Generally, this presentation is about back pain. It contains anatomy, risk factors, etiology, pathophysiology, sign and symptoms, doctor management & physiotherapy management.

1. CHRONIC BACK PAIN
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2. A. Introduction
Anatomy:
• Spine
• Vertebral arch composed of
Cervical (7 vertebrae)
Thoracic (12 vertebrae)
Lumbar (5 vertebrae)
Sacrum (5 vertebrae)
Coccyx (3-5 vertebrae)
Pedicles
Transverse process
Articular process
Lamina
Spinous process
Sources: Southern California Orthopaedic Institute (SCOI) & The Orthopaedic Knowledge Network
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3. • Intervertebral disc made up of 2 parts:
• A fibrous ring
• Functions:
-to stabilize the
disc
-to make sure
spine can rotate
properly
- resist
compression or
other stresses
put on spine
• pulpy interior
that consist of
water, collagen &
proteoglycans.
• functions:
- To help
transmit stress &
weight placed on
the vertebrae
during any
movement &
activity
Source: Neuro Spinal Hospital – understanding Spinal Anatomy: Intervertebral Disc
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4. Function:
Limits extension.
Reinforces anterior
portion of annulus
fibrosus
Region: axis to
sacrum well
developed in
lumbar& thoracic
Function:
Limits flexion
Region:
axis to sacrum
Function:
Limits lateral flexion
Region:
Primarily lumbar
Function: Limits flexion especially in lumbar region
Region: axis to sacrum
Function: Limits flexion
Region: Thoracic & Lumbar
Function:
Limits flexion
Region:
primarily lumbar
Function: to
strengthen the
joint
& give extra
support
• Ligaments
Source: The Orthopaedic Knowledge Network & Kinesiology: Scientific Basis Human Motion
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5. • Facet joint or zygapophyseal joint
Source: The Orthopaedic Knowledge Network
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6. • Muscles
1. Superficial group
Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf
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7. 2. Intermediate group
Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf
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8. 3. Deep group
Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf
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9. • Abdominal muscles & hip muscles
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10. • Nerve
Source: TheSpineClinic.com
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11. Definition:
Chronic Back Pain
“The term chronic back pain is used to describe pain that occurs
between the lower costal margins and the gluteal folds that
persists for >3 months.”
(Jackson, M.A. & Simpson, K.H., Continuing Education in
Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006)
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12. Risk factors
1.Occupation
2.Age
3.Alcohol & drug abuse
4.Family history
5.Gender
6.Level of activity (physical fitness)
7.Obesity
8.Poor posture & alignment
9.Previous back injury
10.Psychological, social & spiritual factors
11.Smoking
12.Sports
13.Other factors – spinal condition
Source: http://www.healingchronicpain.org/content/backpain/pfactors.asp
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13. Etiology
Mechanical Non-
mechanical
Neurological Biomechanical Psychological
 Strain
 Structural
problem
 Ankylosing
Spondylitis
 Neoplasms
 Infections
Artherosclerosis
Disease of the
viscera
Cauda
equina
syndrome
Shingles
Poor posture/
movement
pattern/
everday
activities/
 Pre-
existing
depression,
anxiety &
stress,
together with
lack of
effective
coping skillsSource: http://www.healingchronicpain.org/content/backpain/pfactors.asp &
http://www.medicalnewstoday.com/articles/172943.php
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14. Pathophysiology
Decrease bone strength &
muscle elasticity and tone
Dics thinner –
diminishes dics flexibility
Decrease shock
absorbing capabilities
•Thickening of the ligament
•Boney growth on the vertebral surfaces
- Decrease space between the vertebra
& the space that spinal cord &
nerve roots pass.
•Stress on the tissue and joints
surrounding
• Extruding disc material – impinged
the nerve root.
If left untreated -> repeatedly sent
pain signals
affect the CNS, it will make it more
sensitive;
even the gentle touch will can be
very painful.
Keep on degenerate due to aging
Increase stress on the spine
Aging
Source: Patricia T. Alpert, Management of Chronic Pain, published on 3 October 2013
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15. Sign & Symptoms
• Pain – sharp, shooting, stabbing, burning, achy, numbness,
electrical, and/or tingling.
• Localized to particular area or radiating down to the lower
extremities.
• Aggravated by movements – leg raises, sitting, or standing too
long
• Limited flexibility or range of motion of the back
• Muscles aching
Source: Patricia T. Alpert, Management of Chronic Pain, published on 3 October 2013 &
http://www.mayoclinic.org/diseases-conditions/back-pain/basics/symptoms/CON-20020797
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16. Doctor’s Management
Noninvasive pain
management
Invasive pain management
No drugs pain management:
Physical therapy/
physiotherapy
Behavioral modification
Pharmacologic pain
management:
Analgesics
NSAIDs
Muscles relaxant
Narcotic medications
Antidepressants &
anticonvulsants
Neuromodulating medications
Injections / blocks
Prolotherapy
Radiofrequency radioablation
Surgically implanted
electrotherapy devices
Implantable opioid infusion
pumps
Source: http://www.spine-health.com/treatment/pain-management
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17. Physiotherapy’s Management
Advice and early activity (recent research indicates that one of
the most important treatment for low back pain is movement).
Joint mobilisation/manipulation
McKenzie therapy
General strengthening and stretching exercises
Specific stabilization exercises
Ergonomic advice
Postural advice
Pain relief techniques including electrotherapy devices
Source: http://www.rafflesmedicalgroup.com/ImgCont/323/physio-back-pain.pdf
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18. References
Books
1. Hislop, H.J. & Montgomery, J. (2007). Daniels and Worthingham’s Muscle Testing
Techniques of Manual Examination. (8th
ed.). Philadelphia: Saunders Elsevier.
2. Kisner, C. & Colby, L.A. (2007). Therapeutic Exercise . (5th
ed.).Philadelphia,
Pennsylvania: F.A. DAVIS COMPANY.
3. Petty, N.J. (Ed.). (2011). Neuromusculoskeletal Examination and Assessment (3rd
ed.). Edinburgh: Churchill Livingstone Elsevier
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19. Online articles:
1. Southern California Orthopaedic Institute. Anatomy of the spine. Retrieved from
http://www.scoi.com/spine.php
2. Muscles of the back. (n.d.). Retrieved from
http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back
%20Lectureff.pdf
3. The Orthopaedics Knowledge Network. (2013). Spine anatomy. Retrieved from
http://www.orthopaedicsone.com/display/Main/Spine+anatomy
4. Neuro Spinal Hospital. Understanding Spinal Anatomy: Intervertebral Discs. (n.d.).
http://www.nshdubai.com/intervertebral-discs
5. Dr. Bruce McFarlane. (2010). Notes on Anatomy and Physiology: The Intervertebral Discs.
Retrieved from http://ittcs.wordpress.com/2010/06/01/anatomy-and-physiology-the-
intervertebral-discs/
6. Low Back Pain: Predisposing Factors. (2011). Retrieved from
http://www.healingchronicpain.org/content/backpain/pfactors.asp
Online Journals
1. O’ Sullivan, P. B. (2002). The Effect of Different Standing and Sitting Postures on Trunk Muscle
Activity in a Pain-Free Population.
2. Aspden R. Review of the functional anatomy of the spinal ligaments and the lumbar erector
spinae muscles. Clin Anat 1992;372–87:
3. Gauvin, M.G., Riddle, D.L. & Rothstein, J.M. (1990). Reliability of clinical measurement of
forward bending using modified FTF method. Journal of the American Physical Therapy
Association. PHYS THER. 1990; 70:443-447.
4. Jackson, M.A. & Simpson, K.H. (2006). Chronic Back Pain. Continuing Education in
Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006. doi:10.1093/bjaceaccp/mkl029.
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