Therapeutic Exercises for Low Back Pain: An Overview

1. Therapeutic ExercisesforLow Back Pain:An Overview Presented By: Miriam Grace de Leon Senior Physical Therapist Montefiore Medical Group 1010 Central Park Avenue Yonkers, New York

2. Target Audience Clinicians: • Physiatrists • Physical Therapists • Non-Rehab Specialists

3. Objectives You Will LEARN or REVIEW: • Where therapeutic exercises “fit” in management of low back pain • The four (4) main therapeutic exercise approaches used by Physical Therapists in management of low back pain

4. Sources • 2012 APTA Clinical Practices Guidelines Handbook, Orthopedic Section • 2012 Journal of Orthopedic and Sports Physical Therapy • Annals of Rheumatology, Mar 2014 • Spinal Evaluation and Manipulation, 2009 Edition, University of St. Augustine for Health Sciences • Personal training & clinical experiences from 1983 to present

5. Interesting Facts • 80% of adults in any population will experience low back pain in their lifetime • Low back pain is the leading cause and cost of lost work days in the U.S. • In 1998, low back pain accounted for $26.3 Billion out of the total $90 Billion in healthcare expenditure, and this trend continues

6. Sources of Back Pain NON-INNERVATED Nerves Spinal Cord Disc (except annulus) INNERVATED Annulus Nerve Roots Joints - Facet - SI Muscles Ligaments Bone

7. Lumbar Spine

8. Causes of Low Back Pain NON-MECHANICAL Inflammatory joint conditions - non-degenerative Infections Tumors Neurovascular Kidney stones Endometriosis Fibromyalgia MECHANICAL Spondylosis • degenerative “wear & tear” Sprains/Strains • IVD degeneration/ herniation Radiculopathy (Sciatica) Spondylolisthesis Stenosis - Spinal - Foraminal Skeletal irregularities - Scoliosis - Kyphosis - Lordosis Congenital abnormalities

9. Risk Factors • Age • Fitness Level • Pregnancy • Weight Gain • Occupation • Inactivity • Excessive activity • Abnormal activity • Mental Health • Genetics (Ankylosing Spondylitis) • Backpack Overload in Children • Strain -> muscle fatigue; AAOS recommends no more than 15-20% body weight

10. “Journey” of a Person With Low Back Pain

11. Evaluation • History - Current - Past • Mobility Testing • Pain Assessment: Pain Scales • Imaging - X-Ray • CT Scan / Discography • Myelogram • MRI • Bone Scans • Ultrasound

12. Evaluation (cont’d) • Electrodiagnosis: EMG/NCS/EPS • Blood Test • Outcome Measures: - Oswestry Disability Index - Roland-Morris Disability Questionnaire - Quebec Backpain Disability Scale • Activity Limitation and Participation Restriction Measures

13. Classification ICD categories are based on LBP without signs and symptoms of serious medical or psychological conditions associated with one or more of the following: • mobility impairments of T, L and SI regions • referred/radiating pain to the LE • generalized pain

14. Differential Diagnosis Consider if: • Known or suggestive of serious medical and/or psychological pathology • Inconsistent and/or conflicting clinical manifestation(s) • Symptoms not resolving with intervention(s)

15. Stages of Low Back Pain • Acute: • onset to < 4 weeks • most are self-limiting • Subacute: • 4 to 12 weeks • Chronic: • > 12 weeks

16. Interventions Conventional treatments for acute symptoms: • Ice packs 15-20 minutes at or immediately after onset for first 48 to 72 hours, followed by heat • BRIEF rest for not more than 1-2 days • light activity shown to speed up healing and recovery while avoiding aggravating movements

17. Interventions (cont’d) Immobilization: - bracing - taping Medications: - OTC analgesics - NSAIDs - anti-convulsants: radicular pain - anti-depressants - counter irritants - narcotics Injections: - trigger point - local/epidural - nerve block

18. Other Interventions • Biofeedback • Relaxation/Psychotherapy • Acupuncture • Chiropractic Care • Physical Therapy • Surgery

19. Physical Therapy Evaluation • History • Pain Assessment • ROM: • Spinal mobility - hypermobility - hypomobility - aberrant movements • Hip - IR / ER - F /E

20. Physical Therapy Evaluation(cont’d) • Trunk Muscle Power and Endurance: • Trunk flexors • Trunk extensors • Lateral abdominals • Transversus abdominals • Hip abductors • Hip extensors • Posture • Provocative Tests

21. Physical Therapy Goals • Decrease Pain and Distress • Prevent/Delay: • Progression to Chronic Pain • Recurrence • Increase Functional Mobility for: • ADLs • Occupation • Recreation • Competitive Sports

22. Physical Therapy Treatments • Passive • Active • Patient Education

23. Passive Modalities Therapist-driven, little or no participation from patient • Heat/Cold/Contrast • Electrical Stimulation & Variants • Microwave • Infrared • Shortwave • Ultrasound • Stabilization - bracing - taping • Tractions (off loading) - manual - mechanical

24. Passive Modalities (cont’d) Manual Therapies: • Manipulation / Mobilization - Joints - Bone - Fascia - Soft Tissue (Muscles) - Neurovascular Tissues • Massage • Pressure • Cranio-Sacral • Myofascial Release • Strain & Counterstrain • Muscle Energy • Neuromuscular Re-education

25. Active Modalities THERAPEUTIC EXERCISE! (Aqua Therapy) • Trunk Coordination/Strengthening and Endurance Exercises • Centralization & Directional Preference exercises (McKenzie) • Flexion Exercises (Williams) • Lower Quarter Nerve Mobilization • Progressive Endurance and Fitness/Sports Activities * For this presentation, we will focus on the first four (4) exercise categories *

26. Active Modalities • Trunk Coordination/Strengthening and Endurance Exercises • Typically used for spinal instability from any cause(s) • Includes - stretching exercises • transversusabdominus training • multifidus lumbar stabilization • Also known as core engagement/control strenghtening & stabilization • Useful review - transversus abdominis - multifidi

27. Active Modalities • Trunk Coordination/Strengthening and Endurance Exercises (cont’d) • TVA: originates from iliac crest, 7-12 costal cartilages, inguinal ligament, inserts to xiphoid, linea alba, pubic crest • “Vacuum” or “dead bug” exercises • TVA contraction reduces vertical pressure on the IVD by 40% • Multifidi: fleshy and tendinous fasciculi which fill up the groove on either side of the spinous processes – span from sacrum to axis

28. Dead Bug Exercise

29. Multifidus Exercise

30. TVA and Multifidi

31. Active Modalities • Centralization and Directional Preference Exercises (McKenzie) • Typically used when pain symptoms can be made better or worse by adopting different positions or movements, a.k.a. directional preference • Directional preference causes pain to move AWAY from legs/hips toward lower mid-back

32. Active Modalities • Centralization and Directional Preference Exercises (McKenzie) (cont’d) • Once directional preference identified, back pain can be classified into one of the following syndromes: • postural • dysfunctional – adaptive shortening/ scarring/adherence • derangement – most common hallmark is extreme sensitivity to certain movements

33. Active Modalities • Centralization and Directional Preference Exercises (McKenzie) (cont’d) • Typical McKenzie exercise prescriptions: • postural – sitting and/or standing in correct alignment • dysfunctional – remodelling connective tissue • derangement – reduce symptoms

34. Sitting in Correct Alignment

35. Standing in Correct Alignment

36. Extension Progression in Prone

37. Flexion Progression in Supine

38. Flexion Progression in Sitting/Standing

39. Active Modalities • Typical McKenzie exercise prescriptions: (cont’d) • Additionally for dysfunctional and derangement: • extension progression: • prone lying • prone on elbows • prone full press ups • flexion progression in supine: • supine lying • supine knees bent • supine knee to chest • flexion progression in sitting/standing: • seated bend trunk forward • place hand beneath seat • standing forward bend to touch toes

40. Active Modalities • Flexion Exercises (Williams) • Standard treatment for spinal stenosis and degenerative disc disease • Consists of repeated flexion exercises in supine, seated or standing positions • Opens/expands cross-sectional area of both foraminal and central spinal canals • Relieves compression of nerve roots • Improve spinal flexibility and circulation

41. Active Modalities • Flexion Exercises (Williams)(cont’d) • Seven (7) core WFEs (there are many variations) Consists of repeated flexion exercises in supine, seated or standing positions • Pelvic tilt • Single knee-to-chest • Double knee-to-chest • Partial sit up • Hamstring stretch • Hip flexor stretch • Squat *CAUTION: Osteoporosis/compression fractures

42. Pelvic Tilt

43. Single Knee-to-Chest

44. Double Knee-to-Chest

45. Partial Sit Up

46. Hamstring Stretch

47. Hip Flexor Stretch

48. Squat

49. Active Modalities • Lower Quarter Nerve Mobilization • Most useful for low back pain patients with radicular symptoms: • Unable to improve or worsen with extension/flexion AND • Positive slump test • Patient will, typically, describe pain that is “burning,” “throbbing” and “stabbing” • Two (2) main causes: • Intraneural: edema & scarring • Extraneural: osteophytes, scar tissues, hypertrophic soft tissues, bony contours

50. Active Modalities • Lower Quarter Nerve Mobilization(cont’d) • Two (2) main nerve mobilization techniques: • Flossing • Slacken one end, tighten or pull the other • Tensioning • Pull on both ends