Assessment and Treatment

of Low Back Pain

Steven Stanos, DO

Medical Director
Center for Pain Management
Rehabilitation Institute of Chicago
Asst. Professor, Dept. PM&R
Northwestern University Medical School
Feinberg School Of Medicine
 Goals
• Individualized yet
comprehensive
• Efficient
• Comfortable for patient
• Comfortable for clinician
• Build rapport
• Educate and prepare patient
for treatment
• Monitor for inconsistencies
Physical Exam Overview

– Pain behavior
– Gait
– Motor strength
– Muscle stretch reflexes
– Dural tension testing
– Sacral iliac joint testing
– Myofascial assessment
– Kinetic Chain considerations
Anatomy of LumboSacral Spine

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
 Annulus Fibrosis

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
Lumbar Facets:
zygapophysial joints “z-joint”

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
 Degenerative Cascade

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed. Churchill Livingstone, 1999.
 Definitions
• Somatome: field of somatic and
autonomic innervation based on
embryologic segmental origin of somatic
tissues
three basic elements:
1. Dermatome: cutaneous structures
2. Myotome: skeletal musculature
3. Sclerotome: bones, joints, and ligaments
8

Inman VT, Saunders J. J Nerv Ment Dis 1944;99:660-67.

 Spinal “stability”
Neural
Control Unit

Spinal Column Spinal Muscles

Vertebral Position Muscle

Spinal Loads Activation Patterns
Spinal Motions

Panjabi MM. J Electromyography Kinesiology 2003:12:371-9

 “Core” muscle groups

– Abdominals (Front)
– Paraspinals and gluteals (Back)
– Diaphragm (Roof)
– Pelvic floor and hip muscles (Bottom)

Richardson C, et al .Therapeutic exercise for spinal stabilization and low back pain. Edinburgh
(Scotland): Churchill Livigstone1999.
 Abdominals
Local muscles Global Muscles
(Slow twitch) (Fast-twitch)
• Transversus • Erector spinae
abdominus • External oblique
• Multifidi • Rectus abdominus
• Internal oblique
• Pelvic
ERECTOR SPINAE
floor MULTIFIDI

Panjabi MM. J Electromyography Kinesiology 2003:12:371-9

the “15 minute rotisserie special”
 Pain Behaviors
• Grimace • Equipment
• Groan • Cane
• Guarding • Ice-packs,
• Overreaction • Heating pads
• Inconsistencies • Braces: collars
• Give-way weakness
• Shaking
 Gait
• Balance
• Base of support
• Arm swing/ trunk and shoulder rotation
• Cadence
• Leg: cicumduction, stance time, position
• Pain behavior
 Static Stance Assessment

L4-L5

PSIS

(J. Rittenberg. Photos from practice & personal files used with permission)
 Differential
Diagnosis

Flexion Based Extension Transitional

Muscular Based
Spondylolisthesis
Ligamentous Stenosis
Sacroiliac
Compression Facet
Fracture Facet
Discogenic Spondylosis
Central Disc
 Facet Arthropathy
• Zygapophyseal (z-joint)
• Poor correlation with
history and exam1
• Commonly pain with
extension & rotation
• Referral patterns2

1. Schwarzer AC, et al. Spine 1994;19:1132-7.

2. Slipman, C. Arch PM&R 81:334-338, 2000.

Myofascial Assessment
Myofascial Trigger Points

Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2.
Williams & Wilkins, Baltimore, 1992.
“Muscle pain is not skin
pain”
Jay Shah, MD
 Myofascial Trigger Points
(MTrPs)
Active – cause a clinical pain complaint
or other abnormal sensory symptoms
Latent – show all the other
characteristics of active MTrPs, except
that they’re pain free
 Muscle Pain
• Aching and cramping
• Difficult to localize and refers to other deep
somatic tissues (fascia, muscle, joints)
• Muscle nociceptive activity is processed
differently in the CNS
• Inhibited more strongly by descending
pain-modulating pathways than cutaneous
pain
Symptoms Physical Findings
• Local & referred pain • Local Tenderness
• Pain with iso • Single or multiple
contraction muscles
• Stiffness, limited • Palpable nodules
ROM • Firm or Taut Bands
• Muscle weakness • “twitch response”
• Paresthesia & (LTR)
numbness • Jump sign
• Propriocpetive • Muscle shortening
disturbance • Limited joint motion
• Autonomic • Muscle Weakness
dysfunction
 Motor Strength Testing
• 5 = Normal, full ROM vs. gravity,
max resistance
• 4 = Good, full ROM vs. gravity,
moderate resistance
• 3 = Fair, full ROM vs. gravity,
no resistance
• 2 = Poor, full ROM,
gravity eliminated
• 1 = Trace
• 0 = No activity
Core Stabilization Testing
Muscle Stretch Reflexes
Lower Limb
– Patella (L2, L3,L4)

– Medial hamstring
(L5,S1)

– Achilles (S1, S2)

 Muscle Stretch Reflexes
4 + = hyperactive with clonus
3 + = more brisk
2 + = normal response
1 + = decreased with
facilitation
0 = no response
 Radiculopathy

• Sitting
• Standing
• Walking
• Bending
• Valsalva
or cough

Bogduk N, Clinical Anatomy Lumbar Spine and Sacrum, 3rd. Ed.

Churchill Livingstone, 1999.
Dural Tension Signs
• Straight Leg Raise
(SLR)
• Slump Seated
• Femoral Nerve Stretch

(J. Rittenberg. Photos from practice & personal files used with permission)
Straight Leg Raise:
 Epidural Space
• Contents:
– Loose areolar connective
tissue
– Semiliquid fat
– Lymphatics
– Arteries
– Extensive plexus of veins
– Spinal nerve roots

• Segmented and
discontinuous
Transforaminal Approach
 Injection Techniques

S1 Transforaminal Epidural

Nelemans PJ, et al. Spine 2001;26:501-15.

Dr. Stanos’ personal files.
Caudal Approach
 Axial Low Back Pain

• Degenerative disc disease (DDD)

• Internal disc derangement (IDD)
• Facet dysfunction
• Myofascial dysfunction

© 2005 Rehabilitatio Institute of Chicago

Dorsal Rami
Anatomy
Sacroiliac Joint and Pelvis
Integral Components of SIJ motion
• Form closure: joint surfaces congruently
fit together
• Force closure: muscles & ligaments
provide force to withstand load
• Motor control: timing & sequencing of
muscle activation & release
• Emotion & awareness: emotions can
influence motor control
Vleeming A, et al. Spine 1990;15:133-5
 Sacroiliac Joint Pain Referral
Zones

Buttocks 94%
Thigh 48%
Lower leg 28%
Foot / ankle 13%
Groin 14%
Abdomen 2%

Dreyfuss D, J Am Acad Ortho Surg 2004, 12.

 SIJ Assessment

(J.Rittenberg. Photos from practice & personal files used with permission)
Sacroiliac Joint Provocative Tests:
• SIJ border
tenderness
• Patrick’s test
• Gaenslen’s test
• Prone hip
extension
• Compression
testing
Fortin J, et al, Spine 1994;19:1475-82.
 Sacroiliac Joint Injections

Bogduk N, MJA 2004;19:79-83.

 Lumbar Spinal Stenosis: Posture

Akuthota, V. Pathogenesis of lumbar spinal J. Rittenberg. Used with permission.

stenosis pain. Phys Med Rehab Clin N Am 14:17-28, 2003.
With permission.
 Neurovascular Claudication

• Onset with walking

• “Heavy” sensation
• Variability
• Attempt to increase
flexion
• Stooped posture

BI-Level Central

Porter RW. Spine 1996;21:2046-52.

 Lumbar Spinal Stenosis:
Simian Stance
• Posterior pelvic tile
• Hips, knees flexed
• Hands face backwards
• Hip and psoas tight
• Gluteus and
piriformis inhibited
• Gait: lumbar flexion
 Weak and
Inhibited
Muscles

Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports
Musculoskeletal Med; Aspen Publishers,1998. With permission.
 Finding Balance
Underactive Overactive Shortened
Stabiliser Synergist Antagonist

Glut Medius TFL, QL, Piriformis Thigh adductors

Glut Maximus Iliocast, Hamstring Iliopsoas, Rec Fem

Lower Trapezius Levator Scapulae Pectoralis Major

Upper trapezius
Geraci, M. Rehabilitation of the hip and pelvis. In: Kibler WB. Functional Rehab Sports
Musculoskeletal Med; Aspen Publishers,1998. With permission.
trapezius and cercival spine
Cervical & Scapular Dysfunction

(Janda 2002)
 APS: LBP Guidelines
• Categorize the condition
– Nonspecific low back pain?
– Back pain associated with neurologic deficits,
radiculopathy or spinal stenosis?
– Back pain associated with an alternate
cause?
• Identify patients who require urgent
surgical evaluation

Chou R, et al. Ann Intern Med. 2007;147:478-491.

 Acute Low Back Pain
‘Red Flags’
• Cauda equina syndrome?
• Cancer?
• Infection?
• Fracture?
– Confirmation of red flag conditions may require
• Lab testing [complete blood count (CBC)/erythrocyte
sedimentation rate (ESR)/C-reactive protein (CRP)/
urinalysis (UA) and PSA when appropriate]
• Medical imaging [lumbosacral (LS) radiographs/computed
tomography (CT)/magnetic resonance imaging (MRI)]
• Test results may indicate need for emergent surgical referral

Chou R, et al. Ann Intern Med. 2007;147:478-491.

Chou R, et al. Lancet. 2009;373:463-472.
 Pharmacologic Interventions
Acute Low Back Pain

Level of
Drug Net benefit evidence
Acetaminophen Small to moderate Fair

NSAIDs Moderate Good

Skeletal muscle
Moderate (for acute LBP only) Good
relaxants

Chou R, et al. Ann Intern Med. 2007;147:504-514.

Guideline Highlights
 Guideline Highlights
1. Conduct a focused history and physical
examination
– Assess severity of baseline pain and
functional deficits
2. Evaluation of psychosocial risk factors is
essential to predict the risk for chronic, disabling
low back pain
3. Limit use of diagnostic imaging and testing
– Except in patients with signs of severe or
progressive underlying disease or those with
neurologic deficits

Chou R, et al. Ann Intern Med. 2007;147:478-491.

 Recommendation 6
ACP/APS Guidelines 2007
• Clinicians should consider the use of medications with
proven benefits in conjunction with back care information
and self-care. Clinicians should assess the severity of
baseline pain and functional deficits, potential benefits,
risks, and relative lack of long-term efficacy and safety data
before initiating therapy. For most patients, first-line
medication options are acetaminophen or NSAIDs.
(Strong recommendation, moderate-quality evidence)

Chou R, et al. Ann Intern Med. 2007;147:504-514.

 Pharmacologic Interventions
Drug Net benefit Level of evidence
Acetaminophen Small to moderate Fair
NSAIDs Moderate Good
Skeletal muscle
Moderate (for acute LBP only) Good
relaxants
Tricyclic Small to moderate (for chronic
Good
antidepressants LBP only)
Opioids and tramadol Moderate Fair
Benzodiazepines Moderate Fair
Small (for gabapentin in patients Fair for gabapentin to
Antiepileptic with radiculopathy only) poor for topiramate
medications
Unable to estimate topiramate
Systemic steroids No benefit Good

Chou R, et al. J Pain. 2009;10:113-130.

 Summary
• Comprehensive, but focused
• Efficient
• Exam should be easy on you and the
patient
• Great opportunity to initiate a therapeutic
relationship and dialogue
• Use a “good” exam to improve outcomes
and identify deficits or impairments
Thanks