Mechanical Low Back Pain

Ferius Soewito
Flexfree Musculoskeletal Rehabilitation Clinic
Smart Mind Center, Gading Pluit Hospital
 Introduction: Low Back Pain
• Low back pain (LBP) is the most common musculoskeletal condition
affecting the adult population, with a prevalence of up to 84%.1
• Type of LBP
• Musculoskeletal – mechanical (including Muscle strain, muscle spasm, or
spondyloarthritis); herniated nucleus pulposus, herniated disk; spinal
stenosis; or compression fracture
• Inflammatory – HLA-B27 associated arthritis including ankylosing
spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel
disease
• Malignancy – bone metastasis from lung, breast, prostate, thyroid, among
others
• Infectious – osteomyelitis; abscess
1. Balagué F, et al.: Non-specific low back pain. Lancet. 2012; 379(9814): 482–91
Classification according to the duration

• Acute (pain lasting less than 6 weeks)

• Sub-acute (6 to 12 weeks)

• Chronic (more than 12 weeks)

Etiology
Pain Generator

• Many potential anatomic sources

• Nerve roots
• Muscle
• Fascial structures
• Bones
• Joints
• Intervertebral discs (IVDs)
 Cluneal Nerve entrapment
• Peripheral nerve problems that mimic radiculopathy
• Cluneal nerve: Superior (SCN) and medial cluneal nerve (MCN)
• The incidence of SCN-E in patients with LBP was 14%, MCN-E has similar
incidence
• The incidence of bilateral SCN-E 20-30% in Japanese studies
• LBP due to SCN-E is exacerbated by lumbar movement such as extension,
bending, rotating, prolonged standing, sitting, walking, and rolling
• It produces leg symptoms in 47%–84% of patients and mimics radiculopathy due
to lumbar disorder. SCN-E also elicits intermittent claudication due to worsening
LBP during walking
• In patients with SCN-E, a Tinel-like sign is detected at the site of nerve
penetration

Toyohiko Isu, Kyongsong Kim, Daijiro Morimoto, Naotaka Iwamoto. Superior and Middle Cluneal Nerve
Entrapment as a Cause of Low Back Pain. Neurospine 2018;15(1):25-32.
Cluneal Nerve
 The forgotten brain

• The role of brain to:

• Modulate pain

• Perceive → influence by emotion

• Sensorymotor coordination
Central Sensitization
• Sometimes there is discrepancy between severity of injury and
magnitude of pain
• Repetitive Nociceptive signal that going into the brain → induce
potentiation, sensitization, plasticity → Nociplastic
• Reorganization of fiber at dorsal horn of medulla spinalis → allodynia
• If found in acute low back pain → poor prognosis → will progress to
chronic low back pain
• May explain the poor result of intervention or surgery
• Central sensitization resolve in acute low back pain but can progress
into chronic low back pain if combined with psychological problem
Arendt-Nielsen, L., Fernández-de-Las-Peñas, C. and Graven-Nielsen, T., 2011. Basic Jo Nijs, et al. Central sensitisation in chronic pain conditions: latest discoveries
aspects of musculoskeletal pain: from acute to chronic pain. Journal of Manual & and their potential for precision medicine. Lancet Rheumatol 2021; 3: e383–92
Manipulative Therapy, 19(4), pp.186-193
Diagnostic criteria for central sensitization
• (1) Pain disproportionate to the nature and extent of injury or
pathology
• (2) A disproportionate, non-mechanical, unpredictable pattern
of pain provocation in response to multiple/non-specific
aggravating/easing factors;
• (3) A strong association with maladaptive psychosocial factors,
and
• (4) One sign (diffuse/non-anatomical areas of pain/tenderness
on palpation)
Consider central sensitization
• Unrefreshing sleep
• Sleep problems
• Sensitivity to light
• Spreading pain
• Concentration difficulties
• Stress as an aggravating factor
• Sensitivity to odours
• Restless legs
Chronic low back Pain

• Prolonged low back pain

• More complex
• Prone to progress
• Biopsychosocial influence
• Central sensitization is
more frequently found
• Motor Control Dysfunction
Acute LBP Chronic LBP
Biomechanical aspect of LBP
• Though the injury to the spine is evidenced, biomechanical
factors play an important role also

• Biomechanical factors can be the culprit, obstruct healing,

worsening the condition

• Low back pain can also cause changes to biomechanical

system
 Motor Control Dysfunction
• It has been shown that CLBP is associated with excitability
and/or reorganization of the brain’s motor cortex (M1)

• These changes are presumably correlated with the trunk

muscles’ postural adjustments, which are altered in patients
with CLBP

Shafiee S, et al. Repetitive transcranial magnetic stimulation: a potential therapeutic modality for
chronic low back pain. Korean J Pain 2017 January; Vol. 30, No. 1: 71-72
Biomechanical Considerations

• Body mechanic problem

• Core muscle problem

• Other parts of body

Body Mechanic Problem

• Activity

Compromise Core Asymetry of

• Posture muscle /trunk loading and
stabilizer stretching
• Abdominal
changes
Muscle of the Core
• Erector Spina
• Ext Oblique
• Quadratus lumborum
• Int Oblique
• Latisimus dorsi
• Trans Abd
• Multifidus
• Rect Abd
• InterSpinal
• Abd Fascia
• Thoracolumbar Fascia

The Role:
• Stabilizing trunk in static and dynamic condition
• Mobilizing trunk while still stabilizing it
Core muscles
 In low back pain
• Associated with muscle dysfunction1

• Tranversus abdominis Primary Stabilizer

• Multifidus Increase intra abd pressure

• Reduce proprioceptive input2

1. Kumara T, et al. Efficacy of core muscle strengthening exercise in chronic low back pain patients. Journal of Back and Musculoskeletal Rehabilitation 00 (2014)
1–9
2. Sohn MK. Effects of Acute Low Back Pain on Postural Control. Ann Rehabil Med 2013;37(1):17-25
Diaphragm
• Dual task → respiration and trunk stability
• Along with Tranv abdominis, Multifidus, Pelvic muscle and other
core muscle → increase Intra-abdominal pressure
• Some literature didn’t include diaphragm as core muscle but
actually has the role as the roof of core muscle
• Current evidences have shown the role of diaphragm as spine
stabilizer by providing intra-abdominal pressure
Diaphragm changes in LBP
• Kolar et al: reduced diaphragma movement when resistance is
applied on upper and lower ext → less intraabdominal pressure

Low Back Pain

Normal Patient

Kolar, et al. Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain.
journal of orthopaedic & sports physical therapy.2012;42(4)
Greater diaphragm fatigability
The floor: Pelvic floor muscle
• Duncan, et al: the transversus abdominis muscle thickness
increased 49.71% with abdominal bracing alone. If the pelvic
floor muscles were engaged during this “drawing-in” movement,
the muscle group was found to increase in thickness by 65.81%
• Pelvic floor muscle in coordination with abdominal muscle,
increase intraabdominal pressure during heavy lifting
• They also stabilize lumbopelvic, SI joint and pelvic girdle
• Recent studies → association between LBP and urinary
incontinence (UI) → women with UI are more than twice as
likely to experience frequent back pain as those without UI
Other parts of the body
• Elabd, et al → Integrating Cervical Posture Correction With
Lumbar Stabilization Exercises for Mechanical Low Back Pain
→ better result
• Gluteus maximus → stability of SI joint → stability of
lumbosacral junction
• Cibulka → case report → treatment of hip and subtalar joint
eliminate low back pain
• Casto-Mendez, et al → custom foot orthosis improve low back
pain in over pronated feet.
 Evaluation
• The history and physical examination, with appropriate use of
imaging, can point toward a specific etiology.

• The complexity and biomechanics of the spine make it difficult

to identify a specific anatomic lesion, with a precise diagnosis
made in only 20% of cases

Will JS. Mechanical Low Back Pain. American Family Physician. 2018;98(7)
History
• Evaluation of low back pain should begin with a history and
physical examination
• The presence of red flags that suggest systemic disease or
urgent problems warrants additional evaluation before empiric
treatment
• A higher likelihood of fracture with the presence of one or more
red flags for trauma
• Older age
• Prolonged corticosteroid use
• Significant trauma relative to age, contusions or abrasions.
Other red flags sign
• Constitutional symptoms for malignancy or infection

• Loss of bowel or bladder function

• Progressive motor or sensory loss for cauda equina syndrome

Red Flags
The history should include:
• Assessment of pain
• Type
• Location
• Severity
• Timing
• Aggravating/relieving factors
• Radiation should be used to assess risk of mechanical low back pain
• Physical activity
• Occupational hazards
• Functional Problem
.
Physical examination
• Posture: cervical, thoracal, lumbal, etc
• Gait: Limping gait?
• Strength
• Sensation, and reflexes of the lower extremities.
• Inspection, palpation, and range-of-motion testing of the
lumbosacral musculature are helpful for identifying point
tenderness, restriction, and spasm.
• Examination of other part → foot, lower extremities
Pelvic obliguity
Special Test

Straight leg raise test Patrick test Contrapatrick

Laboratorium
• Rule out infection

• Rule out inflammatory back pain

NCV-EMG
• Radiculopathy

• Other peripheral neuropathy

Imaging
• is not recommended for most patients with nonspecific mechanical
low back pain in the absence of red flags.
• The American College of Radiology Appropriateness Criteria for low
back pain recommends imaging only if there is no improvement after
six weeks of conservative medical and physical therapies, or there is
high suspicion for cauda equina syndrome, malignancy, fracture, or
infection.
• Early routine use of magnetic resonance imaging increases lumbar
spinal surgeries without reciprocal benefits in pain or function.
(Jarvik JG, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back
pain: a randomized controlled trial. JAMA. 2003;289(21):2810-2818)
Imaging
• Xray → Bone, alignment of bone

• MRI → Soft tissue, nerve, disc, muscle, bone

• MRI with contrast → infection, malignancy

Treatment
• Pharmacologic treatment

Should consider
• Non Pharmacologic treatment
• Biopsychosocial

• Surgery
• Biomechanic

• Other
Pharmacology
• Acetaminophen
• NSAID
• Anticonvulsan (gabapentinoids)
• Opioid
• Muscle Relaxant
• Topical Anesthetic
• Oral Corticosteroid → carefully used
• Antidepresant
• Injection → steroid, prolotherapy, Platelet rich plasma
Non Pharmacology
• Pain Education
• Physical modalities
• Exercise
• Manual Manipulations
• Orthotic
• Psycotherapy: CBT, ACT, etc
Pain Education
• Treating
• False believe of pain

• Pain Catastrophizing:The tendency to describe a pain experience in

more exaggerated terms than the average person, to ruminate on it
more (e.g., "I kept thinking 'this is terrible'"), and/or to feel more
helpless about the experience ("I thought it was never going to get
better")

• Kinesiophobia
Physical Modalities
• TENS
• Diathermy
• Laser
• Peripheral Magnetic Stimulation
• Transcranial Magnetic Stimulation
rTMS and rPMS
• Transcranial magnetic stimulation (TMS) and repetitive TMS (rTMS) are
indirect, non-invasive, and painless methods used to induce excitability
changes in the motor cortex, nerve or muscle via a wire coil generating a
magnetic field that passes through the scalp.

When electrical current travels through a wire, it

creates a magnetic field with a direction perpendicular
to the direction of the current → Faraday’s Law of
electromagnetic induction
•.

Peripheral Magnetic Stimulation

• Gate Control Theory

• Proprioceptive feedback → sensorimotor cortex modulation →

Plasticity
Lim YH. Effects of Repetitive Peripheral Magnetic Stimulation on Patients With Acute Low Back Pain:
A Pilot Study. Ann Rehabil Med 2018;42(2):229-238

• Stimulate Pelvic Floor Muscle

Goldberg EP, et al. Electromagnetic pelvic floor stimulation: applications for the gynecologist. Obstet Gynaecolog Surv. 2000
Nov;55(11):715-20.. .
 rPMS and motor control
• Once rPMS activates muscles, proprioceptive afferents are
generated through two pathways: indirect activation of
mechanoreceptors on fibers (type Ia, Ib, II), and direct activation
of sensorimotor nerve fibers
• This proprioceptive influx into the brain is believed to cause
cortical plasticity.
• Studies using MEP has confirmed it

Effects of Repetitive Peripheral Magnetic Stimulation on Patients With Acute Low Back Pain: A Pilot
Study
 Repetitive Transcranial Magnetic
Stimulation (rTMS)
• Modifying central modulation
• Changes in cortical and regional brain activities
• Attenuate overactivity of brain
• Reduce depression, anxiety and sleep disorder (FDA approved)
• Improve postural stability

El-Sharkawy HM, et al. Efficacy of Repetitive Transcranial Magnetic Stimulation on Balance in Patients
with Chronic Low Back Pain. Med. J. Cairo Univ. 2017;85(7):2497-2503
Exercise
• Flexibility

• Motor control exercise

• Core muscle exercise

• Shah, et al → Diaphragma + core exercise give better result than core exercise alone

• Ghaderi, et al → Stabilizing exercise and pelvic floor muscle exercise → women with low
back pain and urinary incontinence

• Aerobic exercise
Exercise

• Exercise of related area:

• Cervical
• Upper extremity, upper back, chest
• Hip
• Lower extremity
Orthosis

• Schott et al → Reviewed the efficacy of Lumbar orthosis for low

back pain →
• Have benefit on functional capacity and pain reduction
• Inconsistent result
• Need further research
• off-training measures has proven to be superior when compared to
orthoses without off-training

Cordelia Schott, et al. Effectiveness of lumbar orthoses in low back pain: Review of the literature
and our result. Orthopedic Reviews 2018;10:7791
Manual Treatment
 Psychological Treatment

Villemure, C. & Bushnell, M. C. Mood influences supraspinal pain processing separately from attention. J. Neurosci. 29, 705–715
(2009
Conclusion
• Mechanical low back pain is a common problems in community
but also a complex case to treat
• Evaluation and treatment of low back pain should not only
limited to the back
• Biopsychosocial assessment and management is important
especially for chronic low back pain
Thank You