Lumbar spine 1 and 2

Terminology - Spondylolysis

"Spondylolysis is defined as a bony defect (important) in the pars interarticularis of the vertebral arch. It presents a weakness or stress fracture in one of the bony bridges that connects the upper with the lower facet joints." - The spotty dog with the head decapitated shows the fracture

Fardon et al 2013 RVW Lumbar disc nomenclature (vers2) TheSpineJournal

'Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulus beyond the disc space, fissuring (ie, annular fissures), mucinous degeneration of the annulus, intradiscal gas [28], osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the end plates'

Terminology - Spondylolisthesis

'Spondylolisthesis is the anterior translation of one lumbar vertebra relative to the next caudal segment as a result of an abnormality in the pars interarticularis. When symptomatic, this causes a variable clinical syndrome of back and/or lower extremity pain, and may include varying degrees of neurologic deficits at or below the level of the injury.' Most common L5/S1 followed by L4/L5 Meyerding classification for spondylolisthesis : Grade 1 Less than 25% slippage (mostly degenerative) Grade 2 25-50% slippage Grade 3 50-75% slippage Grade 4 100% slippage Aka Spondyloptosis (this usually happens in vehicle accidents, they become paralysed, this is traumatic) - Degenerative spondylolisthesis (gradual onset) - Traumatic spondylolisthesis (sudden onset)

Spinal Stenosis Subjective, Objective and Treatment

(signs and symptoms, not all symptoms will be present) : - Patient profile - Usually elderly patient - Location - Pain in lower back/ buttock, Numbness in the lower limb (this is caused by the pseudoclaudication) - Complaint of pain in the lower limb with prolong walking and standing, similar to pseudoclaudication (leg starts to ache) Aggs : - Pain with extension of lumbar spine - Increase symptoms walking down slope (when we walk down slope, we extend our back abit, walking upslope is not that bad) Eases : - relief with flexion (sitting down relieves symptoms) Treatment/Rx : - Similar to the treatment options of facet joint and disc degeneration. - Just get them to move and open up their spine

SIJ as a source of symptoms

- 10-25% of back pain may be caused by SIJ - Can be difficult to differentiate from back pain as similar presentation - When 2 out of 4 of provocation tests it indicates SIJ dysfunction (60%) (Laslettet al 2005)

Metastatic bone disease

- 30% with a primary diagnosis of cancer will go on to develop metastases - Prevalence will increase as adjuvant therapy improves survival rates - 50% will present with Mets 10 years or more later - Metastatic spinal cord compression (MSCC) is a complication of MBD and is an emergency condition. (patients lose complete ability to walk, they may develop CES symptoms. if they are not dealt with, they will not recover) Risk of spinal metastases (Coleman & Holen2014) : Top 3: 1. Breast 2. Prostate 3. Lung 4. Thyroid 5. Kidney 6. Oesophagus 7. GI - If patient comes and tell me they have pancreatic or ovarian cancer, im less worried that they will metastasise to the bone. We will still be aware of that but the reaction to it wont be as strong. - Higher risk of it developing in the thoracic spine, reason being there is very slow, but rich oxygenated blood flow in the thoracic spine Early detection (very critical) : - Patients who have a single MBD do well - Those patients who have bone only do better than those who have bone and visceral (if we got someone with metastases in several levels of their vertebrae, its in their shoulder, pancreas or liver, and it is widespread, they dont do so well) - The greater the burden of the disease the worse the prognosis Considerations : Symptom Pain - Is this an unfamiliar pain? (patient might say they had back pain, but nothing like this) - Is it progressively worsening? - Night pain - Hypercalcemia - Other symptoms Band like pain, odd sensations in their legs, mobility reducing Objective : - Upper and lower motor neuron examination (Babinski and clonus coordination)

1. Ankylosing Spondylitis (AS) - Diagnosis, and treatment

- Autoimmune disorder and falls under the 'rheumatology' tag and is a form of arthritis (specific to the spine) - Chronic inflammation of spinal joints and soft tissues (when the inflammation comes on, they feel alot of pain) - Can lead to fusion of vertebrae in some cases - Has good and bad days For patients with AS, if we ask them to turn around, they will look like glenleejj Risk factors that predispose a person to AS include: - Testing positive for the HLA-B27 marker - A family history of AS - Frequent gastrointestinal infections Unlike other forms of arthritis and rheumatic diseases, general onset of AS commonly occurs in younger people, between the ages of 17 and 45. However, it can also affect children and those who are much older . - Will often require blood tests, X-ray and detailed history to confirm diagnosis - IMPORTANT TO NOTE THAT you can have mechanical and NSLBP issues in this population also MANAGEMENT OF AS : - Exercises, maintain as much range and strength as possible. - Patient education, active involvement and motivation of individuals with AS played an important role in the overall treatment outcomes. (Sharan D et al 2017) - Need to stretch, go for a swim etc. where we move our body and spine. - This is to reduce the rate of AS coming

Fracture

- Causes of spinal fracture Differential diagnosis, reasons increasing chance of having fracture : 1. osteoporosis 2. malignancy 3. myleoma

Ligament restriction to motion

- During extension, the anterior longitudinal ligament located anteriorly becomes taut, limiting extension. - During flexion, all ligaments on the posterior side (supraspinous, interspinous, ligamentum flavum, and posterior longitudinal ligaments) become taut, limiting flexion. - During (right) lateral flexion, the intertransverse ligament on the opposite (left) side becomes taut, limiting this motion. (Note: In this position the opposite side [left] facet joint capsule would also become taut, limiting this motion

Intervertebral foramen (IVF)

- IVF is formed by 2 adjacent articulating vertebrae with their inferior and superior vertebral notch - Posterior margin formed by articular processes.(Superior and inferior) - Anterior border is formed by IV body and disc - The spinal nerve exit the vertebral canal through the intervertebral foramen. • For lumbar spine the existing spinal nerve correspond to the level of the vertebral above (e.g spinal nerve L1 exit between L1/L2 vertebral foramina - Nerve root comes out below the corresponding vertebrae. Except c1. eg, L4 comes out below L4 - The way the nerve exit, it may escape from disc compression which may still affect L5 travelling down.

Objective examination

- If CES is suspected a careful objective neurological examination should be carried out to evaluate and segmental neurological deficit - Sensation of the perineum to pin prick and light touch - Anal tone and anal "wink" reflex should be tested - Residual bladder volume using ultrasound - Full neurological examination - Saddle sensation - light touch and pin prick (poor sensitivity) - Digital Rectal examination - No evidence clinicians ability to perform DRE is better than chance. Test with lowest predictive value for CES was anal tone. Almost half of non-compression group had reduced anal tone (Angus et al, 2018) - So we will still send patient to A and E if he/she complains about symptoms that leads us to think that he has CES, regardless of whether a DRE is done or not - Residual bladder volume - A PVR of 200mls then the probability of having CES is 43% (p< 200 mls had a negative predictive value of 97%. (Venkatesan et al 2019)

Saco-iliac joint pathology

- It is generally accepted that about 13% (95% CI: 9-26%) of patients with persistent low back pain have the origin of pain confirmed as the SIJ - The relationship between perceived motion and positional abnormalities remains unclear There are two clinical perspectives to consider: 1. The SIJ as a load-transferring mechanical junction between the pelvis and the spine that may cause either the SIJ or other structures to produce painful stimuli (SIJ dysfunction) - Dysfunction example - Take not form and force closure (when we stand there is a wedge that holds the sacrum and pevlis, this is form closure. when we exert force, it is more stable, this is force closure) 2. The SIJ as a source of pain (SIJ pain) - Pain = more nociceptive

Visceral presentation

- Liver can cause pain in shoulder - eg. heart can give pain coming down on left arm - Be aware that visceral aspects can cause mechanical pain in our back - how we question to differentiate visceral from mechanical back pain? - eg. gallbladder, does the pain come on after they have eaten some food?

Spondyloarthritis (SpA) (umbrella term)

- Onset of back pain prior to age 45 - Early morning stiffness more than 60 minutes (key things is this, because this is not common in mechanical back pain) - Waking in the early hours of the morning - Rest worse than activity - May have extra-articular features - Peripheral arthropathy/synovitis (30%) - Enthesitis(40%) (is inflammation of the entheses, the sites where tendons or ligaments insert into the bone) - Dactylitis (7%) - Psoriasis (9%) - Iritis/Uveitis (20-26%) - Crohns/Ulcerative Colitis (4-10%)

Cauda Equina Syndrome - history, definition, symptoms and treatment

- Rare - 2%of all prolapse discs, 4 in 10000 back sufferers - Devastating consequences - Serious medico legal implications - Patients self report symptoms of bladder and bowel dysfunction that are NOT related to CES Definition : 'A patient presenting with acute back pain and/or leg pain with a suggestion of a disturbance of their bladder or bowel function and/or saddle sensory disturbance should be suspected of having a CES.' The most common cause is a prolapsed disc, but a tumour, fracture and spinal stenosis can also cause it Signs and symptoms : 1. Altered bladder function leading to painless urinary retention : - Bladder dysfunction is the other most commonly reported symptom and can range from increased urinary frequency, difficulty in micturition, change in urine stream, urinary incontinence and urinary retention. - Bernice - "it is important to note that patients who have CES will not know that they have soiled themselves, its not jus bladder/bowel dysfunction" - Also it would be a sudden onset 2. Loss of anal tone : - loss or reduced anal tone may be evident if a patient reports bowel dysfunction. Bowel dysfunction may include faecal incontinence, inability to control bowel motions and/or in-ability to feel when the bowel is full with consequent overflow. 3. Reduced perineal sensation : - Sensation loss in the perineum and saddle region is one of the most commonly reported symptoms. 4. Loss of sexual function : - Sexual dysfunction is not widely mentioned in the literature but is an important aspect of health and wellbeing that needs discussion with patients, despite the potential embarrassment for both patient and therapist. 5. Other signs may include : - Absence of Achilles tendon reflex on both sides - foot drop, calf muscle or other motor weakness - unilateral or bilateral sciatica - reduced lumbar lordosis and lumbar mobility

Laura Finucane lecture Definition of red flags

- Red Flags are clinical indicators of possible serious spinal pathology - They are physical manifestations of underlying significant medical pathology - Grieve's ''awareness, vigilance and suspicion rather than a set of rules.' - Cyriax 'something serious in the woodshed'

Outcome measures tool

- STarT back tool - EQ-5D - MSK-HQ

Thoracolumbar fascia (TLF)

- The TLF is a complex of several layers that separates the paraspinal muscles from the muscles of the posterior abdominal wall, quadratus lumborum (QL) and psoas major. - When the spine is placed in full flexion, the TLF increases in length from the neutral position by about 30% - Load in the extremities is transferred across the body partly through the TLF

Spinal disc 1

- The intervertebral discs make up approximately 20% to 25% of the total length of the vertebral column. - The function of the intervertebral disc is to act as a shock absorber distributing and absorbing some of the load applied to the spine, to hold the vertebrae together and allow movement between the bones. Distribution of weight of the body and Maintaining intervertebral space height. - With age, the percentage of spinal length attributable to the discs decreases as a result of disc degeneration and loss of hydrophilic action in the disc. A disc joint is composed of three parts: 1. Outer annulus fibrosus - consists of 15 to 25 concentric layer of rings of collagen fibers. The outer layer consists mainly of type I and II collagen to provide circumferential strength and flexibility 2. Inner nucleus pulposus, 3. Two vertebral endplates - Approximately 25% of the height of the spinal column. - Nucleus 70%-90% water (hydrated proteoglycan mixture of thin type II collagen, elastic fibrin and other proteins.) - With increasing age, the nucleus pulposus increasingly resembles the annulus fibrosus. The water-binding capacity of the disc decreases with age, and degenerative changes (spondylosis) begin to occur after the second decade of life. - Initially, the disc contains approximately 85% to 90% water, but the amount decreases to 65% with age. - In addition, the disc contains a high proportion of mucopolysaccharides, which cause the disc to act as an incompressible fluid. However, these mucopolysaccharides decrease with age and are replaced with collagen - The spinal disc joint bears approximately 80% of the weight of the body above it (the other 20% is borne through the facet joints - If we extend our back we put more pressure on the facet joints - If we flex our back we put more pressure on the discs

Innervation of the IVD

- The normal IVD is considered as an organ that is poorly innervated supplied only by sensory and sympathetic perivascular nerve fibers - Damaged IVD releases nociceptive molecules and growth factors that promote nerve ingrowth into the disc. - The whole entire disc becomes more sensitive to pain, any abnormal pressure will cause pain This is why some patients feel more pain than others.

Spinal disc 2 - nutrients

- The outer peripheral rings of the annulus fibrosus normally contain blood vessels. - Essential nutrients (glucose and oxygen) can reach the inner core by diffusion. - Similar nutrients can diffuse from the vertebral body through the end plate to the disc. - Fluctuations of pressure within the nucleus populsus moves fluid in and out of the disc. - if we stay in one position for a very long time, we don't allow for such nutrients and fluids to move in and out of the disc (by removing pressure off of the discs). that is why we tell patients to move around more.

MSCC (malignant spinal cord compression) - Definition & overview

...compression of the dural sac and its contents (spinal cord +/or cauda equina) by an extradural tumour mass. The minimum radiological evidence, is indentation of the theca at the level of clinical features'... (Loblaw and Laperriere, 1998) - Bone / soft tissue metastases expand into spinal canal → impairs blood flow → ischaemia - Irreversible neurological damage may result in paralysis (something we need to be aware of) - Early diagnosis and treatment is essential to prevent neurological damage, improve outcome and quality of life Warning Signs and Symptoms : Pain: - Presenting symptom in over 90% of patients - Neck or back pain, especially thoracic, localised spinal tenderness severe and progressive - Radicular, or tight band around chest / abdomen, often tingling, burning, shooting - Aggravated by movement, coughing, sneezing or straining and lying flat Weakness and sensory changes: - Muscle weakness - Loss of coordination, paralysis - Sensory loss (↓ sensation, light touch, numbness, P&N) Loss of bladder and bowel control (late signs) - Bladder signs range from hesitancy, retention to complete incontinence - Bowel signs range from constipation to complete incontinence 94% patients complain of back pain as their first symptom of MSCC Referred or BAND LIKE pain Escalating Pain: Poor response to treatment Different character or site than previous Funny or 'odd sensations' or 'heavy legs' Lying flat increases pain Agonising or severe back pain Gait disturbance: Unsteady, stairs difficult Sleep disturbance with night pain Established Motor/Sensory/Bladder/Bowel disturbances are LATE SIGNS = poor functional outcome and survival.

Spinal infection

0.01% of all serious pathology Incidence estimated to be 0.2-2.4 per100 000 Can be fatal DEPENDS ON LOCATION OF WORK, WHEN YOU WORK AND TYPE OF SERVICE Clinical Presentation : 1. The majority of SI are of insidious onset and commonly there is a prolonged period of time between onset and diagnosis which can create a complex clinical picture as patients can remain relatively healthy until symptoms manifest themselves in the later stages of the disease. (Nagashimaet al 2019) 2. Back pain is the most common presenting symptom which can progress to neurological symptoms (Neurological dysfunction, Limb weakness, Para/quadriplegia, Para/quadriparesis, Paralysis, Myelopath) and if not treated in a timely manner, lead to serious complications such as paralysis, instability of the spine and can ultimately be fatal. 3. (from textbook) Back pain (most common) may be the main symptom in most patients (Carragee 1997) Patients have severe, progressive back pain of a nonmechanical nature, leading to spinal rigidity; tension signs are common (Macnab and McCulloch 1990). Patients are often unwell, with raised temperature (later stages of the disease), and suffer from general malaise, night pain, night sweats and raised erythrocyte sedimentation rate (Wainwright 2000). However, fever is not always present, varying between 2 7% and 83%, depending on the type of infection Signs and symptoms : - Pain-vague - Insidious - Constant - Worse at night - Fever/sweats/malaise (30%) - Post op 1-2 weeks - Systemically unwell Morbidities (patients who have this have suppressed immunity, so we may need to think that there is something going on if they present with such symptoms) : - Diabetes (immunosuppression) - Cancer - CVD - Liver disease - Renal failure/CKD - HIV - PH TB Red flags associated with spinal Infection : Risk Factors : - Immunosuppression (diabetes) - Surgery and Invasive procedures (either back or abdominal surgery) - Older Age Mean of 57 (±7.97) years - Males 64% more often than females Clinical features (the classic triad) : 1. Fever (absent in 50% of pts) (so we can ask the question that they have a fever, but them saying no is not going to reassure me that they dont have a spinal infection) 2. Spinal pain 3. Neurological dysfunction

Spinal condition by diagnostic evaluation : 8 That we learn

1. Ankylosing Spondylitis (autoimmune disease) 2. Spondylolysis 3. Spondyolisthesis 4. Spinal Sternosis 5. Spondylosis 6. Traumatic fracture 7. Osteoporotics fracture 8. Scoliosis

Mechanical - Disc Herniation

1. Bulging 2. Protrusion (nucleus pulposus coming out) 3. Extrusion (nucleus pulposus coming out more) 4. Sequestration (everything is out)

Serious pathologies of the spine

1. Cauda Equina syndrome 2. Malignancy 3. Fracture 4. Spinal Infection 5. Spondyloarthropathies (briefly) 6. Viscera (briefly)

Subjective examination

1. Communication : - Telling the patient about saddle numbness (do you think the patient will know what saddle numbness is?) 2. Context : - Tell the patient that you are going to ask some important questions - The reason why you are asking such questions is because there are some nerves running down your spine that supplies your bladder and bowel function - And very rarely, sometimes that nerve can be compressed and it can affect your bladder and bowel function 3. Framing of question

Differential diagnosis' of the Lx

1. Non mechanical (pain cannot be reduced, or cannot be increased) (1%) - Inflammation, Infection and cancer Neoplasia (cancer, most common one which have no clear signs, but we need to pick it up. Ie older patient comes to us and say they have pain at night when they want to sleep, the pain just comes and theres nothing she can do to relieve it, it is an excruciating pain, no trauma or anything, these are the patients that we need to take note of) : - Multiple myeloma - Metastatic carcinoma - Lymphoma and leukemia - Spinal cord tumors - Retroperitoneal tumors - Primary vertebral tumors Inflammatory arthritis : - Ankolysing spondylitis - Psoratic spondylitis - Reiter syndrome - Inflammatory bowel disease Infection : - Osteomyelitis - Septic discitis - Paraspinous abcess epidural abcess 2. Referred pain (eg. pain from visceral organs referred to the back) (2%) - Aortic aneurism - Diseases of the pelvic organs - (e.g. Chronic pelvic inflammatory disease) - Gastrointestinal disease (e.g. pancreatitis) - Renal disease (e.g. nephrolithiasis) 3. Mechanical (patient will say, that they will feel better when they lie down or sit down etc.) (27%) - Degeneration of facets or discs - Herniated disc - Internal disc disruption/discogenic pain - Spinal stenosis - Spondylosis - Spondylolysis - Spondylolisthesis - Traumatic fracture - Osteoporotic fracture - Congenital disease : Severe Kyphosis, Severe scoliosis, Transitional vertebrae 4. Non-specific or idiopathic (70%)

Abdominal muscles

1. Rectus abdominis O : Pubis I : Xiphoid process and costal cartilages of 5th, 6th and 7th ribs A : Trunk flexion, compression of abdomen N : 7th to 12th intercostal nerves 2. External oblique muscle O : Lower 8th ribs laterally I : Iliac crest and linea alba A : Bilaterally; trunk flexion; compression of abdomen. Unilaterally; Lateral bending; rotation to opposite side N : 8th to 12th intercostal, iliohypogastric and ilioinguinal nerves 3. Internal oblique muscle O : Inguinal ligament, iliac crest, thoracolumbar fascia I : 10th, 11th and 12th ribs, abdominal aponeurosis A : Bilaterally; trunk flexion; compression of abdomen. Unilaterally; Lateral bending; rotation to same side N : 8th to 12th intercostal, iliohypogastric and ilioinguinal nerves 4. Transverse abdominis muscle O : Inguinal ligament, iliac crest, thoracolumbar fascia and last 6 ribs I : Abdominal aponeurosis and linea alba A : Compression of abdomen N : 7th to 12th intercostal, iliohypogastric and ilioinguinal nerves

Mechanical - Disc Herniation - Bulging

2 things to note... 1. The posterior intervertebral disc as a source of nociceptive pain OR Somatic referred pain (if the bulging compresses a nerve) - Aka 'discogenic pain' - This will be non-dermatonal if referred 2. The relative loss of disc height that would occur - Potential for stenosis and spondylosis - Could then be dermatonal

O'Sullivan Lin Acute LBP Beyond drug therapies Pain-Ed

2. Messages that can heal in patients with nonspecific low back pain Promote a biopsychosocial approach to pain 'Back pain does not mean your back is damaged - it means it is sensitised' 'Your back can be sensitised by awkward movements and postures, muscle tension, inactivity, lack of sleep, stress, worry and low mood' 'Most back pain is linked to minor sprains that can be very painful' 'Sleeping well, exercise, a healthy diet and cutting down on your smoking will help your back as well' 'The brain acts as an amplifier - the more you worry and think about your pain the worse it gets' Promote resilience 'Your back is one of the strongest structures of the body' 'It's very rare to do permanent damage to your back' Encourage normal activity and movement 'Relaxed movement will help your back pain settle' 'Your back gets stronger with movement' 'Motion is lotion' 'Protecting your back and avoiding movement can make you worse' Address concerns about imaging results and pain 'Your scan changes are normal, like grey hair' 'The pain does not mean you are doing damage - your back is sensitive' 'Movements will be painful at first - like an ankle sprain - but they will get better as you get active' Encourage self-management 'Let's work out a plan to help you help yourself' 'Getting back to work as you're able, even part time at first, will help you recover

Laslett 2008 Diagnosis & treatment SIJ JoManManipTher (important article for SIJ)

5 tests, out of the 5, 3 must be positive to diagnose as SIJ

Kinematics of lumbar when bending forward

A = normal kinematic strategy (45 deg LS, 60 deg hip) B: limited hip flexion with excessive lumbar flexion C: limited lumbar flexion with excessive hip flexion

Lower limb and pelvic influence on lumbar

A, Normal-length hamstrings allow full flexion of the trunk and pelvis. B, Short hamstrings (if we sit for too long, we shorten the hamstrings because we bend our knee, and we shorten the hip flexor muscle) become stretched early limiting the amount of pelvis movement. Continued efforts to bend must all occur in the vertebral column through a reversal of the lumbar curve. What happens of the lumbar vertebal column is hypomobile?

Lumbopelvic rhythm : coming up from extension

A: Extension mainly from hip muscles (gluteus and hamstring) B: Shared extension lumbar extensor and hip C: Minimal muscle (cocontraction for stability of lumbar) If the lumbar spine is maintained straight when bending, most of the time it is because the compensation takes place in the upper segment (thoracic)

Sacralisation

Alternatively the fifth lumbar segment may be fused to the sacrum or ilium, resulting in a sacralization of that vertebra - the transverse process of L5 is so huge it touches the iliac bones - Most of the mobility is at the level of L4/L5 because L5 behaves like a sacrum.

Accessory movement in the spine

Antero-posterior Lateral Caudad and cephalad movement

Why is it so rare for the thoracic spine to have a discogenic problem?

Because the thoracic spine is held together by the ribs, its like a brace that holds everything together. - And the thoracic spine favours side bending and not so much flexion and extension

Spinal coupling

Can be due to: - Muscle action - Articular facet alignment - Preexisting posture - Stiffness of connective tissues - Geometry of physiological curve - THE COUPLING CAN BE INCONSISTENT IN THORACIC AND LUMBAR SPINE Basically, side bending comes with some rotation. In general, side bend to the left will result in rotation to the right and vice versa. - This is important because if our patient cannot rotate to the right, we can ask him to side bend to the left.

Keep or refer : 4 cases

Case 1 : - A 53-year-old woman with a fairly sedentary lifestyle complains of a sudden onset of deep, dull, aching pain in the center of the chest, aggravated by movement of the left arm. She cannot identify a precipitating incident or injury. - The pain is not radiating, and there is extreme tenderness to palpation lateral to the sternum. Coughing and sneezing increase the pain. - hang on to her first because the pain is not where the heart is. if the condition does not get better, then we refer Case 2 : - A 65-year-old man with a history of COPD and significant cigarette smoking (some CVD disease??) complains of bilateral buttocks cramping associated with stair climbing beginning about 6 months ago. Over the past 2 months, the cramping has become associated with walking as well. - When he stops walking and stands still, the cramping decreases and then disappears. No reflex or sensory changes are detected, and the pain is not affected by trunk flexion or extension. - signs of claudication, so it may be spinal stenosis, and we can treat that. Keep Case 3 : - A 60-year-old man who apparently is healthy, but inactive, complains of sudden onset of pain in the right knee with no known precipitating incident. - The joint is very tender, warm, and red. ROM is painful and decreased. No other previous or current joint complaints are reported. - For laura, this is non-mechanical, there is no incident, this patient has got something inflammatory going on in the knee. This patient had a septic joint, So refer. Case 4 : - A 17-year-old girl complains of knee pain following an injury that occurred when she was running in from the outfield during a softball game and stepped in a hole. She was unable to compete in the remainder of the game. The medial aspect of the knee is generally tender to palpation and slightly swollen. Pain is increased at the ends of ROM and with valgus stress. No complaints of knee locking

Adams & Roughley 2006 What is IVD degeneration and what causes it? Mechanical - Disc degeneration

Disc degeneration should be defined as an aberrant, cell-mediated response to progressive structural failure.' (means the cell behaves in an abnormal way because of structural failure) 'Definitions of a degenerated disc and early degenerative changes should also refer to structural failure, whereas degenerative disc disease should apply to a degenerated disc, which is also painful' - Disc degeneration doesnt mean they have pain, if they have pain means its called degenerative disc disease. The degeneration probably irritated some of the nerve structure or caused added facet joint issues. 'Disc structural failure is irreversible, always progresses by physical and biologic mechanisms, and is closely associated with mechanical dysfunction and pain.' 'Genetic inheritance, age, inadequate metabolite transport, and loading history can weaken discs to such an extent that structural failure occurs during the activities of daily living'

One vertebrae - anatomy

Inferior vertebral notch of the top vertebra join with the superior vertebral notch of the bottom vertebrae to form the vertebral foramen where the spinal cord goes through.

Physiological movement in the spine

Left is side flexion middle is rotation Right is flexion and extension If we want to feel for the spinous process in our patients, we should ask them to flex abit more or posteriorly tilt their pelvis for the lumbar spine

Lumbarisation

Lumbarization of S1 is when the S1 did not fuse with the sacrum, and it results in a sixth "lumbar" vertebra - Big gap at the bottom and a spinous process sticking out. - Greater mobility in the lumbar spine, at the L5/S1 level (because S1 can move)

Mechanical - Disc Herniation -Sequestration

Material in the disc comes out and is detached.

Degenerative pathologies : Mechanical - Facet pain/degeneration Hx, Objective assessment and Rx

Most commonly, as a result of repetitive stress and/or cumulative lowlevel trauma to the facet joints (eg . extend back, to do painting or construction. the facet joints get worn out ) - This leads to inflammation, which can cause the facet joint to fill with fluid and swell - in turn results in stretching of the joint capsule and subsequent pain generation - Inflammatory chemicals around the facet joint can also generate pain - In some cases the swelling can cause foraminal stenosis which can result in radicular pain or symptoms Eventually the joint surfaces can become irregular and roughened causing stiffness and decreased quality of movement In rare cases, facet joint pain can result from a specific insidious trauma Subjective Ax : (IMPORTANT) Safety first - special questions, clear red flags and thorough Hx - Patient profile - ? Extension based occupation - Onset - often gradual with acute exacerbations (degenerative in nature) - Location - Pain localized either unilateral or bilaterally over the facet area's (if their work requires them to extend their back and twist to one side, then maybe its unilateral. If they always flex or extend their back, then it may be bilateral) - Patient may also have non dermatonal referred pain from facets known as somatic referred pain rather than radicular - make note of the difference (Somatic referred pain is dull, aching and gnawing, and is sometimes described as an expanding pressure. It expands into wide areas that can be difficult to localize) - Also note the similarity of GTPS/gluteal/SIJ pathology Pattern - often very mechanical Aggs : - Often complain on extension based pains (closing of facets) and difficulty with rotation - Standing, walking, laying flat with legs straight, getting up from chair Eases : - Sitting = eases (usually) Objective assessment : - May present with adaptive scoliosis and in a relatively stooped posture - May have increased anterior tilt to pelvis (increases lumbar lordosis which increases the arching) - Extension and side flexion towards the affected side = pain (closing of the joint) - Pain upon muscular contractions into extension and ipsilateral side flexion (extend their leg back) - PAIVM (passive accessory intervertebral movement, sore but feels shiok) may reproduce pains - especially upon closing down/extension based techniques - PPIVMS (passive physiological intervertebral movement) likely to show stiffer movement patterns (we will realised that the spine moves in a block rather than as segments) - Possibility of neurological features in some cases Treatment/Rx : 1. Active : - Exercises into pain free ROM - Exercises into agg movement to regain/train normal movement (likely ext) (slowly ease into moving into this direction) - Behavior change either to help reduce agg activity or help prevent adaptive postures - ? OA classes 2. Passive : - PAIVMS for pain relief or to mobilize hypomobile segment - Maitland rotations for pain relief? - Release/stretch areas along the biomechanical chain if contributing factor - e.g. causing anterior tilt of pelvis 3. Others : - Education - Pain medications/NSAIDS - TENS - Epidurals and other invasive surgeries

Non-specific low back pain (70% of the patient with low back pain)

Muscle Sprain/Strain : - Yes muscle and ligament can be a cause of pain - however far less extreme than in the previous picture!! - This type of pain accounts for approx. 70% of our LBP that we see - Most are due to acute injuries - Most will fully recover within 4-6 weeks - Take note how we manage them is key! - Called non-specific as we are not able to identify a specific pathology/structure as a reason for the patients symptoms - they could still display a movement bias - and the danger of the 'structural approach' - This will link nicely with the pain neuromatrix in neurobiology and week 8 of this module NSLBP : - Acute - still in inflammatory stage - Should follow natural healing process (start to move) - Potential movement bias Chronic low back pain : - Direct and indirect costs, range from $84.1 billion to $624.8 billion in the US alone - Not only costs of care, however economic burden of time lost from work is also considered - NB this is only scratching the surface, you will go through more of CLBP in week 8 and when clinical reasoning

Laura finucane lecture Our challenge, Low back differential diagnosis and considerations

Musculoskeletal conditions are the second largest contributor to disability worldwide, with low back pain being the single leading cause of disability globally DDx : - Lumbar -muscle, joint, nerve, - Thoracic - Hip - Pelvis - SIJ - Visceral - Serious pathology Considerations : - What's causing their symptoms? - Consider differential diagnosis -is there another cause responsible for these symptoms? - Ideas (ask them what they think is causing their pain), Concerns, Expectations (ICE) - What's important to them? (might be important to lift their grandchild, or to drive) - Things change...re -evaluate every time - Clinical reasoning is KEY! Spectrum of presentations : - Mechanical cause (patients who really have done something to their back) (the easy ones) - Sensitisation - Most patients will fall in the middle of the spectrum

Mechanical - Disc Herniation - Protrusion

Part of the annular fibrosus and the material in the disc start to move to one part more.

Pelvic floor dysfunction as a differential diagnosis

Pelvic floor or CES? 1. Do you have pain in your pelvic region during any activity? May report hip, back, groin, or coccyx pain 2. Do you ever lose control of your bladder or bowels? If they say yes, Ask the next question...when? Why? How long? (the patient may then say they have a problem with their bladder when they cough and sneeze) 3. Do you have difficulty emptying your bowel or bladder? Ask the next question...when? Why? How long? 4. Do you ever have to wake up at night to urinate? Can be normal...is this normal for you? Has it changed from your normal? Age related? 5. How frequently do you have to urinate during the day? How frequent? Every 30 minutes is not normal... (we have to understand what is normal for them) 6. Do you have any pain with sexual activity?

Useful outcome measure to note for NSLBP

Questionairre : Oswestry Low back pain disability questionairre The Keele STarT back screening tool

Terminology : radicular pain vs radiculopathy

RADICULAR PAIN : - Pain arising from irritation (not necessarily compression) of the nerve root. Pain will be dermatonal - Disc herniation and associated inflammation is the most common cause of this type of pain - Take not, traditionally referred to as 'sciatica' - Take note NO neurological features or compromise for radicaulr pain alone RADICULOPATHY : - A neurological state in which conduction is blocked along a nerve or at its route, often due to significant compression - When sensory fibres are affected this will result in dermatonal numbness (no pain) - When motor fibres are affected this will result in weakness and lack of reflexes occur - Can also present with radicular pain https://sci-hub.tw/10.1016/j.pain.2009.08.020

Non-mechanical and referred pains

Remember - In total account for approx. 3 % of low back lack pains, therefore rare but very important to pick up on the clues Subjective Ax clues : - how did the pain come along. how long did it take for the pain to come? - Special questions - ? Co-morbidities and PMH - DH - if Rx for infection - General wellness - Location of pain &/or symptoms? Also bilateral - Non mechanical nature to pain &/or symptoms : Night pains , Potentially also inflammatory nature of pains Objective Ax clues : - Non-mechanical (cannot reduce the pain, cant be reproduced pain is always there) - Atypical severity and irritability - ? Loss of curves of the spine (v flat back)

Osteoporosis

Risk increases with age - 30% of white women (age 50-70) are osteoporotic - By the age of 80, 70% are osteoporotic - Nearly all post-menopausal women over age 70 have sustained a vertebral compression fracture - Usually occur between T8 and L2 (higher up) risk factors (ask about the patient's diet) : - Nutritional deficiency - Malabsorption syndromes (e.g., Celiac Disease, IBD) (cannot absorb nutrients efficiently) - Endocrine abnormalities (e.g., hyperparathyroidism) - Medication (e.g., corticosteroids) (corticosteroids taken over a period of 6 months or more will affect the quality of our bones) - Alcohol - Smoking - Early menopause Osteoporosis sites : - Femur - Lumbar - Radius Distribution of fractures : - 46% lumbar - 19% hip - 16% wrist - 19% others Clinical presentations : - Commonly present with sudden onset of pain, mostly in the thoracolumbar region, following low impact trauma such as a slip or trip, or lifting something whilst in a flexed position. - Severe localized pain - Weight bearing activities and active movements are restricted and painful - On examination, an increased prominence of the spinous process at the affected level, and an increased kyphosis. - tender to percussion at the affected level (not always) FRAX risk assessment tool - just to see if the patient is at risk of a fracture - Send them on to a rheumatologist Management : 1. Drug treatment : Bisphosphonates : - Alendronate (Fosamax ®) - Risedronate(Actonel ®) - Ibandronate (Boniva ®) - Zolendronate(Aclasta®) 2. Calcium/Vitamin D Supplementation Combining : - Vitamin D and calcium supplementation has been shown to increase bone mineral density and reduce the risk of fracture - Essentially if the patient is exercising and eating properly, we can make a huge difference - If they have one fracture, our job is to make sure they dont have repeated fractures by exercise and education Vertebroplasty vs placebo : - No difference in short term for: 1. Pain 2. Disability 3. Quality of life - No difference at 1 year - No difference if fracture<6weeks or >6 weeks - Increased risk of fracture with vertebroplasty (20% v 14%) (Cochrane Review 2014)

Spondylolysis Subjective, Objective and Rx

Subjective : - Patient profile - Younger patient, higher in elite adolescent athletes (gymnasts, extension and arching of the back) - low back pain; either localized or diffuse. - Hyperextension or rotation exercises usually exacerbate the pain and rest partially relieves it - Hyperlordotic posture - Tight hamstrings are common. - Neurological symptoms are radicular pain, weakness, tingling, and numbness in the lower limbs - Weak core muscles Treatment : - Most recover with conservative management without surgery in early stage - Rest and reduction of extension to decompress facet joint. - Strengthen trunk muscles to improve lumbar control (minimize hyperlordotic posture) - Surgery if needed (spondylolisthesis due to spondylosis)

Non-specific low back pain Subjective, Objective and Rx

Subjective Ax : - Safety first - special questions, clear red flags and thorough Hx - Patient profile - ? Presenting with yellow flags, potentially inactive - Onset - often acute exacerbation/an acumulation of acute exacerbations with poor management if chronic - Location - Pain poorly localized in the lumbar area - Pattern - often stiffens with inactivity - eases with activity Aggs : - Can be varied ++, however their perceived capacity is often much lower than actual Eases : - Meds - Short term relief with 'passive Rx' Objective assessment : - Often (not always) deconditioned - AROM - global movement restrictions - ? Due to fear or pain - Take note can still show a movement bias - Can show movement impairments - e.g. bracing or most of movement coming from pelvis on hips rather than true Lx ROM - Quite often decreased strength on leg and lumbar movements - sometimes this is an issue of scared to try - PAIVM - my experience - often not that useful in diagnosis but patients usually go - 'ooo that feels nice' - PPIVMS - often poor segmental control What we say to patients can be very powerful! How would you explain NSLBP to a patient? - Your communication skills will be key in these patients to educate and get 'buy in' to active recovery Refer to the slides on abnormal movement. Can other structure be contributing to the LBP. - X-ray and MRI will not be able to capture the muscle action and movement during functional task. - X-ray and MRI will not show the psychological barrier the patient has to movement.

Mechanical - Disc Herniation Subjective, Objective, Rx

Subjective Ax : - Safety first - special questions, clear red flags and thorough Hx - Patient profile - Can be anyone, however manual labourers may be more prone (alot of bending forward, lifting, too much movement, too much twisting, the annulus fibrosus will start to break) - Onset - often acute exacerbations, however can be gradual cumulation - Location - acute pain localized in the lumbar area (Patient may also have either dermatonal (radicular) or non-dermatonal referred pain (somatic referred) depending upon the extent of the pathology) - Pattern - often worse with inactivity - eases with activity (to a limit) Aggs : - Coughing/sneezing - Often complain of flexion based pains and difficulty with loading/lifting - Sitting, driving, cycling, carrying shopping, labouring (all these puts pressure on the disc) Eases : - Laying down (especially with knees bent) - Reduces the pressure in the disc - ? Standing or walking around Objective assessment : - May present with adaptive scoliosis - Flexion = pain - Centralisation phenomenon = patient tells us initially the pain is localised to a spot In the lower back, then the pain travels down, then the pain travels down to the front of the leg. Then when they recover, the pain from the leg goes away, but the pain in the original spot always remains. (Recovering and having the pain go back to the leg is usually spinal stenosis) - Potential pain inhibited muscular contractions - all movements but especially flexion - PAIVM generally sensitive - ? Positive neurodynamics (slump test and straight leg raise will have positive result) - Possibility of neurological features in some cases if there is neural compromise Treatment/Rx : 1. Active : - Exercises into pain free ROM - Exercises into agg movement to regain/train normal movement (likely ext) - Exercises to improve loading capacity as S+I decreases - Behavior change - potentially retraining loading mechanics 2. Passive : - PAIVMS for pain relief or to mobilize stiff segment - Maitland rotations for pain relief - ? traction 3. Others : - Education - Pain medications/NSAIDS - TENS - Epidurals and other invasive surgeries - Take note these are now only recommended in a VERY small percentage of patients

Mechanical - Spondylolisthesis Subjective, Objective and Rx

Subjective Ax : - Safety first - special questions, clear red flags and thorough Hx - Patient profile - more common in females, age, activities level - Onset - can be gradual or sudden - Location - Pain at the Lx most likely with dermatonal referral corresponding to affected level - radicular pain and/or radiculopathy (this translation of the vertebrae can cause narrowing of the IVF and cause compression.) - Pattern - activity dependant Aggs : - Often complain of extension based pains - Standing, walking, loading Eases : - Sitting, flexing Objective assessment: - X-Ray/MRI - May present with either forward stooped posture (if irritable) or with excessive Lx lordosis (nb potential risk factor) - Visible step type deformity (Not all patients display this, may be palpable) - AROM - Extension = pain (Likely bracing from one specific area, or Potential improvement in movement if actively brace) - May have increased hip flexor tightness - ? Need to PAIVM as this is a hyper-mobile related pathology (dont push it in even more, can do rotation but dont do P-A mob) - Potential neurological signs upon testing Treatment/Rx : 1. Active : - Initially offload from agg activity - Exercises to increase lumbar stability, initially into flexion (back muscles must be strong to support their movement, anterior tight muscles must be stretched) (bridging, plank, bird dog etc.) - Progress stability to be able to tolerate extension movement patterns ' - Progress to be able to tolerate loading - Exercises to address neurological features if needed - Behavior change and adapting technique/sport/lifestyle if needed 2. Passive : - Release/stretch areas along the biomechanical chain e.g.... 3. Others - Education - Pain medications/NSAIDS - Surgery in a very small population

Saco-iliac joint pathology Subjective, Objective and Rx

Subjective Ax : - Safety first - special questions, clear red flags and thorough Hx - Patient profile - more common in females, runners or unilateral sports persons susceptible, pregnant or post pregnancy - Onset - often gradual with acute exacerbations - Location - Often diffuse pain in the buttock area (near SIJ) and can show referred leg symptoms, NB pain can also refer anteriorly - Pattern - Often gradual, often easily irritable Aggs : - Single leg stance activities - walking, stairs, raising leg (hip flexion) - Rolling over in bed - Potential difficulty with loading/lifting - ? Unilateral sports Eases : - Offloading from sporting activities - Braces and crutches in severe cases (most often in pregnancy) Objective assessment : - Potential LLD (leg length discrepancy) - Obs - My experience - often increased Lx lordosis and unilateral gluteal muscle wastage (muscle imbalance), may be swaying onto one side - Pain inhibited muscular contractions of the affected leg - ? IMPROVE WITH ACTIVE BRACING - 2 or more positive on Laslett battery of tests - Possibility of neurological features in some cases, including restricted Slump and SLR - Note reliability of motion palpation/stork test (Gillet Test) etc?! (NOT BEING USED ANYMORE) Treatment/Rx : 1. Active : - Exercises to maintain general ROM - Exercises to improve pelvic and glute stability - Single leg stance exercises (lunges, single leg stance hip control, we want the balance to come in) - Exercises for global kinetic chain - Behavior change - load monitoring in some cases 2. Passive : - Release/stretch areas along the biomechanical chain (Potentially hip mobilisations) - Theoretically PAIVM type movement for pain relief 3. Others : - Occasionally changing/reviewing footwear - Education - Pain medications/NSAIDS - TENS - Epidurals v rarely

Mechanical - Fractures Subjective, Objective, Treatment Rx

Subjective Ax ; - Safety first - special questions, clear red flags and thorough Hx - Patient profile - if degeneration related then likely over 60 and may have diagnosis of osteopenia or osteoporosis - Take note clue sometimes in DH - Ca supplements - Onset - acute onset, likely traumatic mechanism - Location - can be localized or diffuse (Depending upon size of # can have neurological symptoms) - Pattern - often constant/medication limited due to acute nature Aggs : - ? Ext based - Can be hypersensitive to touch Eases : - Meds and immobility Objective assessment : - Medical imaging to confirm - Most likely the clues are in the MOI/HOPC - Obs - potential for bruising/swelling - AROM - globally likely to be painful - Potential pain inhibited muscular contractions - all movements - Possibility of neurological features in some cases - PAIVM probably not appropriate in this acute stage Treatment/Rx : 1. Active : - Exercises into pain free ROM to prevent adaptive issues/maintain the mobility that they do have - Offload and adjust lifestyle short term only, then gradual build up of activity 2. Passive : - Occasionally given a brace 3. Others : - Education - Pain medications/NSAIDS - TENS - Surgery if unstable fracture

Mechanical - disc degeneration Ax, Objective assessment, Rx

Subjective/Ax : - Safety first - special questions, clear red flags and thorough Hx - Patient profile - The age does play a part in this kind of condition, for younger people because the fluid in the disc is higher, there is a higher chance of it protruding out. in older people, the fluid is lesser and therefore the chances of it coming out is lower because there is no fluid in the first place. - Onset - often gradual with acute exacerbations (if its sudden pain its usually ligament) - Location - Pain poorly localized in the lumbar area (generally very sore in the back), Patient may also have either dermatonal (radicular) or non-dermatonal referred pain (somatic referred pain/nociceptive) - Pattern - often stiffens with inactivity - eases with activity (to a limit), wake up in the morning or sit down too long the back becomes sore, after moving it becomes better, this is usually a discogenic condition Aggs : - Often complain of flexion based pains and difficulty with loading/lifting (opposite of facet joint pain where extension based pain) - Sitting, driving, cycling, carrying shopping, labouring, bending forward and hugging your legs Eases : - Laying down (especially with knees bent) -? standing Objective assessment : - May present with adaptive scoliosis (tilt to one side because of the pain) - AROM - Flexion = pain - Potential pain inhibited muscular contractions - all movements but especially flexion - PAIVM may reproduce pains - especially upon opening/flexion techniques - PPIVMS likely to show stiffer movement patterns (differentiating between facet joint and discogenic problems can be very tough, some look at age, older patient usually get facet joint issues while younger patients get discogenic problem) - Possibility of neurological features in some cases depending if there's stenosis/nerve root involvement (inflammation can also irritate the nerve, not necessarily just compression) Treatment/Rx (we want to open up the joint) : 1. Active : - Exercises into pain free ROM if S+I (? Opening up) - Exercises into agg movement to regain/train normal movement (likely ext) - Increase ability to tolerate load (some people dont have the strength to maintain the posture) - Behavior change may be necessary - Exercise classes? (gym classes, pilates to get their body to be more aware of their positioning/posture) 2. Passive : - PAIVMS - either for pain relief or to mobilize hypomobile segment(s) - Maitland rotations for pain relief and to improve ROM - ? traction (no clear evidence of traction on discogenic problem) 3. Others : - Education - Pain medications/NSAIDS - TENS - Epidurals and other invasive surgeries - ? Hydrotherapy as a management tool - especially if acute exacerbation - NB not ideal as long term solution as it does not encourage loading capacity

Terminology - Spondylosis (the most common term that we will see in the clinics)

The common name for the natural ageing (osteoarthritis) of the spine - it will often be as a result of a number of pathologies including facet and disc degeneration. It may also be found in conjunction with disc prolapse, bony spurs, stenosis and/or radicular symptoms. Can challenge clinical reasoning as both flex and ext movement patterns could be irritable What will happen to the IV foramen? The IV foramen will become more narrow. - irritation and nerve compression - then pain is radicular pain - numbness would be radiculopathy Important note: Most people over the age of 30 will show degenerative changes to the spine - however not all will be symptomatic?! - It is therefore very important to investigate and discover the drivers of your patients pain using a biopsychosocial approach. (we need to think about what the patient is going through, what kind of work they are doing, are they very stressed) - This is often why scans can be misleading in some cases...

Lumbar lordosis

The natural lordosis of the lumbar spine allows greater loading and minimize muscular effort required to maintain erect posture. - Slight anterior pelvic tilt is the ideal posture

Spinal stenosis

The word 'stenosis' in medical terms refers to an abnormal narrowing of a passage in the body. Lumabr Spinal stenosis is when there is narrowing of the spinal canal in the lumbar spine. Diagnosis is done through a scan (either MRI or Xray)

Facet joints in the spine - And in the lumbar spine

There are ten (five pairs) facet joints (also called apophyseal or zygoapophyseal joints) in the lumbar spine With a normal intact disc, the facet joints carry about 20% to 25% of the axial load, but this may reach 70% with degeneration of the disc. The facet joints also provide 40% of the torsional and shear strength. Injury, degeneration, or trauma to the motion segment (the facet joints and disc) may lead to : 1. spondylosis (degeneration of the intervertebral disc), 2. spondylolysis (a defect in the pars interarticularis or the arch of the vertebra), 3. spondylolisthesis (a forward displacement of one vertebra over another), 4. retrolisthesis (backward displacement of one vertebra on another) - The superior facets, or articular processes, face medially and backward and, in general, are concave; - the inferior facets face laterally and forward and are convex - In the lumbar spine, the transverse processes are virtually at the same level as the spinous processes. These posterior facet joints direct the movement that occurs in the lumbar spine. - Because of the shape of the facets, rotation in the lumbar spine is minimal and is accomplished only by a shearing force. Side flexion, extension, and flexion can occur in the lumbar spine, but the facet joints control the direction of movement. - Facet surfaces of most lumbar apophyseal joints are orientated vertically (L1 to L4) - The apophyseal joint of L5/S1 are oriented more in the frontal plane - Normally, the facet joints carry only a small amount of weight; however, with increased extension, they begin to have a greater weight-bearing function.

Mechanical - Disc Herniation -Extrusion

This is the herniated disc, where the material in the disc comes out

Mechanical - Fractures

Traumatic vs Osteoporotic Compression fracture can occur by bending forward or even sneezing (due to the sudden compression and loading)

Abnormal movement?

Why is the patient moving like that? 1. Is it because some structures are stiff? - Muscular (weak, cannot support movement, bend forward, cannot maintain posture) (or too strong, causing imbalances, when coming back up the patient will twist to one side) - Ligament - Joint changes (osteophytes, arthritic changes, scoliosis, deformity, fracture) 2. Can it be that the patient is unable to control the movement? - Poor movement/muscle control (no idea how to do the pelvic wave, muscles are there but they just dont know how to do it) - Neuromuscular condition (eg. stroke, brain injury, control of the muscles are gone) - Poor body awareness and coordination (aka clumsy) 3. Is there ongoing pain in the patient with movement? - Inflammation of the joint, muscle, ligament restricting movement 4. Are there any psychological barrier to the movement (very scared to do a certain movement because if they do it, either the pain gets worst or something pops out.)? - No pain, but patient is fearful of movement - Pain and patient is also fearful of movement If we can differentiate what is the issue contributing to the abnormal movement, even if its in the elbow or knee, we can manage it correctly and accurately. ie. manage their fear, their muscle weakness etc.

Contributors to low back pain and disability

deconditioned, poor loading : - Physically active does not mean physically fit - conditioning your body from a functional POV - if we were asked to run a marathon tmr, we cant do it - A manual labour worker would say that, because of their job, they are physically fit - Find out what they need to be able to do from a functional point of view to carry out their daily living Fear avoidance : - They believe that their bones are crumbling, that they are going to end up in a wheelchair - Their neighbour had a surgery on their back and they have never been the same All of these things will have an effect on pain If we can dampen down any of these aspects, then the pain will go down, so we have to reassure them.

Weight distribution in the intervertebral discs

if we take some fluid out of the nucleus pulposus, the discs become flatter, and the annulus fibrosus will stick out. Lying down supine is the best in relieving the pressure off the disc. Taking standing as 100%, lying down would reduce the pressure by 50%.

Orientation of the facet joints in the lumbar spine

when we are young, all our facet joints face forward. as we age, the facet joints start to change their orientation to allow for some movement and also for some stability.

Curvature of the spine

with Obese people, the weight carried at the belly will cause them to arch back slightly and that causes increases lumbar lordosis