Lumbar Spine
The lumbar spine is the base or lower part of the spine that is made up of 5 vertebrae (L1-L5). The vertebrae help maintain upright posture. It also protects the spinal cord, which contains nerves that innervate the legs. Between the vertebral bones are discs that provide shock absorption and space between the vertebrae. Low back pain is one of the most common diagnoses seen in physical therapy and can be debilitating for people trying to continue with their daily lives.
Diagnosis
Low Back Pain
Low back pain is the most common diagnosis seen in physical therapy and is an all encompassing term for many different pain symptoms in the low back. Physical therapists are the experts in musculoskeletal pain and biomechanical assessment for stress and strain. It has been shown that people who have gone to the emergency room for acute low back pain do better in the long term if the next health care practitioner they see is a physical therapist (1). Research shows that people with no low back pain can show signs of degeneration and bulging discs on MRI and x-rays (3). It is often difficult to determine the exact structure or reason for low back pain. In fact is has been shown that people who don’t receive a specific musculoskeletal diagnosis do better than one’s that do (3). Low back pain does not have to be a chronic problem and physical therapy can be a solution.
Herniated Disc
The spine is made of bones that are like building blocks sitting on top of one another to provide support and stability to the body. Each bone is connected to the one above and below and as these interconnected bones move they allow for bending, twisting, rotating, and extending. In between each of these bones is a structure called the intervertebral disc which provides shock absorption and spacing between the bones. Spinal discs are a gelatinous substance that can change in shape over a period of time. This change in shape may be classified as a herniated disc.
Depending on the extent of the herniation the disc can be the source of pain because it places pressure on the neighboring nerve of the spinal cord. Generally, nerves give the body sensation by attaching to the skin; and movement by attaching to muscles. When a nerve is pinched by a disc it can cause a multitude of different symptoms; the most typical being pain radiating down the back of the leg.
Physical therapists have many different approaches to this problem. One specific program is called the McKenzie Approach and the goal is to find a directional preference of movement which improves symptoms of low back pain (4). Other techniques focus on core stabilization, manual therapy and modalities to reduce pain and inflammation, and hip and knee strengthening.
Although a herniated disc can be a major source of pain, it may also be a finding on the MRI of a person who does not have back or leg pain. One study reviewed MRI’s of people with no history of low back pain. They found of the people over the age of 40, 50% had some measure of disc bulge, of the over 50 population 60%; and people over the age of 60 up to 69% (5). For this reason, seeing a herniated disc on an MRI does not necessarily it is the root cause of back or leg. A thorough physical exam is still highly recommended to rule out other potential causes.
Sciatica
Sciatica is an umbrella term describing pain radiating down the back of the thigh and leg. The pattern of pain can range from the entire back of the leg to small areas like the buttocks or outside of the foot. There are many different causes of sciatica and a physical therapist will work closely with each individual person to identify the likely cause of pain. Some of the common causes for sciatica pain are a HERNIATED DISC, PIRIFORMIS SYNDROME, or MUSCLE STRAIN or spasm.
The sciatic nerve is a bundle of nerves that come together to make one unit deep in the gluteal muscles. The nerve traverses around the piriformis muscle in the buttocks and descends between the hamstrings into the back of the thigh. At the level of the knee it splits into two different nerves to move the lower leg. Due to the large area innervated by the nerve, symptoms of sciatica can vary wildly between patients. Common symptoms are numbness or tingling down the leg, deep aching, and/or burning. Physical therapists will help discern where the irritation of the nerve is occurring and provide a specific program to help reduce pain, increase range of motion, and improve function. >> top of page <<
Spinal Stenosis or Arthritis
The lumbar spine is made up of five (5) vertebrae that are stacked on top of one another like building blocks. When the bones come together, they create a small space between them to allow for a nerve root to come out from the spinal cord. Normally, there is ample space for the nerve to traverse the space between the vertebra, however as we get older the space narrows because of arthritic changes. This narrowing of the space puts pressure on the nerve and causes symptoms such as numbness, tingling, burning, and aching down the leg.
Symptoms are worse when standing and walking and often completely resolved once seated. This is because when we stand and extend the spine, it increases the narrowing of the spine and places more pressure on the nerve. Once seated the space for the nerve to maneuver through the vertebrae increases and the symptoms resolve. Physical therapy will focus on core stabilization, improving postural awareness in standing and walking, hip strength, and increasing lumbar mobility.
Spondylolithesis
Spondylolithesis is a diagnosis describing the relationship between two vertebrae in which the upper vertebral bone slips forward relative to the bottom vertebrae. The most common area where spondylolithesis occurs is L5/S1, which is the bottom most point of the spine. There are different grades of spondylolithesis depending on the degree of forward movement of the top vertebrae. If postural changes and muscle imbalances aren’t improved, spondylolithesis can progress to a point that causes stress fractures.
Symptoms can start as low back pain but often progresses to pain, burning, and/or tingling in the leg. As the vertebrae progresses forward it may cause irritation and stress to the nerve resulting in SCIATICA symptoms. Physical therapy will focus on core stabilization, improving postural awareness in standing and walking, and hip strength.
Muscle Strain/Spasm
Muscle strain is one of the most common diagnoses seen in physical therapy for people with low back pain. When someone “throws their back out”, it is often because one of the big, strong muscles in the back has been overused and has gone into spasm. For many people, this can be an episodic pattern where the muscle spasms resolve on their own if given time to relax, but will spasm again in the future. Often times, the pain only lasts 24-72 hours but the first spasm predisposes someone to a future episode of pain. The reason for this episodic pattern is the underlying problem of poor stability from the core muscles.
Physical therapy will work on initially relaxing the muscle and reducing the spasm but quickly to progress to core stabilization. Working on the transverse abdominus muscle, a deep muscle that wraps from the front and attaches to the lumbar spine, will provide the necessary stability required by the low back. Episodic low back pain can occur for years and years before people seek physical therapy. Physical therapists are experts at reducing low back pain. By seeking physical therapy services you don’t have to accept low back pain as normal.
Sources
- Lau P, Chow D, Pope M. Early physiotherapy intervention in an Accident and Emergency Department reduces pain and improves satisfaction for patients with acute low back pain: a randomised trial. Australian Journal Of Physiotherapy. 2008;54(4):243-249.
- Borenstein D, O’Mara J, Wiesel S, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. The Journal Of Bone And Joint Surgery. September 2001;83-A(9):1306-1311.
- Ash LM, et al. Effects of Diagnostic Information, Per Se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain. Am J Neuroradiol. 2008 Jun;29(6):1098-103. doi: 10.3174/ajnr.A0999.
- Dunsford A, Kumar S, Clarke S. Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain. J Multidiscip Healthc. 2011; 4: 393-402. doi: 10.2147/JMDH.S24733
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American journal of neuroradiology. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.