There are several potential causes of lower back pain, including muscle strains or sprains, ligament or disc injuries, joint problems, and underlying medical conditions. Treatment involves a three-phase process focusing initially on reducing pain and inflammation, then restoring function through exercises, and finally maintaining strength through continued exercise and preventative measures. Proper functioning of the sacroiliac joint and surrounding muscles is important for low back health.

1. BACK PAIN MANAGEMENT Quoc To Ai Giang D.C.

2. Statistics 75-85% of Americans will suffer from LBP once in their lifetime 90% will improve w/out surgery 50% of those who have an episode will have a recurrent episode within 1 year 5.4 million workers will be disabled for 1 or more years from LBP NeuroSurgery Today March 2006

3. Sacroiliac Joint Lumbo-sacral joint complex functions as a self-compensating mechanism which accommodates, mitigates, balances, stores and redirects forces affecting the pelvis and spine. Forces: gravity, weight bearing, inertia, rotation, acc/deceleration, ground reactive forces

4. Sacroiliac Joint SI joint is essential for load transfer between spine and legs Slight changes in the mobility or stability can be responsible for variety of clinical conditions

5. Sacroiliac Joint Pathology in this joint has been reported in numerous of inflammatory, metabolic, and infective disorders Yet mechanical dysfunctions of this joint remains controversial, largely due to our lack of knowledge about the joint

6. Sacroiliac Joint Composed of 2 innominate bones and a sacrum forming 2 SI joints and pubic symphysis Ligaments, joint capsule, muscle, fascia, articular configuration

7. Sacroiliac Joint Sacrum A tilted wedge or keystone The weight of the spine coupled with gravity forces the sacrum to wedge snugly between the two innominates. This phenomenon along with other passive anatomical features that provide stability are called form closure .

8. Form Closure Osteoarticulo-ligamentous component “ Refers to a stable situation with closely fitting joint surfaces, where no extra forces are needed to maintain the state (stability) of the system” Vleeming

9. Stabilization of the pelvis via ligamentous structures Ligamentous Structures

10. Sacroiliac Joint SI Joint Surfaces: Sacrum: The articular surface, called auricular, is concave, covered in thick hyaline cartilage and is shaped like a plane propeller - wider P-A in the upper aspect and wider A-P in the lower aspect . Ilium: Controversy exists as to if the iliac side is fibrocartilage or hyaline. Either way, its convex surface is irregular (rough). Shape of the SIJ effectively resists flexion.

11. Sacroiliac Joint Ligaments - designed to limit the mobility of the SI joint. The ligaments must oppose strong forces for long periods of time. Simonian noted the strength of the ligaments by cutting through the pubic symphysis and the iliac wings only flared out slightly.

12. Sacroiliac Joint Iliolumbar Ligament: limits axial rotation and anterior glide of L5 on the sacrum. Sacrotuberous Ligament: resists sacral movement into nutation, (tightens the ligament). It also has as an important connection to the long head of the biceps femoris. Sacrospinal Ligament: see #2 Dorsal Sacral Iliac Ligament: this large ligament tightens in counter-nutation. It makes up 2/3 of the posterior SI connections and blends with #2, erector spinae and thoracolumbar fascia. 1 2 4 4 3

13. Sacroiliac Joint Anterior Sacroiliac Ligament: opposes axial translation of the sacrum and separation of the SI joints. Interosseous Ligament (not shown): fills in the irregular spaces posterior and superior to the joint; resists joint separation. 5

14. Sacroiliac Joint - Capsule Superior portion is a caudal extension of the iliolumbar ligament Anterior portion is dense connective tissue and caudally blends with the sacrospinous ligament Posterior portion is made up of multiple interwoven bands (interosseous ligaments) 5

15. Sacroiliac Joint - Innervation Anterior superior joint receives info. from spinal nerves L4 & 5 Anterior inferior joint supplied by S1 & 2 and other sacral nerves 5

16. Sacroiliac Joint Muscles: The major muscles and fascia that are involved in the SI joint are the gluteus maximus and medius, psoas, piriformis multifidus , latissimus dorsi, abdominal obliques, transversus abdominus , biceps femoris , l atissimus dorsi , pelvic floor & diaphragm and thoracolumbar fascia. The forces created by the muscles acting on SI joint to provide stability is called Fo rce Closure.

17. Force Closure “ Force closure refers to a system whereby additional forces are necessary to maintain the joint in place.” J. Snijders Second Interdisciplinary Word Congress on Low Back Pain – San Diego 1995

18. Force Closure Erector Spinali Extends spine and pelvis Contraction creates sacral nutation (locking) thus ligaments tighten and SI joint locks

19. Force Closure Multifidi Tendon pass above interosseous ligament and inserts into sacrum, iliac crest, and sacrotuberous ligament Contraction facilitates nutation

20. Force Closure Gluteus Maximus Hip extensor Directly compresses SI joint due to fiber orientation Fibers blend with sacrotuberous ligament and thoracolumbar fascia

21. Form Closure Latissimus Dorsi Extends, abducts, and medially rotate humerus Deep fibers: lower T/S spinous processes and iliac crest Superficial fibers: oblique caudal fibers blend with thoracolumbar fascia and then contralateral gluteal muscles

22. Force Closure Biceps femoris Long head crosses over the ischeal tuberosity & blends into sacrotuberous ligament Contraction increases sacrotuberous tension

23. Force Closure Piriformis Externally rotates femur Crosses SI joint perpendicular & compresses the joint

24. Force Closure Psoas Quadratus Lumborum

25. Force Closure Adominals The Transverse Abdominals wrap around the spine and goes all the way to the front and when activated it stabilizes the spine and pelvis

26. Force Closure Thoracolumbar fascia Clinical of importance in surgery, it blends with the deep cervical fascia which forms a plane for infection to travel

27. Force Closure Abdominals Transverse Abdominals Deepest of the 3 layers Perhaps the most functional for core stabilization, spinal stabilization

28. Joint Functions If joint is compressed this will result in restriction If joint is not compressed enough this will result in instability or hypermobility If joint does not function in a smooth & efficient manner this can result in abnormal firing patterns

29. Joint Functions The Panjabi Model as modified by Vleeming & Lee

30. Integration Joint function requires normal function of the joint & of the muscles Form Closure Force Closure Joint restriction can be due to muscular and ligamentous elements Local stabilizers vs. Global stabilizers & global maximizers

31. Inner Core Tranversus Abdominus Lumbar Multifidi Pelvic Floor Diaphragm

32. The Tranversus Abdominus Pre-Anticipatory Damaged by: Surgery Overactive Rectus Pendulant Abdomen The rest of the inner unit

33. Lumbar Multifidi Shut off after 3 minutes in slumped posture Atrophy occurs in most of modern (sitting) society Mass is replaced by fatty infiltration

34. Pelvic Floor Damaged by childbirth – a normal vaginal delivery Is affected by the other inner unit muscles not functioning Puborectalis – a muscle of the pelvic floor can be overactive as a consequence of rectus over-activity which is itself a product of Tranversus Abdominus weakness

35. 3 Phases to LBP Rehabilitation Phase I: Acute Phase Physiatrist and treatment team focus on making a diagnosis, developing an appropriate treatment plan, and implementing the treatment regimen to reduce the initial low back pain and source of inflammation. This may include any/all of the items listed above and/or the utilization of ultrasound, electrical stimulation, or specialized injections.

36. 3 Phases to LBP Rehabilitation Phase II: Recovery Phase Once the initial pain and inflammation are better managed, the rehabilitation team then focuses on helping the patient to restore working function of the body. This includes returning the patient to normal daily activities while implementing a specialized exercise program that is designed to help the individual regain flexibility and strength.

37. 3 Phases to LBP Rehabilitation Phase III: Maintenance Phase The goal of this phase of low back pain rehabilitation is two-fold: Educating the individual on ways to prevent further injury and strain to the back Helping the individual to maintain an appropriate level of physical fitness to help further increase strength and endurance.

38. Common Causes Disc Lesions with/out Radiculopathy 98% of Disc lesions occur at L4-5 & L5-S1 Overuse, strenuous activity, or improper use (i.e., repetitive or heavy lifting, exposure to vibration for prolonged periods of time) Trauma/injury/fracture Degeneration of vertebrae (often caused by stresses on the muscles and ligaments that support the spine, or the effects of instability.

39. Common Causes Infection Abnormal growth (tumor) Obesity (often caused by increased weight on the spine and pressure on the discs) Poor muscle tone in the back

40. Common Causes Muscle tension or spasm Sprain or strain Ligament or muscle tears Joint problems Smoking (damage to the vasculatures of discs) Disease (i.e., osteoarthritis, spondylitis, compression fractures)

41. – a term that encapsulates all the possible causes of joint changes Movement Dysfunction

42. – implies some holding element that restricts movement - possible candidates : muscle, ligament or capsular change due to some past trauma to the tissue Joint Fixation or Restriction

43. a. Capsular & Ligamentous Changes following trauma & the inflammatory cascade Clinical Orthopedics, 1987, Akeson, Amiel, Abel, Garfin & Woo (for an overview see the Aging Body by Morgenthal & Boughie – Chapter 3 b. Trigger Points / Myofascial Changes Travell & Simons – Myofascial Pain & Dysfunction – the Trigger Point Manual Volume 1 & 2 c. Muscle Imbalances Janda d. Alterations in the Arthrokinetic Reflex Cassidy / Mooney Movement Dysfunction Causes:

44. Cassidy / Mooney Based on Hilton’s law, the nerves that innervate a joint innervate the muscles around the joint. If there's a problem within the joint the surrounding muscles will be weakened or shut off. This has been proposed as a primary mechanism of dysfunction in all areas of the spine. 1.) SI joint dysfunction and glute inhibition, (Bernard and Cassidy 91) 2.) Lumbar joint dysfunction and multifidus inhibition, (Hides 96) 3.) Cervical spine and L. coli (longissimus coli muscle) inhibition, (Wright, Jull 2001) 4.) Vastus medialis inhibition after knee joint dysfunction, (Richardson PhD thesis) Alterations in the Arthrokinetic Reflex

45. Directional Instability Nutation vs. Counternutation Dominance Sacrotuberus ligament Checks Nutation Long & Short Sacroiliac ligaments Checks Counternutation Nutation Counternutation Nutation Counternutation

46. Assessments Functionally putting the puzzle together: We need to be able to assess the complaints through functional testing.

47. Orthopedic (Functional) Exams/Assessments Acute Vs. Chronic Determine if the problem is an acute vs. chronic complaint

48. Gillet’s Test Performed knee to chest while standing: Pull knees alternately to chest. The PSIS that moves down the furthest in relation to the opposite one is the unblocked side. The blocked side will come very little or appear to move cephalically. Recruitment is from the bottom up. Hip flexion must be at least 90 degrees.

49. Gillet’s Test

50. Piedallu’s Sign : The movement of the posterior superior iliac spines upon forward flexion. A positive Piedallu’s sign is asymetrical movement.

51. Gaelen’s Test: The patient lies on the side with the upper leg (test leg) hyperextended at the hip (1st photo). The patient holds the lower leg flexed against the chest. The examiner stabilizes the pelvis while extending the hip of the uppermost leg. The test can also be performed supine (2nd) but this position may limit the amount of hyperextension. Position patient so the test hip extends beyond the edge pf the table. Then draw up both legs onto the chest then slowly lower the test leg into extension. Pain in the sacroiliac joints indicates a positive test.

52. Gait Analysis

53. Gait How can we incorporate static anatomy into functional anatomy?

54. Gait – Heel Strike Prior to heel strike, heel strike becomes active Which increases tension of sacrotuberous ligament Thus compresses SI joint Forces transmitted across SI joint into spine

55. Gait – Stance Phase Innominates begin anterior rotation counter-nutation begins Loose SI joint. locking Long Dorsal SI ligament tension increases Need to stabilize SI joint Gluteus maximus activates and replaces Biceps femoris Contralateral lats dorsi activates

56. Gait – Swing Phase No weight in SI joint. It is suspended. Ligamentous control of SI joint

57. Gait With Each Phase of Gait Opposite arm and “wringing of spine” (it occurs like taking a rubber band and twisting it, when you let go, it “springs”) Ligaments, discs, and spinal curves maximize yielding energy storage Elastic Energy is released in the next cycle —followed by muscular energy

58. Treatment Treatment should be inclusive to include all the tissues that can affect movement. Each treatment should be tailor made to fit the patients dysfunction, manipulation, mobilization, rehabilitation, stretching & diet/nutrition should a part of every doctor’s practice regiment.

59. Treatments Activity modification Medication Physical rehabilitation and/or therapy Occupational therapy Weight loss (if overweight)

60. INTEGRATED METHOD OF TREATMENT

61. Treatments Following a prevention program (as directed by your physician) Quit smoking Surgery Assistive devices (i.e., mechanical back supports)

62. Why Failures?

63. Application With all our knowledge in anatomy we need to learn how to apply it to the patient who is having pain after all the treatments they’ve had. Extensive connections of sacrotuberous ligaments Gluteus Maximus Piriformis Bicep Femoris Multifidi Thoracolumbar Fascia

64. Application SI joint is located in the middle of considerable force streams Mechanoreceptors Dysfunctional of Form/Force Closure can have significant effects locally at the SI joint and far into the lower/upper limbs or cervical spine. Loss of bracing Shifting of loads into the lumbar/sacral area

65. Applications Often these connections are incomplete, unilateral or asymetrical I.E. - Unilateral shorten biceps Could these differences cause symptoms in the patient? The answer is YES!

66. Applications Our goal is to find these differences Evaluations of: Trigger Points Hyper/Hypotonicity Myofascial bands Decrease muscle length Pain

67. Applications These imbalances will change the function of the SI joints and L/S as a UNIT FAILED SELF BRACING “ Abnormal movement of the sacrum in the SI joints may lead to abnormal stress loads transmitted into the L/S thus abnormal stress on the intervertebral discs and joints.” - Vleeming

68. Failed Self Bracing Imbalances Weak erector spinae leads to insufficient nutation Weak gluteus maximus leads to insufficient SI compression Weak Lats leads to insufficient SI compression Decreased SI joint. compression & poor nutation leads to dysfunction and pain syndromes

69. Failed Self Bracing Sustained counter-nutation leads to: Absent SI compression therefore increasing joint shear forces Lordosis is lost Load is transferred to L/S and discs…increasing shear

70. Failed Self Bracing Irritation of the SI joint inhibits the gluteus maximus Inhibition = weakness Hamstring will attempt to increase hip extension and help increase SI joint compression shorten stride

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76. Low Back Pain Quiz