Spine Clinical Disorders

Low Back Pain (LBP)

• LBP is the second most common source of disability and
lost productive time for adults in the United States
(CDC, 2001)
• Lifetime prevalence of estimated 60-85% (Walker BF,
2000)
• 10-15% will develop chronic LBP
• 8 million American adults cited back or spine problems
as the source of their disability (Ma et al., 2014).
• Chronic pain costs the United States roughly $560-635
billion and 102 million work days annually (IOM, 2011;
Guo et al., 1999).
 Sciatica
• Etiology
• Nerve root compression from
intervertebral disk protrusion,
structural irregularities w/in the
intervertebral foramina
• L4, L5, S1 nerve roots Sciatica
• L2, L3, L4 nerve roots Femoral
nerve (anterior and side thigh pain)

• Signs and Symptoms

• Produces sharp shooting pain, tingling and
numbness
• Sensitive to straight leg raises intensify the pain
 Lumbar Vertebrae # and Dislocation
• Etiology
• Compression #or # of the spinous or transverse processes
• Usually the result of trunk hyperflexion or falling from a
height
• Fractures of the processes are generally the result of a
direct blow
• Dislocations tend to be rare
 Lumbar Vertebrae # and Dislocation
• Signs and Symptoms
• Requires X-rays for detection
• Point tenderness over the area
• Palpable defects over the spinous and
transverse processes
• Localized swelling and guarding
• Management
• Physician referral
• Transport with extreme caution and care
to minimize movement of the segments
• Rehabilitation (similar to spine surgery)
 Low Back Muscle Strain
• Etiology
• Sudden extension
contraction overload
generally in conjunction w/
some type of rotation
• Forward bending and
twisting can cause injury
• Sign & symptom
• Pain may be diffuse or localized; pain w/
active extension and passive flexion
• No radiating pain distal to the buttocks; no
neurological involvement
 Low Back Muscle Strain
• Management
• RICE to decrease spasm; followed by a
gradual stretching and strengthening
program
• Complete bed rest may be necessary if it is
severe enough
• NSAID’s
 Back Contusions
• Etiology
• Significant impact or direct blow
to the back
• Signs and Symptoms
• Pain, swelling, muscle spasm and point tenderness

• Management
• RICE for the first 72 hours
• Ice massage combined with gradual stretching
• Recovery generally last 2 days to 2 weeks
 Myofascial Pain Syndrome
• Etiology
• Regional pain occurs with
pressure or palpation of a
tender spot or trigger point
w/in a muscle

• Signs and Symptoms

• Piriformis - pain in posterior sacroiliac
region, into buttocks and down posterior
portion of thigh; deep ache that increases w/
hip adduction, flexion and medial rotation
 Myofascial Pain Syndrome
• Signs and Symptoms
• Quadratus Lumborum - sharp aching
pain in low back, referred to upper
buttocks and posterior sacroiliac region ;
increased pain with standing, coughing,
sneezing and sit to stand motions

• Management
• Stretching and strengthening of the involved
muscle
• Electric stimulation and ultrasound can be used
to treat discomfort and pain
 Spinal Stenosis
• AKA: Neurogenic claudication
• Narrowing of the central canal or lateral
intervertebral foramina
– Central stenosis
– Lateral stenosis
• Male/ female = 8:1

• Older age (>65 yrs) (wear and tear)

• Neurogenic claudication: Neural compromise due
to obstruction of blood flow to the nerve
 Subjective
• Symptoms
– Mostly bilateral (3:1)
– Localized pain /Numbness and “pins and needles”
in legs, calves or buttocks
– Walking short distance Weakness, tiredness,
heaviness of legs stop
– A decreased endurance for physical activities
• Agg: extension, prolonged standing or walking,
walking downhill, lying flat
• Ease: Leaning on grocery basket, flexion, sitting
or squatting, walking uphill, bike riding
 Objective exam/ Stenosis
• Flat lumbar posture
• Painful / limited or no extension
• Central and unilateral PA pain and stiffness
• Peripheral pulses: present
• Diagnostics: X-ray, CT scan / MRI
 Objective exam
• Bike test
– In neutral position increase symptoms 
claudication
– In flexed position decreased symptom
neurological claudication
– In flexed position no change vascular
claudication
• Treadmill test: Pain with normal level or
down-hill walking, able to tolerate incline
walking
 Intervention
• ADL instruction with neutral spine
• Spinal stabilization exercises
• Flexion exercises / mobility exercises (William’s
flexion) Dutton 1572- 1589
• Stretching: Hamstring, hip flex
• Intermittent Traction
• Joint mobilization (rotation)
-Joint mobilization: Increase space, decrease
shortening of soft structures, increase segmental
mobility
 Intervention
• Abdominal and gluteal muscle strengthening
• NO extension exercises
• Medications (NSAIDS) / epidural steroid
injections
• Laminectomy / Fusion
Lumbar Spine Surgery (LSS)

18
 Acute Facet
• Unilateral pain; sharp over facet
• Increased pain with stretch/compression of joint.
• Limitation side bending and extension
• History: Sudden unguarded movement (flexion,
rotation)
• Local tenderness on palpation
• Radiography: decreased facet joint space/
sclerosis/ or osteophytes
 Intervention
• Manual therapy: Rotational mobilization (lie on
unaffected side)
• Unilateral PAIVMS, traction, manipulation
• Start mobilization on the other side
• Exercises: mobility exercises
• Modalities
• Resolves overtime
 Chronic Facet
• Unilateral pain; less sharp over the joint
• Increased pain with extension
• History: Past acute facet; never entirely symptom
free
• Local tenderness with palpation; stiff, thick
• PPIVM and PAIVM
• Diagnostic: X-ray and CT show facet joint
narrowing / degeneration
 Intervention
• Manual therapy: Rotation, unilateral PAIVMs
• Traction: manual or mechanical
• Exercises: stretching and muscle reeducation
• Facet joint injections or nerve block
• Facetectomy
 Acute Nerve Root (ANR)
• Irritation / inflammation / compression to the nerve
root
• Distal symptoms > proximal
• Can begin as a proximal ache, then more distally
(pain description)
• Severely limits activity
• ROM: very limited motion
• Neurological exam: level specific (motor and sensory)
 Intervention
• Modalities
• Manual traction: supine or sidelying
• Lumbar rotation
• Epidural steroid injection or surgery (e.g.
laminectomy w/ or w/o fusion)
• Exercise program once pain decreases
 Chronic Nerve Root (CNR)
• Chronic irritation of nerve root / adhesion
• History of nerve root injury
• Gradual return of symptoms to lesser degree
• Proximal symptoms > distal
• Minimal limitation of activity
 Chronic Nerve Root
• Neuro: minor responses
• Palpation: localized thickness in tissues, stiff at
segment
• ROM: may report pain with OP
• Neurodynamic: + / -
 Treatment
• Manual therapy: unilateral PAIVMs, rotation,
traction
• Mackenzie
• Neurodynamic flossing/ gliding
• Mobility exercises
• Segmental muscle re-education
 Instabilities
Spondylolysis / Spondylolisthesis
• Defect in pars interarticularis of the spine
• Patients with bilateral pars defects can progress to
spondylolisthesis
• Can be congenital or acquired with repeated
trauma / sports
• Usually teens but can be a
result of trauma or repeated
stress in adults
Spondylolysis Spondylolisthesis
 Subjective
• Can be asymptomatic or pain with extreme ext
and rotation
• Fluctuating symptoms - severe LBP after vigorous
activity
• Extension injuries or flexion injuries
• Most common at L5-S1
• Constantly moving positions / ‘Catch’ pain
• Agg: following vigorous activity; Ease: rest
 Objective
• End of range motions may provoke symptoms
• Hesitation in flexion at 30-40 degrees.
• + Gowers sign
• Extension reveals ‘hinge’ at one segment
• Central PA: Painful and altered end feel
• Neuro: + / -
• Inconsistent findings
 Spondylolisthesis

• Anterior slippage
Grade 1
Grade 2
Grade 3
Grade 4
 Instability: treatment
• Rest
• Avoid agg activities, extreme ranges and sustained
posture
• Stabilization exercises
• External support
• Treat adjacent levels that may be contributing to
problem
• Flexion helps to decrease pain
• Medication / epidural / surgery (fusion)