Low Back Pain
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| what is the approximately percentage of adults who have experience low back pain? | 90%
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| what is definition of low back pain? | Pain between costal angels and gluteal folds
can be localized or diffuse
sometimes accompany by Sciatica
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| Sciatica | describes leg pain that is localized in the distribution of one or more lumbosacral nerve roots, typically L4 to S2, with or without neurological deficit
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| What nerve does Sciatica associate with? | L4-S2
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| what factor determine the type of Low Back Pain/ | The length of time symptom persist
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| Category of Low Back Pain? | 1) Acute LBP: Last <6 weeks
2) Subacute LBP: last between 6-12 weeks
3) Chronic LBP: perisist >12 weeks (3 months)
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| What are etiology of Low Back Pain? | 1) mechanical LBP: 97%, caused by muscle, nerve, joint, ligament injury
2) non-mechanical LBP: 3%, due to cancer, organ pain
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| Why 85% of patient with Acute LBP can not be given a precise pathoanatomical diagnosis? | there is no specific lab test to determine where exactly the pain is originated from and there are many pain generator
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| What are the non-specific name for mechanical LBP? | 1) Strain: micro tear of muscle
2) Sprain: micro tear of ligament
3) degenerative process
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| what are the top 3 causes of Mechanical LBP? | 1st - Lumbar strain and sprain (70%0
2nd - degenerative disc disease/spondylosis/facet (4%)
3rd: disc herniation (3%)
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| what are the causes of non-mechanical LBP | 1) viseral(viseralsomatic)
2) neoplasia
3) infection
4) inflammtory arthritis
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| In case of back pain problem, we should do what type of physical examination? | 1) musculoskeletal exmainatino
2) minimum check for somatic dysfunction (lumbar spine, sacrum, pelvic)
3) neurological exam(red flag): DTR, Sensory and motor testing for lower extremities, striaght leg raising exam
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| what is Red flag when we do inital assessment of patient with LBP? | Detection of potentially serious spinal pathology or other non-spinal pathology
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| what are the red flag for possible trauma | 1) major trauma after accident or fall
2) minor trauma (osteoporosis, metabolic bone disease)
3)pain is usually axial, non-radiating, severe and disabling and follow immediate after trauma
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| What is the most important concern about suspecting possible trauma with red flag sign? | make sure patient history, physical examination and lab test/image match and correlated
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| What are the red flag for possible infection/tumor | 1) risk for cancer: <20 or >50 years old, history of cancer, unexplained weight loss and failure of improvement after 4-6 weeks
2) risk for infeciton: IV drug use, immunosuppresion, fever /chill
3)pain worse when laydown and at night time
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| waht are the red flag for possible cauda equna syndrome | complex of syndrome: lower back pain, unilateral or bilateral sciatica, variable lower extremity motor and sensory, saddle sensory anethesia, bladder and bowel dysfunciton
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| what kind of consultation should physician refer to patient? | early neurosurgical, neurologic or orthopedic consultation
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| in absence of red flag, why imaging studies and further testing of patients are not helpful? | during first 4 weeks, the imaging does not improve clinical outcome, association between symptom and result is weak and 90% of patient recover in 4 weeks
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| list 4 types of neurological examination of lower extremities | 1) deep tendon reflexes
2) straight leg raising test
3) sensation testing (by dermatome)
4) motor strength test (by nerve root)
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| L4 motor: reflex: sensory: disc level | L4
motor: tibialis anterior
reflex: patellar tendon
sensory: medial side of foot
disc level: L3 L4
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| L5 motor: reflex sensory disc level | L5
motor: extensor digitorium long
reflex: N/A (NO REFLEX AT L5)
sensory: dorsal part of foot
Disc level: L4 & L5
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| S1 motor: reflex sensory: disc level | S1
Motor; peroneus longus
reflex: achilles tensdon
sensory: lateral side of foot
disc level: L5, S1
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| example of lumbosacral radiculopathy | HNP (Herniated nucleus pulposus)
lumbar spinal stenosis
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| Spondylosis | -degenerative ostearthritis of articulating aspect of vertebrae
-if happen in facet, we call it facet syndrome
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| Spondylolisthesis | -forward movement of the body of one vertebra on the vertebra below it, or upon the sacrum
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| spondylolysis | -defect in pars interarticularis without anterior displacement of vertebral body (usually on one side)
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| Lumbosacral radiculopathy | nerve root impingement and/or inflammation that has progressed enough to cause neurologic symptoms in the areas that are supplied by the affected nerve roots
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| What is the cause of lumbosacral radiculopathy | usually acute and chronic low back pain assoicatediwht radiculopathy
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| What is the symptom of lumbosacral radiculopathy? | pain, numbness, tingling and/or weakness along the distribution of nerve root (the lower part of leg)
-onset of sudden pain includes low back pain then may travel to leg pain
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| What usually make lumbosacral radiculopathy worse? | sitting, sneezing, coughing
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| What is the most common location for disc herniation? | L4, L5 and S1
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| Which part of body does radiculopathy in root L1-L3 associate with? | Anterior aspect of thigh and typically not raditae below the knee.
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| Lumbar spinal stenosis | spinal canal narrowing, occur in central canal or the lateral recess
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| What structure usually involve with lateral recess stenosis? | Intervertebral foramen
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| what are the clinical presentation of lumbar spinal stenosis | -more common in mean
-age >50
-non specific LBP
-Pain and paresthesia develop gradually in one or both leg
hall mark: neurogenic claudication
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| Neurogenic claudication and its clinical importance | -the hallmark for lumbar stenosis
-patient's leg pain usually worse with walking but better when they sitting, squatting, lying down
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| what is the main difference between vascular claudication and neurogenic claudication? | Vascular claudication: symptom don't go away with sitting, flexing forward
Neurogenic claudication: symptom can be reproduced if patient is hyperextension(aggreate lordosis) and ease when flexing forward
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| Degenerative disc disease | -naturally process with aging
-cause by poor nutrition, smoking, atherosclerosis, joint related activities and genetic
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| feature of discongenic pain | -without nerve root involvement
-usually vague, diffuse and distributed axially
-activity increase intradiscal pressure will intensify symptom
-Vibration stress during driving will worse the symptom
-disc herniation may be coexist
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| What does we usually find in MRI with patient without pain symptom? | -bulge (prevalence increase with age)
-protrusion
-extrusion
-abnormality at more than 1 intervertebral level
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| List conservation treatment for low back pain | -OMT
-Physical therapy
-Ice and Heat
-Medication
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| What is the DOC medication for LBP: | NSAIDS
Non-steroidal anti-inflammatory drug
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| Which OMT technique is a relative contraindicated for very acute LBP? | HVLA
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| Is bed rest and inactivity a good treatment for patient recover from LBP? | No. Studies show patient should return work and normal life activity ASAP
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| etiology of lumbar strain | 1) Direct or indirect trauma 2) muscle spasm due to persistent contractionof muslce 3) paraspinal bcome decondition after injury 4) somatic dyfunction 5) muscle stress (stress in facet) 6) whole function unit is involved
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| Characteristic of lumbar strain | 1) trama history maybe illusive 2) pain localied to lumbar or lumbosacral area 3) pain increase after activity and relief with rest 4) any motion contraction in injured area can reproduce pain
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| Iliolumbar ligament syndrom | pain in multifidus triangle (L4, L5 and iliac crest). Pain in sacroilia, posterior thigh and/or inguinal region, mimic inguinal hernia
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| which syndrome of LBP may mimic inguinal hernia | Iliolumbar ligament syndrome.
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| why hamstring so important for the healing of Lumbar strain? | after 45 degree of lumbar flexion, the rest motion occurs by rotation of pelvic around th ehip joint. Tight hamstring lock pelvic and put burden on lumbar spine and there fore will slow recovery time
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| Treatment for lumbar strain | 1) OMT 2) NSAID & Muscle relaxant 3) Ice 4) Control physical activity for 2 days 5) active exercise program early in treatment 6) Back brace for patient who must remain active during healing process
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| Which OMT technique cant be applied to patient with acute inflammatory LBP? | HVLA
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| Is bed rest for 7 days recommended as a treatment for LBP? | NO
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| When should you give patient back barces? | when patient must remain active during healing process (lifting or heavy labor job). Back braces cause patient to rely on braces to support body instead of his/her muscle.
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| origin and insertion and action of piriformis muscle | Origin: anterior surface of s2-4 segment
Insertion: Superior an posterior of greater traochanter.
Action: external rotation and abduction of hip
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| relationship of sciatic nerve and piriformis muscle | Sciatic arise from L4-S3 nerve roots and join to form a common trunk. It exit pelvic via the greater sciatic forament beneath the pififormis muscle, sometimes 10% of population passthrough the muscle
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| Pathogenesis of piriformis | The compression of sciatic nerve due to tightness of piriformis muscle. Nerve compression usually cause impairment or loss of conduction
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| What attribute to the pain in piriformis syndrome | the combination of nerve entrapment and inflammatory response from epineural irritation.
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| What is the important key to recognize piriformis syndrome | Piriformis syndrome does not have neurologic component which mean patient still have normal reflex and motor function. There is no damage to the nerve root
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| Epineurium | the layer that cover the whole nerve
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| perineurium | the layer surround the nerve fascicle
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| Endoneurium | the layer which surround the neuron
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| What is the restricted range of motion with piriformis syndrome? | Restricted internal hip rotation
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| Dysparuenia | painful intercours which is a symptom of piriformis syndrom due to pelvic diaphragm irritation
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| which OMT technique is best for piriformis syndrome? | Counterstrain
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| How trauma can contribute to piriformis syndrom? | Fall on buttock, usually minimal or lacking
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| What is the most common cause of piriformis syndrome? | psotrual decompensation. Example, short leg which may affect muscle on other leg
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| Piriformis syndrome maybe secondary to which other strain | iliopsoas strain, pelvic shift to other side which may tighten the piriformis muscle
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| What physical finding are expected with piriformis syndrome | 1) negative on neurologic exmaination (DTR, Straight leg test) 2) no motor deficits 3) restricted internal rotation of hip 4) lumbar somatic dysfunction 5) sacral torsion/rotation
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| Treatment for piriformis dysfunction | 1) OMT best with counterstrain
2) NSAIDS & Muscle relaxant
3) home exercise
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| what is the usually position of patient when they are injury with iliopsoas syndrom? | flexed at the time of injury
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| what is key lesion of iliopsoas syndrome? | L1-2 FRS
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| where is piriformis spasm and pelvic shift in a relationship to iliopsoas spasm | the pelvic shift to the opposite of iliopsoas spasm and piriformis spasm to the opposite side as well
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| Treatment for iliopsoas syndrome | 1) OMT (counterstrain, muscle energy)
2) NSAIDS & muscle relaxant
3) home exercise
4) resassure patient of favorable prognosis
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| what are the two key feature in diagnosing Sacroiliitis? | 1) the pain is usually medial and inferior to PSIS
2) Positive Patrick's test
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| Why sacroiliac joint is important? | most body weight will add to the joint and any unleveling will result in inflammation of the joint and led to sacroiliitis
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| what disease is sacroiliitis most assoicated with | autoimmune arthritis disease (repetitive microtrauma, ankylosing spondylitis)
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| treatment for sacroiliitis | 1) lymphatic technique to reduce swelling
2) indirect technique to relieve pain
3) direct technique to improve motion an davoid stressing joint
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| Patrick's test | FABER: Flexion, abduction, external rotation
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