Specific Low Back Pain

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Introduction

Low back pain is a considerable health problem in all developed countries and is most commonly treated in primary healthcare settings. It is usually defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). The most important symptoms of low back pain are pain and disability..

About 90% of all patients with low back pain will have non-specific low back pain, which, in essence, is a diagnosis based on exclusion of specific pathology ^[1]. Those specific pathologies can be defined as:

• Radiculopathy
• Disc Herniation
• Lumbar spinal stenosis
• Spondylolisthesis
• Ankylosing_Spondylitis
• Osteoporosis
• Lumbar_Spine_Fracture
• Skeletal_Metastases
• Cauda_Equina_Syndrome
• Scheuermans Disease
• Scoliosis

Clinically Relevant Anatomy

see Lumbar Anatomy

The human spine is a self-supporting construction of skeleton, cartilage, ligaments and muscles. The lower back (where most back pain occurs) includes the five vertebrae in the lumbar region and supports much of the weight of the upper body. The spaces between the vertebrae are maintained by intervertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain.

Epidemiology/Etiology

Low back pain is a symptom, not a disease, and has many causes. It is generally described as pain between the costal margin and the gluteal folds. It is extremely common. About 40% of people say that they have had low back pain within the past 6 months. Onset usually begins in the teens to early 40s. A small percentage of low back pain becomes chronic^[2,3]. Low back pain is considered acute if its onset occurred less than 1 month ago. The symptoms of chronic low back pain have lasted 2 months or longer. Both acute and chronic low back pain may be further classified as non-specific or specific/radicular^[4].

Characteristics/ Clinical Presentation

Scoliosis ^[5] 

• Not much pain

• Sideways curvature of the spine

• Muscle strains

• Antalgic posture

• Sideways body posture

• One shoulder raised higher than the other

• Local muscular aches

• Local ligament pain

Scheuermann ^[6,7,8] :

• History of deformity because of structural kyphosis in adolescence

• In the lumbar spine, hyperlordosis can occur

• Strong correlation between Scheuermann’s disease and scoliosis

• Hamstring thightness

• Back pain, located distal to the apex of the deformity

• Activity related to pain

• Fatigue

• Muscle stiffness (especially at the end of the day)

• Neurological symptoms

• In severe cases: heart and lung function cab be impaired. Other secondary changes are Schmorl nodes, irregular vertebral endplates and dics space narrowing

• Muscle spasms or muscle cramps 

• Diffuculty exercising

• Limited flexibility

• Tight hamstrings

Ankylosing spondylitis ^[9,10] : 

5 phases:

• Acute inflammation

• Damage to the cartilage because of repeatedly acute inflammations

• Damaged cartilage does not heal and is replaced by bone tissue

• Joint loses his flexibility

• Components of the joint grow towards each other and form 1 piece

Important symptoms

• Iridocyclitis or uveïtis (inflammation of the iris)

• Nerve pain in the chest, abdomen of legs

• Morning stiffness lasting greater than 30 minutes and waking up in the second half of the night

• Pain and stiffness increase with inactivity and improve with exercise

• Respiratory complaints

• Inflammation of achilles tendons

• Psoriasis (abnormity of the skin)

• Intestinal problems (Crohn disease)

• Peripheral joints, eyes, skin and the cardiac and intestinal systems problems

• The hips, shoulder and knees are the most commonly and most severely affected of the extremity joints

• Complaints of intermittent breathing difficulties because of a decrease in chest expansion

• Also fatigue, weight loss and fever are indirect effects of inflammation processes. This can lead to severe psychological issues such as depression

Hernia ^[17] :

Herniated disc not pressing on the nerve:

• No pain

Herniated disc is pressing on the nerve(s):

• Stiffness

• Harp pain

• Tingling and weakness

• Referred pain in legs

• Paralysis

The severity of the complaints depends on the strength of compressive from the hernia on surrounding components.

Radicular syndrome ^[11,12] :

• Sharp, dull, piercing, throbbing, stabbing, shooting or burning pain

• Numbness, tingling and weakness in the arms or legs

• Radicular pain in one leg

• Neurological loss of function

• Unilateral pain radiating to foot or toes

• Numbness and paraesthesia in the same distribution

• Paravertebral pressure above the nerve root causes pain in the periphery

• Failure of the sensible dermatome

• Nerve root entrapment such as sensory deficits, reflex changes or muscle weakness

Spinal canal stenosis ^[13,14,15] :

• Persisting and heavy pain in the low back

• Referred pain in legs

• Symptoms increase when standing straight

• Laying down/ sitting down/ bending forward decreases the pain

• Areas off the body who are not in pain, can feel itchy and inflamed

• Muscle tension in spine

• Sensibility disorders

• Sleeping disorders

• Incontinence problems

• Sexual dysfunctions

• Immobility of low back

• Pain and/or weakness in legs and buttocks

• Neurogenic intermittent claudication

Spondylolisthesis^[16] :

• Instability

• Low back pain

• Stiffness in low back

• Pain in extension

• Referred pain in upper leg
  

• Immobility low back

• Resting decreases pain

• Trophic changes

• Atrophy of the muscles

• Tense hamstrings

• Disturbance in patterns

• Diminished ROM (spine)

• Disturbances in coordination and balance

• Neurological symptoms (possible evolution towards cauda equina syndrome)

Metastasen ^[18] :

• Pain increases at night and in rest

• Paralysis

• Compression on the spinal cord resulting in numbness or tingling in the abdomen and legs, bowel and bladder problems, difficulty walking
  

Cauda equina ^[19] :

• Difficulties to urinate

• Decrease of sensibility in legs

• Low back pain

• Referred pain in legs

• Sensibility disorders of genital organs

• Difficulty walking

Differential Diagnosis

Some conditions can present with similar impairments and should be included in the clinician’s differential diagnosis^[20].

Mechanical

• Lumbar muscular strain/sprain 

• Compression fracture (www.physio-pedia.com/Lumbar_compression_fracture)

Systemic

• Vertebral discitis/ osteomyelitis (www.physio-pedia.com/Osteomyelitis)
• Connective tissue disease (www.physio-pedia.com/Dermatomyositis)

Referred

• Aortic Abdominal aneurysm (www.physiopedia.com/Abdominal_Aortic_Aneurysm)
• Pancreatitis (www.physio-pedia.com/Pancreatitis)
• Nephrolithiasis (www.physio-pedia.com/Nephrolithiasis_(Kidney_Stones))

Diagnostic Procedures

In clinical practice, the triage is focused on identification of “red flags” (see box 1/2) as indicators of possible underlying pathology, including nerve root problems. When red flags are not present, the patient is considered as having non-specific low back pain. Besides those red flags there are yellow flags. Besides the red flags we have to take another kind of flags in consideration, “Yellow flags” have been developed for the identification of patients at risk of chronic pain and disability. A screening instrument based on these yellow flags has been validated for use in clinical practice ^[21]. The predictive value of the yellow flags and the screening instrument need to be further evaluated in clinical practice and research.

Abnormalities in x-ray and magnetic resonance imaging and the occurrence of non-specific low back pain seem not to be strongly associated ^[22]. Abnormalities found when imaging people without back pain are just as prevalent as those found in patients with back pain. Van Tulder and Roland reported radiological abnormalities varying from 40% to 50% for degeneration and spondylosis in people without low back pain. They said that radiologists should include this epidemiological data when reporting the findings of a radiological investigation^[23]. Many people with low back pain show no abnormalities. In clinical guidelines these findings have led to the recommendation to be restrictive in referral for imaging in patients with non-specific low back pain. Only in cases with red flag conditions might imaging be indicated. Jarvik et al showed that computed tomography and magnetic resonance imaging are equally accurate for diagnosing lumbar disc herniation and stenosis—both conditions that can easily be separated from non-specific low back pain by the appearance of red flags. Magnetic resonance imaging is probably more accurate than other types of imaging for diagnosing infections and malignancies ^[24], but the prevalence of these specific pathologies is low.

Outcome Measures

The following list contains commonly used low back pain outcome measures. But these questionnaires are complete and not patient specific. Often medical imaging has to be done to include specific low back pain disorders but your own clinical judgment will be necessary to determine the most useful measure in your clinical setting.

We found that the ‘Back Illness Pain and Disability 9-item Scale, Quebec Back Pain Disability Index and Roland & Morris Disability Questionnaire’ had a goodfactor of reliability.
The ‘Back Pain Functional scale, Back Pain Interference Scales, Clinical Back Pain Questionnaire, Dallas Pain Questionnaire, Hannover Functional Ability Questionnaire, Oswestry Disability Index, Outcome Measure for lumbar spinal stenosis, Resumption of Activities of Daily Living Scale and Waddell Disability Index’ scored acceptable.(LE: 1B)25(LE:2B)26(LE:1A)27

Quebec Back Pain Disability Scale (www.physio-pedia.com/Quebec_Back_Pain_Disability_Scale)

Is a condition–specific questionnaire developed to measure the level of functional disability for patients with low back pain. Intended for those who suffer diseases such as acute LBP, chronic pain, lumbar spinal stenosis, posterior surgical decompression.

Oswestry Disability Index (www.physio-pedia.com/Oswestry_Disability_Index)
Patient-completed questionnaire which gives a subjective percentage of level of function (disability) in activities of daily living in those rehabilitation from low back pain. In acute or chronic low back pain.

Roland-Morris Disability Questionnaire (www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire

The patient is asked to tick off different statements when it is applied to him, that specific time. It is most sensitive for patients with mild to moderate disability.

Back Pain Functional Scale (www.physio-pedia.com/Back_Pain_Functional_Scale)

Is a self-report measure that evaluates functional ability that is intended for people who are suffering from back pain. It consists of 12 items.

VAS: Visual Analog Scale (www.physio-pedia.com/Visual_Analogue_Scale)

Examination

The first aim of the physiotherapy examination for a patient presenting with back pain is to classify the patient according to the diagnostic triage recommended in international back pain guidelines. Serious and specific causes of back pain with neurological deficits are rare but it is important to screen for these conditions. Serious conditions account for 1-2% of people presenting with low back pain. When serious and specific causes of low back pain have been ruled out individuals are said to have non-specific (or simple or mechanical) back pain.

The examination consists of :

1. Inspection

• How does the patient enter the room?
• A posture deformity in flexion or a deformity with a lateral pelvic tilt, possibly a slight limp, may be seen.
• How does the patient sit down and how comfortably/ uncomfortably does he or she sit?
• How does the patient get up from the chair? A patient with low back pain may splint the spine in order to avoid painful movements.

Posture

• Scoliosis (static, sciatic, idiopathic) (Left)
• Lordosis (excessive, flattened) (Centre)
• Kyphosis (thoracic) (Right)
  

Other observations

• Body type
• Attitude
• Facial expression
• Skin
• Hair
• Leg lenght discrepancy (functional,structural)

2. Motion Testing

Active range of motion of the lumbar spine is evaluated with the patient standing. Motion of the lumbar spine occurs in 3 planes and includes 4 directions, as follows:

• Forward flexion: 40°-60°
• Extension: 20°-35°
• Lateral flexion/ side bending (left and right): 15°-20°
• Rotation (left and right): 3°-18°

Scoliosis test: [1]

3. Isometric Muscle Testing

Strength testing of the lumbar spine includes the muscles around the spine column and the large moving muscles that attach onto the axial skeleton. The goal of muscle testing is to evaluate for strength and reproduction of pain.

4. Palpation

The physician can use palpation for two purposes during examination of the lumbar spine:

• To help locate tender areas
• To confirm findings previously demonstrated in the examination

5. Test for Neurological Dysfunction

Straight leg raise test: www.physio-pedia.com/Straight_Leg_Raise_Test

The straight leg raise test is used to evaluate for lumbar nerve root impingement or irritation. This is a passive test in which each leg is examined individually.

• Sensitivity of 35%-97%
• Specificity of 10%-100%

Slump test: www.physio-pedia.com/Slump_Test

The Slump test is used to evaluate for lumbar nerve root impingement or irritation. A positive Slump test result is demonstrated with the reproduction of radicular symptoms. The test is then repeated on the contralateral side.

• Sensitivity of 44%-84%
• Specificity of 58%-83%

Femoral nerve traction test: www.physio-pedia.com/Femoral_Nerve_Tension_Test
The femoral nerve traction test is used to evaluate for pathology of the femoral nerve or nerve routes coming out of the third and fourth lumbar segments.

Compression test: www.physio-pedia.com/Sacroiliac_Compression_Test

6. Tests for Joint Dysfunction

One leg standing test: www.physio-pedia.com/One_Leg_Standing_Test_(Gillet_Test,_Kinetic_Test)

The one leg stand test, or stork stand test, is used to evaluate for pars interarticularis stress fracture (spondylolysis).

• Sensitivity of 50%-55%
• Specificity of 46%-68%

Patrick-FABER test (flexion abduction external rotation test) : www.physio-pedia.com/FABER_Test

The flexion abduction external rotation (FABER) test is used to evaluate for pathology of the sacroiliac joint.

• Sensitivity of 54%-66%
• Specificity of 51%-62%

Quadrant test: www.physio-pedia.com/Lumbar_Quadrant_Test

This test is used to determine if the hip is the source of the patient's symptoms. A positive test is a reproduction of the patient's worst pain that they came with into the clinic.

• Sensitivity: 75%
• Specificity: 43%- 58%

Medical Management

In the next following text, we’ve listed all pathologies that we can define as specific low back pain. This gives a clear view of the pathologies and their specific medical management.

Spondiolestesis:

General [28] , [29] (

• Initially resting and avoiding movements like lifting, bending and sports.
• Analgesics and NSAIDs reduce musculoskeletal pain and have an anti-inflammatory effect on nerve root and joint irritation.
• Epidural steroid injections can be used to relieve low back pain, lower extremity pain related to radiculopathy and neurogenic claudication.
• A brace may be useful to decrease segmental spinal instability and pain. [30]

Surgery

Patients with chronic and disabling symptoms, who fail to respond to conservative management may be referred for surgery. [31](LE: 1B). For any further information concerning Spondiolisthesis and Medical Management:
- Medical_Management www.physio-pedia.com/Spondylolisthesis - Medical_Management

Scoliosis:

Patients with early-onset scoliosis, defined as a lateral curvature of the spine under the age of 10 years, are offered surgical treatment when the major curvature remains progressive despite conservative treatment (Cobbs angle 50 degrees or more). Spinal fusion is not recommended in this age group, as it prevents spinal growth and pulmonary development.[32](LE 1A)

Conservative treatment:

In conservative treatment, the use of braces mainly aims to prevent the progression of secondary curves that develop above and below the congenital curve, causing imbalance. In these cases, they may be applied until skeletal maturity[32](LE: 1A)

Surgical treatment: Spinal surgery in patients with congenital scoliosis is regarded as a safe procedure and many authors claim that surgery should be performed as early as possible to prevent the development of severe local deformities and secondary structural deformities that would require more extensive fusion later. Most of the time surgery is performed during adolescence, but newer techniques allow good correction to be accomplished into early adulthood. The goals for surgical treatment are to prevent progression and to improve spinal alignment and balance. [32] (LE:1A)

For any further information concerning Scoliosis and Medical Management: - Medical_Management www.physio-pedia.com/Scoliosis - Medical_Management

Radicular Syndrome:

Lumbar radicular syndrome can be treated in a conservative or a surgical way. The international consensus says that in the first 6-8 weeks, conservative treatment is indicated.[33] (LE 2C). Surgery should be offered only if complaints remain present for at least 6 weeks after a conservative treatment.[34] (LE 1A). A chirurgical intervention for sciatica is called a discectomy and focuses on removal of disc herniation and eventually a part of the disc. [35](LE 2C)

For any further information concerning Radicular Syndrome and Medical Management: - Medical_Management www.physio-pedia.com/Lumbar_Radiculopathy - Medical_Management

Cauda Equina syndrome:

Once CES is diagnosed, emergent surgical decompression is recommended to avoid potential permanent neurological damage[36].(LE 1A)

The role of surgery is to relieve pressure from the nerves in the cauda equina region and to remove the offending elements[37].(LE 1A)

For any further information concerning Cauda Equina Syndrome and Medical Management: - Medical_Management www.physio-pedia.com/Cauda_Equina_Syndrome - Medical_Management

Scheuremann:

The treatment of Scheuermann’s Disease depends on the patient’s age, degree of angulation, and estimated remaining growth.

Non-operative treatment:

If the thoracic kyphosis exceeds 40-45° during the growth period and if there are radiological sings of Scheuermann’s disease, non-operative treatment is indicated. This consists of bracing, casting and exercises. [38](LE 2A).

Operative treatment: Patients with Scheuermann’s disease rarely undergo surgery because the natural history of the disease is in most cases benign. Conservative treatment is usually not effective for large curves (above 75°) or in the adult. Spinal pain and unacceptable cosmetic appearance are the most common indications for surgery. It’s important to be careful in counselling these patients because these criteria are subjective. Because of this, there are also no evidence-based criteria for an indication of surgery. [38](LE 2A).[39](LE 2B)[40](LE 2B)

For any further information concerning Scheuermann and Medical Management:www.physio-pedia.com/Scheuermanns_Disease#Medical_Management

Spinal Canal stenosis:

If non-operative treatment has failed, surgical treatment may be considered. The key in deciding whether or not to have surgery is the degree of physical disability and disabling pain. In most cases of advanced claudication (spinal or vascular), a decompression surgery is required to alleviate the symptoms of spinal stenosis. [42](LE 2B)

Steroid injections and Non-steroidal Inflammatory Medications can also be used to treat lumbar spinal stenosis.[41](LE 3A) [42](LE 2B)

For any further information concerning Spinal Canal Stenosis and Medical Management: www.physio-pedia.com/Lumbar_spinal_stenosis#Medical_Management

Physical Therapy Management

Spondylolisthesis:
Spondylolisthesis should be treated first with conservative therapy, which includes physical therapy, rest, medication and braces [43](LoE: 3A) [44](LoE 2B). Non-operative treatment should be the initial course of action in most cases of degenerative spondylolisthesis and symptomatic isthmic spondylolisthesis, with or without neurologic symptoms [45](LoE: 3A) [44](LoE 2B). Children or young adults with a high-grade dysplastic or isthmic spondylolisthesis or adults with any type of spondylolisthesis, who do not respond to non-operative care, should consider surgery.
Traumatic spondylolisthesis can be treated successfully using conservative methods, but most authors suggested it would result in posttraumatic translational instability or chronic low back pain [45](LoE: 3A). Exercises should be done on a daily basis [44](LoE: 2B).
For any further information concerning Spondylolisthesis and Physical Therapy Management: www.physio-pedia.com/Spondylolisthesis#Physical_Therapy_Management

Scoliosis:

Physical therapy and bracing are used to treat milder forms of scoliosis to maintain cosmetic and avoid surgery [46](LoE: 1A). Scoliosis is not just a lateral curvature of the spine, it’s a three-dimensional condition. To manage scoliosis, we need to work in three planes: the sagittal, frontal and transverse. Different methods have already been studied [47] (LoE: 5).
The conservative therapy consists of: physical exercises, bracing, manipulation, electrical stimulation and insoles. There is still discussion about the fact that conservative therapy is effective or not. Some therapists follow the ‘wait and see’ method. This means that at one moment; the Cobb degree threshold will be achieved. Then, the only possibility is a spinal surgery [48] (LoE: 1A).
For any further information concerning Scoliosis and Physical Therapy Management: www.physio-pedia.com/Scoliosis#Physical_Therapy_Management

Lumbar Radiculopathy:

The more treatable condition of lumbar radiculopathy, however, arises when extruded disc material contacts, or exerts pressure, on the thecal sac or lumbar nerve roots [49] (LOE 1A). The literature support conservative management and surgical intervention as viable options for the treatment of radiculopathy caused by lumbar disc herniation. In the first place a conservative management is chosen. In a recent systematic review was found that a conservative treatment does not always provide for the disappearance of the symptoms of the patient [50] (LOE 1A).

Providing information to the patient about the causes and prognosis can be a logical step in the management of lumbosacral radiculopathy, but there are no randomized, controlled studies [51] (LOE 1A).

For any further information concerning Lumbar Radiculopathy and Physical Therapy Management: www.physio-pedia.com/Lumbar_Radiculopathy#Physical_Therapy_Management

Cauda equina syndrome:

The ultimate goals of physical management are to ensure maximum neurological recovery and independence, a pain-free and flexible spine, maintenance of mobility and strength in lower limbs, of core strength, improvement of standing and walking function, improvement of bladder, bowel and sexual function, improvement of endurance and safe functioning of the various systems of the body with minimal or no inconvenience to patients and prevention or minimization of complications [52] (LoE: 1A). It is equally important for patients to regain assertiveness, take control of their own lives, and return to activities of their choice. The importance of on-going support to maintain health and independence following discharge should be strongly emphasized [53] (LoE:1A) [54] (LoE:3A).

For any further information concerning Cauda equina syndrome and Physical Therapy Management: www.physio-pedia.com/Cauda_Equina_Syndrome#Physical_Therapy_management

Scheuermann:

Treatment of Scheuermann's disease depends on the severity or the progression of the disease, the presence or absence of pain and the age of the patient. Patients with a mild form are suggested to exercise and get a prescription from the doctor for physiotherapy. 

The methods of physical therapy include exercise programs to maintain flexibility of the back, correct lumbar lordosis, and strengthen the extensors of the back, electrostimulation and vertebral traction for increasing flexibility before a cast is applied. Although physical therapy has no role in correcting the underlying deformity [55] (LoE: 2B). Physical therapy is recommended in combination with bracing [56] (LoE: 2B).

For any further information concerning Scheuremann’s disease and Physical Therapy Management: www.physio-pedia.com/Scheuermanns_Disease#Physical_Therapy_Management

Spinal canal stenosis:

Lumbar spinal stenosis (LSS) patients frequently receive early surgical treatment, although conservative treatment can be a viable option. Not only because of the complications that can arise from surgery, but also because mild symptoms of radicular pain often can be lightened with physical therapy [57] (LoE 2B). However, in patients with severe LSS, surgery overall seems to be a better option than conservative interventions such as injections and rehabilitation. Still, its specific content and effectiveness relative to other nonsurgical strategies has not been clarified yet [58] (LoE 1A). Postoperative care after spinal surgery is variable, with major differences reported between surgeons in the type and intensity of rehabilitation provided and in restrictions imposed and advice offered to participants. Postoperative management may include education, rehabilitation, exercise, behavioral graded training, neuromuscular training and stabilization training [59] (LoE 1A). Numerous physical therapy interventions have been recommended for patients with lumbar spinal stenosis, suggesting a role for general conditioning using body weight–supported treadmill walking or stationary cycling, strengthening exercises for the trunk and lower extremities, and manual therapy for the spine and hips [58] (LoE 1A).

For any further information concerning Spinal Canal Stenosis and Physical Therapy Management: www.physio-pedia.com/Lumbar_spinal_stenosis#Physical_Therapy_Management

Clinical Bottom Line

We must screen for these serious pathologies and specific conditions that lead to neurological deficit in the assessment of an individual with low back pain to direct appropriate management.

Physical therapy has a beneficial effect in the treatment of specific low back pain, when it’s part of a treatment program. Goals of the rehabilitation, nonoperative and postoperative, are reducing pain and muscle tension, strengthen the stabilizing muscles and regain proprioception, neurological recovery and movement automatism. Physical therapy consists of passive and active mobilization and strengthening exercises.

90% of people will have no clear pathoanatomical diagnosis and an absence of red flags, these people have non-specific LBP.

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