BACK PAIN IS ONE OF THE GREAT AFFLICTIONS OF MANKIND TODAY.
THE LUMBAR SPINE GIVES SUPPORT FOR THE UPPER BODY AND AIDS IN TRANSMITTING
THIS WEIGHT TO THE PELVIS AND LOWER LIMBS.
THE POSTERIOR APOPHYSEAL JOINTS (FACETS),DIRECT THE MOVEMENT THAT OCCURS
IN THE LUMBAR SPINE.
ROTATION IS MINIMAL WHILE FLEXION, EXTENSION AND LATERAL BENDING OCCURS
MORE FREELY.
NORMALLY THE FACETS ARE NONWEIGHTBEARING. AS WE GO INTO EXTENSION THEY
BEGIN TO HAVE A WEIGHTBEARING FUNCTION.
TRANSITIONAL SEGMENTS:
LUMBARIZATION
SCARALIZATION
IVD’S MAKE UP APPROXIMATELY 25% OF THE TOTAL LENGTH OF THE VERTEBRAL COLUMN.
WITH AGE THIS % DECREASES AS A RESULT OF DISC DEGENERATION AND LOSS OF
HYDROPHILIC ACTION OF THE DISC
INITIALLY THE DISCS CONTAIN 85-90% WATER.
THIS WILL DECREASE TO 65% WITH AGING.
THE SHAPE OF THE DISC CORRESPONDS TO THAT OF THE BODY TO WHICH IT IS ATTACHED.
USUALLY THE IVD HAS NO NERVE SUPPLY EXCEPT FOR THE PERIPHERAL POSTERIOR
ASPECT OF THE ANNULUS WHICH MAY BE INNERVATED BY THE SINUVERTEBRAL NERVE.
THE PAIN SENSITIVE AREAS AROUND THE DISC INCLUDE THE A.L.L., P.L.L, VERTEBRAL
BODY, NERVE ROOT AND THE CARTILAGE OF THE FACET JOINT.
AN ADULT IS USUALLY 1-2CM TALLER IN THE A.M. THAN IN THE P.M.
NACHEMSON SHOWED THAT POSTURAL CHANGES AFFECT INTRADISCAL PRESSURE AT L3
WITH FORWARD BENDING BEING ONE OF THE WORST AGGRESSOR AT 150% INITIAL PRESSURE.
PICKING UP AN OBJECT WITH THE BACK BENT AND KNEES LOCKED =169%
THE L5/S1 SEGMENT IS USUALLY THE MOST COMMON SITE OF LUMBAR PROBLEMS BECAUSE
IT BEARS MORE WEIGHT THAN ANY OTHER PART OF THE VERTEBRAL COLUMN.
LOWER BACK PAIN IS THE 2ND LEADING CAUSE OF HOSPITALIZATION. PREGNANCY
IS FIRST.
85-90% OF ALL PEOPLE WILL HAVE BACK PAIN AT ONE TIME OR ANOTHER.
APPROX. 10 MILLION PEOPLE HAVE LBP/DAY
50% OF THE POPULATION WILL HAVE DISABLING D.J.D.
93 MILLION WORK DAYS ARE LOST EACH YEAR TO LOWER BACK PAIN.
THE VERTEBRAL MOTOR UNIT CONSISTS OF:
2 VERTEBRAE
1 DISC
ALL RETAINING STRUCTURES
THE NERVE EMINATING FROM THE 2 VERTEBRAE
ANTERIOR MOTOR UNIT IS HYDROLLIC IN NATURE AND INCLUDES THE
2 VERTEBRAE, DISC AND A.L.L. AND P.L.L.
75-90% OF ALL WEIGHTBEARING OCCURS ON THE ANTERIOR MOTOR UNIT OF THE LUMBAR
SPINE.
POSTERIOR MOTOR UNIT: BEHIND THE P.L.L. INCLUDES THE POSTERIOR JOINTS
IT IS ACUTELY PAIN SENSITIVE (SINUVERTEBRAL NERVE) 15-24% OF WEIGHTBEARING
OCCURS HERE.
A.L.L. GOES FROM VERT. BODY TO VERT. BODY AND SLIGHTLY TO THE DISCS.
P.L.L. ATTACHES FROM DISC TO DISC AND TAPERS IN THE LUMBAR SPINE TO GIVE
LITTLE SUPPORT.
FLEXABILITY OF THE DISC ALLOWS IT TO DISSIPATE STRESSES PLACED ON IT.
FACETS ARE RESPONSIBLE FOR MOVEMENT WHILE THE DISCS ARE RESPONSIBLE FOR
WEIGHT BEARING.
L1-L4 FACETS ARE SAGGITAL AND THIS ALLOWS FLEXION.
L5/S1 ARE SEMISAGITTAL AND AID IN LATERAL FLEXION.
IN THE LUMBAR SPINE WHEN YOU LATERALLY BEND, THE SPINOUS PROCESSES DEVIATE
INTO THE CONCAVITY.
70% OF ALL SPINAL FLEXION OCCURS AT THE LUMBOSACRAL ARTICULATION ACCORDING
TO DR. GOLDWAITH.
WOLF’S LAW: OSTEOGENESIS IS AFFECTED BY STRESS. EG. CANCELLOUS
BONE WILL INCREASE IN THE FEMUR DUE TO STRESSES PLACED ON IT.
WEIDER-VOLKMAN PRINCIPLE:INCREASE IN PRESSURE OVER A GROWING
ENDPLATE WILL INHIBIT GROWTH AT THAT ENDPLATE.
FREQUENCY OF DISC PROTRUSION: ACCORDING TO CYRIAX:
L4/L5
L5/S1
L1/L2
C5/C6
THIS SHOWS THAT THERE ARE MORE DISC PROTRUSIONS AT L4/5 THAN
L5/S1.
LUMBAR CONDITIONS:
LUMBAR SUBLUXATION
OSSEOUS ANOMALY
FRACTURE
DISCAL DISEASE
INFECTION OF THE LUMBAR SPINE
ANKYLOSING SPONDYLITIS
SCOLIOSIS
OSTEOPOROSIS
SCIATICA
NEOPLASM
D.I.S.H.
MALINGERER
EVALUATION:
PHYSICAL CONSIDERATIONS
PATIENT MOTIVE
AGE OF PATIENT
OCCUPATIONAL ERGONOMICS
SPORTS HABITS
PATIENT HISTORY
O.P.Q.R.S.T. APPROACH
IT IS IMPORTANT TO GET INFORMATION CONCERNING THE PATIENT’S FAVORITE PASTTIME
ACTIVITIES AND WHAT ACTIVITIY ORIGINALLY CAUSED THE BACK PAIN.
HAVE THE PATIENT DESCRIBE THE TYPE OF PAIN SINCE IT CAN BE DEEP, SUPERFICIAL,
SHOOTING, BURNING OR ACHING IN VARIETY.
ARE THERE ANY ACTIVITIES THAT EASE THE PAIN?
INFORMATION ON SLEEPING POSTURE IS IMPORTANT.
YOU MUST QUESTION THE PATIENT ABOUT THEIR BOWEL AND BLADDER HABITS AND
ANY CHANGES NOTED.
DETERMINE IF COUGHING OR SNEEZING EXACERBATES THE COMPLAINT.
DETERMINE IF THE PAIN AND STIFFNESS IS WORSE IN THE A.M. OR AS THE DAY
GOES ON. (O.A IS WORSE IN THE MORNING AND IMPROVES WITH ACTIVITY) .
DETERMINE TYPE OF MEDICATION PATIENT IS TAKING. REMEMBER, STEROIDAL PAIN
MEDICATION CAN LEAD TO OSTEOPOROSIS.
OBSERVATION/INSPECTION
REMEMBER: THE BODY SHOULD BE SUITABLY DRESSED FOR YOU TO OBSERVE THE SPINE
OBSERVE THE LORDOSIS:
LOOK FOR INCREASED ANGULATION
LOOK FOR A SPRUNG BACK ( FLATTENED LORDOSIS
SEEN WITH TIGHT HAMSTRINGS MAINLY IN FEMALES 15-35 YR GROUP)
OBSERVE FOR SCOLIOSIS:
REMEMBER, SCOLIOSIS IS LISTED ON THE SIDE OF CONVEXITY. BODY
ROTATION WILL DECIDE IF IT’S A LOVETTE + OR LOVETTE - SCOLIOSIS.
DETERMINE BODY TYPE:
ECTOMORPH: THIN BODY BUILD
MESOMORPH: MUSCULAR OR STURDY BODY BUILD
ENDOMORPH: HEAVY AND OR FAT BODY BUILD
OBSERVE PATIENT GAIT AND EASE OF MOVEMENT.
OBSERVE TOTAL SPINAL POSTURE FROM ANTERIOR, POSTERIOR AND LATERALLY.
PALPATION:
PALPATE FOR TENDERNESS, MUSCLE SPASM, TEMPERATURE ALTERATION AND SWELLING.
PALPATE THE LUMBAR SPINE FOR JOINT PLAY AND MOTION OF THE SPINAL SEGMENTS
EXAMINATION:
RANGES OF MOTION
ACTIVE VS PASSIVE
ACTIVE AGAINST RESISTANCE
NEUROLOGICAL EXAMINATION
DERMATOME EXAMINATION
MYOTOME EXAMINATION
REFLEXES
ORTHOPAEDIC EXAMINATION
RADIOGRAPHIC EXAMINATION
LUMBAR RANGES OF MOTION:
NOTE** RANGES OF MOTION ARE USUALLY COUPLED WITH THAT
OF OF THORACIC SPINE AND CALLED THORACO-LUMBAR RANGES OF MOTION
FLEXION=
EXTENSION=
ROTATION=
LAT. FLEXION=
DERMATOMES:
Definition:
L4:
L5:
S1:
MYOTOMES:
Definition:
L4:
L5:
S1:
MUSCLE GRADING SCALE: WEXLER’S SCALE:
5/5 =
4/5 =
3/5 =
2/5 =
1/5 =
0/5 =
REFLEXES
Definition:
L4:
L5:
S1:
ORTHOPAEDIC TESTING:
REMEMBER THAT ORTHOPAEDIC TESTING IS DESIGNED TO BE PROVOCATIVE
IN NATURE.
PATIENT’S SHOULD BE ADVISED THAT THEY MAY FEEL WORSE POST
EXAMINATION.
ORTHOPAEDIC TESTING IS DESIGNED TO LOCATE THE INJURED TISSUE.