Charlie Kornberg's Musculoskeletal Physiotherapy Home Page |
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Lower back pain has been a problem to the Westernized world for centuries. Recently published figures indicate that the escalation of its incidence shows no sign of reduction. At last count, 80% of the Westernized population will suffer some form of lower back pain, in their lifetime, and it continues to be a major contributor to increasing health costs and days lost from work. A variety of factors have been identified, which may predispose a person to develop lower back pain. These include sedentary occupations, jobs that include bending and/or twisting, exposure to vibration and interestingly, lack of fitness. There is a group of patients, usually very active (and most commonly sports people), who suffer from chronic lower back pain and unresolving symptoms, secondary to repetitive movements at the extremes of range. Activities include gymnastics, cricket, weightlifting, ballet and similar participations. Broadly, but ill-defined, these patients are defined as sufferers of "lumbar instability". The term instability has been bandied around, recently, as a major cause of lower back pain. Unfortunately, very little scientific evidence exists regarding its defining objective presentation. Various concepts exist, but very little in the form of investigation, has been able to identify the entity known as instability. There is contention as to whether there is association between instability and spondylolisthesis (Fig. 1), as well as instability and hypermobility. The term hypermobility relates to a situation where there is excessive mobility in the motion segment, but there is control utilizing the muscular system (Fig. 2). This differs from instability, in that there is very little or no muscle control of the motion segment in the unstable joint. In the hypermobility patient, treatment is aimed at improving the control of the motion segment, usually utilizing dynamic lumbar stabilization exercises. Fig 1. Normal L5 on S1 presentation (left) and Grade 1 spondylolisthesis of L5 on S1 (right). Fig 2. Hypermobility seen in a young gymnast. Another term that is being utilized, at present, is "Functional Instability". This is characterized by good structural integrity of the joint, but involving lost or impaired control of movement. This loss of muscular control may result from loss of fitness, sedentary lifestyle (including occupational and recreational activity), repetitive activity - resulting in overuse injury and muscle imbalances. An arc of pain, usually into flexion, but can be other movements. This may also include "walking up" the legs when returning from the flexed position; Pain on relaxed postures i.e. when the muscles are relaxed; Pain on quick movements, where there is little or no muscular control; Excessive range of intervertebral movement at the motion segment i.e. by passive testing of gliding motion and physiological movements; Pain, either 'catching' or sharp, on changing positions following a prolonged period of time; An alternating 'list' or scoliosis, with a catch of pain when this corrected; Often good range of motion, with some degree of pain at the end range; X-ray findings are inconclusive, as traction spurs, posterior subluxation and excessive translation of one vertebral body on another during flexion/extension radiography may suggest instability, however 'functional instability' may still exist in the absence of x- ray findings. An anterior slip of one vertebral body on the adjacent vertebral body; Traction spurs; Disc and zygapophysial joint degenerative changes (which may include gas within the intervertebral disc in older age groups). As the name implies, dynamic radiological examination, relates to signs seen when the spine is subjected to movement. The common findings seen with this examination are: Angulation of the disc space; An anterior slip of one vertebral body on the adjacent vertebral body. It is commonly accepted that if there is a greater than 3 mm slip, a structural instability should be suspected. Spondylolisthesis. Lateral lumbar spinal radiograph in a pediatric patient shows spondylolysis with grade 1 spondylolisthesis. Most efforts should be made to providing the patient a programme of self-help exercises, to encourage spinal stability. These come in the form of dynamic lumbar stabilization exercises which have been shown to be effective in providing core muscle stability. In the case of failed conservative treatment, surgery may be indicated, in the form of spinal fusion.
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Brighton Spine Institute | 441 Bay Street Brighton, Victoria 3186 | AUSTRALIA | Tel. + 61 3 9596 7211 | Fax. + 61 3 9596 7871 |