LOW BACK ACHE


INTRODUCTION

Back pain is a universal problem

particularly in the Largely sedentary western
world. New information about this condition is
stimulating new ways to manage it , focassing
particularly on new approaches to exercise.
The spinal column is supporting
complex of our body. The whole weight of our body
is beared on the spinal column.
 ANATOMY

LUMBO-SACRAL JUNCTION:

It is an important functional unit of the body. It

consists of five lumbar vertebrae and the sacrum.
LUMBAR VERTEBRAE:

Vertebral body:

 The body of lumbar vertebra is large kidney shaped Structure.

 It is wider from side to side and its posterior aspect is from moderately

concave at the first segment to flat or mildly convex at the fifth.

 The size of the vertebral bodies increases from L1 TO L5 because

of the increasing loads each body has to carry.

 Vertebral arch:

 The vertebral arch is horseshoe shaped structure made of

the lamina and pedicles projecting from it are seven processes.

 Paired superior and inferior articular processes a spinous process and

paired transverse process.

 The pedicles are short and stocky and are attached to the cranial half

of the body.
 The lamina are broad,flat structures blending in
medially with the spinous process.

The transeverse processes project laterally and

slightly posteriorly.
SACRUM

 The sacrum, a narrow, wedge shaped stucture, is made of five

fused vertebrae.

It articulates proximally with the fifth lumbar vertebra,

laterally with ilum, and distally with the coccyx.
LIGAMENTS:

The stability to the lumbo sacral and the sacro iliac

complexes is provided by:

posterior longitudinal ligament

Anterior longitudinal ligament

Supra spinatous ligamen

 Sacro-tuberous ligament

Dorsal & ventral sacro-iliac ligaments

Interosseous ligament

Ilio-lumbar ligament
 BIO-MECHANICS

The vertebral column protects spinal cord.

The functions require

Stability

Mobility

 The structural requirements for stability are opposite to the

requirements for mobility.
 CAUSES

SPECIFIC CAUSES

 DYSFUNCTION

Stability of the lumbar spine is diminished during periods of iow

muscular activity .

Vulnerable to injury in the presence of stress

The spine buckles if the activity of lumbar multifidus and

erector spinae is zero
PREDISPOSING FACTORS

POSTURAL STRESS

 Dynamic postures

 Repetative extension.

 Repetative flexion.
Sustained postures:

 Occupations involved sustained standing or sitting have been

proven to have a high incidence of low back pain.

 Working with computers requires a distorted body posture

maintained for hours without respite.
  Sustained extension

 Sustained flexion

 ADOLESCENT POSTURES AND PAIN

Low appears to be a relatively common in adolescence.

Stress on lumbar spine in flexion activites gives compensate for limited

pelvic rotation – Low Back Pain may result.
Work Related Stress:

Physical Stress:

1.Force:

In soft ware industries there is often too great a force

required to perform a job with too little time to relax.
Emotional Stress;

It depends upon

1.work frequency
2.Duration.
3.Pressure.
Poor Recovery From Of Soft Tissue;

1.In adequate treatment.

2.Lack of re education

 OBESITY

1.The weight of a large abdomen pulls the lumbar.

2.Low Back Pain occurs to increased load compression on

IVDs.
 Disability Conditions:

LBA associated with a episode of a minor systemic illness.

 Precipitating Factors:

These are the direct and sudden causes of backpain.

Abnormal stress on a normal back

Normal stress on an abnormal back
Normal stress on an unprepared back
CLINICAL FEATURES
PAIN:

Sharp pain in the back can arise suddenly as aresult of bending,twisting

and lifting.

Pain may be:

Central in back
Diffuse over lumbo sacral
Refered down to limb
REFFERED PAIN:

Dull poorly defined acne over the

Back
Sacro iliac joint
Buttock
Thigh

This is due to pressure or stress on ligaments,muscles and fascia.

Shearing, sharp,stapping,shooting pain down to the leg due to irritation of nerve root.
PARAESTHESIA or NUMBNESS:

Pins and needle may be felt in a nerve root distribution.

Numbness deducted when tested by touch,pinprick or

temperature test tube.

Weakness due to nerve root compression.

 MUSCLE WEAKNESS:

Compression of nerve root interrupts impulse

transmission causes weakness of muscles.

TENDON REFLEX CHANGES:

The quadriceps (L3 & L4) are tendocalcaneal.

The (L5 & S1) reflexes are diminished when there is

nerve root compression.
COUGHING & SNEEZING:

 Back pain increases due to this.

 It is due to increased intrathecal pressure.

TENDERNESS:

 On palpitation over lumbar spine tenderness is seen and causes muscle

spasm.

SKIN:

 It is slightly warm and moist over the site of lesion.

 INVESTIGATIONS

Laboratory Test;

 Results are entirely normal in patients with traumatic and

degenerative causes.

Plain Radiography;

 Herniated nucleus pulposus:

Disc space narrowed and osteophyte formation.

Spinal Stenosis:

 Loss of disc space

 Decreased interpedicular distance

 Decreased sagittal canal diameter

.
COMPUTER TOMOGRAPHY;

Herniated nucleus pulpous:

Disc bulge be seen .

Spinal Stenosis:

Reduction in dimension in the bony canal.

MRI:

 Able to detected entrncement and direct impingement of

spinal nerve roots.

Other Investigation:

 Single photon emission tomography.

 Radio neuclied imaging.

 Myelography.
Electromyography.

Tomography.

Epidural venography.

Ultrasonography.

Spinalangiography.
 MEDICAL MANAGEMENT

MEDICAL MANAGEMENT:

Nonsteriodal anti inflammatory drugs

 Asprin

 Ibuprofen

 Naproxin
Muscle relaxants

 Cyclobenzapine

 Diazepam

 Carisoprodol

 Antidepperesants
Epidural injections.

 A one time of a cortico steroid in to the area around the

spinal column may short cut sciatic pain until the body heals
itself.

 Local anaesthetic

Hyper tonic saline

Hyalunonidase
Botulinum injection of botulinum toxin in the lower back.
 PHYSIOTHERAPY ASSESMENT

PHYSIOTHERAPY ASSESSMENT
Name
Age
Sex
Occupation
History:
1. Note the patient age and occupation.
2. Find out about the onset of pain.
when did the symptoms commence
 was the onset slow and insidious, rapid or sudden because
the later is strongly suggestive of mechanical factor
 Was there a history of an injury such as a sudden twist or
strain or sneeze occurred when the patient was in flexed position.
3. Ask any directly relevant previous history:
 Is there a history or a previous similar attack?
 Is there a history of any previous trouble with spine
Is there is history of hypertension, diabetes
mellitus,ischemic heart disease, epilepsy, muscular
dystrophy, respiratory problems like asthma, wheeze.
4. Ask about the site and nature of pain:
Where is the pain situated? Is it well localized or it is
diffuse?
Is the pain always present or does it disappears at
times? The later suggestive of a mechanical course
Are there any factors, which aggravate or alleviate
the pain?
Investigation:
Laboratory test:
Results are entirely normal in patient with traumatic and
degenerative causes.
Plain radiography:
Herniated nucleus purposes: Disc space narrowed and
osteophyte formation.
Spinal Stenosis: Loss of disc space, decreased
interpedicular distance, decreased saggittal canal
diameter.
Spondylolysis / spondylolisthesis: Colker on the scattic
dog's neck
C.T. Scan:
Heraiated nucleus pulposus: disc bulge can
been seen
Spinal stenosis: reduction in the dimension in
the bony canal
MRI Scan:
Able to detected entrancement and direct
impingement of spinal nerve roots.
Others Investigation:
Single photo emission tomography
Radio neuclode imaging
Myleography
Tomography
Epidural venography
Ultrasonography
Spinal ongiography
Specific physiotherapy assessment:
On observation:
 Built of the patient
 Redness
 Unusual skin marking
 Posture - hyperlordosis, flatback, scoliosis,
kyphosis etc.,
Anterior pelvic tilt - spondylolisthesis, tight low back muscle.
Posterior pelvic tilt - tight back muscle, weak hip flexors
Lateral pelvic tilt - unilateral lumbosacral strain.
Gait analysis - in the gait analysis we check for heel
strike / foot flat/ mid swing / cadence / step length /
stride length.
Palpation:
The clinician palpates the lumbar spine and any other
relevant areas. It is useful to record palpation findings
on a body chart or palpation chart.
The Clinician Should Note The Following:
The temperature of the area
Localized increased skin moisture
 The presence of edema or effusion
Mobility and feel of superficial tissues, e.g. ganglions,
nodules and the lymph node in the femoral triangle
The presence or elicitation of any muscle spasm
Tenderness of bone, trochanteric and psoas bursae
(palpation if swollen) ligaments, muscle (Baer's points,
for tenderness/ spasm if iliaccus, lies a third of the way
down a line from the umbilicus to the anterior superior
iliac spine) tendon, tendon sheath, trigger points and
nerve.
Increased or decreased prominence of bones.
Pain provoked or reduced on palpation
Wide spread, superficial, non- anatomical
tenderness suggests illness behavior.
Examination:
Range of motion:
Movement Normal range

Flexion 80 – 90 degree

Extension 20 – 30 degree

Lateral bending 20 – 35 degree

Rotation 20 – 45 degree
Sensory examination:
Pins and needles may be felt in a nerve root
distribution and numbness may be detected when
tested by touch, pin prick or temperature test tubes.
 Special test
Straight leg raising test
(SLR):
 Patient is in supine
position; the examiner raises
the leg straight one after up to
30° nerve is not put under
stretch between 30° - 70°
nerve comes contact with the
prolapse disc and the patient
complains of the pain.
 Beyond 70° patient
complains of pain it is usually
not due to disc prolapse but
could be due to sacroiliac
joint invol
L1asegue's sign:
 Here the hip is flexed,
knee is flexed and leg is
slowly straightened. The
test is positive for sciatic
rediculopathy.
When
1. No pain is elicited when
hip and leg are flexed.
2. pain is present when hip is
flexed and leg extended.
Braggad's test:
With the patient in supine position raise his or her
leg to point of pain lower the leg 5 degree and
dorsiflex the foot. Dorsiflexion of foot exerts a
suction pressure to sciatic nerve posterior thigh or
leg pain indicated sciatic radiculopathy. Dull non
specific posterior thigh is indicative to tight
hamstring muscle.
Sajerstan zan 's test:
With patient in supine position place his or
leg a top your shoulder and exert pressure on
hamstring muscle. If the pain is not elicited apply
pressure over popliteal fossa. Pain in lumbar region
or radiculopathy indicates nerve root compression.
 Valsalva maneuver:
Ask the patient to
bear down as if he were
trying to move his bowels,
this increase the intrathecal
pressure, if bearing down
causes pain in to back and
radiating pain down the
legs, there is problem
pathology either causing
intrathecal pressure or
involving the theca itself.
merical scale:
They can be divided into five grades from 0 to 4 depending up
on the degree of assistance required in carrying out each
activity.

Scoring scale:
0 - Unable to perform activity
1- Able to perform only with maximal assistance
2 - Able to perform with minimal assistance
3 - Able to perform independently but has pain while
performing
4 - Pain free full activity
 PHYSIOTHERAPY MANAGEMENT

AIMS:

To decrease pain.

To strengthen weak muscles

To improve endurance of muscle

To decrease mechanical steps to spinal structures

To stabalise hypermobile structures

To improve posture

To improve mobility

To improve flexibility

To improve fitness level to prevent the recurrence.

To improve ADL activities

PHYSICAL MODALITES :

In addition to exercise, physical therapist use various physical

modalities to

relieve patient symptoms.

Treatment modalities may include

Traction

Cryotherapy

Thermotherapy
REST

Diathermy

Ultrasound

Transcutaneous electrical nerve stimulation

High voltage electrical stimulation

TRACTION:

Traction is a non-standardized conservative treatment

modality for low back pain.

The basic premise of traction is that unloading

the components of the spine by
 Stretching muscles
 Ligaments
 Functional spinal unit.
CRYOTHERAPY ( COLD):

Patients with acute low back pain may experience analgesia

with ice massage and cold packs.

Therapeutic cold will reduce,

 Pain

 Swelling

 Muscle spasm
Local metabolic activity

Muscle spindle activity

Nerve conduction
HEAT THERAPIES:

SUPERFICIAL HEAT:

 Infrared heating

 Whirlpool

DEED HEAT:

 Shortwave diathermy
 Ultrasound
SHORTWAVE DIATHERMY:

 Shortwave diathermy penetrates the soft tissues

and delivers heat to deeper structures, such as muscle, bone,
and ligaments.

 Diathermy has been shown to be effective in

decresing pain in trigger points including the low back.
ULTRASOUND:

 Delivers heat more deeply than diathermy.

 Not used in acute conditions.

 It is used for 20 min sessions 3 times a week for 2 to 3

weeks.

 Therapy is delivered to paraspinous structures but not over

the spinal cord itself or gas containing organs.

CORSETS AND BRACES:

> The rationale for the use of external supports

arises from the work of Bartelink.

> He proposed the theory that increased intra-

abdominal pressure imparts force against
the diaphragm and thoracic spine decreasing
the load on the lumbar spine

.
decrease of 25% in intradiscal pressure to a value the
intermediate between the supine and standing
position by the use of an inflatable corset that
increased intra- abdominal pressure and or
decreased the compressive force of the iliopsoas on
the lumbar spine
 The rationales cited for use of braces included restriction of lumbosacral

motion, abdominal supports and postural correction.

 The use of external supports may cause disuse atrophy of those muscles

that specifically support the lumbar spine.

 The patients who had pain relief when bent forward or in supine position

had pain relief with a rigid brace.

 EXERCISETHERAPY

Lumbar Stabilization
Exercises with Swiss
Ball

 abdominal muscles
must remain contracted
during each exercise.
 Lie on your back
with knees bent and calves
resting on ball.
 Slowly Straighten
one leg contracting your
abdominal muscles at
the same time.
Lie on your Stomach
over Ball

 Slowly raise both

legs.
 Hold for five
seconds.
 Relax.
 Repeat 10 times
CROSS CRAWL EXERCISE
Keeping abdomen tight,
alternate lifting opposite
arm and leg i.e. right leg
with left arm in the
quadraped position ("all
fours"). Keep back, arm
and leg parallel to the
floor.
FLEXION EXERCISES
 Exercise 1: Pelvic
Tilt. Lying on the back
with knees bent and feet
on the floor, flatten the
area immediately below
the belt line and keep it
pressed against the floor
for 10-15 seconds. Repeat
7-10 times. (Note: Keep
the upper back flat and
pull in the lower
abdominal wall
concentrating on the
oblique muscles.)
Exercise 2: Curl Up. Maintain pelvic tilt and
bent knees, tuck chin and slowly curl up until the
shoulder blades are off the floor. Feet remain on the
floor. Hold this position for 10-15 seconds. Repeat
the full exercise 7-10 times. Roll down slowly. As in
Exercise 1, keep the abdominal muscles tucked in
throughout the exercise.
Exercise 3: Curl Up With Rotation. Get in the
Curl Up position as in Exercise 2. Twist the body to
one side, hold for 10-15 seconds and roll back down
to the floor. Now curl up and twist to the other side
holding for 10-15 seconds. Repeat the full exercise 7-
10 times. Be sure to maintain a pelvic tilt and do not
allow the hips to rotate or come off the floor - they
should remain squarely on the floor.
Exercise 4: Lower Back Stretch. Lying on the
back, press the lower back flat against the floor. Pull
the knees to the chest using the abdominal. Wrap
arms under knees. Keep the head on the floor and
the neck stretched long. Hold position for 20-30
seconds. Repeat 3-4 times. This is especially good for
overcoming swayback.
 1. Stand with feet about
hip width apart opposite a
chair.

2. Release into squat and

lower stance until your
hands make contact with
the chair. - for advice on
going into a squat see
squat exercise also a
good procedure to
strengthen your lower
back.
 3. Moving only from you ankle joints let your head
lead your body over the top of the chair and allow the
weight to go through to the chair.
4. As you move forward from your ankle joints
appreciate the muscles in your back responding to
the changes in weight distribution. Be aware of the
extra push coming up from the chair, through your
arms and into your shoulders. Do not tightening
your arms - let your reflexes coordinate your muscle
activity.
5. Again moving from the ankles, rock back slowly so
more weight is passing down to your feet. As before
allow your back muscles respond without doing it
yourself.
6. Repeat this forward and backward gentle rocking
motion whilst being careful not to tighten your neck,
shoulder of back muscles. The objective is to allow
the muscles to be coordinated by your movement
reflexes.
HIP FLEXOR LUNGE STRETCH
SEATED HAMSTRING STRETCH
STANDING QUAD STRETCH
LOWER EXTREMITY EXTERNAL ROTATOR
STRETCH
EXTENSION EXERCISE
CORE MUSCLE STRENTHENING EXERCISE

PELVIC BRIDGING
TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION

 TENS therapy may allivate chronic pain including back pain.

 TENS activates larger diameter afferent A-alpha nerve fibres.

 TENS preferentially stimulates the low-treshold A-alpha fibres.

 Electrical stimulation to the nerves may be accomplished by TENS

Using

Surface electrodes applied to the skin.

Subcutaneus implanted electrodes

Electrodes implanted directly on the nerve

Stimulation applied directly to the spinal cord or

through the Dura.
HIGH- VOLTAGE STIMULATION:

 High-voltage stimulation is a form of TENS that utilizes high-voltage,

monophasic pulses of short duration to stimulate soft tissue structures in

the lumbosacral spine.

 Repeated electrical stimulaton relaxes protective muscle spasm, there by

decreasing muscle fatigue

IONTOPHORESIS:

A variety of medications including corticosteriods ,

epinephrine, and local anesthetics may enter soft
tissue without an injection.
 76 % had marked relief pain with iontopho-resis of
solution composed of lidocaine and dexamethasone.

Another proposed electrical therapy for low back

pain is

 laser therapy.
HINTS FOR GOOD POSTURE MAINTANENCE

Here are some hints that will help you achieve better posture & reduce back
pain”.

 Exercise regularly to keep abdominal muscles strong. This helps support

the spine.

 Avoid carrying heavy items to one side (example a heavy bag worn over a
shoulder).

 Always bend at the knees, not the back, and quickly drop the load if it’s
too heavy.
When standing your feet should be shoulder width apart.

 Use a lumbar roll or back support to support the lower back.

Maintain an arch.

 Leave your computer screen every 20 minutes and stretch and

stroll for a minute.

 Cross ankles rather than knees when sitting.

 Don’t tighten up muscles when in the straight posture. Relax

into it.
 Sit with back against chair, and knees in line with
your hips.

 At desk, arms should be flexed at a 70 to 90 degree

angle to elbows.

 Walk tall. Think of pulling the entire body upwards

towards the sky.
 CONCLUSION

 Low back pain is prevalent among the soft ware

engineers this is due to bad posture and wrongly
style. Bad posture leads to musculo skeletal
dysfunction.

 It is the important role on the side of

physiotherapist to reduce this aching problem. The
physiotherapist works sincerely in order to get ride
of back pain.
 CASE STUDY

Case Study
Name : X
Age : 30
Sex : Male
Occupation Software Professional

Subjective examination :
Chief complaints : sever low back pain interferes with
activities of daily living.
Past medical history : history of pain for past 2 months.
Analgesics taken
Present medical history : undergoing physiotherapy treatment
Pain history :
Onset : gradual
Duration : 2 months
Type : Sharp dull aching pain
Aggrevating factors : forward bending
Relieving factors : rest
Objective examination :
On observation :
Posture : Kyphotic posture
Gait: Normal
Muscle : absent
Swelling : absent
On Palpation :
Tenderness : over L4-L5 region
Muscle spasm : over paraspinal area
On examination Visual analog scale for pain

0 1 2 3 4 5 6 7 8 9 10
No Pain severe pain
Range of motion :
Flexion limited.
Extension normal
Rotation normal.
Special test :
SLRT-Positive on left side
Lasezques test positive
Naffziger test positive
Clinical impression :
Treatment :
Aims :
 To decrease pain
 To increate strength of muscles
 To stabilize the joints
 To improve range of motion
 To prevent recurrence
 To improve posture
To relive pain :
Traction
SWD
IFT
To strength the muscles :
Spinal exercises :
 Pelvic tilt
 Knee to chest
 Prone resting on pillows
 Neck lift
 Neck lifting along with shoulder
 Full extension with arms extended and legs lifted
To prevent recurrence :
Home advice :
Avoid lifting heavy weights
Use lumbo sacral corset
Use firm mattress
Do not maintain single posture for long time change the
position frequently
Flex the knees for picking up things from the floor
Follow the exercise programme.
THANK YOU