LOWER BACK ACHE

Any pain observed in and around the lower back area or lumbar area, is referred to as Low Back Pain.

The anatomy of spine consists of 4 sections, starting from neck and walking down. So, these sections include the cervical spine (neck), thoracic spine (upper back), lumbar spine (lower back) and the sacral region.

In the lumbar area, the vertebrae are separated by a disc. The lumbar spine typically curves slightly inward, which is known as lumbar lordosis.

Large muscles of the lower back support the spine and help in twisting and bending movements. Strained lower back muscles are a common cause of lower back pain.

The facet joints connect the vertebrae in the spine and allow them to extend and bend.

The two lowest sections (L5 and S1) of the lumbar spine bear the most weight and move more than the other three vertebrae. This makes these two sections the most prone to injury.

Since the lower area of the spine both, moves the most and bears the most weight, the discs in this area are more likely to herniate or degenerate which can further lead to low back ache radiating pain into the legs and feet.

The spinal cord travels from the base of the skull to the joint at T12-L1. The nerve roots of the spinal cord branch out here to form Cauda Equina. The nerve roots can be compressed by certain conditions causing radiating pain in the lower extremities which is called Radiculopathy.

1. STRAIN

Back pain commonly originates from strain, tension or injury. The frequent causes include:

• Strained muscles or ligament
• Muscle spasm
• Muscle tension
• Damaged disks
• Injuries, fractures or falls

Activities that can cause strain and spasm are:

• Lifting something improperly
• Lifting something too heavy
• Making an abrupt and awkward movement

2. STRUCTURAL PROBLEMS

• Ruptured Disks: Each vertebra in the spine is cushioned by disks. If the disks ruptures there will be more pressure on the nerve, resulting in nerve pain.
• Bulging Disks: In the same way as the ruptured disks a bulging disk may also result in more pressure on the nerve.
• Sciatica: A sharp and shooting pain travels through the buttock and down the back of the leg, caused by bulging or herniated disk pressing on the nerve.
• Arthritis: Osteoarthritis can cause problems with the joints in the hips, lower back and other places. In some cases there is narrowing of the spinal canal which is known as Spinal Stenosis.
• Abnormality In The Curvature Of The Spine: If the spine curves in an unusual way it can cause pain. For example in scoliosis where there is lateral bending of the spine.
• Osteoporosis: In this case, the vertebrae become brittle and porous causing compression fractures.
• Kidney Problems: kidney stones or infections can lead to back pain (referred).

3. MOVEMENT AND POSTURE

Some every day activities or poor postures can also lead to low back pain. Few examples of such movements are:

• Twisting
• Coughing or sneezing
• Muscle tension
• Over stretching
• Bending awkwardly or for long periods
• Pushing, pulling, tilting or carrying something
• Standing or sitting for long periods
• Straining neck in forward postures such as driving or using a computer.
• Long driving sessions
• Sleeping on a mattress that does not support the body and keep the spine straight.

4. OTHER CAUSES

Some medical conditions can lead to back pain.

• Cauda Equina Syndrome: Cauda equina is a bundle of spinal nerve roots that arise fromthe lower end of the spinal cord. Its symptoms include a dull pain in the lower back and upper buttocks as well as numbness in the buttocks, genetalia and thighs. Sometimes there may be bowel and bladder dysfunctions.
• Cancer of Spine: A tumour on the spine can also lead to pressure on the nerve leading to back pain.
• Other Infections: Pelvic Inflammatory disease, bladder or kidney infections may also cause back pain.
• Sleep Disorders: People with sleep disorders can also lead to back pain.
• Shingles: Any infection affecting the nerves can also cause back pain.

Main symptoms of low back pain is an ache anywhere in the low back area, sometimes all the way down to the buttocks and legs.

Some back issues can cause pain in the other parts of the body depending on the nerve affected.

ALARMING SIGNS

• Weight loss
• Fever
• Inflammation/swelling on the back
• Persistent back pain, where lying down or resting does not help
• Radiation of pain in the legs
• Recent injury, blow or trauma to the back
• Urinary incontinence
• Numbness around genitals
• Faecal incontinence
• Numbness around the anus
• Numbness around the buttocks

The following factors are linked to a higher risk of developing low back pain:

• Occupational activities
• Pregnancy
• Sedentary lifestyle
• Physical fitness
• Old age
• Smoking
• Obesity and excess weight
• Strenuous physical work and exercise
• Genetic factors

NOTE: low back pain can be observed more commonly in women than in men, possibly due to hormonal factors, stress, anxiety and mood disorders.

• MRI findings in the patients of low back pain is mainly focused on single imaging findings such as modic changes or disc degenerations and only weak association with the presence of pain was found. However numerous MRI findings almost always co-exist in the lumbar spine and are often present at more than one lumbar level. It is possible that multiple MRI findings are more strongly associated with LBP than single MRI findings.
• Sometimes the symptoms are not related to the MRI findings. They can be present due to the muscle imbalance. So a proper assessment and diagnosis is required.

1. MECHANICAL BACK PAIN

• 97% of the cases are the cases of mechanical back pain.
• Cab be diagnosed using special manual tests.
• CT scan, X-ray and MRI can be used for diagnosis.

Common reasons of mechanical back pain are:

• Lumbar strain/sprain (70%)
• Degenerative process of disks and facets usually age related.
• Herniated disks
• Spinal stenosis
• Osteoporotic compression fracture
• Spondylolisthesis
• Traumatic fractures
• Severe kyphosis, severe scoliosis, transitional vertebrae, spondylolysis, internal disk disruption or discogenic low back pain

2. NON MECHANICAL LOW BACK PAIN (1%)

Conditions responsible for non mechanical low back pain are:

• Tumours: tumours can be extradural, intradural-extramedullary and intramedullary.
• Multiple Myeloma: primary malignant bone tumour. There is excessive plasma cell growth in the bone marrow resulting in bone re-absorption leading to osteoporosis.
• Infections in the spine
• Osteomyelitis
• Shingles
• Ankylosing spondylitis
• Pagets Disease: affects an estimated 3% of people over the age of 40 and it is more common in men than women. This disease disrupts the replacement of old bone tissues with new bone tissues.
• Cauda equina:

Common features include-

• Back pain with nerve root distribution of pain
• Sciatica
• Saddle Paraesthesia/anaesthesia around anus, perineum or genitals
• Bladder dysfunction
• Weak/heavy legs
• Gait disturbances
• Malignant spinal cord compression:
• Pain can start off as mild but escalates out of control despite analgesia.
• Pain can be referred around abdomen and chest in a band like manner which is described as being squeezed.
• Renal/Urologic: Back pain at the level of kidneys. It can be caused by ovarian or testicularpain. There is presence of back and shoulder pain which can be alternate or together. Associated symptoms are blood in urine, frequency, testicular pain.
• Cardiovascular: presence of throbbing back pain. There is pain radiating in the leg that is eased by standing still or rest. The back pain is present in all spinal positions and is increased with exertion. There is pulsing sensation or palpable abdominal pulse.

The diagnosis can be done in the following ways:

• MRI
• CT scan
• X-ray
• Physical assessment
• Special tests

      TESTS FOR THE ASSESSMENT OF LBP

1. Functional Tests:

• Functional demonstration of pain provoking movements.
• Squat test can be done to highlight lower limb pathologies but not in the patients having arthritis, lower limb pathologies, pregnant ladies or old patients having weakness or hypo mobility.

2. Movement Testing:

• AROM
• Over pressure at the end of all AROM.
• Sustained positions
• Combined movements
• Repeated movements
• MMT

3. Neurologic Assessment:

Myotomes testing:

• L2: Hip flexion
• L3: knee extension
• L4: ankle dorsiflexion
• L5: Great toe extension
• S1: ankle plantar flexion, ankle eversion, hip extension
• S2: knee flexion

      Dermatomes testing

      Reflexes

• Patellar (L3-L4)
• Medial hamstring (L5-S1)
• Lateral hamstring (S1-S2)
• Posterior tibial (L4-L5)
• Achilles

4. Special Tests:

For neurological dysfunction:

• Straight leg raise test
• Cross straight leg raise test
• Femoral nerve traction test
• Slump test

For lumbar instability:

• H and I test
• Passive lumbar extension test

For joint dysfunction:

• Bilateral straight leg raise test
• One leg standing

Muscle tightness

• 90-90straight leg raise
• Ober test

• Education
• Exercise (lumbar stabilisation, strengthening exercises, ROM exercises, stretching, aerobic conditioning)
• Spinal manipulation
• Postural correction
• Taping technique
• Dry needling over the tight structures
• Soft tissue release
• MFR
• TENS
• IFT
• Ultrasonic therapy
• Heat/cold

Expert Treatment

Many times, it happens that it is not always the joint structure which is completely involved but it is the secondary involvement, the primary being the soft tissues. Due to the involvement of the soft tissue structures, which causes Low back pain. The back muscles, hip muscles and the thigh muscles  get shortened and tensed which alters the posture, or compresses the spinal structures. In 90% cases our expert treatment helps to resolve the problem completely.

There are various advanced techniques available these days which gives a better and complete recovery from the ailment. As compared to with the conventional and traditional treatments which are available with most of the therapist, these new techniques give the best results in the long run.

In these treatments, we work on the muscles and fascia. Basically, whenever there is pain, inflammation, injury, postural imbalance, due to overstretching or over-contraction etc. result in taught band formation known as trigger points. These points are basically reducing the length of the muscle which impairs the joint function and ROM. Every muscle has a trigger point patter. We are working on the faulty biomechanics by releasing these trigger points. Releasing the trigger points results restoring the normal biomechanics, with normal ROM and joint function.

These techniques include:

• Soft tissue release: This helps in restoring the length of the muscle, by releasing the trigger points with various techniques like myofascial release, IASTM, Ischemic compression, Active release technique, passive release technique, Positional release technique and muscle energy technique.
• Dry Needling: In this technique, we insert thin filament needles in the trigger points of the muscles to break them resulting in muscle relaxation, only after having a thorough knowledge of anatomical structures.
• Deep tissue Release: there are many advanced techniques, which includes massage strokes, and are modifies to address specific conditions like cramps, strains, light, muscular and joint stiffness or breakdown of adhesions and bad scars. This stand alone in the form of tissue treatment, if therapist wants to target deeper muscles or to increase range of motion at any joint using basic but very specific techniques of compression and stretching of the muscles. This is applied by the therapist to treat patients.
• Joint mobilizations: These techniques help in restoring the normal joint ROM by giving graded oscillations to the joints. We use the latest 3-d mobilization technique known as KKMT which gives very fast results to restore the movement by correcting the altered biomechanics.
• Lymphatic Drainage: Our body tends to accumulate extracellular fluid, in cause tissue trauma and lymphoedema is a common condition when the lymph nodes are excised due to which the lymphatic fluid accumulates. This can be drained by lymphatic drainage to release the pressure in the tissues and also helps in increasing the blood circulation.
• Taping: We use various tapes and techniques to apply it. We use Kinesio tape, rigid tape, semi- elastic etc. Taping helps in restoring the function of the muscle, supporting the structure involved, and restricting the joint or the muscle movement.