med back of lbp

8/3/2019 MED BACK of LBP

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ANATOMY AND BIOMECHANICS OF THE LUMBAR SPINE (Braddom,2000)

General concepts- The lumbar spine has 2 role in terms of function, which is

strength coupled with flexibility.- The typical lordotic framework of the lumbar spine assists

with this flexibility but also increases the ability of thelumbar spine to absorb shock, which is important role dueto the amount of forces that travel through the spine on aregular basis.

The vertebrae- The bony anatomy of the lumbar spine consists of five

lumbar vertebrae.

- The lumbar vertebrae have distinct components, whichinclude the vertebral body, the neural arch, and theposterior elements.

- The vertebral body increase in size as you travel down thespine.

- The sides of the bony neural arch are the pedicles, whichare thick pillars that connect the posterior elements to thevertebral bodies.

- The posterior elements consist of the laminae, the articularprocesses, and the spinous processes.

- The superior and inferior articular processes of adjacentvertebrae create the zygapophyseal joints.

- The pars interarticularis is a part of the lamina between thesuperior and inferior articular processes.

- The pars is the site of stress fractures (spondylolysis),because it is subjected to large bending forces as the forcestransmitted by the vertically oriented lamina undergo achange in direction into the horizontally oriented pedicle.

The jointsThe intervertebral disk- The intervertebral disk and its attachment to the vertebral

end plate are considered a secondary cartilaginous joint, orsymphysis.

- The disk consists of the internal nucleus pulposus and theouter annulus fibrosus.

- The nucleus pulposus is the gelatinous inner section of thedisk. It consists of water, proteoglycans and collagen. Atbirth the nucleus pulposus is 90% water.

-Disks desiccate and degenerate as we age, and lose someof their height, which is one reason we are slightly shorterin our geriatric years.

- The annulus fibrosus consists of concentric layers of fibersat oblique angles to each other, which help to withstandstrains in any direction. The outer fibers of the annuluscomprise more collagen, and less proteoglycans and water,than the inner fibers.

- The varying composition supports the outer fibers functionalrole in acting more as a ligament to resist flexion,

extension, rotation, and distraction forces.- The main function of the intervertebral disk is shockabsorption.

The zygapophyseal joints- The zygapophyseal joints (Z joints) are paired synovial

joints, they have a synovium and a capsule.- The lumbar Z joints lie in the sagittal plane, and thus

primarily allow flexion and extension, although some lateralbending and very little rotation are allowed, which limittorsional stress on the lumbar disks.

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- The majority of flexion and extension (90%) occurs at theL4-5, thus contributing to the high prevalence of diskproblems at these levels.

Biomechanics- Because flexion loads the anterior disk, the nucleus is

displaced posteriorly. If the forces are great enough, thenucleus can herniate through the posterior annular fibers.

- The posterolateral portion of the disk is most at risk, withforward flexion accompanied by lateral bending.

The ligaments- There are 2 mains sets of ligaments of the lumber spine;

longitudinal ligaments and segmental ligaments.- The two longitudinal ligaments are the anterior and

posterior longitudinal ligaments. The anterior longitudinalligament acts to resist extension, translation, and rotation,

whereas the posterior longitudinal ligament acts to resistflexion.

- The main segmental ligament is the ligamentum flavum,which is a paired structure joining adjacent laminae and isthe ligament that is pierced when performing lumbarpunctures. It is a very strong ligament but also elasticenough to allow flexion.

- The other segmental ligaments are the supraspinous,interspinous, and intertransverse.

- The supraspinous ligaments are the strong ligaments that

join the tips of adjacent spinous processes and act to resistflexion. These ligaments, along with the ligamentumflavum, act to restrain the spine and prevent excessiveshear forces in forward bending.

The musclesMuscles with origin on the lumbar spine

- The posterior muscles include the latissimus dorsi and theparaspinals.

- The lumbar paraspinals consist of the erector spinae(iliocostalis, longissimus, and spinalis), which act as thechief extensors of the spine, and the deep layer (rotatorsand multifidi).

- The multifidi are tiny segmental stabilizers that act to

control lumbar flexion, because they cannot produce enoughforce to truly extend the spine. Their more importantfunction has been hypothesized as more of a sensory organto provide proprioception for the spine.

- The anterior muscles of the lumbar spine include the psoasand quadratus lumborum.

- Psoas have a direct attachment on the lumbar spine,tightening this muscle emphasize the normal lumbarlordosis. This can increase forces on the posterior elementsand can contribute to Z joint pain.

- The quadratus lumborum acts in side bending and canassist in lumbar flexion.

Abdominal musculature- The superficial abdominals include the rectus abdominis and

external obliques.- The deep layer consists of internal obliques and the

transversus abdominis.- The tranversus abdominis has received significant attention

over the recent past as an important muscle to train intreating low back pain. Its connection to the thoracolumbarfascia (and consequently its ability to act on the lumbarspine) has probably been the major reason it has receivedsuch attention of late.

Thoracolumbar fascia- The thoracolumbar fascia, with its attachments to the

transversus abdominis and internal obliques, acts as inabdominal and lumbar brace.

- It decreases some of the shear forces that other musclesand lumbar motion create.



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Pelvic stabilizers- The pelvic stabilizers are considered core muscles due to

their indirect effect on the lumbar spine, even though theydo not have direct attachment to the spine.

- The gluteus medius stabilizes the pelvis during gait.

Weakness or inhibition of this muscle results in pelvic instability.

- The piriformis, as a hip and sacral rotator, can causeexcessive external rotation of the hip and sacrum when nitis tight. This can result in increased shear forces at thelumbosacral junction.

Biomechanical lifting in relation to muscular activity and disk loads

- The activity of the lumbar muscles correlates well withintradiskal pressures. These pressures change depending onspine posture and the activity undertaken.

The nerves- The conus medullaris ends at the bony level L2. And below

this level is the cauda equina.- The cauda equina consists of the dorsal and ventral rootlets,

which join together in the intervertebral neuroforamen tobecome the spinal nerves.

- The spinal nerve gives of the ventral primary ramus, which,together from the other levels, forms the lumbar andlumbosacral plexus to innervate the limbs.

- The dorsal primary ramus, with its three branches (medial,intermediate, and lateral), innervates the posterior half of the vertebral body, the paraspinal muscles, and thezygapophyseal joints, and provides sensation to the back.

- The medial branch innerbates the zygapophyseal joints andlumbar multifidi and is the target during radiofrequencyneurotomy for presumed zygopophyseal joint pain.

LOW BACK PAIN

A. DefinitionLBP began with the development of bipedal ambulation and

the requirement for a flexible multiaxial spinal column. It is asyndrome and not a disease. Pain is usually felt in the low lumbar,lumbosacral or sacroiliac regions. It is often accompanied bysciatica which is pain radiating down one or both buttocks in thedistribution of the sciatic nerve. B. Epidemiology

Low back pain can happen anywhere below the ribs and above the legs. Thelower back is the connection between the upper and lower body, and it bearsmost of the bodys weight. So it's pretty easy to hurt your back when you lift,reach, or twist. In fact, almost everyone has low back pain at one time or another. It can be caused by different entities. May be affected by variouspsychosocial factors. (De Lisa, 1998)

Statistics appear in the literature that, in some stages in life, mosthuman beings (80%) will experience low back pain, with 2 - 5% of the average population seeking medical attention. It is of interestthat disabling LBP is becoming a Western Disease. In itsincidence and prevalence, LBP ranks as a cause of lost working

days among the Americans, 2nd

only to common cold as a reasonfor outpatient visits. It represents the single most common andmost expensive industrial and occupational health problemscausing approximately $25 billion per year for direct and indirectcause. LBP appears to be most prevalent in the active workingyears of a persons life, age 30 to 45 years. Both sexes areaffected, males more commonly affected than females with a ratioof 10:1. It tends to increase with age, reaching 50% in personsabove 65 years old.

Factors which contribute to the incidence of LBP

http://www.webmd.com/back-pain/lumbosacral-region-of-the-spine-lower-backhttp://www.webmd.com/back-pain/lumbosacral-region-of-the-spine-lower-back


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a. occupation and workplace (i.g., drivers, materialhandlers, and health care workers, especiallynurses)

b. lifting both in and out of the workplace (esp. lifting morethan 25 lbs or hand-to-hand lifting)

c. lifestyled. sporting activities (e.g. gymnastics, football, weight

lifting, wrestling, dancing and rowing)

C. Etiology1. Most common LBP is caused by strain of the muscle around thelower part of the spine. This may be due to unaccustomed exercise- a weekend spent shoveling snow, for example - or sitting forprolonged periods in an unsatisfactory posture. Strains on thespine are least when the back is straight; a chair which forces thespine into a curve is likely to provoke chronic back strain. It mayalso be back strain due to poor posture, poor conditioning or

mechanical factors like over-use, obesity or pregnancy.2. Damage to one of the intervertebral disks in the lumbar regionof the spine is most likely to occur from lifting a heavy weight whilethe back is curved. Pressure on the disc, which consists of acapsule and a soft, elastic center, may rupture the capsule andallow part of the central nucleus to protrude. If this protrusionextends into spinal canal it may press upon one of the spinalnerves or even the spinal cord. Protruding or ruptured IVD withsubsequent herniation of the nucleus pulposus into the spinalspinal canal can cause inflammatory or direct mechanical nerveroot pressure. Typically, the pressure on the disc causes painextending down the main sciatic nerve which runs from thebuttocks to the foot. The pain (sciatica) is made worse bycoughing, straining, or bending the back. If the symptoms persistthere may also be loss of feeling in the foot or the lower part of theleg and some muscular weakness.3. LBP is usually related to acute ligamentous or muscular sprain orthe more chronic OA or ankylosing spondylitis of the lumbosacralarea.4. Micromyalgia (Lumbago) is used to describe an acute or severepain felt in the lower part of the back which no definite causefound. Here, the pain is often localized to one extremely painful

spot in the muscle, usually in the lower lumbar regions and slightlyto one side of the midline. It is often experienced after acombination of unaccustomed exercise and cold digging the gardenin sprain, for example, and may be severe enough for the victim tobe unable to move out of bed. The cause is believed to be spasm of a group of muscle fibers.5. Traumatic ligament rupture, stress function of the parsinterarticularis or paraspinous muscle tear6. Fracture, infection or tumor involving the back, pelvisorretroperitoneum.7. Bilateral loss of substance in pars interarticularis(sponylolisthesis)8. Stenosis of the spinal canal.9. Nonmechanical pain due to adjacent visceral disease.

The causes of LBP are manifold but may be classified under thefollowing headings:

PSYCHOGENIC PAINA purely psychogenically induced back pain is not so

common. Hence, in patients who have such nervous or emotionalbreakdowns, the physician must prepare to accept the possibility of an underlying significant pathological process and investigate itsprobability.

VISCEROGENIC BACK PAINThese may be derived form:

a. lesions of the lesser sacb. disorders of the kidneys or pelvic viscera, andc. retroperitoneal tumors

VASCULAR BACK PAINAneurysm or peripheral vascular disease may give rise to

backache or symptoms resembling sciaticaAbnormal aneurysms may present as boring type of deep-

seated lumbar pain unrelated to activity.Insufficiency of the superior gluteal artery may give rise to

buttock pain of claudicant character, aggravated by walking, andrelieved by standing still. The pain may radiate down the leg in a



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sciatic distribution. However, the pain is not precipitated oraggravated by other activities putting on specific stress on thespine such as stooping, bending, etc.

Peripheral vascular disease presents with intermittentclaudication or intermittent pain in the calf. This may on occasionmimic sciatic pain produced by root irritation. The symptomsproduced by peripheral vascular disease may be mimicked byspinal stenosis. A patoent suffering from this condition frequentlycomplains of pain in the legs, initiated and aggravated by the act of walking a short distance. One distinguishing feature, however, isthat in spinal stenosis, the pain is not relieved by standing still.

NEUROGENIC BACK PAINThis type of pain may come from:

a. tension, irritation, or compression of a lumbar nerve rootwhich causes referral of the pain symptoms down one or both leg,and is also The most common cause of neurogenic back pain, &

a. lesions of the CNS, such as thalamic tumors which maypresent or develop a causalgic type of leg pain. Also, arachnoidirritation from any cause as well as tumors of the spinal duramay produce back pain.There are also pathological lesions which will most likely give riseto confusion in diagnosis. These are:

a. neurofibromab. neurolemmac. ependymoma, & d. other cysts and tumors involving the nerve roots that

usually occur in the upper lumbar spine

SPONDYLOGENIC BACK PAINThis can be derived from the spinal column and its associatedstructures. The pain is aggravated by activity and is relieved, tosome extent, by recumbency:

a.) lesions involving the bony components of the spinal columnb.) changes in the sacroiliac joints andc.) changes occurring in the soft tissues.

Spondylogenic back pain is said to be the most common source of low back pain seen in the clinical practice.

STATIC LOW BACK PAINPoor posture to low back pain. Excessive lordosis- a marked

sway back has been a considered abnormal and a frequent causeof static low back pain. In excessive lordosis three things canoccur.

1. The facets approximate with compression and canbecome a site of nociceptive impulses.

2. The intervertebral foramen closes and encroaches on thenerve root dura and all its contents.

3. The disc can bulge posteriorly, putting pressure on thepost. longitudinal ligament.In the static spine, the vast majority o painful states can beattributed to an increase in the lumbosacral angle with aconsequent accentuation of the lumbar lordosis commonly termed

sway back, 75% of all static or postural low back pain isacredited to such lordosis.KINETIC LOW BACK PAIN

This implies irritation of pain- sensitive tissues by movement of thelumbosacral spine. Pain can originate in one of three basicmanners:

1.) Normal stress on unprepared normal back2.) Abnormal stress on normal low back .3.) Normal stress on a abnormal low back.

D .SITES AND CAUSATION OF PAIN1. Functional Unit composed of two vertebral bodies

separated by the intervertebral disc. It is the weight bearingstructure. The functional unit must be studied andunderstood on its function to explain the cause of pain toindicate the tissue from which pain can occur.

2. Intervertebral disc separates the two vertebrae of eachfunctional unit. There are more than 30 disc in the entirevertebral column , but the ones that are of concern in theLBP are the 5discs of the lumbar spine.

3. Disc is a hydraulics system that keeps the vertebraeapart. It acts to cushion any balance or pressure andpermits the functional unit to move in flexion to the front;extension to the back and to the side. It is made of an outerlayer that is termed the annulus fibrosus nd a central core



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termed the nucleus pulposus. It is 88% water. this water isheld in a gelatinous substance that has been called the

matrix.4. Longitudinal ligaments these ligaments limit the amount

of bending of two adjacent vertebral bodies [pain(+)];a.) Anterior Longitudinal ligament the ligament in the

anterior aspect of the spine.b.) Posterior Longitudinal ligament - the ligament down

the back of the spine.5. Neural Canal behind the vertebral bodies in the functional

unit are bones that form a canal. It contains all the nervesof the spinal cord. [pain(+)].

6. Facets these are joints with surfaces that face each other ,glide upon each other, and permit the spine to bend forwardand backward, prevent the spine from rotating to the left othe right and from bending sideways to any significantdegrees.[pain(+)].

Ligamentum flavum and interspinous disc normally isavascular and remains controversial as a source of pain.Intradiscal injections of irritating substances have beenfound to cause LBP esp. when there has been someherniation of the nucleus into the surrounding annulus.

E. PATHOLOGY/ PATHOGENESISThree aspects of LBP will be discussed:

1. exertional factor2. change in muscle3.changes in the facet joints and intercostal discs.

The most common emotional disturbances pertaining to LBP aretension, stress, anxiety, resentment and depression. Other factorssuch as repeated trauma come into play to localize the site of vascular change. Any of these emotional these factors act throughthe autonomic nervous system to produce local areas of vasoconstriction in muscle. Vasoconstriction and sustained musclecontraction with accumulation of the metabolites leads to fatigue.This in turn leads to changes in the recruitment of motor units inan individual muscle and individual muscle group used for aparticular movement. One result of these changes is an alteredpattern of muscle contraction with sudden violent uncontrolled

contractions of involuntary and other muscle. The result of theselong term changes in muscle is that spinal movement becomegrossly restricted and painful.

Changes in the facet joints and intervertebral discs include:a. disc protrusion any change in the shape of the annulusthat causes it to bulge beyond its normal parameter.b. disc herniation

1.)prolapse a protrusion of the nucleus thats stillcontained by the outer layers of the annulus andsupporting

ligamentous structures.2.) extrusion a protrusion in which the nuclear

material ruptures through theouter annulus and lies under that posteriorlongitudinal ligament.

3.) free sequestration the extruded nucleus has

moved away from the prolapsed area.Annular fibers breakdown may occur with fatigue loading over timewhich usually occurs with repeated overloading of the spine withasymmetric forward bending and torsional stresses. With torsionalstresses, annulus becomes distorted most obviously at theposterolateral corner opposite the direction of rotation. The layersof the outer annulus fibrosus lose their cohesion and begin toseparate from each other. Each layer then acts as separate barrierto the nuclear material. Eventually, radial tears occur and therescommunication of the nuclear material between the layers. Withrepeated forward bending an lifting stresses, layers of the annulusare strained; they become tightly packed together in theposterolateral corner, radial fissures develop and the nuclearmaterial radiates down the tissues. Outer layers of annular fiberscan contain the nuclear material as long as they remain acontinuous layer. If nucleus reaches the contents of the spinalcanal or the intervertebral foramen, there will be pressure andirritation of the tissue contained therein and pain and disabilityresults. Because the posterior longitudinal ligament lies in front of the SC, is essentially at the outer layer of the annulus, and issensitive, LBP can result.



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2. Pain without precise movement3. Weight loss

INTRASPINOUS TUMORS1. Same as disc herniation2. (+) myelography, CT scan, MRI, bone scan and biopsy test

PROGRESSION OF THE DISEASEAt any one level, the intervertebral joint is made up of 3

components, formed by two posterior facet joints and a disc.Changes affecting the posterior facet joints also affect the disc andvice versa. Strains and stresses commonly affecting the lumbarspine most often result in injury to all 3 parts, but rotation is morelikely to injure the facet joints while compression with flexion ismore likely to injure the disc.

Progression of this disease has been divided in to 3 phases(degenerative cascade):

PHASE 1 SEGMENTAL DESTRUCTIONState of abnormally reduced movement of the motion

segment. Initial clinical presentation reflects joint dysfunctionwhich includes reactive synovitis and articular cartilagedegeneration which leads into joint pain, inflammation, andhypomobility. Clinical presentation maybe the classical sprain,strain syndrome. Low back pain maybe worst with static standing,walking, extension or extension combined with rotation. Localtenderness, muscle spasm, limited range of motion and normalneurological examination are usual findings. Examination willreveal the hypertonic state of the segmental posterior muscle ateither L4-5 or L5-S1. Normal movement is restricted in onedirection.

PHASE 2 EXCESSIVE SEGMENTAL MOTION/TRUNK SEGMENTALINSTABILITY

Difficult to conceptualize because it is somewhat arbitrary (Iand II). Anyone who has not been symptomatic may enter phaseII. Abnormalities of the facet joint includes capsular laxity and jointsublaxation. Movements may not be detectable by standard lateralflexion and extension x-rays because translation occurs but the

instantaneous center of rotation may move abnormally. Clinicalimpression appears that the quality of motion is morerepresentative than quantity.

PHASE 3 SEGMETAL STABILIZATIONFacet joint become fibrosed, enlarged, and arthrosed. The

intervertebral disc becomes increasingly degenerated anddesiccated allowing approximation of the bertebral end-plates andosteophyte formation combination of anterior and posterior changescan manifest in ankylosis of the motion segment, although lesserdegree of spondylosis are common. Spinal nerve root entrapmentis relatively common in this phase. Neurogenic claudication orpseudoclaudication is typical presentation of lumbar radiculopathyin this phase.

Sometimes the changes in phase I pass directly to phase 3or sometimes may undergo phase II before it reaches III. Theexplanation for this is not yet known.

H. MEDICAL APPROACH/TREATMENTI. DIAGNOSISClinical diagnosis of low back pain would include:

1. PHYSICAL EXAMINATIONThe examination must confirm what thehistory has allowed to as being a factorcausing, maintaining, or aggravating the pain.It is a tissue analysis as well as a position andmovement analysis clarifying where and whattissue is responsible for the pain.

2. GENERAL OBSERVATION OF THE PATIENTThe manner in which the patient enters theoffice, sits, or stands, and approaches theexaminer is revealing. The attitude of thepatient depicted by the posture the tone of voice and the visual confrontation begins theexamination. The first observation is theerectness of the head posture.

3. BONE SCANNING (SCINTIGRAPHY)The location of the metastic bone lesionsremain the commonest indication for bone



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scanning. Bone scanning is also being used indetection of osteonecrosis, the study of failed

joint prostheses and the investigationunexplained bone pain.

4. PLAIN X-RAYSIn diagnosis, the main function of an x-ray isto exclude serious disease, such as infection,ankylosing spondylitis and neoplasms.

5. MYELOGRAPHY, COMPUTERIZED AXIALTOMOGRAPHY, MRI

Provide a precise definition of not only thenature of the lesion but also the location of the offending pathology.

II. MEDICATIONMedication should be taken 4-6 hours. Taking themedication whenever necessary can cause drugdependency. Pain medicine used focuses on the

feeling of pain and its intensity whereas medicineused on a prescribed specific time schedule thebuildup of pain sensation.1. Oral anti-inflammatory drugs blocks the

transmission of substances that could irritate softtissue of the low back

2. NSAID provides antiprostaglandin B formation3. Steroids for severe pain4. Muscles relaxants muscular tension compresses

all the inflamed tissues and restricts movementswhich causes pain

5. Sedatives tranquilizers6. Anti-depressants endorphine formation7. Intra-muscular injection an injection of an

anaesthetic agent with soluble steroid inectedinto the multifidus triangle which frequentlyinterrupts the painful low back pain cycle.

III. SURGICAL INTERVENTIONTo operate merely to relieve pain is not and should

not be indication for surgery. Bear in mind that pain is verysubjective.1. LAMINECTOMY AND/OR LAMINOTOMY

- is the surgical approach to seeing and ultimatelyremoving the offending disc or osteophytesLaminotomy implies removing a sufficient portion of the lamina to view the nerve within the neural canal orwithin the foramen.Laminectomy implies removing all the half of thelamina thus giving a larger view of the disc and nervesor widening the neural canal to free the nerve root.

2. FORAMINOTOMY- is a technique of widening a foramina that has beenconfirmed to be narrow or deformed by bone spur thusbeing narrow for the emerging nerve root.

3. NUCLECTOMY- is essentially disk surgery

4. FACETECTOMY- surgical removal of the facet joint

*Failed Back Surgery a term applied for unsuccessful surgery;surgery apparently adequately performed after a clear indicationfor surgery that failed to accomplish its purpose.

PHYSICAL THERAPY APPROACH

I. ASSESSMENT

Subjective Assessment: HISTORY

Includes questions about the site of the pain specifically where in the low back area is the pain felt. Thisindicates the tissue, area of the spine that is involved. Informationmust also be obtained from the patient as to the onset of painwhich indicates the action that initially caused the pain andultimately may denote the position or movement that caused,causes, or aggravates the pain. Through knowledge of the

mechanics of the lumbosacral spine, the movement of thespine causing the pain can be indicated. The patient must also beable to describe or characterize the pain he/she is feeling inthe low back. An ache may be muscular or ligamentous.Burning may involve fascia or nerve. Soreness is often



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muscular. Stinging may be ligamentous. Tingling or shooting painmay be a nerve sensation. The intensity of the pain mayindicate the severity of the tissue or this may indicate thetolerance of the patient to the pain.

Objective Assessment: STRUCTURE

Involves careful inspection of the area of complaint.A meaningful examination must reveal a significant structuraldeviation and relate it to the current symptoms. The basicaxiom of evaluating the functional basis of low back pain is: If thecharacteristic pain can be produced by a position or by amovement and the precise relationship of that position andmovement to the functional anatomy of the part is understoodthe cause of the pain becomes clear.

EVALUATION OF POSTURE (STATIC SPINE)Posture is assessed with the patient sitting as well as

in the standing position. The erect posture is examined before thepatient is aware of being evaluated. Examined from the side,the relationship of all the spinal curves to the center gravity isimmediately apparent:

The head should be directed in the center of gravity.The shoulders should be loosely held at side with noexcessive dorsal. kyphosis. The lumbar lordosisshould be minimal.The abdomen should not protrude excessively.

Further examination of the static postures a factor in determiningpostural pain requires that the postural pain must be reproduced.Manually increasing the lordosis may aggravate pain whereasdecreasing the lordosis may decrease pain. The opposite effectmay also be revealing.

PELVIC LEVEL: LEG LENGTHThe patient must stand without shoes, with legs

together, feet facing forward and knees locked inextension. The examiner, who stands behind the patient,places the fingertips of both hands on the pelvic brims and sightsthe equal level of the two hands. The level of the iliac crestscan then be determined. An obliquity can be ascertained and

act degree determined by placing a board of known thicknessunder the: short: leg and re-examining the crest level.

The length of the leg can also be measured byplacing a tape measure at the anterior-superior spineprominence and measuring the distance of both legs to themedial malleolus of the ankle. With the patient supine and thelegs flexed 90 at knees and hips, the height of the kneecaps canbe viewed from above to measure the length of the tibia.

When a significant leg length discrepancy exists, afurther observation will reveal if the discrepancy is due tosevere genu valgum or genu varum. A contracted gastrocsocleusmuscle causing a severe foot equinus will lengthen the leg of that side as a severe genu recurvatum (knee hypertension) willshorten the leg on that side.

The flexibility of the hips must also be determined asthis may place a stress on the static or an impediment uponthe kinetic spine. The hamstring range of motion is determined

by measuring the difference of SLR, one leg against the otherleg. This can be done by placing the patient supine and each legraised slowly, then measuring the angle at the hips.

The hip flexors also must have equal elongation. Thisis difficult, as the lumbar spine can extend, become morelordotic, and confuse which is being tested the hip flexorsor the lumbar lordosis. With the patient supine and one leg heldby the patient against the chest, the other leg is loweredfrom the side of the table.

The hip joint flexibility must be tested to ascertaindegenerative joint changes that can influence the static of kineticspinal movement. The Patrick test is used.

LUMBAR PELVIC RHYTHMOnce totally flexed, the person is asked to return to

the erect position. This is accomplished by gradual decrease of the lumbosacral kyphosis to the erect lumbar lorodsis.

A faulty sequence or a limited portion of eitheraspect of the sequence that is noted may indicate a pattern thathas led to pain and impairment. If the person regains the lumbarlordosis while the pelvis is still rotated forward, pain may occurin the low back. This premature lordosis can cause low backpain in the forward flexed position just as it can in the erect



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posture with the addition of the added weight of the bodyahead of the center of gravity.

The patient must also be examined not only inresuming the erect position from the bent-over position but fromthe bent-over and twisted (rotated) position.

LATERAL ROTATION FLEXIBILITYWith the patient standing erect and viewed from

behind, the lateral flexibility of the spine can be tested andrecorded. With both legs apart a few inches for balance, theperson is passively bent top one side then the other. Notethat the exclusive lateral spine flexion without rotation isphysiologically impossible. Some rotation occurs with lateralflexion; thus, limitation one-sided lateral flexion indicates

restriction from either soft-tissue restriction or protectivespasm.

PALPATIONThis can give valuable information about the

condition of the skin, subcutaneous tissue, muscle, ligament,and bone. NEUROLOGIC EXAMINATION

Determines whether there is nerve root involvementalong with the low back pain. With nerve root involvement, painmay be felt in the legs as well as the back. This impliesirritation of the nerve roots as they emerge from the cauda equineof the spinal cord in their passage to the legs through theforamen. The neurologic exam determines nerve irritation andreveals what nerve it is, at which level in the lumbosacral spineis often to what degree it is damaged.

To test the integrity of L3: deep knee bends,stairclimbing, getting out of a chair, and so on. L3 supplies theknee jerk reflex and the anterior thigh muscles.

L4 does not supply a specific muscle group and hasno specific reflex. Diagnosis of L4 damage is done throughtesting skin sensation with a pin, light touch or a pledged of cotton on the inner side of the lower leg.

L5 supplies the hallucis longus muscle which lifts thebig toe. It also supplies the anterior tibialis muscle. L5 damageis seen when the anterior tibialis muscle drags the big toe whenwalking.

S1 supplies the ankle jerk reflex. Tests for theintegrity of S1 is letting the patient rise up on toes, walk ontoes, jump and run.

MOBILITYAssess the posture and passive active range of

movement of the whole lumbar spine and its segment. SPECIAL TESTS

When the examiner performs special tests in thelumbar assessment, the straight leg raise test, the proneknee bending test and the slump test should always be done.The other tests need to be done only if the examiner feels theyare relevant or will confirm the diagnosis.

1. Straight Leg Raise TestMethod: The subject lies supine and raises one limb to 90

of hip flexion. The hip is slightly adducted and internally rotated,and the knees are fully extended. The angle between theelevated lower limb and table at the point of onset of symptoms is

noted if the test is positive.Result: Normal range should approach 80-90 of hipflexion. Limitation of range accompanied by reproduction of symptoms (lower back pain,sciatic pain or paresthesias) is apositive test result.

2. Lasegues SignMethod: The subject lies supine and flexes one lower limb at

the hip to90, with the knee and ankle in a relaxed position. With the

ankle in neutral position, the knee extended until symptomsare reproduced or a full extension position is attained.

Results: The result is a positive if symptoms are reproducedin the lower back or in the involved limb.

3. Prone Knee Bending (Nachlas Test)Method: the subject lies prone while the examiner passively

flexes the knee as far as possible so that the patients heelrests against the buttocks, patient hip should not be rotated. If it is difficult to flex the patients knee past 90 because of pathological condition, the test may be done by passiveextension of the hip while the knee is flex as much aspossible.



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Result: Unilateral pain in the lumbar area may indicate al L2or L3 nerve root lesion. The test also stretches the femoral nerve.Pain in the anterior thigh indicates tight quadriceps ms. I f the rectus femoris is tight, the examiner should remember thattaking the heel to the buttocks may cause anterior torsion tothe ilium, which could lead to sacroiliac or lumbar pain. Theflexed knee position should be maintained for 45 to 60seconds.

4. Slump TestMethod: The subject is seated on the edge of the examining

table with the legs supported, the hips in neutral position.( norotation or abd/add.) and the handle behind the back. Thepatient asked to slump the back into full thoracic and lumbarflexion. The examiner maintains the chin in neutral position toprevent neck and head flexion. The examiner then uses onearm to apply overpressure and maintain flexion of the thoracicand lumbar spines.

While this position is held, the patient is asked to flex thecervical spine and head as much as possible(chin to chest).The examiner then applies overpressure to maintain flexion of allthree parts of the spine. (cervical, thoracic and lumbar) usingthe hand of the same arm to maintain overpressure incervical spine.

With the other hand the examiner holds the patientsfoot in the maximum dorsiflexion. While the knee examinerholds these positions, the patient is asked to actively straightenthe knee as much as possible. The test, is repeated with theother leg and then with both legs together.

Results: If the patient is unable to fully extend the kneebecause of pain, the examiner, releases the pressure to thecervical spine and the patient actively extends the neck. If the knee extends further, the symptoms decrease with theneck extension, or the positioning of the patient increases thepatient symptoms, then the test the considered positive forincreased tension in the neuromeningial tract.

TEST FOR DURAL SIGNS BY INCREASED TENSION ONSPINAL NERVE ROOTS

1. Straight Leg Raise (SLR) Test

2. Lasegues Sign3. Braggards TestMethod: the subject lies supine and raises the involved

lower limb to the point just short of where symptoms begin. Theankle of the limb is then passively dorsiflexed.

Results: the result is positive if pain is reproduced in thelower back or the involved extremity.

4. Lhermittes Test (crossed leg-straight leg raise)Method: the subject lies supine and raises the uninvolved

lower limb.Results: the result is positive if pain is reproduced in the

back or in the involved extremity. It may indicate evidenceof a space-occupying lesion such as herniated disc in thelumbar area.

5. Brudzinkis TestMethod: the subject lies supine with both hands behind the

neck. The examiner helps the subject flex the head and neck

and upper back.Results: A positive result is indicated by pain in the lowback, pelvic girdle, or lower limb.

6. Kernigs TestMethod: the subject lies supine on the examining table and

places both hands behind his head to forcibly flex his head onto hischest.

Result: pain in the cervical spine and occasionally, in thelow back or

down the legs, is an indication of meningeal irritation ornerve involvement of the dural coverings of the nerve root.

7. Soto-Hall TestMethod: the subject lies supine. The examiner raises the

involved lower limb, keeping it straight, to a point just shortof the onset of pain. The subjects head and neck arethen passively flexed.

8. Crains Test (Bowstring Test, Popliteal Pressure Test)Method: the subject lies supine. The examiner raises the

involved straight leg to the point of onset of pain then slightlyflexes the knee until the pain is alleviated. The knee positionis maintained; the hip is flexed further to a point just short of



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the onset of pain. The examiner then press on the posteriortibial nerve where it passes through the popliteal fossa.

Results: the results are positive if symptoms arereproduced.

TESTS TO INCREASE INTRATHECAL PRESSURE1. Valsalva ManeuverMethod: the subject is asked to hold a breath and then bear

down, as if to have a bowel movement.Results: test results are positive if the subject reports

reproduction of exacerbation of spinal pain or radiating intothe limb.

2. Milgrams TestMethod: the subject lies supine. The examiner asks the

subject to lift both lower limbs simultaneously 2 to 4 inches off thetable while holding the position for 30 seconds.

Results: test results are positive if the subject is unable to

hold the limbs elevated for 30 seconds, or experiencesreproduction of pain in the spine or radiation into the limb.3. Naffzigers TestMethod: the subject lies supine. The examiner gently

compresses the internal jugular veins bilaterally forapproximately 10 seconds then asks the patient to cough.

Results: test results are positive if the subject experiencesreproduction of pain either in the spine or the limbs.* Note: a positive result of any of the three tests above

suggests either intrathecal or extrathecal pathology (e.g. discprotrusion, tumor), including the meninges themselves.

REPEATED FORWARD AND BACKWARD BENDING: STANDING ANDLYING (McKenzies Extension Principles)Indication: Repeated bending is performed to differentiate betweenderangement of the disc and mechanical dysfunction of other spinalstructures.Method: for all of the following test, the effect of the firstmovement on the subjects pain is noted. The effect is noted again

after the repeated movements have been performed.Movements should be repeated as many as ten times unless thesubject reports of reproduction or increased intensity or radiationof pain into the lower limb. The subjects ROM during therepeated motions must also be observed.

1. Forward Bend StandingThe subject stands with the feet about 12 inches apart and

is asked to run the hands down the front of the legs, as if to touchthe toes, as far as can be tolerated and then return to the uprightposition.2. Backward Bend Standing

The subject stands with the feet 12 inches apart and thehands placed in the small of the back. The subject bendsbackwards over the hands then returns to the upright position.(Note: if the subject is in a lateral shift position related to thesymptoms, the examiner should attempt to correct his postural

fault with a side glide technique before repeated testing of backward bending).3. Forward Bend Supine

The subject is supine, grasping both knees with the hands.The subject bends forward, pulling the knees to the chest. Kneeflexion eliminates compression of the spine by the body weight andtension on the nerve root.4. Backward Bend Prone

The subject lies prone with the hands positioned as if to doa push-up. The subject is asked to straighten the upper limbsand raise the trunk, keeping the pelvis and lower limbs in contactwith the table and then to return to the starting position. In thisposition, body weight compression is diminished.

Results: the results of these tests are considered to indicate discderangement, joint or soft tissue dysfunction or a posturalsyndrome.

TEST TO EVALUATE MALINGERING1. Flig SignIndication: the flip sign is used to assist in determining if thesubject may be inventing symptoms.



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Method: if the subject has a positive SLR test when supine butwhen the examiner suspects malingering, the subject is requestedto assume a short sitting position with the legs dangling over theside of the table. Under the guise of examining for an unrelatedproblem (e.g. check the knee or foot), the subject extends theknee now set up in variant of the SLR position. Results:Reproduction of stretch of an irritated nerve root should occur inboth supine and sitting positions for this test. The subject who ismalingering may fail to report symptoms in the variant position.The examiner should then be alerted to observe the subjectcarefully in the seated may merely lean back or grimace ratherthan verbalized the complaints.2. Hoovers TestIndication: Hoovers Test is used to help determine whether thesubject may be malingering or withholding effort.Method: with the examiner supine, the examiner places one handunder each heel then asks the subject to raise one lower limb. The

examiner should feel an increase in pressure under the oppositeheel as the subject tries to gain leverage with the effort. The test isrepeated with opposite limb.Results: if no increased pressure is felt from the opposite limb, thesubject is probably not putting forth full effort.3. Burns TestMethod: the subject is asked to kneel on a chair and bend to touchfingers to the floor.Results: the subject who is unable to perform the task oroverbalances the chair is likely to be malingering.

TEST TO ROCK THE SACROILIAC JOINT1. Pelvic Rock TestMethod: the subject lies supine on the examining table. Theexaminer places his hands on the subjects iliac crests with thumbson the ASIS and the palms on the iliac tubercles. Then, forciblycompress the pelvis toward the midline of the body.Results: pain around the sacroiliac joint is an indication of pathology in the joint itself, such as infection or problemssecondary to trauma.2. Gaensiens Sign

Method: the subject lies supine on the table and draws both legs tohis chest. Examiner shifts the patient to the edge of the table whilethe other remains on it. Allow his unsupported leg to drop over theedge while his opposite leg remains flexed.Results: the subject who feels pain in the area of the sacroiliac

joint may have a pathology in that area.3. Patricks TestMethod: Subject lies supine on the table and places the foot of hisinvolved side on his opposite knee. The hip joint is now flexed,abducted and externally rotated.Results: in this position (flexion, abduction, and external rotation),the inguinal area may be the site of pain and this is a generalindication that there is a pathology in the hip joint area or thesurrounding muscles.Method: When the end-point flexion, abduction, and externalrotation has been reached, the femur is fixed in relation to thepelvis. To stress the sacroiliac joint, extend the ROM by

placing the hand on the flexed knee joint and the other hand onthe ASIS of the opposite side. Press down on each of these pointsas if you were opening the binding of the book.Results: An increase in the pain felt is an indication of pathology inthe sacroiliac joint.

OTHER TESTS:1. Schobers TestMethod: Patient is standing, points are marked midway betweenthe PSIS 5cm below and 10cm above; the distance betweenthe points is measured before and after the patient is asked to flexthe spine forward and extend and it backward.2. Beevors SignMethod: Ask the patient to quarter sit-up with is arms crossed onhis chest. While he hold this portion, the examiner observesthe umbilicus.3. Provocative Nuclear Extrusion TestMethod: Place the patient prone and extend the low back extendingthe arms.Results: the test result is positive if it causes radicular pain downthe leg which produces compression on the posterior nucleus andannulus forcing more extrusion.



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4. Compression and DistractionIndications: Compression and distraction are used to assess for thepresence of a bulging disc that may be compressing the spinalnerve roots.Method:Compression : The examiner stands behind the seated subject.Placing the hands on the subjects shoulders, the examinerprovides moderate, even downward force through the trunk, takingcare not to cause forward, backward, or sideways bending.Distraction : The subject sits with the upper limbs crossed. Theexaminer, standing behind, reaches around the thorax, graspingthe subjects ipsilateral forearm. By straightening up or leaningback, the examiner can distract the spine along its vertical axis. If the subject has shoulder pathology, the examiner may put lessstrain on the area by just bear hugging around the thorax anddistracting without applying forces to the shoulder.Results: in the presence of a bulging disc, increased compression

tends to exacerbate symptoms while distraction tends to diminishthem.5. Femoral Nerve StretchIndication: Femoral nerve stretch is used to determine whetherthere is any irritation of the femoral nerve or root.Method: the subject is prone. The examiner flexes the subjectsknee while supporting the thigh just proximal to the knee. Theexaminer stabilizes the pelvis while extending the hip toprovide a further stretch to the femoral nerve.Results: Pain reproduced or exacerbated in the subjects backindicates a positive femoral or nerve root irritation.

II. COURSE OF TREATMENT AND RATIONALERehabilitation principles can be applied to all spinal

disorders whether in acutely injured or chronic pain patients,athletes or injured workers, nonsurgical or postsurgical patients.

1. Correction of soft tissue inflexibility due to spasm ortightness.

2. Improvement of segmental motion.3. Increase in trunk stabilization, strength and endurance.4. Proper education and training regarding posture,

proprioception and body mechanics.

Goals of Spinal Rehabilitation1. Full, pain free of motion of the injured and adjacent

segments, as well as hip, girdle, spinal and lower extremitystructures that influence the lumbar spine.

2. Optimal strength, endurance and coordination of theneuromuscular system affecting the lumbar spine.

3. Prevention of further injury and recurrence.4. Return to normal functional activities.

ACUTE PHASE: GOALS1. Decrease pain and inflammation2. Protect injured area from further injurySUBACUTE PHASE: GOALS1. Regain soft tissue flexibility and segmental motion.2. Restore full function to injured and supporting structures.3. Maximize lower extremity muscular flexibility for normal

lumbar motion.4. Optimal joint mobility.CHRONIC PHASE: GOALS1. Address psychological barriers to recovery and generaldeconditioning.2. Multidisciplinary pain management3. Improve functional ADLs4. Return to gainful employment5. Claim closure6. Discontinue use of health care system7. Pain control

III. TREATMENT OUTLINE

Acute (0-4 weeks)Rule out serious problemso Short course of bed rest accepted position would

be modified Fowlers position which is reclining thebody with hips and knees flexed and the low back ina slightly flexed position. The flexed knees positionpermits the hamstrings to relax, slight flexion of thelumbosacral spine reverse the lordosis and separates



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the facet joint, therefore avoids approximation of their inflamed synovial tissues.

o Posture Correction/Exerciseo Education on proper body mechanics and sitting and

standing postures is an important component in anyback care program.

o Lumbar supporto Decrease Pain/inflammation/spasm

Modalities : Cryotherapy / Ice brushingElectrical stimulation for increasing

blood flow and promotehealing once edema is stabilized.

Diathermyo Keep them active

Early activity Purpose:1. Maintain muscle tone and cardiovascular

endurance2. Provide extension of lumbar spine3. Maintain joint mobility4. Increase blood flow to the injured segment

o Some pain is okayo Teach patient what to avoid

Subacute (1-10 weeks)o Increase mobilityo Strength, flexibility, and fitnesso Body mechanics trainingso Back care educationo Work stimulationo Posture trainingo Evaluate work environmento Return to work

Chronic (after 7-10 weeks)o Increase work stimulationo Increase strength, flexibility and fitnesso Rehabilitation psychologyo Behavior modificationo Modify work environmento Focus on patient responsibilities

o Return to worko Settle problem cases

THE ACUTE STAGEThe Approach to Treatment

The approaches are used to determine the basis fortreatment. The first approach bases the treatment plan on aspecific pathological diagnosis. Each entity presents a uniqueclinical picture. This approach is ideal. The second approachattempts to identify the patients problems, such as pain,decreased soft tissue or joint mobility, abnormal posture andmuscle weakness.

USING THE PATHOLOGICAL DIAGNOSIS1. Sprains and Strains

Treatment of the inflammation from minor repetitive stress,involves Reconditioning Exercises to promote strength, flexibility

and fitness, with education and ergonomic changes to reduce theeffect of stressful activities. True sprain/strain injuries are bestmanaged by an athletic approach that involves rest,immobilization and protection from further injury in the very earlystage of treatment. A program to promote healing and maintaingeneral strength, flexibility and fitness is begun immediately. Asthe injured part heals, more vigorous exercises and a gradual,progressive return to normal activity are prescribed.2. Herniation of the Nucleus Pulposus

For treatment, McKenzie advocate correction of the lateralshift and passive extension exercises. He believes that this movesthe nucleus of the disc centrally, maintenance of correct posture isimportant for healing. If the peripheral pain is increased by acorrective maneuver, it is unwise to persist in this.

Activities such as flexion exercise, forward bending andprolonged sitting that increase intradiscal pressure should beavoided. There must be strict compliance with this program for 2 to10 weeks. Treatment should also be directed pain relief,restoration and mobility. Modality therapy may allow relief of painand muscle guarding. A support may be used to allow the patientmore pain-free activity and to aid postural correction.



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Later, a full physical program should be implemented andactive extension exercises may be used to increase strength andfurther promote correct posture. In more severe cases, tractionmay be necessary before posture correction and extensiveexercises can be implemented.3. Post-surgical Cases

A full rehabilitation program should be implemented for allpatients after surgery, directed towards restoring normal posture,flexibility, strength, and physical fitness. Patient education onproper body mechanics and lifestyle modification necessary for ahealthy back should be included.4. Degenerative Disc and Facet Joint Disease

Treatment is directed toward measures to increase mobility.When there is a neurological complication, caution is necessary.The therapist should discontinue exercises, activities and positionsthat increase the peripheral signs and symptoms.5. Nerve Root Adhesions

Treatment of the disorder consists of mobilizing the nerveroot adhesion by straight leg raise stretching.6. Spondylolisthesis

The patient with this disorder is vulnerable to sprains andtrains. Such a patient may need to avoid heavy labor and vigorousphysical activities. Attention to posture, abdominal musclestrengthening another flexion exercises and abdominal musclestrengthening. Weight loss is important.7. Sacroiliac disorders

Treatment includes mobilization if the joint is hypermobile.The wearing of a support is often helpful if the joint is hypermobile.When the joint is fixe, manipulation will be necessary to reducethis. Stabilization with sacroiliac support is often helpful.

TREATING THE PROBLEM1. Pain, muscle guarding, spasm, and inflammation

Immobilization and rest for short periods is often useful.This may take the form of bed rest, lumbar supports and/orpillows, with the restriction of certain activities. Immobilization andrest should be prescribed with caution. For most patients somemovements, even when it is painful, will be beneficial.

Modality therapy, the various forms of heat and cold areusually effective as are electrotherapy and massage. Manymodalities have the added benefit of increasing the circulation,which speeds the healing of tissue and promotes relaxation of themuscle spasm.

Mobilization is often effective in relieving pain. Thetechniques usually employed are gentle traction and/or gradedmovements in the pain-free range.2.Hypomobility

As soft tissue and joint injuries begin to heal, the lattermany become hypomobile. This may lead to early degenerativechanges. To avoid this possible chain of events, mobilization should be used, the sooner the better,provided that it is done without aggravating any concomitant softtissue injury.

Exercises in the form of soft tissue and connective tissuesmassage, contract-relax techniques, passive stretch, AROM and

PROM exercises all increase the mobility of soft tissue.Traction may be effective. Correction of faulty postureallows for increased mobility. Ultrasound has a loosening effect onsoft tissue that is stiff.3. Hypermobility

Strengthening exercises for the muscles around ahypermobile joint give support to the joint. Correction of posturalsometimes used to reduce joint mobility if other methods fail.4. Abnormal Anatomical Relationship

Mechanical and manual traction techniques are sometimeseffective in the management of a disc protrusion. They can stretchadaptively shortened soft tissues.

Certain corrective exercises help restore normalphysiological length to soft tissues. Specific posture techniques canimprove and maintain normal length of soft tissues.

Mobilization techniques often restore the normal andanatomical relationship of joints. The ultimate purpose is to restorea full, painless, active range of motion.5. Abnormal Function

Treatment through various types of exercises, education,mobilization, and the modalities of physical therapy to



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restore active function is the most important part of the practice of orthopedic physical therapy.6. Injured and Inflamed Tissues

Immobilization and rest help the patient avoid activities thatinjured tissue further or inhibit the healing process. Modalities suchas ice, heat, electrical stimulation, and massage all promotehealing. This is accomplished by reducing edema, improvingcirculation, and stimulating cellular activity.7. Poor posture

Patient education of proper body posture and bodymechanics are necessary.

8. Poor Physical and Mental ConditionTreatment to improve general physical and mental fitness

has a direct effect upon musculoskeletal problems, many physicalactivities are influenced by general strength, coordination,endurance, flexibility, and cardiovascular fitness.

9. Poor Body MechanicsThe therapist should be skilled at designing an individualhome program and in motivating the patient to carry it out. Thismay take the form of specific exercises or of instruction in the bodymechanics and activities of daily living. The patient should betaught which activities are potentially harmful and which arehelpful to the condition being treated.10. Exercises for the Acute Stage of LBP

o WILLIAMS FLEXION EXERCISESExercise 1 : Pelvic TiltObjective: To decrease the lumbar lordosisProcedure: Lying flat on your back on a firm surface with

knees bent and feet flat on the surface. Flatten thesmall of your back against bed, tightening your abdominalmuscles and buttocks. Next, tuck your chin in so as toflatten the back of your neck against the surface. Hold thisposition for 5 seconds. Do not hold your breath. To relax,slowly release in this order, the neck and the shoulders, abdomenand buttocks. Repeat this exercise 10x.

Exercise 2Objective: To stretch the tight extensor muscles and other

soft tissues of the hips and back.

Procedure: Repeat exercise 1 to the hold position. Bring oneknee upward toward your chest as far as possible, then reach upwith your arms and pull the knee down to your chest. Tuckchin in and attempt to place the forehead on knee. Hold for 5seconds. Slowly return starting with neck and then knee. Nowrelax as in exercise 1. Repeat using the other leg.

Exercise 3Objective: To stretch the tight hip flexors and heel cordsProcedure: Repeat exercises 1 to the hold position. Bend

(R) knee to the chest, grasp it with both hands and draw theknee firmly to the chest. Slide the heel of the (L) leg down untilthe leg is flattened against the surface. Keep the (L) kneestraight with the back of the knee pressed against the tableand pull the foot upwards toward the chin. Hold for 5 seconds.Slowly slide the (L) heel back to starting position (SP). Relax asin exercise 1. Repeat with the (L) knee.

Perform 5 sets.

Exercise 4: Straight Leg RaisingObjective: To stretch the tight hamstring musclesProcedure: Repeat exercise 1 to the hold position.

Straighten one knee and pull the foot upwards towards the shin.Raise the leg toward your head as far as possible withoutbending your knee. Hold for 5 seconds then bringing it down toSP. Relax as in exercise 1.

Exercise 5: Curl-up/Sit-upsObjective: To provide maximal strengthening of the

abdominal muscles.Procedure: Repeat exercise 1 to the hold position. Have

someone press on your ankles or feet or secure the feet underthe edge of the plinth or bed. With both arms reachingforward, tuck in the chin and slowly curl-up in a sittingposition. Hold for 5 seconds. Uncurl by allowing the mid-back toreach the floor first followed by the shoulders, neck andhead. Relax as in exercise 1.

Exercise 6: Posture exerciseObjective: to teach the patient proper posture for standing

and walking.



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Procedure: Stand with the back against the frame of adoorway. Place the heels 4 inches away from the frame.Flatten the low back into the frame of the door, allowingyour knees to bend a little. Tuck the chin and attempt to flatten orpress the neck against the frame. Straighten both knees. Atthis point, your entire trunk should be pressing against the doorframe. Hold for 5 seconds and then relax. Exercise for 6 repetitionsall of the maneuvers of exercises 1 but is performed in an

upright weight bearing position.o ROBIN MCKENZIES EXTENSION EXERCISES

Note: All exercises are done 6-8 times dailyGeneral objective: centralization of the pain factorExercise 1Usefulness: For acute low back painProcedure: Face lying with arms at the sides, forearmpronated and head turned to one side. Maintain position,take a few deep breaths, relax completely for 4 to 5

minutes (tension of the low back is eliminated or relax).Exercise 2Usefulness: For severe LBPProcedure: SP is the same as in exercise 1. Place elbowsunder shoulders so that you can lean on your forearms.Take a few deep breaths then completely relax the low backmuscles. Stay for 5 minutes.Exercise 3Usefulness: Most effective or useful procedure for acute LBPProcedure: SP is the same as in exercise 1. Place handsunder shoulders in the press-up or push-up then straightenelbows and push the top half of the trunk as far as painpermits (entire LE should be completely relaxed). Maintainfor 2 seconds then return to SP. To progress, each time themovement cycle is repeated, try to raise the upper trunk alittle bit higher so that in the end, the back is extended asmuch as possible with arms as straight as possible.Exercise 4Procedure: Stand straight with feet slightly apart (stridestanding). Place the hands in the small of the back, withfingers pointing backwards, bend trunk backwards at thewaist as far as possible or as far as you can using the hands

as fulcrum (knees are in tight extension). Maintain for 2seconds then go back to SP. To progress, bend backwards alittle farther each time one repeats movement cycle until fulldegree of extension is reached.Exercise 5 Procedure: Back lying with knees bent and feet flat on thefloor. Bring both knees up towards the chest placing bothhands around the knees or at the back of them. Gently butfirmly pull the knees as close to the chest as pain permits.Maintain for 2 seconds then go back to SP. Do not raisehead or straighten leg as you lower them during exercise.To progress, try to pull knees as little closer to the chestevery repetition until you can reach a maximum degree of flexion.Exercise 6Procedure: Sit on the edge of a steady chair with knees andfeet well apart. Bend trunk forward and touch floor with

hands then return immediately to SP. To progress, try tobend a little farther every time you repeat the exercise untilthe head is as close as possible to the floor. Arms movebehind legs or hands, hold ankles and pull yourself downfarther.

THE SUBACUTE PHASETreatment1. To regain soft tissue and flexibility and segment motio

a. myofascial releaseb. joint mobilization or manipulationc. muscle energy technique to improve segmental

mobilityd. stretching

2. Self-stretching techniques

THE CHRONIC PHASETreatment1. Multidisciplinary approach2. Multiple treatment foci

a. educationb. physical reactivation and conditioning



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c. work conditioningd. counselinge. ergonomic assessment

3. Isokinetic trunk strength and range of motion

Exercise training for Lumbar disc disorders1. Soft tissue flexibility

- Hamstring musculotendinous unit- Quadriceps musculotendinous unit- Ilipsoas musculotendinous unit- Gastrosoleus musculotendinous unit- External and internal hip rotators

2. Joint mobility- Lumbar spine segmental mobility- Hip ROM- Thoracic segmental mobility

3. Stabilization program

- Finding neutral position (eg standing,sitting, jumping, prone)- Prone gluteal squeezes with armraises, alternate arm raises, arm and legraises, alternate and leg raises- Supine pelvic bracing- Bridging progression: basic position,one leg raised with ankle weights, stepping,balancing on gym ball, quadruped, kneelingstabilization, wall slide quadricepsstrengthening position transition with posturalcontrol

4. Abdominal program- Curl-ups- Dead bugs (supported, unsupported)- Diagonal curl-ups- Diagonal curl-ups on incline board- Straight leg lowering

5. Gym program- Latissimus pull-downs- Angled leg press- Lunges

- Hyperextension bench- General upper-body weight exercises- Pulley exercises to stress posturalcontrol

6. Floor exercises- Abdominal bracing- Modified sit-ups- Low back stretch or double knee tochest- Mountain and sag knee to elbow- Extension exercise

7. Aerobic program- Walking start slowly and progress to1 mile in 15 minutes if possible.- Swimming the water supports yourbody and takes the weight off your low back.Avoid breast stroke.

What is the proper sequencing of a rehabilitation program?( Young, OYoung & Stiens, 2009 )

o Control of inflammation

o Control of pain

o Restore spine and extremity range motion

o Improve muscular strength

PREVENTION OF RECURRENCE OF LOW BACK PAINPain reduction

Exercises suggested for pain reduction and/or painelimination are supine lumbar flexion, prone lumbarextension, side lying rotation, lateral glides and prone lyingoscillationsRestoration of function

Exercises suggested for the restoration of functionare supine lumbar flexion, prone lumbar extension,



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hamstring stretches, hip flexion stretch, sitting rotations,side lying rotations, lateral glidesProphylaxis

Exercises suggested for prophylaxis are supineflexion, prone extension, hamstring stretches, hip flexorstretches, prone rotations, abdominal strengtheningexercise, paraspinal and gluteal strengthening exercises

In prevention of recurrence of LBP, the person must:1. Regain or acquire adequate flexibility of the pertinent soft tissueof the lumbosacral spine and pelvic region.2. Regain and acquire adequate strength of the pertinent musclesrelated to low back function.3. Learn or relearn and implement the proper bending, stooping,lifting, pushing, pulling, turning, twisting and sitting.4. Recognize, control or avoid any interfering psychological,professional, of personal emotional factors that can impair low back

function.o Proper erect posture

Require that all curves are held at a minimum. Exercise fortotal postural effort by standing with the shoulder blades tothe wall, feet some 6 inches from the wall. The back of thehead is pressed to the wall and neck is gradually tucking thechin therefore standing taller.

o Proper flexibility exercises1. Hamstring stretching exercises

Tight hamstring places added stress on thelumbosacral spine. Sit with one leg flexed with thefoot on the ground and heel near the buttocks. Theother leg to be stretched is held extended. Slowgradual body flexion, reaching toward the toes,stretches the hamstring of the extended leg. Theflexed leg protects the low back by avoidingexcessive flexion of the lumbosacral spine.

2. Heelcord stretching exercisesTight heel cord places excess stress on the

hamstring and ultimately on the lumbosacral spineon bending forward. Squat and sit on both heels. The

feet are placed slightly apart and externally rotated.The stretching motion is rhythmic up and downbounce with balance maintained against a wall orchair.

3. Hip flexor stretching exercisesTight hip flexors exert an adverse action on

the pelvis and lumbosacral spine. This is due to thefact that iliopsoas attach from the anterior aspect of the lumbar spine as well as the inner aspect of theilia. From these attachment they can influence thelumbar spine.

o Active and passive stretchMainstay of relaxing the muscle and regaining elongation

o IceBest modality. Ice is a local anesthetic and decreases painand apprehension, decreases nerve conduction of sensoryfibers. Use for 10 to 15 mins several times a day for 2 days.

o Hot packsMoist heat penetrates better

o Fetal positionBest low back exercise. Low back flexibility exercises. Thelegs are used as a lever to flex the lumbar spine. Descentfrom flexion exercise, after having flexed the low back to itsmaximum, one leg should be returned to the floor whilemaintaining a flexed pelvis. This prevents the return of lordosis during the descent of both legs, which may bepainful.

o Modified yoga/sitting positionLow back exercise that eliminates the hamstrings. With apatient in a squat position, with knees and hips flexed, thelow back is gradually flexed until the head approaches thefloor or the toes. This exercise fully stretches the entirespine.

o Prone arch and sag exerciseBeing up on ones hands and knees causes the low back tosag which extends the low back. The low back then iselevated to its fullest which stretches the back extensortissue.



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o TractionSimple home traction. Pelvic traction by placing legs onchair and sufficient pillows, the body is lifted from the floor.This flexes and stretches the low back. Remain in thisposition as long as possible.

o Pelvic tilting exerciseSequence:1. The low back is pressed on the floor.2. Once pressed to the floor, it must not be allowed to raisefrom the floor.3. the buttocks is raised slowly and gently from the floor.

o Erect pelvic tilting exerciseWith the patient standing against a wall with feet slightlyforward, the pelvis is flattened against the wall as it isagainst the floor in the supine exercise. This trains thepatient to feel the position of the flat lumbar spine.

o Strengthening of the appropriate muscles

Abdominals, erector spinae and quadricepsReasons: (1) abdominal muscles contain the contents of theabdominal cavity which forms an airbag (2) strongabdominals balance the forces of the erector spinae andspine (3) the abdominals strengthen the fascia of theerector spinae

1. Abdominal strengthening exerciseSit-up depending on the original

conditioning of the individual. The exercise is bestdone in gradual stages

Stage 1 is best done with the arms on thefloor at the persons side, gradually sliding themtoward the feet

Stage 2 requires raising the shoulder furtherfrom the floor

Stage 3 is raising the shoulder blades fromthe floor with arms extended forward toward thefeet

Stage 4, while coming to a full flexed positionthe hands

are placed behind the head with elbowsforward. This arm position assists sitting up with

the forward held arms placing weight ahead of the center of gravity.

Stage 5, finally, the sit-up is done with handsbehind the head and the elbows behind the head.This arm position places added resistance to theabdominals by adding weight behind the center

of the gravitySit-back this is for a person with weak

abdominals. From the seated position with bothhips and knees flexed and the hands behindthe head and at first the elbow forward, theperson slowly leans back a few degrees. The

person holds at the point that is possible withcomfortable effort. Gradually, a few more degreesof leaning back followed by a sit-up is possibleas strength increases. The arms behind the headposition held initially with elbow forward is

gradually changed to placing the elbows behind thehead.Walking best low back abdominal exercise

2. Lateral trunk muscles strengtheningStand maintaining balance by holding on to

an object and raise to the opposite leg to theside as far as possible and hold it. This exercisealso strengthens the hip abductors-glutei which arealso pelvic rotators.

RECURRENCE OF LBPWhen a patient feels warning signs of impending back pain,

use the first aid technique. If the first aid regimen every hour doesnot help significantly in the first 48 hours or if you experience adifferent back or leg pain from that experience before, see yourdoctor for advice.

First aid for LBPo Listen to mother nature. Get off your feet. Elevate your legso The first line of defense is AIM (Aspirin, Ice, Movement)o Do the exercises that helped reduce the pain in the past



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o Dont continue this program or bed rest for more than 48hours without obtaining professional help and advice

o If numbness, weakness or other neurological deficit ispresent, do not delay seeking help.


med back of lbp

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