backache

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You need to determine whether your patient is suffering from anterior element pain, posterior element pain, movement related pain or mechanical pain without postures or movement exacerbation (static sensitive). In my view your patient may be suffering from problems of both anterior element and posterior element pain at the same time. So you may start with both flexion and extension exercises of spine to relieve the structures of both anterior element and posterior element of spine which include dics, facets, vertebral bodies and ligament derangements. Have a look over the detail of management of element pain as under:

Anterior element pain

Anterior element pain has been defined as pain made worse by sustained flexion of lumbar spine. Anterior element pain is made worse by sitting and is relieved by standing. Patients assume hyperlordotic posture to relieve their pain. Fracture of vertebral bodies and prolapsed intervertebral discs produce anterior element pain. Extension exercises and press ups are more likely to produce remission than flexion exercises. This is because flexion exercises increase the intradiscal pressure whereas extension exercises unload the discs. Therefore, extension exercises advocated by Cyriax and McKenzie are logical for patients with anterior element pain. Lesions resulting in chronic anterior element pain are obscure; it is tempting to assume that anterior element pain is discogenic in origin, but there is no evidence for this. Unlike the acute group, the patients with chronic anterior element pain may respond to manipulative techniques.

Posterior element pain

Pain is worse by increasing the lumbar lordosis, standing and walking. It is eased by maintained forward flexion, sitting and hip flexion (with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show features of posterior element pain. Pain from rotation and extension is usually of facet origin. Flexion treatment frequently improves the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse.

Movement related pain

Patients with movement related pain are most comfortable at rest; pain is precipitated only by activity and jarring. Heavy manual work, repeated twisting, fast walking and running (especially on hard surfaces) and traveling in car on rough grounds all precipitate pain. Movement related pain occurs in traumatic fracture dislocations, in symptomatic spondylolysis or spondylolisthesis and as a result of chronic degenerative segmental instability. Diagnosis may be confirmed by lateral flexion and extension roentengenograms of the lumbar spine and noting abnormal translational movement. A basic scheme of progressive stabilization by strengthening regional and segmental musculature isometrically should be considered. According to Grieve mature patients and those in most pain may need to start abdominal exercises with knee bent and progress more slowly. Side lying stabilization techniques and dynamic abdominal bracing may also be used. Home exercises should be efficiently monitored and the patient taught avoidance of posture and activities known to constitute his specific additional stimuli.

Mechanical pain without posture and movement exacerbation ( Static Sensitive)

Patient with static sensitive low back pain have the have an inability to maintain any one position ( other than lying) for a normal length of time and obtain relief by changing position and moving. Many of these patients appear to have a discrete structural disease, such as scoliosis.

Altered pattern of muscle recruitment have been clearly delineated. One of the most common of those is overuse and early recruitment of low back muscles. Another pattern associated with low back pain is over use of hip flexor (iliopsoas) and weakness of abdominals. It is frequently important to retrain the gluteal muscles and inhibit overuses of lumbar extension, a maladaptive pattern.

Dynamic trunk stabilizers, aside from gluteal maximus which originates or inserts into the lumbodorsal fascia, are the latissimus dorsi, transversus abdominis and internal obliques muscles. The main purpose of strengthening these muscles is to produce a forceful couple that is designed to stabilize the trunk and effectively controls the antigravity weight line or the way in which this area bears weight.

There are many types of isometrics exercises and Grieve provides some good examples to improve power of gluteal and abdominal muscles in the treatment of chronic low back pain, including abdominal wall and abdominal bracing exercises. These exercises avoid the higher intradiscal pressure and emphasize the eccentric control, free breathing and maintenance of functional position of spine. When performing exercises for upper abdominals, the feet should be plantar flexed to inhibit action of psoas.

Isotonic exercises can be helpful for some patients and may be used in all patients as progression of exercise programme, with or without manual or mechanical resistance.


References:

1-Management of Common musculoskeletal disorders, Physical therapy Principles and methods, 2nd edition, By Darlene Hertling and Randolph M. Kessler

2-Tidy's Physiotherapy, 12th Edition, By Ann Thomson, Alison Skinner, Joan Piercy

3- Textbook of Orthopaedic Medicine, Volume 1, Diagnosis of Soft Tissue Lesions, By James Cyriax

4-Mobilisation of Spine, A primary handbook of clinical methods, By Gregory P. Grieve, Fifth Edition