LOW BACK PAIN

Low Back Pain

(Nyeri Pinggang Bawah)
Mengenai :
5 kolumna vertebre lumbal / sendi
5 kolumna vertebre sakral / sendi
Diskus intervertebralis
Ligamentum
Otot

Penyebab
I. Kelainan Mekanik :
A. Deformitas :
Spondilolistesis
Sakralisasi / lumbalisasi
Spina bifida okulta

B. Trauma
Benturan / sprain / angkat berat
Fraktur kompresi
Osteoporosis

II.

Inflamasi :
Spondilitis
Arthritis

III. Sistemik
Osteoporosis
Gangguan metabolik

IV. Neoplasma
Hemangioma / meningioma
Tumor primer / sekunder

V.
VI.

Gangguan vaskuler : aneurisma

Kelainan degenerasi

Spondilosis deforman
Degenerasi diskus
Osteoartritis
HNP

VII. Psikogen, ansietas, tonus otot meninggi

Gejala :
Nyeri pinggang saat bergerak
Mobilitas berkurang dan sakit
nyeri pada tekanan, batuk, mengedan

PATIENT HISTORY
OPQRSTU
Onset
Palliative/Provocative factors
Quality
Radiation
Severity/Setting in which it occurs
Timing of pain during day
Understanding - how it affects the patient

Red Flags in back

pain
Hx of cancer
Unrelenting nocturnal pain
Weight loss
Fever, chills, night sweats
Age < 15 or > 50
Neurologic deficits
Decreased motor and/or sensory innervation
Urinary and/or fecal incontinence

Intervertebral Disc
Most common site of back pain
Normally comprises ~ 25% of length of spine
Consists of a central nucleus pulposus
Reticulated and collagenous substance
Composed of ~ 88% water

Annulus fibrosus
Consists of concentric lamellae of fibrocartilage
fibers arranged obliquely
With each layer, they are arranged in opposite
directions

Physical Examination
Inspection
Palpation
Bony
Soft Tissue
Range of Motion
Neurologic Examination
Special Tests

Neurologic Examinaion
Includes an exam of entire lower extremity, as

lumbar spine pathology is frequently

manifested in extremity as altered reflexes,
sensation and muscle strength
Describes the clinical relationship between
various muscles, reflexes, and sensory areas
in the lower extremity and their particular
cord levels

Neurologic Examination
(T12, L1, L2, L3 level)
Motor
Iliopsoas - main flexor of hip
With pt in sitting position, raise thigh against
resistance
Reflexes - none
Sensory
Anterior thigh

Neurologic Examination
(L2, L3, L4 level)
Motor
Quadriceps - L2, L3, L4, Femoral Nerve
Hip adductor group - L2, L3, L4, Obturator N.
Reflexes
Patellar - supplied by L2, L3, and L4,
although essentially an L4 reflex and is
tested as such

L2, L3, L4 testing

Neurologic Examination
(L4 level)
Motor
Tibialis Anterior

Resisted inversion of ankle

Reflexes
Patellar Reflex (L2, L3, L4)
Sensory
Medial side of leg

Neurologic Examination
(L5 level)
Motor
Extensor Hallicus Longus
Resisted dorsiflexion of great toe
Reflexes - none
Sensory
Dorsum of foot in midline

Neurologic Examination
(S1 level)
Motor
Peroneus Longus and Brevis
Resisted eversion of foot
Reflexes
Achilles
Sensory
Lateral side of foot

Special Tests
Tests to stretch spinal cord

or sciatic nerve
Tests to increase
intrathecal pressure
Tests to stress the
sacroiliac joint

Tests to Stretch the Spinal Cord or

Sciatic Nerve

Straight Leg Raise

Cross Leg SLR
Kernig Test

Test to increase intrathecal pressure

Valsalva Maneuver
Reproduction of pain

suggestive of lesion pressing

on thecal sac

Tests to stress the Sacroiliac Joint

Pelvic Rock Test

FABER Test

Flexion
ABduction
External
Rotation

Herniated
Discs

Anatomy
Vertebral column (spin)

consists of 33 vertebrae
Spine is divided into
thoracic, lumber,
cervical
Each section of spine
containing 5-12
vertebrae
We will be focusing on
the lower back or
lumbar region

Lumbar Anatomy
The lumbar section

of the spine is
made up of the
lower 5 vertebrae
Commonly referred
to as L1 to L5
L5 connects to the
top of the sacrum

Anatomy of Lumbar
Verebra
The vertebral body

is a thin ring of
dense bone
Consisting of the
body, pedicles and
liminae
Vertebral foramen
is a whole in
vertebral body that
spinal cord runs
through

Intervertebral Discs
Gel like Tissue

between each vertebra

fibro cartilaginous
cushions
serve as the spine's
shock absorbing
system
protect the vertebrae,
brain, and other
structures
The discs allow some
vertebral motion
extension and flexion.

Intervertebral Discs
The disc is made

up of 3 structures
the
(1) Nucleus
pulposus,
gelatinous center
(2) Annulus
Fibrosus. Its job is
to contain the
nucleus
(3) Vertebral end
plates that attach
the disc to the

Herniated disk
Can Occur when

there is enough
pressure from the
vertebrae above
and below
This can force
some or all of the
nucleus pulposus
through a
weakened or torn
part of the annulus
fibrosus.

The ruptured nucleus

will often come

incontact with and
press on nerves near
the disc.
This can result in
severe pain
About 90% of
herniated discs occur
in the lumbar region.
The discs in the
cervical region are
affected about 8%,
those of the thoracic
region only about 1-2%
Herniated disks are
one of the most
common causes of
back pain

Mechanism of injury
There are 3 main ways discs can become

herniated of ruptured
Many older people get herniated disks because the
disks have worn down over time
The extremely overweight are very susceptible
because they are carrying around excess weight which
puts extra pressure on the intervertebral disks
Improper lifting form, usually associated with bending
with back and not with knees. Which can cause a
sudden strain. This can be everyday lifting of objects or
actual weight training
Twisting violently can also cause a sudden strain that
could possible herniate a disk

Recognition
How can we recognize a herniated disk?
Sharp and shooting pain the runs down patientlow
back, buttocks and down the thigh
If the patient complains of numbness or tingling
anywhere in lower back, buttocks or leg
If patient complains pain gets worse after any kind
of strain to the body
Sometimes, the disk can pinch the nerve controlling
bladder functioning

Evaluation
The first thing that should be asked would

be the history of the injury; if the patient felt

the pain immediately after performing a
heavy deadlift would be a good indicator of a
herniated disk
Ask patient where the pain is, sciatica is very
typical with herniated disks

Doctors Evaluation
The patient must be sent to a doctor to

perform an MRI (magnetic resonance imaging)

or a CT (computerized tomography)
An MRI is the best choice because it can
clearly show the bones nerves and disks that
might be damaged

Treatment
The first thing that

should be done is
to rest and stay
away from activity
the agitate the
symptoms
Then the
application of ice
and heat

This acts to relax the

muscles in the back
which can calm pain
and any muscle

Treatment
Physical Therapy
Although performing

physical Therapy
does not directly
help the disks, it
does strengthen the
muscles around it,
so as to increase
stability, which can
help prevent
herniated disks in
the future

Treatment
Pain relievers are

often given to
patient to alleviate
pain
Anti-inflammatory
drugs are given to
reduce swelling
Although not all
patients report
having back pain

Physical Therapy
Exercises
Exercise #1 while

lying on your back

bend your left knee up.
Clench abs and butt,
keeping back in
neutral position.
Raise your other leg
about 12in off floor,
while knee is straight
Hold the position for 3
seconds
Then lower leg, do for
10 reps
Repeat the same with
your other leg

Physical Therapy
Exercises
Exercise #2 Start with

both knees on floor, clench

abs and butt, back is
straight
Put your hands on your
hips.
Pickup your right foot and
place on floor in front of
you, while your left knee is
still on floor
Lunge forward,.
Hold your position for 3-5
seconds
Return your right knee to
floor
Do for 10 reps
Then repeat with the other

Surgery
Surgery is very rarely required for herniated

disks
The treatment previously described is almost
always done prior to surgery
Generally if symptoms, such as pain and
numbness grow worse over time surgery is
required
If herniated disk interferes with bladder and
bowl movements, surgery is also required

Rehabilitation
Herniated disks can vary in severity and the

rehabilitation plan can vary depending on the

severity of the symptoms;
Phase #1 Rest- This can last from 2 days up
to 2 months depending on the nature of the
injury, typically the older the patient the
longer the rest period. As stated before, rest
should include immobilization of spinal column
as well as icing and heating of the lower back

Rehabilitation
Phase #2 After symptoms have subsided,

anywhere from 10days to a few months

exercises should be done to strengthen
muscles around spinal column to help prevent
another hernia. Doctors clearance is preferred
so as not to begin exercises to early, which
could cause a re injury. These exercises may
be done with some slight lower back pain

Rehabilitation
Hamstring stretch
Lay down face up

with one leg in door

way other leg on
wall
This stretches out
ligaments and
tendons that
connect from leg to
lower back

Rehabilitation
Cat and Camel
On your hand and

knees, allow your

back to sag for 5
seconds, then arch
your back for 5
seconds
Repeat for 10 reps

Rehabilitation
Arm/Leg Raise
On your hands and

knees
Tighten abs so
spinal column is stiff
Raise right arm and
left leg as shown to
the right
Do 10 reps and
switch arm/leg

Rehabilitation
After all pain has gone

the following exercise

may be performed
Partial curl-lying on
your back with knees
bent and feet on floor
Tuck the chin into the
chest
Curl upper body
forward intill your
shoulder blades are off
the floor
Hold the position for 3
seconds and repeat for
10 reps