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ANATOMY AND BIOMECHANICS OF THE LUMBAR SPINE (Braddom, 2000) General concepts - The lumbar spine has 2 role in terms of function, which is strength coupled with flexibility. The typical lordotic framework of the lumbar spine assists with this flexibility but also increases the ability of the lumbar spine to absorb shock, which is important role due to the amount of forces that travel through the spine on a regular basis. The pars is the site of stress fractures (spondylolysis), because it is subjected to large bending forces as the forces transmitted by the vertically oriented lamina undergo a change in direction into the horizontally oriented pedicle.

The vertebrae - The bony anatomy of the lumbar spine consists of five lumbar vertebrae. The lumbar vertebrae have distinct components, which include the vertebral body, the neural arch, and the posterior elements. The vertebral body increase in size as you travel down the spine. The sides of the bony neural arch are the pedicles, which are thick pillars that connect the posterior elements to the vertebral bodies. The posterior elements consist of the laminae, the articular processes, and the spinous processes. The superior and inferior articular processes of adjacent vertebrae create the zygapophyseal joints. The pars interarticularis is a part of the lamina between the superior and inferior articular processes.

The joints The intervertebral disk - The intervertebral disk and its attachment to the vertebral end plate are considered a secondary cartilaginous joint, or symphysis. - The disk consists of the internal nucleus pulposus and the outer annulus fibrosus. - The nucleus pulposus is the gelatinous inner section of the disk. It consists of water, proteoglycans and collagen. At birth the nucleus pulposus is 90% water. - Disks desiccate and degenerate as we age, and lose some of their height, which is one reason we are slightly shorter in our geriatric years. - The annulus fibrosus consists of concentric layers of fibers at oblique angles to each other, which help to withstand strains in any direction. The outer fibers of the annulus comprise more collagen, and less proteoglycans and water, than the inner fibers. - The varying composition supports the outer fibers functional role in acting more as a ligament to resist flexion, extension, rotation, and distraction forces. - The main function of the intervertebral disk is shock absorption. The zygapophyseal joints - The zygapophyseal joints (Z joints) are paired synovial joints, they have a synovium and a capsule. - The lumbar Z joints lie in the sagittal plane, and thus primarily allow flexion and extension, although some lateral bending and very little rotation are allowed, which limit torsional stress on the lumbar disks.

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The majority of flexion and extension (90%) occurs at the L4-5, thus contributing to the high prevalence of disk problems at these levels. Biomechanics - Because flexion loads the anterior disk, the nucleus is displaced posteriorly. If the forces are great enough, the nucleus can herniate through the posterior annular fibers. - The posterolateral portion of the disk is most at risk, with forward flexion accompanied by lateral bending. The ligaments - There are 2 mains sets of ligaments of the lumber spine; longitudinal ligaments and segmental ligaments. - The two longitudinal ligaments are the anterior and posterior longitudinal ligaments. The anterior longitudinal ligament acts to resist extension, translation, and rotation, whereas the posterior longitudinal ligament acts to resist flexion. - The main segmental ligament is the ligamentum flavum, which is a paired structure joining adjacent laminae and is the ligament that is pierced when performing lumbar punctures. It is a very strong ligament but also elastic enough to allow flexion. - The other segmental ligaments are the supraspinous, interspinous, and intertransverse. - The supraspinous ligaments are the strong ligaments that join the tips of adjacent spinous processes and act to resist flexion. These ligaments, along with the ligamentum flavum, act to restrain the spine and prevent excessive shear forces in forward bending. The muscles Muscles with origin on the lumbar spine - The posterior muscles include the latissimus dorsi and the paraspinals. The lumbar paraspinals consist of the erector spinae (iliocostalis, longissimus, and spinalis), which act as the chief extensors of the spine, and the deep layer (rotators and multifidi). - The multifidi are tiny segmental stabilizers that act to control lumbar flexion, because they cannot produce enough force to truly extend the spine. Their more important function has been hypothesized as more of a sensory organ to provide proprioception for the spine. - The anterior muscles of the lumbar spine include the psoas and quadratus lumborum. - Psoas have a direct attachment on the lumbar spine, tightening this muscle emphasize the normal lumbar lordosis. This can increase forces on the posterior elements and can contribute to Z joint pain. - The quadratus lumborum acts in side bending and can assist in lumbar flexion. Abdominal musculature - The superficial abdominals include the rectus abdominis and external obliques. - The deep layer consists of internal obliques and the transversus abdominis. - The tranversus abdominis has received significant attention over the recent past as an important muscle to train in treating low back pain. Its connection to the thoracolumbar fascia (and consequently its ability to act on the lumbar spine) has probably been the major reason it has received such attention of late. Thoracolumbar fascia - The thoracolumbar fascia, with its attachments to the transversus abdominis and internal obliques, acts as in abdominal and lumbar brace. - It decreases some of the shear forces that other muscles and lumbar motion create. -

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Pelvic stabilizers - The pelvic stabilizers are considered core muscles due to their indirect effect on the lumbar spine, even though they do not have direct attachment to the spine. - The gluteus medius stabilizes the pelvis during gait. Weakness or inhibition of this muscle results in pelvic instability. - The piriformis, as a hip and sacral rotator, can cause excessive external rotation of the hip and sacrum when nit is tight. This can result in increased shear forces at the lumbosacral junction. The medial branch innerbates the zygapophyseal joints and lumbar multifidi and is the target during radiofrequency neurotomy for presumed zygopophyseal joint pain. LOW BACK PAIN A. Definition LBP began with the development of bipedal ambulation and the requirement for a flexible multiaxial spinal column. It is a syndrome and not a disease. Pain is usually felt in the low lumbar, lumbosacral or sacroiliac regions. It is often accompanied by sciatica which is pain radiating down one or both buttocks in the distribution of the sciatic nerve. B. Epidemiology Biomechanical lifting in relation to muscular activity and disk loads - The activity of the lumbar muscles correlates well with intradiskal pressures. These pressures change depending on spine posture and the activity undertaken. The nerves - The conus medullaris ends at the bony level L2. And below this level is the cauda equina. - The cauda equina consists of the dorsal and ventral rootlets, which join together in the intervertebral neuroforamen to become the spinal nerves. - The spinal nerve gives of the ventral primary ramus, which, together from the other levels, forms the lumbar and lumbosacral plexus to innervate the limbs. - The dorsal primary ramus, with its three branches (medial, intermediate, and lateral), innervates the posterior half of the vertebral body, the paraspinal muscles, and the zygapophyseal joints, and provides sensation to the back. Low back pain can happen anywhere below the ribs and above the legs. The lower back is the connection between the upper and lower body, and it bears most of the bodys weight. So it's pretty easy to hurt your back when you lift, reach, or twist. In fact, almost everyone has low back pain at one time or another. It can be caused by different entities. May be affected by various psychosocial factors. (De Lisa, 1998) Statistics appear in the literature that, in some stages in life, most human beings (80%) will experience low back pain, with 2 - 5% of the average population seeking medical attention. It is of interest that disabling LBP is becoming a Western Disease. In its incidence and prevalence, LBP ranks as a cause of lost working days among the Americans, 2nd only to common cold as a reason for outpatient visits. It represents the single most common and most expensive industrial and occupational health problems causing approximately $25 billion per year for direct and indirect cause. LBP appears to be most prevalent in the active working years of a persons life, age 30 to 45 years. Both sexes are affected, males more commonly affected than females with a ratio of 10:1. It tends to increase with age, reaching 50% in persons above 65 years old. Factors which contribute to the incidence of LBP

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a. occupation and workplace (i.g., drivers, material handlers, and health care workers, especially nurses) b. lifting both in and out of the workplace (esp. lifting more than 25 lbs or hand-to-hand lifting) c. lifestyle d. sporting activities (e.g. gymnastics, football, weight lifting, wrestling, dancing and rowing) C. Etiology 1. Most common LBP is caused by strain of the muscle around the lower part of the spine. This may be due to unaccustomed exercise - a weekend spent shoveling snow, for example - or sitting for prolonged periods in an unsatisfactory posture. Strains on the spine are least when the back is straight; a chair which forces the spine into a curve is likely to provoke chronic back strain. It may also be back strain due to poor posture, poor conditioning or mechanical factors like over-use, obesity or pregnancy. 2. Damage to one of the intervertebral disks in the lumbar region of the spine is most likely to occur from lifting a heavy weight while the back is curved. Pressure on the disc, which consists of a capsule and a soft, elastic center, may rupture the capsule and allow part of the central nucleus to protrude. If this protrusion extends into spinal canal it may press upon one of the spinal nerves or even the spinal cord. Protruding or ruptured IVD with subsequent herniation of the nucleus pulposus into the spinal spinal canal can cause inflammatory or direct mechanical nerve root pressure. Typically, the pressure on the disc causes pain extending down the main sciatic nerve which runs from the buttocks to the foot. The pain (sciatica) is made worse by coughing, straining, or bending the back. If the symptoms persist there may also be loss of feeling in the foot or the lower part of the leg and some muscular weakness. 3. LBP is usually related to acute ligamentous or muscular sprain or the more chronic OA or ankylosing spondylitis of the lumbosacral area. 4. Micromyalgia (Lumbago) is used to describe an acute or severe pain felt in the lower part of the back which no definite cause found. Here, the pain is often localized to one extremely painful spot in the muscle, usually in the lower lumbar regions and slightly to one side of the midline. It is often experienced after a combination of unaccustomed exercise and cold digging the garden in sprain, for example, and may be severe enough for the victim to be unable to move out of bed. The cause is believed to be spasm of a group of muscle fibers. 5. Traumatic ligament rupture, stress function of the pars interarticularis or paraspinous muscle tear 6. Fracture, infection or tumor involving the back, pelvis orretroperitoneum. 7. Bilateral loss of substance in pars interarticularis (sponylolisthesis) 8. Stenosis of the spinal canal. 9. Nonmechanical pain due to adjacent visceral disease. The causes of LBP are manifold but may be classified under the following headings: PSYCHOGENIC PAIN A purely psychogenically induced back pain is not so common. Hence, in patients who have such nervous or emotional breakdowns, the physician must prepare to accept the possibility of an underlying significant pathological process and investigate its probability. VISCEROGENIC BACK PAIN These may be derived form: a. lesions of the lesser sac b. disorders of the kidneys or pelvic viscera, and c. retroperitoneal tumors VASCULAR BACK PAIN Aneurysm or peripheral vascular disease may give rise to backache or symptoms resembling sciatica Abnormal aneurysms may present as boring type of deepseated lumbar pain unrelated to activity. Insufficiency of the superior gluteal artery may give rise to buttock pain of claudicant character, aggravated by walking, and relieved by standing still. The pain may radiate down the leg in a

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sciatic distribution. However, the pain is not precipitated or aggravated by other activities putting on specific stress on the spine such as stooping, bending, etc. Peripheral vascular disease presents with intermittent claudication or intermittent pain in the calf. This may on occasion mimic sciatic pain produced by root irritation. The symptoms produced by peripheral vascular disease may be mimicked by spinal stenosis. A patoent suffering from this condition frequently complains of pain in the legs, initiated and aggravated by the act of walking a short distance. One distinguishing feature, however, is that in spinal stenosis, the pain is not relieved by standing still. NEUROGENIC BACK PAIN This type of pain may come from: a. tension, irritation, or compression of a lumbar nerve root which causes referral of the pain symptoms down one or both leg, and is also The most common cause of neurogenic back pain, & a. lesions of the CNS, such as thalamic tumors which may present or develop a causalgic type of leg pain. Also, arachnoid irritation from any cause as well as tumors of the spinal dura may produce back pain. There are also pathological lesions which will most likely give rise to confusion in diagnosis. These are: a. neurofibroma b. neurolemma c. ependymoma, & d. other cysts and tumors involving the nerve roots that usually occur in the upper lumbar spine SPONDYLOGENIC BACK PAIN This can be derived from the spinal column and its associated structures. The pain is aggravated by activity and is relieved, to some extent, by recumbency: a.) lesions involving the bony components of the spinal column b.) changes in the sacroiliac joints and c.) changes occurring in the soft tissues. Spondylogenic back pain is said to be the most common source of low back pain seen in the clinical practice. STATIC LOW BACK PAIN Poor posture to low back pain. Excessive lordosis- a marked sway back has been a considered abnormal and a frequent cause of static low back pain. In excessive lordosis three things can occur. 1. The facets approximate with compression and can become a site of nociceptive impulses. 2. The intervertebral foramen closes and encroaches on the nerve root dura and all its contents. 3. The disc can bulge posteriorly, putting pressure on the post. longitudinal ligament. In the static spine, the vast majority o painful states can be attributed to an increase in the lumbosacral angle with a consequent accentuation of the lumbar lordosis commonly termed sway back, 75% of all static or postural low back pain is acredited to such lordosis. KINETIC LOW BACK PAIN This implies irritation of pain- sensitive tissues by movement of the lumbosacral spine. Pain can originate in one of three basic manners: 1.) Normal stress on unprepared normal back 2.) Abnormal stress on normal low back . 3.) Normal stress on a abnormal low back. D .SITES AND CAUSATION OF PAIN 1. Functional Unit composed of two vertebral bodies separated by the intervertebral disc. It is the weight bearing structure. The functional unit must be studied and understood on its function to explain the cause of pain to indicate the tissue from which pain can occur. 2. Intervertebral disc separates the two vertebrae of each functional unit. There are more than 30 disc in the entire vertebral column , but the ones that are of concern in the LBP are the 5discs of the lumbar spine. 3. Disc is a hydraulics system that keeps the vertebrae apart. It acts to cushion any balance or pressure and permits the functional unit to move in flexion to the front; extension to the back and to the side. It is made of an outer layer that is termed the annulus fibrosus nd a central core

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termed the nucleus pulposus. It is 88% water. this water is held in a gelatinous substance that has been called the matrix. 4. Longitudinal ligaments these ligaments limit the amount of bending of two adjacent vertebral bodies [pain(+)]; a.) Anterior Longitudinal ligament the ligament in the anterior aspect of the spine. b.) Posterior Longitudinal ligament - the ligament down the back of the spine. 5. Neural Canal behind the vertebral bodies in the functional unit are bones that form a canal. It contains all the nerves of the spinal cord. [pain(+)]. 6. Facets these are joints with surfaces that face each other , glide upon each other, and permit the spine to bend forward and backward, prevent the spine from rotating to the left o the right and from bending sideways to any significant degrees.[pain(+)]. Ligamentum flavum and interspinous disc normally is avascular and remains controversial as a source of pain. Intradiscal injections of irritating substances have been found to cause LBP esp. when there has been some herniation of the nucleus into the surrounding annulus. E. PATHOLOGY/ PATHOGENESIS Three aspects of LBP will be discussed: 1. exertional factor 2. change in muscle 3.changes in the facet joints and intercostal discs. The most common emotional disturbances pertaining to LBP are tension, stress, anxiety, resentment and depression. Other factors such as repeated trauma come into play to localize the site of vascular change. Any of these emotional these factors act through the autonomic nervous system to produce local areas of vasoconstriction in muscle. Vasoconstriction and sustained muscle contraction with accumulation of the metabolites leads to fatigue. This in turn leads to changes in the recruitment of motor units in an individual muscle and individual muscle group used for a particular movement. One result of these changes is an altered pattern of muscle contraction with sudden violent uncontrolled contractions of involuntary and other muscle. The result of these long term changes in muscle is that spinal movement become grossly restricted and painful. Changes in the facet joints and intervertebral discs include: a. disc protrusion any change in the shape of the annulus that causes it to bulge beyond its normal parameter. b. disc herniation 1.)prolapse a protrusion of the nucleus thats still contained by the outer layers of the annulus and supporting ligamentous structures. 2.) extrusion a protrusion in which the nuclear material ruptures through the outer annulus and lies under that posterior longitudinal ligament. 3.) free sequestration the extruded nucleus has moved away from the prolapsed area. Annular fibers breakdown may occur with fatigue loading over time which usually occurs with repeated overloading of the spine with asymmetric forward bending and torsional stresses. With torsional stresses, annulus becomes distorted most obviously at the posterolateral corner opposite the direction of rotation. The layers of the outer annulus fibrosus lose their cohesion and begin to separate from each other. Each layer then acts as separate barrier to the nuclear material. Eventually, radial tears occur and theres communication of the nuclear material between the layers. With repeated forward bending an lifting stresses, layers of the annulus are strained; they become tightly packed together in the posterolateral corner, radial fissures develop and the nuclear material radiates down the tissues. Outer layers of annular fibers can contain the nuclear material as long as they remain a continuous layer. If nucleus reaches the contents of the spinal canal or the intervertebral foramen, there will be pressure and irritation of the tissue contained therein and pain and disability results. Because the posterior longitudinal ligament lies in front of the SC, is essentially at the outer layer of the annulus, and is sensitive, LBP can result.

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F. CLINICAL MANIFESTATIONS Chronic LBP Syndrome A.K.A. Chronic Lumbosacral Strain (De lisa, 1998) Majority of instatnces underlying pathologic process is degenerative disc disease & secondary changes in facet jt. & supporting structures. Back pain > 6 mos. Accompanied by changes in pts lifestyle & behavior The longer the pein has been present,the more resistive it becomes to therapeutic intervention. Tingling paresthesias Palpable ledge on the lumbosacral spine Segmental lordosis Rectal examination may reveal a hard mass in the front of the sacrum 6. Tight SLR 7. X-ray and CT scans reveal pathogmonic factors SACROILIAC PATHOLOGY CAUSING LBP 1. Tenderness over the sacroiliac joint 2. Tenderness over the sympysis pubis 3. Pain or discomfort on attempted mobilization of the joint 4. Resisted abduction of the extended leg 5. Pain on the SI joint by hyperextending the leg 6. (-) x-rays RHEUMATIOD SPONDYLITIS 1. Aching of the low back with nocturnal discomfort-unrelated to any specific motion 2. Limited trunk flexibility 3. Decreased chest expansion on deep breath 4. Ultimately a positive antigen HLA-B27 on the blood testing 5. Fuzziness of the SI joint on the oblique x-ray view 6. Concavity of the manubrial sternal joint 7. Increased uptake on bone scan OSTEOMYELITIS 1. Urinary tract infection 2. Spread from an adjacent abscess 3. Backache not related to movement 4. Deep tenderness 5. Nocturnal pain 6. Severe muscle spasm 7. (-) x-ray; becomes (+) after 6 weeks DISKITIS; DISC SPACE INFECTION 1. Severe pain 2. Protective muscle spasm 3. (+) bone scan 4. Disc space becomes hazy 5. Needle biopsy how specific bacteria BONE TUMORS 1. Nocturnal pain 2. 3. 4. 5.

Low back pain is only a symptom, not a disease. There are other diseases of the body that can and do cause low back pain. So the clinical manifestations are associated with other symptoms of these diseases. NERVE ROOT ENTRAPMENT 1. Low back pain 2. Hypalgesias/paresthesias 3. Weakness of a specific myotome 4. Tenderness of the muscles innervated 5. If there is disc hernation a. Limited trunk flexion b. Functional scoliosis may exist c. (+) SLR d. (+) neurologic signs of a specific disc level SPONDYLOSIS 1. Early morning stiffness 2. Generalized low back aching 3. Limitation of movement (bending, twisting, and turning) 4. Certain degree of relief is noted from local heat and from ingestion of salicylates SPONDYLOLISTHESIS 1. Low back pain with referred pain laterally into the region of the sacroiliac joints

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2. Pain without precise movement 3. Weight loss INTRASPINOUS TUMORS 1. Same as disc herniation 2. (+) myelography, CT scan, MRI, bone scan and biopsy test PROGRESSION OF THE DISEASE At any one level, the intervertebral joint is made up of 3 components, formed by two posterior facet joints and a disc. Changes affecting the posterior facet joints also affect the disc and vice versa. Strains and stresses commonly affecting the lumbar spine most often result in injury to all 3 parts, but rotation is more likely to injure the facet joints while compression with flexion is more likely to injure the disc. Progression of this disease has been divided in to 3 phases (degenerative cascade): PHASE 1 SEGMENTAL DESTRUCTION State of abnormally reduced movement of the motion segment. Initial clinical presentation reflects joint dysfunction which includes reactive synovitis and articular cartilage degeneration which leads into joint pain, inflammation, and hypomobility. Clinical presentation maybe the classical sprain, strain syndrome. Low back pain maybe worst with static standing, walking, extension or extension combined with rotation. Local tenderness, muscle spasm, limited range of motion and normal neurological examination are usual findings. Examination will reveal the hypertonic state of the segmental posterior muscle at either L4-5 or L5-S1. Normal movement is restricted in one direction. PHASE 2 EXCESSIVE SEGMENTAL MOTION/TRUNK SEGMENTAL INSTABILITY Difficult to conceptualize because it is somewhat arbitrary (I and II). Anyone who has not been symptomatic may enter phase II. Abnormalities of the facet joint includes capsular laxity and joint sublaxation. Movements may not be detectable by standard lateral flexion and extension x-rays because translation occurs but the instantaneous center of rotation may move abnormally. Clinical impression appears that the quality of motion is more representative than quantity. PHASE 3 SEGMETAL STABILIZATION Facet joint become fibrosed, enlarged, and arthrosed. The intervertebral disc becomes increasingly degenerated and desiccated allowing approximation of the bertebral end-plates and osteophyte formation combination of anterior and posterior change scan manifest in ankylosis of the motion segment, although lesser degree of spondylosis are common. Spinal nerve root entrapment is relatively common in this phase. Neurogenic claudication or pseudoclaudication is typical presentation of lumbar radiculopathy in this phase. Sometimes the changes in phase I pass directly to phase 3 or sometimes may undergo phase II before it reaches III. The explanation for this is not yet known. H. MEDICAL APPROACH/TREATMENT I. DIAGNOSIS Clinical diagnosis of low back pain would include: 1. PHYSICAL EXAMINATION The examination must confirm what the history has allowed to as being a factor causing, maintaining, or aggravating the pain. It is a tissue analysis as well as a position and movement analysis clarifying where and what tissue is responsible for the pain. 2. GENERAL OBSERVATION OF THE PATIENT The manner in which the patient enters the office, sits, or stands, and approaches the examiner is revealing. The attitude of the patient depicted by the posture the tone of voice and the visual confrontation begins the examination. The first observation is the erectness of the head posture. 3. BONE SCANNING (SCINTIGRAPHY) The location of the metastic bone lesions remain the commonest indication for bone

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scanning. Bone scanning is also being used in detection of osteonecrosis, the study of failed joint prostheses and the investigation unexplained bone pain. 4. PLAIN X-RAYS In diagnosis, the main function of an x-ray is to exclude serious disease, such as infection, ankylosing spondylitis and neoplasms. 5. MYELOGRAPHY, COMPUTERIZED AXIAL TOMOGRAPHY, MRI Provide a precise definition of not only the nature of the lesion but also the location of the offending pathology. II. MEDICATION Medication should be taken 4-6 hours. Taking the medication whenever necessary can cause drug dependency. Pain medicine used focuses on the feeling of pain and its intensity whereas medicine used on a prescribed specific time schedule the buildup of pain sensation. 1. Oral anti-inflammatory drugs blocks the transmission of substances that could irritate soft tissue of the low back 2. NSAID provides antiprostaglandin B formation 3. Steroids for severe pain 4. Muscles relaxants muscular tension compresses all the inflamed tissues and restricts movements which causes pain 5. Sedatives tranquilizers 6. Anti-depressants endorphine formation 7. Intra-muscular injection an injection of an anaesthetic agent with soluble steroid inected into the multifidus triangle which frequently interrupts the painful low back pain cycle. III. SURGICAL INTERVENTION To operate merely to relieve pain is not and should not be indication for surgery. Bear in mind that pain is very subjective. 1. LAMINECTOMY AND/OR LAMINOTOMY - is the surgical approach to seeing and ultimately removing the offending disc or osteophytes Laminotomy implies removing a sufficient portion of the lamina to view the nerve within the neural canal or within the foramen. Laminectomy implies removing all the half of the lamina thus giving a larger view of the disc and nerves or widening the neural canal to free the nerve root. 2. FORAMINOTOMY - is a technique of widening a foramina that has been confirmed to be narrow or deformed by bone spur thus being narrow for the emerging nerve root. 3. NUCLECTOMY - is essentially disk surgery 4. FACETECTOMY - surgical removal of the facet joint *Failed Back Surgery a term applied for unsuccessful surgery; surgery apparently adequately performed after a clear indication for surgery that failed to accomplish its purpose. PHYSICAL THERAPY APPROACH I. ASSESSMENT Subjective Assessment: HISTORY Includes questions about the site of the pain specifically where in the low back area is the pain felt. This indicates the tissue, area of the spine that is involved. Information must also be obtained from the patient as to the onset of pain which indicates the action that initially caused the pain and ultimately may denote the position or movement that caused, causes, or aggravates the pain. Through knowledge of the mechanics of the lumbosacral spine, the movement of the spine causing the pain can be indicated. The patient must also be able to describe or characterize the pain he/she is feeling in the low back. An ache may be muscular or ligamentous. Burning may involve fascia or nerve. Soreness is often

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muscular. Stinging may be ligamentous. Tingling or shooting pain may be a nerve sensation. The intensity of the pain may indicate the severity of the tissue or this may indicate the tolerance of the patient to the pain. Objective Assessment: STRUCTURE Involves careful inspection of the area of complaint. A meaningful examination must reveal a significant structural deviation and relate it to the current symptoms. The basic axiom of evaluating the functional basis of low back pain is: If the characteristic pain can be produced by a position or by a movement and the precise relationship of that position and movement to the functional anatomy of the part is understood the cause of the pain becomes clear. EVALUATION OF POSTURE (STATIC SPINE) Posture is assessed with the patient sitting as well as in the standing position. The erect posture is examined before the patient is aware of being evaluated. Examined from the side, the relationship of all the spinal curves to the center gravity is immediately apparent: The head should be directed in the center of gravity. The shoulders should be loosely held at side with no excessive dorsal. kyphosis. The lumbar lordosis should be minimal. The abdomen should not protrude excessively. Further examination of the static postures a factor in determining postural pain requires that the postural pain must be reproduced. Manually increasing the lordosis may aggravate pain whereas decreasing the lordosis may decrease pain. The opposite effect may also be revealing. PELVIC LEVEL: LEG LENGTH The patient must stand without shoes, with legs together, feet facing forward and knees locked in extension. The examiner, who stands behind the patient, places the fingertips of both hands on the pelvic brims and sights the equal level of the two hands. The level of the iliac crests can then be determined. An obliquity can be ascertained and act degree determined by placing a board of known thickness under the: short: leg and re-examining the crest level. The length of the leg can also be measured by placing a tape measure at the anterior-superior spine prominence and measuring the distance of both legs to the medial malleolus of the ankle. With the patient supine and the legs flexed 90 at knees and hips, the height of the kneecaps can be viewed from above to measure the length of the tibia. When a significant leg length discrepancy exists, a further observation will reveal if the discrepancy is due to severe genu valgum or genu varum. A contracted gastrocsocleus muscle causing a severe foot equinus will lengthen the leg of that side as a severe genu recurvatum (knee hypertension) will shorten the leg on that side. The flexibility of the hips must also be determined as this may place a stress on the static or an impediment upon the kinetic spine. The hamstring range of motion is determined by measuring the difference of SLR, one leg against the other leg. This can be done by placing the patient supine and each leg raised slowly, then measuring the angle at the hips. The hip flexors also must have equal elongation. This is difficult, as the lumbar spine can extend, become more lordotic, and confuse which is being tested the hip flexors or the lumbar lordosis. With the patient supine and one leg held by the patient against the chest, the other leg is lowered from the side of the table. The hip joint flexibility must be tested to ascertain degenerative joint changes that can influence the static of kinetic spinal movement. The Patrick test is used. LUMBAR PELVIC RHYTHM Once totally flexed, the person is asked to return to the erect position. This is accomplished by gradual decrease of the lumbosacral kyphosis to the erect lumbar lorodsis. A faulty sequence or a limited portion of either aspect of the sequence that is noted may indicate a pattern that has led to pain and impairment. If the person regains the lumbar lordosis while the pelvis is still rotated forward, pain may occur in the low back. This premature lordosis can cause low back pain in the forward flexed position just as it can in the erect

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posture with the addition of the added weight of the body ahead of the center of gravity. The patient must also be examined not only in resuming the erect position from the bent-over position but from the bent-over and twisted (rotated) position. LATERAL ROTATION FLEXIBILITY With the patient standing erect and viewed from behind, the lateral flexibility of the spine can be tested and recorded. With both legs apart a few inches for balance, the person is passively bent top one side then the other. Note that the exclusive lateral spine flexion without rotation is physiologically impossible. Some rotation occurs with lateral flexion; thus, limitation one-sided lateral flexion indicates restriction from either soft-tissue restriction or protective spasm. PALPATION This can give valuable information about the condition of the skin, subcutaneous tissue, muscle, ligament, and bone. NEUROLOGIC EXAMINATION Determines whether there is nerve root involvement along with the low back pain. With nerve root involvement, pain may be felt in the legs as well as the back. This implies irritation of the nerve roots as they emerge from the cauda equine of the spinal cord in their passage to the legs through the foramen. The neurologic exam determines nerve irritation and reveals what nerve it is, at which level in the lumbosacral spine is often to what degree it is damaged. To test the integrity of L3: deep knee bends, stairclimbing, getting out of a chair, and so on. L3 supplies the knee jerk reflex and the anterior thigh muscles. L4 does not supply a specific muscle group and has no specific reflex. Diagnosis of L4 damage is done through testing skin sensation with a pin, light touch or a pledged of cotton on the inner side of the lower leg. L5 supplies the hallucis longus muscle which lifts the big toe. It also supplies the anterior tibialis muscle. L5 damage is seen when the anterior tibialis muscle drags the big toe when walking. S1 supplies the ankle jerk reflex. Tests for the integrity of S1 is letting the patient rise up on toes, walk on toes, jump and run. MOBILITY Assess the posture and passive active range of movement of the whole lumbar spine and its segment. SPECIAL TESTS When the examiner performs special tests in the lumbar assessment, the straight leg raise test, the prone knee bending test and the slump test should always be done. The other tests need to be done only if the examiner feels they are relevant or will confirm the diagnosis. 1. Straight Leg Raise Test Method: The subject lies supine and raises one limb to 90 of hip flexion. The hip is slightly adducted and internally rotated, and the knees are fully extended. The angle between the elevated lower limb and table at the point of onset of symptoms is noted if the test is positive. Result: Normal range should approach 80-90 of hip flexion. Limitation of range accompanied by reproduction of symptoms (lower back pain,sciatic pain or paresthesias) is a positive test result. 2. Lasegues Sign Method: The subject lies supine and flexes one lower limb at the hip to 90, with the knee and ankle in a relaxed position. With the ankle in neutral position, the knee extended until symptoms are reproduced or a full extension position is attained. Results: The result is a positive if symptoms are reproduced in the lower back or in the involved limb. 3. Prone Knee Bending (Nachlas Test) Method: the subject lies prone while the examiner passively flexes the knee as far as possible so that the patients heel rests against the buttocks, patient hip should not be rotated. If it is difficult to flex the patients knee past 90 because of pathological condition, the test may be done by passive extension of the hip while the knee is flex as much as possible.

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Result: Unilateral pain in the lumbar area may indicate al L2 or L3 nerve root lesion. The test also stretches the femoral nerve. Pain in the anterior thigh indicates tight quadriceps ms. I f the rectus femoris is tight, the examiner should remember that taking the heel to the buttocks may cause anterior torsion to the ilium, which could lead to sacroiliac or lumbar pain. The flexed knee position should be maintained for 45 to 60 seconds. 4. Slump Test Method: The subject is seated on the edge of the examining table with the legs supported, the hips in neutral position.( no rotation or abd/add.) and the handle behind the back. The patient asked to slump the back into full thoracic and lumbar flexion. The examiner maintains the chin in neutral position to prevent neck and head flexion. The examiner then uses one arm to apply over- pressure and maintain flexion of the thoracic and lumbar spines. While this position is held, the patient is asked to flex the cervical spine and head as much as possible(chin to chest). The examiner then applies overpressure to maintain flexion of all three parts of the spine. (cervical, thoracic and lumbar) using the hand of the same arm to maintain overpressure in cervical spine. With the other hand the examiner holds the patients foot in the maximum dorsiflexion. While the knee examiner holds these positions, the patient is asked to actively straighten the knee as much as possible. The test, is repeated with the other leg and then with both legs together. Results: If the patient is unable to fully extend the knee because of pain, the examiner, releases the pressure to the cervical spine and the patient actively extends the neck. If the knee extends further, the symptoms decrease with the neck extension, or the positioning of the patient increases the patient symptoms, then the test the considered positive for increased tension in the neuromeningial tract. TEST FOR DURAL SIGNS BY INCREASED TENSION ON SPINAL NERVE ROOTS 1. Straight Leg Raise (SLR) Test 2. Lasegues Sign 3. Braggards Test Method: the subject lies supine and raises the involved lower limb to the point just short of where symptoms begin. The ankle of the limb is then passively dorsiflexed. Results: the result is positive if pain is reproduced in the lower back or the involved extremity. 4. Lhermittes Test (crossed leg-straight leg raise) Method: the subject lies supine and raises the uninvolved lower limb. Results: the result is positive if pain is reproduced in the back or in the involved extremity. It may indicate evidence of a space-occupying lesion such as herniated disc in the lumbar area. 5. Brudzinkis Test Method: the subject lies supine with both hands behind the neck. The examiner helps the subject flex the head and neck and upper back. Results: A positive result is indicated by pain in the low back, pelvic girdle, or lower limb. 6. Kernigs Test Method: the subject lies supine on the examining table and places both hands behind his head to forcibly flex his head onto his chest. Result: pain in the cervical spine and occasionally, in the low back or down the legs, is an indication of meningeal irritation or nerve involvement of the dural coverings of the nerve root. 7. Soto-Hall Test Method: the subject lies supine. The examiner raises the involved lower limb, keeping it straight, to a point just short of the onset of pain. The subjects head and neck are then passively flexed. 8. Crains Test (Bowstring Test, Popliteal Pressure Test) Method: the subject lies supine. The examiner raises the involved straight leg to the point of onset of pain then slightly flexes the knee until the pain is alleviated. The knee position is maintained; the hip is flexed further to a point just short of

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the onset of pain. The examiner then press on the posterior tibial nerve where it passes through the popliteal fossa. Results: the results are positive if symptoms are reproduced. TESTS TO INCREASE INTRATHECAL PRESSURE 1. Valsalva Maneuver Method: the subject is asked to hold a breath and then bear down, as if to have a bowel movement. Results: test results are positive if the subject reports reproduction of exacerbation of spinal pain or radiating into the limb. 2. Milgrams Test Method: the subject lies supine. The examiner asks the subject to lift both lower limbs simultaneously 2 to 4 inches off the table while holding the position for 30 seconds. Results: test results are positive if the subject is unable to hold the limbs elevated for 30 seconds, or experiences reproduction of pain in the spine or radiation into the limb. 3. Naffzigers Test Method: the subject lies supine. The examiner gently compresses the internal jugular veins bilaterally for approximately 10 seconds then asks the patient to cough. Results: test results are positive if the subject experiences reproduction of pain either in the spine or the limbs. * Note: a positive result of any of the three tests above suggests either intrathecal or extrathecal pathology (e.g. disc protrusion, tumor), including the meninges themselves. after the repeated movements have been performed. Movements should be repeated as many as ten times unless the subject reports of reproduction or increased intensity or radiation of pain into the lower limb. The subjects ROM during the repeated motions must also be observed. 1. Forward Bend Standing The subject stands with the feet about 12 inches apart and is asked to run the hands down the front of the legs, as if to touch the toes, as far as can be tolerated and then return to the upright position. 2. Backward Bend Standing The subject stands with the feet 12 inches apart and the hands placed in the small of the back. The subject bends backwards over the hands then returns to the upright position. (Note: if the subject is in a lateral shift position related to the symptoms, the examiner should attempt to correct his postural fault with a side glide technique before repeated testing of backward bending). 3. Forward Bend Supine The subject is supine, grasping both knees with the hands. The subject bends forward, pulling the knees to the chest. Knee flexion eliminates compression of the spine by the body weight and tension on the nerve root. 4. Backward Bend Prone The subject lies prone with the hands positioned as if to do a push-up. The subject is asked to straighten the upper limbs and raise the trunk, keeping the pelvis and lower limbs in contact with the table and then to return to the starting position. In this position, body weight compression is diminished. Results: the results of these tests are considered to indicate disc derangement, joint or soft tissue dysfunction or a postural syndrome. TEST TO EVALUATE MALINGERING 1. Flig Sign Indication: the flip sign is used to assist in determining if the subject may be inventing symptoms.

REPEATED FORWARD AND BACKWARD BENDING: STANDING AND LYING (McKenzies Extension Principles) Indication: Repeated bending is performed to differentiate between derangement of the disc and mechanical dysfunction of other spinal structures. Method: for all of the following test, the effect of the first movement on the subjects pain is noted. The effect is noted again

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Method: if the subject has a positive SLR test when supine but when the examiner suspects malingering, the subject is requested to assume a short sitting position with the legs dangling over the side of the table. Under the guise of examining for an unrelated problem (e.g. check the knee or foot), the subject extends the knee now set up in variant of the SLR position. Results: Reproduction of stretch of an irritated nerve root should occur in both supine and sitting positions for this test. The subject who is malingering may fail to report symptoms in the variant position. The examiner should then be alerted to observe the subject carefully in the seated may merely lean back or grimace rather than verbalized the complaints. 2. Hoovers Test Indication: Hoovers Test is used to help determine whether the subject may be malingering or withholding effort. Method: with the examiner supine, the examiner places one hand under each heel then asks the subject to raise one lower limb. The examiner should feel an increase in pressure under the opposite heel as the subject tries to gain leverage with the effort. The test is repeated with opposite limb. Results: if no increased pressure is felt from the opposite limb, the subject is probably not putting forth full effort. 3. Burns Test Method: the subject is asked to kneel on a chair and bend to touch fingers to the floor. Results: the subject who is unable to perform the task or overbalances the chair is likely to be malingering. TEST TO ROCK THE SACROILIAC JOINT 1. Pelvic Rock Test Method: the subject lies supine on the examining table. The examiner places his hands on the subjects iliac crests with thumbs on the ASIS and the palms on the iliac tubercles. Then, forcibly compress the pelvis toward the midline of the body. Results: pain around the sacroiliac joint is an indication of pathology in the joint itself, such as infection or problems secondary to trauma. 2. Gaensiens Sign Method: the subject lies supine on the table and draws both legs to his chest. Examiner shifts the patient to the edge of the table while the other remains on it. Allow his unsupported leg to drop over the edge while his opposite leg remains flexed. Results: the subject who feels pain in the area of the sacroiliac joint may have a pathology in that area. 3. Patricks Test Method: Subject lies supine on the table and places the foot of his involved side on his opposite knee. The hip joint is now flexed, abducted and externally rotated. Results: in this position (flexion, abduction, and external rotation), the inguinal area may be the site of pain and this is a general indication that there is a pathology in the hip joint area or the surrounding muscles. Method: When the end-point flexion, abduction, and external rotation has been reached, the femur is fixed in relation to the pelvis. To stress the sacroiliac joint, extend the ROM by placing the hand on the flexed knee joint and the other hand on the ASIS of the opposite side. Press down on each of these points as if you were opening the binding of the book. Results: An increase in the pain felt is an indication of pathology in the sacroiliac joint. OTHER TESTS: 1. Schobers Test Method: Patient is standing, points are marked midway between the PSIS 5cm below and 10cm above; the distance between the points is measured before and after the patient is asked to flex the spine forward and extend and it backward. 2. Beevors Sign Method: Ask the patient to quarter sit-up with is arms crossed on his chest. While he hold this portion, the examiner observes the umbilicus. 3. Provocative Nuclear Extrusion Test Method: Place the patient prone and extend the low back extending the arms. Results: the test result is positive if it causes radicular pain down the leg which produces compression on the posterior nucleus and annulus forcing more extrusion.

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4. Compression and Distraction Indications: Compression and distraction are used to assess for the presence of a bulging disc that may be compressing the spinal nerve roots. Method: Compression: The examiner stands behind the seated subject. Placing the hands on the subjects shoulders, the examiner provides moderate, even downward force through the trunk, taking care not to cause forward, backward, or sideways bending. Distraction: The subject sits with the upper limbs crossed. The examiner, standing behind, reaches around the thorax, grasping the subjects ipsilateral forearm. By straightening up or leaning back, the examiner can distract the spine along its vertical axis. If the subject has shoulder pathology, the examiner may put less strain on the area by just bear hugging around the thorax and distracting without applying forces to the shoulder. Results: in the presence of a bulging disc, increased compression tends to exacerbate symptoms while distraction tends to diminish them. 5. Femoral Nerve Stretch Indication: Femoral nerve stretch is used to determine whether there is any irritation of the femoral nerve or root. Method: the subject is prone. The examiner flexes the subjects knee while supporting the thigh just proximal to the knee. The examiner stabilizes the pelvis while extending the hip to provide a further stretch to the femoral nerve. Results: Pain reproduced or exacerbated in the subjects back indicates a positive femoral or nerve root irritation. II. COURSE OF TREATMENT AND RATIONALE Rehabilitation principles can be applied to all spinal disorders whether in acutely injured or chronic pain patients, athletes or injured workers, nonsurgical or postsurgical patients. 1. Correction of soft tissue inflexibility due to spasm or tightness. 2. Improvement of segmental motion. 3. Increase in trunk stabilization, strength and endurance. 4. Proper education and training regarding posture, proprioception and body mechanics. Goals of Spinal Rehabilitation 1. Full, pain free of motion of the injured and adjacent segments, as well as hip, girdle, spinal and lower extremity structures that influence the lumbar spine. 2. Optimal strength, endurance and coordination of the neuromuscular system affecting the lumbar spine. 3. Prevention of further injury and recurrence. 4. Return to normal functional activities. ACUTE PHASE: GOALS 1. Decrease pain and inflammation 2. Protect injured area from further injury SUBACUTE PHASE: GOALS 1. Regain soft tissue flexibility and segmental motion. 2. Restore full function to injured and supporting structures. 3. Maximize lower extremity muscular flexibility for normal lumbar motion. 4. Optimal joint mobility. CHRONIC PHASE: GOALS 1. Address psychological barriers to recovery and general deconditioning. 2. Multidisciplinary pain management 3. Improve functional ADLs 4. Return to gainful employment 5. Claim closure 6. Discontinue use of health care system 7. Pain control III. TREATMENT OUTLINE Acute (0-4 weeks)Rule out serious problems o Short course of bed rest accepted position would be modified Fowlers position which is reclining the body with hips and knees flexed and the low back in a slightly flexed position. The flexed knees position permits the hamstrings to relax, slight flexion of the lumbosacral spine reverse the lordosis and separates

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the facet joint, therefore avoids approximation of their inflamed synovial tissues. o Posture Correction/Exercise o Education on proper body mechanics and sitting and standing postures is an important component in any back care program. o Lumbar support o Decrease Pain/inflammation/spasm Modalities: Cryotherapy / Ice brushing Electrical stimulation for increasing blood flow and promote healing once edema is stabilized. Diathermy o Keep them active Early activity Purpose: 1. Maintain muscle tone and cardiovascular endurance 2. Provide extension of lumbar spine 3. Maintain joint mobility 4. Increase blood flow to the injured segment o Some pain is okay o Teach patient what to avoid Subacute (1-10 weeks) o Increase mobility o Strength, flexibility, and fitness o Body mechanics trainings o Back care education o Work stimulation o Posture training o Evaluate work environment o Return to work Chronic (after 7-10 weeks) o Increase work stimulation o Increase strength, flexibility and fitness o Rehabilitation psychology o Behavior modification o Modify work environment o Focus on patient responsibilities o o Return to work Settle problem cases

THE ACUTE STAGE The Approach to Treatment The approaches are used to determine the basis for treatment. The first approach bases the treatment plan on a specific pathological diagnosis. Each entity presents a unique clinical picture. This approach is ideal. The second approach attempts to identify the patients problems, such as pain, decreased soft tissue or joint mobility, abnormal posture and muscle weakness. USING THE PATHOLOGICAL DIAGNOSIS 1. Sprains and Strains Treatment of the inflammation from minor repetitive stress, involves Reconditioning Exercises to promote strength, flexibility and fitness, with education and ergonomic changes to reduce the effect of stressful activities. True sprain/strain injuries are best managed by an athletic approach that involves rest, immobilization and protection from further injury in the very early stage of treatment. A program to promote healing and maintain general strength, flexibility and fitness is begun immediately. As the injured part heals, more vigorous exercises and a gradual, progressive return to normal activity are prescribed. 2. Herniation of the Nucleus Pulposus For treatment, McKenzie advocate correction of the lateral shift and passive extension exercises. He believes that this moves the nucleus of the disc centrally, maintenance of correct posture is important for healing. If the peripheral pain is increased by a corrective maneuver, it is unwise to persist in this. Activities such as flexion exercise, forward bending and prolonged sitting that increase intradiscal pressure should be avoided. There must be strict compliance with this program for 2 to 10 weeks. Treatment should also be directed pain relief, restoration and mobility. Modality therapy may allow relief of pain and muscle guarding. A support may be used to allow the patient more pain-free activity and to aid postural correction.

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Later, a full physical program should be implemented and active extension exercises may be used to increase strength and further promote correct posture. In more severe cases, traction may be necessary before posture correction and extensive exercises can be implemented. 3. Post-surgical Cases A full rehabilitation program should be implemented for all patients after surgery, directed towards restoring normal posture, flexibility, strength, and physical fitness. Patient education on proper body mechanics and lifestyle modification necessary for a healthy back should be included. 4. Degenerative Disc and Facet Joint Disease Treatment is directed toward measures to increase mobility. When there is a neurological complication, caution is necessary. The therapist should discontinue exercises, activities and positions that increase the peripheral signs and symptoms. 5. Nerve Root Adhesions Treatment of the disorder consists of mobilizing the nerve root adhesion by straight leg raise stretching. 6. Spondylolisthesis The patient with this disorder is vulnerable to sprains and trains. Such a patient may need to avoid heavy labor and vigorous physical activities. Attention to posture, abdominal muscle strengthening another flexion exercises and abdominal muscle strengthening. Weight loss is important. 7. Sacroiliac disorders Treatment includes mobilization if the joint is hypermobile. The wearing of a support is often helpful if the joint is hypermobile. When the joint is fixe, manipulation will be necessary to reduce this. Stabilization with sacroiliac support is often helpful. TREATING THE PROBLEM 1. Pain, muscle guarding, spasm, and inflammation Immobilization and rest for short periods is often useful. This may take the form of bed rest, lumbar supports and/or pillows, with the restriction of certain activities. Immobilization and rest should be prescribed with caution. For most patients some movements, even when it is painful, will be beneficial. Modality therapy, the various forms of heat and cold are usually effective as are electrotherapy and massage. Many modalities have the added benefit of increasing the circulation, which speeds the healing of tissue and promotes relaxation of the muscle spasm. Mobilization is often effective in relieving pain. The techniques usually employed are gentle traction and/or graded movements in the pain-free range. 2.Hypomobility As soft tissue and joint injuries begin to heal, the latter many become hypomobile. This may lead to early degenerative changes. To avoid this possible chain of events, mobilization should be used, the sooner the better, provided that it is done without aggravating any concomitant soft tissue injury. Exercises in the form of soft tissue and connective tissues massage, contract-relax techniques, passive stretch, AROM and PROM exercises all increase the mobility of soft tissue. Traction may be effective. Correction of faulty posture allows for increased mobility. Ultrasound has a loosening effect on soft tissue that is stiff. 3. Hypermobility Strengthening exercises for the muscles around a hypermobile joint give support to the joint. Correction of postural sometimes used to reduce joint mobility if other methods fail. 4. Abnormal Anatomical Relationship Mechanical and manual traction techniques are sometimes effective in the management of a disc protrusion. They can stretch adaptively shortened soft tissues. Certain corrective exercises help restore normal physiological length to soft tissues. Specific posture techniques can improve and maintain normal length of soft tissues. Mobilization techniques often restore the normal and anatomical relationship of joints. The ultimate purpose is to restore a full, painless, active range of motion. 5. Abnormal Function Treatment through various types of exercises, education, mobilization, and the modalities of physical therapy to

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restore active function is the most important part of the practice of orthopedic physical therapy. 6. Injured and Inflamed Tissues Immobilization and rest help the patient avoid activities that injured tissue further or inhibit the healing process. Modalities such as ice, heat, electrical stimulation, and massage all promote healing. This is accomplished by reducing edema, improving circulation, and stimulating cellular activity. 7. Poor posture Patient education of proper body posture and body mechanics are necessary. 8. Poor Physical and Mental Condition Treatment to improve general physical and mental fitness has a direct effect upon musculoskeletal problems, many physical activities are influenced by general strength, coordination, endurance, flexibility, and cardiovascular fitness. 9. Poor Body Mechanics The therapist should be skilled at designing an individual home program and in motivating the patient to carry it out. This may take the form of specific exercises or of instruction in the body mechanics and activities of daily living. The patient should be taught which activities are potentially harmful and which are helpful to the condition being treated. 10. Exercises for the Acute Stage of LBP o WILLIAMS FLEXION EXERCISES Exercise 1: Pelvic Tilt Objective: To decrease the lumbar lordosis Procedure: Lying flat on your back on a firm surface with knees bent and feet flat on the surface. Flatten the small of your back against bed, tightening your abdominal muscles and buttocks. Next, tuck your chin in so as to flatten the back of your neck against the surface. Hold this position for 5 seconds. Do not hold your breath. To relax, slowly release in this order, the neck and the shoulders, abdomen and buttocks. Repeat this exercise 10x. Exercise 2 Objective: To stretch the tight extensor muscles and other soft tissues of the hips and back. Procedure: Repeat exercise 1 to the hold position. Bring one knee upward toward your chest as far as possible, then reach up with your arms and pull the knee down to your chest. Tuck chin in and attempt to place the forehead on knee. Hold for 5 seconds. Slowly return starting with neck and then knee. Now relax as in exercise 1. Repeat using the other leg. Exercise 3 Objective: To stretch the tight hip flexors and heel cords Procedure: Repeat exercises 1 to the hold position. Bend (R) knee to the chest, grasp it with both hands and draw the knee firmly to the chest. Slide the heel of the (L) leg down until the leg is flattened against the surface. Keep the (L) knee straight with the back of the knee pressed against the table and pull the foot upwards toward the chin. Hold for 5 seconds. Slowly slide the (L) heel back to starting position (SP). Relax as in exercise 1. Repeat with the (L) knee. Perform 5 sets. Exercise 4: Straight Leg Raising Objective: To stretch the tight hamstring muscles Procedure: Repeat exercise 1 to the hold position. Straighten one knee and pull the foot upwards towards the shin. Raise the leg toward your head as far as possible without bending your knee. Hold for 5 seconds then bringing it down to SP. Relax as in exercise 1. Exercise 5: Curl-up/Sit-ups Objective: To provide maximal strengthening of the abdominal muscles. Procedure: Repeat exercise 1 to the hold position. Have someone press on your ankles or feet or secure the feet under the edge of the plinth or bed. With both arms reaching forward, tuck in the chin and slowly curl-up in a sitting position. Hold for 5 seconds. Uncurl by allowing the mid-back to reach the floor first followed by the shoulders, neck and head. Relax as in exercise 1. Exercise 6: Posture exercise Objective: to teach the patient proper posture for standing and walking.

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Procedure: Stand with the back against the frame of a doorway. Place the heels 4 inches away from the frame. Flatten the low back into the frame of the door, allowing your knees to bend a little. Tuck the chin and attempt to flatten or press the neck against the frame. Straighten both knees. At this point, your entire trunk should be pressing against the door frame. Hold for 5 seconds and then relax. Exercise for 6 repetitions all of the maneuvers of exercises 1 but is performed in an upright weight bearing position. o ROBIN MCKENZIES EXTENSION EXERCISES Note: All exercises are done 6-8 times daily General objective: centralization of the pain factor Exercise 1 Usefulness: For acute low back pain Procedure: Face lying with arms at the sides, forearm pronated and head turned to one side. Maintain position, take a few deep breaths, relax completely for 4 to 5 minutes (tension of the low back is eliminated or relax). Exercise 2 Usefulness: For severe LBP Procedure: SP is the same as in exercise 1. Place elbows under shoulders so that you can lean on your forearms. Take a few deep breaths then completely relax the low back muscles. Stay for 5 minutes. Exercise 3 Usefulness: Most effective or useful procedure for acute LBP Procedure: SP is the same as in exercise 1. Place hands under shoulders in the press-up or push-up then straighten elbows and push the top half of the trunk as far as pain permits (entire LE should be completely relaxed). Maintain for 2 seconds then return to SP. To progress, each time the movement cycle is repeated, try to raise the upper trunk a little bit higher so that in the end, the back is extended as much as possible with arms as straight as possible. Exercise 4 Procedure: Stand straight with feet slightly apart (stride standing). Place the hands in the small of the back, with fingers pointing backwards, bend trunk backwards at the waist as far as possible or as far as you can using the hands as fulcrum (knees are in tight extension). Maintain for 2 seconds then go back to SP. To progress, bend backwards a little farther each time one repeats movement cycle until full degree of extension is reached. Exercise 5 Procedure: Back lying with knees bent and feet flat on the floor. Bring both knees up towards the chest placing both hands around the knees or at the back of them. Gently but firmly pull the knees as close to the chest as pain permits. Maintain for 2 seconds then go back to SP. Do not raise head or straighten leg as you lower them during exercise. To progress, try to pull knees as little closer to the chest every repetition until you can reach a maximum degree of flexion. Exercise 6 Procedure: Sit on the edge of a steady chair with knees and feet well apart. Bend trunk forward and touch floor with hands then return immediately to SP. To progress, try to bend a little farther every time you repeat the exercise until the head is as close as possible to the floor. Arms move behind legs or hands, hold ankles and pull yourself down farther. THE SUBACUTE PHASE Treatment 1. To regain soft tissue and flexibility and segment motio a. myofascial release b. joint mobilization or manipulation c. muscle energy technique to improve segmental mobility d. stretching 2. Self-stretching techniques THE CHRONIC PHASE Treatment 1. Multidisciplinary approach 2. Multiple treatment foci a. education b. physical reactivation and conditioning

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c. work conditioning d. counseling e. ergonomic assessment 3. Isokinetic trunk strength and range of motion Exercise training for Lumbar disc disorders 1. Soft tissue flexibility - Hamstring musculotendinous unit - Quadriceps musculotendinous unit - Ilipsoas musculotendinous unit - Gastrosoleus musculotendinous unit - External and internal hip rotators 2. Joint mobility Lumbar spine segmental mobility Hip ROM Thoracic segmental mobility 3. Stabilization program Finding neutral position (eg standing, sitting, jumping, prone) Prone gluteal squeezes with arm raises, alternate arm raises, arm and leg raises, alternate and leg raises Supine pelvic bracing Bridging progression: basic position, one leg raised with ankle weights, stepping, balancing on gym ball, quadruped, kneeling stabilization, wall slide quadriceps strengthening position transition with postural control 4. Abdominal program Curl-ups Dead bugs (supported, unsupported) Diagonal curl-ups Diagonal curl-ups on incline board Straight leg lowering 5. Gym program Latissimus pull-downs Angled leg press Lunges Hyperextension bench General upper-body weight exercises Pulley exercises to stress postural control 6. Floor exercises Abdominal bracing Modified sit-ups Low back stretch or double knee to chest Mountain and sag knee to elbow Extension exercise 7. Aerobic program Walking start slowly and progress to 1 mile in 15 minutes if possible. Swimming the water supports your body and takes the weight off your low back. Avoid breast stroke. What is the proper sequencing of a rehabilitation program? (Young, OYoung & Stiens, 2009) o Control of inflammation o o o Control of pain Restore spine and extremity range motion Improve muscular strength

PREVENTION OF RECURRENCE OF LOW BACK PAIN Pain reduction Exercises suggested for pain reduction and/or pain elimination are supine lumbar flexion, prone lumbar extension, side lying rotation, lateral glides and prone lying oscillations Restoration of function Exercises suggested for the restoration of function are supine lumbar flexion, prone lumbar extension,

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hamstring stretches, hip flexion stretch, sitting rotations, side lying rotations, lateral glides Prophylaxis Exercises suggested for prophylaxis are supine flexion, prone extension, hamstring stretches, hip flexor stretches, prone rotations, abdominal strengthening exercise, paraspinal and gluteal strengthening exercises feet are placed slightly apart and externally rotated. The stretching motion is rhythmic up and down bounce with balance maintained against a wall or chair. 3. Hip flexor stretching exercises Tight hip flexors exert an adverse action on the pelvis and lumbosacral spine. This is due to the fact that iliopsoas attach from the anterior aspect of the lumbar spine as well as the inner aspect of the ilia. From these attachment they can influence the lumbar spine. Active and passive stretch Mainstay of relaxing the muscle and regaining elongation Ice Best modality. Ice is a local anesthetic and decreases pain and apprehension, decreases nerve conduction of sensory fibers. Use for 10 to 15 mins several times a day for 2 days. Hot packs Moist heat penetrates better Fetal position Best low back exercise. Low back flexibility exercises. The legs are used as a lever to flex the lumbar spine. Descent from flexion exercise, after having flexed the low back to its maximum, one leg should be returned to the floor while maintaining a flexed pelvis. This prevents the return of lordosis during the descent of both legs, which may be painful. Modified yoga/sitting position Low back exercise that eliminates the hamstrings. With a patient in a squat position, with knees and hips flexed, the low back is gradually flexed until the head approaches the floor or the toes. This exercise fully stretches the entire spine. Prone arch and sag exercise Being up on ones hands and knees causes the low back to sag which extends the low back. The low back then is elevated to its fullest which stretches the back extensor tissue.

In prevention of recurrence of LBP, the person must: 1. Regain or acquire adequate flexibility of the pertinent soft tissue of the lumbosacral spine and pelvic region. 2. Regain and acquire adequate strength of the pertinent muscles related to low back function. 3. Learn or relearn and implement the proper bending, stooping, lifting, pushing, pulling, turning, twisting and sitting. 4. Recognize, control or avoid any interfering psychological, professional, of personal emotional factors that can impair low back function. o Proper erect posture Require that all curves are held at a minimum. Exercise for total postural effort by standing with the shoulder blades to the wall, feet some 6 inches from the wall. The back of the head is pressed to the wall and neck is gradually tucking the chin therefore standing taller. Proper flexibility exercises 1. Hamstring stretching exercises Tight hamstring places added stress on the lumbosacral spine. Sit with one leg flexed with the foot on the ground and heel near the buttocks. The other leg to be stretched is held extended. Slow gradual body flexion, reaching toward the toes, stretches the hamstring of the extended leg. The flexed leg protects the low back by avoiding excessive flexion of the lumbosacral spine. 2. Heelcord stretching exercises Tight heel cord places excess stress on the hamstring and ultimately on the lumbosacral spine on bending forward. Squat and sit on both heels. The

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o Traction Simple home traction. Pelvic traction by placing legs on chair and sufficient pillows, the body is lifted from the floor. This flexes and stretches the low back. Remain in this position as long as possible. Pelvic tilting exercise Sequence: 1. The low back is pressed on the floor. 2. Once pressed to the floor, it must not be allowed to raise from the floor. 3. the buttocks is raised slowly and gently from the floor. Erect pelvic tilting exercise With the patient standing against a wall with feet slightly forward, the pelvis is flattened against the wall as it is against the floor in the supine exercise. This trains the patient to feel the position of the flat lumbar spine. Strengthening of the appropriate muscles Abdominals, erector spinae and quadriceps Reasons: (1) abdominal muscles contain the contents of the abdominal cavity which forms an airbag (2) strong abdominals balance the forces of the erector spinae and spine (3) the abdominals strengthen the fascia of the erector spinae 1. Abdominal strengthening exercise Sit-up depending on the original conditioning of the individual. The exercise is best done in gradual stages Stage 1 is best done with the arms on the floor at the persons side, gradually sliding them toward the feet Stage 2 requires raising the shoulder further from the floor Stage 3 is raising the shoulder blades from the floor with arms extended forward toward the feet Stage 4, while coming to a full flexed position the hands are placed behind the head with elbows forward. This arm position assists sitting up with the forward held arms placing weight ahead of the center of gravity. Stage 5, finally, the sit-up is done with hands behind the head and the elbows behind the head. This arm position places added resistance to the abdominals by adding weight behind the center of the gravity Sit-back this is for a person with weak abdominals. From the seated position with both hips and knees flexed and the hands behind the head and at first the elbow forward, the person slowly leans back a few degrees. The person holds at the point that is possible with comfortable effort. Gradually, a few more degrees of leaning back followed by a sit-up is possible as strength increases. The arms behind the head position held initially with elbow forward is gradually changed to placing the elbows behind the head. Walking best low back abdominal exercise 2. Lateral trunk muscles strengthening Stand maintaining balance by holding on to an object and raise to the opposite leg to the side as far as possible and hold it. This exercise also strengthens the hip abductors-glutei which are also pelvic rotators. RECURRENCE OF LBP When a patient feels warning signs of impending back pain, use the first aid technique. If the first aid regimen every hour does not help significantly in the first 48 hours or if you experience a different back or leg pain from that experience before, see your doctor for advice. First aid for LBP o Listen to mother nature. Get off your feet. Elevate your legs o The first line of defense is AIM (Aspirin, Ice, Movement) o Do the exercises that helped reduce the pain in the past

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23 o Dont continue this program or bed rest for more than 48

hours without obtaining professional help and advice present, do not delay seeking help.

o If numbness, weakness or other neurological deficit is

arzula.nepomuceno.tiama.vidal 11-25-11