2/20/2020

1

Evaluation and Rehabilitation of the Low Back Pain Patient

M. Duarte, DC,MS, DABCO, DACBSP, MSAc, DACBA.

Impact for Primary Care

354 million patient visits per year for acute care in the United States.

42% are seen by primary care providers.

28% are seen in the emergency room.

20% are seen by specialists. Weinick,2010.

Visits to primary care are for LBP are equally split between Chiropractors and allopathic clinicians.

LBP is the fifth most common cause for an office visit to all clinicians. Deyo, 2006

The majority of visits are not due to pain but associated disability with Low Back symptoms. Ferreira,2010

2/20/2020

2

History and Exam

• Pain characteristics- location, character, intensity, exacerbating and alleviating factors, duration.

• Sensory changes.

• Strength changes.

• Job and activity associations.

• History and review of symptoms should be sufficient to rule out “red flags”.

Identifying Red flags

• Cancer- 50 years or older

• History of cancer

• Unexplained weight loss

• Failure to improve after six weeks

• Spinal infection-Hx. Of Intravenous drug use

• Immunosupression

• Urinary tract infection

• 100.4 fever greater than 48 hours

2/20/2020

3

Cauda Equina Syndrome

• New onset of urinary incontinence

• Urinary retention

• Saddle anesthesia

• Bilateral sciatica

• Sensory defects

• Motor defects

Risk Factors for Fracture

• Osteoporosis

• History of steroid use.

• Immunosuppression.

• Serious accident or injury.

• Clinical suspicion of ankylosing spondylitis.

• Drug or alcohol abuse.

• Unrelenting night pain or pain at rest.

2/20/2020

4

Oswestry Disability Questionnaire: • Used to assess the patients

subjective rating of perceived disability related to functional disabilities.

• The higher the score the more perceived disability.

2/20/2020

5

Functional Classification of Muscles

• Tonic- flexors, adductors internal rotators

• Phasic- extensors, abductors, external rotators

• Muscles must be balanced for efficient movement

2/20/2020

6

The Body Functions as a

Whole

• The entire kinetic chain is only as strong as its weakest link

• Muscles must be balanced for efficient movement

2/20/2020

7

Upper Crossed Syndrome

Lower Crossed Syndrome

2/20/2020

8

2/20/2020

9

2/20/2020

10

LLI May Leads to

• Increased disc abnormalities

• Facet arthritis • Trochanteric bursitis • Hip arthritis • Piriformis syndrome • Myofascial pain

syndrome • Iliotibial band syndrome • Levator scapulae pain

Exciting New Technology!

2/20/2020

11

Chiropractic Treatment

• With leg length discrepancy it is important to improve the function of the entire spine & pelvis, using manipulations, mobilization techniques, and rehabilitative exercises.

• Massage therapy & stretching of tight shortened musculature

• Foot Leveler Orthotics will help to:

1.Reduce low back pain caused by leg length discrepancy

2.Reduce spinal scoliosis, lordosis and/or kyphosis

3.Normalize lower extremity biomechanics weight distribution

Application of orthotics

• Discrepancies greater than 6 mm may require an orthotic

• Pelvic & spinal manipulation prior & during orthotic therapy will enhance effect by minimizing functional causes

• Heel lift height should be built up gradually to allow body time to adapt to changes

• Height of heel lift should be determined by: • Age of patient: younger patients will

tolerate greater corrections than older patients

• Severity of scoliotic curve: more severe curves may require more gradual therapy

• Activity of the patient: more active patients may require a more precise & dynamic lift

2/20/2020

12

2/20/2020

13

2/20/2020

14

2/20/2020

15

2/20/2020

16

Anterior View

Checkpoint Compensation Probable

Overactive Muscles

Probable Underactive

Muscles

Example Flexibility

Exercise (SMR & Static)

Example Strengthening

Exercise

Foot Foot Turns Out • Soleus • Lat.

Gastrocnemius • Biceps Femoris

(short head)

• Med. Gastrocnemius

• Med. Hamstring • Gluteus

Medius/Maximus • Gracilis • Popliteus

• Calf Stretch • Hamstring

Stretch • Standing TFL

Stretch

• Single-leg Balance Reach

Knee Moves Inward • Adductor Complex

• Biceps Femoris (short head)

• Tensor Fasciae Latae

• Vastus Lateralis • Lat.

Gastrocnemius

• Gluteus Medius/Maximus

• Vastus Medialis Oblique (VMO)

• Med. Hamstring • Med.

Gastrocnemius

• Adductor Stretch

• Hamstring Stretch

• TFL Stretch • Calf Stretch

• Lateral Tube Walking

• Ball Squat w/ Abduction

• Ball Bridge w/ Abduction

Moves Outward • Piriformis • Biceps Femoris • Tensor Fasciae

Latae • Gluteus

Minimus/Medius

• Adductor Complex

• Med. Hamstring • Gluteus Maximus

• Piriformis Stretch

• Hamstring Stretch

• TFL Stretch

• Ball Squat w/ Adduction

• Ball Bridge w/adduction

2/20/2020

17

Lateral View Checkpoint Compensation Probable

Overactive Muscles Probable Underactive Muscles

Example Flexibility Exercise

Example Strengthening Exercise

L-P-H-C Excessive Forward Lean

• Soleus • Gastrocnemius • Hip Flexor

Complex • Abdominal

Complex (rectus abdominus, external oblique)

• Anterior Tibialis

• Gluteus Maximus

• Erector Spinae

• Calf Stretch • Hip Flexor

Stretch • Ball Abdominal

Stretch

• Ball Squat

Low Back Arches • Hip Flexor Complex

• Erector Spinae • Latissimus Dorsi

• Gluteus Maximus

• Hamstrings • Intrinsic Core

Stabilizers (transverse abdominis, multifidus, internal oblique, transversospinalis, pelvic floor muscles)

• Hip Flexor Stretch

• Latissimus Dorsi Stretch

• Erector Spinae Stretch

• Ball Squat • Floor Bridge • Ball Bridge

Lateral View (cont’d) Checkpoint Compensation Probable

Overactive Muscles

Probable Underactive Muscles

Example Flexibility Exercise (SMR & Static)

Example Strengthening Exercise

L-P-H-C (cont’d) Low Back Rounds • Hamstrings • Adductor

Magnus • Rectus

Abdominis • External

Obliques

• Gluteus Maximus

• Erector Spinae

• Intrinsic Core Stabilizers

(transverse abdominis, multifidus, internal oblique, pelvic floor muscles, transversopinalis)

• Hamstring Stretch

• Adductor Magnus Stretch

• Ball Abdominal Stretch

• Floor Cobra • Ball Cobra • Ball Back

Extension

2/20/2020

18

Lateral View (cont’d)

Checkpoint Compensation Probable Overactive

Muscles

Probable Underactive

Muscles

Example Flexibility Exercise (SMF &

Static)

Example Strengthening

Exercise

Upper Body Arms Fall Forward

• Latissimus Dorsi • Pectoralis

Major/Minor • Teres Major • Coracobrachialis

• Mid/Lower Trapezius

• Rhomboids • Rotator Cuff • Posterior

Deltoid

• Latissimus Dorsi Stretch

• Pec Stretch • SMR Thoracic

Spine

• Floor Cobra • Ball Cobra • Stretch to

Row

Forward Head (pushing/pulling assessment)

• Levator Scapulae • SCM • Scalenes

• Deep Cervical Flexors

• Levator Scapula Stretch

• SCM Stretch • Scalene Stretch

• Tuck chin, keeping head in neutral position during all exercises

Shoulder Elevation (pushing/pulling assessment)

• Upper Trapezius • SCM • Levator Scapulae

• Mid/Lower Trapezius

• Rhomboids • Rotator Cuff

• Upper Trapezius Stretch

• SCM Stretch • Levator Scapulae

Stretch

• Floor Cobra • Ball Cobra

Posterior View

Checkpoint Compensation Probable Overactive

Muscles

Probable Underactive

Muscles

Example Flexibility Exercise

Example Strengthening

Exercise

Foot Foot Flattens • Peroneals • Lat.

Gastrocnemius • Biceps Femoris

(short head) • Tensor Fascia

Latae

• Anterior Tibialis

• Posterior Tibialis

• Med. Gastrocnemius

• Gluteus Medius

• Peroneal Stretch

• Calf Stretch • Hamstring

Stretch • Standing TFL

Stretch

• Single-Leg Balance Reach

• Single-Leg Medial Calf Raise

Heel Rises • Soleus • Anterior Tibialis

• Soleus Stretch

• Single-Leg Balance Reach

• Single-Leg Squat

L-P-H-C Asymmetrical Weight Shift

• Adductor Complex

• Tensor Fascia Latae (same side)

• Piriformis • Biceps Femoris • Gluteus Medius

(opposite side)

• Gluteus Medius (same side)

• Adductor Complex (opposite side)

• Adductor Stretch (same side)

• Tensor Fascia Latae Stretch

• Piriformis Stretch

• Hamstring Stretch (opposite side)

• Gluteus Medius (same side)

• Adductor Complex (opposite side)

2/20/2020

19

Pelvic Tilt

No imbalance exists in isolation

Lateral shift and rotations are compensations for the unilateral anterior tilted pelvis

Treat the anterior tilt first and the compensations will be much easier to treat

Groin strain, sacrum, coccyx , gluteal pain and trigger points

Treating the trigger point is not enough

Go to the source!

Neutral Position of the Lumbar Spine

Refers to an overall movement of the lumbar spine.

Midway between full flexion and full extension.

Places minimal stress on the body tissues.

Postural alignment is optimal.

Most effective position from which trunk muscles can work.

2/20/2020

20

Pelvic tilt

Iliopsoas

• Iliopsoas crosses the hip and attaches to the lumbar vertebra

• Shorten and pull the lumbar spine into lordosis affecting the Quadratus lumborum and the other back extensors to accommodate the pelvic tilt

2/20/2020

21

Lumbopelvic Stabilization Model

• An active approach to low back pain based on motor control exercises.

• The goal is to reestablish the impairment or deficit in motor control around the neutral zone of the spinal motion segment by restoring the normal function of the local stabilizer muscles.

• Ferreira et al., 2006 Specific stabilization exercise for spinal and pelvic pain; a systematic review. Aust J Physiother 2006; 52(2) :79-88

Instability Vs Hypermobility

• Both possess the feature of range of motion greater than normal.

• Instability- an excessive range of abnormal movement for which there is no protective muscular control.

2/20/2020

22

Instability Vs Hypermobility

• Hypermobility- the excessive range of movement has complete muscular control (Maitland 1986).

• Stability- the ability of the body to control the whole range of motion of a joint, in this case the lumbar spine.

Fluid Cannot be Compressed

• Excessive movement of the unstable spine may either stretch or compress pain-sensitive structures, leading to inflammation

• (Kirkaldy-Willis 1990; panjabi 1990)

2/20/2020

23

Physical Signs of Instability

Step deformity on standing, which reduces on lying

Transverse band of muscle spasm, which reduces when lying

Localized muscle witching while shifting weight from one leg to the other

Shaking when bending forward

Passive intervertebral motion testing suggests excessive mobility in the sagital plane

Spinal Stability

• Interrelated systems maintain spinal stability.

• Inert- provide passive support.

• Contractile- active support.

• Neural- control centers coordinate sensory feedback from both systems (Panjabi 1992).

2/20/2020

24

Muscle Adaptations

Patients with chronic low back pain (CLBP)are poorer at using internal oblique.

Transversus abdominis is the only abdominal muscle to be active in trunk movements in all directions. It’s activity always precedes that of the other abdominal muscles in normal subjects.

Iliopsoas vs. Rectus

• Iliopsoas- generates compression and shear forces on the lumbar spine

• Abdominals- the rectus abdominals and lateral fibers of external oblique are prime movers for trunk flexion

2/20/2020

25

Psoas or Rectus

2/20/2020

26

The Thoracolumbar Fascia (TLF)

• The TLF exerts a stabilizing effect as a hydraulic amplifier(Gracovetsky et al. 1977)

• As the erector spinae contract, the TFL resists the expansion of the bellies of the shortening muscles by increasing tension in the fascia

• Increases the stress generated by these muscles by as much as 30% (Hukins et al. 1990)

Fundamental Skills

Back stability programs begin with muscle reeducation

Pelvic tilt

Neutral position of the lumbar spine

Abdominal hollowing

Voluntarily contraction the multifidus

2/20/2020

27

Stabilization exercise has become the most popular treatment method in spinal rehabilitation.

Some studies have reported reduction of pain and disability in chronic but not acute low back pain.

Reduces the recurrence rate of LBP.

Ferreira et al., 2006 Specific stabilization exercise for spinal and pelvic pain; a systematic review. Aust J Physiother 2006; 52(2) :79-88

Exercise as a Treatment of Chronic Low Back Pain

Substantial evidence exists supporting the use of exercise as a therapeutic tool to improve impairments in back flexibility and strength

Most studies observe improved pain ratings, and lessen behavioral, cognitive, affect and disability aspects of back pain symptoms

The Spine Journal 4 2004 106-115

2/20/2020

28

Chronic Pain Associated With Spondylolisthesis

10 Week exercise treatment

Deep abdominal muscles, lumbar multifidus

Significant reduction in pain and functional disability, after a 30 month follow up

Spine- December 15, 1997, 22:24> Eval. Of Specific Stabilizing Exercises on Chronic Low back Pain of Spondylolisthesis

Fundamentals

Prone single leg/arm lift

Sidelying abductor

Supine Bridge

Opposite side sidelying abductor exercise

All other increased challenges build off these exercises

When to begin a rehabilitation program?

When to progress to the next challenge?

2/20/2020

29

Levels of lumbopelvic stabilization exercise progression

Press up

2/20/2020

30

Glut Squeeze

The basics

2/20/2020

31

Basics continued

Bird dog progression

2/20/2020

32

Bird dog progression

• Begin with single arm lift

• Single leg lift

• Alternate arm and leg lift

Bridge progression

2/20/2020

33

Bridge progression continued

• Breathe and perturb the physio ball

Abduction progression

2/20/2020

34

Abduction continued

Band walks

2/20/2020

35

Do the Palloff Press for a Strong Core

Additions as necessary

2/20/2020

36

Modifications

Time to stretch

2/20/2020

37

Advanced therapeutic

exercise

2/20/2020

38

Stability ball walk outs

Curl up

2/20/2020

39

Side bridge

Bird dog

2/20/2020

40

2/20/2020

41

EMG Analysis of Gluteus Medius And Gluteus Maximus During Rehabilitation Exercises. International Journal of Sports Physical Therapy. Volume 6, Number 3. September 2011. Page 206

YOU WERE BORN WITH THE ABILITY TO CHANGE SOMEONES LIFE DON’T WASTE IT

Thank you to Foot Levelers and the Wisconsin

Chiropractic Association for sponsoring this program

Peace, Love and Good Posture Dr. Duarte