriorly so usually only have
signs of nerve root compression

Examples of Differential Diagnosis for Cervical & Lumbar Pathologies

Cervical and Lumbar Facet Joint Problems

Similarities:

Acute episodes of lumbar & cervical facet joint pain are typically intermittent,

generally unpredictable, and occur a few times/month/year

Most patients will have a persisting point of tenderness overlapping the inflamed

facet joints and some degree of loss in the spinal muscle flexibility (mm guarding)
Typically there will be more discomfort while leaning backward than while leaning
forward

Differences:

Pain from lumbar facet joint problem often radiates down the back of the into the
buttocks & down the back of the upper leg, pain is rarely present in front of the leg,

or rarely radiates below the knee

Cervical facet joint problems may radiate pain locally or into the shoulders/upper

back & rarely radiates below the knee

Facet joint problems in the lumbar area may indicate that standing may be somewhat
limited but sitting & riding in a car is worst.

Cervical & Lumbar Spondylosis

Similarities:

Sensory & motor disturbances such as severe pain in the neck, shoulder, arm, back

and or leg accompanied by muscle weakness

Both refers to spine degeneration, natural wear & tear breaks down the spinal
anatomy, which can result in a loss of flexibility & mobility, stiffness & mm aches &

pains
Both can lead to poor reflexes

Differences:

Cervical spondylosis may result to myelopathy, characterized by global weakness,

gait dysfunction, loss of balance & loss of bowel/ bladder control

Cervical spondylosis patients may experience a phenomenon of shocks (paresthesia

in hands and legs because of nerve compression and lack of blood flow
Lumbar spondylosis only affects the lower limb, cervical spondylosis may affect the

limbs & head

Cervical spondylosis has a more worse prognosis
Lumbar spondylosis can cause sciatica

Cervical & Lumbar Disc Herniation

Similarities:

Both are the same spine degenerative disorders which may both easily lead to

neuralgia
Both condition may be due to trauma, lifting injuries or idiopathic causes

Differences:

Lumbar disk herniation signs and symptoms are more easily overlooked by patients

and mostly misdiagnosed by doctors

Lumbar disc herniation usually affects L4-L5/ between L5-S1, symptoms may affect
the lower back, buttocks, thigh, anal/genital region and may radiate to foot /toe.

Sciatic and femoral nerve are usually affected

For cervical disc herniation, it usually affects C5 & C6 or C6& C7, symptoms would
affect back of skull, neck, shoulder girdle & scapula, shoulder, arm & hand, nerves
commonly affected are cervical & brachial plexus

Muscles supporting the spine and their function

Muscle Groups
Four groups of muscles provide support to the spine: the extensors, the flexors,
lateral flexors, and rotators of the spine. Normally the extensors and rotators are the main
supportive muscles of the spine. The massive musculotendinous bulk over the upper sacral
and lower lumbar vertebrae are the origin in of the erector spinae muscles, which extend the
vertebral column. Deep to the erector spinae lie the semispinalis muscles. The interspinal
muscles are between spinous processes. The main role of the back muscles in erect posture
is to resist gravity. When a movement of the spine is initiated, and once the vertebral
column is bent far enough in any direction, the muscles of the back that resist their
movement must actively contract to provide smooth and controlled movements and also to
prevent falling. Some muscles that have no vertebral attachments also participate in

movements of the spine. The abdominal muscles are significant flexors and lateral flexors of
the trunk and also participate in rotation.
Lumbar Spine
Resting Position

: Midway between flexion and extension

Close pack position

Capsular pattern

: Extension

: Side flexion and rotation, equally limited extension

DEFINITION

Low back pain is a symptom that can be caused by various disease entities and can
be affected by various psychosocial factors
-Braddom

CLASSIFICATION
There are many different system available to classify LBP into any of several categories.
The 3 general categories for classification of LBP by origin are:
Mechanical- it includes non specific musculoskeletal strain, herniated disk, a compressed
nerve root, degenerative disk/ joint disease & vertebral fracture)
Non-mechanical spinal problems-includes neoplastic disease, inflammatory conditions
such as spondyloarthritis infection
Referred pain-these is a classification where pain felt is from internal organs use such as
(GI diseases, and renal failure)
LBP may be classified based on signs and symptoms:
Non-specific (most common) diffuse pain that does not change in response to particular
movements & is localized to the lower back without radiating into the buttocks
Radicular- pain which radiates down the leg below the knee, located in 1 particular side (in
case of disk herniation) or bilateral (spinal stenosis) and changes in intensity in response to
a particular position/movement

Urgent/ Specialized attention- pain that is accompanied by certain red flags such as
trauma, fever, a history of cancer or significant muscle weakness may be indicative of a
more serious underlying problem
There is general agreement of the chronicity of LBP: it may be classified by the
duration of symptoms as follows:
Acute- pain lasting less than 6 months
Sub-acute- pain lasting 6-12 weeks
Chronic- more than 12 weeks

SOME COMMONLY ENCOUNTERED PAINFUL DISORDERS OF THE SPINE

Mechanical Low Back Pain
Mechanical low back pain is a descriptive term commonly used for non- discogenic
pain that is provoked by physical activity and relieved by rest. The mechanism of injury may
be an episode of trauma or continued mechanical stress of postural or occupational type. It
does not point to one to a single or particular cause. This type of pain is usually often due to
stress or strain of the back muscles, tendons and ligaments and is usually attributed to
strenuous daily activities, heavy lifting, or prolonged standing or sitting. The pain usually
worsens during the day because daily physical activities such as bending, twisting, lifting,
prolonged sitting and standing often aggravate the pain. There are no associated
neurological symptoms or signs, nor a cough or sneeze effect on the lower limbs.
The lumbosacral joint, situated at a critical level between movable and immovable
portions of the spine, is particularly liable to injury from forces applied in an obliquely
anteroposterior direction, as in violent flexion or hyperextension of the spine, falls on the
buttocks, and gravitational stresses associated with excessive lordosis. The lower lumbar
area is especially susceptible to injury from torsion. Lumbosacral sprains are therefore
frequently encountered. The sacroiliac joints in the other hand are large and are protected
by strong ligamentous structures; little motion can be demonstrated in them (5 degrees in
young women). They may nevertheless be injured by occasional violence applied to the
blowback in a rotatory or obliquely lateral manner. During pregnancy, temporary relaxation
of the ligaments of symphysis pubis and the sacroiliac joints occurs normally and sometimes
may be sufficient degree to play a part in causing back pain

Acute and Chronic mechanical strains of the low back

Acute low back pain syndrome

also called acute low back strain or acute lumbosacral strain

is the most common affectation of the lower back, usually associated with some form
of trauma, which may be major, as in lifting a very heavy object, or minor, as in

simple act of bending forward

up to 4 weeks of symptoms

Chronic low back pain syndrome

Also called as chronic low back or lumbosacral strain

Symptoms are less severe and the physical findings less obvious although repeated

acute exacerbations with findings of acute strain may occur

In majority of instances, the underlying pathologic processes are degenerative disk

disease and secondary changes in the facet joints and supporting structures
Often necessitates change in patients occupation and lifestyle

Lesions of the Lumbar Intervertebral Disk

Most commonly causes pain in the lower lumbar region: degenerative joint disease
Most common cause of sciatica: Herniation of IVD

Degenerative Joint Disease

Degenerative joint disease (DJD) occurs with aging and can begin during the third decade of
life. Lumbar DJD can remain asymptomatic. If the disease is symptomatic, the associated
pain is centered in the lower back and is often increased with movement of the spine.
Stiffness, morning stiffness, and stiffness after having been in one position for an extended
period of time are common. Range of motion of the spine may be limited and is often
relieved by rest. Improvement of spinal muscle support through proper strengthening
exercises can alleviate pain.
Degenerative Disease of Facet Joint
Degenerative arthritis of the facet joints results in localized spine pain, which is often
episodic, that sometimes extends to the limb and can mimic radicular pain. The onset of
each attack is usually abrupt. Range of motion especially with extension, is often limited. In
some instances, facet joint DJD, more diffuse DJD and even degenerative disc disease may
coexist. Pain is increased with activity and relieved by rest.
Disc Herniation
Overall, the mean age of patients with lumbar disc herniation is the early 40s. Disc
herniation may occur in the midline, but it often occurs to one side. The cause is usually a
flexion injury. Repetitive injury results in degeneration of the posterior longitudinal ligaments
and annulus fibrosus. Different types and degrees of disc herniation may occur. Macnabs
classification is useful, and correlates well with MRI findings as follows:

Degenerated A bulge and convexity of disc beyond the adjacent vertebral disc margins,
but with intact annulus fibrosus and Sharpeys fibers

Prolapsed Disc. The disc herniates posteriorly through an incomplete defect in the annulus
fibrosus
Extruded Disc. The disc herniates posteriorly through a complete defect in the annulus
fibrosus
Sequestered Disc. Part of nucleus pulposus is extruded through a complete defect in
annulus fibrosus and has lost continuity with the present nucleus pulposus.
The most common levels of lumbar disc protrusion, herniation, or extrusion, in
decreasing order of frequency are L5 to S1, L4 to L5, L3 to L4, and L2 to L3. Therefore, the
most common lumbosacral radiculopathies related to lumbar disc herniation are L3, L4, L5
and S1 radiculopathies. Lower lumbar and S1 radiculopathies are usually a result of
degeneration or herniation of discs and are usually unilateral. Large midline disc herniations
can cause bilateral radiculopathies or cauda equine syndrome severe enough to produce
sphincter problems.
Post-traumatic Compression Fracture

Usually results from compressive flexion trauma

Can occur spontaneously in patients with osteoporosis, osteomalacia, multiple

myeloma, hyperparathyroidism, and metastatic cancer

Upper lumbar spine or the middle to lower thoracic spine is most commonly affected

Congenital Anomalies of the Lumbar Vertebra

In interpreting the relationship of bony abnormalities to the clinical symptoms, the PT
must remember that anomalies re often present in individuals who are symptom free. The
most common anomalies of the low back are the following;
i) Sacralization of the Last Lumbar Vertebra
A bony conformation in which one or both of the transverse processes of the last
lumbar vertebra are long and wing shaped and articulate with the sacrum, the ilium or both
is termed sacralization of the last lumbar vertebra. The disk space between sacralized
vertebra and sacrum is usually narrow, it is often bilateral than unilateral. Bilateral
sacralization may increase stabilization may increase stability at the lumbosacral junction,
placing excessive stresses on the joint above and leading to early disc degeneration in it. In
unilateral sacralization there may be pseudarthrosis between the long transverse process
and the ilium. Usually, in situations like this, probable cause of patients lowback pain is
degenerative disc disease at a higher level.

ii)

Defects of the Lamina (spina bifida occulta)

Clefts are frequently found in the vertebral lamina and may be associated with

underdevelopment of supporting ligaments. Partial or complete lack of fusion between the

laminaof the last lumbar vertebra or of the first sacral segment is common. There is little
evidence of any causal relationship between mild degrees of spina bifida and mechanical
low back pain.
iii)

Variations of the spinous processes

When the neural arch has failed to fuse, the spinous process may be attached to only

one lamina. In other instances a spinous process associated with normal lamina maybe so
large and elongated that it touches the spinous process of the vertebra above or below.
Increased lumbar lordosis and narrowed intervertebral disks tend to increase such contact
between the spinous processes, which may lead to the formation of painful bursa. The
symptoms can usually be relieved by flexion exercises without resort to surgical treatment.
iv)

Variations of the lumbosacral angle

Increase of the lumbosacral angle is often associated with a so-called horizontal

sacrum and lumbar lordosis. In such backs the lumbosacral joint may be especially
subjected to strain and degenerative changes, with subsequent formation of small bony
spurs about the margins of the vertebral bodies. In treatment, flexion exercises are helpful.
v)

Variations in the articular facets

Variations in the size and plane of these small but important joint surfaces are

common. The facets between L5 to S1 are susceptible to such variations. Asymmetrically

aligned facets may contribute to the torsion stresses that are a cause of disk degeneration.
Sagitally aligned facets probably contribute to the development of the degenerative form of
spondylolisthesis.
vi)
Constitutional Variations
Short, stocky individuals: sometimes with only 4 lumbar vertebrae
Tall, thin persons: sometimes with L6 vertebra

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LS joint lacks the support of strong iliolumbar ligaments

Spondylosis

AKA Scotty dog

Neural arch defect in the continuity of pars intercularis commonly involving L5 &

occasionally L4 vertebra
Fx of Pars interarticularis
Leads to spondylolisthesis if bilateral
Commonly affects ballet dancers & athletes, males>females

Spondylolisthesis

AKA decapitated dog

Forward slipping of a vertebra& superincumbent spinal column on the vertebra above
Most commonly at LS level followed by L4 on L5

Grading on the amount of subluxation

1= forward displacement of < 25%
2= 25-50%
3= 50-75%
4= > 75%
Spondylolisthesis has been classified by Wiltse and others into five types:
1. Dysplastic, in which congenital bony anomalies of the lumbosacral junction allow
the slipping, or listhesis, to occur

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2. Isthmic, the commonest form of spondylolisthesis, in which a lack of normal bony

continuity in each pars interarticularis or isthmus, the narrowest part of the neural
arch, permits the displacement
3. Degenerative, in which the slipping vertebra remains a single bone but has become
unstable because of degenerative disease of its facet, or zygaphophyseal joints
4. Traumatic, in which a fracture through part of the vertebra other than the isthmus,
usually caused by severe violence results in anterior displacement
5. Pathologic, in which the slipping is a sequel of deforming or destructive bone
disease affecting the articular facets
Spondylolysis

Refers to a bony defect in the pars intercularis

AKA Scotty dog with collar
Bilateral isthmus defect without forward displacement of the vertebral body due to
narrowing IVD, degenerative changes in the disk and proliferative changes about the
intervertebral foramina

Spinal Stenosis

Localized narrowing of the spinal canal from a structural abnormality of its bony

components
Reduction in the transverse diameter, AP diameter or both of the spinal canal
May lead to compression of the cauda equine if the narrowing is at the lumbar level-

> LBP and pain in the LE chiefly on walking

Congenital or acquired local bony deformities
Achondroplasia= short pedicles & decrease interpediculate space
Pagets disease= bony thickening
Degenerative spinal disease= most common cause

Different forms of Spinal Stenosis (Braddom)

I.
II.

III.

Primary
A. Congenital
B. Developmental
Secondary
A. Degenerative spondylolysis
B. Late sequelae of fracture
C. Late sequelae of infection
D. Systemic bone disease Pagets Disease of Bone)
Mixed
A. Spinal Stenosis due to degenerative joint disease

Low Back Pain in Pregnancy

Develops at some point during pregnancy

12

Factors as heavy labor, smoking, parity, and a previous history of low back pain
predisposes women

Pagets Disease

Common in elderly patients, marked by focal disturbance of bone architecture due to

abnormally increased osteoblastic activity

May involve a single bone (monostotic) or several bones (polyostotic)

Low Back Pain due to Neoplastic Disease

Extramedullary intraspinal tumors such as meningiomas, or neurolemomas, as well

as primary tumors whether benign or malignant can also cause LBP

Most common neoplastic diseases causing LBP are the metastatic spinal or epidural

cancers (multiple myeloma and malignant lymphomas included)

LBP related to neoplastic disease can be steady or may be provoked by physical

activity or change in posture

However, one of the hallmarks of cancer pain is pain at rest, particularly nocturnal
pain

Ankylosing Spondylitis

A chronic inflammatory sero-negative rheumatic spondyloarthropathy that affects

skeletal and extraskeletal tissues

Mainly affects the spine and invariably involves the sacroiliac joints
80-90% of patients are HLA-B27-postiitve

Diffuse Idiopathic Skeletal Hyperostosis

Also known as ankylosing hyperostosis, fairly common in non-reforming, ossifying

disease that occurs in elderly and middle-aged patients, particularly men

Ossification occurs in the anterior and lateral spinal ligaments without disk narrowing,
sclerosis and fusion

Pyogenic Vertebral Spondylitis

The condition includes infectious discitis and infectious vertebral osteomyelitis

Mechanism is from a contiguous infection or by lymphatic seeding from a remote site
Common sources of infection are pneumonia, urinary tract, cutaneous and dental

infections
More common with diabetes, malignancy, renal failure, alcoholism and AIDS have
been implicated

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Visceral Affectations Causing Low Back Pain

Disorders of the GIT pain is not aggravated by mechanical factors

LBP may be caused from pelvic organs
Chronic progressive occlusion of the aorta or common iliac arteries
May cause buttock, or lower limb pain
Not aggravated by single motions ex forward bending or coughing
Brought out by more prolonged activity ex walking
Tumors of the spinal cord, cauda equina
Tumors of the female pelvic organs
Diseases of the genitourinary tract
Infections and tumors of the prostate gland, kidneys
Febrile illness ex Influenza

EPIDEMIOLOGY OF LOW BACK PAIN

Leading cause of disability

Second only to headache as a cause of pain
Prevalence greatest in 55-64 years old age group
Third leading cause of disability in individual < 45 years old
Second highest reason for repeat consultation
Third highest cause for surgery
Fifth highest cause for hospitalization
It is the leading cause of expenditure for Workers Compensation
A study suggests that 25 million Americans lost 1 or more days of work annually

because of LBP
50%-80% of adults will have LBP at some point in their lives
There is a lifetime rate of LBP of about 60-90% and an annual rate of about
5%,overall incidence is equal in men and women, but women report more LBP after

60 years
Lumbar radiculopathies often occur in patients during the fourth and fifth decades of
life, average

Age of patients who undergo lumbar laminectomy and diskectomy is 42 years

ETIOLOGY
Various disease entities can cause LBP. The causes of LBP are many, which can be
categorized as follows:
Table 2: Different Etiology of LBP (Braddom)
Cause

Common Disease

14

1. Degenerative

Degenerative

2. Inflammatory

Spondylolysis
Facet joint disease, facet DJD
Degenerative Spondylolisthesis
Degenerative disc disease
Diffuse Idiopathic skeletal hyperostosis
Spondyloarthropathies (ankylosing spondylitis

(non

Joint

Disease,

OA,

Lumbar

infectious)
Rheumatoid Arthritis
Pyogenic vertebral spondylitis
Intervertebral disc infection
Epidural Abscess
Osteoporosis or osteopenia
Pagets disease of the bone
Benign
Spinal (benign bony tumors of spine)
Intraspinal (metastasis,high-grade ependymomas,

3. Infectious
4. Metabolic
5. Neoplastic

6. Traumatic
7. Congenital

or

astrocytomas, meningeal carcinomatosis

Fractures or dislocations
Sprains (lumbar, lumbosacral,sacroiliac)
Dysplastic spondylolisthesis

developmental
Scoliosis
Acute or chronic lumbar strain
Mechanical lowback pain
Myofascial pain syndromes
Fibromyalgia, tension myalgia
Tension myalgia of the pelvic floor, Coccygodynia
Postural abnormalities, pregnancy
Upper genitourinary disorders
Retroperitoneal disorders
Abdominal Aortic Aneurysm or dissection
Renal artery thrombosis or dissection
Stagnation of venous blood (nocturnal backpain of

8. Muscoloskeletal

9. Viscerogenic
10. Vascular

pregnancy)
Compensation neurosis
Conversion disorder

11. Psychogenic
12. Postoperative
multiply

and

operated

on

back

Risk factors for LBP (PT-OT Reviewer)

1. Occupation-hard labor and heavy work; work that involves lifting, pulling & pushing,
twisting, slipping, sitting for extended periods and exposure to prolonged vibration;
also noted in persons who find their work boring, repetitious and dissatisfying
2. Age- back pain more likely after 55 years old

15

3.
4.
5.
6.
7.

Sex- after 60, females at higher risk due to osteoporosis

Body built- obese and very tall individuals
LOM of spine
Weak abdominals or weak spinal extensors
Psychosocial factors- depression, anxiety, hypochondriasis, hysteria, alcoholism,
divorce, chronic headaches noted to present with high frequency in patients with

chronic back pain

8. Smoking appears to increase risk for back pain maybe because of the increased
incidence of osteoporosis with smoking
9. Physical fitness and conditioning appears to have a preventive effect on low back pain

PATHOPHYSIOLOGY

Non Radicular Low Back Pain Diagram

16

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i f t i n

t h

i n

i c

i p

l a

I n

j u

i f t i n

r y

T o

Diagram for Radicular Lowback Pain

17

r s

i o

i p

l a

t h

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j u

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i n

i c

L
d
D
g
,
C
t
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N
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p
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f
m
e
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s
I
in
P
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c
a
B
w
o
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b
&
/
y
The pathophysiology of nonradicular low back pain is usually indeterminate. In fact,

one of the defining features of this disorder is its nonspecific etiology. Pain can arise form a

number of sites, including the vertebral column, surrounding muscles, tendons, ligaments,
and fascia. Stretching, tearing, or confusion of these tissues can occur after such sudden

unexpected force applied to the spine from events such as heavy lifting, torsion of the spine,
and whiplash injury. Whether muscles spasm is a significant etiology of lumbar spine pain,
either as cause or effect is of back injury has not been proved.

The pathophysiology of radicular spine pain and lumbosacral radiculopathy is usually

more obvious. Disk herniation through the annulus fibrosus does not in itself produce pain,
but compression by disk of the dural lining around the spinal nerve is one likely explaination
for the back pain associated with acute disk herniation. This is also likely to contribute to the

pain from spinal nerve root compression from arthritic spurs at degenerated facet and

uncovertebral joints. Compression can directly stretch nociceptors in dura or nerve root
tissues, but ischemia from compression of vascular structures, inflammation, and secondary
edema is also likely to play a role in some cases.

CLINICAL MANIFESTATION

Acute Low Back Pain syndrome

18

Onset: sudden or gradual

Pain:
catching, usually severe and often incapacitating pain localized to the
lumbosacral area or spread diffusely across the lower back and the buttocks,

and may radiate to the posterior thighs, occasionally as far as the knees
the radiation is a deep aching, somatic type of pain in contrast to the sharp

lancinating radicular pain of sciatica characteristic of lumbar disk lesions

pain is usually aggravated by any movement of the back such as bending
or twisting and relieved by recumbency, but it is often difficult to find a

comfortable position
patient on physical examination are often seen to hold the back quite rigidly,
paravertebral mm are taut, in spasm, and normal lumbar lordosis is flattened,
when patient is asked to bend forward, patient does it in hip joints and the

thoracolumbar area with most of the lumbar spine rigid

attempts with forward flexion are accompanied by flexion of the knees, and
patient usually places hands on the thighs for support, patient walks with

cautious gait to avoid jarring the back, but no limping can be observed
when patient is in supine, movements of the hip are normal until the extremes

are reached, when motion transmitted to the pelvis and spine causes pain
SLR is painless until pull by the hamstring muscles transmits movement via

the pelvis to the lumbosacral joint, usually beyond 60 degrees of elevation

neurologic findings including reflexes, motor, and sensory tests are normal
palpation of the spine with the patient in prone usually demonstrates

tenderness at the lumbosacral or lower lumbar levels

tenderness may also be present over the paravertebral muscles but not over
the sacroiliac joints

Chronic Low Back Pain (3-6 months)

History of several previous attacks of acute back pain

Chronic aching, tired feeling in the lower back
Aggravated by prolonged standing or sitting, by bending, twisting, or lifting
Improved by recumbency
Pain predominantly L5 but often radiates to the sacrum and buttocks, occasionally to
the posterior thigh

Lesions of the lumbar intervertebral disks

1 degree complaint, pain in low back & leg

History of previous attacks of non-radiating LBP
Onset: abrupt or gradual, may be associated with
Immediate snapping sensation in the low back when lifting a heavy object
Catching sensation in the back while stooping
Leg pain a few days to several weeks after the onset of back pain:

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Deep, aching pain extending to the thigh and leg

Sharp, lancinating pain shooting down the limb to the lateral side of the leg

and ankle and even into certain toes

Leg & back pain aggravated by spinal motion & by activities that increases

intraspinal pressure ex coughing or sneezing

Numbness of foot or toes & occasional weakness & instability of feet & ankle
Loss of bladder or bowel control and decrease sensation in the perianal region (S3-

S4) in large central disk herniation

Patients usually:
Back held stiff
Lumbar lordosis flattened & often reversed
Lumbar spine shifted to the (L) or ( sciatic scoliosis)
Towards the side opposite to the lesion if protrusion is lateral to the
root
Towards the same side as the lesion if the protrusion lies medial to the

root
Spasm & tenderness of lumbar muscles
Abnormalities in the LE secondary to nerve root injury
Muscle weakness and atrophy
Reflex changes
Hyperesthesia & other sensory disturbances
S1 nerve root (protrusion at L5-S1 level)
Hyperesthesia in the lateral aspect of leg & foot
Absent or diminished ankle jerk
L5 nerve root involvement (protrusion at L4-L5 level)
Hypesthesia of the dorsum of the foot & 1st 2 toes
Weakness of the extensor of the big toe
Femoral Nerve Involvement (above L4 vertebra)
Anterior thigh pain. Alterations in the knee jerk
(+) SLR including Lasegues sign, Bragards sign
(+) Bilateral SLR and crossed SLR= large disk protrusion
(+) Reverse SLR for lesions involving L3-L4 roots

Lumbar Herniations/Radiculopathies

Pain often radiates into the buttock, the posterior thigh, and lateral calf or lateral or
medial malleoli (L5 or S1 radiculopathies) (Sciatic nerve distribution and known as

sciatica)
Pain radiates to anterior thigh in L3 or L4 radiculopathies
In cases of disc extrusion, LBOP is often relieved or decreased, but radicular limb

symptoms becomes more prominent

Examination of the back often shows paraspinal muscle spasm, loss of lumbar
lordosis, listing of the spine away from the side of the root pain, limitation of motions
of the lumbar spine with corkscrew phenomenon on flexion and straightening,
positive SLR test and sometimes, crossed SLR in cases of L5 or S1 radiculopathies

20

When radiculopathy occurs, several features, including distribution of pain, reflex

changes, distribution of weakness and sensory alterations, provide reliable information that
enables the clinician to localize the level of disc protrusion or root irritation as follows:
Table 3: Clinical
(Braddom)

Manifestations/Features

21

of

Lumbosacral

Radiculopathies

Roo

Distribution of

Paresthesia

Pain

or

L1

Lower

Loss
Lower

Iliopsoas

Hypogastric

abdomen, groin,

abdomen,

(+,-)

Cremasteric

or

inguinal

upper

Weakness

Decreased

Sensory

Absent Reflexes

anterior medial

region

L2

thigh
Groin,

Anterior

L3

or Medial Thigh
Anterior thigh or

medial thigh
Anterior thigh

thigh or both
Quadriceps

and

L4

knee
Can

and knee
Inner leg

thigh adductors
Quadriceps
and

thigh

Anterior

extend

below
often
leg
L5

S1

to
or

and

and

Iliopsoas or adductors of

knee,

adductors

and

inner

Anterior (+,-)

Tibialis

Quadriceps

Quadriceps

and

medial hamstring

medial

malleolus
Posterolateral

Outer leg and

Tibialis

thigh,

dorsum

extensors, and extensors,

ankle

(therefore

normal, sometimes

heel-walking),

decreased but not

lateral

of

Anterior,

calf to dorsum

foot to great

hallucislongus

of foot

toe

impaired

toe

Medial

hamstring,
jerk

often

hamstrings, perinea, and

absent

tibialis posterior, gluteus

only L5 root lesion

because

Posterior thigh,

Posterior leg,

medius
Gastrocnemius-Soleus and

Ankle

calf, and lateral

lateral

toe

lateral hamstring

malleolus

last two toes

foot,

flexors(

impaired

therefore

toe-walking),

hamstring,

gluteus

Variable

maximus
Intrinsic foot muscles (+,-),

and

posterior

rectal sphincter (+,-)

occasionally calf

thigh, saddle

S3

Buttock

area
Saddle

to

upper posterior

perianal area,

S4

thigh

perianal area

S2

or

Posterior

thigh

and
or

and

Rectal Sphincter

perianal region

LBP in Pregnancy

22

Anal

Anal

Jerk

and

Nocturnal back pain

Occurs 1-2 hrs. after lying down
Related to stagnation of venous blood flow due to:
1. Return of fluid of dependent edema of pregnancy to the circulation during
recumbency
2. Venous blockage caused by pressure of the fetus on the vena cava on the other
Low dorsal pain
Lumbar pain, which may or may not extend to one or both lower limbs
Sacroiliac region pain
The most common type of back pain in pregnancy
Caused by the production of relaxin ( hormone secreted by corpus luteum)

during pregnancy
Risk Factors include the following:
Age
Heavy labor
Previous history of LBP
Smoking
Parity

Spondylosis

Localized LS pain worst with ext.& partially relieved by flexion

Local tenderness
Muscle spasm
Neurological exam

Isthmic Spondylolisthesis

Pain may be severe, slight or entirely absent which is often localized in the
lumbosacral joint region but may radiate down one or both legs along the course of

sciatic nerves and especially in the distribution of peroneal nerves

There is often complaint of stiffness of the back, and all the symptoms become worse

with exercise and strain

On examination, the low back appears lordotic, the spinous process of the detached

neural arch is prominent on palpation and is evident on inspection

In cases of extensive slipping the torso is shortened, the ribs may rest on the iliac

crests, and the abdomen may protrude

There may be great limitation of anteroposterior motion in the affected area and

spasm of the erector spinae and hamstring muscles

In severe cases, the gait is sometimes awkward and waddling

Degenerative Spondylolisthesis

Typical patient is a woman aged 50 years or more who complains of long-standing

pain in the low back, buttocks, or thighs

Pain has rarely been incapacitating and has undergone long remissions

23

It is relieved by sitting or reclining

On forward flexion, low back mobility is often limited and vicarious hip flexion is

increased
Lower limb pain is often unaccompanied by significant neurologic signs

Spondylolysis

Pain, slight, severe or entirely absent

Pain localized in the LS region but may radiate down 1 or both legs along the course

of the peroneal nerves

Stiffness of the back
Symptoms worst with exercise and strain
Low back appears lordotic
Palpation: prominent spinous process of the detached neural arch with a tender

depression just above it

Spasm of the erector spinae & hamstrings muscle

Spinal Stenosis

Man over 40
Pain, paresthesia & numbness in

relieved completely by sitting or lying down (neurogenic claudication)

Weakness of the legs as the symptoms progress
Long history of LBP
(N) Back on exam or with spasm or stiffness
Mm weakness & wasting in the legs
Decrease or loss of ankle jerk, frequently with no neurologic changes
Sensory losses in advanced cases

the legs brought on by exercise ex. walking &

Sacroiliac Joint Disorders

Unilateral, frequently in the absence of low back pain

Commonly in buttock, lower abdomen, groin, and anteromedial or posterior thigh
Non-dermatomal paresthesia, vague heaviness in the buttock or leg, and subjective

numbness/tingling
Symptoms may be in sciatic distribution
Pubic symphysis pain may occur in a severe sacroiliac problem
Patient may report sharp catches, clicking, deep clunking and may state that the hip
or back feels out of place

DIAGNOSIS
Physical examination
Inspection

24

Look for deformities, paraspinal spasm, birthmarks, unusual hair growth, listing to one
side, corkscrew deformity, decrease or increase in lordosis, presence of scoliosis, muscular
atrophy, or asymmetries.
Palpation and Percussion
Determine whether there are tender or trigger points, local tenderness or pain on
percussion, spasm, or tightness of the paraspinal muscles. Observe patients reaction to
pain.
Range of Motion
ROM should be determined for flexion, extension, lateral bending and rotation. Values for
normal ROM of the lumbar spine are as follows:
Flexion

: 40 degrees

Extension

: 15 degrees

Lateral bending

: 30 degrees

Lateral rotation

: 40 degrees

Several techniques and instruments can be used for measurement of ROM of the spine as
follows:
A. Tape Measure Method
Originally described by Schober, this method is a simple and practical way to determine
the amount of flexion in the lumbar spine. A line is drawn that connects the dimple of
Venus. Then, two marks are made along a line that perpendicularly bisects the first line.
One mark is 5 cm below and the other is 10 cm above the point of bisection, with the
distance between these two marks being 15 cm. The patient is then asked to bend forward
maximally. The measured distance beyond the original 15 cm gives an estimate of the
degree of spinal flexion.
B. Inclinometers
These were initially introduced by Asmussen and Heeboll-Nielsen and further developed
by Loebl. This method however fails to separate hip motion from spine motion. A doubleinclinometer method: zero starting position. The inclinometers are aligned over T12 and the
sacrum and their gauges are set at 0 degrees. The subject then positions the spine in

25

maximal flexion. The degrees recorded on the sacral inclinometer are subtracted from the
degrees recorded on the inclinometer positioned over the T12 spinous process
Neurological examination
Gait, Station and Coordination
One should look for antalgic gait, foot drop, and functional or hysterical features. The
patient should do toe-walking, and tandem gait. It should be determined whether the patient
can stand on either one foot or can squat and rise. Alternate motion rates are to be done
rapidly and regularly. They depend on an intact sensory motor system. These can also be
affected by pain, diseases of joints, insufficient effort, poor cooperation and functional
factors
Muscle Stretch Reflexes
An increase, decrease, or absence of muscle stretch reflexes should be recorded. A patients
reflexes must be compared with other muscle stretch reflexes, particularly of the
corresponding opposite side. Reflex asymmetry, however, is most often significant
Muscle Bulk
Inspect for muscle atrophy. Comparison of the circumference of the lower limbs, determined
with a tape measure, at different levels (such as mid-calf level) is sometimes useful. One
should also look for muscle fasciculations.

Muscle strength
It is important to determine whether the muscle weakness is genuine or whether it is a
giving-way as the result of pain, functional factors, or poor effort. It should be noted whether
the distribution of the weakness corresponds to as single root or multiple roots or toa
peripheral nerve or plexus, or whether the weakness is of upper motor neuron type.
Laboratory
Plain Radiography

26

Plain radiography is a quick and less costly screening study; it is helpful in detecting
fractures, dislocations, degenerative joint disease, and spondylolisthesis, narrowing of
intervertebral disc space, and many bony diseases and tumors of the spine.
Radioisotope Bone Scanning
Radioisotope scanning is a valuable test for screening the entire or a large part of the
skeleton. It is useful for the detection of tumors, particularly bony metastases. Gallium
scanning is used if infection is suspected.
CT and MRI
Both CT and MRI are useful in detecting disc disease, herniated, or extruded disc, or tumors
(vertebral, epidural, meningeal, intradural, or cord). Overall, MRI is superior to CT. MRI can
image the entire lumbar spine in a single scanning session and shows the soft tissues better
than the CT. It is an excellent method for detecting epidural, intradural, and some of the
intra axial spinal cord lesions, such as tumor, cyst or even demyelinating plaques. CT can
define or demonstrate bony lesions better.
Myelography
Still used by many surgeons before a final decision is made regarding lumbar surgery. CT
myelography remains the most accurate imaging method for the diagnosis of disc
herniations and extrusions.
Electromyography
Electrodiagnostic studies are useful for detecting neurogenic changes and denervation, as
well as the extent of these changes and level of involvement.

Special Tests
The various maneuvers can be classified based on the potential cause of the back pain as
follows:
Nerve Root Compression
SLR
Lasegues
Kernigs
Braggarts
Crosssed SLR
Hoovers

27

A. Sacroiliac Pathology
Patricks
Ericksons
Gaenslens
Pelvic Rock
B. Hip Joint Pathology
Patricks
C. Intrathecal Pathology
MilgramsNaffzigers
ValsalvaManeuver
D. Tightness of Muscles
Thomas
Obers
1. Straight Leg Raising Test
Starting Position: Supine
Procedure
: Raise the leg of the patient by lifting the heel while keeping
the knee extended
NormaL test
Positive test

: leg can be raised up to 80 degrees without pain

: pain in the raised leg, usually following the distribution of the

sciatic nerve Anywhere between 30-80 degrees

Interpretation
: suggest either a sciatic nerve compression or hamstring
tightness. Thus, if the test is positive, a Braggarts or Lasegues test should be done
to differentiate between sciatic irritation and hamstring tightness.
Note: If patient refuses to raise legs because he claims it is too painful then a
Hoovers test should be done to rule out malingering
2. Well Leg Staight Leg raising Test or Crossed SLR
Same as above but done on the normal leg with pain referred to the involved

or opposite extremity side

Said to be more highly correlated to disc herniation than the SLR

3. Ericksons Test
Starting Position

: Side lying with the side to be tested in contact with the bed;

both hips and knees are extended with one leg on top of the other; examining bed
should be firm
Testing procedure : examiner applies downward pressure over the greater
trochanter
Positive procedure : pain felt over the sacroiliac area
Interpretation/Use : suggest a sacroiliac joint pathology or sacroiliitis
4. Pelvic Rock Test
Starting Position
Procedure

: Supine
:Place hands on both iliac crests with thumbs at ASIS and palm

on the ilac tubercles; forcibly compress the pelvis towards the midline of the body
Positive test
: pain around the sacroiliac joint
Interpretation
: suggest a pathology at the sacroiliac joint

28

5. Milgrams Test
Starting Position
Procedure

: supine
: ask patient to keep both feet raised about two inches from the

table, with knees kept straight for 30 sec

Positive test
: pain is felt at the lumbosacral area
Interpretation
: suggest increased intrathecal pressure
Use
:used for the disorders of the vertebral discs
6. Naffziger Test
Starting Position
Procedure

:supine
:gently compress the jugular veins of the patient for about 10

sec until the patients face begins to flush; then ask patient to cough
Positive test
: pain is felt at the lumbosacral area upon coughing
Interpretation
:suggest increased intrathecal pressure
Use
: vertebral disc pathology
7. Valsalva Maneuver
Starting Position :sitting or supine
Testing maneuver :ask the patient to take one deep breath and then keep the
mouth closed as he tries to strain
Positive test
: (+) pain at the side of the vertebral disc pathology in the
vertebral spine
Interpretation and use :same as Milgrams and Naffzinger
8. Braggards Test
Starting position
Procedure
Negative test

:supine
:recurrence of painsuggest sciatic nerve irritation
:pain during SLR was secondary to hamstring tightness

9. Obers Test
Starting position
Procedure

: side lying
: maximally abduct the hip and flex the knee while the hip is

neutral or in slight extension then release the leg

Positive test
: (+) continued abduction after letting go of the leg
Interpretation/Use : for detection of iliotibial band tightness
10.Thomas test
Starting position : supine
Procedure:
1. Place one hand under patients back
2. Flex both hips and observe loss of lumbar lordosis
3. Patient keeps unaffected leg flexed while he extends the opposite leg
Positive test
: the hip cannot be fully extended so that an angle is formed
between the thigh and the bed which is measured and represents the degree of hip
flexion contracture; some patients may attempt to correct this angle by arching the
back so this should be noted by the examiner
Interpretation/use
: test to detect hip flexion contractures and evaluate range of
hip flexion

29

11.Brudzingskis Sign
Starting position
: supine
Testing position: examiner places his hand behind the patients head and flexes the
neck forward
Positive test and interpretation patient is malingering; he is not at all trying to
lift the leg
12.Kernigs Test
Starting position
Testing Procedure

: supine
:examiner flexes one of the patients hip and knee and

straightens it
Positive test and interpretation/use:
1. If pain is felt at the back of the neck with or without resistance felt on extension,
this suggest a meningeal irritation.
2. If pain is felt at the lumbosacral area, then this may suggest disc pathology; this
test however, has to be interpreted in relation to the rest of the clinical
presentation.

PROGNOSIS
Acute Low Back Pain

Course: 3-6 weeks

Likely to suffer other attacks in the future
May develop into chronic LBP

Chronic Low Back Pain

Course: 3-6 months

A completely (N) back not to be expected
Favorable outcome if adjustments can be made in occupation and other activities
May ultimately develop sciatica & other symptoms of disk disease

Lesions of the Lumbar Intervertebral Disks

Treatment is focused to provide relief and a back that allows the patient to resume

his/her occupation
Occasional recurrent symptoms should be expected
Possible risk that disk rupture may occur later or to another level
In some cases, satisfactory relief of symptoms are obtained through conservative
means
DIFFERENTIAL DIAGNOSIS

30

1. Lumbar Compression Fracture

Similarities between LBP and Lumbar Compression Fracture
Similarities of LBP and Spondylosis

Moderate to severe back pain that is made worse by movement

Tenderness on lower lumbar area

Differences between LBP and Lumbar Compression Fx

May lead to deformity such as dowagers hump

Loss of height
Crowding of internal organs
Loss of mm & aerobic conditioning

2. Coccyx Pain

Similarities between LBP and coccyx pain

Pain in lower lumbar area

Back mm weakness

Differences between LBP and coccyx pain

3.

Pain is markedly worst when sitting

Pain that is worse from sitting to standing
Pain that is worse with constipation
Osteoporosis

Similarities between LBP and osteoporosis on the lower lumbar area

Aching type of pain that is aggravated by motion

Localized tenderness at lower lumbar area

Differences Of LBP and Osteoporosis at lower lumbar area

Swelling and warmth in one/more joints especially during weather changes

Presence of crepitus
Abnormal curve in the spine due to mm spasm
4. Herniated Disc

Similarities between LBP and herniated disc

Pain on lower lumbar area

31

Tenderness on lower lumbar area

Differences between LBP and Herniated disc

LBP usually has localized pain while herniated disc has undefined pain in thighs,

muscular weakness, paralysis, paresthesia and affectation of reflexes

Herniated disc usually comes with sciatica
LBP does not cause sexual dysfunction but herniated disc in L3-L5 may present with
erectile dysfunction

MANAGEMENT

Table 4: Some Causes of Acute Low Back Pain and Their Treatment
(Braddom)

Cause
Muscoloskeletal

Muscle

Ligamentous Sprain
Herniated Disc

Conservative treatment

Nonprogressive

Injection

Progressive

Laminectomy and disc excision

Neurological Signs
Traumatic Fracture

Spinal Orthoses

Stable

Analgesics

Unstable
Inflammatory disease

Fusion, bone graft, or instrumentation

Conservative
management,
treatment

Strain

48 hrs)/heat, massage

or

(acute

spondyloarthropathies)
Infections
(Vertebral

infection)
Compression

disc
Fracture

are present

(Osteopenia,
Osteoporosis)
Degenerative
disease
without

abnormality
Malignancy,
pathological

Immobilization, antibiotics, surgery and drainage

of pus if pressure effect and neurological deficits

intervertebral

of

underlying disease

spondylitis,

Treatment
Symptomatic treatment(bed rest, corset, cold(first

with

Bed

rest

(2-3

days),

back

support,

simple

analgesics, treatment of underlying disease

joint

Conservative treatment

or

Posture Instructions

facet

Back support

Radiation

therapy,

usually

high

dose

dexamethasone at onset if cord compromise is

32

compression fractures

present;

orthosis

for

stabilization;

surgical

decompression and stabilization in selected areas

Table 5: Some Causes of Chronic Low Back Pain and Treatment (Braddom)

Cause
OA; DJD

Lumbar Spondylosis

Treatment
Improve
muscular

back

support, corset
Weight loss
Avoid lumbar hyperextension

Facet Pain Syndrome

Facet DJD

Improve muscular support

Consider Injection

Dynamic,

Static

posture

Spondylolisthesis

principles
Flexion exercise program

Stable

Spinal Orthosis

Progressive neurological deficit

Spinal Stenosis

Activity precautions
Decompression and fusion
Spinal flexion exercises

Pseudo claudication

Weight reduction

Lateral recess syndrome

Correction of posture

Metabolic bone disease

Decompression
Isometric
back

Osteopenia

Osteoporosis

extension

program

Treat underlying disease

Avoid heavy lifting (5 to 10

lbs)

Chronic Inflammatory Disease

(Ankylosing

Spondyloarthropathies)
Fibromyalgia

Spondylitis,

Chronic

Chronic Pain Syndrome

Conservative Treatment

Biofeedback

Relaxation

Correction of posture
Multidisciplinary
behavioral
approach

33

Psychological Testing

Stretching

Stretch

Management

to

consider antidepressants

Electromyographic
biofeedback

34

Acute Low Back Pain

Medical

Analgesics with acetaminophen, sedative mm relaxants can be used

Better to avoid codeine and its derivatives because constipation induced by these

agents aggravates back pain as a result of straining intraspinal pressure

Patient is instructed to use a firm matress
In very acute and painful phase, rest in bed may be needed by
Patient in semi-Fowler position

Surgical

Acute low back pain does not require surgical procedures unless the pain lingers and
further evaluation had been done

PT Rehab Management

Cold packs x 20 mins during first 48 hrs after strain or sprain on lower back
-for reduction of edema
Hot Moist Pack x 20 mins thereafter on lower back
-for pain reduction
Infrared heat lamp x 20 mins on lower back
TENS x 10 mins on lower back
-for pain relief
McKenzie for extension bias patient or Williams exercise for flexion bias patients

Typical McKenzie Back Extension Exercises

1. Prone lying. Lie on your stomach with arms along your sides and head turned to
one side. Maintain this position for 5 to 10 minutes.

2. Prone lying on elbows. Lie on your stomach with your weight on your elbows
and forearms and your hips touching the floor or mat. Relax your lower back.
Remain in this position 5 to 10 minutes. If this causes pain, repeat exercise 1, then
try again.

3. Prone press-ups. Lie on your stomach with palms near your

shoulders, as if to do a standard push-up. Slowly push your shoulders up, keeping
your hips on the surface and letting your back and stomach sag. Slowly lower your
shoulders. Repeat 10 times.

4. Progressive extension with pillows. Lie on your stomach and

place a pillow under your chest. After several minutes, add a second

pillow. If this does not hurt, add a third pillow after a few more minutes. Stay in this
position up to 10 minutes. Remove pillows one at a time over
several minutes.

5. Standing extension. While standing, place your hands in the small of your back
and lean backward. Hold for 20 seconds and repeat. Use this exercise after normal
activities during the day that place your back in a flexed position: lifting, forward
bending, sitting, etc.

How to Perform Williams Flexion Exercises

1. Pelvic tilt. Lie on your back with knees bent, feet flat on floor. Flatten the
small of your back against the floor, without pushing down with the legs. Hold
for

to

10

seconds.

2. Single Knee to chest. Lie on your back with knees bent and feet flat on the floor.
Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the
knee

and

repeat

with

the

other

knee.

3. Double knee to chest. Begin as in the previous exercise. After pulling right knee
to chest, pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly lower
one

leg

at

time.

4. Partial sit-up. Do the pelvic tilt (exercise 1) and, while holding this position,
slowly curl your head and shoulders off the floor. Hold briefly. Return slowly to the
starting

position.

5. Hamstring stretch. Start in long sitting with toes directed toward the ceiling and
knees fully extended. Slowly lower the trunk forward over the legs, keeping knees
extended,

arms

outstretched

over

the

legs,

and

eyes

focus

ahead.

6. Hip Flexor stretch. Place one foot in front of the other with the left (front) knee
flexed and the right (back) knee held rigidly straight. Flex forward through the trunk
until the left knee contacts the axillary fold (arm pit region). Repeat with right leg
forward

and

left

leg

back.

7. Squat. Stand with both feet parallel, about shoulder's width apart. Attempting to
maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and
feet flat on the floor, the subject slowly lowers his body by flexing his knees.

(Note:

Difference

between

McKenzie

and

Williams

flexion

exercise

discussed in Addendum)

Myofascial release for low back

Performing Direct Myofascial Release

Land on the surface of the lower back area with the appropriate 'tool' (knuckles, or
forearm etc.).

Sink into the soft tissue.

Contact the first barrier/restricted layer.

Put in a 'line of tension'.

Engage the fascia by taking up the slack in the tissue.

Finally, move or drag the fascia across the surface while staying in touch with the
underlying layers.

Exit gracefully

How to Perform Indirect Myofascial Release

Lightly contact the fascia with relaxed hands.

Slowly stretch the fascia until reaching a barrier/restriction.

Maintain a light pressure to stretch the barrier for approximately 35 minutes.

Prior to release, the therapist will feel a therapeutic pulse (e.g., heat).

As the barrier releases, the hand will feel the motion and softening of the tissue.

The key is sustained pressure over time

Educate patient how to get in and out of bed properly

Educate patient on back precaution (no bending on trunk, no twisting & etc.)
Twisting or pulling a muscle or tendon can result in a strain. It can also be caused by
a single instance of improper lifting or by overstressing the back muscles. A chronic

strain usually results from overuse involving prolonged, repetitive movement of the

muscles and tendons.

A sprain often results from a fall or sudden twist, or a blow to the body that forces a
joint out of its normal position. All of these conditions stretch one or more ligaments

beyond their normal range of movement, causing injury.

In addition, there are several factors that put a person at greater risk for a back strain
or sprain, including excessively curving the lower back, being overweight, having
weak back or abdominal muscles, and/or tight hamstrings (muscles in the back of the
thighs). Playing sports that involve pushing and pullingsuch as weightlifting and

footballalso increases the risk of a low-back injury.

Use good body mechanics when sitting, standing and lifting. For example, try to keep
your back straight and your shoulders back. When sitting, keep your knees bent and
your feet flat on the floor. Dont over-reach, and avoid twisting movements. When

lifting, bend your knees and use your strong leg muscles to help balance the load.
Educate patient on proper body mechanics
Proper body mechanics
If prolong sitting is required for an occupation, one should get up every 20
minutes
For driving a car, the seat should be brought close to the steering wheel so
that the knees are slightly higher than the hips
Stomach muscles should be tightened before coughing or sneezing
Begin a progressive low back isometric strengthening exercise program and
perform stretching exercises to increase flexibility for performing daily
activities
Forward bending increase intradiskal pressure, therefore kneeling is advisable
when picking an object from the floor or making a bed
When getting into bed, one should sit on the edge of the bed, turn and roll
slightly to one hip, bring the knees up with the feet hanging over the edge of
the bed, slowly recline, pushing up with the arms on the bed to support the

body. For getting out of bed, one needs to reverse this procedure
Soft Tissue Mobilization
-can help relax muscles of lower lumbar area
Manipulation-rotating the pelvis on the trunk or by flexion
Role of Manual Therapy-Mobilization and manipulation in Spine pain
Standard grades of mobilization used for pain control or to generate motion:
Grades I and II- oscillation; low velocity forces applied repetitively within
resistance free ROM of a joint; used manily for pain control
Grade III and IV- stronger forces that move joint into its restricted range and
are useful in producing motion
Grade V- called manipulation; includes small amplitude, high velocity thrust at
or just beyond the normal physiologic range of the joint without exceeding its
anatomic integrity

 Results of studies have shown that spinal mobilization and manipulation may
be beneficial but only to small subgroups of back pain patients, the patients
who are more

likely to benefit from manipulation are:

Acute low back pain of < 3 weeks duration
Minor or absent LE neurologic signs
No evidence of dural tension signs

Chronic Low Back Pain

Medical

When symptoms are pronounced and incapacitating, a period of 1 or 2 weeks of

complete bed rest may be necessary

Use of analgesics

Surgical

Spinal fusion if unrelieved by conservative measure

PT Management

Use of a firm matress and bed board especially for patients whose back pain is worse

after a nights sleep

Acute recurrent flare-ups treated as LBP
Adjustment in chair height and inclination may help patients whose back pain get

worse after prolong sitting

Exercise programs designed to build up abdominal and gluteal muscles, including

hamstring stretching and general postural exercises

Patient education on proper body mechanics
1-2 weeks of complete rest when symptoms are pronounced and incapacitating
Traction to the pelvis or legs

Disk Herniation

Medical

Pain reliever
Bed rest; semi-fowler position

Surgical

Partial laminectomy
Indications of disk surgery

 Severe symptoms that fail to improve by adequate conservative program

Progressive neurologic involvement, especially if bladder or sphincter

function is becoming impaired

Disabling symptoms with inadequate response to non-operative treatment
Chemonucleolysis- injecting the NP with the enzymes chymopapain which causes
hydrolysis of the glycoproteins of the nucleus

PT Management

Traction to the legs or pelvis

Exercises to strengthen abdominal muscles and decrease lumbar lordosis
Bilateral forced flex of hips and knees on the pelvis with accompanying rotatory

movement
Cold packs x 20 mins during first 48 hrs after strain or sprain on lower back
-for reduction of edema
Hot Moist Pack x 20 mins thereafter on lower back
-for pain reduction
Infrared heat lamp x 20 mins on lower back
TENS x 10 mins on lower back
-for pain relief
McKenzie for extension bias patient or Williams exercise for flexion bias patients
Myofascial release for low back
Educate patient how to get in and out of bed properly
Educate patient on back precaution (no bending on trunk, no twisting & etc.)
Educate patient on proper body mechanics
Soft Tissue Mobilization
-can help relax muscles of lower lumbar area
Manipulation-rotating the pelvis on the trunk or by flexion

Low Back Pain in Pregnancy

Medical

Acetaminophen-the analgesic of choice for management of LBP during pregnancy

PT Management

Prophylaxis
Reducing the load of the spine by appropriate changes in lifestyle and work

environment
Avoidance of excessive weight gain during pregnancy
Educating the patient regarding proper posture
Proper techniques for lifting, working positions and resting positions

Lesions of the for Intervertebral Disks

Medical

Salicylates, acetaminophen, & non-steroidal anti-inflammatory drugs

Opiods for acute pain (not for chronic patients)
Benzodiazepines, methocarbamol and cyclobenzaprine for muscle relaxants
Ibuprofen, flurbiprofen, naproxen

Surgical

Partial laminectomy, exposure of the protruding mass and excision of the mass as
well as nuclear material remaining in the disk, indications for disk surgery are as
follows:
1) Severe symptoms that fail to improve with treatment by an adequate
conservative program
2) Progressive neurologic involvement, especially if bladder or sphincter function is
becoming impaired
3) Disabling symptoms with inadequate response to non-operative therapy

PT Management

Traction applied to the legs or hips

Exercises to strengthen the abdominal muscles and decrease lumbar lordosis
Bilateral or unilateral SLR and hyperextension of the spine or hips

Isthmic spondylolisthesis

Medical

Immobilization of the spine in a flexed position by means of a plaster cast extending

from the lower part of the thighs to above the costal margins, will relieve most of the

acute pain
Back brace
Anti-inflammatory medications
Epidural injection
Prednisone for severe radicular symptoms

Surgical

Surgical fusion of the last two lumbar vertebrae to the sacrum in cases of severe or

progressive slipping
Laminectomy in cases of pressure on the cauda equina

PT Management

Exercises to decrease pelvic tilt and lumbar lordosis

Electrical stimulator
Lumbar traction
-can help with reactive mm spasm

ROME
-to help maintain joint motion

Degenerative Spondylolisthesis

Medical

Analgesics
Low back corsets
Fracture boards
Adequate rest

Surgical

Disk replacement (involves removing the disk and replacing it with artificial parts

similar to replacements of hip/knee)

Decompressive laminectomy
Spinal fusion

PT Management

TENS @ 9 hertz x 10 mins

HMP
-can help increase joint mobility
Cryotherapy
-can reduce pain and edema
US
Stretching Exercises with 7 sec hold x 10 reps
PREs x 10 reps
Traction

ADDENDUM

Overview on McKenzie & Williams Flexion Exercises

Williams Flexion Exercises

Williams lumbar flexion exercises are set of system related to physical therapy
intended to enhance lumbar flexion, avoid lumbar extension & strengthen the

abdominal & gluteal musculature in an effort to manage LBP non-surgically

It was devised devised by Dr Paul C. Williams (1900-1978) then a Dallas orthopedic

surgeon
It is a cornerstone in the mx of LBP for many years for treating a wide variety of back

problems regardless of diagnosis/ chief complaints

In many cases, it is usually used when the cause/ characteristics of the disorder were
not fully understood by PT/ Physician

It is a standard in non-surgical LBP treatment

McKenzie Extension Exercises

Devised by Robin McKenzie

In contrast to Williams flexion exercise, it suggests that all spinal pain can be
attributed to alteration of the position of the discs nucleus pulposus, in surrounding

to annulus, mechanical deformation of soft tissue caused by postural stress

McKenzie concluded that a continually flexed lifestyle may cause the nucleus to
migrate more posteriorly, resulting to LBP

General Principles on Exercises for Low Back Pain

Objectives

Decrease pain
Restore normal function
Prevent recurrence

1. Williams Exercises: used for anterior disc protrusion

Posterior Pelvic Tilt

5 sec hold, 10 reps

Unilateral, alternate knee to chest

5 sec hold, 10 reps

II

Bilateral knee to chest

5 sec hold, 10 reps

Straight Leg Raising

5 sec hold, 10 reps

Partial curl ups

5 sec hold, 10 reps

Hurdles position

5 sec hold, 10 reps

Wall slides

sec hold, 10 reps

II

2.Mc Kenzie Back Exercise: Used for posterior disc protrusion

Lie face down with arms on side

Head turned to one side

Remain face down

Lean on both elbows

Remain face down

Place hands in press up position
Push upper half of the body

Stand upright
Hands on small of back
Bend hands as fulcrum keeping knees as straight as possible

Sit on stool or chair

Allow to slouch completely
Draw self-up and accentuate lordosis for 5 sec
Allow self to sink back to slouch position

10

10

10

Lie on back
Knees bent up
Feet flat on bed
Both knees

3. Reagans Exercise (for lordotic posture)

a. Pull knees towards armpits

b. Curl up and toe reach in semi-fowler position

c. Sitting on edge of a straight hard chair or stool

d. Assume a balance stance

4. Wedge Maneuver: Lateral disk herniation

Criteria for the continuation of LBP exercise:

Centralization of pain
No aggravation of symptoms
Decrease neurologic symptoms
Exercise to prevent recurrence of back pain
Supine flexion
Hamstring stretches
Prone rotators

10

Strengthening exercise for the abdominals, gluteus maximus and medius and

erector spinae
Prone extension
Hip flexor stretches
Exercise to prevent recurrence of back pain
Supine flexion
Hamstring stretches
Prone rotators
Strengthening exercise for the abdominals, gluteus maximus and medius and
erector spinae
Prone extension
Hip flexor stretches
Preventive Measures:
Pain is managed using sedative physical measures and analgesics
Observe proper body mechanics

GENERAL PRINCIPLES IN LBP REHABILITATION

Serious Red Flags

Spinal cord signs and symptoms
Recent trauma (spinal fx or instabilities that have not been ruled out
Serious pain that cannot be explained mechanically
Stages of Recovery
Acutelasts less than 4 weeks
Sub acute- 4-12 weeks
Chronic- more than 12 weeks
1. Acute Inflammatory Stage
Constant pain
Signs of Inflammation
No position or movement completely relieves the symptoms
Medical intervention with anti-inflammatory medications is usually warranted
2. Acute Stage Without Signs of Inflammation
Intermittent symptoms related to mechanical deformation
Those who cannot:
Stand longer than 15 minutes
Sit longer than 30 minutes
Walk more than mile without worsening their status
Patients may be categorized into:
a) Extension Bias- symptoms are lessened in positions or extension
b) Flexion Bias- symptoms are lessened in positions of spinal flexion and provoked

in extensions
Ex. Spinal Stenosis, Spondylosis, and Spondylolisthesis
c) Nonweight-Bearing Bias- symptoms are lessened in a non-weight bearing
positions
Spinal pressure is reduced by leaning on the UE, by leaning the trunk

against a support, or when in a pool

Condition is gravity sensitive ex symptoms worsen in activities that
increase spinal pressure


3.

4.

Often traction or aquatic therapy is the only intervention that decrease the

symptoms
Sub acute Stage
Some instrumental activities of Daily living still provoke symptoms
Basic lifestyle cannot be resumed
Chronic Stage
Emphasis: to return the patient to hi-level demand activities
TECHNIQUES OF INTERVENTION USING AN EXTENSION APPROACH IN THE

LUMBAR SPINE

ACUTE PHASE: Severe Symptoms

Bed rest with short periods of walking at regular intervals
Patient should use crutches, if he/she cannot stand upright
ACUTE PHASE: Posterior Disk Protrusion, treatment begins with:
Passive extension
Lateral shift correction
Patient education
Traction
Time should be short:
<15 mins of intermittent traction
<10 mins of sustained traction
SUBACUTE PHASE of a disk lesion
Teach simple spinal movements in pain free ranges using gentle pelvic
tilts-> tilted anteriorly, while spine is in extension
Teach the patient basic stabilization techniques utilizing the core trunk

muscles
Initiate passive SLR with intermittent dorsiflexion and plantarflexion
Management when the DISK Symptoms have STABILIZED
Signs of Improvement
Loss of spinal deformity
Increase motion of the back
Absence of dural mobility signs
Teach the patient the following principles:
Following any flexion exercises, perform extension exercises
In a prolonged flexed posture, interrupt with backward bending and

pelvic tilts at least once every hour

If developing symptoms are felt, immediately perform press-ups or
backward bending to prevent the progression of symptoms

TECHNIQUES OF MANAGEMENT UTILIZING A FLEXION APPROACH

Management of Acute symptoms:

Indication:
1) Rest and Support
Lumbar corset-> provide rest to the inflamed or swollen facet
joints

Discontinue use of such devices as acute symptoms decrease to

avoid dependency, and promote learning of dynamic control

2) Functional position for comfort
This position will provide maximal opening of the intervertebral
foramina to minimize impingement of the nerve root
For flexion bias in the lumbar spine: hip and knees flexed
3) Traction
Gentle intermittent joint distraction and gliding techniques

inhibit painful muscle response

Dosages must be very gentle (grade I and II).
In spondylosis or stenosis, with signs of nerve root irritation,

stronger traction forces may be beneficial

Contraindication:
Patients with rheumatoid arthritis due to ligamentous necrosis and

vertebral instability
Correction of lateral shift if present
Correction of meniscoid impingement if present
Traction is applied:
Manually
Mechanically
Longitudinally along the axis of the spine
With side-bending and rotation of the spine
Management when acute symptoms have subsided:
Hypomobile joints require stretching but not in a hypermobile region
Traction techniques may be effective if the hypermobile region is stabilized

during stretching
Develop dynamic stability through muscle control in the hypermobile

regions while gaining mobility in the restricted regions

The patient should avoid postures and activities of hyperextension if there

are bony changes and osteophystic spurs

Postures and motions emphasizing flexion of the spine are usually
preferred

GUIDELINES FOR PT MANAGEMENT OF MUSCLES AND SOFT TISSUE LESIONS:

Strains, Tears, Overuse and Contusions

Management during the Acute Stage

a. Modulate pain and control edema and inflammation
Use TENS and STM
Use corsets as passive support

b. Maintain muscle integrity

Identify the functional position

Begin gentle muscle-setting techniques in its shortened position

Dosage is critical
Resistance is minimal
Use only enough to generate a setting contraction

c. Gentle oscillating motion

d. Adapt the environment

GUIDELINES FOR MANAGEMENT OF IMPAIRMENTS WITH A NONWEIGHT BEARING BIAS

A. Management of Acute Symptoms

1. Traction
2. Harness
3. Pool
B. Progression
As healing occurs, begin weight bearing, as tolerated
Identify the impairments and functional limitations, after re-examination and
assessment

REFERENCES

Brashear Jr., Handbook of Orthopedic Surgery, 10th edition

Braddom, Physical Therapy Medicine and Rehabilitation

Magee, Orthopedic Physical Assessment, 5th edition

Santos Ramona, PT-OT Reviewer, 2nd edition

NPTE Manual

Prepared by:

Cherry Ann Sevilleno-Bangoy

PT IV

Iloilo Doctors College

Submitted to:

Mr. Fernando Padilla Jr., PTRP

Clinical Instructor

Mr. Armel Altillero, PTRP

Clinical Instructor