Functional Anatomy

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  • Neuro pain – due to chemical or mechanical stimulation of the nerve root. Dermatomal distribution. Intensity depends on type, position, speed of onset and degree of local inflammation. As symptoms improve pain centralizes. Back pain increases with flexion Sensory – numbness or parasthesia Muscle weekness – L4 = Tib Ant (almost exclusive – weakness more profound). L5 = EHL, peronei Reflexes – S1 = ankle, L4 (L3)= knee Cramps – abnormal excitability of motor neurones
  • Descriptive terms to describe a defect and subluxation respectively between vertebrae, from the Greek spondylo , meaning vertebrae, and lysis meaning to seperate, listhesis meaning slip or slide. Commonest Level for both – L5 S1 Classification – different systems Developmental/Congenital Acquired Traumatic Post surgical Pathalogical degenerative
  • Repetitive stresses ? Flexion extension – greatest experimental stresses (Dietrich & Kurowski Spine 1985) – rowing, gymnastics front on fast bowling. ? Hyperextension with rotation (McGill 1997) Fracture usually on opposite side to activity – left side in right handed player (Buckner & Khan)
  • Back pain – episodic, low grade, agg by prolonged sitting/standing/walking. May be acute. Pain may radiate into buttocks, thighs. May cause sciatica unilateral. Gait – knees bent, stiff spine, pronounced lordosis, post pelvic rotation, wide base.
  • The aim of core stability training is to effectively recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements. The deep trunk muscles, particularly Transversus Abdominis (TA), multifidus (MF), but also Internal Oblique (IO), paraspinal, pelvic floor, are key to the active support of the lumbar spine. The co-contraction of these muscles produce forces via the "theracolumbar fascia" (TLF) and the "intra-abdominal pressure" (IAP) mechanism which stabilise the lumbar spine, and the paraspinal and MF muscles act directly to resist the forces acting on the lumbar spine. It is not just the recruitment of these deep-trunk muscles, but how they are recruited that is important. Hodges and Richardson (1996) showed that the co-contraction of the TA and MF muscles occurred prior to any movement of the limbs. This suggests that these muscles anticipate dynamic forces which may act on the lumbar spine and stabilise the area prior to any movement.
  • Functional Anatomy

    1. 1. Low Back Pain Dr Mike England Medical Director RFU Community Rugby & RFU Injured Players Foundation
    2. 3. Outline <ul><li>Assessment </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Examination – key points </li></ul></ul><ul><li>Common conditions </li></ul><ul><li>Postural Control (Practical!!) </li></ul>
    3. 4. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society <ul><li>Clinicians should conduct a focused </li></ul><ul><li>history and physical examination to help place patients with ow back pain into 1 of 3 broad categories: </li></ul><ul><ul><li>nonspecific low back pain, </li></ul></ul><ul><ul><li>back pain potentially associated with radiculopathy or spinal stenosis, </li></ul></ul><ul><ul><li>back pain potentially associated with another specific spinal cause. </li></ul></ul><ul><li>The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain </li></ul>
    4. 5. Assessment of LBP <ul><li>Rule out serious pathology ‘Red Flags’ </li></ul><ul><li>Confirm that the pain: </li></ul><ul><ul><li>Is in the lower back - always assess the hip joint </li></ul></ul><ul><ul><li>Is mechanical — aggravated or relieved by certain movements or postures. </li></ul></ul><ul><ul><li>Is not inflammatory — that is: </li></ul></ul><ul><ul><ul><li>Not worse in the second half of the night or after waking. </li></ul></ul></ul><ul><ul><ul><li>Not associated with morning stiffness lasting more than 30 minutes. </li></ul></ul></ul><ul><ul><ul><li>Not relieved by activity. </li></ul></ul></ul><ul><ul><ul><li>Not associated with laboratory tests for inflammation </li></ul></ul></ul><ul><li>Exclude specific causes of low back pain </li></ul>
    5. 6. Classification of LBP <ul><li>Conventionally low back pain is categorised according to its duration as: </li></ul><ul><ul><li>acute (<6 weeks), </li></ul></ul><ul><ul><li>sub-acute (6 weeks - 12 weeks) </li></ul></ul><ul><ul><li>chronic (>12 weeks) </li></ul></ul><ul><ul><li>(Spitzer, W. O. and Leblanc, F. E., 1987). </li></ul></ul>
    6. 7. Copyright ©2002 BMJ Publishing Group Ltd. Main, C. J et al. BMJ 2002;325:534-537 No Caption Found
    7. 8. Red Flags <ul><li>Red flags for the cauda equina syndrome include: </li></ul><ul><ul><li>Saddle anaesthesia. </li></ul></ul><ul><ul><li>Recent onset of bladder dysfunction or faecal incontinence. </li></ul></ul><ul><ul><li>Major motor weakness. </li></ul></ul><ul><li>Red flags that suggest spinal fracture include: </li></ul><ul><ul><li>Sudden onset of severe central pain in the spine which is relieved by lying down. </li></ul></ul><ul><ul><li>Major trauma such as a road accident or fall from a height. </li></ul></ul><ul><ul><li>Minor trauma, or even just strenuous lifting, in people with osteoporosis. </li></ul></ul><ul><ul><li>Structural deformity of the spine. </li></ul></ul><ul><li>Red flags that suggest cancer or infection include: </li></ul><ul><ul><li>Onset in a person over 50 years, or under 20 years, of age. </li></ul></ul><ul><ul><li>History of cancer. </li></ul></ul><ul><ul><li>Constitutional symptoms, such as fever, chills, or unexplained weight loss. </li></ul></ul><ul><ul><li>Intravenous drug abuse. </li></ul></ul><ul><ul><li>Immune suppression. </li></ul></ul><ul><ul><li>Pain that remains when supine; aching night-time pain disturbing sleep; and thoracic pain (which also suggests aortic aneurysm) . </li></ul></ul>
    8. 9. Yellow Flags <ul><li>Yellow flags are psychosocial barriers to recovery. They include: </li></ul><ul><li>The belief that pain and activity are harmful. </li></ul><ul><li>Sickness behaviours, such as extended rest. </li></ul><ul><li>Social withdrawal, lack of support. </li></ul><ul><li>Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress. </li></ul><ul><li>Problems or dissatisfaction at work. </li></ul><ul><li>Problems with claims for compensation or applications for social benefits. </li></ul><ul><li>Prolonged time off work (e.g. more than 6 weeks). </li></ul><ul><li>Overprotective family. </li></ul><ul><li>Inappropriate expectations of treatment, such as low expectations of active participation in treatment. </li></ul>
    9. 10. Examination <ul><li>Observation + Tip Toe </li></ul><ul><li>Palpation – muscle spasm/deformity/masses </li></ul><ul><li>(Range of motion) </li></ul><ul><li>Neurological tests </li></ul><ul><li>Provocation tests : </li></ul><ul><ul><li>SLR & Crossed SLR </li></ul></ul><ul><ul><li>(SLUMP) </li></ul></ul><ul><ul><li>(Femoral Nerve ST) </li></ul></ul><ul><li>Abdomen /Hip/Lower Limb Circulation </li></ul>
    10. 11. Investigation <ul><li>Do not offer X-ray of the lumbar spine for the management of non-specific low back pain. </li></ul><ul><li>MRI for non-specific low back pain should only be performed within the context of a referral for an opinion on spinal fusion. </li></ul><ul><li>Consider referral for MRI if sciatica persists > 6 weeks </li></ul><ul><li>ESR/CRP if suspect cancer, infection, Ank Spond </li></ul><ul><li>HLA B27 if suspect Ank Spond </li></ul>
    11. 12. Mangement <ul><li>Education </li></ul><ul><li>Remain active </li></ul><ul><li>Analgesia/ ? Heat </li></ul><ul><li>Therapies: </li></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Manual therapy </li></ul></ul><ul><ul><li>Acupuncture </li></ul></ul><ul><ul><li>Psychological </li></ul></ul>
    12. 13. Pharmacological Mnx <ul><li>Regular paracetamol </li></ul><ul><li>Consider offering NSAIDs for short-term use when paracetamol is ineffective. </li></ul><ul><li>Consider offering strong opioids for short-term use to people in severe pain. </li></ul><ul><li>Consider referral to Pain Clinic for people who may require prolonged use of strong opioids. </li></ul><ul><li>Consider offering a trial of tricyclic antidepressants. Not SSRIs for treating pain. </li></ul><ul><li>Benzodiazepines & muscle relaxants </li></ul><ul><li>Gadbapentin </li></ul>
    13. 14. Exercise <ul><li>Maintain a physically active lifestyle. </li></ul><ul><li>Consider offering a structured exercise programme - stretching, low impact aerobic, and strengthening exercises aimed at all main muscle groups </li></ul><ul><li>Offer supervised group exercise programmes in preference to one-to-one supervised exercise programmes. </li></ul>
    14. 15. Manual Therapy <ul><li>End range </li></ul><ul><li>High velocity </li></ul><ul><li>Small amplitude </li></ul><ul><li>Physiotherapist </li></ul><ul><li>Osteopath </li></ul><ul><li>Chiropracter </li></ul>
    15. 16. Acupuncture/Injection Therapy <ul><li>Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks10. </li></ul><ul><li>Do not offer injections of therapeutic substances into the back e.g. Nerve blocks, caudal epidural, prolotherapy </li></ul>
    16. 17. LBP - Referral for Surgery <ul><li>Completed a comprehensive package of care including a combined physical and psychological treatment programme and who have persistent severe non-specific low back pain for which the patient would consider surgery. </li></ul><ul><li>People who have psychological distress should receive appropriate treatment for this before referral for spinal fusion. </li></ul><ul><li>If spinal fusion is being considered, refer the patient to a specialist surgical service. </li></ul><ul><li>Do not refer people for intradiscal electrothermal therapy (IDET), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) or radiofrequency facet joint denervation. </li></ul>
    17. 18. Specific Conditions <ul><li>Disc prolapse </li></ul><ul><li>Spinal Stenosis </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Spondylolysis </li></ul>
    18. 19. Disc Prolapse - Symptoms <ul><li>Neurological pain </li></ul><ul><li>Back pain </li></ul><ul><li>Sensory disturbances </li></ul><ul><li>Muscle weakness </li></ul><ul><li>Loss of reflexes </li></ul><ul><li>Cramps </li></ul>
    19. 20. Disc prolapse - Management <ul><li>Bed Rest – max 48 hours </li></ul><ul><li>Analgesia </li></ul><ul><li>Remain active </li></ul><ul><li>Referral Therapies: </li></ul><ul><ul><li>Physiotherapy </li></ul></ul><ul><ul><li>? Caudal epidural </li></ul></ul><ul><ul><li>Surgery : </li></ul></ul><ul><ul><ul><li>Red Flags </li></ul></ul></ul><ul><ul><ul><li>Failure to respond to conservative treatment </li></ul></ul></ul>
    20. 21. Sciatica - When to Refer <ul><li>Remember that motor deficits and bowel or bladder disturbances are more reliable than sensory signs. </li></ul><ul><li>If red flags suggest a serious condition refer with appropriate urgency. </li></ul><ul><li>If there is progressive, persistent, or severe neurological deficit: </li></ul><ul><ul><li>Refer for neurosurgical or orthopaedic assessment (preferably to be seen within 1 week). </li></ul></ul><ul><li>If pain or disability remain problematic for more than a week or two: </li></ul><ul><ul><li>Consider early referral for physiotherapy or other physical therapy. </li></ul></ul><ul><li>If, after 6 weeks, sciatica is still disabling and distressing: </li></ul><ul><ul><li>Refer for neurosurgical or orthopaedic assessment (preferably to be seen within 3 weeks). </li></ul></ul><ul><li>If pain or disability continue to be a problem despite appropriate pharmacotherapy and physical therapy: </li></ul><ul><ul><li>Consider referral to a multidisciplinary back pain service or a chronic pain clinic. </li></ul></ul>
    21. 22. Red Flags <ul><li>There is difficulty with micturition. </li></ul><ul><li>There is loss of anal sphincter tone and faecal incontinence. </li></ul><ul><li>Saddle anaesthesia by the anus perineum or genitals. </li></ul><ul><li>Widespread or progressive motor weakness in the legs or gait disturbance. </li></ul><ul><li>Pain is constant, progressive and non-mechanical in nature. </li></ul><ul><li>Sciatic symptoms are not resolving after four to six weeks of conservative treatment. </li></ul><ul><li>The patient is systemically unwell. </li></ul><ul><li>There is widespread neurology. </li></ul><ul><li>There is structural deformity. </li></ul><ul><li>ESR is abnormal. </li></ul>
    22. 23. Spinal Stenosis <ul><li>Leg pain on walking, eased by leaning forward or sitting, but not by standing still (unlike vascular claudication, where pain does improve after standing still). </li></ul><ul><li>Normal peripheral circulation; normal straight leg raising (nerve root signs appear late). </li></ul><ul><li>More likely in over-60s or ankylosing spondylitis. </li></ul>
    23. 24. Ankylosing Spondylitis <ul><li>Suspect in anyone with chronic or recurrent low back pain, fatigue and stiffness, especially if: </li></ul><ul><li>They are a teenager or young adult. </li></ul><ul><li>The back pain and stiffness is inflammatory (rather than mechanical). </li></ul><ul><li>They have current or previous: </li></ul><ul><ul><li>Buttock pain </li></ul></ul><ul><ul><li>Arthritis - predominately asymmetric and in the lower limbs. </li></ul></ul><ul><ul><li>Enthesitis, costochonditis or epicondylitis. </li></ul></ul><ul><ul><li>Anterior uveitis (iritis) </li></ul></ul><ul><ul><li>Psoriasis or inflammatory bowel disease, or recent infective diarrhoea or sexually transmitted disease </li></ul></ul>
    24. 25. Spondylolysis and - listhesis <ul><li>Defect and subluxation between vertebrae </li></ul><ul><li>Commonest level –L5/S1 </li></ul><ul><li>Defect may be uni or bilateral. </li></ul>
    25. 26. Risk Sports <ul><li>Occurs in sports which involve repetitive stresses across Pars </li></ul><ul><li>Gymnastics </li></ul><ul><li>Cricket </li></ul><ul><li>Throwing </li></ul><ul><li>Tennis </li></ul><ul><li>Rowing </li></ul>
    26. 27. Clinical Presentation <ul><li>Asymptomatic </li></ul><ul><li>Active young individuals </li></ul><ul><li>Back pain </li></ul><ul><li>Leg pain </li></ul><ul><li>Stiffness </li></ul><ul><li>Deformity </li></ul><ul><li>Gait </li></ul>
    27. 28. Grades of Spondylolisthesis <ul><li>Grade 1 </li></ul><ul><li>Grade 2 </li></ul><ul><li>Grade 3 </li></ul><ul><li>Grade 4 </li></ul>
    28. 29. “ Core Stability” <ul><li>TA activated before movements of limbs delayed in back pain </li></ul><ul><li>Multifidis activation = good postural control </li></ul><ul><li>? Quadratus lumborum </li></ul><ul><li>Rehab more effective if re-education of postural muscles incorporated </li></ul><ul><li>Recurrence rate of LBP reduced if postural control incorporated in rehab </li></ul>

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