LOW BACK PAIN

IG.A.A. SRI WULANDARI PRAMANA

• Low back pain:
• Any pain/discomfort lumbosacral region until
sacral/gluteal region

• Clasification:
• Mechanical
• Non mechanical
• Viscerogenic
• psikogenic
clasification
Mechanical Sprain/strain
Spondylosis
HNP
Spondylolisthesis
Spondylisis
Fracture

Non mechanical Infection

Tumor/malignancy

viscerogenic
psikogenic
 Spinal Pathologies Related to
Preferred Practice Patterns

PATHOLOGY IMPAIRMENTS

Postural stress, strain impaired posture

Abnormal posture

Muscle strain, tear, contusion impaired muscle performance

Acute low back pain impaired joint mobility, motor function, muscle performance,
and ROM associated with localized inflammation
 Con’t…
• Degenerative disk disease (DDD),disk herniation impaired joint mobility, motor function, muscle
• Degenerative joint disease (DJD), spondylosis performance, ROM, and reflex integrity associated with
• Rheumatoid arthritis spinal disorders
• Radiculopathy, nerve root lesions, sciatica
• Spinal stenosis
• Segmental instability
• Spondylolistheses
• Sprains, strains

Compression fracture impaired joint mobility, muscle performance, and ROM

associated with fracture

• Spondylosis with myelopathy impaired motor function, peripheral nerve integrity, and
• Intervertebral disk disorders sensory integrity associated with nonprogressive disorders
of the spinal cord
HNP
• A disc injury in which
the nuclear pulposus
migrates through the
annular fibers
 Treatment HNP
• Conservative care
- Relative rest
- Medications
o NSAIDs
o Analgesics
o Oral steroids
o Adjuvants (tricyclic antidepressants, serotonin reuptake
inhibitors)
o Muscle relaxants
Treatment HNP…
• Conservative care
- Rehabilitation Program
o Patient education
o Stretching program (focus on hamstring flexibility)
o Strengthening program (focus on abdominal)
o Spinal stabilization
 Mackenzie program is an extension-biased program designed to
centralize extremity pain. Extension-biased programs may be used
for posterior-lateral HNP.
 Neutral or flexion-biased program may be used for far lateral HNP.
Treatment HNP…
• Conservative care
- Rehabilitation program
o Modalities
 Thermal therapies (heat, cold), electric stimulation
 Traction
 Vertebral distraction may relieve nerve
compression
Cervical region: 20–30° of flexion with 25
pounds of resistance. Less flexion for treatment
of muscle spasm
Lumbar region: May require increased force or a
split table to overcome friction
Treatment HNP…
• Conservative care
- Rehabilitation program
o Modalities
 Traction
 Indications
Radicular pain
Paraspinal muscle spasm
 Contraindications
Ligamentous instability
Radiculopathy of uncertain etiology
Acute injury
Rheumatoid arthritis
Vertebrobasilar arteriosclerotic disease
Spinal infections (Pott’s disease)
Treatment HNP…
• Conservative care
- Bracing
o Lumbar corsets

- Home exercise program

o Proper back mechanic

- Other
o Epidural steroid injection
o Psychologic interventions, muscle relaxation techniques,
acupuncture
Treatment HNP…

• Surgical care
• - Considered for progressive weakness
• - unremitting pain
• - cauda equina syndrome
• - myelopathy
Spinal Stenosis

• Degenerative
changes occur to the
spine resulting in disc
space narrowing,
vertebral body
osteophytosis, and
joint arthropathy
Treatment Spinal
Stenosis
 Conservative care
 - Relative rest
 - Medications
 - Rehabilitation program: Focus on a flexion based or neutral
positioned program and spinal stabilization
 - Epidural steroid injections
 - Aquatic therapy

 Surgical care
 - Spinal procedures including decompression and/or
stabilization.
Spondylolisthesis
• A forward (anterolisthesis) or backward
(retrolisthesis) slippage of one vertebral body on
another.
Treatment Spondylolisthesis
• Conservative care
- Grade 1, Grade 2, and asymptomatic Grade 3
o Relative rest, eliminate aggravating activities. Rehabilitation
program: Focus on spinal stabilization exercises in a flexion
biased position and hamstring flexibility.
o Asymptomatic Grade 1 slips may return to any activity but
asymptomatic Grade 2 and 3 slips are restricted from
contact sports.
o TLSO bracing is used if increased pain occurs despite
decreased activity or an increase slippage is suspected
Treatment
Spondylolisthesis…
• Surgical care
- Symptomatic Grade 3 and Grades 4 and 5
• - Spinal procedures including a bilateral posterolateral
fusion with or without decompression
Spondylolisis
• A vertebral defect occurs at the pars
interarticularis, which is formed at the junction of
the pedicle, transverse process, lamina and the
two articular processes
Treatment Spondylolisis

• - Same with
spondylolistheses
General—Stage of
Recovery
• Acute with inflammation (0–4 weeks).
• Acute without inflammation (0–4 weeks):
intermittent symptoms with acute nerve root
symptoms  mechanical deformation
• Subacute (4–12 weeks).
• Chronic ( 12 weeks).
• Chronic pain syndrome ( 6 months).
 Spinal Pathologies Related to
Preferred Practice Patterns

PATHOLOGY IMPAIRMENTS

Postural stress, strain impaired posture

Abnormal posture

Muscle strain, tear, contusion impaired muscle performance

Acute low back pain impaired joint mobility, motor function, muscle
performance, and ROM associated with localized
inflammation
 Con’t…
• Degenerative disk disease (DDD),disk herniation impaired joint mobility, motor function, muscle
• Degenerative joint disease (DJD), spondylosis performance, ROM, and reflex integrity associated with
• Rheumatoid arthritis spinal disorders
• Radiculopathy, nerve root lesions, sciatica
• Spinal stenosis
• Segmental instability
• Spondylolistheses
• Sprains, strains

Compression fracture impaired joint mobility, muscle performance, and ROM

associated with fracture

• Spondylosis with myelopathy impaired motor function, peripheral nerve integrity, and
• Intervertebral disk disorders sensory integrity associated with nonprogressive
disorders of the spinal cord
MANAGEMENT GUIDELINES—Acute
Spinal Problems/Protection Phase

Impairments and Functional Limitations

• Pain and/or neurological symptoms
• Inflammation
• Inability to perform ADLs
• Guarded posture (prefers flexion, extension, or
non-weight-bearing)
 Acute Spinal
Problems/Protection Phase
Plan of care Intervention

1. Educate the patient. Engage patient in all activities to learn self-management.

Inform patient of anticipated progress and precautions.

2. Decrease acute symptoms. Modalities, massage, traction, or manipulation as

needed. Rest only for first couple days if needed.

3. Teach awareness of neck and pelvic position and Kinesthetic training : pelvic tilts, neutral spine.
movement.

4. Demonstrate safe postures. Practice positions and movement and experience effect
on spine. Provide passive support/bracing if needed.
 Cont…
Plan of care Intervention

5. Initiate neuromuscular activation and Core activation techniques : drawing-in maneuver,

control of stabilizing muscles. multifidus con- traction. Basic stabilization: with arm
and leg motions (passive sup- port if needed, progress
to active control).

6. Teach safe performance of basic ADLs Roll, sit, stand, and walk with safe postures. Progress
tolerance to sitting 30 minutes, standing 15 minutes,
and walking 1 mile.
Correct posture
Core stabilizing
muscle
Activate the
stabilizing muscle
Drawing-in manuver
MANAGEMENT GUIDELINES—Subacute
Spinal Problems/Controlled Motion
Phase

Impairments and Functional Limitations

• Pain: only when excessive stress is placed on
vulnerable tissues
• Impaired posture/postural awareness
• Impaired mobility
Impaired muscle performance: poor neuromuscular
control of stabilizing muscles
• decreased muscle endurance and strength
• General deconditioning
 Subacute Spinal Problems/Controlled
Motion Phase

Plan of Care Intervention

1. Educate the patient in self-management and how to Engage patient in all activities emphasizing safe movement
decrease episodes of pain. and postures.

2. Progress awareness and control of spinal alignment. Practice active spinal control in pain-free positions and with
all
exercises and activities. Practice posture correction.

3. Increase mobility in tight muscles/joint/fascia. self-stretching.

 cont…
Plan of Care Intervention
4. Teach techniques to develop neuromuscular Progress stabilization exercises; increase repetitions and
control, strength, and endurance. challenge.
Initiate extremity-strengthening exercises in conjunction
with core muscle activation.
Initiate and progress dynamic trunk strengthening
exercises.

5. Develop cardiopulmonary endurance. Low to moderate intensity aerobic exercises; emphasize

spinal bias.

6. Teach techniques of stress relief/relaxation. Relaxation exercises and postural stress relief.

7. Teach safe body mechanics and functional Practice stable spine lifting, pushing/pulling, and reaching.
adaptations.
Self stretching
Techniques to Increase Lumbar Flexion
Self stretching-
Techniques to Increase Lumbar
Extension
Self stretching-
Techniques to Increase
Lateral Flexibility in the Spine
Stabilization Training
Cont…
Dynamic Strengthening—Abdominal
Muscles
Dynamic Strengthening—Erector
Spinae and Multifidus Muscles
Dynamic Strengthening –
Trunk Side Bending (Lateral Abdominals,
Erector
Spinae, Quadratus Lumborum)
MANAGEMENT GUIDELINES—Chronic
Spinal Problems/Return to Function Phase

Impairments and Functional Limitations

• Pain: only when excessive stress is placed on
vulnerable tissues in repetitive or sustained nature for
prolonged periods
• Poor neuromuscular control and endurance in high-
intensity or destabilized situations
• Flexibility and strength imbalances
• Generalized deconditioning
• Inability to perform high-intensity physical demands
for extended periods of time
 Chronic Spinal
Problems/Return to
Function Phase
Plan of Care Intervention
1. Emphasize spinal control in high-intensity and repetitive Practice active spinal control in various transitional activities
activities. that challenge balance.

2. Increase mobility in tight muscles/joints/fascia. self- stretching.

3. Improve muscle performance; dynamic trunk and Progress dynamic trunk and extremity resistance exercises
extremity strength, coordination, and endurance. emphasizing functional goals.

4. Increase cardiopulmonary endurance. Progress intensity of aerobic exercises.

5. Emphasize habitual use of techniques of stress Motions and postures to relieve stress.
relief/relaxation and posture correction. Apply any ergonomic changes to work/home environment.
 cont…
Plan of Care Intervention

6. Teach safe progression to high-level/high- Progressive practice using activity-specific training

intensity activities. consistent with desired functional outcome, emphasizing
spinal control, endurance, timing, and speed.

7. Teach healthy exercise habits for self-maintenance. Engage patient in all activities and educate as to benefits of
maintaining fitness level and safe body mechanics.
Modalitas
Physical modalities are used physical energy for their
therapeutic effects:
• Thermotherapy (heat and cold modalities)
• Electrotherapy
 Thermotherapy- Deep heat
therapy
USD SWD MWD

• Sound waves • Radio waves • Microwaves

• Frequency: 0.8 to 1.1 MHz • Frequency: 27.12 MHz • Frequency: 915 to 2,456 MHz
• Heats at 8 cm depth • Heats at 4 to 5cm depth • Superficial heat: 1 to 4 cm
(Deepest penetration) depth

• Chronic inflammation • Myalgia Superficial heat for muscles and

• Musculoskeletal pain • Back spasms joints
• Subacute trauma
Electrotherapy - TENS

low TENS (1-20 Hz) untuk

nyeri kronik
high TENS (80-120 Hz) untuk
nyeri akut
References
- Kisner C, Colby L. A, Theraupetic Exercise, 5th edition.
2007.
- Cuccurullo S, Physical Medicine and Rehabilitation
Board Review. 2004.
Terima Kasih