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PAIN
(Project Work)
By AFRANA SYIEMLIEH
BPT (internship)
Krupanidhi College of Physiotherapy
Submitted to
Dr. Deepshika Baruah (HOD)
Little Sisters of the Poor
Important structures of the low back includes the bony lumbar spine (vertebrae), 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.
• Bony lumbar spine (vertebrae) - is designed so that vertebrae "stacked"
together can provide a movable support structure while also protecting the
spinal cord (nervous tissue that extends down the spinal column from the
brain) from injury. Each vertebrae has a spinous process, a bony prominence
behind the spinal cord, which shields the cord's nervous tissue. They also
have a strong bony "body" in front of the spinal cord to provide a platform
suitable for weight bearing of all tissues above the buttocks. The lumbar
vertebrae stack immediately atop the sacrum bone in between the buttocks.
On each side, the sacrum meets the iliac bone of the pelvis to form the
sacroiliac joint of the buttock.
• Discs -The discs are pads that serve as "cushions" between each vertebral
body. They help to minimize the impact of stress forces on the spinal column. Each disc is designed
like a jelly donut with a central softer component (nucleus pulposus) and a surrounding outer ring
(annulus fibrosus). The central portion of the disc is capable of rupturing (herniating) through the
outer ring, causing irritation of adjacent nervous tissue and sciatica, as described below.
• Ligaments -Ligaments are strong fibrous soft tissues that firmly attach bones
to bones. Ligaments attach each of the vertebrae and surround each of the discs.
• Spinal cord and Nerves -The nerves that provide sensation and stimulate the
muscles of the low back as well as the lower extremities (the thighs, legs, feet, and toes) exit the
spinal column through bony portals called "foramen.
• Muscles - Many muscle groups that are responsible for flexing, extending, and rotating
the waist, as well as moving the lower extremities, attach to the lumbar spine through tendon
insertions.
• Skin -The skin over the lumbar area is supplied by nerves that come from nerve roots
that exit from the lumbar spine.
The low back, or lumbar area, serves a number of important functions for the human
body. These functions include structural support, movement, and protection of certain body
tissues.
When we stand, the lower back is functioning to hold most of the weight of the body.
When we bend, extend or rotate at the waist, the lower back is involved in the movement.
Therefore, injury to the structures important for weight bearing, such as the bony spine, muscles,
tendons, and ligaments, often can be detected when the body is standing erect or used in various
movements.
Protecting the soft tissues of the nervous system and spinal cord as well as nearby
organs of the pelvis and abdomen is a critical function the lumbar spine and its adjacent muscles.
There are several causes of low back pain (sometimes referred to as Lumbago). Some
of the common causes are listed below.
Lumbar strain most often occurs in people in their forties, but it can happen at any age.
The condition is characterized by localized discomfort in the low back area with onset after an
event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild
to severe, depending on the degree of strain and resulting spasm of the muscles of the low back.
2. NERVE IRRITATION
The nerves of the lumbar spine can be irritated by mechanical
impingement or disease any where along their paths—from their roots at the
spinal cord to the skin surface. These conditions include lumbar disc disease
(radiculopathy), bony encroachment, and inflammation of the nerves caused
by a viral infection (shingles).
3. LUMBAR RADICULOPATHY
Lumbar radiculopathy is nerve irritation that is caused by
damage to the discs between the vertebrae. Damage to the disc
occurs because of degeneration ("wear and tear") of the outer ring
of the disc, traumatic injury, or both. As a result, the central softer
portion of the disc can rupture (herniate) through the outer ring of
the disc and abut the spinal cord or its nerves as they exit the bony
spinal column. This rupture is what causes the commonly
recognized "sciatica" pain that shoots down the leg. Sciatica can
be preceded by a history of localized low-back aching or it can
follow a "popping" sensation and be accompanied by numbness
and tingling. The pain commonly increases with movements at
the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be
accompanied by incontinence of the bladder and/or bowels.
4. BONY ENCROACHMENT
Any condition that results in movement or growth of the vertebrae of the lumbar spine can
limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony
encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through
which the spinal nerve passes from the spinal column, out of the spinal canal to the body),
spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis
(compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal
canal). Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down
the lower extremities. Spinal stenosis can cause lower-extremity pains that worsen with walking and
are relieved by resting (mimicking poor circulation).
Bone and joint conditions that lead to low back pain include those existing from birth
(congenital), those that result from wear and tear (degenerative) or injury, and those that are from
inflammation of the joints (arthritis).
Congenital bone conditions —Congenital causes (existing from birth) of low back pain
include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine that
can be caused when one lower extremity is shorter than the other (functional scoliosis) or
because of an abnormal design of the spine (structural scoliosis).
Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with
absence of the spinous process. This birth defect most commonly affects the lowest lumbar
vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of
the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the
condition can also be accompanied by serious nervous abnormalities of the lower extremities.
Degenerative bone and joint conditions —As we age, the water and protein content of
the body's cartilage changes. This change results in weaker, thinner, and more fragile cartilage.
Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of
cartilage, these areas are subject to wear and tear over time (degenerative changes). Degeneration
of the disc is called spondylosis. Spondylosis can be noted on x-rays of the spine as a narrowing
of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that
predisposes the disc to herniation and localized lumbar pain ("lumbago") in older patients.
Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain
that can be detected with plain x-ray testing.
Injury to the bones and joints—Fractures (breakage of bone) of the lumbar spine and
sacrum bone most commonly affect elderly people with osteoporosis, especially those who have
taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on
the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can
collapse (vertebral compression fracture). The fracture causes an immediate onset of severe
localized pain that can radiate around the waist in a band-like fashion and is made intensely worse
with body motions. This pain generally does not radiate down the lower extremities.
Arthritis —the spondyloarthropathies are inflammatory types of arthritis that can affect the lower
back and sacroiliac joints. Examples of spondyloarthropathies include reactive arthritis (Reiter's
disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease.
Each of these diseases can lead to low back pain and stiffness, which is typically worse in the
morning. These conditions usually begin in the second and third decades of life.
Kidney infections, stones and traumatic bleeding of the kidney (hematoma) are frequently
associated with low back pain.
PREGNANCY
OVARY PROBLEMS
• TUMOR
Low back pain can be caused by tumors, either benign or malignant, that originate in
the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate
elsewhere and spread to these areas (metastasize). Symptoms range from localized pain to
radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool)
depending on whether or not the tumors affect the nervous tissues.
HISTORY
History
Cancer
Unexplained weight loss
Immunosuppression
Prolonged use of steroids
Intravenous drug use
Urinary tract infection
Pain that is increased or unrelieved by rest
Fever
Significant trauma related to age (e.g., fall from a height or motor vehicle accident in a young
patient, minor fall or heavy lifting in a potentially osteoporotic or older patient or a person with
possible osteoporosis)
Bladder or bowel incontinence
Urinary retention (with overflow incontinence)
Physical examination
Saddle anesthesia
Loss of anal sphincter tone
Major motor weakness in lower extremities
Fever
Vertebral tenderness
Limited spinal range of motion
Neurologic findings persisting beyond one month
OBSERVATION
Build of the patient- Endomorphic/ectomorphic / mesomorphic
Gait and Posture- Observation of the patient's walk and overall posture is suggested for all patients
with low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or
neurogenic involvement.
Range of Motion- The examiner should record the patient's forward flexion, extension, lateral
flexion and lateral rotation of the upper torso.
Pain with forward flexion is the most common response and usually reflects mechanical causes.
If pain is induced by back extension, spinal stenosis should be considered.
External appliances - use of external aids like cane, crutch, walker, brace etc.
PALPATION/ PERCUSSION
Point tenderness over the spine with palpation or percussion may indicate fracture or an infection
involving the spine. Palpating the paraspinous region may help delineate tender areas or
muscle spasm.
Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the
sciatic nerve or nerve roots.
Heel-Toe Walk and Squat and Rise- A patient unable to walk heel to toe, and squat and rise may
have severe cauda equina syndrome or neurologic compromise.
Straight Leg Raising Test(SLR)- With the patient in the supine position, each leg is raised
separately until pain occurs. The angle between the bed and the leg should be recorded. Pain
occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root
irritation.
Crossed SLR Test- The contralateral, uninvolved leg is raised. The test result is positive when pain
is produced. This test is less sensitive but much more specific for disc herniation.
Popliteal Compression Test- Bending the knee while maintaining hip flexion should relieve the pain,
and pressure in the popliteal region should worsen it.
Lasegue’s Sign- If placing the knee back in full extension during straight leg raising and dorsiflexing
the ankle also increase the pain (Lasègue's sign), nerve root and sciatic nerve irritation is likely.
LABORATORY TESTING
They are generally not necessary for initial evaluation of acute low back pain.
Complete Blood Cell Count and ESR- If tumour and infection suspected.
HLA-B27 antigen test- If Ankylosing Spondylitis suspected.
Serum Protein Electrophoresis- If multiple myeloma suspected.
Urine analysis
RADIOGRAPHIC TESTING
X-RAY
If red flags suggest cauda equina syndrome or progressive major motor weakness, the prompt use
of computed tomography (CT), magnetic resonance imaging, myelography or combined CT and
myelography is recommended. In the absence of red flags after one month of symptoms, it is
reasonable to obtain an imaging study if surgery is being considered.
CONSERVATIVE MANAGEMENT
Patients should be instructed to watch for worsening symptoms such as an increasing loss of motor
or sensory functions, increasing pain and the loss of bladder or bowel function. Should any of these
occur, the patient should undergo further evaluation and treatment immediately, with weekly follow-
up.
Patients should gradually return to their normal activities, as tolerated. Continuing ordinary
activities within the limits permitted by pain leads to a more rapid recovery than either bed rest
or back-mobilizing exercises.
• Bed rest
• Medications-NSAIDS (to relief pain), Muscle Relaxants (to relief spasm)
• Patient’s education
• Psychological support to the patient is required if patient is under stress (stress
management)
SURGICAL MANAGEMENT
Surgery maybe necessary if back pain is severe n depending on the cause of pain.
Some of the surgeries done are- surgical decompression, laminectomy, dissectomy,
vertebroplasty etc.
PAIN RELIEF Physiotherapy of different types can be used to treat lower back pain.
− Acupuncture is fast becoming an important method for the relief of such pain. The
patient lies face-down and inserts the acupuncture needles across the back. Pain relief after a
series of treatments usually lasts months.
− Back massage is also used for lower back pain.
− Modalities are also used to treat back pain. They are:-
The low back exercise program is a series of stretching exercises and strengthening exercises. The
purpose of this exercise program is to improve the flexibility and strength of trunk musculatures
essential for low back care.
1. KNEE TO CHEST
2. PELVIC TILT
Starting Position: Lie on your back on a table or firm surface. Your feet
are flat on the surface and the knees are bent.
Action: Push the small of your back into the floor by pulling the lower
abdominal muscles up and in. Hold your back flat while breathing easily
in and out. Hold for five seconds. Do not hold breath. Do Not Cause Pain.
3. HIP ROLLING
Starting Position: Lie on your back on a table or firm surface. Both knees
bent, feet flat on the table.
Action: Cross your arms over your chest. Turn your head (trunk) to the right
as you turn both knees to the left. Allow your knees to relax and go down
without forcing. Bring knees back up, head to centre. reverse directions. Do
Not Cause Pain.
4. PELVIC LIFT
Starting Position: Lie on your back on a table or flat surface. Your feet are flat
on the surface and your knees are bent. Keep your legs together Cross your
arms over your chest.
Action: Tilt your pelvis and push your low back to the floor as in the previous exercise, then slowly
lift your buttocks off the floor as far as possible without straining. Maintain this position for 5
seconds. Lower your buttocks to the floor. Do not hold breath. Do Not Cause Pain.
Action: A. Bring one knee toward your chest. Hold this position for ____ secon
Lower your leg to the starting position. Then repeat on your opposite knee.
B. Bring one knee toward your chest. Straighten the knee Hold for ____
seconds. Slowly lower the leg to the starting position. Repeat on
opposite leg.
C. Raise your leg keeping your knee straight. Hold for ____ seconds. Slowly lower
the leg to the floor.Repeat on the opposite leg. Maintain your pelvic tilt and keep your
resting leg relaxed at all times. Do not hold your breath. Do Not Cause Pain.
6. CURL UPS
Starting Position: Lie on your back on a table or flat surface. Your feet are flat on the surface and
your knees are bent. Maintain your pelvic tilt for the curl up exercises.
B. Fold your arms on your chest. Tuck your chin to your chest and slowly reach
your elbows to your knees, curling your trunk. Keep neck muscles relaxed and
breathe normally.Return to the starting position.
C. With your hands behind your head, slowly curl your head to your chest and the
your trunk. Relax, breathe and then slowly return to the starting position. Do Not
Cause Pain.
12. PRESS UP
Starting Position: Lie on your stomach on a mat. Place your hands palms
down, under your shoulders.
Action: Straighten your arms, raising your upper trunk off the floor. Keep
your pelvis against the mat, allowing your lower back to arch. Hold for ____
seconds. Return to starting position and repeat. Do Not Cause Pain.
• Front walkout - Place chest on exercise ball and walk forward on hands as far as
possible, rolling exercise ball from chest toward feet, keeping stomach muscles tight to keep lower
back flat. Start by moving exercise ball to thighs; to increase difficulty move exercise ball to knees
then feet. Walk hands back to starting position. Repeat 3 to 5 times.
• Back walk-out - Sit on exercise ball with arms to sides; walk feet forward as far as
possible, rolling exercise ball from buttocks toward neck, keeping stomach muscles tight to keep
lower back flat and do not raise head. Start by moving exercise ball to upper back; to increase
difficulty move exercise ball to neck. Walk feet back and return to sitting position. Repeat 3 to 5
times. For more difficulty, complete exercise with arms straight overhead; with exercise ball at neck,
lift and straighten one leg at a time, 5 times each leg.
• Reverse crunch - Place chest on exercise ball and walk forward on hands until ball is at
kneecaps, keeping stomach muscles tight to keep lower back flat. Pull the ball up towards arms by
bending at hips and knees, then straighten and push the ball back. Repeat 5 times. Walk hands
back to starting position.
• Reverse extension - Place chest on exercise ball and walk forward on hands until
exercise ball is at kneecaps, keeping stomach muscles tight to keep lower back flat. Roll the ball to
thighs by keeping hands in place, moving arms to an overhead position, bringing head and chest
down near floor; return arms to perpendicular to body with exercise ball back at knee caps. Repeat
5 times. Walk hands back to starting position.
• Combination - Complete the reverse crunch and reverse extension in one continuous,
controlled movement, pulling exercise ball up to chest and extending back 5 times.
• Half crunch - Sit on exercise ball with arms raised across chest or on hips; lean
back half way, flexing at hips without moving feet but raising up on toes; use
abdominal muscles to sit up without moving feet but rocking back on heels. Rock
back and forth on the ball smoothly 5 times. Increase difficulty with arms straight
overhead
• Obliques - Sit on exercise ball with arms raised straight overhead; lean back half
way, flexing at hips without moving feet but raising up on toes; lower one arm at a time slowly
towards the opposite knee. Alternate arms 10 times each side.
• Full crunch - Sit on exercise ball with arms at sides and feet flat on
floor and out in front, sitting slightly forward on ball; lean back all the way, rolling ball
to the low back then mid-back; keeping feet flat on the floor, use abdominal muscles
to sit up. Repeat 5 times.
AEROBIC EXERCISES
Aerobic exercises such as walking are excellent for reducing and preventing
lower back pain as well.
SPINAL SUPPORTS
ERGONOMIC ADVICES
The patient has to continue the exercise programme at home once/twice a day.
Maintain fitness by doing activities.
PROPER WALKING PROPER STANDING
PROPER LIFTING
PROPER SITTING TECHNIQUE