Class Consensus

Low Back Pain

Physiotherapy Batch 2016

Definition

Low back pain is defined as pain and discomfort, localised below the
costal margin and above the inferior gluteal folds, with or without leg pain. It is
one of the most commonest cause of seeking physician office visits, secound
cause of sick leave, and because of high direct and indirect costs it has great
medical, social and economic impact for individual, family and society.

Pain in the low back can be a result of conditions affecting the bony
lumbar spine, discs between the vertebrae, ligaments around the spine and discs,
spinal cord and nerves, muscles of the low back, internal organs of the pelvis and
abdomen, and the skin covering the lumbar area. Spinal degenerative disorders,
such as disc herniation, spinal stenosis, and degenerative spondylolisthesis may
lead to LBP.

Epidemiology

LBP represents a major social and economic problem. The prevalence of

CLBP is estimated to range from 15 to 45% in French healthcare workers; the
point prevalence of CLBP in US adults aged 20–69 years old was 13.1%. The
general population prevalence of CLBP is estimated to be 5.91% in Italy. The
prevalence of acute and CLBP in adults doubled in the last decade and continues
to increase dramatically in the aging population, affecting both men and women in
all ethnic groups. LBP has a significant impact on functional capacity, as pain
restricts occupational activities and is a major cause of absenteeism . Its economic
burden is represented directly by the high costs of health care spending and
indirectly by decreased productivity
 Low back pain is second only to upper respiratory illness as a cause for
visiting a physician.1 Up to two thirds of the population has low back symptoms at
some time in their lives. In 1995 there were about two worker’s compensation
claims for low back pain for every 100 workers. Seventy-five percent of patients
with acute low back pain are back to work within 1 month of the onset of
symptoms, and only 5% are disabled for more than 6 months.However, among
those with continuing pain 6 to 10 weeks after onset, most still have some
symptoms at 1 year.

Pathophysiology

Pain is mediated by nociceptors, specialized peripheral sensory neurons

that alert us to potentially damaging stimuli at the skin by transducing these
stimuli into electrical signals that are relayed to higher brain centers 35.
Nociceptors are pseudo-unipolar primary somatosensory neurons with their
neuronal body located in the DRG. They are bifurcate axons: the peripheral
branch innervates the skin and the central branches synapse on second-order
neurons in the dorsal horn of the spinal cord. The second-order neurons project to
the mesencephalon and thalamus, which in turn connect to somatosensory and
anterior cingulate cortices in order to guide sensory-discriminative and affective-
cognitive features of pain, respectively. The spinal dorsal horn is a major site of
integration of somatosensory information and is composed of several interneuron
populations forming descending inhibitory and facilitatory pathways, able to
modulate the transmission of nociceptive signals. If the noxious stimulus persists,
processes of peripheral and central sensitization can occur, converting pain from
acute to chronic. Central sensitization is characterized by the increase in the
excitability of neurons within the central nervous system, so that normal inputs
begin to produce abnormal responses . It is responsible for tactile allodynia, that is
pain evoked by light brushing of the skin, and for the spread of pain
hypersensitivity beyond an area of tissue damage. Central sensitization occurs in a
number of chronic pain disorders, such as temporomandibular disorders, LBP,
osteoarthritis, fibromyalgia, headache, and lateral epicondylalgia. Despite
improved knowledge of the processes leading to central sensitization, it is still
difficult to treat. Peripheral and central sensitization have a key role in LBP
chronification. In fact, minimal changes in posture could easily drive long-lasting
inflammation in the joints, ligaments, and muscles involved in the stability of the
low back column, contributing to both peripheral and central sensitization.
Furthermore, joints, discs, and bone are richly innervated by A delta fibers whose
continuous stimulation could easily contribute to central sensitization

Etiology

a. HNP

Herniation of the nucleus pulposus (HNP) occurs when the

nucleus pulposus (gel-like substance) breaks through the anulus fibrosus
(tire-like structure) of an intervertebral disc (spinal shock absorber).
Disk herniation is most often the result of a gradual, aging-related
wear and tear called disk degeneration. As you age, your spinal disks lose
some of their water content. That makes them less flexible and more
prone to tearing or rupturing with even a minor strain or twist.

b. Spondylolisthesis
 Spondylolisthesis is a slipping of vertebra that occurs, in most
cases, at the base of the spine. Spondylolysis, which is a defect or
fracture of one or both wing-shaped parts of a vertebra, can result in
vertebrae slipping backward, forward, or over a bone below.
Spondylolisthesis can occur as a complication of spondylolysis due
to a loss of posterior stabilisation in the affected segment. It is then
referred to as isthmic spondylolisthesis and should not be confused with
other forms of spondylolisthesis, such as degenerative spondylolisthesis.

c. Ischialgia/Sciatica

Sciatica describes leg pain that is localized in the distribution of

one or more lumbosacral nerve roots, typically L4-S2, with or without
neurological deficit. However, physicians often refer to leg pain from any
lumbosacral segment as sciatica. When the dermatomal distribution is
unclear, the descriptive phrase nonspecific radicular pattern " has been
advocated. When initially evaluating a patient with lower back and leg
pain, the physician must first determine that pain symptoms are
consistent with common activity-related disorders of the spine resulting
from the wear and tear of excessive biomechanical and gravitational
loading that some traditionally describe as mechanical.

d. Hyperlordosis Lumbar

Hyperlordosis lumbar is an increase in the lumbosacral angle

(angle formed from the first sacral bone with a normal horizontal line of
300) Where this increase in lumbar lordosis will increase the anterior
pelvis tilt and hip flexion. This increase in the lumbar curve will cause
parts the back of the lumbar functional unit will approach each other. The
facet joint will be the foundation of all body weight, even though this facet
joint does not function as a weight gain. Likewise, the intervertebral
 foramen and nerves coming out of the intervertebral foramen, the pedicles,
muscles and ligaments behind the body, will be depressed.

e. Spondylosis

Lumbar spondylosis is a chronic, noninflammatory disease caused

by degeneration of lumbar disc and/or facet joints. The etiology of lumbar
spondylosis is multifactorial. Patients with lumbar spondylosis complain
of a broad variety of symptoms including discomfort in the low back
lesion, whereas some of them have radiating leg pain or neurologenic
intermittent claudication (lumbar spinal stenosis). The majority of patients
with spondylosis and stenosis of the lumbosacral spine can be treated
nonsurgically.

f. Compression Fracture

A compression fracture occurs when part of a vertebra, or bone in

the spine, collapses. The bones of the spine have two main section. The
vertebral arch is a ring-shaped section that forms the roof of the spinal
canal and protects the spinal cord. You can feel the spinous process, a
projection from this arch, when you press on the skin in the middle of your
back. The vertebral body is the cylindrical shaped portion of the vertebral
one that lies in front and provides the majority of structural support. In a
compression fracture, the vertebral body collapses.

The most common type of compression fracture is a wedge

fracture, in which the front of the vertebral body collapses but the back
does not, meaning that the bone assumes a wedge shape. Sometimes, more
than one vertebra fractures, a condition called multiple compression
fractures. Multiple compression fractures can lead to kyphosis, a spinal
deformity when the upper back curves forward, creating the appearance of
a hunchback. In some cases, a person who experiences multiple
compression fractures may notice a loss of height. Compression fractures
usually occur in the thoracic (middle) or lumbar (lower) spine.
Symptoms

The pain most often occurs on one side of the body. Symptoms vary
depending on the site of injury, and may include the following:
 With a slipped disk in your lower back, you may have sharp pain in one
part of the leg, hip, or buttocks and numbness in other parts. You may also
feel pain or numbness on the back of the calf or sole of the foot. The same
leg may also feel weak.
 With a slipped disk in your neck, you may have pain when moving your
neck, deep pain near or over the shoulder blade, or pain that moves to the
upper arm, forearm, and fingers. You can also have numbness along your
shoulder, elbow, forearm, and fingers.

The pain often starts slowly. It may get worse:

- After standing or sitting
- At night
- When sneezing, coughing, or laughing
- When banding backward or walking more than a few yards or meters

You may also have weakness in certain muscles. Sometimes, you may not
notice it until your health care provider examines you. In other cases, you will
notice that you have a hard time lifting your leg or arm, standing on your toes on
one side, squeezing tightly with one of your hands, or other problems. Your
bladder control may be lost.

The pain, numbness, or weakness often goes away or improves a lot over weeks to
months.
Level of Severity

in spite of the hard work done by the International Association for the
Study of Pain, there remains a degree of confusion in the medical community
regarding the definitions of back pain, referred pain, radicular pain, and
radiculopathy.

Muscle tension and spasm are among the most common reasons for LBP, for
example, in patients with fibromyalgia. In other cases, LBP can be attributed to
different pain generators, with specific characteristics, such as radicular, facet
joint, sacro-iliac, and discogenic pain, as well as spinal stenosis.

1. Radicular pain

Radicular pain is pain evoked by ectopic discharges emanating from an

inflamed or lesioned dorsal root or its ganglion; generally, the pain radiates from
the back and buttock into the leg in a dermatomal distribution. Disc herniation is
the most common cause, and inflammation of the affected nerve rather than its
compression is the most common pathophysiological process. Radicular pain is
pain irradiated along the nerve root without neurological impairment. Even
though it is nociceptive pain, it is distinguished from usual nociception because
in radicular pain the axons are not stimulated along their course or in their
peripheral terminals but from the perinevrium. Radicular pain differs from
radiculopathy in several aspects. Radiculopathy impairs conduction down a
spinal nerve or its roots. The impairment of sensory fibers causes numbness
(dermatomally distributed); however, blockade of motor fibers causes weakness
(myotomal). Sensory or motor block may result in diminished reflexes. Although
radiculopathy and radicular pain often accompany one another, radiculopathy has
been observed in the absence of pain, and radicular pain may happen in the
absence of radiculopathy. It is important to underline that, contrary to popular
belief, it is not possible to make a distinction among the patterns of L4, L5, and
S1 radicular pain. estimated. In such cases, the dermatomal distribution of
numbness indicates the
2. Facet joint syndrome

Diagnosis of facet joint syndrome is often difficult and requires a careful

clinical assessment and an accurate analysis of radiological exams. Patients
usually complain of LBP with or without somatic referral to the legs terminating
above the knee, often radiating to the thigh or to the groin. There is no radicular
pattern. Back pain tends to be off-center and the pain intensity is worse than the
leg pain; pain increases with hyperextension, rotation, lateral bending, and
walking uphill. It is exacerbated when waking up from bed or trying to stand after
prolonged sitting. Finally, patients often complain of back stiffness, which is
typically more evident in the morning.

3. Sacroiliac joint pain

SIJ pain is often underdiagnosed. It has to be considered in every situation

in which the patient complains of postural LBP that worsens in a sitting position
and with postural changes. Furthermore, it is possible that SIJ pain is often strictly
related to facet joint syndromes as both are related to postural problems.

4. Lumbar spinal stenosis

The most frequent symptoms of lumbar stenosis are midline back pain,
radiculopathy with neurologic claudication, motor weakness, paresthesia, and
impairment of sensory nerves. Symptoms may have a different distribution
depending on the type of LSS. If the LSS is central, there may be involvement of
the area between the facet joints, and pain may be bilateral in a non-dermatomal
distribution. With lateral recess stenosis, symptoms are usually found
dermatomally because specific nerves are compressed, resembling unilateral
radiculopathy. Trunk flexion, sitting, stooping, or lying can all ease the
discomfort, while prolonged standing or lumbar extension can aggravate the pain.
Sitting or lying down become less effective in alleviating pain as the condition
progresses, and rest pain or a neurogenic bladder can develop in severe cases.
Neurogenic claudication pain is the classical symptom of LSS, caused by venous
congestion and hypertension around nerve roots. Pain is exacerbated by standing
erect and by downhill ambulation but alleviated with lying supine more than
prone, sitting, squatting, and lumbar flexion.

5. Discogenic pain

Despite numerous recent advances, the main issue is how inflammation is

initiated and sustained to lead to CLBP. A possible explanation could involve the
growth of nerves capable of signaling pain deep into the annular structures.

Level of Pain

1. Faint paint
Your mobility and activities of daily living are in no way impacted. You feel

no need to seek treatment or medical attention

2. Mild pain
You are aware of the lower back pain but it is very easy to ignore. You do not
notice any restriction in movement of your back.
3. Moderate pain

Uncomfortable but tolerable level of pain in your lower back that is noticeable but
easy to forget or ignore over time. You are able to continue daily activities and
your quality of life is not yet impacted.
4. Uncomfortable pain

This level of throbbing lower back pain that is constantly on your mind. Over time
and untreated, this level of pain will impede your ability to live a normal life. Pain
that has started in your lower back may now be spreading to your hips, groin,
arms, legs or upper back.
Interferes with many activities of daily living and requires changes to daily
lifestyle to manage pain symptoms. Lower back pain is more noticeable and it
becomes increasingly important to seek treatments.
Examples
 Deep lumbar pain
 Deep muscle strain
 Piercing ligament strain
 Microscopic muscle tear
 Sacroiliac joint disease

5. Distracting pain
Piercing deep, penetrating lower back pain that makes it difficult to manage your
activities of daily living. The pain becomes consistently noticeable and you
become more anxious and psychologically impacted by your pain symptoms.

7. UNMANAGABLE PAIN

The level of radiating lower back pain is completely dominating your mindset and
outlook on recovery. You are reaching a point where your pain level is impeding
your ability to operate daily functions and cognitive thinking. Management of this
level of pain requires more medical expertise, prescription drugs, and the level of
severity has you considering surgery (eg. spinal cord stimulation) as a treatment
option.

8. INTENSE PAIN

Your pain is so intense that you can no longer think clearly and are experiencing
personality changes. Your lower back is experiencing shooting pain that results in
numbness, tingling, and extreme discomfort where it impedes your ability to be
mobile and active.
9. SEVERE PAIN
This level of excruciating pain is so intense that you are unable to tolerate the
level of pain and are seeking stronger medications, surgery, and emergency
psychological intervention to manage the pain.
At this stage you are no longer able to engage in normal activities and seeking
support from a caregiver, stronger medications, are in the market for potential
surgery, or are seeking less invasive surgical solutions like spinal cord stimulation
to help improve your ability to function independently. Examples
 Bulging disc
 Cauda equing syndrome
 Crushed lower back
 Complex regional pain syndrome
 Crushed vertebra
 Herniated disc
 Severe fall
 Severe car accident
 Slipped discs
 Spinal stenosis
 Spinal trauma

10. DEBILITATING PAIN

This unimaginable level is so intense you may go unconscious. This type of pain
is likely incurred during a severe accident (eg. spinal trauma) and your body is
unable to recover on its own. Emergency treatment is needed.

Treatment

Treatment for low back pain generally depends on whether the pain is acute or
chronic. In general, surgery is recommended only if there is evidence of
worsening nerve damage and when diagnostic tests indicate structural changes for
which corrective surgical procedures have been developed.
Conventionally used treatments and their level of supportive evidence include:

1. Hot or cold packs have never been proven to quickly resolve low back injury;
however, they may help ease pain and reduce inflammation for people with
acute, subacute, or chronic pain, allowing for greater mobility among some
individuals.

2. Activity: Bed rest should be limited. Individuals should begin stretching

exercises and resume normal daily activities as soon as possible, while
avoiding movements that aggravate pain. Strong evidence shows that persons
who continue their activities without bed rest following onset of low back
pain appeared to have better back flexibility than those who rested in bed for
a week. Other studies suggest that bed rest alone may make back pain worse
and can lead to secondary complications such as depression, decreased
muscle tone, and blood clots in the legs.

3. Strengthening exercises, beyond general daily activities, are not advised for
acute low back pain, but may be an effective way to speed recovery from
chronic or subacute low back pain. Maintaining and building muscle strength
is particularly important for persons with skeletal irregularities. Health care
providers can provide a list of beneficial exercises that will help improve
coordination and develop proper posture and muscle balance. Evidence
supports short- and long-term benefits of yoga to ease chronic low back pain.

4. Physical therapy programs to strengthen core muscle groups that support the
low back, improve mobility and flexibility, and promote proper positioning
and posture are often used in combinations with other interventions.

5. Medications: A wide range of medications are used to treat acute and chronic
low back pain. Some are available over the counter (OTC); others require a
physician’s prescription. Certain drugs, even those available OTC, may be
unsafe during pregnancy, may interact with other medications, cause side
effects, or lead to serious adverse effects such as liver damage or
gastrointestinal ulcers and bleeding. Consultation with a health care provider
is advised before use. The following are the main types of medications used
for low back pain:

a. Analgesic medications are those specifically designed to relieve pain.

They include OTC acetaminophen and aspirin, as well as prescription
opioids such as codeine, oxycodone, hydrocodone, and morphine.
Opioids should be used only for a short period of time and under a
physician’s supervision. People can develop a tolerance to opioids and
require increasingly higher dosages to achieve the same effect. Opioids
can also be addictive. Their side effects can include drowsiness,
constipation, decreased reaction time, and impaired judgment. Some
specialists are concerned that chronic use of opioids is detrimental to
people with back pain because they can aggravate depression, leading
to a worsening of the pain.
b. Nonsteroidal anti-inflammatory drugs (NSAIDS) relieve pain and
inflammation and include OTC formulations (ibuprofen, ketoprofen,
and naproxen sodium). Several others, including a type of NSAID
called COX-2 inhibitors, are available only by prescription. Long-term
use of NSAIDs has been associated with stomach irritation, ulcers,
heartburn, diarrhea, fluid retention, and in rare cases, kidney
dysfunction and cardiovascular disease. The longer a person uses
NSAIDs the more likely they are to develop side effects. Many other
drugs cannot be taken at the same time a person is treated with NSAIDs
because they alter the way the body processes or eliminates other
medications.
c. Anticonvulsants—drugs primarily used to treat seizures—may be useful
in treating people with radiculopathy and radicular pain.
d. Antidepressants such as tricyclics and serotonin and norepinephrine
reuptake inhibitors have been commonly prescribed for chronic low
back pain, but their benefit for nonspecific low back pain is unproven,
according to a review of studies assessing their benefit.
 e. Counter-irritants such as creams or sprays applied topically stimulate
the nerves in the skin to provide feelings of warmth or cold in order to
dull the sensation of pain. Topical analgesics reduce inflammation and
stimulate blood flow.

6. Spinal manipulation and spinal mobilization are approaches in which

professionally licensed specialists (doctors of chiropractic care) use their
hands to mobilize, adjust, massage, or stimulate the spine and the surrounding
tissues. Manipulation involves a rapid movement over which the individual
has no control; mobilization involves slower adjustment movements. The
techniques have been shown to provide small to moderate short-term benefits
in people with chronic low back pain. Evidence supporting their use for acute
or subacute low back pain is generally of low quality. Neither technique is
appropriate when a person has an underlying medical cause for the back pain
such as osteoporosis, spinal cord compression, or arthritis.

7. Traction involves the use of weights and pulleys to apply constant or

intermittent force to gradually “pull” the skeletal structure into better
alignment. Some people experience pain relief while in traction, but that relief
is usually temporary. Once traction is released the back pain tends to return.
There is no evidence that traction provides any longterm benefits for people
with low back pain.

8. Acupuncture is moderately effective for chronic low back pain. It involves the
insertion of thin needles into precise points throughout the body. Some
practitioners believe this process helps clear away blockages in the body’s life
force known as Qi (pronounced chee). Others who may not believe in the
concept of Qi theorize that when the needles are inserted and then stimulated
(by twisting or passing a low-voltage electrical current through them)
naturally occurring painkilling chemicals such as endorphins, serotonin, and
acetylcholine are released. Evidence of acupuncture’s benefit for acute low
back pain is conflicting and clinical studies continue to investigate its
benefits.
9. Biofeedback is used to treat many acute pain problems, most notably back
pain and headache. The therapy involves the attachment of electrodes to the
skin and the use of an electromyography machine that allows people to
become aware of and selfregulate their breathing, muscle tension, heart rate,
and skin temperature. People regulate their response to pain by using
relaxation techniques. Biofeedback is often used in combination with other
treatment methods, generally without side effects. Evidence is lacking that
biofeedback provides a clear benefit for low back pain.

10. Nerve block therapies aim to relieve chronic pain by blocking nerve
conduction from specific areas of the body. Nerve block approaches range
from injections of local anesthetics, botulinum toxin, or steroids into affected
soft tissues or joints to more complex nerve root blocks and spinal cord
stimulation. When extreme pain is involved, low doses of drugs may be
administered by catheter directly into the spinal cord. The success of a nerve
block approach depends on the ability of a practitioner to locate and inject
precisely the correct nerve. Chronic use of steroid injections may lead to
increased functional impairment.

11. Epidural steroid injections are a commonly used short-term option for
treating low back pain and sciatica associated with inflammation. Pain relief
associated with the injections, however, tends to be temporary and the
injections are not advised for long-term use. An NIH-funded randomized
controlled trial assessing the benefit of epidural steroid injections for the
treatment of chronic low back pain associated with spinal stenosis showed
that long-term outcomes were worse among those people who received the
injections compared with those who did not.

12. Transcutaneous electrical nerve stimulation (TENS) involves wearing a

battery-powered device consisting of electrodes placed on the skin over the
painful area that generate electrical impulses designed to block incoming pain
signals from the peripheral nerves. The theory is that stimulating the nervous
system can modify the perception of pain. Early studies of TENS suggested
 that it elevated levels of endorphins, the body’s natural pain-numbing
chemicals. More recent studies, however, have produced mixed results on its
effectiveness for providing relief from low back pain.

Surgery

When other therapies fail, surgery may be considered an option to relieve pain
caused by serious musculoskeletal injuries or nerve compression. It may be
months following surgery before the patient is fully healed, and he or she may
suffer permanent loss of flexibility.

Surgical procedures are not always successful, and there is little evidence to show
which procedures work best for their particular indications. Patients considering
surgical approaches should be fully informed of all related risks. Surgical options
include:

1. Vertebroplasty and kyphoplasty are minimally invasive treatments to repair

compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty
uses three-dimensional imaging to assist in guiding a fine needle through the
skin into the vertebral body, the largest part of the vertebrae. A glue-like bone
cement is then injected into the vertebral body space, which quickly hardens to
stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior
to injecting the bone cement, a special balloon is inserted and gently inflated to
restore height to the vertebral structure and reduce spinal deformity.

2. Spinal laminectomy (also known as spinal decompression) is performed when

spinal stenosis causes a narrowing of the spinal canal that causes pain,
numbness, or weakness. During the procedure, the lamina or bony walls of the
vertebrae, along with any bone spurs, are removed. The aim of the procedure is
to open up the spinal column to remove pressure on the nerves.

3. Discectomy or microdiscectomy may be recommended to remove a disc, in

cases where it has herniated and presses on a nerve root or the spinal cord,
which may cause intense and enduring pain. Microdiscectomy is similar to a
 conventional discectomy; however, this procedure involves removing the
herniated disc through a much smaller incision in the back and a more rapid
recovery. Laminectomy and discectomy are frequently performed together and
the combination is one of the more common ways to remove pressure on a
nerve root from a herniated disc or bone spur.

4. Foraminotomy is an operation that “cleans out” or enlarges the bony hole

(foramen) where a nerve root exits the spinal canal. Bulging discs or joints
thickened with age can cause narrowing of the space through which the spinal
nerve exits and can press on the nerve, resulting in pain, numbness, and
weakness in an arm or leg. Small pieces of bone over the nerve are removed
through a small slit, allowing the surgeon to cut away the blockage and relieve
pressure on the nerve.

5. Intradiscal electrothermal therapy (IDET) is a treatment for discs that are

cracked or bulging as a result of degenerative disc disease. The procedure
involves inserting a catheter through a small incision at the site of the disc in
the back. A special wire is passed through the catheter and an electrical current
is applied to heat the disc, which helps strengthen the collagen fibers of the
disc wall, reducing the bulging and the related irritation of the spinal nerve.
IDET is of questionable benefit.

6. Nucleoplasty, also called plasma disc decompression (PDD), is a type of laser

surgery that uses radiofrequency energy to treat people with low back pain
associated with mildly herniated discs. Under x-ray guidance, a needle is
inserted into the disc. A plasma laser device is then inserted into the needle and
the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the
tissue in the disc, reducing its size and relieving pressure on the nerves. Several
channels may be made depending on how tissue needs to be removed to
decompress the disc and nerve root.

7. Radiofrequency denervation is a procedure using electrical impulses to

interrupt nerve conduction (including the conduction of pain signals). Using x-
 ray guidance, a needle is inserted into a target area of nerves and a local
anesthetic is introduced as a way of confirming the involvement of the nerves
in the person’s back pain. Next, the region is heated, resulting in localized
destruction of the target nerves. Pain relief associated with the technique is
temporary and the evidence supporting this technique is limited.

References

1. Vrbanić TS. Reumatizam. 2011;58(2):105-7. Review. Croatian.

2. Johns Creek (2016). Herniated disk. Journal of Smart Engage. Diseases &
ConditionsRetrievedfrom https://remote-
lib.ui.ac.id:2155/docview/2085068562/fulltext/4C456F549A594F39PQ/1?acc
ountid=17242
3. Spine Universe, ‘Herniated Discs: Definition, Progression, and Diagnosis‘, 24
April 2018, <https://www.spineuniverse.com/conditions/herniated-
disc/herniated-discs-definition-progression-diagnosis > [Retrieved 19
September 2018]
4. Marchetti PG, Bartolozzi P. Spondylolisthesis: classification of
spondylolisthesis as a guideline for treatment. Textbook of spinal surgery.
Philadelphia: Lippincott-Raven, 1997
5. Wheeler AH. Diagnosis and management of low back pain and sciatica. Am
Fam Physician. 1995 Oct. 52(5):1333-41, 1347-8.
6. https://www.physiopedia.com/Low_Back_Pain_Related_to_Hyperlordosis
7. Meta-analysis: exercise therapy for nonspecific low back pain.
8. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW
9. Ann Intern Med. 2005 May 3; 142(9):765-75.
10. Jenis, A. (n.d.). Vertebral Compression Fracture. (M. F. William C. Shiel Jr.,
Editor) Retrieved September 27, 2018, from
https://www.emedicinehealth.com/vertebral_compression_fracture/article_em
.htm#when_to_seek_medical_care_for_vertebral_compression_fracture
11. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81
12. Hunt SP, Mantyh PW: The molecular dynamics of pain control. Nat Rev
Neurosci. 2001;2(2):83–91. 10.1038/35053509
13. Dubin AE, Patapoutian A: Nociceptors: the sensors of the pain pathway. J
Clin Invest. 2010;120(11):3760–72. 10.1172/JCI42843
14. Julius D, Basbaum AI: Molecular mechanisms of
nociception. Nature.2001;413(6852):203–10. 10.1038/35093019
15. Nijs J, Malfliet A, Ickmans K, et al. : Treatment of central sensitization in
patients with 'unexplained' chronic pain: an update. Expert Opin
Pharmacother.2014;15(12):1671–83. 10.1517/14656566.2014.925446
16. "Back Pain Fact Sheet", NINDS, Publication date December 2014.