The document discusses low back pain, including its prevalence, causes, types (acute, subacute, chronic), and potential pain generators. It describes the biomechanics of the lumbar spine, including the vertebrae, intervertebral discs, zygapophyseal joints, ligaments, and muscles. Potential causes of low back pain with leg pain greater than back pain and management options are provided. Specific conditions like lumbar spinal stenosis, spondylolysis, and pregnancy-related back pain are explained. The role of ergonomics and lifestyle factors like backpack weight are also summarized.

1. Low Back Pain
Dr Sushil Kumar
Nayak
Asst. professor
Dept. of PMR

2. Low back pain is a symptom, not a
disease, and has many causes.

3. Pain between the costal margin and
the gluteal folds.
• Prevalence in India-
– Annual- 51%
– Lifetime- 66%
Prevalence of low back pain in India: A systematic review and meta-analysis - Gautam
M Shetty 1 2 3, Shikha Jain 2, Harshad Thakur4, Kriti Khanna2

4. • Acute- an episode resolves in <6wks
• Subacute- persisting for 6wks- 12wks
• Chronic- persistent for >12wks.

5. Biomechanics of Lumbar Spine
• Dichotomous role in terms of function, which
is strength coupled with flexibility.
• Supports and protects (strength) the spinal
canal contents (spinal cord, conus, and cauda-
equina).
• Provides inherent flexibility by allowing us to
place our limbs in appropriate positions for
everyday functions.

6. • The strength of the spine results from the size
and arrangements of the bones, ligaments and
muscles.
• The inherent flexibility results from three-joint
complex of vertebral segment.
• And the typical lordotic framework of the
lumbar spine.

7. vertebrae
• Body
• Neural Arch
• Posterior Elements

10. Intervertebral Disc
• Secondary cartilaginous joint, or symphysis
• Internal Nucleus pulposus and the Outer
Annulus fibrosus.

11. Nucleus pulposus
• It consists of water, proteoglycans, and
collagen.
• The nucleus pulposus is 90% water at birth.

12. Annulus fibrosus
• concentric layers of fibers at oblique angles to
each other, which help to with-stand strains in
any direction.
• The outer fibers have more collagen and less
proteoglycans and water than the inner fibers.

13. • The main function of the intervertebral disc is
shock absorption.
• Posterolateral disc herniations the most
common.
• The activity of the lumbar muscles correlates
well with intradiscal pressures.

15. Zygapophyseal Joints
• Paired synovial joints with a synovium and a
capsule.
• The lumbar zygapophyseal joints lie in the
sagittal plane and thus primarily allow flexion
and extension.

18. Ligaments
• Longitudinal ligaments and the Segmental
ligaments.
• Longitudinal ligaments- Anterior(ALL) and
Posterior(PLL)
• ALL resists extension, translation, and rotation.
• PLL resists flexion.
• ALL is twice as strong as PLL.

19. Segmental ligaments
• Ligamentum flavum
• Supraspinous,
• Interspinous, and
• Intertransverse

20. Muscles
• Muscles with Origins on the Lumbar Spine
• Abdominal Musculature
• Thoracolumbar Fascia
• Pelvic Stabilizers

21. • The posterior muscles include the latissimus
dorsi and the paraspinals.
• The anterior muscles include psoas and
Quadratus lumborum.

22. Abdominal Musculature
• The superficial abdominals include the rectus
abdominis and external obliques.
• The deep layer consists of internal obliques
and the transversus abdominis.

23. Pelvic Stabilizers
• Also known as “Core muscles” .
• Indirect effect on the lumbar spine, even
though they do not have a direct attachment
to the spine

24. Nerves

26. Potential Pain Generators of the Back
• Aging Spine: A Degenerative Cascade-
(Kirkaldy-Willis et al.)
• Centralization and Pain
• Psychosocial Factors and Low Back Pain
– Depression, Anxiety, and Anger
– Patient Beliefs About Pain and Pain Cognition.

28. Management
• History & Examinations
• Investigations, if needed.

29. Red flags

30. Yellow flags

31. Back pain greater than Leg pain
• Nonspecific LBP.
• Lumbar Spondylosis.
• Lumbar Disc Disease-
– Degenerative disc disease,
– Internal disk disruption, and
– Disc herniation.

33. Treatment
• Reassurance and Patient Education
• Back Schools
Medication-
• Nonsteroidal Anti-inflammatory Drugs.
• Muscle Relaxants.
• Antidepressants.
• Anticonvulsants.

34. • Exercises
• Physical modalities-
– TENS
– Manual massaging

35. • Lumbar spondylolysis
• Spondylolisthesis
• Spondyloarthropathies
• Spinal infection
• Cancer pain

36. Leg Pain Greater Than
Back Pain
• Lumbosacral Radiculopathy

38. Lumbar Spinal Stenosis
• Congenital
• Achondroplasia or dwarfism
• Idiopathic
• Acquired
• Degenerative
• Iatrogenic or postsurgical
• Traumatic
• Combined

39. • Mechanical compression of the nerves can
occur as a result of
– central canal narrowing,
– lateral recess narrowing, and
– Intervertebral foraminal narrowing

40. Symptoms
• Neurologic claudication B/L LL
• Initiated by walking, prolonged standing, and
walking downhill, relieved by sitting or
bending forward.
• Radicular pain in specific dermatome.
• Forward-flexed posture.

41. Treatment
• Oral medications,
• Epidural steroids, and
• Comprehensive functional Exercise program.
– flexion-based lumbar stabilization exercises.
• Bracing with an abdominal corset might be
beneficial for overweight patients with a
protuberant abdomen

42. • Surgical indication-
Intractable pain resistant to nonoperative
management, profound or progressive
neurologic deficit, or lifestyle impairment.
• Mode- Decompressive Laminectomy

43. Non-lumbar Spine Causes of Radicular
Leg Symptoms
• Joint Disorders- SI joint, Hip joint
• Soft Tissue Disorders-
– Piriformis syndrome
– Greater Trochanteric Pain Syndrome
– Iliotibial Band Syndrome.
• Vascular Disorders- Vascular claudication
• Peripheral Neuropathy

44. Low Back Pain in Pregnancy
• Two categories-with low back pain and those
with pelvic girdle pain i.e. below iliac crest
pain.
• estimated the prevalence of low back pain in
pregnancy at 49% to 76%.
• Risk factors-
– History of previous back pain,
– Previous pregnancy-related back pain, and
– Low back pain during menses.

45. • Can begin at any time during the pregnancy
and generally reaches a peak at 36 weeks.
• Improved by 3 months postpartum.
• Etiology- Altered hormonal influence and/or
Increased biomechanical strain.
• Management- Individualised rehab with
respect to weeks of gestation.

46. Pediatric Low Back Pain
• Nonspecific
• Spondylolysis with or without spondylolisthesis
• Lumbar disk herniation
• Slipped vertebral apophysis
• Scheuermann disease
• Discitis
• Vertebral osteomyelitis
• Neoplasm
• Rheumatic disease
• Somatization

47. Backpack & Backache
• Carrying a greater than 7.5% to 15% of the
wearer’s body weight increases the metabolic
demands over what is required to move a
person’s body weight alone.
• The general recommendation for a child’s
backpack weight is limited to 10% of body
weight.
Mackenzie WG, Sampath JS, Kruse RW, et al: Backpacks in children, Clin Orthop409:78–84, 2003

50. Ergonomic modifications
• The science of applying physical and
psychological principles within an environment
to increase both productivity and well-being.

51. Good sitting posture

52. Dynamic sitting
• Involves the used of both active and
passive implements to encourage regular
movement of the trunk and lower
extremities in a seated position.
• O'Sullivan, K., O'Keeffe, M., O'Sullivan, L., O'Sullivan, P. and Dankaerts, W. (2012) The effect of dynamic sitting
on the prevention and management of low back pain and low back discomfort: a systematic review.
Ergonomics 55(8): 898-908.

53. Movement Breaks
• For those individuals who are in a seated
position for prolonged periods of time.
• Short, regular breaks of standing from a
seated position.
heahan, P., Diesbourg, T. and Fischer, S. (2016) The effect of rest break schedule on acute low
back pain development in pain and non-pain developers during seated work. Applied
Ergonomics 53: 64-70.

54. Thank you