Chapter 17
The Lumbar Spine

INTRODUCTION: the problem of low back dysfunction

  1. Incidence: 80% of US population, 2-5% annually

    1. tremendous advances have been made in imaging techniques, surgical procedures, and rehab techniques. However, the number of people disabled by back pain increased by 161% from 1971 to 1986. This was 14 times faster than the population increase.

    2. Many physical therapy procedures have been described for the treatment of LBP. The efficacy of these procedures, however remains unclear. The need for valid clinical research relative to the efficacy of physical therapy procedures in the treatment of LBP is critical.

    3. The barriers to research in LBP are many. Among these are:
      1. Measurement problems
        1. spinal motion
        2. spinal muscle performance
        3. pain
        4. functional capacity
      2. Natural history: 60% return to work in one week, 80% return in less than 6 weeks.
      3. Difficulty in matching subjects: 80-90% of patients with LBP lack a precise patho-anatomical diagnosis. There is a wide variation of clinical findings within this group.
      4. Physiological effect of treatment vs. placebo effect.
      5. When reviewing the literature there are great variations of treatment types and combinations, therefore it is difficult to compare various studies.
      6. Potential for secondary gain: litigation, compensation.

    4. The disability of chronic LBP:
      1. Back pain is the main cause of disability in individuals under 44 years of age in U.S.
      2. <40% chance of ever returning to work if out of work for 6 months
      3. <15% if out of work >12 months
      4. Profound secondary changes:
        1. psycho-social
          1. behavioral issues: avoidance learning based upon past experience of pain. Failure of treatment increases illness behavior.
          2. dependency: on family, health care practitioners, substance abuse.
        2. altered sensory interpretation, RSD?
        3. physiological: deconditioning
      5. It is critical to differentiate:
        1. impairment: a physical finding, eg. limited spinal extension, vs.
        2. a functional limitation: eg. can't sit,
        3. vs. a disability: eg. unable to work at desk.

    5. Risk factors for the development of LBP:
      1. Aging: spine is more easily traumatized, slower recovery.
        1. disc and bony changes: DJD, stenosis, senile osteoporosis
        2. neuro-muscular changes
      2. Acute Trauma (often a combination of different injuries)
        1. spinal fracture, disc herniation, end plate injuries
        2. soft tissue injuries
      3. Mechanical, Occupational Stresses
        1. lifting: consider frequency, magnitude, height and "angie"
        2. patterns of asymmetrical postural demands
        3. prolonged sitting
        4. vibration
      4. General Health risk factors for the development of LBP
        1. high correlation between cigarette smoking and LBP
        2. cardio-vascular disease
        3. diabetes
        4. obesity
      5. General "Fitness". Patient's with chronic LBP tend to have reduced srinal flexibility, impaired muscle performance, and decreased cardio-vascular fitness.
        1. Which came first, LBP or poor fitness?
        2. Concept of chronic LBP as a deconditioning syndrome
      6. Psychosocial factors: "symptom" magnifier

  2. Current trends in the treatment of LBP

    1. reduced bed-rest for acute LBP: 2 days generally as effective as 7. Prolonged bedrest leads to deconditioning and depression.

    2. reduced surgical intervention: during the 70's there was 400% more spinal surgery in the U.S. than anywhere else in the world.

    3. increased emphasis on functional restoration as opposed to pain reduction.

    4. emphasis on patient's active participation in rehab

    5. emphasis on health and wellness

  3. Diagnosis vs. Classification: can we identify the structures which cause the patient's symptoms? Approximately 80-90% of patients with LBP lack a precise pathoanatomical diagnosis. Some reasons for this are:

    1. Radiography and imaging findings do not always correlate with pain.

    2. The spine consists of multiple levels of three joint complexes, all of which influence each other and are presumably injured together.

    3. There is potential for referred pain from soft tissues and joint structures such as:
      1. muscle, fascia
      2. facet joint
      3. non-musculoskeletal tissues

    4. How important is it for us to know the presence of spinal abnormalities? Issues of treatment planning vs. precautions.

  4. The role of physical therapy in the treatment of LBP:

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    (active and passive)

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