Mechanical Lower Back Pain

(MLBP).
By Karl Hewitt
Definitions of MLBP-

Defined by the NHS as “Most back pain is what's known as "non-specific" (there's no obvious
cause) or "mechanical" (the pain originates from the joints, bones or soft tissues in and around
the spine)” (NHS 2017).
My definition:
Also defined as an umbrella term for issues with postural back problems, disc, facet and OA
degeneration- This is to try and de-medicalise the  ‘back pain’ and give patients the
responsibility and tools to manage their pain and rehab.
Causes for MLBP (NHS 2017)

 Physically demanding jobs

 Trauma
 Obesity
 Smoking
 Mental illnesses
 Stress
 Soft tissue injuries or soft tissue imbalances
 Posture e.g. due to foot posture or other spinal pathologies
 Degenerative changes of the spine
 Subjective Assessment -(Banks and Hengeveld
2010)
 Expectation from Physiotherapy
 Pain- does it radiate? Is it constant? On a scale 1-10 how much does it hurt? P&N
 Aggs
 Eases
 Hobbies and interests
 Sleep pattern
 24 hours pattern
 PMH
 Drug History
RED flags (Cauda equina)-Butler (2010)

 Saddle anaesthesia
 Bladder and bowel disturbances
 Back pain
 Sexual dysfunction
 Bilateral weakness
 Laxity of anal sphincter
What is cauda equina? - Butler (2010)

• Cauda equina is a bundle

of nerve that form at the
end of your spinal cord.
• These bundle supply the
muscle in your lower
limbs.
• These bundles of nerve
forms at around L2-L3
Yellow Flags- Samantha et al. (2003)

  Yellow flags are pyschosocial factors shown to be indicative of long term chronicity and
disability:
 A negative attitude that back pain is harmful or potentially severely disabling
 Fear avoidance behaviour and reduced activity levels
 An expectation that passive, rather than active, treatment will be beneficial
 A tendency to depression, low morale, and social withdrawal
 Social or financial problems
Black Flags (Physiopedia 2018)

 Legislation restricting options for return to

work.
Conflict with insurance staff over injury claim.
Overly solicitous family and health care
providers.
Heavy work, with little opportunity to modify
duties.
Neurological screening- Hattam and Smeatham
(2010)
 If the patient has reported any sign and symptoms that are indicative
to any neurological issue.
 Any numbness or pins and needles needs to documented on the
body chart and investigated further.
 This can be done by assessing myotomes dermatomes and reflexes
to rule out any neurological problems.
Dermatomes- (Keyon and Keyon 2009)
Myotomes(Isometric resisted test)- (Keyon and
Keyon 2009)
 L1- No test
 L2- Hip Flexion
 L3- Knee Extension
 L4- Dorsiflexion
 L5- Hallux Extension
 S1- Hip Extension/Knee Flexion
 S2- Knee Flexion
Reflexes- (Keyon and Keyon 2009)

 Knee reflex/patella tendon- L3

 Ankle reflex/achillies tendon- L5/S1

Other tests- Hattam and Smeatham (2010)

 Babinski- UMN lesions

 Clonus- UMN lesions
 LLD- true leg length or apparent leg length
 Clearing the SIJ and the hip by FABERS or quadrant test
 Slump test
 Femoral nerve
Assessing a patient with MLBP- Observations
(Banks and Hengeveld 2010)
Looking at the patient posture
Gait
WB status
STS from chair
Muscle spasms
Anterior/ posterior pelvic tilt
Haematoma
Scaring
Patch of hair-?Spinal bifida
Muscle Atrophy
AROM-PQRRS

 Pain
 Quality
 Range
 Resistance
 Spasm

 PROM- Only perform passive overpressure when all red flags are cleared.
Palpation

 Palpating is important as you can try to isolate the pain to a specific structure or
area. In addition when palpating you can feel for any abnormalities of the
surrounding structures that could be producing the patient’s pain.
 It is also important to identify the patient's pain therefore, if you reproduce the
pain you have an idea of where the pain is being produced from.
 It is important when palpating to have a feel for any abnormal temperature
changes as it could be a sign of a possible infection. However, it is important to
be aware that the back will be hotter compared to the peripheral joints.
Treatments

 Exercise
 Spinal manipulation
 Mobilisations
 Soft tissue technique (such as massage)
 Education- self management
 Trigger pointing
 Taping
 Gel inner soles
Evidence for physiotherapy treatments- NICE
guidelines (2016)
NICE Guidelines- The NICE guidelines support the use of exercises therapy and manual
therapy combine with more complexed patients.
They also support the use of educating the patients to self manage especially more simpler
cases of MLBP.

NICE guidelines does not support-

 Orthotics- Belts/corsets, foot orthotics or rocker sole shoes.
 Acupuncture
 Electrotherapy
 Traction mobilisations
Evidence for manual therapy- Balthazard et al.
(2012)
 6/10 [Eligibility criteria: Yes; Random
allocation: Yes; Concealed allocation:
Yes; Baseline comparability: Yes; Blind
subjects: No; Blind therapists: No; Blind
assessors: No; Adequate follow-up: Yes;
Intention-to-treat analysis: No; Between-
group comparisons: Yes; Point estimates
and variability: Yes. Note: Eligibility
criteria item does not contribute to total
score] *This score has been confirmed*
Description of evidence

 This article was score 6/10 on the PEDro scale.

 Aims: The aim of this pilot study was first, to assess whether MT has an immediate analgesic effect, and second, to
compare the lasting effect on functional disability of MT plus AE to sham therapy (ST) plus AE.
 Methods: Forty-two CNSLBP patients without co-morbidities, randomly distributed into 2 treatment groups, received either
spinal manipulation/mobilization (first intervention) plus AE (MT group; n = 22), or detuned ultrasound (first intervention)
plus AE (ST group; n = 20).
 Results : Thirty-seven subjects completed the study. MT intervention induced a better immediate analgesic effect that was
independent from the therapeutic session (VAS mean difference between interventions: -0.8; 95% CI: -1.2 to −0.3).
Independently from time after treatment, MT + AE induced lower disability (ODI mean group difference: -7.1; 95% CI: -
12.8 to −1.5) and a trend to lower pain (VAS mean group difference: -1.2; 95% CI: -2.4 to −0.30). Six months after
treatment, Shirado test was better for the ST group (Shirado mean group difference: -61.6; 95% CI: -117.5 to −5.7).
Insufficient evidence for group differences was found in remaining outcomes.
 Conclusion: This study confirmed the immediate analgesic effect of MT over ST. Followed by specific active exercises, it
reduces significantly functional disability and tends to induce a larger decrease in pain intensity, compared to a control
group. These results confirm the clinical relevance of MT as an appropriate treatment for CNSLBP. Its neurophysiologic
mechanisms at cortical level should be investigated more thoroughly.
Critique appraisal of evidence

 Only looks at patient without other comorbidities

 Small sample size in relation to the general population therefore not generalisable. However they stated why they didn’t
reach a good sample size. This was because they didn’t have enough funding.
 Randomised control- to decrease bias a number generator was used. They allocated the groups using odd (ST) and evens
(MT).
 The therapist, assessor and participants were not blinded through out therefore this could have lead to increase bias. This is
where the article dropped points on the PEDro scale
 There was only one physiotherapist who provided the treatment for both groups therefore there could be a risk of bias.
 Also, the results state that the Sham therapy group had a better result on the shirado test (testing the muscle endurance of
erector spinae and abdominals.
 Balthazard et al (2012). State that they had a drop out percentage off 10-14% therefore this limits the result even more as
there is even less results to support the overall aims of this article.
 It is not stated the percentage of males to females
 The results do support the immediate effect of MT on the participant VAS- pain levels. 
References

 Balthazard, P., de Goumoens, P., Rivier, G., Demeulenaere, P., Ballabeni, P. and Dériaz, O., 2012. Manual therapy followed by specific active exercises
versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a
randomized controlled trial. BMC musculoskeletal disorders, 13(1), p.162.
 Butler, L., 2010. Red Flags II: A guide to solving serious pathology of the spine. International Journal of Osteopathic Medicine, 13(4), p.171.
 Hattam, P. and Smeatham, A., 2010. Special tests in musculoskeletal examination: an evidence-based guide for clinicians. Elsevier Health Sciences.
 Hengeveld, E and Banks, K. (2010) Maitland’s clinical companion: An essential guide for students. Edinburgh, Elsevier.
 Hengeveld, E. and Banks, K. eds., 2013. Maitland's vertebral manipulation: management of neuromusculoskeletal disorders(Vol. 1). Elsevier Health
Sciences.
 Hubert, R and VanMeter, K. (2018) Gould’s Pathophysiology for the health professions. 6 th ed. St. Louis, Elsevier.
 Kenyon, K and Kenyon, J. (2009) The physiotherapist’s pocket book: Essential facts at your fingertips. 2nd ed. London, Elsevier.
 National institute for health and care excellence. (2016) Low back pain and sciatica in over 16s: assessment and management [Internet]. Available from
https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#education-and-self-management-2 [Accessed 24th February 2019].
 NHS. (2017) Back pain [Internet]. Available from https://www.nhs.uk/conditions/back-pain/ [Accessed 8th February 2019].
 Samanta Jo, Kendall Julia, Samanta Ash. Chronic low back pain BMJ 2003; 326 :535
 The Flag System. (2018, September 9). Physiopedia, . Retrieved 21:32, February 24, 2019 from 
https://www.physio-pedia.com/index.php?title=The_Flag_System&oldid=197829.
Mini QUIZ-

1. Name the three main group of muscles that form the erector spinae?
2. What potential sign would you look for if a patient had spina bifida?
3. What bundle of nerves form at L2-L3?
4. How many vertebrae are there in the spine?
5. Name the two nerves that form from the Sciatic nerve?
6. Name the two leg length measurements? How do you measure them?
Answers

1. Spinalis, longissimus and iliocostalis.

2. Tuff of hair at the base of the back.
3. Cauda Equina
4. 33
5. Common peroneal and tibial nerve
6. Apparent- Umbilicus to Medial Malleolus      True- ASIS to medial malleolus