Treatment of Neck and Back Pain MASUD

Treatment
of
Neck and Back Pain
Treatment
of
Neck and Back Pain
Vinayagam Deiva Sigamani

BSc BPT APTA (USA), MIAP, MA (PSY), MPT (Sports Medicine)
PGD Sports Med and ALT Med, DPM and DRM (New York)
Principal, Professor and Head of Department

AMS College of Physiotherapy
Anna Salai, Chennai
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021,
+91-11-23245672, Rel: 32558559 Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com
Visit our website: www.jaypeebrothers.com
Branches
• 2/B, Akruti Society, Jodhpur Gam Road Satellite, Ahmedabad 380 015
Phones: +91-079-26926233, Rel: +91-079-32988717, Fax: +91-079-26927094
e-mail: jpamdvd@rediffmail.com
• 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East,
Bangalore 560 001 Phones: +91-80-22285971, +91-80-22382956
Rel: +91-80-32714073, Fax: +91-80-22281761 e-mail: jaypeemedpubbgl@eth.net
• 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road,
Chennai 600 008 Phones: +91-44-28193265, +91-44-28194897,
Rel: +91-44-32972089, Fax: +91-44-28193231 e-mail: jpchen@eth.net
• 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road,
Hyderabad 500 095 Phones: +91-40-66610020, +91-40-24758498
Rel:+91-40-32940929, Fax:+91-40-24758499, e-mail: jpmedpub@rediffmail.com
• No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road, Kochi 682 018, Kerala,
Phones: 0484-4036109
• 1-A Indian Mirror Street, Wellington Square, Kolkata 700 013
Phones: +91-33-22451926, +91-33-22276404, +91-33-22276415
Rel: +91-33-32901926 Fax: +91-33-22456075, e-mail: jpbcal@dataone.in
• 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel
Mumbai 400 012 Phones: +91-22-24124863, +91-22-24104532
Rel: +91-22-32926896 Fax: +91-22-24160828
e-mail: jpmedpub@bom7.vsnl.net.in
• “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road,
Nagpur 440 009 (MS)
Phones: Rel: 3245220, Fax: 0712-2704275 e-mail: jaypeenagpur@dataone.in
Treatment of Neck and Back Pain
© 2007, Vinayagam Deiva Sigamani

All rights reserved. No part of this publication should be reproduced, stored in a
retrieval system, or transmitted in any form or by any means: electronic, mechanical,
photocopying, recording, or otherwise, without the prior written permission of the
author and the publisher.
This book has been published in good faith that the material provided by author
is original. Every effort is made to ensure accuracy of material, but the publisher,
printer and author will not be held responsible for any inadvertent error(s). In case
of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2007

ISBN 81-8061-881-1
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida 201 301, India
To
My Father
Sri K Vinayagam
Preface
This book has been written to provide knowledge in treatment

techniques to implement therapy and care of a person who is suffering
from upper back and lower back pain with various pathological medical
conditions.
In a modern world, everybody would prefer to take treatment
without any adverse side-effects, naturally people shall prefer Physical
Therapy to relieve pain and modify muscle tone, prevent disability
and promote balanced body mechanism.
This book helps, how to implement therapeutic way of healing the
back pain by correct selection of physical therapy approaches and
do’s and don’ts for the day-to-day daily activities.
However, any treatment whether in clinical approaches, dogmatic
approach and psychological approaches, their concept is to neutralize
the body’s energy flow by either activates energy field or feeds from
external or internal through different means to achieve the well-being
state of normal healthy human system.
The topics, which I have written in multidimensional ways based
on my experience.
I hope this topic will enrich the knowledge of the students, young
medical graduates and back pain sufferers to learn complete
understanding of Cervical, Thoracic and Lumbosacral pain.
I have tried my level best to avoid errors and discrepancies, if
reader note any, might be brought into my knowledge for re-correction,
will be appreciated. Reader must cross check from the text and
clinically experienced expertise prior to send the suggestions for further
clarification.
Of course, any medical practice is an Art and Science effects may
varies, depends upon the reliability and validity.
This work was like my first mission, in fact, sharing my knowledge
with readers. Hope this book will help the health care providers and
back pain sufferers. I am sure, they will certainly be in a position to
render very rewarding services to the patients.
viii Treatment of Neck and Back Pain
Finally, through this book, I have given how to manage patient

suffering with back pain. “Although we are dressing the wound,
certainly God only heals it”.
Vinayagam Deiva Sigamani

Acknowledgements
This book would not have been possible without the help and
encouragement of Janab Segu S. Jamaludeen, Secretary and Corres-
pondent of AMS group of Educational Institutions. He has provided
best environment and support for writing this textbook “Treatment
of Neck and Back Pain”.
I would like to express my thanks to all my teachers who gave me
valuable suggestions to finish this project.
Dr Francis Lillypushpam, Senior Physiotherapist has made helpful
comments on sections of the manuscript, which has helped to shape
up this text.
In fact, I have learned from my students, patients and teaching
staff in clinics for many stimulating discussions in Back Pain over a
year. However, thorough practical knowledge of back pain could be
used to understand and treat patient’s problems.
I express my thanks to Mr M Govindan, Dr M Ramesh Babu
(PT), Dr J Julie Sangeetha (PT), Dr Sangeetha Mohan (PT) and
Dr KG Smitha (PT) and our teaching staff who helped and made this
possible.
Contents
1. Introduction .............................................................................. 1
2. Anatomy and Biomechanics ................................................... 3
3. Pain .......................................................................................... 18
4. Posture .................................................................................... 26
5. Brachial Neuralgia ................................................................. 36
i. Cervical Spondylosis .......................................................... 38
ii. Cervical Disc Prolapse ........................................................ 39
iii. Brachial Plexus Lesion ........................................................ 40
iv. Thoracic Outlet Syndrome ................................................. 43
a. Cervical Rib ................................................................... 45
b. Pectoralis Minor Syndrome .......................................... 46
c. Claviculo Costal Syndrome ........................................... 46
d. Anterior Scalenus Syndrome ........................................ 46
e. Neurological Amyotrophy ............................................. 47
v. Brachial Neuralgia Assessment ........................................... 48
vi. Treatment of Cervical Conditions ....................................... 55
6. Low Back Pain ........................................................................ 77
i. Intervertebral Disc Prolapse ............................................... 78
ii. Sciatic Nerve ...................................................................... 85
iii. Lumbar Spondylolisthesis ................................................... 90
iv. Lumbar Spondylosis ........................................................... 94
v. Lumbar Stenosis ................................................................. 95
vi. Osteoporosis ....................................................................... 96
vii. Idiopathic – Spina Bifida ..................................................... 96
viii. Spinal Osteitis ..................................................................... 98
ix. Assessment for Low Back Pain ......................................... 98
x. Fitness Test ....................................................................... 100
xii Treatment of Neck and Back Pain
xi. Physical Therapy for Low Back Pain ............................... 105

xii. Low Back Pain Surgical Procedure and Treatment ......... 120
xiii. Ergonomics ....................................................................... 123
xiv. Low Back Pain and Sex .................................................... 136
Bibliography ........................................................................... 139
Index ....................................................................................... 141

C HAPTER
1 Introduction
Man identifies from animal by his erect posture. Erect spine and posture
considered as social highness, improves his personality and braveness.
Backbones aids for erect posture, vertebral bones connected by
ligaments and disc covered and coated by muscles. (Fig. 1.1)
Pain in the back is a complex multifaceted health problem that
represents excitatory challenges to health care provider. Back pain
affects the physical, psychological, emotional, financial and social
aspects of a person’s life. Physiotherapists are health care provider
well trained in the psychosocial and physical aspects of rehabilitation,
in fact, an important medical professional member of the health care
team.
Fig. 1.1: Vertebral column

2 Treatment of Neck and Back Pain
Fig. 1.2: Vertebral load
The treatment and prevention of back pain have increased the

attention in the community because of high cost of health care. Also
diminishes ability to perform the day-to-day activities. Person who sit
prolonged period causes more stress on their back. Almost 90 percent
of backaches are due to spasm of back muscles. Such aches are
sooner or later go away. However, backache is present because of
muscle spasm than think about any pathology that you may live with
it. However, you can reduce the discomfort by reconditioning your
back by therapeutic exercise and analgesics, physical agents with
correct ergonomics of course every treatment counts with positive
mental attitude. The succeeding chapter would give all the aspect of
back pain and treatment. (Fig. 1.2)
C HAPTER
2 Anatomy and
Biomechanics
Axial skeleton forms upright of the body. It consists of head, thorax,

trunk and it has total number of 80 bones. Appendicular skeleton
attaches number of axial skeleton which contain 126 bones. We have
totally 206 bones in our body.
Bone is made up of 1/3rd organic (living) material and 2/3rd
inorganic (nonliving) material. Organic material gives elasticity,
inorganic provides hardness, strength which makes the bone opaque
on the X-ray reading.
Vertebral Bones and its Spinal Segments (Fig. 2.1)
Vertebrae Vertebral segments Spinal segments
Cervical 7 8
Thoracic 12 12
Lumbar 5 55
Sacral 5 5
Coccygeal 1 1
Fig. 2.1: Vertebral curves

BACK BONES (Fig. 2.2)

Structure Cervical Thoracic Lumbar
• Size • Smallest • Intermediate • Largest
• Body • Small oval • Heart shaped facets • Large oval
to connect ribs
• Vertebral foramen• Large triangular • Smallest • Intermediate
• Transverse • Foramen for verte- • Facets connects ribs • No foramen
process bral artery, short, long, thick point post- • No
point laterally eriorly and laterally articulations
• Spinous • Short, shout bifid • Long slender point • Thick point

process inferiorly posteriorly
• Superior articular • Face posterior • Face posteriorly • Face medially
process and laterally
• Vertebral • Equal depth • Deeper inferior • Deeper inferior
notches notch notch
Fig. 2.2: Vertebral parts (Typical Lumbar Vertebra) VB indicates vertebral body: P.
Pedicle; TP, Transverse process; SP, spinous process; L. Lamina; SAP, superior
articular process; IAP, inferior articular process; Saf, superior articular facet; iaf,
inferior articular facet; MP, mammillary process; AP, accessory process; Vf,
Vertebral foramen; RA, ring apophysis; NA, neural arch.
Anatomy and Biomechanics 5
PARTS OF VERTEBRA (Fig. 2.3)

1. Spine and spinal column and vertebral column are synonymous
terms referring to the bony components housing the spinal canal.
2. Facet is a small, smooth flat surface on a bone found on thoracic
vertebrae at the point of contact with a rib. Facet joints is the
articulation between the superior articular process of the vertebrae
below the inferior articular process of vertebrae above.
3. Body primarily cylindrical mass of cancellous bone, anterior
portion of the vertebra at the major weight bearing structure. It
is not present in atlas (C1) and axis (C2). Between C3 and S1
bodies progressively larger.
4. Neural arch also called vertebral arch, posterior portion of vertebra
with many different parts.
5. Vertebral foramen opening formed by joining of the body and
neural arch through which the spinal cord passes.
6. Pedicle portion of neural arch just posterior to the body and
posterior to the lamina.
7. Lamina posterior portion of the neural arch that unites from each
side in the midline.
8. Transverse process formed the union of the lamina and pedicle.
9. Vertebral notches depression located on the superior and inferior
surfaces of the pedicles.
10. Intervertebral foramen opening formed by superior vertebral
notch of vertebra below the inferior vertebral notch of the vertebra
above.
Fig. 2.3: Superior view vertebra

11. Articular process projecting superiorly and inferiorly off the

posterior surface of the each lamina, superior articular processes
face posteriorly on medially, inferior processes face anteriorly or
laterally (Fig. 2.4).
12. Spinous process posterior projection on the neural arch, located
at the junction of the two lamina.
13. Intervertebral disk articulates with adjacent bodies. They are 23
in number. They absorb and transmit shock and maintain flexibility
of the vertebral column. Disk makes 25 percent of length of the
vertebral column.
Pelvic Girdle
Following bones forms the pelvic girdle.
1. Sacrum
2. Coccyx
3. Hip bones comprised ilium, ischium, pubis
Joints of Pelvis
• Posterior laterally – Sacroiliac joints
• Anteriorly – Pubis symphysis
• Superiorly – Lumbosacral
Sacroiliac Joints
• Synovial and Non-axial joint.
• The normal lumbosacral angle is 30 degrees.
Fig. 2.4: Side view of vertebra

PELVIC TILT
Anterior Pelvic Tilt
Anterior superior iliac spine of the pelvis move anteriorly and inferiorly
closer to the anterior aspect of the femur.
Range of motion: Hip flexion, lumbosacral extension
Muscles: Hip flexors, spinal extensors
Posterior Pelvic Tilt

Posterior superior iliac spine moves posteriorly and inferiorly close to
the posterior aspect of femur.
Range of motion: Hip extension, lumbar flexion
Muscles: Hip extensors, spinal flexors
Standing stability is done by hip flexors and spinal extensors.
Lateral Pelvic Tilt

• Hip hiking side hip adduction.
• Hip drop side hip abduction.
• Lumbar curve convexity on hip drop side.
Muscles: Elevated side quadratus lumborum
Drop side reverse pull of gluteus medius. Passive support done by
iliofemoral ligament and iliotibial band on elevated side (standing leg).
Pelvic Rotation
When unsupported side of the pelvis move forward it is called forward
rotation of the pelvis. The trunk concurrently rotates opposite and the
femur on stabilized side concurrently rotates internally.
When unsupported side of the pelvis moves backward, it is known
as backward rotation of pelvis. Trunk rotates forward, femur on the
stabilized side rotates externally.
Lumbar Pelvic Rhythm

Open chain movement of hip, pelvis and lumbar spine reaching the
floor by flexion of trunk and extended knee. Hip can flex 90 degrees
with anterior pelvic tilt than lumbar spine incline the trunk forward by
45 degrees. (Fig. 2.5)
Fig. 2.5: Lumbar pelvic rhythm
PRIME MOVERS OF NECK

Action Muscle
Flexion • Sternocleidomastoid
Extension • Splenius capitis
• Splenius cervicis
• Erector spinae
Lateral bending • Sternocleidomastoid
• Splenius capitis
• Sclenes
• Erector spinae
Rotation (same side) • Splenius capitis
Rotation (opposite side) • Sternocleidomastoid
PRIME MOVERS OF TRUNK
Action Muscle
Flexion • Rectus abdominus
• External oblique
• Internal oblique
Extension • Erector spinae
• Transversespinalis
• Interspinalis
Lateral bending • Quadratus lumborum
• Erector spinae
• Intertransversarii
Contd...
Contd...
Action Muscle
Rotation (same side) • Internal oblique
Rotation (opposite side) • External oblique
• Transverse spinalis
Compression of abdomen • Rectus abdominus
• Transverse abdominus
MUSCLE ACTION OF NECK

Action - Flex the neck
Muscles - Sternocleidomastoid
Nerve - Accessary nerve (cranial nerve XI)
Second and Third cervical nerve
Action - Bilaterally neck flexion
Unilaterally neck lateral bending
Muscles - Scalene
Nerve - Lower cervical nerve
Action - Bilateral extend head
Unilateral rotate and laterally bend the head to
same side
Muscles - Splenius capitis
Nerve - Middle and lower cervical nerve
Action - Bilaterally extend head at neck unilateral rotate
and laterally bend the neck to same side
Muscles - Splenius capitis
Nerve - Middle and lower cervical
TRUNK ACTION
Action - Trunk flexion and compression of abdomen
Muscles - Rectus abdominus
Nerve - Seventh through twelfth intercostal nerves
Action - Bilaterally trunk flexion
Compression of abdomen
Unilaterally lateral bending rotation to opposite
side
Muscles - External oblique
Nerve - Eight through twelfth intercostals

Nerve iliohypogastric nerve and ilioinguinal nerve
Action - Bilateral trunk flexion and compression of
abdomen. Unilateral lateral bending and rota-tion
same side
Muscles - Internal oblique
Nerve - Eight through twelfth intercostals, iliohypo-
gastric and ilioinguinal nerves
Action - Compression of abdomen
Muscles - Transverse abdominus
Nerve - Seventh through twelfth intercostal, iliohypo-
gastric and ilioinguinal nerves
Action - Bilateral extension of trunk
Unilateral lateral bend
Muscles - Erector spinae
Nerve - Spinal nerve
Action - Bilateral extension of the trunk
Unilateral rotation to the opposite side
Muscles - Transversospinalis muscles
Nerve - Spinal nerves
Action - Trunk rotation
Muscles - Interspinalis muscle
Nerve - Spinal nerve
Action - Trunk lateral bending
Muscles - Intertransversarii muscles
Nerve - Spinal nerves
Action - Trunk lateral bending
Muscles - Quadratus lumborum
Nerve - Twelfth thoracic and first lumbar nerves
ARTICULATIONS OF VERTEBRAL SEGMENTS

Cartilaginous Joint
Between vertebral bodies and disk.
Diarthrodial or Synovial Joint
Between superior articular process of one vertebrae and inferior
articular process of adjacent vertebrae (these joints are called
Zygapophyseal joints).
Synovial Joint
Joint where the vertebral column articulates with the ribs and the
skull.
MUSCLES OF SPINE
Muscles provide stability, mobility, strength and endurance.
Paravertebral musculature of lumbar spine is divided in three groups:
• Psoas major and psoas minor
• Quadratus lumborum and intertransverse laterallis
• Lumbar back muscles
Psoas Major
It is a muscle for flexion of hip and can not flex lumbar spine. During
sit-ups psoas major exerts compression of intervertebral discs.
Quadratus Lumborum
Principal action is flexion of the 12th rib during respiration. Weak
action is to flex the lumbar spine laterally.
Intertransversarii Lateralis
Acts synergically with quadratus lumborum in lateral flexion of lumbar
spine.
LUMBAR BACK MUSCLES (Fig. 2.6)
Muscle Action
• Intertranversarii medialis • Serves in larger propriceptive transducers
• Interspinalis • Proprioceptive function
• Multifidus • Extend the lumbar spine
• Control flexion
• Oppose flexion during rotation of lumbar
spine
• Longissimus thoracis • Unilaterally lateral flexion
• Bilaterally saggital rotation and posterior
translation of the lumbar vertebrae
• Iliocostalis lumborum • Similar like longissimus thoracis.
About 50 percent of extension power of the lumbar spine is provided

by thoracic fibers of longissimus and iliocostalis muscles acting
Fig. 2.6: Back muscles
through the erector spinae aponeurosis. 50 percent is exerted by

multifidus and 50 percent by intrinsic lumbar fibers of longissimus
and iliocostalis.
LIFTING MUSCLE ACTION

Flexion in the forward position during lifting increase intradiskal
pressure in lower area. Intra-abdominal pressure (IAP) first proposed
by Bartelink in 1957.
Contraction of abdominal muscles is closed glottis raise the intra-
abdominal pressure, supporting the thorax and assist the back muscles
to raising the weight. IAP increase systolic aortic blood pressure.
According to Gracovetsky back extensors assist lifting by generate
passive tension in the posterior ligamentous system and passive and
active tension in the thoracolumbar fascia,
IAP is low tension in thoracic lumbar fascia is reduced consequently
extension movement decreased.
ROTATORS AND LATERAL FLEXORS

Rotation of trunk to left side need simultaneous contraction of right
external oblique and left internal oblique. Right side requires left external
oblique and right internal oblique.
Lateral flexion same side iliocostalis, longissimus, spinalis,

quadratum lumborum and serratus posterior superior.
Unilateral contraction of quadratus lumborum will hike the hip or
laterally tilt the pelvis in frontal plane.
Psoas major acts to flex the hip when femur, pelvis and lumbar
are fixed.
LIGAMENTS AND ITS FUNCTION

Vertebrae are supported by means of ligaments for maintaining stability
and to prevent excessive motion. The ligament that supports the
vertebral complex and functions are as follows:
Ligaments Functions
• Anterior longitudinal ligament • Limit extension
• Posterior longitudinal ligament • Limit flexion
• Ligamentum flavum • Limit flexion especially lumbar
• Supraspinous • Limit flexion
• Anterior atlanto-axial (continuation of
anterior longitudinal ligament) • Limit extension
• Posterior atlanto-axial (continuation of
ligamentum flavum • Limits flexion
• Tactorial membrane (continuation of
posterior longitudinal ligament) • Limit flexion
• Interspinous • Limit flexion
• Intertransverse • Limits lateral flexion
• Alar ligament • Limits rotation
• Capsular ligament –
INTERVERTEBRAL DISCS
Intervertebral disc constitutes 20–30 percent of the total vertebral
height. It acts as:
• Shock absorber for spine
• Distribution of forces
• Pivot for movements
• Stability and integrity of spine
Thickness of intervertebral discs is 3 mm in cervical. Greater the
disc thickness will have the greater mobility.
Intervertebral disc consists of three components:

a. Central gelatinous NUCLEUS PULPOSUS
b. Surrounding ANNULUS FIBROSIS
c. Pairs of vertebral endplates that sandwich the nucleus
In newborn baby, there is a capacity of 88 percent fluid content,
but in the age of 77, fluid content goes to 65 percent. Young disc will
hold more fluid.
Fluid and proteoglycans concentrations are highest in nucleus and
lowest in annulus. Composition of nucleus pulposus and annulus
fibrosis compounds of water, collagen and proteoglycans.
Collagen consists of type I and type II. Type I fiber resist tensile
force present in skin, tendon and bone, whereas type II resist
compressive forces.
Annulus fibrosis consists of concentric laminae of collagen fibers,
arranged in rings and keep the nucleus under constant pressure.
Vertebral endplates are cartilaginous structures that cover the
superior and inferior surfaces of each vertebral body within the area
encircled the ring apophysis. The two endplates of each disc cover
nucleus pulposus in and annulus fibrosus out.
Innervation for intervertebral disc are vertebral and sinuvertebral
nerves. Nutrition are through diffusion via cartilaginous end plate.
Glycosaminoglycane
Chemically they are long chains of polysaccharides. Each chain
consists of repeated sequence of two molecules called “Repeated
Unit”. Repeating unit consists of sugar molecules with an amine
attached. The length of the individual GAG’s characteristically about
20 repeating unit.
Repeating unit in human intervertebral disc are:
• Chondroitin 4 sulphate (fluid attraction capacity maintained)
• Chondroitin 6 sulphate
• Keraton sulphate
• Hyaluronic acid
Proteoglycans
These molecules consisting of glycosaminoglycans are linked to
proteins, 2 basic forms:
1. Proteoglycon units
2. Proteoglycon aggregates
Proteoglycon units are formed when several glycoaminoglycons

are linked to a polypeptite chain known as “Core Protein”. Proteoglycon
aggregates are formed when several proteoglycon units are linked in
a chain of hyaluronic acid. A single hyaluronic chain may bind 20 to
100 proteoglycon units. The linkage between proteoglycon units and
hyaluronic acid is stabilized by a small mass of protein known as
“Link Protein”.
Collagens
It consists of strands of protein molecules. The fundamental units of
collagen is Tropocollagen molecule, consists of three polypeptide
chains rounded around one another in helical fashion and held together
end to end by hydrogen bonds. There are two types of collagen found
in connective tissue. The principle type of collagen found in the
intervertebral disc is type I and type II.
LOADED STATE OF DISC AND SELF STABILIZATION

OF INTERVERTEBRAL JOINTS
When vertebrae compression force works on intervertebral disc
nucleus bear 75 percent force and the annulus fibrosis 25 percent.
However, in the horizontal plane, nucleus transmits some of the forces
in to annulus.
If a disc is exposed a violent force, the thickness of the disc
exhibits dampened oscillation over a period of one second. If this
force is too violent the intensity of this oscillatory reaction can destroy
the fibers of the annulus, this is the cause of deterioration of the
intervertebral disc exposed to repeated violent stresses.
WATER INHIBITION OF NUCLEUS

When the nucleus rest in the intervertebral disc, there is numerous
microscopic pore linking the nucleus and the vertebra. During standing,
water contained with the gelatinous matrix of nucleus escapes in to
the vertebral body through these pores. These static pressure is
maintained throughout the day, during night nucleus contain more
water than in morning. So the disc is thicker. This is 2 cm in healthy
person. During night, when one lies flat, the vertebral bodies not in
force of gravity or muscle. At this time, the water absorbing capacity
of nucleus great, so it takes back the water from the vertebral bodies,
disc regain its original thickness. (Fig. 2.7)
Fig. 2.7: Loading over vertebral column
This is reason one is taller in the morning than at night, and also
flexibility is marked at time. With aging water absorbing capacity is
decreased. Each vertebra can be compared to a system of first order.
Zygapophyseal joints are fulcrum, interverterbal disc weights and
paravertebral muscles are effort. Disc thickness is at lumbar is 9 mm,
thoracic is 5 mm, and cervical is 3 mm. Disc/body ratio is at lumbar
is 1/3, thoracic is 1/5, and cervical is 2/5. Greater the ratio, greater
mobility. (Fig. 2.8)
SPINAL CORD
Spinal cord is the lower elongated cylindrical part of the Central Nervous
System (CNS). It extends from upper border of the Atlas to the lower
Fig. 2.8: Inter vertebral disc

border of the Vertebra L1 or upper border of L2 Vertebra. It is about

45 cm long. The lower end of conical end called “Conus Medullaris”.
Continuation of the medulla, spinal cord runs within the vertebral
canal from foramen magnum to the cone-shaped conus medullaris at
the level of the second lumbar vertebra. Below the L2 collection of
nerve roots running down from the spinal cord like horse tail, hence
it is named as “Cauda Equina”.
Cauda equine made up of the nerve roots from L2 through S5. A
thread like non-neural filament running from the conus medullaris
called “Filum Terminale. Spinal cord is approximately 17 inches in
length protected by three layers as brain. Cerebrospinal fluid flow in
between arachnoid layer and pia matter. Vertebral foramen is the
passage for the spinal cord, protected by bony structure of each
individual vertebra, intervertebral foramen located on the sides of the
vertebral column. Intervertebral foramen is formed by superior
vertebral notch of the vertebra below at the inferior vertebral notch of
vertebra above. Through this opening spinal nerve root exists the
vertebral canal.
Cross sectional view of the spinal cord shows center gray matter
and peripheral white matter. Grey matter is middle of the cord in “H”
shaped or butterfly shape. Top portion of the “H” is posterior horn
responsible for transmitting sensory inputs lower portion of the anterior
horn, transmits motor impulse.
C HAPTER
3 Pain
Pain is defined as “an unpleasant sensory and emotional experience

associated with actual or potential tissue damage. Result of muscle
spasm and guarding or protection of injured part (protective spasm).
Prolonged spasm which leads to circulatory deficiency, muscle
atrophy, disuse habits, conscious or unconscious guarding.
PURPOSE OF PAIN
Pain is a protective mechanism for the body, occurring whenever any
tissues are being damaged and it causes the individual to react to
remove the pain stimulus.
Acute pain is useful pain, a symptom of disease in trauma, lasting
for 3 months. Head and lower limbs are the most common sites of
acute pain.
Chronic pain has lost its biological purpose, e.g. arthritis, cancer,
lasting for at least 6 months. Back is the most common site for chronic
pain. Pain without an organic pathology called chronic pain syndrome.
Behaviour of pain is characterized by verbal expression, grimacing,
guarding movement, decreased activity levels, limited range of
movement of joint and also overuse of pain relieving medications,
signs of depression and viability to work.
AETIOLOGY OF PAIN
• Somatic
• Neuropathic
• Psychogenic
• Viral, Bacterial, Fungal
• Inflammatory
• Degenerative
• Neoplastic
Pain 19
• Ischemic
• Endocrine, metabolic
• Autoimmune
• Traumatic
FACTORS AFFECTING PERCEPTION OF PAIN

Personality
Extroverts express pain freely. Introverts feels the pain intensely but
complain less.
Social Context
Pain is perceived during wars, electric surgery, labour, ceremonies.
Culture
Face or withdraw pain alone openly seek help or support. Pain is
necessary evil for further spiritual benefits.
Past Experience of Pain

Child birth.
State of Mind
Anxiety, depression, increases the perception of pain.
PAIN RECEPTORS
Receptors in the skin called nociceptors (noceicep-damage) or free
nerve endings. Nociceptor neuron present in dorsal root ganglion,
near the spinal cord, which transmit pain signal afferent neuron or
nerve fibers conduct impulses from periphery to brain. Efferent neuron
conduct impulses from brain to periphery.
Once nociceptor is stimulated, it releases neuropeptide (substance
“P”) goes towards the afferent neuron to spinal tract.
Free nerve endings present in periosteum, arterial wall, joint
surfaces, falax and tentorium of cranial vault.
TYPES OF PAIN
Fast Pain (Pin Prick)
Transmitted “A” delta fibers, processed in spinal cord. Dorsal horn
lamina—later spinothalamic tract. Transmits pain at a speed of 15 m/

second.
Slow Pain (Aching, Throbing, Burning)

Transmitted through “C” fibers. It is totally protective, aversive
reaction. Response medial spinothalamic tract transmit at a speed of
1 m/second.
When a person experiencing pain following signs can be take place:
• Increase heart rate
• Increase blood pressure
• Pupillary dilatation
• Sweating
• Hyperventilation
• Anxiety
• Protective behaviour
STIMULATION OF PAIN
Mechanical
Pain last only as long as the deformation is present and resolves when
deformation is corrected.
Thermal
Pain occurs when noxious chemical substances occur in quantities is
sufficient to irritate the nociceptors.
Chemical
Pain is dull relieved when concentration of chemical returns to
subthrushold level.
Emotional psychological aspect of pain are projection to limbic
system. Pain memory storage areas present in temporal lobes.
ORIGIN OF PAIN
Pain from the Central Nervous System
Central nervous system pain can occur immediately after the insult
pain from injury to the dorsal horns felt ipsilateral side. Pain from
cortical lesion felt face, hand and feet.
Pain 21
Pain from Autonomous Nervous System

Sympathetic and parasympathetic fibers travel in the wells of blood
vessels. Automatic pain is spread throughout the involved vessels
distribution.
Pain from Thalamic (Thalamic Pain)

Usually in contralateral extremities, elicited by movement, skin contact,
heat, cold and vibration.
Pain from Periphery

Pain results from noxious irritation of the nociceptors. Nature of the
pain may be parasthesia, pins and needles, e.g. diabetic neuropathy.
Referred Pain
Pain is not felt at the site of the pathology, but distant location, e.g.
pain in the jaw, neck, radiate upper limb due to angina.
COGNETIVE BEHAVIORAL METHOD TO PAIN RELIEF

1. Relaxation exercises—deep breathing, Jacobsons training
(reversing endorphin depletion).
2. Aromatherapy
3. Hydrotherapy - General
4. Hypnosis
5. Operant conditioning
6. Music
7. Group therapy
8. Biofeedback
9. Body scanning Reiki and Pranic Healing.
Other Methods
i. Behaviour modifications –
1. Learn the difference
2. Between hurt and harm
3. Grade exercise
4. Programme
ii. Yoga
iii. Guided imagery
iv. Positive reinforcement and educational support
v. Teaching coping skills –
1. Relax, pacing activity
2. Distraction technique
3. Cognitive restructuring
4. Problem solving
PHYSIOTHERAPY TREATMENT IN PAIN

1. Tens
2. Heat and cold therapy
3. Electrical nerve stimulation
4. Manipulative procedure—
Massage and mobilization
5. Traction
6. Hydrotherapy
7. Counter irritant
8. Therapeutic exercises—daily walking, posture, strengthening of
muscles, range of motion exercises.
Analgesic physical agents used in physiotherapy to slow or block
the impulses ascending along the “C” afferent neural pathways.
Enkephalines and seratonin active in descending pathways thought to
block the pain message.
Physical Agent (Analgesic Type) Effects as follows:

1. Moderating the release of inflammatory medications.
2. Modulating pain at the spinal cord level.
3. Altering nerve conduction
4. Increase endorphin level.
INHIBITARY MECHANISMS
1. Blocking the pain: Impulse through afferent pathway called “Gate
control theory” and
2. Descending analgesic pain control.
Pain 23
Gate Control Theory

For example, Rubbing massage. Ascending impulses on these A delta
and C fibers stimulate substantia gelatinosa when the stimulus enter
the dorsal horn of spinal cord.
Stimulated substantia gelatinosa inhibits synaptic transmission in
the large and smaller afferent fibers.
Depends upon the input from the small and large diameter afferent
determines the pain message is blocked or gated.
Descending Pain Control

Pharmacological Approach of Pain Management
Systemic Analgesics
1. Non-steroidal anti-inflammatory drugs (NSAIDs)
2. Acetaminophen
3. Opiates and opioids
4. Antidepressants.
1. NSAID’s
Side Effects
1. Gastro intestinal bleeding or irritation
2. Decreased platelet aggregation and thus prolonged bleeding time
3. Kidney damage
4. Bone marrow suppression
5. Rashes, anorexia
6. Decreased renal blood flow in dehydrated patients.
Drugs
• Asprin
• Ibuprofen
• Naproxen sodium
• Piroxicam
2. Acetaminophen (Mild to Moderate Pain)
Side effect: Prolonged use can damage liver.
Drug: Tylenol
3. Opitates (Narcotic drug that contain opium)
Used for post-operative pain.
Side effects: Nausea, vomiting, sedation, suppression of cough.

Drug: Morphine, hydromorphine, fentanyl, meperidine.
4. Antidepressents (for chronic pain)
Drug: Amitryptiline (elavil)
Spinal Analgesia
Drug: Opitates, local anaesthesia, corticosteroids
Procedure
Inject in to the epidural or subarachnoid space of the spinal cord. Fat
soluble opiates have rapid action. Water soluble opiates have slow
action. It blocks the nociceptor in the spinal column.
Side Effects
Fat and muscle wasting, osteoporosis, cushings syndrome—symptoms.
Local Injection
Administered corticosteroid and local anaesthesia in the joints, bursa,
trigger points around tendon.
Side Effects: Tissue breakdown, deterioration.
(Note: For acute trauma, this drug is not administered, because it
reduces the inflammatory response and may impair healing of
structures.)
PSYCHOLOGICAL ASPECT OF BACK PAIN

Physiologically pain is a warning sign of bodily dysfunction, but
psychologically it can be a cry for sympathy or expression of guilt. At
a deep level aggression may be sublimated turned for defense, used
for punishment and enclosed in love and sympathy.
Physical illness and disability may satisfy security and dependence
needs without stigmatizing the patient, because the sick role is accepted
by most societies. In addition, patient may wish to continue the
financial support which the disability allows, with through Insurance,
Government or Family.
Pain 25
Psychiatric evaluation may help to unravel symptoms and signs in

such patients. Look at the chart how emotional factor causes back
pain.
Three factors must be consider for back pain:

1. Emotional
2. Changes in muscles
3. Changes in facet
The most common emotional disturbance for low back pain are
Tension, Stress, Anxiety, Fear, Resentment and Depression.
Emotional disturbance acts through automatic nervous system to
produce local areas of vasoconstriction of muscles.
Changes in histological zones in muscle have been variation by
several different investigations.
Multifidus muscle is rotator of lumbar and also postural muscle
which is controlled involuntarily. It is commonly affected. Controlled
contraction produces rotational injury to facet joints and disc. Injury
to this structure leads to reflex sustained contraction of muscle.
C HAPTER
4 Posture
Posture is defined as “a position or attitude of the body, the relative

arrangement of body parts for a specific activity or characteristic
manner of bearing one’s body”.
Ligaments, faciae, bones and joints are inert structures that support
the body, whereas muscles, tendinous attachments are the dynamic
structures that maintain the body in a posture or move is from one
posture to another.
Gravity plays an important role to maintain upright posture of the
body. Normally gravitational line goes through the physiologic curves
of the spinal column and they are balanced. If the weight in one region
shifts away from the line of gravity, the remainder of the column
compensates the regain equilibrium.
For weight bearing joint to be stable, or in equilibrium, the gravity
line of the mass must fall exactly through the axis of rotation, or there
must be a force to counteract the force of gravity. In body, the counter
force is either muscle or inert structures. Upright posture, usually
involves a slight anterior – posterior swaying of the body of about ‘4’
cm.
Pain Related to Poor Posture

Postural Fault
Posture that deviates from normal alignment but has no structural
limitation pain due to mechanical stress for prolonged period pain
relieved with activity. Muscles flexibility and strength are normal.
Postural Dysfunction
Adaptive shortening of muscles and weakness of muscles are involved
causes may be prolonged poor posture results contraction and tight-
ness.
Posture 27
Postural Habits
Flexibility and strength is essential following trauma or surgery. Good
postural habits are important to avoid abnormal stresses on growing
bones and adaptive changes in muscles and soft tissues.
Types of Posture
Static Posture
Body and segments are aligned and maintained in certain posture,
e.g. lying or standing. Static posture control involves maintenance of
particular posture against gravity.
Dynamic Posture
Body and body segments moving that is walking and running, jumping,
throwing and lifting. Dynamic posture involves maintenance of
stability during movements of the body.
Human than the ability to arrange and to rearrange the body
segments to form larger variety of postures such as bilateral single leg
erect standing, sitting, lying down and kneeding, maintain erect bipedal
stance is difficult. It allows person to use their upper extremities for
the performance of large and small motor tasks. Erect posture increases
work of heart increases stress on the vertebral column, pelvis and
lower extremities and reduces stability.
The human center of gravity located with the body at the level of
second sacral segment is relatively distant from the basis of support.
Maintain the static erect posture requires very little energy expenditure
in the form of muscle contraction. The bones, joints, ligaments and
able to provide the major torques needed counteract gravity, and
frequent changes in body position assist in permitting circulatory
return.
Postural Control
Person’s ability to maintain stability of the body segments in response
to forces that threaten to disturb the body’s structural equilibrium.
Central Nervous System able to respond to all of this input with
appropriate output to maintain the equilibrium of the body.
Musculoskeletal system must have a range of motion that is need
for specific work. Muscle must respond with appropriate speeds and
force.
Central Nervous System receives and process information from

all systems and must be interpret information from the receptors
regarding the position of the body in space. When inputs altered or
absent in weightless conditions during spacelight or decreased
sensation in the lower extremities the control system must respond to
incomplete or distorted data thus person posture may be altered.
NORMAL POSTURE
Standing
Lateral View (Plumb Line)
• Head • Through the ear lobe
• Shoulder • Through tip of the acromion process
• Thoracic • Anterior to the vertebral bodies
• Lumbar • Posterior to the vertebral bodies
• Pelvis • Level with an anterior or posterior tilt
• Hip • Through the greater tuberosity slightly posterior to the hip
joint axis
• Knee • Slightly posterior to patella anterior to the knee joint knee
extension
• Ankle • Slightly anterior to the lateral malleolus with ankle joint in
neutral position.
Anterior View
• Head • Extended and level
• Shoulder • Level and not elevated or depressed
• Thoracic • Centered in midline
• Lumbar • Level with both ASIS in the same plane
• Pelvis • Slightly apart
• Hip • Level and not bowed or knock
• Knee • Normal arch in feet
• Ankle • Slight outward toeing
Posterior View
• Head • Extended not flexed or hyperextended
• Shoulder • Level
• Spinous process • Centered in the midline
• Hip • Level with PSIS in same line
• Leg • Slight apart
• Knees • Level and not bowed or knock
• Ankle • Calcaneous should be straight
Posture 29
Sitting Position or Ischial Support (Typing)

Without resting on back of the chair, pelvis is in state of equilibrium.
Trapezius in action to stabilize the vertebral column. In long sitting,
this position becomes painful and the condition is called “Typist’s
syndrome” or “Trapezius syndrome”.
Sitting on Ischio-Femoral Support

Flex the trunk in supported by ischeal tuberosities and posterior aspect
of the thighs, trunk may be supported by arms resulting on knees.
Flattening of lumbar curve. Trunk is stable with minimal muscular
support and can fall asleep. Relax paravertebral muscles. Decrease
the shearing forces on lumbosacral disc.
Sitting on Ischiosacral Support

Trunk rest on back of the chair, supported by ischial tuberosities,
posterior sacrum, coccyx, pelvis tilted backward. Lumbar curvature
flattend, thoracic curve increases, sleep is possible. Breathing
hampered by neck flexion help reduces slipping of L5, relax posterior
muscle and relieve pain of spondylolisthesis.
Supine with Extended Limbs

• Resting position
• Psoas is stretched
• Lumbar curvature exaggerated
Supine with Flexed Lower Extremities

• Relaxation of psoas
• Backward tilt of pelvis
• Flattening of the lumbar curvature
• Relax spinal and abdominal muscles
Supine with Semiflexed Lower Limbs with Elevation

Head and Upper Trunk Mild Elevation
• Achieved with help of specially designed chairs
• Thoracic curvature accentuated
• Lumbar and cervical flattening
• Hip flexion
• Psoas and hamstring are relaxed.
Side Lying
• Vertebral curved
• Thoracic convex superiorly
• Not relaxed
• Respiratory difficulty
Prone Lying
• Lumbar curvature exaggerated with respiratory difficulty
• Pushing back the viscera on to the diaphragm
• Pressure for over there hours sore will develop.
Disc Pressures in Various Positions

• Supine – 25% of body
weight
• Side lying – 75%
• Standing – 100%
• 20 Degree Mild Trunk Flexion – 150%
• 40 Degree Moderate Trunk Flexion – 220%
• Sitting (Typist) – 140%
• Sitting Mild Tunk Flexion – 185%
(Back unsupported)
• Sitting with leaning Forward – 275 %
(Back unsupported)
• Slouched Posture with back support – Nearly 36 lbs
of weight compress the posterior structures.
Least amount of intervertebral disc pressure occur while supine
lying. Kneeding stool reduces disc pressure while sitting.
Common Faulty Postures

Lordotic Posture
It is characterized by an increased lumbosacral angle (normal 30
degree). Increase in anterior pelvic tilt and hip flexion secondary to
that increase thoracic kyphosis and forward head position. For
example, pregnancy, obesity and weak abdominal muscles.
Posture 31
Relaxed or Slouched Posture (Sway Back)

It is characterized by excessive shifting of the pelvis segment anteriorly,
resulting in hip extension and shifting of the thoracic segment
posteriorly, resulting in flexion of the thorax on the upper lumbar
spine. A compensation increased thoracic kyphosis and forward head
placement are also seen. For example, attitude of a peuon, fatigue.
Flat low back
It is characterized by decreased lumbosacral angle, decreased lumbar
lordosis and posterior tilt of the pelvis. For example, over emphasis
of flexion exercise.
Flat upper back
It is characterized by decreased thoracic curve, depressed scapulae,
depressed clavicle and an exaggeration of axial extension, flexion of
the occiput on atlas and flattening of the cervical lordosis, e.g.
exaggerated upright posture.
Cervical Region
Forward Head Posture
It is characterized by increased flexion of the lower cervical and upper
thoracic regions. Increased extension of the occiput on the first
cervical vertebra, increased extension of the upper cervical vertebra.
May be temporomandibular dysfunction with retrusion of the mandible,
e.g. leaning forward for long period.
Flat Neck Posture
Decreased cervical lordosis increased flexion of the occiput on atlas
seen exaggerated military posture, temporomandibular problems and
protraction of mandible.
Low Back Pain Due to Faulty Posture
Abnormal pelvic tilt is a common feature which could occur as a
result of various musculoskeletal imbalances. Habitual wrong posture
result in muscular tightness eventually leading to fixed deformity. Trunk
flexion or pelvic tilt wrong posture precipitate low back pain.
Deformity Causitive factor

• Pelvic tilt anterior • Weak abdominals
• Tight low back muscles
• Tight hip flexors
• Tight tensor fascia latae
• Weak hamstrings
• Posterior • Tightness and over development of low
back muscles
• Lateral • Scoliosis (structural and functional)
• Limb length discrepency
• Trunk flexion deformity • Cartilaginous locking in flexion to accom-
modate protusion.
Posture is a position or attitude of the body relative arrangement

of body parts for a specific activity.
Gravity places stress on the structures responsible for maintaining
the body in upright posture. Normally the gravity line goes through
the physiologic curves of the spinal column and they are balanced.
Postural Problems and Pain

1. When muscle fatigue the load is shifted to the inert tissues
supporting the spine at the end ranges with continuous load, creep
and distention occurs in the inert tissues causing mechanical stress.
2. Continuous stress to pain sensitive structures such as joint capsule,
blood vessels, ligaments, nerve endings which leads to pain. If the
mechanical stress exceed then breakdown of tissues will occur.
3. If the muscle guarding is prolonged, result prolonged muscle
contraction result buildup of metabolic waste products and reduced
irritation. This altered local environment leads to irritation of free
nerve endings. So the muscle forced to continue their contraction
result becomes source of additional pain.
Faulty posture strains ligaments will cause pain. If torn, there
will be hyper mobility of the segment. Once healing complicated
naturally adaptive shortening or scar formation leads to postural
alignment.
Repeated loading or twisting leads strain in lumbosacral fascia,
quadratus lumborum, erector spinae, and iliolumbar ligament.
Common site of injury is lumbar and iliac crest. Strain to upper
thoracic muscle and fascia is common with postural stresses such
Posture 33
as prolonged sitting in faulty posture. Emotional stresses increases

tension with the posterior cervical and lumbar region.
4. Postural fault is a posture that deviates from normal alignment. If
a person maintain prolonged period of faulty posture strength and
flexibility. Imbalance leads to postural pain syndrome. Good
postural habits are necessary to avoid postural pain syndromes. In
children, good postural habits are important to avoid abnormal
stresses on growing bones and adaptive changes in muscle and
soft tissues.
Lordotic Posture
Increase lumbar lordosis and increase anterior pelvic tilt and hip
flexion. This posture seen person with thoracic kyphosis and forward
head position.
Muscle Imbalance
Hip flexors, lumbar extensors.
Muscles Stretched
Stretching lead to weakness of abdominal muscles.
Source of Pain
Stress anterior longitudinal ligament, narrowing of posterior disc space
and narrowing of intervertebral forament.
Common Causes
Pregnancy, obesity, sustained faulty posture, weak abdominal muscles
and high heel shoes.
Relaxed Posture (Slouched)

This posture is also called sway back. Shifting of entire pelvic segment
anteriorly result hip extension, thoracic segment moves posteriorly,
result flexion of the thorax on the upper lumbar spine, this increases
lordosis in the lower lumbar region, increase kyphosis in lower thoracic
region.
Source of Pain
Stress to iliofemoral ligament, lower lumbar spine, posterior
longitudinal ligament, stress to iliotibial band and narrowing of
intervertebral foramen.
Muscle Imbalance
Tight upper abdominal muscles, hip extensors, lower lumbar extensor.
Muscle Stretched
Lower abdominal muscles and hip flexor muscles.
Causes
Muscle are not properly used for support and attitudinal.
Flat Low Back Posture

Characterized by decreased lumbosacral angle, decreased lumbar
lordosis, hip extension, posterior tilting of the pelvis.
Source of Pain
Umbar region, stress on posterior longitudinal ligament.
Muscle Imbalance
Trunk tight flexor and hip extensor
Stretches
Weak lumbar extensor and hip flexors
Causes
Flexing the trunk in sitting and standing and over dose of flexion
exercise.
Round Back or Increased Kyphosis

Increase thoracic curve, protracted scapulae.
Source of Pain
Stress in posterior longitudinal ligament, fatigue of erector spinae,
and thoracic outlet syndrome.
Muscle Imbalance
Tight intercostals muscles, muscles of upper extremities and originate

from thorax.
Muscle Stretched
Weak thoracic erector spinae and scapula retractor.
Posture 35
Causes
Flat low back posture, continued slouching and over dose of flexion
exercise.
Flat Upper Back

This posture decreases the thoracic curve, depressed scapulae,
depressed clavicle flat neck posture (military posture).
Source of Pain
Fatigue of muscles and compression of neurovascular bundle.
Muscle Imbalance
Tight thoracic erector spinae, scapular retractors, weakness of scapular
protraction and intercostals muscles.
Causes
Exaggerating the upright posture.
Scoliosis (Lateral Curvature)

Involves in thoracic and lumbar regions.
Source of Pain
Muscle fatigue and ligament strain on the side of the convexity, nerve
root irritation on the side of the cocavity.
Muscle Imbalance
Tight structure on the concave side of the curve, stretched and weak
structure on the convex side of the curve.
Causes
Hemivertebra, osteomalacia, rickets, asymmetry of hips, pelvis, lower
limbs, muscle guarding, spasm and habitual.
C HAPTER
5 Brachial Neuralgia
Greek words Brachium – Arm

Neuron – Nerve
Alcos – Pain
Pain radiating down the arm due to involvement of cervical spinal
cord, vertebral and shoulder or pain in the nerves, supply the various
parts of the arm.
Incidence: 25 to 40% > 45 years
Anatomy: 7 Cervical vertebra
Typical – 3 to 6
Atypical – 1, 2 and 7
Root → Trunk → Division → Cord → Branches
Brachial Plexus
Lateral Cord (LML)
1. Lateral pectoral nerve
2. Lateral root of median nerve
3. Musculocutaneous nerve
Medial Cord (4MU)
1. Medial root of median nerve
2. Medial pectoral nerve
3. Medial cutaneous nerve of arm
4. Medial cutaneous nerve of forearm
5. Ulnar nerve
Posterior Cord (SSLCR)
1. Upper subscapular nerve
2. Lower subscapular nerve
Brachial Neuralgia 37
3. Nerve to latissimus dorsi

4. Circumflex nerve
5. Radial nerve
Nerve to serratus anterior, nerve to rhomboids (Dorsal scapular
nerve)—arising from root.
Suprascapular nerve, nerve to subclavions—arising from trunks.
Rami, trunk lies above the clavicle. Division behind the clavicle
between scalneus anterior and medius. Cord and branch lies infra-
clavicular in the axilla.
CAUSES OF BRACHIAL NEURALGIA

A. Intra-spinal conditions (Irritation of intra-spinal origin of brachial
plexus)
1. Spinal tumours
2. Syringomyelia
3. Chronic arachnoiditis
4. Meningo radiculitis
5. Extradural tumours
B. Brachial plexus injuries
C. Thoracic inlet syndrome (stretching the plexus)
1. Cervical rib
2. Scalenus anticus syndrome
3. Pectoralis minor syndrome
4. Descend of shoulder girdle—postural
5. Costo clavicular syndrome
D. Brachial neuritis
E. Functional causes
1. Hysteria
2. Psychoneurosis
3. Malingering
F. Thoracic outlet syndrome
BRACHIAL NEURALGIA—CLINICAL CHARACTER

• Disease of cervical spinal cord
• Cervical intervertebral disc prolapse
• Cervical spondylosis
• Tumor of cervical vertebra, root, meninges, spinal cord
• Tuberculosis of cervical spine
• Fracture dislocation of cervical vertebra
• Infective brachial radiculitis

• Brachial plexus injuries
I. CERVICAL SPONDYLOSIS
Arthrosis or Degenerative changes in the intervertberal joints of the
cervical vertebra including facet joints of spine.
Common Sites
C4 – C5, C5 – C6, C6 – C7
Age
Above 30 years.
Pathology
1. Degeneration of disc begin in annulus fibrosis.
2. Collagen fibres becomes coarse.
3. Nucleus pulposus loses fluid becomes fibrous.
4. Nucleus gradually emerges with annulus.
5. Disc degeneration loses its height.
6. Osteophytes gives mechanical irritation.
Reduction of the heights leads narrowing of intervertebral foramen.
Capsular thickening causes pressure on the nerve roots.
Clinical Features
1. Pain posterior aspect of neck.
2. Pain in the arm, no pain in neck.
3. Pain present in the dermatome of involved nerve roots of the upper
limb.
4. Pain referred down to the thoracic area, medial border of scapula.
5. Muscle spasm of upper trapezius.
6. Coughing, sneezing, straining increases the discomfort in the arm.
Investigations
i. Radiology
1. Shows narrowing of joint space
2. Osteophytic changes
3. Narrowing of joint space posterior intervertebral joints.
ii. CT Scan
iii. MRI
II. CERVICAL DISC PROLAPSE

Lower cervical spine is a common site for acute brachial neuralgia.
Age
Between 20 – 55.
Sex
Male more prone than female.
Site
C5 – C6 and C6 – C7
Pathology
i. Disc protrusion: Secondary to trauma.
Bulge of nuclear fluid through weak annulus.
Sudden burst in the annulus causes nucleus to extrude.
ii. Disc extrusion: Split occurs in the annulus fibrosus and nucleus
is under tension.
Clinical Features
1. Neck is stiff, neck muscles in spasm.
2. Pain in neck during active and passive movements.
3. Tenderness over C5, C6 and C7 spinous process.
4. Range of motion limited.
5. Neck rigid, or slightly flexed towards the side of the lesion.
6. Abduction of shoulder, flexion and elbow relieve pain.
7. Pain worsens on coughing and sneezing.
8. Disc herniation causes sensory, motor, reflex changes.
Root Motor Sensation Reflex
C5 Levator scapulae, Upper scapula, lateral Biceps
rhomboids aspect of arm
C4 – C5 Suprasinatus infra-
spinatus deltoid
Contd...
Contd...
Root Motor Sensation Reflex
C5 – C6 Biceps Outer border of forearm, Brachio–
C6 Brachialis ] thumb, index finger radialis
C7 – C8
C7 ] Wrist flexion
Index,
Middle Triceps
Finger
Investigations
1. Narrowing of affected disc space with sclerosis of adjacent
vertebral border.
2. Anterior osteophytes formation forms after few attacks.
Diagnostic Methods
CT Scan Thermography
Myelography EMG Examination
MRI Discography
III. BRACHIAL PLEXUS LESION

Disability in the upper limb, arm pain is lone factor that contributes in
addition to the muscle paralysis and sensory loss.
Aetiology
1. Trauma and traction—Erb’s palsy, motor-cycle accidents.
2. Pressure during prolonged period—post-anaesthetic palsy.
3. Post-radiation fibrosis, electric shock.
4. Following surgery—removal of cervical rib.
5. Tumours.
6. Vascular lesion.
7. Inflammation.
Pathology
Two Types
1. Pre-ganglionic
2. Post-ganglionic
Pre-ganglionic lesion
Here the nerve root are avulsed out of the spinal cord.
Post-ganglionic lesion
a. Injury to the nerve roots distal to the posterior nerve root ganglion.
Two types of post-ganglionic lesion are:
1. Nerve roots, sheath are intact, axon disrupted
2. Nerve root intact rupture of nerve sheath.
b. Lesion involving upper trunk – Erb’s palsy (C5–C6)
c. Lesion involving lower trunk—Klumpke’s paralysis (C8–T1).
Character of Pre- and Post-ganglionic lesion

Pre-ganglionic Lesions
Causes
1. Collision accident—high speed head.
2. Loss of consciousness associated injuries, e.g. fractures, head
injuries.
Signs
1. Positive horner’s sign
Sympathetic nerve supply to the eyes as it merges at T1 root
causes ptosis, miosis, anhydrosis, loss of ciliospinal reflex.
2. Positive sensory action potential.
3. Meningocoele in myelogram.
4. Crushing pain even at rest.
5. High cervical scoliosis.
6. Paralysis of Dorsal scapular muscle and serratus anterior results
flail limbs.
Post-Ganglionic Lesions
History of slow speed trauma, person being thrown due to sudden
half of vehicle. No injuries and loss of consciousness.
Signs
1. No Horner’s sign.
2. Absence of sensory action potential.
3. Positive Tinel sign: Tapping along the course of nerve from distal
to proximal. Tingling is felt in distribution of nerves. There are
two sites of Tinel’s sign.
a. At the site of lesion.
b. At the point of regeneration.
Stronger distal sign indicates axonal regrowth at clinical recovery.
4. Complete lesion, all muscles of upper limb, excluding dorsal scapular
muscles and serratus anterior and paralysed.
Root Avulsion Injuries

Loss of sensory impulses to the spinal cord constant pain that is
central in origin is felt in the dermatome root.
Clinical Characters
1. Pain begins 2 to 3 weeks after injury.
2. Constant burning pain (arm is on fire) or arm is hit repeatedly
with hammer or sudden, sharp, electric shock like shooting pain,
high in few seconds and gradually comes as burning pain.
3. Pain 2 - 3 times per day.
4. During the time of intense pain, patient may stop talking, takes his
breath away grip his arm.
5. Difficulty of sleep.
6. Cold, illness, emotional stress, aggravating the pain.
Investigations
1. Electrodiagnostic Test
• Provide information to confirm denervation.
• Diagnose the nature of lesion, whether pre-ganglionic (avulsion)
or post-ganglionic.
2. Electromyography (EMG)
a. Presence of small fibrillation protentials or large fibrillation
potentials called sharp positive waves at rest indicate wallarian
denervation.
b. Needle EMG is appropriate in determining whether root avulsion
has occurred, e.g. limb muscle is denervated but erector spinae
at corresponding functioning normally indicate post-ganglionic
lesion.
c. Polyphasic unit indicates regeneration but clinical evidence takes

many weeks.
3. Sensory action potential (SAP)
Detection of either reduced or normal amplitude sensory action
potentials with absence of motor conduction, in a flail and
anaesthetic limb indicates that the nerve is in continuity with its
cell body with lesion being present proximal to the dorsal root
ganglion indicates avulsion of root (pre-ganglionic).
Negative sign indicates lesion to the dorsal root ganglion with
an intact root post-ganglionic.
4. Somatosensory evoked potentials
Provides information about the various pathways and conditions
of intraspinal roots. If root is avulsed, evoked potential will not be
obtained because of lack of central connection even though the
sensory peripheral nerve conduction may be normal.
Nerve Conduction Velocity

Normal conduction indicates intact conductivity.
When not measurable indicates the severance of nerve root fibers
with wallerian degeneration.
Both the techniques of motor and sensory nerve conduction
velocities should be done to distinguish root avulsion from distal
ruptures.
Myelogram
Myelography with radio-opaque dye will show “meningocele” in the
presence of root avulsion.
CT Scan and Magnetic Resonance Imaging

CT scan help to display any spinal fracture and its impact on the
spinal root.
MRI makes use of magnetic properties of atomic nuclei that
indicates any spinal cord lesions and root avulsion in a better way
(Fig. 5.1).
IV. THORACIC OUTLET SYNDROME (TOS)

Narrow upper end of thorax which is continuous with neck that is
sterno costo vertebral spaces.
Fig. 5.1: MRI
Boundries
Anterior : Upper border of Manubrium Sterni
Posterior : Superior surface of body of first vertebra
Laterally : First rib with its cartilage.
There are many important structures passing through the inlet namely,
• Trachea
• Esophagus
• Lung
• Thymus
• Arteries
• Nerves
Arteries
• Left common carotid artery
• Left subclavion artery
• Brachiocephalic artery and vein
Nerves
• Phrenic nerve
• Vagus nerve
• Sympathetic trunk
• C8 and T1 trunk of brachial plexus
The compression syndrome of upper thoracic outlet (inlet)
syndrome was first described by Thorburn in 1905. It is a neuro-
vascular compression syndrome comprises:
• Cervical rib
• Anterior scalene syndrome
• Costo clavicular syndrome
• Pectoralis minor syndrome
a. Cervical Rib
This is a congenital condition characterized by an extra rib arising
from seventh cervical vertebra. Commonly present in right side.
Types
Complete: Completely bony rib from C7 vertebra.
Bulbous end: Here anteriorly forms a bulbous end.
Tapering: Anteriorly fibrous and tapers.
Fibrous band: Transverse process of C7 vertebra is enlarged and
connected to first rib.
Pathology
Increased angulation causes stretching of brachial plexus over the
cervical rib or anterior scalene compress the nerve against the cervical
rib.
Subclavian artery arches over the cervical rib, stretched beyond
this point leads to stenosis. This becomes thrombus formation, later
this may emobolise causing digital gangrene.
Predisposing Factors
• Loss of tone in shoulder girdle muscles
• Traction due to carrying heavy weight
• Drooping of shoulder girdle after thoracoplasty
Clinical Features
• Pain, paresthesia—tingling sensation or numbness down medial
aspect of forearm and hand.
• Sensory anaesthesia over the lower trunk of brachial plexus.
• Muscle wasting in T1 distribution—small part of hand.

• Tendency to drop things.
• Inability to perform small repetitive finger movements like winding
a watch, buttons.
• Horner’s syndrome may be observed.
• Pain worse at night, pain increased by turning the head towards
the unaffected side and downward traction of shoulder.
• Tender of scalenus muscle.
b. Pectoralis Minor Syndrome

Muscle originate from 3rd, 4th, and 5th ribs inserted into the coracoid
process of scapula. Compression due to repetitive movements of the
arms above the head. Shoulder elevation and hyper-abduction.
c. Claviculo Costal Syndrome

Compression of neurovascular bundle beneath the clavicle at first rib
causes group of symptoms termed claviculo costal syndrome.
Predisposing Factors
Fatigue, anxiety, depression, poor posture-drooping of heat at shoulder
causes reduce space between clavicle and first rib causing compression
of structures.
In middle aged women, medial side of clavicle is lower than men.
So reduce the clavicle and first rib space reduced.
Scapula ptosis is greater in female with large breast due to
attchment of pectoralis major muscles.
d. Anterior Scalenus Syndrome

Muscles originate from transverse process of C3 to C6 vertebra, insert
in upper surface of the first rib. Brachial plexus and subclavian artery
passes over the first rib, posterior to scalenus anterior.
Strenuous physical activity, anxiety, tension, hyper-extension,
injuries causes spasm of the muscles. Deep breathing in turning the
head compressing the bundle.
Clinical Features
• Numbness, tingling sensation in forearm, hand and digits.
• Pin and needles of heads and fingers.
• Weakness of hand muscles.

• Sleep disturbed due to pain.
• Dull deep vague aching type pain.
e. Neurological Amyotrophy (Brachial Neuritis or

Parsonage—Turner Syndrome)
Condition characterized by severe pain in the shoulder and neck followed
by weakness of upper limb muscles.
Aetiology
1. Viral infection—Cytomegalovirus
2. Serum sickness or inoculation with tetanus toxoid
3. Interavenous injection
Clinical Features
• Sudden onset of severe pain followed by muscle weakness
• Muscle wasting like supraspinatus, deltoid, serratus anterior,
trapezius, triceps, biceps, diaphragmatic muscles, forearm
muscles, especially flexor pollicis longus weakness.
• Sensory loss over deltoid, radial aspect
• Reflex loss in biceps, triceps
• Arm is maintained in flexion and adduction at shoulder to minimize
traction in brachial plexus.
Investigation
• Viral titres positive.
• CSF shows mild protein rise and pleocytosis.
• Electrophysiological studies shows involvement in upper limb
nerves.
• Nerve conduction studies shows slowing the conduction of the
affected nerves after 7 to 10 days.
• EMG shows fibrillation and positive sharp waves.
Prognosis
• Pain stop in few days to 3 weeks
• Motor function is good
• Full recovery achieved only 2 to 3 years.
V. BRACHIAL NEURALGIA ASSESSMENT

Subjective Examination
Name, Age, Sex, Diagnosis.
Chief Complaints: Foremost difficulties and disabilities.
Behaviour of Symptoms
• When the pain started.
• Type of pain.
• State of pain.
• Radiating or localized.
• Constant or intermittent.
• Any predisposing injury
• Aggravating and relieving factors
Pain Assessment Scales

I. Visual Analogue Scale
Patient is asked to record the severity on a 10 centimeter line with
anchors of “no pain” and worse pain at either ends.
0 1 2 3 4 5 6 7 8 9 10
No Severe
pain pain
Record each session before and after the treatment.
Note: Always open ended structured question to rule out nature of
pain.
II. Simple Descriptive Scale
Verbal Scale
Ask the patient to pick a word that reflect the intensity of the pain
from a list of words or words spaced along horizontal or vertical line.
No pain Mild Moderate Severe Very Worst

severe pain
III. Numerical Scale
Patient has to pick a number from 0 to 10 that represents his pain.
0 means no pain and 10 means worst pain.
0 1 2 3 4 5 6 7 8 9 10
No pain Moderate Worst pain
IV. Submaximal Effort Tourniquet Test

Blood pressure cuff over the arm, inflate the cuff, ask the patient to
rhythmically clench and unclench grip his hand. As the hand becomes
progressively ischemic, ask him to match this ischemic pain to actual
pain felt.
V. Somatic Differential Scale
MC GILL Pain Questionnaire
Word lists and categories that represent various aspect of pain
experience. Give the list to the patient, ask to select from these lists,
words that best describe his present experience of part.
VI. Spatial Distribution of Pain Exam
Give body diagram for marking the location and nature of pain intensity.
Ask to mark the type, location and nature of pain.
M → shooting pain, → pin and needle → sharp pain.
Objective Examination
Observation
1. Posture
Sitting and standing. Observe any deviation in the neck, drooping
shoulder.
2. Attitude of Limb
Position in arm is held whether abducted or adducted.
3. Soft Tissue Analysis
Skin condition: Colour change, scar.
Swelling: Digits, forearm, arm.
Erythema: Cervical, upper limb.
4. Muscle Bulk
Check wasting of arm, forearm, hand.
5. Check whether patient is left or right handed
Present Medical History Need to Consider

• Onset of symptoms
• X-ray, CT scan, MRI, Discography, EMG
• Earlier attack
• Treatment modality use.
Past Medical History

Hobbies and habits like smoking, alcoholic, knittry, sewing, forceful
game. Number of pillows uses while sleeping.
On Examination
Measure Range of Motion
Movements Range
Flexion 0 - 45 Degree
Cervical Extension 0 - 45 Degree
Lateral flexion 0 - 40 Degree
Rotation 0 - 45 Degree
Flexion 0 - 90 Degree
Extension 0 - 45 Degree
Abduction 0 - 180 Degree
Adduction
Shoulder Internal 0 - 70 Degree
Rotation
External 0 - 90 Degree
Rotation
Manual Muscle Testing

Based on MRC Grading
• Neck flexors, lateral flexors, extension
• Deltoid
• Biceps
• Wrist extensors and flexors
• Finger and thumb.
Palpation
Warmth
Check temperature by dorsum of the examiner hand and compare the
normal side.
Muscle Spasm
Protective muscle spasm of neck muscles and upper limb.
Skin Moisture
Tenderness
Over the bone, ligament, muscles and tendon.
Sensory Deficit
Parathesia, hyperthesia and anaesthesia.
Reflexes
Biceps Jerk (C5)
Arm is relaxed, slightly flexed, palpate the biceps tendon with thumb
and strike with tendon hammer.
Response: Elbow flexion and biceps contraction.
Brachioradialis Jerk (C6)
Strike lower end of radialis.
Response: Elbow and finger flexion.
Triceps Jerk (C7):
Strike few inches above the olecranon process.
Response: Elbow extension and triceps contraction.
Grading of Reflexes
O - Absent
1+ - Tone is slightly changed. transient with no movement of
extremities
2+ - Visible movement of extremities
3+ - Exaggerated reflex with full movement of extremities
4+ - Oscillatory and sustained movement which lasts for more

than 30 seconds also known as clonus.
Sensations
Mark on body chart for numbness and tingling. Exact site and location
of radiating pain. Touch sensation by scratching by pin and cotton
wool.
Special Test
Spurling Neck Compression Test
Patient is seated; head laterally flexed and rotated to the side of the
pain, axial compression is exerted downward upon the head. This
test reproduces the symptoms.
This test closes the foramina on the side towards which pain is
felt. Downward compression further closes the foramen and compress
the disc thus increasing its protrusion and increases the impingement
of the osteophytes up in the nerve roots.
Axial Manual Traction or Distraction Test
Traction manually disappears or diminishes the symptoms result is
positive indicates nerve root compression. Patient should be in the
sitting position.
Arm Abduction Test
Patient in sitting position, elevate the affected arm and apply traction
to it. Relief of radiating pain indicates brachial plexus etiology.
Adson or Scalene Maneuver
Patient in sitting position, examiner locate the radial pulse. Patient
rotates either head towards the tested arm and less the head tilt
backwards or extend the neck while examiner extends the patient
arm.
Result: Disappearance of pulse indicates positive test of Thoracic
Outlet Syndrome etiology.
Allen Test
Patient sitting position, examiner flexes the patient elbow to 90 degree
while shoulder is extended horizontally and laterally rotated.
Patient is asked to turn their head away from the tested arm.
Radial pulse is palpated and if it is disappeared as the patient’s head is
rotated to the test is considered as positive.
Hanch-UP or East Test
Patient brings their arms up with elbows slightly behind the head.
Now patient opens and closes their hands slowly for 3 minutes.
Result: Positive test indicated by pain, heaviness or arm weakness
numbness and tingling of head.
Costo-Clavicular Maneuver
Patient in sitting position, examiner located the radial pulse and draws
the patient’s shoulder down and back as the patient lifts their chest in
exaggerated “Attention” posture. Positive test indicated by absence
of pulse complain symptoms.
Provocative Elevation Test
Patient in sitting position, performed on patient who already present
with the symptoms. Patient is seated. Patient has to cross the upper
limb with flexed elbow in front of the chest. Passively shoulders are
elevated forward and into full elevation. Maintain their position for 30
seconds or more. Increased pulse, skin colour change increased hand
temperature, signs of numbness by pin and needles.
Assessment for Brachial Plexus Lesions
Same general assessment as early. In addition to that include the
following:
Subjective
Mechanism of Injury
According to Frampton it is divided into 2 types:
High speed, large impact injuries—preganglionic plexus injury, e.g.
RTA.
Low speed, small impact injuries—postganglionic plexus injury,
e.g. roll down a staircase.
Objective
Observation in front, side and behind.
Muscle Atrophy
• Upper Quarter
• Wing of Scapula
• Supraspinatus
• Infraspinatus
• Deltoid
Side View—Forward
• Head posture
• Kyphosis
• Protrusion
• Elevation of scapula
Front
• Attitude of Limb
• Constriction of Pupils (or) Ptosis (indicates Horner’s syndrome).
Passive Range of Motion Test

Assess all the joint in upper limb. Note contraction of:
Shoulder – Elevation, abduction, external rotation
Elbow – Extension
Forearm – Supination
Wrist – Flexion or Extension
Metacarpophalangeal – Flexion
Interphalangeal – Extension
Motor Strength Evaluation

Manual muscle testing based on MRC helps in pinpointing the extend
of lesion.
Sensation
Assists in diagnosis of level of plexus lesion. Total evulsion results in
anaesthesia. Check for:
• Sensation of light touch
• Temperature
• Deep pressure
• Sterognosis
• Two point discremination
Co-ordination
Loss of sensation and muscle power in the presence of plexus lesion
result loss of gross and fine motor co-ordination in the affected upper
extremity.
Vascular Status
Vasomotor changes like dry or cold skin should be checked. Check
radial or carotid pulse.
Oedema
Assisted by manual palpation. Oedema can be measured by using
volumeters and circumferential measurements. Oedema should be
reduced to prevent stiffness in the joints.
VI. TREATMENT OF CERVICAL CONDITIONS

(Modalities to reduce pain)
TRACTION
Traction is the process of “Drawing or Pulling”. When used to draw
or pull in spinal column called spinal traction.
Effects and Uses
• Decrease cervical lordosis
• Open the intervertebral foramina
• Reduce the protective muscular spasm of cervical musculature.
• Relieve the never root compression
• Nullifies the effect of gravity
• Prevent adhesion in dural sleeves joint capsule
• Increase circulation in epidural space and nerve roots
• Reduce the joint derangement and inflammatory response
• Allowing synovial fluid exchange to nourish the cartilage
• Decreases the degenerative changes of joint
• Increases proprioceptive discharge from facet joint structure
provides decrease pain perception.
Indication of Traction
• Degenerative disc or joint lesions, e.g. spondylosis, spondylo-
listhesis.
• Joint dysfunctions, e.g. spinal mobility and muscle spasm.

• Low back pain, e.g. sciatica.
Contraindications
• Osteomyelitis
• Joint instability
• Osteoporosis
• Acute stage of joint sprain
• Pregnancy
• Recent abdominal or pelvic surgery
• Claustophobic patient
• Peripheral vascular disease patient.
Mode of Traction Application
• Manual
• Mechanical
MANUAL PROCEDURE
Patient supine on treatment table. Therapist standing at the head of
the treatment table supporting the weight of the patient head in the
hands.
Therapist applies traction to the neck by holding the patient head
between the two hands.
Duration and force applied is determined by response of the patient
and the ability of the therapist technique.
Place the fingers of both hands under the occiput. Place one hand
over frontal region and other hand under the occiput.
Place the index finger around the spinous process above the
vertebral level to be moved. This gives specific traction only to the
vertebral segment below the level at which the fingers are placed.
A treatment belt around the therapist’s hips can be used to reinforce
the fingers and increase the ease of applying the traction force.
Angle of Pull in Manual Traction

20 degree of flexion. Angle of pull and head position can be controlled
by therapist.
Uses
Before initiating mechanical traction, manual traction will give guidelines
above the tolerance and benefit gained of this modalities.
Indication for Manual Traction

• Neck stiffness
• Disc problems.
MECHANICAL TRACTION - TECHNIQUE

Cervical Traction (Fig. 5.2)
Angle of Pull
0–15 degree flexion for upper cervical spine. Angle should be increased
by 5 degree for each progressive lower cervical segment.
Fig. 5.2: Cervical traction - sitting
Position of Spine
Cervical spine neutral or extended position to effect anterior
intervertebral structure.
Cervical spine flexed, forward bend position to effect posterior
intervertebral structure.
Weight or Resistance
1/10 to 1/8 of the patient body weight. In cervical initially 10 to 15 lbs
and increased to 30 lbs. Higher force lesser duration or lower force
longer duration.
Duration of Cervical Traction
Acute Disc Hernia—static or sustained traction for 20–25minutes, 3
to 6 times daily.
Chronic Stage—intermittent traction for 15–20 minutes, 3 times a

week.
Procedure
• Can be applied in supine position in traction table
• Alternately can be applied in sitting position
• Apply head halter to fit the patient comfortably
• Major traction force must be against the occiput and not the chin
• Attach halter to the spreader bar
• Set controls
• Activate the unit.
Physical Agents
1. To control inflammation
2. To control pain and muscle spasm
3. To control stiffness of soft tissues and joints
4. To assist mobility
5. To increase blood supply and relieve ischemia
A. Superficial heating modalities
i Hot packs
ii Hydrocollateral Pad
iii Infrared radiation
B. Deep heating modalities
i. Short wave diathermy
ii. Microwave diathermy
iii. Ultrasound
C. Cryotherapy
i. Ice massage
ii. Ice towel
ii. Ice packs
D. Interferential current
E. Transcutaneous electrical nerve stimulation
Note: Check contraindication of all physical Agents.
A. Superficial Thermotherapy
Hot Packs – Pad
Heating pad, hot water bottle or electrical pad are effective to reduce
pain. Heating pad applied within lying or half lying position with neck
supported can reduce muscle spasm, increase circulation and remove
metabolites.
Duration: 10 to 20 minutes, twice a day during acute pain.
Hydro Collateral Pad

A canvas pack filled with silica gel which is heated by immersing in
water between 165–170°F.
Duration: 20 to 30 minutes.
Infrared Radiation
Wavelength is 760 to 1 nm. Depth of heat penetration will be 1–3 nm.
Distance between the treatment part and lamp should be 18 to 20
inches. So the ray strikes to 90 degree.
Turn on lamp and allow 5 to 10 minutes for warm up. Place
reflector at right angles to surface area.
DEEP HEATING MODALITIES

Short Wave Diathermy (27.12 MHz)
It is an alternating current with a frequency of oscillations of a million
or more per seconds produces heat below the skin surface.
1. Machine should be in good condition before use. Place the hand in
between the electrodes. Switch on the machine, increase current
until comfortable warmth is felt.
2. Patient is supine lying, neck and arm supported. Area should be
dry, clothing is normal, metal object and damp must be removed,
skin sensation tested before the first treatment.
3. One electrode is placed over the neck affected side and other
electrode at affected region of upper limb.
4. Leads should be in correct length. Leads must be separated from
patient skin by distance as great as the electrode spacing.
5. Current is turned on, circuit turned, patient has to appreciate the
heat. End of treatment, returned to zero, switched off and electrode
removed.
6. Skin may be fairly pink and should be no strong reactions.
Dosage
Acute herniations : 10 to 15 minutes
Chronic herniations : 15 to 20 minutes
Position of Electrodes
Radiating pain : Coplanar
No radiating pain : Monoplanar
Use of Short Wave Diathermy
Pain relief by counter irritation, increases circulation, removes
metabolites.
Dangers of Short Wave Diathermy
Burns, scalds, overdose, precipitation of gangrene, electric shock,
sparking, faintness and giddiness.
Contra-indications of Short Wave Diathermy
Haemorrhage, deep vein thrombosis or phlebitis, arterial diseases, metal
in the tissues, disturbed skin sensations and tumors.
Microwave Diathermy
High frequency electromagnetic energy applied through a direct
frequency of 2450 Hz.
• Treatment applicator should be centered over treatment area.
• Treatment area exposed to allow for perspiration.
• Turn intensity to desired level similar to short wave diathermy.
• Treatment intensity: Patient should experience comfortable mild
heat.
• Treatment time: 20 to 30 minutes.
Indications and contra-indications are similar to short wave
diathermy.
Ultrasound Therapy
High frequency acoustical energy frequency ranges 0.8 to 3 MHz.
Direct contact (moving technique) moving head in contact with
relatively flat body surface.
• Apply generous amount of coupling agent to skin
• Ultrasound requires homogenous medium (mineral oil, water,
commercial gel) for effective transmission.
• Place sound head at right angle to skin surface.
• Move sound head slowly. 1.5 inches per second in overlapping

circles or longitudinal strokes maintaining sound head to body
surface angles.
• Each motion covering one half of previous circle or stroke.
• Do not cover an area greater than two to three times the size of
the effective radiating area per five minutes of treatment.
• While sound head is moving and in firm contact, turn up intensity
to desired level.
• Treatment intensity: 0.3 to 1.5 W/cm2. Lower intensity for acute
conditions and higher intensity for chronic conditions or thick
tissues (low back).
• Periosteal pain occurring during treatment due to high intensity,
momentary slowing or cessation of moving head is adviced.
• Treatment time: 3 to 10 minutes.
Contra-indications
Acute inflammatory joint pathologies, healing fractures, thrombo-
phlebitis. No ultrasound applied over brain, ear, epiphysis of growing
bone, eye, heart, cervical ganglia, carotid sinuses, reproductive organ,
spinal cord, over cardiac pacemaker, pregnant uterus.
Precautions
Metal implants in field, osteoporosis, plastic implants, primary repair
of tendon or ligament or scar tissues.
Phonophorosis
Use of ultrasound to drive medications through the skin in to the
deeper tissues. Local analgesics (lidocaine) and anti-inflammatory
drugs (dexamethasone, salicylates) are often used. Medicinal agents
is used and or is part of coupling medium.
Treatment intensity: 1-2 W/cm2
Treatment time: 5 to 10 minutes
Low intensity and longer time are more effective in introducing
medication in to skin.
Indication: Subacute and chronic musclo-skeletal conditions.
Contra-indications: See general information above.
CRYOTHERAPY
Ice Cube Massage
Large block of ice, e.g. water frozen in a Yoghurt Pot, one end wrapped
in towel, the other end left free. The neck and arm is exposed and
supported.
Application: Massage in circular manner over the pain area with
minimal pressure.
Duration: 10 minutes.
ICE Towel
Two terry towel are immersed with ice solutions filled in buckets or
large bowl of crushed ice. Apply to the neck and arm over the affected
dermatome.
ICE Packs
Crushed ice is placed inside a specially made terry towel bag or towel
fold. Apply over neck and painful region in the upper limb.
(Note: To prevent ice burns vegetable oil or nut oil is spread over the
skin on which the ice pack is to be placed).
INTERFERENTIAL THERAPY
Two medium frequency current are used to produce a low frequency
effect.
Procedure
Arm lean sitting position with forehead and face supported on a pillow
or side lying position on unaffected side. Skin is washed, skin lesion
is protected by petroleum jelly. Conduction jelly are applied over the
rubber electrode and vacuum pads are used. One pair of electrode
placed over the neck on site of pain. Another pair should be positioned
in the arm.
Dosage
Frequency: 80 to 100 MHz rhythmic mode is used to reduce pain.
Intensity turned up till to get tingling sensation.
Therapeutic Massage
Deep sedative massage like effleurage, circular kneading, friction to
localized area of pain to reduce spasm and pain. Kneading helps to
reduce tightness in upper fibers of trapezius. Finger kneading to
trapezius muscles and transverse process of vertebra.
Mobilization
It helps to elongate the ligamentous capsule and muscular restrains. It
helps to reduce the nerve root irritation. It helps normal physiological
motion. Relaxed passive movements of head and neck in lying position.
Assisted exercises for head and neck and shoulder girdle.
Stabilization Exercises
Sitting or standing self resisted isometric exercises in all movements
of flexion, extension, side bending, and rotation.
Strengthening Exercises of Neck
Prone lying or prone kneeling and progress to sitting. Prone lying—
chin lift, adduct scapulae.
Free Exercises
To all movements.
Proprioceptive Neuromuscular Facilitation

Hold and relax techniques are used to lengthen the upper fibers of
trapezius. Holding the head steady and applying hold–relax to gain
shoulder girdle depression. Depression and elevation of scapula with
rotation around the chest wall. Similarly, hold–relax can be applied to
lengthen the muscles especially the side flexors and upper cervical
spine extensors.
Shoulder Girdle Muscle Exercises

Sitting, standing should be encouraged. For retractors of scapula,
bend sitting, elbow pulling backward, shoulder bracing and manual
resistance can be applied by the therapist at posterior aspect of elbow.
Surgical Management
Indication of Surgery
1. Significant neurological compromise in the form of progressive
muscle weakness in the upper limb or numbness or paraesthesia
resulting in functional disability.
2. Progressive increase of pain despite conservative management
for 6 weeks.
3. If pain is severe and unremitting surgery is indicated prior to 6
weeks.
Operative procedures are anterior approach, posterior approach,
spinal fusion. The main difference is for period of immobilization and
mobilizing procedure to cervical spine.
Anterior Approach
Post-operative cervical collar to be given for 2 to 3 weeks after which
mobilization of cervical spine is begins.
Posterior Approach
Minerva jacket, posterior collar is provided for 4 to 6 weeks.
Spinal Fusion
Minerva jacket for 3 months.
Post-Operative Physiotherapy Management

Aims
1. To keep the chest clear and expanding fully
2. To maintain the muscle strength of upper and lower limbs and
trunk
3. To maintain nerve root mobility
4. To restore posture
5. To teach back care
Means
1. Diaphragmatic Breathing Exercises
Patient in crook lying, place hand on diaphragm in costal angle,
ask patient to push away hand while breathing in and pull in while
breathing out. In supine or crook lying, control breathing exercise
should be done.
2. General Exercise
For upper limb, lower limb and trunk.
3. Rolling Mobilization
More lower limb and hip joint than shoulder.
4. Bed Mobility
Patient is turned on to pain-free side, slides his hip over the side of
the bed and comes to the sitting, pushing up with both arms while
the legs go down with gravity. The arms are supported with the
back in sitting position.
• This will help to overcome the initial dizziness.
• Patient is made to stand using support.
• Re-education of the balance with arm support should be
practiced.
• Isometric neck exercise should be begun.
• Walking training is progressed.
• Gradual mobilization of cervical spine is begun.
– After 3 weeks in anterior approach.
– After 6 weeks in posterior approach.
– After 12 weeks in spinal fusion.
The muscle power of the neck musculature is built by isometric
exercise and resisted exercises.
• Postural re-education:
Correct position of head is taught in front of mirror. Forward
head, rounded upper back postures to be corrected.
• Ergonomic advice:
Correct anatomical positioning of body part during sitting in a
chair, working in desk, standing at work place to be taught.
• Proper relaxation of structure.
• Functional re-education activities to achieve early return to
job. Patient can return to work by 4 to 5 weeks.
• Patient doing heavy work can return to work after 8 to 12
weeks.
(Note: Patient need to consult physiotherapy professionals to carryout
the above said advice to prevent further problems and the betterment
of their health improvement)
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

(TENS)
TENS is the application of pulsed rectangular wave current via surface
electrodes on the patient skin.
• Pain modulations through activation of central inhibition of pain
transmission (Gate Control Theory)
• Presynaptic inhibition of T-cells closes the gate and modulates the
pain.
• Pain modulation through descending pathways generating
endogenous opiates. Noxious stimuli generate endorphin production
from the pituitary glands. Exogenous opiate rich nuclei,
periaqueductal gray matter in the mid-brain and thalamus are also
activated by strong stimuli.
• Asymmetrical biphasic with a zero net direct current component.
Also pulsed monophasic current have been used.
• Modulation: Continuous or burst.
Electrode Placement
Dermatome distribution of involved nerve, over painful site, proximal
or distal to pain site, segmentally related myotomes or trigger points.
Indications: Acute and chronic pain.
Contra-indications: Patient with demand type, pacemaker or over
chest of patient with cardiac disease, mucosal membranes, over eyes,
laryngeal or pharyngeal, head and neck following (CVA), epilepsy.
TENS Parameter
Electrode placement – Crossed pattern
Position of electrode – Paravertebral region (cervical)
Treatment session – 30 minutes daily 7 days.
Intensity – 0 to 60 milliseconds
Frequency – 150 Hz.
Pulse Shape (Rectangle)
Pulse width is measured in microseconds and is often fixed at
100 ms. Other units can vary the pulse width from 50 ms through to
300 ms.
Frequency can be as low as 2 Hz or as high as 600 Hz. A frequency
of 150 Hz is commonly used.
Intensity can be varied from 0 to 60 milliamps on many units. The

patient or physiotherapist can control the intensity and a tingling
sensation should be felt.
TREATMENT FOR BRACHIAL PLEXUS INJURIES

Treatment is divided into three stages as:
• Early Stage
• Middle Stage
• Late Stage
Early Stage
1. To control pain
2. To prevent complication in anaesthetic limb
3. To maintain full mobility
4. To aid in functional recovery—splinting.
Pain control
The avulsion lesion of the plexus is most distressing.
Drug Therapy
Dislatgesic and codeine derivatives.
Physiotherapy
TENS with Pulse Rectangular wave.
Frequency : 50 to 100 Hz.
Pulse : 100 ms to 30 ms.
Intensity : up to 30 mA.
Electrode placement : Over proximal to the site of anaesthesia, over
the area in sensory input, nerve trunk one electrode.
For Total Lesion (TENS)
Electrode: Inner side of the upper arm over T2 (usually spared).
Another electrode over the neck or shoulder over C2, C3 and C4
dermatome C5 - C6. Electrode can be placed over the upper arm.
Duration of TENS
Patient is encouraged to wear the stimulator the whole day. Minimum
duration is 8 hours a day for 3 weeks.
Effect
Stimulation of large diameter afferent fibers at the level of the spinal
cord inhibits the release of impulses from the dorsal horn neurons.
TENS is contraindicated in infants.
Surgical Management
To Relieve Pain
• Cordotomy
• Rhizotomy
• Sympathectomy
Maintenance of Full Mobility of Soft Tissues
Limb hang in medially rotated position, head of humerus subluxated,
elbow is extended, forearm pronated, hand becomes blue and swollen.
Passive movement should begun twice a day and encouraged
compensatory movement.
Aiding Functional Recovery of Splinting
Fitting of flail arm. It comprises shoulder support, elbow locking
device, wrist support, forearm platform and standard appliances like
split hook, universal tool holder, C-grip are attached. Patient adjust
the elbow lock himself while appliances are operated by standard
cable harness, controlled by contralateral shoulder (like Amputee).
Middle Stage Management

After 3 weeks the extend of lesion should be reassessed to establish
the prognosis. In avulsion injuries, prognosis is very poor and in post-
ganglionic lesion, the prognosis is good.
If evidence of reinnervation present exercise to focus re-education
of the movement and muscles.
• Electrical stimulation to functional muscles
• Weak movement repeated—assisted and resisted
• Hydrotherapy techniques—increase range of motion, progressive,
resisted exercises in water
• Stimulating techniques—brushing and icing
• PNF techniques in functional diagonal patterns
• Functional activities of affected limb
• If pain present, TENS should be given.
Late Stage Treatment

Re-assessment is necessary. Two years most recovery would have
taken. If no improvement, consider other option surgery.
Indication of Surgery
Tropic ulcers, infection develops.
Procedure
Amputation of limb.
Arthrodesis of shoulder after fitting with prosthesis.
For Residual Paralysis
Reconstructive surgical procedures depends upon the extend of nerve
trunk/root involvement. For example in C5–C6 lesions with hand
function spread is improved by arthrodesis of shoulder.
Trapezius transfer to neck of humerus provide a range of
abduction. Elbow function improved by transfer of latissimus dorsi,
or pectoralis major in external rotation. Osteotomy to biceps or by
Steindler’s flexoplasty, i.e. advancing the origins of the extensors and
flexors of the forearm up the humerus. Wrist and fingers extension is
achieved by muscle transplants.
1. Pronator teres to extensor carpi radialis brevis
2. Flexor carpi ulnaris to extensor digitorum, flexor digitorum
superficialis to extensor carpi radialis brevis
3. Flexor carpi ulnaris to extensor digitorum
4. Flexor digitorum superficialis to extensor digitorum, extensor
pollicis longus.
5. Palmaris longus to abductor pollicis longus.
MANAGEMENT OF THORACIC OUTLET SYNDROME (TOS)

The treatment focus to facilitate more balance in the shoulder girdle
to affect lower trunk brachial plexus off the first rib or reduce pressure
from the pectoralis minor over the nerves.
Physiotherapy Aims
• Control symptoms
• Restore the normal length of muscles
• Restore muscle balance
• Improve posture
• Development of stress management
• Prevent recurrence of symptoms
Control Symptoms
Modalities like heating pad, cryotherapy, ultrasound, IFT, SWD,
temporary pain relief.
Careful positioning of upper extremity neither compressed nor
stretched the brachial plexus.
Position to be Followed
Sitting
• Scapula abduction and elevation
• Shoulder internal rotation and adducted
• Forearm pronation
• Wrist mild extension, finger mild flexion
Position to be maintained for long periods.
Supine Position
Pillows are used in triangular foam wedge used to support thoracic
spine, scapula and arm.
Upper Limb
• Shoulder adduction
• Elbow flexion
• Forearm and hand rest on the body
Affected arm supported and neutral in position to prevent neutral
pain.
Restore the Normal Length of Muscles
Shortened tissues may either compress or prevent normal movement
of the brachial plexus. Pain reducing modalities used to lengthen the
inflammatory response. Self stretching programme of every 2 to 4
hours with 5 to 10 repetition.
• Self stretching performed from a position of rest to point of strain
or pain.
• Stretch levator scapula, pectoralis major and pectoralis minor and
all neck muscles.
• Stretch the back or neck muscles. Head turn away from the pain
side. Hand behind head help to stabilize. Take deep inspiration,
exhale slowly.
• Sit down in hard chair to stretch back muscles of neck.
• Turn the head away from the tight side, look down until a slight
stretch is felt. Reach down with the hand on the tight side and
hold on to the chair with the other hand pull the head forward
gently.
• Stretching the chest: Stand facing the corner of the doorway with
arm “U” or “V” against the wall with knee bend lean slightly forward
from the ankles.
• Stretching the side of the neck.
Stretching the Shoulder
• Sit in a chair next to table slide the arm forward while bending at
the waist as far as possible without pain. Head should be in level
with the side of the table.
• Stand with back to the table and grasp the edge with the fingers
facing forward.
• Bend the knees and lower the body allowing the elbow to bend, let
the knees do the work, sit firm. Hand of the tight side grasping the
edge, lean away slowly.
Restore Muscle Balance
Imbalance in shoulder girdle with tight anterior and medial structures
and weakness in posterior and lateral structures.
Strengthen: Scapula retractors—rhomboidus, middle trapezius
Scapula elevators—levator scapula, upper trapezius
Upward rotators—upper trapezius, serratus anterior
Shoulder—deltoid (posterior), infraspinatus, teres minor.
Scapula Retractors (Strengthening)
• Prone lying, edge of the couch: Hang their limb with extended
hold weight or resistance while lifting adduct the scapula.
• Ask the patient to grasp the hand together behind the low back,
initiate adduction of scapula.
Shoulder Elevators
• Sitting or standing: Weight in the hands, neck retracted, shoulder
elevated slowly against resistance to pull elevation.
• Use water filled bucket for alternative method.
Shoulder Upward Rotators
Movements combined with humeral elevation. Patient lying in prone
or sitting shoulder abduction (90 degrees) and elbow (90 degrees)
then contract rotation laterally and medially.
Cervical Muscle Strengthening
Cervical Movement—Flexion
Place both hand on forehead and press it like nodding fashion, but
does not allow motion.
Side Bending
Press one hand against the side of the head and attempt to side bend
trying to bring the ear towards the shoulder not allowing movement.
Axial Extension
Mobilization Technique
• Shoulder girdle depression,
• Shoulder abduction, external rotation,
• Elbow extension,
• Wrist extension,
• Contralateral cervical side flexion
If discomfort start back to rest position. If improvement shows
by no restriction or discomfort during movement add more abduction
and external rotation range and wrist extension and contralateral
cervical side flexion added to produce further stretch.
Brachial Plexus Stretch in Lying/Standing
Supine lying: Using wrist extension, shoulder abduction 90 degree
external rotation.
Standing: Leaning in to the corner of the wall stretch like “U” or “V”.
Improvement of Posture
Defect: Shoulder protraction
Dorsal kyphosis
Dropping shoulder
Lower cervical flexion
Forward head posture.
Relaxation Methods
Body in horizontal position reducing muscle tension. In lying contract
the shoulder girdle and neck extensors, upper thoracic region, using
contract and reciprocal methods. Massage trapezius and surrounding
muscles.
Posture Correction
Avoid forward position of the head hold the shoulder in level.
• Taught to keep his shoulder very slight shrugged most of the
time, i.e. to maintain postural tone in trapezius.
• Use cervical collar to relieve muscular tension and treatment
becomes effective.
• Retraction neck exercise to improve posture.
• Use figure of eight harness strap to pull the shoulder back out of
their forward rounded shoulder posture.
Diaphragmatic Breathing
Secondary respiratory muscles like scalene and sternocleidomastoid
hypertrophies in cases of patient working with hands above chest
level. This causes gradual weakness of diaphragm and altered
pulmonary ventilation. So concentrate diaphragmatic breathing by
abdominal breathing exercises.
Method
Patient crook lying, one hand on the chest and the thumb of the other
hand just below the navel. During inhalation, abdomen protrudes.
Instructs the patient to exhale through pursed lip while manually
assisting the abdomen to draw inward.
Abdominal Weight Exercises

5 to 10 minutes, 2 times daily. Abdominal weight exercises carried
out with foot of the bed raised approximately 16 inches and use of a
one pound weight on the abdominal muscles. Patient position is in
supine.
Prevent Recurrence of Symptoms

1. Relaxation methods to be followed
2. Emotional depression to be treated by means of medication or
yogic practice
3. Maintain correct posture
4. Weight reduction when the patient obese
5. Avoid wearing heavy coats, down coats are preferable
6. Avoid carrying heavy weights
7. Use arm chair while sitting
8. Lying painful arm should be supported in the neutral position by
pillows
9. Scrutinize the daily activities and working conditions and make
appropriate adjustments.
Surgical Treatment of TOS

Indication
1. Progressive signs of muscle wasting
2. Intermittent paraesthesia replaced by sensory loss
3. Incapacitating pain.
Techniques
1. Extra periosteal resection of cervical rib
2. Anterior scalenotomy or depression of scalene muscles
3. Resetting of first rib
4. Removal of clavicle
5. Severing of pectoralis minor muscles
Post-Operative Management
Aims
1. Keep the chest clear and expanding fully
2. Maintenance of full range of motion of shoulder girdle and upper
limb joints
3. Strengthening muscles of shoulder girdle and upper limb joints
4. Posture correction
5. Ergonomic advise
Means
1. Breathing exercises as taught to the patient prior to the surgery.
Diaphragmatic and costal breathing exercises.
2. General mobility exercises to the lower limbs, trunk, unaffected
upper limbs, also taught.
3. Sutures are removed after 12–14 days.
4. Upper limb mobility exercises
The above treatment helps to reduce adhesion of the brachial plexus
by tissue formation strengthening exercises helps to build up strength
and endurance. Postural correction helps to gain good posture.
Ergonomic advice is useful in functional activities, a bid to prevent
the recurrence of symptoms.
Prevention of Brachial Neuralgia

1. High incidence of brachial neuralgia is due to faulty postural
mechanism. So correct bad posture. Teach correct body
mechanics.
2. “Back schools” helps to prevent back pain.
3. Neck schools prevent neck stiffness and arm pain.
4. Instruct the basic neck anatomy in the school curriculum. Teach
them proper exercises, proper posture.
5. Body mechanics during activities of daily living, at home.
6. Emotion also affect the posture and impair control of muscles,
leading to neck and arm pain.
7. Avoid any one posture for prolonged period. If continuous
postures are necessary take frequent breaks and carry out full
active range of motion of neck and arm at least every one hour.
8. Avoid hyperextended neck or forward head posture for prolonged
periods.
9. Flexibility and strengthening exercises should be performed
regularly for good condition of body.
10. When experience of pain, check posture and re-correct to good
posture.
Advise in Sleeping Environment
11. Firm support of mattress to prevent any extreme stresses. Too
soft—sags and stress the ligaments, too firm – can not relax.
12. Pillow should be comfortable height and density to promote

relaxation. Soft malleable pillow is ideal. Foam, rubber pillows
should be avoid (causes increased muscle tension).
13. Sleeping prone is bad for the neck. Pillow can be folded to form
slope. Cheek can be rest against it with the face and nose facing
the mattress. No neck rotated position while sleeping.
C HAPTER
6 Low Back Pain
Low back pain is pain in the lumbosacral junction, which can be

listed as:
CAUSES OF LOW BACK PAIN

Degenerative : Osteoarthritis,
Degenerative joint disease,
Lumbar spondylosis,
Facet joint, disease,
Degenerative disc disease,
Idiopathic skeletal hyperostosis
Inflammatory : Spondyloarthropathies
(Ankylosing Spondylitis)
Rheumatoid arthritis
Infectious : Pyogenic vertebral
Spondylitis intervertebral disc infection
epidural abscess
Metabolic : Osteoprosis or osteopenia
Paget’s disease of bone
Neoplastic : Benign spinal tumours meningiomas,
neurofibromas neurolemomas malignant
tumours spinal bone, soft tissue tumours,
intraspinal metastasis.
Traumatic : Fracture or dislocation,
Sprain—lumbosacral
Congenital or : Dysplastic spondylolisthesis
Developmental and scoliosis
Musculoskeletal : Acute or chronic lumbar strain mechani-
cal low back pain fibromyalgia, tension
myalgia, Tension myalgia of the pelvic

floor, postural abnormalities, pregnancy
Viscerogenic : Upper genitourinary disorders
Vascular : Abdominal aoetic
aneurysm renal artery,
thrombosis stagnation of venous blood
(nocturnal back pain)
Psychogenic : Compensation neurosis, conversion
disorder
Post-Operative and multiply operated on back
I. INTERVERTEBRAL DISC PROLAPSE

Definition
Intervertebral disc prolapse is defined (falling, sinking or sliding of
IVD) as rupture of fibrocartilage surrounding on intervertebral disc
releasing the nucleus pulposus that cushions the vertebrae above and
below.
Mechanisms
When the weight of the body rest on one limb, the pelvis tilts to the
opposite side at the vertebral column forced to bend as first in lumbar
region, becomes convex towards the resting limb then concave in the
thoracic region and convex cervical. The muscular tightness adopt
automatically to restore equilibrium under the control of extrapyramidal
system.
Vertebral Column Curvatures

• Cervical curvature
• Thoracic curvature
• Lumbar curvature
• Sacral curvature
During phylogeny (evolution) formation of curve starts from
quadruped to biped started. First the straightening and then the
formation of the lumbar concave curve, which has convex
posteriorly.
Low Back Pain 79
During ontogeny (development of individual) 5th month lumbar

curve concave anterior, disappears on 13th month. From 3 years
onwards the lumbar lordosis begin to appear and clear by 8 years.
Full maturity as adult at 10 years.
Abnormal ossification of thin rim of
vertebral border leads to vertebral epiphysitis
(Schauermann’s disc). 800 kg is required to
crush the whole vertebra.
Annulus fibers begin to degenerate often
25 years of age, allowing tearing of fibers.
Under stress, nucleus material stream out
through the torn annulus. Anterior prolapse is
rarest. Posterior prolapse is frequent especially
posteriolateral prolapse (Fig. 6.1).
1. This nucleus stream out and
touches posterior longitudinal Fig. 6.1: Disc prolapse
ligament, which is not tear, so the
nucleus can get back by vertebral
traction (Fig. 6.2).
2. When the posterior longitudinal
ligament breaks the nucleus called
free type of disc prolapse.
3. If the stream traps under posterior
longitudinal ligament.
4. Nucleus reaching the deep aspect
of the posterior longitudinal ligament Fig. 6.2: Prolapse without
either superiorly or inferiorly, this Ligament Damage
is called subligamentous prolapse.
If the herniated nucleus presses against deep surface of the
posterior longitudinal ligament the nerve endings of the ligament
stretched causing low back pain (Lumbago). If compress the nerve,
i.e. Sciatica.
Disc Prolapse
1st Stage
Occur if the disc has deteriorated as result of microtrauma, if annulus
fibers have started to degenerate. Disc prolaspse usually lifting weights
with trunk flexed forward.
2nd Stage
As soon as weight is lifted, the increased compressive force crushes
the whole disc and nucleus substance drives violently posterior side
of the disc till the posterior longitudinal ligament.
3rd Stage
Hernia remains trapped under the posterior longitudinal ligament.
This causes acute pain felt in the loin, lumbago—sciatica complex
(Fig. 6.3).
Fig. 6.3: Lumbago Stages of Herniation
At this point, it contact with nerve root often one of the sciatic
nerves. Hernia protrudes posterolaterally where posterior longitudinal
ligament is weak. Finally is impaired reflexes—achillis tendon reflex,
motor weakness with paralysis.
If the prolapse occur L4 – L5, the root L5 is compressed and pain
is felt over:
• Posterolateral aspect of thigh.
• Knee
• Lateral border of calf
• Lateral border of instep of foot
• Dorsal surface of foot at big toe
If the prolapse occur L5 – S1, the root S1 is compressed and pain
is felt over:
• Posterior aspect of thigh
• Knee
• Calf
• Knee and lateral border of foot at the fifth toe
Spinal cord stops at L2 to become Conus Medullaris. Below nerve
root arranged as horse tail fashion (Cauda Equina).
Low Back Pain 81
Table 6.1: Different pain perceptions in disc prolapse
Behavior of pain Possible mechanism

• Constant ache • Inflammatory process, venous hypertension
• Pain on movement • Noxious mechanical stimulus, stretch,
pressure and crush
• Pain accumulates on with • Repeated mechanical stress
sustained postures • Inflammatory process
• Degenerative disc
• Pain increases with sustained • Fatigue of supporting muscles
postures • Graded creep of tissues may stress affected
part of motor unit
• Latent nerve root pain • Movement has produced an acute and
temporary neuropraxia
Acute Symptoms Lateral Disc Prolapse

Signs and Symptoms
1. Acute disc prolapse is usually preceded by episodic low back pain
with or without irritation of the nerve root.
2. When the disc ruptures and the nucleus is extruded on to the
nerve root, the symptomatic changes to those of “sciatica” with
loss of back pain.
3. If there is pain, numbness and tingling in all parts of the distribution
of the compressed nerve. The pain exacerbated by coughing,
sneezing, lifting and straining.
4. On examination of the back may reveal a loss of the normal lumbar
lordosis and the presence of “sciatic scoliosis”.
5. They may be paravertebral muscle spasm. Straight leg raising
(SLR) test is positive.
6. Leg pain by elevation of the opposite leg crossed leg pain is
pathognomonic of a prolapsed intervertebral disc prolapse.
7. Compression of L5 nerve root by L4 L5 disc causes pain in
buttock, lateral thigh and anteriolateral calf, radiating across the
dorsum of the foot to the hallux and second toe with numbness
and tingling in the same distribution. Weakness of the extensor
hallucis longus but the ankle reflex (S1) preserved.
8. Compression of L4 nerve by L3 L4 disc causes pain in the
posteriolateral aspect of the thigh and the anteriormedial part of
the leg. The quadriceps femoris (L1, L2, L3 and L4) may be weak
and knee may feel unstable to the patient. Knee jerk may be absent.
Acute Massive Central Disc Prolapse

Signs and Symptoms
1. Onset is sudden following herniation of a massive amount of disc
material down the backs of both thighs and legs with numbness in
the same distribution.
2. The ankle are weak or paralysed.
3. Sphincter of bowl and bladder weak
4. The ankle jerk are absent.
Symptoms of pain in the low back with or without pain radiating
down the back of the leg. Nature of symptoms like acute back pain is
severe, chronic back pain is dull and diffuse usually made worse by
exertion, forward bending, sitting and standing reduced by SLR. Pain
aggravated by coughing, sneezing and straining.
Static pain; when pain radiating to the gluteal region, back of the
thigh and leg. The pattern of radiation depends upon the root
compressed.
L5 root compression the pain radiates to the anterolateral aspect
of the leg and ankle. Radiation may begin on walking and is relieved
by rest (neurological claudication).
In L4, L5 lesion pain is radiated to the dorsum of the foot and big
toe.
Forward bending is restricted in acute stage due to marked muscle
spasm.
Signs
Paraspinal muscles are often in spasm particularly on the side opposite
the leg pain and are tender on to palpation.
Tenderness is deep pressure is exerted over the interspace to one
side of the midline.
Nerve tension signs: that is extensive of the hip and flexion of the
knee causes tension on the femoral nerve roots L2, L3, L4.
Neurological signs like motor and sensory signs are present such
as:
• Atrophy of leg muscles
• Inability to walk on heels (L5)
Low Back Pain 83
• Weakness of dorsiflexion
• Inability to walk on toes (S1 root L5 disc).
Fourth lumbar dermatomes affected by L3 disc caused sensory
deficit on the anteromedial aspect of the leg and inner ankle and foot.
Fifth dermatomes affected by the L4 disc causes sensory deficit
on the anterolateal aspect of the leg, medial aspect of the dorsum of
the foot and dorsum of the great toe.
Investigation of IVD Prolapse

Plain X-rays
No positive sign in acute disc prolapse. In cases of chronic disc
prolapse affected disc space may be narrowed. There may be lipping
of the vertebral margins, posteriorly.
Myelography
Complete or incomplete block to the flow of dye at the level of disc
shows root cut off signs.
CT Scan
In disc prolapse, posterior border of the disc appears flat or convex
in axial section. There will be loss of pre-thecal fat shadow. Herniated
disc material can be seen within the spinal canal, pressing the nerve.
MRI Scan
Shows posterior prolapsed disc, theca, nerve roots, etc.
Electromyography
Denervation of muscle, distribution of particular nerve root.
Lumbar Discography
Helps diagnostic information to obtained morphology of the normal
degenerative and herniated discs.
Physiological Lumbar Disc Evaluation
Normal disc accepts 0.5 to 1.5 ml of saline or contrast during injection.
Abnormal disc accepts greater than 1.5 ml of saline or contrast with
songy endpoint.
Physiotherapy Assessment in IVDP

Lying
• Palpation of muscles and bony marks.
• Motor strength abdominals, back extensors and hip adductor
• Hip flexors
• Limb length
• SLR
Sitting
• Tension sing (valsalva maneuver)
• Motor strength hip flexors
• Deep tendon reflexes knee
Standing
• Assess posture like pelvic tilt, bony marks
• Assess range of motion
• Assess gait
• Assess for motor power, heel walk and toe walk
• Skin inspection
• Palpation of soft tissues, spinal curve
• Pain intensity, nature and site
• Functional activities
Reflex Tests
• Patellar L3—L4
• Medial hamstrings L5—S1
• Posterior tibial L4—L5
• Tendo achillis S1
Check behaviour sign
Examination of hip, rectum, and pelvis may also refer pain to
lumbar spine.
Special Test (Neurodynamic Test)
1. Straight leg raising test
2. Modified straight leg raising test
3. Unilateral straight leg raising test
4. Bilateral straight leg raising test
Low Back Pain 85
5. Prone knee bending test

6. Slump test
7. Brudzinski—Kernig test
8. Bowstring test
9. Gluteal skyline test
10. Positioning to the myotomes
11. Kernig test
12. Milgram test
13. Naffziger test
14. Valsalva maneuver
15. Hoover test for Malingering
II. SCIATIC NERVE (ANATOMY)

Sciatic nerve is the thickest nerve in our body. Upper part forms a
band about 2 cm wide. It begins in the pelvis and terminates at the
superior angle of the popliteal fossa by dividing in to the tibial and
common peroneal nerves.
Origin and Root Value

This is the largest branch of the sacral plexus
• Tibial part is formed by the ventral divisions of the anterior primary
rami of the L4, L5, S1, S2, and S3.
• Common peroneal part is formed by the dorsal divisions of the
anterior primary rami of L4, L5, S1, S2, and S3.
Course and Relations

In pelvis, the nerve lies in front of the piriformis under cover of its
fascia. In gluteal region, it enters through greater sciatic foramen. It
runs downwards, passing between the ischial tuberosity and the greater
trochanter.
In Gluteal Region
Superficial (Posterior)
• Gluteus maximus and posterior cutaneous nerve of thigh.
Deep (Anterior)
• Body of the ischium, nerve to Quadratus Femoris.
• Tendon of the obturator internus with the Gammeli
• Quadratus femoris, obturatus externus and ascending branch of
the medial circulflex femoral artery.
Medial Sides
• Inferior gluteal nerve.
• Sometimes posterior cutaneous nerve of thigh.
In the Thigh
Sciatic nerve enters the back of the thigh at the lower border of the
Gluteus Maximus, runs vertically downwards up to the superior angle
of the popliteal fossa, where it dividing tibial and common peroneal
nerves.
Superficial (Posterior): Crossed by long head of biceps femoris
Deep (Posterior): Lies on the Adductor Magnus.
Medial: Semimembranosus and Semitendinosus
Lateral: Biceps Femoris
Sciatic nerve is accompanied by small companion artery branch
of inferior gluteal artery.
Branches
• Articular Branches: Hip joint from gluteal region.
• Muscular Branches: Lower part of the gluteal region or in the
upper part of the thigh.
• Tibial part supplies semitendinosus, semimembranosus, adductor
magnus and long head of biceps femoris.
• Common peroneal part supplies short head of biceps.
SCIATICA
Definition
Nuralgia along the course of the sciatic nerve. Classic syndrome
includes pain in the lower back, pain radiating in the gluteal region,
and down the leg sometimes in the foot numbness wither paresthesia
Low Back Pain 87
or anaesthesia of the dermatomes innervated by lumbar or sacral nerve

roots, weakness of musculature innervated by the affected sciatic
nerve or nerve segment.
Disc could herniate and protrude was not realized till 1934 AD.
Two Harward Professors Mixter and Barr were first report about
disc herniation.
Incidence
Above 40 years. Female more commonly affected. Site is L4 - L5 or
L5 - S1.
Causes
• Lumbar disc herniation
• Lumbar spinal stenosis
• Degenerative diseases of the disc
• Spondylolisthesis
• Piriformis syndrome
• Osteoarthritis of hip
• Sacroiliac joint dysfunction
• Muscular fibrositis
• Neuritis
Types
• Spinal sciatica
• Radicular sciatica
• Ganglionic sciatica
• Neuritic sciatica
• Referred sciatica
• Functional sciatica
Spinal Sciatica
Irritation of intraspinal origin of sciatic nerve.
Causes
• Tumour
• Chronic arachnoiditis
• Irritation of meninges by haemorrhage
• Intrathecal injection and infection
• Backward herniation of disc

• Vascular abnormalities.
Radicular Sciatica
Irritation of sciatic nerve at its root.
Causes
• Spondylosis
• Disc herniation
• Pott’s disease
• Fracture and dislocation of lumbar vertebra.
Ganglionic Sciatica
Irritation of ganglia.
Causes
Herbes zoster
Neuritis Sciatica
Irritation of sciatic nerve and in branches (lumbosacral plexus)
Causes
• Cyst and tumors of pelvis, rectum
• Uterus during labor
• Neuritis due to diabetes, alcohol, toxin
• Penetrating injury
• Neurofibromatosis of sciatic nerve
Referred Sciatica
Irritation of nerve endings in other areas of the body from which pain
is referred to sciatic area.
Causes
• Arthritis of sacroiliac joints
• Tumors of sacrum, pelvis bone
• Fibrositis and Ateroma
• Thromoangitis, obliterans of femoral vessels.
Low Back Pain 89
Functional Sciatica
Causes
Hysteria, psychoneurosis and malignancies
Pathology
Two Mechanics
• Mechanical effects
• Non-mechanical effects
Fig. 6.4: (a) Mechanical, (b) Non-mechanical effects
Nuclear pulposus sensitize the nerve roots to produce pa when

exposed to mechanical deformation. Proprioceptive touching of nerve
roots that have been exposed to disc herniation under local anaesthetic
reproduces sciatic pain.
Local changes I exposed nerve tissue and upgradation of central
pain mechanism in the spinal cord or at higher levels are likely to
relate to the chronicity of symptoms.
Nucleus Degeneration
Softening of the nucleus and its fragmentation along with weakness
and disintegration of posterior part of the annulus.
Nucleus Displacement
When annulus becomes weak, even small area of injury, the nucleus
tends to bulge through the defect. This is called Disc Protrusion.
If the nucleus is degenerated and fragmented then comes out of
the annulus and lies under the posterior longitudinal ligament. It has
not lost contact with the parent disc. This is called Disc Extrusion.
III. LUMBAR SPONDYLOLISTHESIS

Anterior slipping of one vertebra over other is termed as spondy-
lolisthesis. It occur between L5 and S1 vertebrae. However, a slip
between L4 and S1 vertebra is also seen. It could be congenital or
acquired.
Clinical Presentation
Slipping of the vertebral body may result in low back pain due to:
1. Lumbo-Sacral segmental instability.
2. Compression of the duramater and lumbo-sacral nerve roots.
3. Reduction of the spinal canal.
4. Prolapsed intervertebral disc.
Pathophysiology of Low Back Pain

During early stage of the disease, particularly, in adolescent patients,
acute back ache may present.
Increased stress on the pars may lead to marked paraspinal muscle
spasm and localized lumbar back pain. There may be tightness in the
Hamstrings, producing positive straight leg raising test.
Fibrous tissue due to pseudoarthrosis of spondylolisthesis may
cause irritation of the nerve roots resulting in radicular pain.
Local lesions in the muscle, ligaments or joints may give rise to
referred pain.
Osteopytes at the posterior joints may also cause pressure on the
nerve roots.
Low Back Pain 91
Diagnosis
Radiological examination in lateral view of lumbosacral complex reveals
various aspects of listhesis like
1. Percentage of slip.
2. Sacral inclination
3. Overall degree of lumbar lordosis.
Percentage of slip can be calculated by measuring the anterior slip
of the vertebral body.
Displacement of L5 on S1
Percentage of slip =
Width of S1
Sacral inclination is measured on angle formed by the posterior

sacral border with the vertical.
Degree of lumbar lordosis is measured from the top of T12 to the
top of both L5 and S1. Determined from lateral view of Roentgeno-
graph.
Treatment
Aim: Maximum correction of the exaggerated lordotic curve and
maintenance of the correction.
Grade I and II can be managed successfully by conservative
treatment.
Grade III and IV with unremitting symptoms need surgical
intervention.
Conservative Management
Bracing forms an important part of management. Anti-lordotic total
contact, thoracolumbosacral moulded brace is fabricated in the
corrected position of the lordosis.
Brace has to be worn continuously with period of 24 months.
1. Deep heating modalities like short wave diathermy.
2. Correct posture – Maintain flexion attitude is important.
3. Correction of deformity by corrective exercise, relaxation exercise.
General mobility of the spine are initiated first.
Advantages and Disadvantages of Corsets

Advantages
1. It provide natural splintage effect as it maintains the physiological
lumbar curve.
2. It provides partial immobilization. These protects the lumbar spine
from stress of movements.
3. It helps to reduce pain and spasms.
4. It allows transmission of forces in gravity and weight, facilitate
early walking.
5. It provides support and reassurance.
6. It supports the abdomen thereby unloading the effect of gravity
on disease (Figs 6.5 to 6.7).
Disadvantages
1. Present trend to discourage the use of lumbosacral support.
2. It reduces muscle activity, resulting weakness, atrophy and
reduction of time.
Fig. 6.5: Braces (Belt)

Low Back Pain 93

3. It creates psychological dependence on the appliance for the

patients.
IV. LUMBAR SPONDYLOSIS

Spondylosis is the defect in the neural arches of L5–S1 or L4–L5
vertebra, where the bone is replaced by fibrous tissue with loss of
continuity between the superior and inferior articular process.
The common site of spondylosis is L5–S1 interspace. The body
of the 5th lumbar vertebra which is exposed to the major portion of
body weight from head downwards to trunk rests on unstable L5–S1
disc space.
Treatment
Same like grade I spondylolisthesis.
Low Back Pain 95
V. LUMBAR STENOSIS
Constriction of the spinal canals in to lumbar region from congenital
or acquired cases. Smaller spinal canals are more likely have symptoms
which results from nerve root compression result from Down’s
Syndrome, Osteogenesis Imperfecta, Acromegaly, Fracture and
Lumbar Spondylosis.
Symptoms
1. Low back pain with uni or bi-lateral sciatica worsened by exercise
and relieved by rest (Spinal Claudication) with bending forward
position.
2. Pain heaviness or paresthesia in the lower limbs after walking
relieved by sit down for few minutes.
3. Neurological examination of the lower limbs may be normal or
Bizarre Neural Defect.
4. Severe case signs of Cauda Equina.
Table 6.2: Difference between spinal stenosis and

intervertebral herniation
Spinal stenosis IVD herniation

• Old age onset • Young age
• Chronic pain • Acute pain
• Lumbar lordosis maintained • Lumbar lordosis flattened
• Sciatic tilt is less common • Sciatic tilt is common
• Gluteal muscles unaffected • Dropping of the gluteal muscles
• Less restriction of spinal movement • Marked restriction of the spinal
movements
• Symptoms—bilateral • Symptoms—unilateral
Treatment
Conservative
1. Emphasis flexion exercise
2. Avoid extension exercise of spine
3. Pain and inflammatory drugs
4. Back ergonomics avoid extension attitudes
5. Gentle passive manipulation technique is effective.
VI. OSTEOPOROSIS
It is defined as gradual loss of bone mass in both the calcium and
protein components being deficient occurs naturally after the
menopause in women and about 10 years later in man. It also occur
from inactivity due to prolonged splintage, paralysis, arthritis or simple
lack of physical exercise, hormonal deficiency (estrogen and androgen)
or corticosteroid drug intake.
Osteoporosis is severe pathological fracture may occur in vertebral
bodies neck of femur and at the lower end of radius.
Osteoporosis spine give rise to low grade backache with increasing
long segment kyphosis and loss of height common in thoracic region,
so it develops a position of flexion (Dowager’s Hump).
In lumbar region, the loss of height causes the 11th and 12th ribs
to impinge on the pelvis and leads to protuberance of abdomen and
redundant of folds of skin.
Vertebral compression fracture can occur spontaneously. Severe
pain is present but spinal paralysis is very rare. Pain gradually reaches
over several weeks.
Onset of osteoporosis in old age can be postponed by vigorous
physical activity if heart, lungs and joints allow.
There seems to be a small increase in endometrial carcinoma as a
result of long term estrogen therapy.
If diet is deficient in calcium, protein, vitamin D and K then
supplements may delay the progression of osteoporosis.
Goals and Treatment

Medications: Estrogen Replacement Therapy and Fluoride Therapy
Promote health: Daily Calcium – 1000 mg per day Vitamin D – 200-
400 IU per day. No high salt or protein which inhibit calcium absorption.
Postural training: Maintain good posture and postural exercise.
Exercise and strengthen bone: Weight bearing exercises, e.g. walking
and isometric exercises, flexibility training and fall prevention
advise.
VII. IDIOPATHIC – SPINA BIFIDA

Spina Bifida Occulta arises from a failure of fusion of the neural and
skeletal elements of the spine in early embryonic life. More severe
form gives external Myelomeningocoele and Paraplegia.
Low Back Pain 97
Occulta form may present in childhood or early adult life with low
back pain with or without slow progressive neurological deficit of
different types. Motor defect leads to asymmetry of leg length and
shape, sensory defect gives injuries or ulceration.
Treatment of Idiopathic Low Back Pain

Acute Pain
Phase of excruciating pain, therefore reduction of pain, spasm and
inflammation. Muscle spasm is protective in nature during the initial
stage. Therefore stretching of the muscles should be avoided. If it is
allowed to persist, it may lead to contracture of the soft tissue elements
like Erector Spinae muscles, Lumbosacral Fascia, Ligaments and Facet
joint capsule.
1. Each attempts to release spasm through relaxation technique is
primary importance so cryotherapy, steam packs are effective in
relieving spasm.
2. Bed rest for first 3 to 5 days or well guarded relaxed movements
only in the pain free range.
3. Proper back care technique to avoid strain.
4. Frequent change of posture preferably lying in prone is encouraged.
5. Analgesics and anti-inflammatory drugs.
6. Pain relieving physical agents to control pain and inflammation.
Sub-acute Phase
Symptoms improve, further relief can be achieved by gradual
mobilization through relaxation.
1. Continuous relaxed rhythmic passive movements beneficial to
reduce pain and improving nutrition of the disc.
2. Relaxation Technique: (i). Initiate relaxed pelvic and chest rotation,
(ii). Use PNF techniques only if pain free and (iii). Encourage
relaxation exercise.
3. Corrective Exercise: For maintaining the correct posture and also
specify exercise to correcting faulty posture.
4. Mobilization Exercise: Initiate early, if general condition allows
progress to conditioning and Aerobics. Exercise aimed to gradual
loading concentrating large muscle groups.
5. Activities of Daily Living to be encouraged.
VIII. SPINAL OSTEITIS

Frequently associated with a diabetes, rheumatoid arthritis and
immunosuppression. It occur in any part of the vertebral body.
Constant pain leading to limitation of movement. Spine may ankylosed
in flexion.
Treatment
Prevention spinal flexion and maintain chest expansion.
IX. ASSESSMENT FOR LOW BACK PAIN

Examination of Posture
Posture and gait should be observed and evaluate any gross deviations
from normal physiological curves of the spine, e.g. Hyperlordosis,
Flat Back, Scoliosis, Kyphosis.
Erect posture, should be examined from front, back and side.
Note the Anterior Pelvic Tilt result of protruding abdomen, e.g.
obese people, tight lower back muscles, hip flexors, hamstring weak
abdominal muscles or in spondylolisthesis.
Posterior Pelvic Tilt result of tight low back muscles, weak hip
flexors or localized spasm, lumbar lordosis in to flat back.
Lateral Pelvic Tilt result of pelvic drops on one side could be limb
length discrepancy. Unilateral lumbo-sacral strain, structural scoliosis
due to unilateral muscle spasm.
Muscle imbalance due to gluteus medius with strong hip adductors
and lateral rotators on the raised side of the pelvis. Tightness of
adductors on the opposite side tenderness on the articulating facet of
the 5th lumbar vertebrae.
Palpation
Done in prone position. Each spinous process is palpated separately
with firm pressure in the anterior and lateral directions. Bony tenderness
is palpated over the posterolateral and interspinous area lumbosacral
junction and sacroiliac joints. Palpation also due to detect local muscular
spasm and trigger points over the paravertebral region, posterior aspect
of gluteal region, thigh and the calf muscles.
Low Back Pain 99
Percussion
Light percussion to the spine from the root of neck to the sacrum
with the patient in forward bend position marked pain indicates
tuberculosis or any other infection.
Intervertebral joint alignment is tested by palpating over the spinous
process. Undue movements of the spinous process with definite gap
and exaggerated lumbar lordosis indicates spondylolisthesis.
Gentle tap over the kidney area in the absence of localized sign
and the presence of girdle pain indicate kidney pathology.
Evaluation of Functional Status

1. Personal hygiene
2. Dressing
3. Standing from sitting and reverse
4. Level walking
5. Walking up steps and inclines, coming down
6. Running
7. Gait – In Low Back Pain rotation of pelvis and lateral bending
reduced because of pain. Note time and distance.
8. Posture - Static
Scoring Scale
0 - Unable to perform
1 - Able to perform with maximum assistance
2 - Able to perform with minimal assistance
3 - Able to perform independently with pain.
4 - Pain free – full activity
Working Diagnosis of Low Back Pain

Extensive elaborate physical examination is ideal but it is not feasible
in all low back pain patients. A quick working diagnostic test can be
useful to identify serious underlying pathology.
Severe Pain at Rest : Infectious, neoplasmic lesion
Acute Pain Radiating : Major disc lesion, fracture
To Leg : Infectious disease
Pain Relieved by Rest : Mechanical origin.
X. FITNESS TEST
These tests will helps to evaluate your spine flexibility, strength and
range of movement. Do not carryout the test in hand surface you
have to make sure the patient comfort, wear clothes as allow free and
easy movement.
Test 1: Forward Bending (Trunk Flexion)

Aim: Flexibility of back.
Starting position: Stand on a erect, balanced position with both upper
limbs, raised above the head.
Procedure
Slowly and smoothly flex the trunk, bring both upper limb down in an
arc stoop forward as much as possible.
Score 4 : You can able to place your palm flat on the floor
with hip and knee extended position – Excellent.
Score 3 : Able to touch the floor with finger tips – Good
flexibility.
Score 2 : Not able to touch the floor. However palms go
much below knee level – fair
Score 1 : Not able to reach much below the knee level –
poor
(Note: Movement should be smooth, slow and non-jerky score of
less than score 3 need immediate active steps to regain back flexibility.)
Test 2: Bent Knee Sit-up

Aim: Primarily to determine the flexibility of back secondary to strength
of the abdominal muscles.
Starting postion: Lie down on your back with hands interlocked behind
the neck. Knee bent at 45 degree and the feet placed on the ground.
Procedure
Without allowing your feet to raise off the ground, sit up slowly and
smoothly.
Score 4 : Able to sit up with knee bend and hands behind
the neck—Excellent.
Low Back Pain 101
Score 3 : Able to sit up with knees bent and arms folded

across the chest—Good (need to strengthen
stomach muscles).
Score 2 : Able to sit up with knees bent and arms held out
straight—Fair (need to improve spinal flexibility
and abdominal strength).
Score 1 : Unable to sit up with knee bent—Poor (need great
improvement in both strength and flexibility).
Note: Do not raise your trunk with jerky manner. This may aggravate
neck problem or sprain your back. Do not tuck your feet under
something or holding.
Type 3: Bilateral Straight Leg Raise

Aim: Strength of the abdominal muscles.
Starting position: Lie down on your back, place your palms underneath
the hollow of your back.
Procedure
Eliminate the hollow of your back by contracting abdominal muscles.
Hold your back tightly against your palms.
Score 4 : Able to keep the back flat while raising the legs
for ten seconds—Excellent.
Score 3 : Able to raise the legs for several seconds but the
back curves part away through the test—Good
(need to improve abdominal strength).
Score 2 : Able to lift the leg, but back curves as soon as the
legs are raised—Fair (need pelvic balance and
abdominal muscle strength)
Score 1 : Unable to lift both legs but can lift one at a time—
poor (need intensive training for abdominal and
pelvic balance).
Note: Raising the head of the ground renders test easier but invalid.
Injury to the legs too high also makes the test easier. Concentrate
lumbar lordosis than lifting legs. Check any hip flexion tightness.
Test 4: Single Leg Knee – Chest Position

Aim: To determine the length and flexibility of the hip flexors, i.e.
Psoas muscles.
Starting position: Lie down on the ground with leg stretched out in
front.
Procedure
Bend your right leg towards the chest wall. Grasp the knee and force
your thigh against your trunk. Check the position of your left leg.
Does it entirely lie on the ground or partially or completely raised off
the ground? Return to the original position. Repeat the test with the
left leg also.
Score 4 : Able to bring your knee completely to chest and
keep the other leg flat on the floor—Excellent (hip
flexors of tended side limb are in proper length).
Score 3 : Able to bring your knee to your chest but the
other leg lifts straight off the floor—Good (need
to slightly stretch hip flexors).
Score 2 : Leg lifts completely off the floor when your knee
is pulled to your chest—Fair (improve hip flexor
length).
Score 1 : Leg tilts up in to the air, when your knee is held
against your chest—Poor (need more stretching).
Note: Head must be remain on the floor and knee has to move to the
chest. Shortness of a muscle weakness, hip flexor muscles important
for erect standing, bending and lifting.
Test 5: Lateral Trunk Lift (Side Flexion)

Aim: To determine the strength of the lateral muscles of the trunk and
the legs.
Starting position: Lie down on your right side with both legs extended
straight position. Fold your arms across your chest. Have somebody
firmly hold your feet down by the ankles so that they do not come off
the ground during test.
Procedure
Slowly and smoothly raise your shoulder and the trunk off the ground.
Raise your shoulder up as far as possible and hold for ten counts.
Low Back Pain 103
Slowly return to the starting position. Repeat the test in the other
sides.
Score 4 : Able to raise the upper body completely and hold
for ten counts—Excellent.
Score 3 : Able to raise the upper body up easily but cannot
hold for ten counts – Good (need to improve the
power)
Score 2 : Able to raise the upper body only few inches and
unable to hold—Fair
Score 1 : Unable to raise the body off the floor—Poor.
Note: Do not use your elbow to push up your body. Your body must
be in one straight line during the entire test. No forward or backward
movements.
Test 6: The Upper Back Raise (Extension)

Aim: Determine strength of upper back muscles.
Starting position: Lie down on your stomach with arm extended above
the head. Have some one hold your feet firmly down by the muscles.
Procedure
Slowly smoothly raise your extended arms, head and the trunk off
the ground. Hold on for five counts. If unable to raise the body,
interlock the fingers behind your trunk off the floor. Hold for 5 counts
if unable to raise the body, buttocks and then raise your head and
your trunk off the floor. Hold on for five counts.
Score 4 : Able to lift the body off the ground with hands
interlocked above the head—Excellent.
interlocked behind the neck—Good.
interlocked behind the buttocks—Fair
Score 1 : Can not lift the body off the ground—Poor.
Test 7: The Double Leg Raise Lying on the Stomach

Aim: To determine the strength of the lower back muscles.
Starting position: Lie down on your stomach with the arms at the
sides of your body and the palms tucked beneath the respective
groins.
Procedure
Raise both the legs off the ground. Hold on for five counts. If unable
to raise both the legs simultaneously raise first the right leg and then
the left leg. Hold on for ten counts each time.
Score 4 : Able to raise both legs off the ground and hold on
for five counts—Excellent
Score 3 : Able to raise the legs off the ground but unable to
hold on—Good
Score 2 : Able to raise only one leg at a time. Can be held
for ten counts.
Score 1 : Able to raise only one leg at a time but unable to
hold on even ten counts—Poor.
Test Evaluation
S. No Test Score
1. Forward bending
2. Bend knee sit up
3. Bilateral staight leg raising
4. Single leg knee-chest
Position
Right Leg
Left Leg
5. Lateral Trunk Lift
Right Leg
Left Leg
6. Upper Back Raise
7. Double Leg Raise Lower Back
Total
Note: If a person’s age is above 45, add 4 with your total score.
Result
1. Score above 35 to 40 : Back is in excellent shape.
2. Score 30 to 34 : Back is in average shape.
3. Score 20 to 29 : Back is in satisfactory shape.
4. Score 10 to 19 : Back is in a poor shape.
If your performance has been less than excellent, you have got
some work to do to prevent back problems. Good power need to do
maintenance exercise to stay fits ever.
Low Back Pain 105
XI. MANAGEMENT—TREATMENT
PHYSICAL THERAPY FOR LOW BACK PAIN
Physical Agents
Various types of physical modalities can be applied in the treatment of
LBP. Selection of modality depends upon the mode of action of the
modality of suitable symptomatology and the nature of tissue
mirohement. The object of using physical therapy through physical
agents are:
1. The control pain and spasm
2. To reduce inflammation
3. To facilitate the use of specialized techniques like mobilization,
traction and exercises.
1. Ultrasound therapy: (Frequency Range 0.8 – 3 MHz)
a. It can be given in acute as well as chronic phase of LBP
b. It can be used for driving the indication like hydrocortisone,
xylocaine, analgesic cream into the skin over the target tissues
by phonophorresis.
c. It increases cortisol present in the spinal, nerve roots and
lumbosacral plexuses thereby improving mobility by
decreasing pain.
d. It increases extensibility of the connective tissues like Tendons
and joint capsule. This particular action of ultrasound is impor-
tant as it can improve the accessory movements in the apophy-
seal joints. The accessory movements in the apophyseal joints.
Therefore, it is ideal before applying mobilization techniques.
2. Shortwave Diathermy: (Frequency 27.12 MHz)
SWD is preferred for deep heating of the tissues over larger areas.
However, drum electrodes or induction electrodes can be used
where superficial is advisable.
Two modes of diathermy is continuous and pulsed is ideal in
dealing with acute conditions or after surgery. In chronic LBP a
continuous modality is preferred.
Various other modalities like interferential current, helium neon
laser, microwave diathermy has been used for effective control of
back pain with musculo-skeletal trigger points.
3. Cryotherapy: (Ice Therapy)
Simple and effective procedure which reduces muscle spasm and
inflammation in the acute phase over the painful areas. It acts as
an analgesis. Method of cryotherapy are cold packs, ice packs,
ice towels and ice massage.
4. TENS (Transcutaneous Electrical Nerve Stimulation)

Applied over the trigger prints or motor points has been reported
to be effective in both acute as well as chronic conditions. It
reduces the perceived pain by Gate Central Theory.
5. Moist Heat: (165 to 170 F for Treatment)
In the form of hydrocollater packes reduces pain and spasm in
the acute phase. It can be used adjunct before applying specialized
techniques or even before TENS, SWD or Ultrasonic Therapy.
Effect is supercial structure of the body.
6. Electrical Stimulation
High intensity electrical stimulation over the motor points or trigger
print area helps especially in LBP of psychogenic origin.
Iontophoresis with continuous direct current can be very useful
for therapeutic purposes.
7. Massage
Gentle soothing massage is more helpful to reduce spasm. It helps
to removing nociceptive substances by improving blood circulation.
It also gives relaxation of muscles.
EXERCISE FOR LBP
Exercise programme for low back pain should be specific based on
the correct physical examination exercises should be limited to the
point of discomfort.
Aim of Exercise Programme
1. To decrease pain
2. Strengthen weak muscles
3. Improve endurance of muscles
4. Decrease mechanical stress to spinal structures
5. Stabilise hypermobile structures
6. Imporve posture
7. Improve mobility and flexibility
8. Improve fitness level to prevent recurrence
Effects of Exercises
1. Increase strength of bones, ligaments and muscles.
2. Improve nutrition to joint cartilage including intervertebral disc.
3. Enhance oxidizing capacity of skeletal muscles.
4. Improve neuro-motor control and co-ordination.
Low Back Pain 107
5. Increase the level of endorphine in cerebro-spiral fluid and blood

which is found to be reduced in patient with LBP (Endorphine has
significant pain modifying effect).
6. Enhance psychogenic effects and reduce the symptoms of
depression and anxiety.
Mobility exercises are the main contribution to the mechanical
efficiency of the spine and the whole body. Relaxation of the muscles
and joints are important to improve the mobility.
Aerobic exercises are effective in the control of LBP. These should
be started gradually so that there is no undue strain. Activities like
brisk walking, jogging, swimming, cycling, rope jumping and dancing
have been found very useful in controlling as well as preventing LBP.
Physiotherapy to be followed (Fig. 6.15)
1. Flexion exercise
2. Extension exercise (Figs 6.8 A to E), Fig. 6.9
3. Rotational exercises
4. Mobility exercises (Fig. 6.12)
5. Stretching exercises
6. Self correction and maintenance exercise
7. Aerobic exercise
8. Endurance exercise
9. Pelvic tilt exercise (Fig. 6.10)
10. Trunk stability exercise with Bobath Ball (Figs 6.13, 6.14, 6.16,
6.17)
Fig. 6.8A to E: Extension exercise
Fig. 6.9: Back and pelvis stabilization exercise

Low Back Pain 109
Fig. 6.10: Pelvic tilt exercise
Efficacy of Exercise Programme in LBP

Changes in the intensity of pain and its location gives valuable guidance.
It is important to monitor the efficacy of exercise programme right
from day one.
1. Centralisation of pain to the centre of the guidance an important
clue to the correctness of the therapeutic programme (Good Sign)
Incorrect posture, improper exercise or wrong activities causes
pain to move away from centre of the spine to the periphery.
2. At the initial exercise session slight increase of pain is expected.
The pain should decrease in the subsequent sessions with
centralisation. However, increase in the intensity of pain and its
migration to the periphery is a warning to stop exercise immediately
(Bad Sign).
3. In a situation where tightness or weakness of muscles and fascia
is the cause of LBP, increase in pain is expected due to repeated
stretching and muscle fatigue.
4. The response may be slow and the improvement may be delayed
in patients with LBP of longer duration. It may take 10-15 days
for a notieable relief.
Exercise to be Avoided
1. Forward bending and trying to touch the toes in sitting as well as
standing.
2. Bilateral straight by raising in supine lying.
3. Prone lying position both arms and legs straight during overhead
action with back arching in posteriorly.
4. Backward bending in standing.
Lumbar extensor group muscles are anti-gravity muscles, stronger
naturally right from the childhood. It remains the same unless any
surgery in that group (incision). Strengthening procedure are not really
needed for these muscles unless they are for a specific purpose.
Strengthening of extensions leads to limitation of trunk flexion. This
should be remembered in planning the exercise programme to maintain
lumbar lordotic curve.
PHYSIOTHERAPY MANAGEMENT FOR

CHRONIC LOW BACK PAIN
Pain is a perception which reflect not only bodily events but also
thoughts and emotion.
Causes of chronic low back pain may be psychosomatic disorders
such as peptic ulcer, allergic rhinitis, asthma, colitis, migraine, tension
headache, idiopathic cardiac palpitations, angio-neuritic oedema,
neurodermatitis, eczema, psoriasis may give rise to low back pain.
Peptic ulcer alone accounts for about 72 percent psychosomatic low
back pain. These disorders originate in limbic nuclei and are mediated
through the autonomous nervous system. Tension myositis also one
of the common factor in chronic low back pain. Its typical charac-
teristics are:
• Minor trauma precipitate acute, excruciated pain.
• Long standing pain without any neurological deficit.
• Complaining pain simultaneously in the muscles of the upper and
lower back.
• Person with certain personality character like over ambition,
compulsiveness, perfectionism, depression, over anxiety.
Location of pain usually does not fit in any typical area of
distribution is diagnosed tension myositis.
Treatment
For effective management patient to accept the diagnosis.
• TENS is effective in chronic low back pain.
• Exercise prescribed by physiotherapist as follows:
Low Back Pain 111
1. Gradual active mobilization: Help to reduce anxiety,

depression.
2. Strengthening exercises: Back extensor muscles play an
important role in the control of chronic low back pain.
3. Endurance exercise: Increases the level of endorphine in blood
and cerebrospinal fluid which has been reported to be diminished
in chronic low back pain.
4. Isometric exercises: Strong exercise effective in chronic back
pain especially of myofascial origin.
5. Progressive mobility exercises: Helps to improve flexibility of
the body.
6. Physical fitness through aerobics: Effective method to decrease
muscle tension. Aerobics increases alpha - wave activity
producing central and peripheral relaxation responses, e.g.
aerobics like swimming, cycling, brisk walking.
SPINAL TRACTION
Precautions
1. Constants supervision is necessary. Do detect any difficulty is
breathing (or) gastrointestinal (or) cardiopulmonary complications.
2. Gradual increase of traction to be regulated to the level of comfort
and reduction in the symptoms. Release of traction should also be
gradual.
3. Cough and sneeze during traction can aggravate pains. Therefore
before applying traction. Make sure that the patient is not saving
or cold. If present, he should avoid jerking the back.
Contra Indications
1. Patient with impaired cardiac or respiratory functions, e.g. cardiac
failure, emphysema, asthma, etc.
2. Instability of spine
3. Marked osteoporosis, hiatus hernia, claustrophobia, pregnancy.
4. Tumors (or) infection of spine.
5. Vascular compromise condition for which the movement is
contraindicated
6. Massive disc prolapse causing neurological deficit
7. Osteomyelitis, tuberculosis of spine.
Lumbar Traction (Fig. 6.11)

Angle of pull: 15 to 30 flexion for effect on L1 L2 L3 vertebra
Position: Supine lying
Resistance (or) Weight:
Sustained traction 1/4th of the body weight required. No inter
vertebral disc separation would take place if you place weight less
than 1/4th of the body weight. For intermittent pelvic traction 1/3rd
of the body weight to be placed.
In lumbar, initial starting weight should to be with less than 1/4th
of body weight be used to determine whether traction will have effect
in symptoms.
Force necessary to cause effective vertebral separation between
65 lbs and 200 lbs.
Note: 440 lbs or greater force is dangerous it damage to the lumber
spine components.
Manual Lumbar Traction

1. Lumbar spine is flexed, using the upper leg as a lever, physio-
therapist palpates the interspinous area between two spinous
processes. The upper Spinous process is one at which maximum
effect is desired. Therapist feels motion of the lower spinous
process with palpating hand. Foot is placed against the opposite
leg so that further flexion is not allowed.
Fig. 6.11: Lumbar traction

Low Back Pain 113
2. For maximum effects: Patient trunk is rotated by physical therapist

until motion of the upper spinous process is felt by the PT’s trunk
rotation should be passively produced by PT’s, positioning the
patient upper arm with hand on the rich cage, pulling the patients
lower arm, creating trunk rotation towards the upper arm. In this
case it is rotation to the left
3. Position the patient is maximum effect and palpating the
interspinous processes where maximum traction effect is desired.
The PT then places his chest against the anterior superior iliac
spine at the patient’s upper hip, physical therapist leans toward
the patient’s feet.
4. Unilateral leg pull traction: Place thoracic harness for counter-
traction. Bring patients hip in to 30 degree flexion, 30 degree
abduction at maximum external rotation. Steady pull is then applied.
Positional Traction
1. Patient side lying with blanker roll between iliac crest at rich cage.
This increases intervertebral foramen size of the opposite side
(superior ) of the lumbar spins.
2. Side lying right side: Maximum opening of the intervertebral
foramen of the left side of the lumbar spine is achieved by flexing
the upper hip and knee of left side at rotating the patient shoulders,
so he is looking over the left shoulder (left rotation).
3. In herniated disc of left side patient side lying over the blanket roll
on right side to open up foramen or nerve roots.
Effect on Ligaments
When the ligaments stretched, ligaments put pressure on (or) move
other structures within the ligamentous structure (proprioceptive
nerves) and external to ligamentous structure (Disk material, synovial
fringes, vascular, nerve roots. This pressure or movements can have
a big import on painful problems if pressure on a sensitive structure
vascular nerve reduced. Activation of the proprioceptive system will
also relieve pain by providing a great effect similar to transcutaneous
electrical nerve stimulation treatments.
Effect on Nerves
Unrelieved pressure on nerve will cause slowing or loss of impulse
conduction. Signs of weakness numbness becomes progressively more
indicate nerve degeneration.
Decrease pressure on nerve increases blood circulation to the
nerve, decreasing edema and allowing the nerve to return to normal
function.
Effect on Spine
Separation of 1 to 2 mm per intervertebral disk space have been
reported. This changes is transient and the spine quickly returns to
the previous intervertebral space relationship when traction is released
and the erect posture is assumed.
Decrease pain, paresthesia, tingling while applying traction is good
sign, traction should be continued.
Effect of Traction Force

One to two mm per intervertebral space have been encouraged to
decrease pain, paresthesis (or) tingling sensation are effect of separation
of IVD. If these changes occur progress for the patient is good and
traction should be continued.
The effect of traction may be destroyed by allowing a patient to
sit after treatment.
Facet joint, can be affected by traction primarily through increase
separation of the joint surfaces but when you have to increases joint
separation for the purpose.
Bone Effect
1. Decompress the articular cartilage.
2. Allowing the synovial fluid exchange to nourish the cartilage.
3. Decrease the degenerative change from osteoarthritis.
4. Increase the proprioceptive discharge from the facet joint structure
provides some decrease in pain perception.
Muscle Effect
1. Initial stretch should come from body positioning.
2. Addition of traction will then provide additional stretch.
Low Back Pain 115
3. Muscle stretch would lengthen tight muscle to stretch allowing

better blood flow activate muscle proprioceptors.
4. All the above properties leads to decrease muscular irritation and
pain.
Inverted Position Traction

Two second is the minimum treatment time 2 (or) 3 times with 2-3
minutes rest period maximum treatment time 10 to 30 minutes.
If diastolic blood pressure rises 20 mm of mercury above the
resting diastolic pressure physiotherapist should stop treatment.
Contraindication of Inversion Traction

• Hypertensive 140/90
• Heart diseases
• Glaucoma
• Sinus problem
• Diabetes
• Thyroid condition
• Asthma
• Migraine headache
• Detached retinas
• Initial hernias
Meals (or) snack should not be eaten during the hour before
treatment.
Test to Tolerance of Inversion Traction

Hand knee position, put his head on the floor holding that position for
60 seconds any vertigo, dizziness (or) causes are not advised to
prescribe inverted position traction.
GENTLE MOBILIZATION EXERCISES (Fig. 6.12)

1. Lie on the floor with both knees bend and feet on the floor. Roll
both knees from side to side a few degrees, gradually increasing
the roll as the days pass until your knees touch on either side
repeat 6 to 10 times.
Fig. 6.12: Mobilization exercise
2. Lie on the floor, pull one knee up towards your chest while you
push the other leg straight down on to the floor. Repeat with other
leg, alternately three times each.
3. Lie on the floor with both knees bent and feet floor. Pull both
knees gently up towards your shoulders, using your hands to help
the up. Replace your feet on the floor. Repeat 5 to 10 times with a
free - flowing movement, no jerk or rock.
4. Lie on the floor, with both knees bent and feet on the floor. Lift
your buttocks off the floor so that your hips are high and body is
straight, then tighten your abdomen and buttocks at the same
time. Hold the position for a count of 10. Repeat three times.
Back Care Advice

• Extend yourself for every half an hour
• Maintain an erect posture while sitting
• Cushion seat was advised to prevent more vibration
• Back rest with pillow support was advised to maintain lordotic
curvature in lumbar region.
Low Back Pain 117
MCKENZIE TECHNIQUES
McKenzie utilizes the response of a patient to the repetition of all four
basic movements of the lumbar spine. Identification of the movement
which reduces pain or brings about its centralization that is peripheral
pain is moved towards midline of the spine forms the basis of the
therapy. Hence, it is called movement therapy.
He also stresses the importance of maintenance of the normal
physiological curve of lumber lordosis in all the body positions and
activities with spiral ergonomics. McKenzie categorized the origin of
LBP basically three principles
1. Derangement Syndrome
2. Dysfunction Syndrome
3. Postural Syndrome
1. Derangement syndrome: Anatomical disruption or displacement
occurs within the intervertebral disc. In younger age group
displacement of annulus complex of fluid nucleus. Whereas in
older age group degenerated annulus of fibrosed nucleus may be
present.
Disc derangement may be:
a. Minor or Major posterior disc disturbance.
b. Minor or Major posterolateral disc disturbance with impinge-
ment of nerve root and dural sleeve with sciatica with or without
deformity
c. Anterior or Anterolateral disc disturbance.
2. Dysfunction syndrome: Common in the age of thirty years due to
lack of exercise, poor postural habits (or) organization of fibrons,
collagenous scar tissue during the process of repair may be the
precipitating factors pain is present adjacent to the spine only at
the extreme range of movements due to the overstretching of
shortened soft tissues and never during movements.
a. Treatments consists extension in lying.
b. Flexion is lying.
c. Side gliding is standing.
It involves stretching of the contracted soft tissues some pain
is expected. To be effective, exercise performed long enough
maintaining stretched positions.
3. Postural syndrome: Common in below thirty age group, pain is
present adjacent to the spine. The cause is the over-stretching of
the normal tissues because of poor sitting or standing postures or

due to lack of stretching exercises in sedentary lifestyle and job.
Treatment to be focused in self-corrective postural exercises. This
exercise may be associated with new pains due to adjustment to
the new postural attitude.
Method of McKenzie Approach

1. Patient is taught self-correction of the bad posture with emphasis
maintaining normal lumber lordosis in all the situations.
2. Exercise programme begins as an extensive exercise, flexion
exercise are incorporated later by (2-3 weeks) or when acute pain
subsides.
Extension Exercise to Restore Normal Lumber Lordosis

1. Prone Lying: For relaxation of basic muscles.
2. Prone lying with forearm and elbow support. Elbows are placed
in shoulder joins. Trunk is raised in extension be leaning on the
forearm and curling of shoulders and upper back.
Note: If constant pain is relieved progress the following exercise
3. Prone lying extension on hand support. Trunk is gradually extended
by leaning on the hands.
4. Standing-extension exercise standing upright Bend Trunk
backwards as much as possible.
Note: Exercises 1 and 2 can give in acute stage in pain free.
SPINAL MANIPULATION
Manipulation is very specialized technique which involves skilled
gentle, precise passive movement of a joint either within or beyond its
active range of motion by manual force.
A small, firm gentle force is applied to restore, the lost movement
by producing a desired joint play or to achieve unlocking.
Aims
1. To relieve pain
2. To promote increased function.
Low Back Pain 119
Effects of Manipulation
1. Mechanically it improves the extensibility of the connective tissue
elements of the capsule, ligaments, muscle and facia.
2. Neuropysiologically it blocks the centripetal transmission of
nociceptive pain pathways, through sensory input, which could
be encouragement to the patient.
3. Sensory stimulation skilled joint mechanics and soft tissues itself
provides enough sensory stimulation and encouragement to the
patients.
Indication of Manipulation
1. Vertebral mal position
2. Abnormal vertebral motion
3. Abnormal joint play or end feel
4. Soft tissue abnormalities
5. Muscle contracture or spasm
6. Severe nerve root pain
7. Chronic spondylotic changes
8. Chronic discogenic pain
Contraindication
1. Unskilled manipulator
2. Acute disk prolapse with advancing neurological signs.
3. Instability spondylogic and fracture.
4. Active inflammatory joint disease.
5. Advanced osteoporosis, disease of bone
6. Bleeding disorders.
7. Pregnancy
Supportive modalities before and or after manipulation like ice,
heat, massage, ultrasound and TENS helps to release soft tissues.
Techniques of Manipulation
a. Oscillation Technique:
It is employed in a recently injured joint where some minimal
movement is indicated to retain its function.
b. Stretch Technique:
Joints presenting restrictions due to capsular or myofascial changes
are benefited by stretch manipulations.
c. Thrust Technique:
Joints demonstrating sudden hard stop to a movement in one
direction due to adhesions will respond better to a thrust technique.
d. Rotation and side bending Techniques:
When there is restriction of the fact joint mobility. During the
movements of forward, backward or side bending, the facets
distract from each other restrictions on the mobility of lumbar
fact joint instantaneously respond to rotation and side bending
manipulation techniques.
XII. LOW BACK PAIN SURGICAL

PROCEDURE AND TREATMENT
Discectomy (Disc Excision)
Indication
1. Backache with or without radicular pain, associated with
neurological deficie.
2. Cauda equina syndrome
3. Severe backache with CT scan or MRI and myelographically proved
Disc Herniation.
Disc Excision
Interlaminar (or) Fenestration Technique
Prolapsed disc excised through a space created between the laminae
of two adjacent vertebrae after removing the ligamentum flavum.
a. Laminectomy
Wide and adequate exposure can be obtained by laminectomy.
The spinous process and laminae are excised from one or two
vertebrae and the disc is exercised from one or two vertebrae and
the disc is exercised through the opening. A wide laminectomy
can jeopardize the stability of the spine. This procedure is useful
in lumbar canal stenosis.
b. Hemilaminectomy
The lamina of one side only removed to take on the disc material.
Damage is less.
c. Spinal Fusion
In addition to disc excised some surgeons prefer spinal fusion. It
helps to stabilize the spine for the instability caused by the
degenerative changes in the intervertebral joints.
Low Back Pain 121
Post-Operative Management
Patient is in the bed for at least 10 to 12 days after operation. No
useful purpose is served by endeavouring to get the patients up and
walking in a few days as advised by many surgeons. As per the clinical
judgments of experienced physical therapists with the consultation of
surgeon based on the patient aims the goal can be fixed.
The patient if disc excisions by fenestration method are allowed
to take turns in bed in the secured or third postoperative day. Spinal
extension exercises are started at the end of the week.
Ambulation starts in the second week.
Patients with spinal fusion are give a Pop Jacket or Lumbosacral
corset for a period of 3 months.
PHYSIOTHERAPY GOAL
Patient is mobilized as early as possible to prevent the complication of
prolonged bed rest
1. Thrombophlebitis
2. Gastrointestinal disturbances
3. Muscle weakness
4. Atrophy of muscle
5. Urinary tract infections.
Safe methods of early mobilization is concentrated.
Strenuous Trunk flexion put extra strain on the operated area,
should not be included during first week of surgery. The normal
physiological lumbar curve must be maintained during all activities.
Patient with lumbar fusion should not be mobilized in lumbar.
PHYSIOTHERAPY MANAGEMENT
FOLLOWING SURGERY
a. Following inter-laminar or fenestration technique (Stability of the
spine is not disturbed)
Immediate Postoperative Phase

1. Ankle and toe movement
2. Chest physiotherapy
3. Upper extremity movement
4. Static gluteal and quadriceps exercises.

5. Graded hip and knee flexion by heel dry in supine.
On 2nd and 3rd Postoperative Day

6. Turning supine to side initiated with assistance. Done by bending
the hip and knee. The whole body is turned as one unit.
7. Assisted spinal extension exercise initiated by forearm supports
is prone.
8. Isometrics abdominal exercise, with pain free.
9. Supported suit with maintained lumbar lordosis.
10. Guided ambulating and graduated flexion with trunk rotation
initiated.
By 3 Weeks
11. Ambulation with correct posture and gait. Spinal extension
exercises are made progressive in stages from forearm support
to hand support and finally hands on the back.
12. Gradual spinal rotation forward flexion, side flexion are introduced
and progressed.
13. Proper ergonomic advice is emphasized with retention of lumbar
lordosis during activities.
Patient should be back to normal activities by 6-8 weeks.
Following Laminectomy
The basic approach in physiotherapy during initial stage remains the
same as in inter-laminar or fenestration surgery. Except for the initiation
of spinal mobilization and ambulation
Spinal movements are progressed gradually as follows:
1. Back arching in supine (bridging) is initiated by the second week
with assisted turning in bed.
2. Strong isometrics abdominal exercise without producing spinal
flexion.
3. Prone lying and forearm supported hyper-extension to be initiated
by 2 to 3 weeks. Sitting up from side lying is initiated by 3 weeks.
4. Ambulation and other spiral movement could be begun by the end
of 4th week.
Low Back Pain 123
Following Hemilaminectomy
Physiotherapy management following this procedure on the same line
as laminectomy. Mobility procedure can be initiated earlier because
surgical procedure is less extensive. Patient should be back to pre-
operative activities by 4-6 weeks.
Following Spinal Fusion

Extensive surgical procedure and subsequently prolonged immo-
bilization leads to muscular weakness and limitation of spinal movement
physiotherapy needs to be concentrated into two aspects.
Initially mobilization is given in plaster jacket. Besides the other
procedure described for laminectomy special attention is needed as
follows:
1. With support of plaster jacket improve the tone and strength of
flexors and extensors of spine.
2. Gradual turning in bed to side prone lying can be initiated by 3rd
week.
3. Assisted setting from side lying to be initiated by 4th week with
lumbo-sacral corset.
4. Graduated walking and other ambulated procedures can be
introduced by 6th week.
5. Spinal movements in smaller range can initiated by 8th week.
Flexion should be initiated carefully with rotation.
6. Spinal corset can be gradually removed from 10th week and
discarded by 12th week.
7. Spinal mobilization and strengthening to be made vigorous. Patient
resume his daily activities and light sports by 8 to 12 weeks and
continue to follow the principles of back ergonomics.
XIII. ERGONOMICS
Ergonomics is the science of examining people and their working
environments as it affects the efficiency, safety and ease of action.
Person’s work place should be designed to enhance efficiency
and performance. It helps to prevent risk of injury and identified the
risk. Since Brachial Neuralgia occurs frequently in working population
belonging to assembly line workers, cash register operator, students,

computer professionals and Typist.
Also, common in overhead work personal like electricians, painters
and plasterers. Ergonomics plays an important role in the prevention
of any occupational related neck and arm pain.
Posture in Standing at a Workplace

Work surface should be waist high or slightly below such that the
elbows are bent not more than 10-15 degrees below 90 degrees, when
the hands are resting on the surface. If the surface is too low in set or
raise the workshop form and neck bending should be divided.
Fig. 6.13: Spine stabilization Exercise (See-saw progression)

Low Back Pain 125
Fig. 6.14: Bobath ball exercise (Trunk stability)
Sitting at Desk
Top should be high enough to support the forearms comfortably Hib
elbows bent to a right angle without having to slump forward on to
the desk. Table slope for writing or reaching the top should stop
upward at about 10 to 15 degrees. (Fig. 6.18)
This helps to prevent the forward thrust position of the neck. The
object should be placed at distance of about 30 cm from the eyes. All
copy materials placed on an adjustable stand, either centrally or
alternated from side to side every other day. This help to avoid frequent
head and neck rotation. The chair should be back close to the desk,
the back should be well supported. Person should not bend back
(Fig. 6.20).
Fig. 6.15: Therapeutic exercise
Visual Display Unit Operation of Computers

Spending hours each day in front of a computer causes pain in the
neck and shoulder, radiating arm pain and wrist pain. Hence, to prevent
these correct positions to be followed (Fig. 6.19).
Low Back Pain 127
Fig. 6.16: Trunk stability exercise with Bobath Ball
Monitor
The screen should be flicker, glare, and reflection free with clear well
defined characters. Top of the screen should be in level with the
forehead so the eyes can more through an angle of 0-15 degree
downwards from the horizontal.
Fig. 6.17: Trunk stability exercise with Bobath Ball

Low Back Pain 129
Fig. 6.18: Sitting at Desk
Chair
Height of the chair adjusted in relation to the keyboard such that the
upper arms hang vertically, forearms horizontal wrist in level, hand
straight on keyboard.
Typing position the elbows should be neither above nor below the
keyboard. They should be in same line.
Keyboard
Keyboard must be at right height. The space on the work surface
in front of the keyboard must be sufficient to provide supportive
Fig. 6.19: Sitting with Computer

Fig. 6.20: Sitting at Desk (side)
just for the hands, i.e. between 6 and 8 cm of wrist rests equal in
height.
Mouse
Mouse, trackball or similar pointing device should be practiced as
clue to the keyboard as possible such that the arm is relaxed with the
wrist hold straight. Workers should change the working hand from
right to left and vice versa taking short breaks and exercising the arm
and neck.
Reading Glasses
Bifocal reading glasses should be avoided, fine in order to look through
the lenses, the person has to hip the head back into extensions. Special
variable focus glasses or glasses with focal length measured for
computer is ideal.
Telephone Talk
Avoid wholly the telephone between the ear and shoulder, since it
caused cervical spine problems and upper limb disorder.
For School Pupils (6.21A and B)

1. The number of books carried should be reduced.
2. Weight can be carried as a small load in each hand (or) carry the
weight clasped closed to you.
3. Use a back pack or sling across from the opposite shoulders.
Low Back Pain 131
Fig. 6.21A and B For school pupils
Sitting in the Class (Fig. 6.22)

1. Chair should be in right height to have both feet on the floor,
without the chair pressing into the back of your thigh.
2. Desk should be high enough such that the elbows can rest on it
without causing the back to slump into curve. The desk should
slope upwards slightly.
Fig. 6.22: Sitting in the class

Posture in Sitting (Fig. 6.23)

1. Change position often, remaining on one position for longer than
half an hour is stressful.
Fig. 6.23: Posture in sitting
2. Chairs should support your body in good position.

3. Back of chair should be at an angle of 110-115 degree to hold the
back in an upright position
4. While reading avoid bend sitting, have the book well supported.
While Driving a Car (Fig. 6.24)

1. Seat must be at comfortable distance from the pedals.
Fig. 6.24: Driving a Car

Low Back Pain 133
2. Back seat must be set up at an angle of 95 to 100 degrees. Arms

comfortably relaxed in slight flexed position. Head rest immediately
behind head.
3. The height inside should allow one to look out of windscreen with
back upright and the head hold straight with the chain tracked in.
Posture in Carrying
1. Do not carry heavy weights. Balance the weight such that the
body remains straight carry two bags of equal weight instead of
one.
2. If the weight is excessive, trolley can be used.
3. Follow the lying, sitting, standing, lifting, pushing methods (Figs
6.25 to 6.29)
Exercises for Computer Professional or any

Type of Desk Workers
Note: Do not do any of the following exercise if there is already pain
in the neck and arm until the cause that has been diagnosed.
Fig. 6.25: Pushing method

1. Sit with hands placed lightly behind the neck rowrd the back,
dropping your elbows down and the head towards the abdamon.
Straighten up opening out the elbows and really arch the upper
back, pressing both elbows backwards.
2. Bend the right arm to the right shoulder stretching the left side of
the neck, repeat to the left.
3. Sit up straight, reach the nose forward as if you smell something,
pull the head back, stretching the back of the neck, do not press
the chin down.
4. Sit up straight, arms relaxed; lengthen the collar bones, widening
the chest. Retract the head with chin neutral.
5. Clasp both hands in fronts. Turn down inside out, keep the elbows
straight and stretch both arms up above the head, stretching up
and back towards the ceiling.
Fig. 6.26: Lifting method

Low Back Pain 135
Fig. 6.27: Lying with pillow
Fig. 6.28: Standing method
Fig. 6.29: Sitting method

6. Touch the right shoulder with right hand straighten out the arms
side ways, palm facing up then point the palm towards the floor,
do not jerk the movements or overstretch. Repeat with other side
arm.
7. Stand with arms by the side; lift the arm sideways up and down 5
times. The back of the hand towards the side and bend the wrist
away from the body.
8. Press the palms together, stretching the front of the wrist. Touch
the chest with tip of the fingers and point the tips away from the
chest fast repeat the movement quickly.
9. Get up frequently and walk armed the room, when get up from
sitting, arch you back and stretch.
XIV. LOW BACK PAIN AND SEX

A recent study in Mayo Clinic USA showed that two-thirds of backache
patients suffered from an impairment of sexual satisfaction. Sexual
problems included difficulty in becoming sexually aroused and in
reaching orgasm more women were affected than men. Medicine
taken for pain relief may decrease libido. Tranquilizers sedatives and
narcotic analyesics all may reduce sexual drive. Drugs like
corticosteroids may decrease the response to genital stimulation. These
drugs may reduce impotence in males.
Sexual Intercourse is one of the natural activities common in man
and animals. Everybody want to please and be pleased by our lovers.
When sex is painful because of back pain, naturally several kinds of
emotional disturbance, affect both partners’ family life without clean
communication misunderstanding quickly starts.
First step discuss with your partner about your problems in frank
relaxed compassionate manner. Always think and start with positive
approach.
Understand the body position which has no pain while love making
with your partner. Allow more time to precortical preparation. Partner
may need warm-up period similar to athlete activities.
Application of moist heat to the lower lumbar spine, warmbaths,
showers or compresses help to limber up joints prior to having sexual
relations.
Encourage couple bathes together before sex and also mutual
application of moist heat. The pleasure of bathing also give therapeutic
values. Pain free partner stimulates specific pain relieving points on
his/her partner body as a part of foreplay for pain relief and pleasure.
Low Back Pain 137
a. Midpoint of the crease below the buttocks

b. Midpoint of the crease at the back of knee
c. Posterior surface of thigh (Mid Point)
d. Posterior to the lateral maleolus.
Dorsal aspect between third and second metatarsal. Webspace of
Thumb and index finger.
How to make love with Low Back Pain
a. During sexual activities do not bend forward with knee straight,
even in lying position because this position puts tremendous strain
on the lower spine. It also stretches the sciatic nerve, so always
keep slightly flexed spine, hips and knees.
b. Maintain correct pelvic till avoid lumbar lordosis during intercourse.
Arch the back makes the disc bulge towards the back and places
more stress on the posterior structures of the spine. Such as facet
joints.
c. Avoid lying supine or prone with Hip and Knee extended position
which stretches, psoas muscles which run anterior to the lumbar
spine and below the hip joint. When you flex those muscles and
take off the pressure on lower back.
POSITION FOR SEX

The patient can discover their own position as long as both of them
pain free
1. Side lying both partner with hips, knees and spine mild flexion. So
neither has no support his/her own body weight on partner. Female
should guard against getting into swayback position. This position
is the good for make love in Acute stage of back ache.
2. Female, lying in supine with spine mild flexed position with her
thighs on the male lovers thigh male should kneel in between the
thighs of female.
3. Female LBA patient stays Top over the female flexes hip, knee and
spine she can support the weight by her hand.
4. Both partner in kneeling position.
When to Start
It is best to abstain from intercourse for few days because of backache.
Not the very first day or night you go off the medications, when you
walk without pain and require little or nothing in the way of pain
killers, try a practice run. First start making love in air, as you slowly
try sexual maneuvers without your partner. If there is no pain, try it
again a little more vigorously. If there is no pain again, Try a dry run
in one or two of the recommended position (still with air)
If you develop sore back, want for a day or two before resuming
your affairs with air. If you have no pain, break of with air. Now try
gentle intercourse with your lover in one of the recommended position.
If you can make love without pain or pain is much less and also
does not last for more than a few minutes afterwards, enjoy as you
wish.
If anyone maintains correct body-positions they need not worry
at all.
Patient suffering from chronic back pain sexual activity made
them feel better, even some patient states that the sexual act relieved
their pain.
Bibliography
1. Clinical Neurology – Brain and Bannister

2. Barr’s Human Nervous System – John A Keirnam
3. Disorder of Cervical Spine – Bland H John
4. Clinical Challenges in Orthopaedics shoulder – Bunker D Timothy, Schranz
J Peter
5. Critical pathway in Therapautic Intervention Upper Extremity – David C
saidoff andrew L Mc Donough.
6. Peripheral nerve lesian Diagnosi and Therapy – Mark Mumentaler Hans
Schliacic
7. Mobilization of Nervous System – DS Butler
8. Low back pain syndrome – Rene Cailiet, Kenneth Mills
9. Colour atlas and low back pain
10. Managing Low Back Pain – W.H. Kinkaldy Wills
11. Essentials of orthopaedics and applied physiotherapy – Jayanthi Joshi,
Prakash Kotwal
12. Physicaltherapy of Low Back - Taylor
13. Common vertebral joint problem – Grieve
14. Clinical Neurology – Brain and Banister
15. Orthopaedic Physical Examination – Bruce Reider
16. Back Pain – The Facts – Malcolm I.V. Jayson
17. Managing Low Back Pain – W.H. Kirkaldy Willis, Charles V. Burton
18. Essentials of orthopaedics and Physiotherapy – Jayant Joshi Prakash
Kotwal
19. Spine Care – Arthur H White
20. Tidy’s physiotherapy – ann Thomson, Alison Skinner
21. The Adult Spine – John W Frymoyer
22. Therapeutic Exercise – Crolyn Kisner
23. Principles of Exercise Therapy - Dena Gardinez
Index
A IVD prolapse 83
physiotherapy 84
Abdominal weight exercises 73
signs and symptoms 82
Adson or Scalene maneuver 52
Cervical disc prolapse 39
Allen test 52
Cervical rib 45
Anterior scalenus syndrome 46
Cervical spondylosis 38
Arm abduction test 52
Articulations of vertebral segments 10 Claviculo costal syndrome 46
Clonus 52
Compression syndrome 45
B
Core protein 15
Back bones 4 Costo-clavicular maneuver 53
Back muscles 12 Cryotherapy 62
Back pain 1, 24, 25, 31 ice cube massage 62
factors 25 ice packs 62
psychological aspect 24 ice towel 62
treatment 2
Brachial neuralgia 36, 75, 123 D
brachial neuralgia assessment 48
brachial plexus lesion 40 Deep heating modalities 59
causes 37 microwave diathermy 60
cervical disc prolapse 39 short wave diathermy 59
cervical spondylosis 38 ultrasound therapy 60
clinical character 37 Derangement syndrome 117
prevention 75 Descending pain control 23
thoracic outlet syndrome 43 Diaphragmatic breathing 73
treatment of cervical conditions 55 Disc prolapse 79, 81
Brachial plexus injuries, treatment 67 Distraction test 52
early stage management 67 Dysfunction syndrome 117
late stage treatment 69
middle stage management 68 E
Brachial plexus lesion 40
Ergonomics 124
C for school pupils 130
posture in carrying 133
Cauda equina 17, 80, 95 posture in standing at a work-
Cauda equina syndrome 120 place 124
Central disc prolapse 82 sitting at desk 125
investigation 83 sitting in the class 131
sitting with computers 126 causes 77

while driving a car 132 corsets 92
diagnosis 91
F ergonomics 123
exercise 106
Fenestration technique 120 fitness test 100
Fitness tests for low back pain 100 intervertebral disc prolapse 78
bent knee sit-up 100 lumbar spondylolisthesis 90
bilateral straight leg raise 101 lumbar spondylosis 94
double leg raise 103 lumbar stenosis 95
forward bending 100 McKenzie techniques 117
lateral trunk lift 102 osteoporosis 96
single leg knee – chest position 102 pathophysiology 90
test evaluation 104 physical therapy 105
upper back raise 103 physiotherapy management 110
physiotherapy management
G following surgery 121
position for sex 137
Gate control theory 23, 66 sciatic nerve 85
spina bifida 96
I spinal manipulation 118
spinal osteitis 98
Idiopathic low back pain, treatment 97 surgical procedure and treatment
Interferential therapy 62 120
mobilization 63 treatment 91
stabilization exercises 63 working diagnosis 99
strengthening exercises of neck 63 Lumbar back muscles 11
therapeutic massage 63 Lumbar pelvic rhythm 7
Intervertebral discs 13 Lumbar traction 112
Intra-abdominal pressure 12
Inversion traction, contraindication M
115
Manipulation 118
L aims 118
contraindication 119
Lateral disc prolapse effects 119
signs and symptoms 81 indication 119
Lifting muscle action 12 techniques 119
Ligaments and its function 13 Manual lumbar traction 112
Link protein 15 Manual muscle testing 50
Loaded state of disc 15 Muscle action of neck 9
Low back pain 77, 105 Muscles of spine
and sex 136 intertransversarii lateralis 11
assessment for 98 psoas major 11
back care advice 116 quadratus lumborum 11
Index 143
O Pre- and post-ganglionic lesion 41

Prime movers of neck 8
Osteoporosis, goals and treatment 96 Prime movers of trunk 8
Provocative elevation test 53
P
Pain 18, 36 R
aetiology 18 Repeated unit 14
factors affecting 19 Root avulsion injuries 42
inhibitary mechanisms 22 Rotators and lateral flexors 12
method to pain relief 21
origin 20
S
physiotherapy treatment 22
purpose of 18 Scapula retractors 71
receptors 19 Sciatica 86
stimulation 20 functional sciatica 89
types 19 ganglionic sciatica 88
Pain assessment scales 48 neuritis sciatica 88
Parts of vertebra 5 radicular sciatica 88
Pectoralis minor syndrome 46 referred sciatica 88
Pelvic rotation 7
spinal sciatica 87
Pelvic tilt
Spinal cord 16
anterior pelvic tilt 7
Spinal stenosis and intervertebral
lateral pelvic tilt 7
herniation, difference 95
posterior pelvic tilt 7
Pin prick pain 19 Spinal traction
Positional traction 113 contraindications 111
Post-operative physiotherapy precautions 111
management 64 Spondylosis 94
Postural syndrome 117 Spurling neck compression test 52
Posture 26, 32, 98 Subligamentous prolapse 79
common faulty postures 30 Superficial thermotherapy
flat low back posture 34 hot packs 58
flat upper back posture 35 hydro collateral pad 59
lordotic posture 33 infrared radiation 59
normal posture 28
pain related to poor posture 26 T
postural control 27
postural problems and pain 32 TENS 110
relaxed posture 33 Tension myositis 110
round back posture 34 Therapeutic exercise 2
scoliosis 35 Thoracic outlet syndrome manage-
slouched posture 31 ment 69
types of 27 control symptoms 70
physiotherapy aims 69 Turner syndrome 47

restore muscle balance 71 Typist’s syndrome 29
restore the normal length of
muscles 70 V
surgical treatment 74
Vertebral bones 3
Transcutaneous electrical nerve
stimulation 66, 110
Trapezius syndrome 29 W
Treatment of cervical conditions 55 Water inhibition of nucleus 15
manual procedure 56
mechanical traction 57 Z
traction 55
Trunk action 9 Zygapophyseal joints 10, 16

Treatment of Neck and Back Pain MASUD

Transféré par

Informations du document

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Treatment of Neck and Back Pain MASUD

Transféré par

Droits d'auteur :

Formats disponibles

Treatment

Vinayagam Deiva Sigamani

Principal, Professor and Head of Department

Treatment of Neck and Back Pain

© 2007, Vinayagam Deiva Sigamani

First Edition: 2007

This book has been written to provide knowledge in treatment

Finally, through this book, I have given how to manage patient

Vinayagam Deiva Sigamani

xi. Physical Therapy for Low Back Pain ............................... 105

Bibliography ........................................................................... 139

Index ....................................................................................... 141

Fig. 1.1: Vertebral column

Fig. 1.2: Vertebral load

The treatment and prevention of back pain have increased the

Axial skeleton forms upright of the body. It consists of head, thorax,

Fig. 2.1: Vertebral curves

BACK BONES (Fig. 2.2)

• Spinous • Short, shout bifid • Long slender point • Thick point

PARTS OF VERTEBRA (Fig. 2.3)

Fig. 2.3: Superior view vertebra

11. Articular process projecting superiorly and inferiorly off the

Fig. 2.4: Side view of vertebra

Posterior Pelvic Tilt

Lateral Pelvic Tilt

Lumbar Pelvic Rhythm

Fig. 2.5: Lumbar pelvic rhythm

PRIME MOVERS OF NECK

PRIME MOVERS OF TRUNK

MUSCLE ACTION OF NECK

Nerve - Eight through twelfth intercostals

ARTICULATIONS OF VERTEBRAL SEGMENTS

LUMBAR BACK MUSCLES (Fig. 2.6)

About 50 percent of extension power of the lumbar spine is provided

Fig. 2.6: Back muscles

through the erector spinae aponeurosis. 50 percent is exerted by

LIFTING MUSCLE ACTION

ROTATORS AND LATERAL FLEXORS

Lateral flexion same side iliocostalis, longissimus, spinalis,

LIGAMENTS AND ITS FUNCTION

Intervertebral disc consists of three components:

Proteoglycon units are formed when several glycoaminoglycons

LOADED STATE OF DISC AND SELF STABILIZATION

WATER INHIBITION OF NUCLEUS

Fig. 2.7: Loading over vertebral column

Fig. 2.8: Inter vertebral disc

border of the Vertebra L1 or upper border of L2 Vertebra. It is about

Pain is defined as “an unpleasant sensory and emotional experience

FACTORS AFFECTING PERCEPTION OF PAIN

Past Experience of Pain

lamina—later spinothalamic tract. Transmits pain at a speed of 15 m/

Slow Pain (Aching, Throbing, Burning)

Pain from Autonomous Nervous System

Pain from Thalamic (Thalamic Pain)

Pain from Periphery

COGNETIVE BEHAVIORAL METHOD TO PAIN RELIEF

PHYSIOTHERAPY TREATMENT IN PAIN

Physical Agent (Analgesic Type) Effects as follows:

Gate Control Theory

Descending Pain Control

Side effects: Nausea, vomiting, sedation, suppression of cough.

PSYCHOLOGICAL ASPECT OF BACK PAIN

Psychiatric evaluation may help to unravel symptoms and signs in

Three factors must be consider for back pain: