Non specific low back pain for physiotherapists

non specific low back pain for college students of department of physiotherapy

1. Low Back Pain (LBP) HAWLER MEDICAL UNVERSITY CLLEGE OF HEALTH SCIENCES DEPARTMENT OF PPHYSIOTHERAPY 3 RD STAGE BY DR DIYAR ISMAEL

2. Introduction (LBP) is defined as pain, tension, or stiffness localized between the lower rib margins and the gluteal folds, with or without radiation to the legs . I t affects 70–80 % of individuals at some point in life. Leading cause of disability worldwide • Physiotherapists frequently manage LBP

3. Vertebral structure Lumbar vertebrae are designed for load-bearing and mobility . The vertebral bodies are kidney-shaped and larger than thoracic vertebrae. Facet joints (zygapophyseal joints): Oriented sagittally → favor flexion/extension. Limit axial rotation. Intervertebral foramen : passageway for spinal nerves → narrowing here causes radiculopathy.

4. Intervertebral discs Nucleus pulposus (gelatinous, 80% water) → acts as a shock absorber. Annulus fibrosus (concentric fibrocartilage rings) → resists tensile forces. Degeneration → dehydration, loss of elasticity, herniation.

5. Muscular Control Global stabilizers : erector spinae , rectus abdominis. Local stabilizers : transversus abdominis, multifidus (most important ). Dysfunction of multifidus is strongly linked to recurrent/chronic LBP.

6. Biomechanics Lumbar spine allows: Flexion/extension : ~60°/25°. Lateral flexion : ~25°. Rotation : limited (~10° total). Load distribution: Standing → discs bear 80% load, facets 20%. Sitting → increased disc pressure (reason prolonged sitting worsens LBP).

7. Pathophysiology Overview 1. Mechanical Pain Caused by abnormal stress/strain on structures (discs, ligaments, muscles). Typically worse with activity and better with rest .

8. 2. Radicular Pain From nerve root compression/inflammation . Sharp, shooting pain radiating below the knee ( sciatica ).

9. 3. Central Sensitization In chronic LBP, the nervous system becomes hypersensitive. Pain persists even after tissues heal → explains why chronic pain is not proportional to tissue damage.

10. Clinical Classification 1. Non-specific LBP (90–95 %) , no serious pathology, usually mechanical in nature 2. LBP with radiculopathy/sciatica (5–10 %) caused by disc herniation or foraminal stenosis 3. LBP due to serious pathology (<1 %) such as cancer, infection, fracture, inflammatory disease

11. Differential Diagnosis - Mechanical • Lumbar strain/sprain Disc herniation Facet syndrome Degenerative disc disease Spondylosis (degeneration of vertebrae/discs) Spondylolisthesis (slippage of vertebra) Spinal stenosis (narrowing of canal/foramen)

12. Differential Diagnosis - Red Flags

13. Referred Pain Sources

14. Assessment History Pain location, radiation, duration Functional impact ( walking, sitting, sleeping) Psychosocial factors → stress, depression, work dissatisfaction

15. Physical Examination • Inspect posture, gait • Palpate tenderness/spasm • ROM limitation • Neurological exam ( myotomes , dermatomes, reflexes)

16. Special Tests SLR test : indicates nerve root compression (L4–S1). Slump test : for neural tension. Prone instability test : for segmental instability. Patrick’s (FABER) test : SI joint involvement.

17. Management Principles Avoid bed rest → early mobilization is encouraged. Most cases improve within weeks → education and reassurance are crucial. Physiotherapy is first-line treatment for non-specific LBP.

18. Physiotherapy in Acute LBP Pain relief modalities : TENS, ultrasound, cryotherapy/heat. Manual therapy : gentle mobilization, soft tissue release. Education : posture, ergonomics, importance of movement. Activity : walking, avoid prolonged sitting/lying.

19. Physiotherapy in Chronic LBP Exercise therapy (core treatment): Core stabilization (multifidus, transversus abdominis). McKenzie method (extension exercises) – effective in discogenic pain. Flexion-based exercises for spinal stenosis. Pilates and yoga for flexibility and control. Manual therapy: Mobilization/manipulation of spine and sacroiliac joints. Neuromuscular re-education: Improve motor control of deep stabilizers. Functional training: Task-specific activities (lifting, sports rehab).

20. Cognitive-Behavioral Approach • Address fear-avoidance beliefs • Graded exposure to feared movements

21. Yellow Flags in Low Back Pain Category Brief Description Example Patient Statements / Behaviors Attitudes & Beliefs Unhelpful thoughts about pain and recovery. "I must rest completely until the pain is gone." "My back is ruined." Behaviors Actions based on fear rather than actual harm. Avoiding movement, work, or hobbies. Over-relying on rest or passive treatments. Compensation & Work Issues related to claims or the workplace. "My job is the reason this happened." Lack of support from workplace. Diagnosis & Treatment Problems with how care is delivered or received. Seeking multiple opinions for a "cure." Relying only on passive treatments (e.g., injections, massage). Emotions Negative emotional responses to pain. Feeling depressed, anxious, helpless, or easily angered by the pain. Family & Social Context Social interactions that reinforce disability. Family does everything for the patient. Lack of social support

22. Multidisciplinary Approach • Physiotherapist, psychologist, physician, pain specialist • NSAIDs, muscle relaxants if needed

23. Prevention Strategies Posture education : maintain lumbar lordosis during sitting. Workplace ergonomics : adjust chair height, lumbar support, monitor at eye level. Regular exercise : strengthen core and back extensors. Weight management : reduce load on lumbar spine. Lifestyle changes : smoking cessation, stress management.

24. Prognosis • Acute LBP: recovery in 4–6 weeks • Chronic LBP: influenced by psychosocial factors

25. References 1. Kisner C et al., Therapeutic Exercise, 2017 2. Magee DJ, Orthopedic Physical Assessment, 2014 3. Maher C et al., Lancet, 2017 4. Delitto A et al., JOSPT, 2012 5. Brukner P, Khan K., Clinical Sports Medicine, 2017 6. Physiopedia , 2023