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Lumbar

 

The Lumbar Spine & SI Joint

The lumbar vertebrae (bones) are the largest segments of the movable part of the vertebral column. They are designated from top to botoom L1 to L5. This region of the spine is the source of large amounts of motion (flexion and extension) and some small rotation. The Lumbar spine also supports most of the body weight.


 

Disc Injuries

The intervertebral disc is one of the most common sources of low back pain. Intervertebral discs are structures in between the lumbar vertebrae that act as shock absorbers for the spine. They help aid trunk motion, transmit loads from one vertebral body to the next, and help protect various structures in the low back such as the lumbar vertebrae and nerve roots.

 

The intervertebral disc is made up of two parts, the annulus fibrosus and the nucleus pulposus. The nucleus pulposus contains a gel made primarily of water and proteoglycans and acts to resist axial compression and distribute compressive forces. The annulus fibrosus is made primarily of collagen fibers and encloses the nucleus pulposus; which helps withstand tension within the disc. There are several theories as to the source of pain generation in a disc injury involving an intervertebral disc that is either degenerative or herniated. Mechanical compression and an inflammatory response is one hypothesis to explain pain from a disc injury. Compression of a nerve alone is not necessarily painful although if the nerve is inflamed than it can cause severe pain with very little compression.

 

The most common presentation of lumbar pathology involving the intervertebral disc is a disc protrusion resulting in radiculopathy. This will typically involve unilateral leg pain, increased pain when sitting and decreased pain when standing or walking. Lower extremity weakness may also be present due to myelopathy. Forward trunk bending, rotation, or a combined trunk flexion-rotation movement usually causes this type of injury.

 

Possible Treatments in Physical Therapy

1. Manual Intervention: to focus on improving lumbar ROM, normalize mechanics of the spine and sacrum.

2. Soft Tissue Mobilization: as indicated to reduce muscle guarding and soft tissue overload to restore normal resting muscle length and full pain free ROM.

3. Strengthening: with activities emphasizing segmental mobility and strengthening emphasizing lumbar stabilization. Postural training and reconditioning.

4. Traction: manual and/or mechanical traction of the lumbar spine will help reduce compressive forces on the herniated disc by unloading the lumbar spine.

5. Modalities: as indicated to reduce pain and inflammation at the lumbar spine.

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006. Physical Rehabilitation: Assessment and Treatment, 4th Edition. Susan B. O’Sullivan and Thomas J. Schmitz, 2001. www.emedicine.medscape.com/article/94554-overview

Disc

 

Disc

 

DDD

 

Disc

 

Disc

DDD

 

 

DDD

 

 

DDD

Degenerative Disc Disease (DDD)

The intervertebral disc is one of the most common sources of low back pain. Intervertebral discs are structures in between the lumbar vertebrae that act as shock absorbers for the spine. They help aid trunk motion, transmit loads from one vertebral body to the next, and help protect various structures in the low back such as the lumbar vertebrae and nerve roots. The intervertebral disc is made up of two parts, the annulus fibrosus and the nucleus pulposus. The nucleus pulposus contains a gel made primarily of water and proteoglycans and acts to resist axial compression and distribute compressive forces. The annulus fibrosus is made primarily of collagen fibers and encloses the nucleus pulposus; which helps withstand tension within the disc. The intervertebral disc undergoes the most age-related changes of all connective tissue. Over time and with repeated stresses, the nucleus pulposus becomes replaced with fibrocartilage, and the gel within the disc decreases in water and proteoglycans causing a loss of disc height.

The degenerative changes are seen in three stages:
The first stage is the Dysfunction Stage. This stage involves outer annular tearing, cartilage destruction, and joint dysfunction. The symptoms include local low back pain, muscle guarding, and decreased trunk mobility.
The second stage is known as the Instability Stage. At this stage disk resorption occurs as well as a loss of disk height. The symptoms include a feeling of the back “giving way” or “catching” when moving the back. Pain when standing from a forward trunk position is also typical.
The last stage is the Restabilization Stage. Dusring this stage the progressive degeneration leads to osteophyte formation and stenosis. Syptoms are those of the dysfunction stage.

 

Possible Treatments in Physical Therapy:
1. Patient Education: emphasizing proper body mechanics and lumbar ergonomics with daily activities. An understanding of the natural history of disc injury.
2. Manual Treatment: as indicated to decrease soft tissue tension due to secondary muscle guarding.
3. Strengthening/Stretching Program: emphasizing lumbar stabilization and neuromuscular re-education to maintain a neutral spine throughout static and dynamic activities.

References:
Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006. www.emedicine.medscape.com/article/309767-overview

 

Lmbar

lumbar sprain

 

Disc

 

 

Lumbar Sprain

Low back pain is one of the most common musculoskeletal pathologies, with a reported lifetime incidence of 60-90%. Lumbar sprains and strains are the most common cause of low back pain, especially among athletes. Sprains are ligamentous injuries that can be caused by a sudden or violent contraction, sudden torsion, or a direct impact. The posterior ligaments are the most prone to injury due to location and being less developed then the anterior ligaments. Strains are tears (partial or complete) of a muscle-tendon unit. This occurs typically with a sudden contraction while the muscle is in a forcefully elongated position. The paraspinal muscles are the most susceptible because they span several joints. The lumbar spine and the hips are responsible for the majority of movement in the trunk. The L4-5 and L5-S1 joints bear the highest loads and undergo the most motion in the lumbar spine. These joints also have been found to sustain the most lumbar sprain or strain injuries. These injuries are most commonly seen with coupled motions such as side bending and forward bending or side bending with trunk rotation. Most lumbar sprain or strain injuries are sustained while lifting weight with improper body mechanics or when performing one of the above coupled motions unexpectedly. During these activities, tremendous loads are placed on the lumbar spine, which can cause a temporary instability leading to an injury to the soft tissue surrounding the lumbar spine.

 

Possible Treatments in Physical Therapy

1. Manual Therapy: joint and soft tissue mobilizations as indicated to restore range of motion, reduce muscle guarding and acute pain.

2. Strengthening/Stretching Program: for the paraspinal and abdominal muscles. Postural strengthening may be indicated to improve stability and biomechanics.

3. Ice and other modalities: as needed to reduce acute inflammation and pain.

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006. Physical Rehabilitation: Assessment and Treatment, 4th Edition. Susan B. O’Sullivan and Thomas J. Schmitz, 2001. www.emedicine.medscape.com/article/95444-overview

 

 

Stress Fractures

Lumbar Stress Fractures Stress fractures at the lumbar spine are typically due to a defect of the pars interarticularis, which is the area where the two vertebrae connect on the outsides. A defect at this articulation can occur on both sides (spondylolisthesis) and one side (a unilateral pars defect), which is known as spondylolysis. Spondylolysis, or a pars interarticularis injury is most commonly seen in adolescent athletes and is the result of a stress fracture at the pars interarticularis. Lumbar stress fractures most likely occur because of continued forces placed on the spine, especially with young athletes in sports that require repetitive spinal motion. Higher risk activities include gymnastics, rowing, tennis, dancing, volleyball, soccer, football, and wrestling. These sports all create mechanical stresses at the lumbar spine with extension loading, and can cause weakened pars eventually resulting in a pars fracture. Lumbar stress fractures may present with several symptoms, including low back pain, decreased trunk mobility, hamstring tightness, or an increased curve in their low back. Aggravating factors typically include repeated movements most commonly with extension or rotation. It is possible for a person with this pathology to have no symptoms at all depending upon their level of activity and trunk stability. The vast majority of cases that are symptomatic have been treated conservatively with great success.

 

Possible Treatments in Physical Therapy:

1. Strengthening/Stretching Program: emphasizing lumbar stabilization in neutral or flexed positions to avoid excessive forces in extension. Stretching will focus on restoring muscle length and balance.

2. Manual Treatment: as indicated to reduce tissue tensions caused by muscle guarding and help restore full ROM.

 

References:

Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006. Physical Rehabilitation: Assessment and Treatment, 4th Edition. Susan B. O’Sullivan and Thomas J. Schmitz, 2001. www.emedicine.medscape.com/article/95848-overview

SI joint

 

SI Joint

Sacro Iliac Joint

The sacroiliac joint (SIJ) is the junction at which weight is transferred from the sacrum (tailbone) to the ilium (one of the bones of the pelvis). As it transfers this weight it also acts as a cushion to modulate the forces from the low back to the legs. This joint is an important part of the pelvic ring which allows it to accommodate changes in size (ie in pregnancy). The movements at this joint are very minimal compared to other joints of the body but are essential in everything from stepping off a curb to climbing stairs. Pain is this joint is referred to as Sacroiliac Joint Dysfunction.

SI Joint Dysfunction:
Many muscles cross the SIJ including muscles of the lumbar spine, hips and abdominal wall. These muscles act to stabilize this joint and can be strengthened when this joint is unstable. Women aged 15 to 40 years old injure this joint most commonly although men are not immune. Females are more prone to injury because the body weight falls behind the axis of support of the hip and this causes strain to the SIJ ligaments.

Pain in the SIJ is common in runners due to the repetitive loading and impact forces through this joint at heel strike. Prolonged standing on one leg (persistent poor posture), poor muscle extensibility and heavy lifting can all irritate the SIJ. This leads to pain with negotiating stairs, getting in and out of a car and with torsional movements (ie golfing). There is usually pinpoint pain at the SI joint (Fortin’s point) which can help in the diagnosis of this condition.

Spondy

Spondy

 

Spondy

 

Spondy

 

Spondy MRI

Spondylolisthesis

Spondylolisthesis is a condition in which there is a forward slippage of one vertebrae over the vertebral body beneath it. The most common occurrence is at the lumbosacral junction of L5 slipping over S1. The anterior slippage is due to a bilateral defect of the pars interarticularis, which is the area where the two vertebrae connect on the outsides. A defect at this articulation on both sides causes the vertebral body above to slip forward. If only one articulation is disrupted (a unilateral pars defect) then no slippage will occur, this is called spondylolysis. Most defects of the pars interarticularis begin as a stress fracture that most likely persist because of continued forces placed on the spine, especially with trunk extension movements.

Higher risk activities include gymnastics, rowing, tennis, and wrestling. These sports all create mechanical stresses at the lumbar spine with extension loading, and can cause weakened pars eventually resulting in a pars fracture. Spondylolisthesis may present with several symptoms, including low back pain, radiculopathy (due to pressure on nerves from forward slippage), decreased trunk mobility, hamstring tightness, or an increased curve in their low back. It is possible for a person with this pathology to have no symptoms at all depending upon their level of activity and trunk stability. The vast majority of cases that are symptomatic have been treated conservatively with great success.

Possible Treatments in Physical Therapy:

1. Strengthening/Stretching Program: emphasizing lumbar stabilization in neutral or flexed positions to avoid excessive forces in extension. Stretching will focus on restoring muscle length and balance.
2. Manual Treatment: as indicated to reduce tissue tensions caused by muscle guarding and help restore full ROM.

 

Spondy Grading


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References:
Orthopedic Physical Assessment, 4th Edition. David J. Magee, 2006. Physical Rehabilitation: Assessment and Treatment, 4th Edition. Susan B. O’Sullivan and Thomas J. Schmitz, 2001. www.emedicine.medscape.com/article/1266860-overview


 

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