Introduction
- Facet Joint dysfunction by altered joint alignment, motion or physiological function |
- Non-radicular discomfort |
- Mechanical and Reflexive |
- Mechanical: outside force acting on a segment; brief trauma/extended period of overuse |
- Reflexive: Sustained visceral nociceptive irritation triggers muscle guarding - altered joint mechanics |
- Can be caused by psychological and emotional factors |
- Hypomobility can cause increased local nociceptive activity & decreased mechanoreceptive input |
- Hypomobility - inflammation, muscular hypertonicity (Hilton's law) and imbalance |
Hilton's law states that the nerve supplying the muscle extending directly across and acting at a given joint not only supplies the muscle, but also innervates tthe skin overlying the muscle
Demographics (LBP)
- Up to 80% of the population will experience LBP |
- Single most common cause of disability in workers <40 yo |
- Between 45-60 yo |
- Equal in males and females |
- Higher in whites |
Risk factors (LBP)
- Hx of LBP |
- Age |
- Physical Activity |
- Obesity |
- Smoking |
- Alcohol |
- Narcotic use |
- Heavy manual labour |
- Repetitive bending |
- Twisting and lifting |
- Static postures |
- Short sleep duration |
- Exposure to whole body vibration |
- Psychosocial/psychological factors: Stress, anxiety, depression, dissatisfaction with job, low educational status |
- Vitamin D deficiency |
- Negative attitude/fear avoidance behaviours |
Presentation
- Subacute unilateral LBP |
- Can radiate into butt/thigh - NO SYMPTOMS DISTAL TO THE KNEE |
- Aggravated by static loading of the spine (prolonged sitting/standing), long lever activities (vacuuming/working with arms extended away from body), overhead working (end range spinal loading), prolonged flexion |
- Relieved by light activity - walking/constantly changing position, lying down |
- ROM discomfort upon extension, diminished lateral flexion |
- Hamstring hypertonicity |
- Diminished lumbar lordosis |
- +Ve Mcgills, +ve Kemps, +ve Yeomans |
- Gluteal + abdominal muscle weakness |
- Hypertonicity of thoracolumbar erectors, rectus femoris,ilipsoas, TFL |
- Assess for foot hyperpronation |
- Neurological testing unremarkable (Check for Cauda equina in LBP) |
Imaging
- Only if red flags are present |
- Hx of cancer |
- Unexplained recent weight loss |
- Bone disease |
- Systemic Disease |
- Inflammatory Arthropathy |
- Steroid use |
- Immune suppression |
- Fever |
- Nocturnal pain |
- Prior lx surgery |
- Suspected congenital defect/instability |
- Severe, prolonged pain unaffected by position |
- MRI only for patients with radicular complaints (epidural steroid injections), major trauma, severe neurologica compromise, suspicions of vertebral infection |
DDx
- Can co-exist with other mechanical conditions of the spine |
- Disc lesions |
- Degeneration |
- Stenosis |
DDx: |
- Myofascial pain |
- Spondylolysis |
- Spondylolisthesis |
- Sprain/strain |
- Disc lesion |
- F# |
- Compression f# |
- DDD/DJD |
- Stenosis |
- Neoplasm |
- Infection |
- SIJ dysfunction |
- Hip pathology/OA |
- AAA |
- Referred pain - GU, GI |
- Inflammatory Arthropathy |
Management
- 60% recover in 6 weeks |
- 75% recover within 3 months |
- 2/3rd will experience a recurrence within one year |
- SMT (Chemotactic cytokine production levels improve following SMT) - 12 visits over 6 weeks) of spine, pelvic |
- If instability - spinal stabilisation over SMT |
- Heat/Ice |
- Myofascial release of Lx erectors, QL, hip flexors, hip rotators, gluteals, piriformis, hamstrings, iliolumbar ligament |
- Flexability exercises - knee to chest stretch, hamstring stretch, psoas stretch, ext/flex biased exercises |
- Stability exercises - side bridge, bird dog, dead bug, hip abductor strengthening |
- Postural correction |
- Breathing exercises |
- Lifestyle modification - lfting mechanics, work activities, sleep positions, shoe wear |
- Limitation on prolonged sitting/standing |
- Encourage yoga/taichi |
- Dietary counselling |
- Unresponsive - consider viscerosomatic referral |
Criteria for success of SMT
- Pain <16 days |
- No symptoms distal to the knee |
- Low fear avoidance (FABQ score <19) |
- Hip internal rotator >35 degrees |
- Hypomobility of a least one lx segement |
- First two factors more sigificant |
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