LBP can be attributed to different pain generators, with specific characteristics, such as radicular, facet joint, sacro-iliac, and discogenic pain, as well as spinal stenosis

1. Electrotherapy for Low Back Pain
Aditya Johan Romadhon,SST.FT, M.Fis

2. Introduction
Low back pain is a considerable health problem in all developed countries
It is usually defined as pain, muscle tension, or stiffness localised below
the costal margin and above the inferior gluteal folds, with or without leg
pain (sciatica)
The most important symptoms of non-specific low back pain are pain and
disability
Low back pain (LBP) is the most common musculoskeletal condition
affecting the adult population, with a prevalence of up to 84%

3. Pain Generator
LBP
symptoms
can derive
from many
potential
anatomic
sources
nerve roots
Muscle
fascial
structures
Bones
Joints
intervertebral
discs (IVDs)
organs within
the
abdominal
cavity
(doi: 10.12688/f1000research.8105.1)

4. LBP can be attributed to different pain generators, with specific characteristics, such as
radicular, facet joint, sacro-iliac, and discogenic pain, as well as spinal stenosis
Radicular pain is pain evoked by ectopic discharges emanating from an inflamed or
lesioned dorsal root or its ganglion
Generally, the pain radiates from the back and buttock into the leg in a dermatomal
distribution
Radicular pain is pain irradiated along the nerve root without neurological impairment
Radicular pain differs from radiculopathy in several aspects
Radiculopathy is a neurological state in which conduction is impaired along a spinal
nerve or its roots

5. Radiculopathy L2-L4
L2, L3, L4 lumbar radiculopathy
are considered a group
This group has a marked
overlap of the innervation of the
anterior thigh muscles
patient experiencing radiating
back pain to the anterior aspect
of the thigh, which may progress
into their knee, and possibly
radiate to the medial aspect of
the lower leg, into the foot
patients can have weakness in
knee extension, hip adduction,
and or hip flexion
There is often a loss of
sensation over the anterior thigh
along the area of pain
The patient may show a reduced
patellar reflex (L4)

6. Radiculopathy L5
If severe enough, L5
radiculopathy can
cause weakness in
leg abduction when
the gluteus minimus
and medius are
affected
Chronic L5
radiculopathy can
cause atrophy of the
extensor digitorum
brevis as well as the
tibialis anterior of the
anterior leg
there may be a
reduction in muscle
strength with big toe
extension (extensor
hallucis longus), foot
eversion, inversion,
toe extension, and
foot dorsiflexion
In L5 radiculopathy,
patients will
often complain of
acute back pain,
which radiates down
the lateral leg, into
the foot

7. Radiculopathy S1
The ankle reflex (S1)
can also be lost or
diminished
There can also be a
sensation loss along
the posterior leg and
lateral aspect of the
foot
On examination,
there can be a
weakness in plantar
flexion.
S1 radiculopathy,
sacral or buttock
pain will radiate into
the posterior aspect
of the patient's leg,
into the foot or the
perineum
https://www.ncbi.nlm.nih.gov/books/NBK546593/

9. 10 LBP radiculopathy with disc herniation and 10 apparently healthy control

10. Facet Joint Syndrome
Nociception
originating in the
synovial
membrane, hyaline
cartilage, bone, or
fibrous capsule of
the facet joint
Activate
nociceptive
afferents and that
are also modulated
by sympathetic
efferent fibers
These joints have a
large amount of
free and
encapsulated nerve
endings
The lumbar
zygapophyseal
joints are the
posterior articular
process of the
lumbar column

11. Facet Joint Symptoms
Pain increases with
hyperextension,
rotation, lateral
bending, and
walking uphill
It is exacerbated
when waking up
from bed or trying
to stand after
prolonged sitting
Finally, patients
often complain of
back stiffness,
which is typically
more evident in the
morning
With MRI, we can
find non-specific
signs of arthrosis,
osteophytes, and
hypertrophy of
flaval ligaments

12. Muscle Pain
Muscle pain is a
major medical
problem: in , the
majority (60% to
85%) of the
population has had
(nonspecific) back
pain of muscular
origin
Muscle pain differs
in many ways from
pain in the skin or
viscera
Muscle pain is
produced by the
activation of specific
receptors (so-called
nociceptors)
can be sensitized
and activated by
strong mechanical
stimuli, such as
trauma or
mechanical
overloading
as well as by
endogenous
inflammatory
mediators including
bradykinin (BK),
serotonin, and
prostaglandin E2
(PGE2)

13. Muscle Pain Induced by Endogenous and Neuropeptides
These peptides are
released when nerve
endings are activated
and induce local
edema by dilating the
local blood vessels
and increasing their
permeability
Muscle nociceptors
contain
neuropeptides,
including substance P
(SP) and calcitonin-
gene-related peptide
(CGRP)
These two activating
substances increase
the sensitivity of
nociceptors to
external stimuli
Endogenous
substances such as
BK and E2
prostaglandins are
released by muscle
lesions of all kinds

14. Muscle Pain Induced by Chemical Substances
Two activating chemical
substances are
particularly important
for the generation of
muscle pain: adenosine
triphosphate (ATP) and
protons (H+ ions)
ATP activates muscle
nociceptors mainly by
binding to the P2X3
receptor molecule
located in the
membrane of the nerve
ending
These receptor
molecules are channel
proteins that span the
membrane of the nerve
ending and mainly
permit Na+ ions to
enter the neuron
These Na+ ions then
induce neural
excitation
DOI: 10.3238/artzebl.2008.0214

15. Patophysiology of Spinal Pain
Pain is mediated by nociceptors
specialized peripheral sensory
neurons that alert us to
potentially damaging stimuli by
transducing these stimuli into
electrical signals that are
relayed to higher brain centers
The spinal dorsal horn is a
major site of integration of
somatosensory information
Composed of several
interneuron populations forming
descending inhibitory and
facilitatory pathways
Able to modulate the
transmission of nociceptive
signals

16. If the noxious stimulus persists, processes of
peripheral and central sensitization can occur
Converting pain from acute to chronic
Central sensitization is characterized by the
increase in the excitability of neurons within the
central nervous system
Normal inputs begin to produce abnormal
responses
Allodynia and Hyperalgesia

17. Electrical Stimulation for Pain Management
Electrotherapy
produces three
excitatory responses :
sensory, motor and
noxious (pain)
While stimulation with
lower frequencies (2-
5Hz) can be used to
activate the opioid
mechanisms to
providing a degree of
pain relief
The 90-130Hz
frequencies stimulate
the pain gate
mechanisms and
mask the pain
symptoms
Electrical stimulation
has widespread
clinical use for pain
relief

18. Counter Irritant Theory
Spinal inhibition by releasing GABA and enkephalin
https://clinicalgate.com/pain-and-pain-management/

24. Group A consisted of
20 patients
(conventional TENS) :
alternating current,
rectangular impulse,
impulse duration 100
µs, frequency of 100
Hz, 60-min duration of
a single treatment
Group B consisted of
20 patients
(acupuncture-like TENS)
: alternating current,
rectangular impulse,
impulse duration 200
µs, frequency of 10
Hz, 60-min duration of
a single treatment
Group C initially
consisted of 20
patients completed the
therapy (high-voltage
electrical stimulation) :
alternating current,
spike impulse, impulse
duration 100 µs,
frequency of 100 Hz,
50-min duration of a
single treatment
Group D 21 patients
completed the therapy
(interferential current
stimulation) :
alternating current,
sinusoidal impulse,
impulse duration 100
µs, basic frequency
4000 Hz, alternating
frequency 50–100 Hz,
20 min duration of a
single treatment
Group E consisted of
22 patients
(diadynamic currents) :
(sequentially DF 10 ms,
100 Hz, CP 10 ms, 50–
100 Hz, LP 10 ms, 50–
100 Hz), 9-min
duration of a single
treatment (DF, LP, and
CP were 3 min each)
Group F (21 patients,
control group) were
treated only by means
of motor improvement
exercises

29. THANKS