The document discusses low back pain from multiple perspectives. It covers epidemiology, costs, causes, mechanics, common injuries, and treatment approaches. The causes of low back pain are multi-factorial, involving both mechanical and central nervous system factors. A common story of low back pain progression is described. Treatment focuses on thorough education, addressing impairments, and modifying activities to reduce mechanical stresses on the spine.

1. LOW BACK PAIN
A pragmatic approach for real world
application

2. Michael Stare, DPT, CSCS,
FAAOMPT, CNS
U of Illinois: biomechanics/kinesiology, certified
personal trainer.
Boston U: Masters in Physical therapy
Doctorate in PT at MGH
Fellowship in Orthopedics manual therapy, research on
Low back pain
Board certified nutritionist, American College of
Nutrition.

3. Epidemiology
2nd most common reason to see MD behind
respiratory compliants.
Many cases resolve over time, up to 84% will
reoccur

4. Cost
86% with a duration of < 1 month account for 11% of
cost
<5% with duration of >1 year account for 65% of the
costs

5. Why do we stuggle to solve
LPB?
Lack of understanding the cause.
Focus on treating the symptoms, instead of the cause.
Limited emphasis on patient education and instruction.
Feeding into patient’s desire to be a passive recipient of
care.

6. Causes: Where is pain
coming from?
The brain!
“pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue
damage” -IASP
“Pain is the individual response to threat to the body
tissue, real or perceived” -Moseley

7. Causes: What is pain?
Response to damaged anatomy: mechanical or chemical
Product of altered peripheral nervous system
Product of altered central nervous system

8. Peripheral Nervous
System=Pain
Hypersensitivity of the PNS can occur in response to
chronic mechanical or chemical irritation
“irritability threshold” decreases
Solution=desensitize through touch, movement, graded
exposures.

9. Altered Central Nervous
System=Pain
Brain centers for processing pain can be altered in
response to chronic pain.
Solutions: education

10. What movement is the spine
equipped for?
Cervical: rotation
Thoracic: Sidebending
Lumbar: flexion/extension

11. What Mechanical forces
Cause Damage?
Compression
Torsion
Shear
Vibration
Tension

12. Compression
Vertebral endplate is the first to buckle
Only an unhealthy annular matrix will herniate
Compression is from both sudden impact but mostly
from repeated or prolonged compression.
The position of the spine and the speed of movement
dictates the spines tolerance to compression (Adams
1994)

13. Torsion
Damages the annular rings, causing fissures (Farfan
1984)
Maximal tolerance for elongation of the annular fibers
is 4% (3 degrees of rotation)
Lumbar spine can only tolerate 15 degrees of total
rotation before sustaining damage.
The facets will forcefully impact exposing them and the
posterior arch to damage
This is why we educate to get more rotation from the
hips

14. Shear
Increase in flexion, extensors are unable to resist shear
loads in flexion (McGill et al 2000)
As a result of spondylolisthesis
Causes damage to the disc
If you have an unstable spine: reduce flexion or
extension shearing

15. Enemies of the spine
Prolonged sitting
Repeated<sustained bending (McGill,
Callahan,Gordon, Little et al 2005)
Repeated twisting (McGill)
Sit-ups, crunches, oblique twists, hyperextensions
(McGill 2006)
Golfing or any bending/twisting first thing in the
morning or after prolonged sitting (McGill, Adams
1987, Snook, et al 1998)

16. Common Enemies of the
Spine
Low back stretches: deadens neural response and
replicates mechanism of injury (Kokkonen 98,
Solomonow 00, McGill 06)
Most hamstring stretches (McGill 2006)
Lifting with a flexed spine (Gunning 01, 43% higher
load on disc)
Spine power (Adams et al 1994)- more power from the
hips
Fear/Avoidance

17. A Common Low Back Pain
Story

18. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.

19. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.
Ligament laxity

20. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.
Ligament laxity
Microfractures of the vertebral endplates

21. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.
Ligament laxity
Microfractures of the vertebral endplates
Microfractures of the annulus

22. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.
Ligament laxity
Microfractures of the vertebral endplates
Microfractures of the annulus
Sporadic episodes of low back pain

23. A Common Low Back Pain
Story
Lots of sit ups, prolonged sitting, flexed spine lifting,
occasional heavy compression, etc.
Ligament laxity
Microfractures of the vertebral endplates
Microfractures of the annulus
Sporadic episodes of low back pain
Microfractures and fissures continue, and more sitting,
flexed spine lifting

24. A common low back pain
story

25. A common low back pain
story
To relieve pain more stretching, add in decreased hip,
ankle and mid back mobility, and decreased leg
strength

26. A common low back pain
story
To relieve pain more stretching, add in decreased hip,
ankle and mid back mobility, and decreased leg
strength
Ligaments become more lax and...

27. A common low back pain
story
To relieve pain more stretching, add in decreased hip,
ankle and mid back mobility, and decreased leg
strength
Ligaments become more lax and...
Symptoms occur more frequent, and more severe

28. A common low back pain
story
To relieve pain more stretching, add in decreased hip,
ankle and mid back mobility, and decreased leg
strength
Ligaments become more lax and...
Symptoms occur more frequent, and more severe
Blood resulting from microfractures penetrates via
annular fissures, interacting with nucleus altering
chemical composition and integrity of nucleus and
ability to load.

29. A common low back pain
story

30. A common low back pain
story
Cascade of degredation is set in place

31. A common low back pain
story
Cascade of degredation is set in place
Other factors may contribute: nutrition, infection,
genetics, age

32. A common low back pain
story
Cascade of degredation is set in place
Other factors may contribute: nutrition, infection,
genetics, age
Altered motor control of the spinal stabilizers in
response to improper training and episodes of pain.

33. A common low back pain
story
Cascade of degredation is set in place
Other factors may contribute: nutrition, infection,
genetics, age
Altered motor control of the spinal stabilizers in
response to improper training and episodes of pain.
Load bearing capacity of disc decreases, stress shifts to
facets, facet get irritated, intermittent swelling irritates
nerves, instability perpetrates disc and facet irritation
and the cycle goes on...

34. A common low back pain
story

35. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).

36. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).
MRI and muscle relaxers and various treatments are
offered: findings inconclusive, treatments variable

37. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).
MRI and muscle relaxers and various treatments are
offered: findings inconclusive, treatments variable
Cause still not found

38. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).
MRI and muscle relaxers and various treatments are
offered: findings inconclusive, treatments variable
Cause still not found
Compensatory arthritic changes occur to restore
stability

39. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).
MRI and muscle relaxers and various treatments are
offered: findings inconclusive, treatments variable
Cause still not found
Compensatory arthritic changes occur to restore
stability
Less space for the nerve- stenosis

40. A common low back pain
story
Very benign incidents trigger back issues (picking up a
pen).
MRI and muscle relaxers and various treatments are
offered: findings inconclusive, treatments variable
Cause still not found
Compensatory arthritic changes occur to restore
stability
Less space for the nerve- stenosis
Disc hardens: less effective, but less vulnerable

41. History
Red flags
Onset
Mechanism
Preciptating activity
Alleviation
Prior treatment
Imaging
Prior history
What do you think is going on?

42. PT- Examination
History
Where pain coming from?
What stresses are the tissue sensitive to? compression, position sensitive....
What are the impairments that make them susceptible to LBP?
Posture: Are they listing, trying to unload the spine? Position of pelvis.
Function: squat, lunge, transfers, work, sport specific, ADLs
AROM
Neuro-exam
Joint mobility: prone extension test, prone instability test

43. PT examination
Palpation
Motor control: assessing lumbopelvic proprioception
Muscle performance: endurance significantly correlated with decreased incidence
of LBP (prone plank, lateral plank), testing length.
Oswestry disability questionnaire
Fear avoidance questionaire
Waddel’s signs

44. Treatment
Based on thorough assessment
Thorough education
Ergonomic and ADL modification
Address acute symptoms
Address key impairments
Give them a HEP they understand

45. Treatment
Classifications: systematic arrangement of patients into
treatment groups they are likely to benefit from based
on characteristics
Manipulation, stabilization, specific exercise:
extension,flexion, lateral shift, or Traction.

46. Support for traction based
classification
Fritz et al, spine 2003: Patients treated based on TBC
improved functionally more than those based on
current practice guidelines
Brennan et al, Spine, 2006: Patients randomly assigned
to one of the TBC’s ended up doing better than if
assigned to the classification they would actually be in.

47. Manual Intermittent
Traction
Prone, supine, hook lying, 90/90, standing
Belt or harness (Morgan pelvic harness)
Intermittent pressure <10sec prevents ligamentous
creep
Intermittent pressure allows for graded forces
Intermittent pressure improves diffusion of nutrients

48. Ergonomic and ADL
modification
Prolonged sitting: manual traction (10 sets of 10
seconds) seated, standing at table, hanging from lat pull
down or towel over door, hooklying in doorway.
Reaching and lifting: hip hinge, golfers lift
Forward bending compensations
Sumo squat

49. Exercises
Planks
Deloaded lunges: reduces intradiscal pressure
Inverted rows: activates mostly mid back, least stress
on lumbar
Lat pull downs: with hip not back extension
Pull throughs
Terminal hip extensions (esp. w/ geriatric patients)
Hip flexor and hamstring stretching

50. The art of education
Instability scenario: wrist analogy
Position sensitivity scenario: punching with a bent
wrist
Load sensitivity scenario: How do we manage a broken
foot?
Movement apprehension scenario: movement provides
nutrition, prevents “the guards” from getting lazy and
teaches the brain that the threat is under control.

51. Art of education
Over doing it scenario: back budget
Strong invincible scenario: how strong do you need to
be to throw a punch with a bent wrist?
Explaining motor control: doesn’t matter how bright
the light bulb is if you can’t find the switch.

52. Art of education
Out of pain/out of mind scenario: Most issues will
return if we don’t address the cause. Damage may
occur before pain occurs like tooth decay.
Deficits associated with low back pain linger for
years even without symptoms (McGill 2003).

53. The impact of education on
pain
Randomized controlled trials have demonstrated that 1
to 1 patient education will:
Change beliefs and attitudes about pain
Improve performance
Increase pain thresholds
(Moseley 2002, Hodges, Nicholas 2004)

54. Summary- Causes of LBP
Multi-factorial
LBP is not simply a pathoanatomical issue, but rather a
biopsychosocial issue.
The brain is the source of pain
Solutions must take into consideration the cause
Education is the Key