PHYSIOPATHOLOGY AND REHABILITATION OF CERVICAL AND LOW BACK PAIN

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PHYSIOPATHOLOGY AND REHABILITATION OF CERVICAL
AND LOW BACK PAIN

• Dr. Pembe Hare Yigitoglu
• Near East University Faculty of Medicine
• Department of Physical Medicine and
  Rehabilitation
• 2012

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• Low back and neck pain are second only to the
  common cold as the most common affliction of
  mankind.
• Low back and neck pain are symptoms, not
  diseases, and they have many causes.

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• The symptom of axial skeleton pain is associated
  with a wide variety of mechanical and systemic
  disorders.
• Mechanical disorders cause the vast majority of
  low back or neck pain episodes.
• Most of these mechanical disorders resolve over a
  short period of time.

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Disorders affecting the low back and neck

• Mechanical
• Rheumatologic
• Endocrinologic/Metabolic
• Neurologic/Psychiatric
• Infectious
• Neoplastic/Infiltrative
• Hematologic
• Referred pain

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LOW BACK PAIN

• Low back pain has become a leading cause of
  disability and loss of productivity.
• It is extremely common.

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• About 40 of people say that they have had low
  back pain within the past 6 months.
• Studies have shown a lifetime prevalence as high
  as 84.
• Most patients have short attacks of pain that are
  mild or moderate and do not limit activities.

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Red flags (Risk Factors for Secondary LBP Due to
Important Pathologies)

• Back pain in children lt18 y with considerable
  pain or onset gt55 y
• History of violent trauma
• Mild trauma in an aged patient
• Constant progressive pain at night
• History of cancer
• Systemic steroids
• Drug abuse, human immunodeficiency virus infection

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Red flags (Risk Factors for Secondary LBP Due to
Important Pathologies)

• Weight loss
• Systemic illness
• Persisting severe restriction of motion
• Intense pain with minimal motion
• Structural deformity
• Difficulty with micturition
• Loss of anal sphincter tone or fecal
  incontinence saddle anesthesia
• Progressive motor weakness or gait disturbance

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Red flags (Risk Factors for Secondary LBP Due to
Important Pathologies)

• Inflammatory disorders (ankylosing spondylitis)
  suspected
• Gradual onset lt40 y
• Marked morning stiffness
• Persisting limitation of motion
• Peripheral joint involvement
• Iritis, skin rushes, colitis, urethral discharge
• Family history

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Mechanical disorders of the lumbosacral spine

• Back strain
• Lumbar disc herniation
• Lumbosacral spondylosis
• Lumbar spinal stenosis
• Spondylolisthesis
• Scoliosis

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Back strain

• Back strain is preceded by some traumatic event
  that can range from coughing to lifting a heavy
  object.
• Muscle strain is acute back pain that radiates up
  the ipsilateral paraspinous muscles, across the
  lumbar area, and sometimes caudally to the
  buttocks without radiation to the thigh.
• No neurologic abnormalities are present.

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Lumbar disc herniation

• The disc's structure is composed of outer annulus
  fibrosus and inner nucleus pulposus.
• The nucleus pulposus have regions with highly
  hydrophilic.
• The hydrated nucleus within the annulus acts as a
  shock absorber to cushion the spinal column from
  forces that are applied to the musculoskeletal
  system.
• Nuclear material is normally contained within the
  annulus, but it may cause bulging of the annulus
  or may herniate through the annulus into the
  spinal canal.

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• Neurologic examination may reveal sensory
  deficit, asymmetry of reflexes, or motor weakness
  corresponding to the damaged spinal nerve root.
• More than 95 of lumbar disk herniations occur at
  the L4L5 and L5S1 levels

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Lumbosacral spondylosis

• Osteoarthritis of the lumbosacral spine may cause
  localized low back pain.
• Oblique views of the lumbar spine demonstrate
  facet joint narrowing, periarticular sclerosis
  and osteophytes.

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Lumbar spinal stenosis

• The narrowing of the spinal canal that occurs in
  stenosis results from the degenerative changes.
• Neurologic claudication is the most common
  presenting symptom of lumbar stenosis.
• It is classically described as bilateral leg pain
  initiated by walking, prolonged standing, and
  walking downhill (relative lumbar extension).
• It is typically relieved by sitting or bending
  forward.

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Spondylolisthesis

• Lumbar spondylolisthesis is the anterior
  displacement of a vertebral body in relation to
  the underlying vertebra.
• Spondylolisthesis usually is secondary to
  degeneration of intervertebral discs.
• The most common level affected in a degenerative
  slip is the L4L5 level.

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Scoliosis

• Scoliosis is a lateral curvature of the spine in
  excess of 10.
• Most commonly begins to develop in adolescent
  girls.

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Cancer and Low Back Pain

• The spine is the most common site for bony
  metastases.
• Vertebral body metastases are found in more than
  one third of cancer patients.
• The most common cancers that involve the spine
  are
• lung,
• breast,
• prostate,
• renal cell.

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Spinal Infections

• Spinal infections include
• osteomyelitis,
• diskitis,
• pyogenic facet arthropathy,
• epidural infections.

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• It is important to diagnose and treat spinal
  infections quickly
• to prevent increased morbidity and mortality,
• to prevent complications such as epidural
  abscesses that can cause paralysis.

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Spondyloarthropathies

• Spondyloarthropathies are a group of diseases
  associated with the HLA-B27 allele.
• They include
• Ankylosing spondylitis,
• Reactive arthritis,
• Psoriatic arthritis,
• Enteropathic arthritis,
• Undifferentiated spondyloarthropathy.

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Ankylosing Spondylitis

• Ankylosing spondylitis is the prototype for the
  spondyloarthropathies.
• It generally first presents with morning
  stiffness and a dull ache in the low back or
  buttocks.

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Rehabilitation

• Patient Education
• Education should include providing as much of an
  explanation as patients need in terms they can
  understand.
• Back Schools
• The term back school is generally used for group
  classes that provide education about back pain.
• They include information about the anatomy and
  function of the spine, common sources of low back
  pain, proper lifting technique and ergonomic
  training, and sometimes advice about exercise and
  remaining active.

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• Exercise
• Exercise results in positive outcomes in the
  treatment of chronic low back pain.
• The most effective exercise for low back pain
  includes an individualized regimen learned and
  performed under supervision that includes
  stretching and strengthening.
• Patients who have not tolerated land-based
  exercises are often able to participate in pool
  exercises.

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Medication

• Nonsteroidal Antiinflammatory Drugs
• Muscle Relaxants
• Antidepressants (Tricyclic antidepressants)
• Topical Treatments (Lidocaine patches,
  antiinflammatory creams)

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• Injections and Needle Therapy for Mechanical Low
  Back Pain
• Myofascial Pain and Trigger Point Injections
• Acupuncture
• Steroid Injections and Other Spinal Procedures

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• Lumbar Supports
• Superficial and deep heat
• Transcutaneous Electrical Nerve Stimulation
• The stimulation of large afferent fibers inhibits
  small nociceptive fibers, causing the patient to
  feel less pain.

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• Lumbar epidural steroid injections have become a
  common adjuvant for the treatment of lumbosacral
  radiculopathy.
• Surgical management of lumbosacral radiculopathy
  is best reserved for those patients who have
• significant persistent symptoms despite 6 to 8
  weeks of maximized conservative management,
• neurologic progression or
• cauda equina syndrome.

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CERVICAL PAIN

• The prevalence of neck pain with or without upper
  limb pain ranges from 9 to 18 of the general
  population.
• One of three individuals can recall at least one
  incidence of neck pain in their lifetime.

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Mechanical disorders of the cervical spine

• Neck strain
• Cervical disc herniation
• Cervical spondylosis
• Myelopathy
• Whiplash

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Neck strain

• Neck strain is rarely associated with a specific
  trauma.
• It is typically triggered by sleeping in an
  awkward position, turning the head rapidly.
• Physical examination reveals local tenderness in
  the paracervical muscles, with decreased range of
  motion and loss of cervical lordosis.
• No abnormalities are found on neurologic
  examination.

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Cervical disc herniation

• Intervertebral disc herniation in the cervical
  spine causes radicular pain that radiates from
  the shoulder to the forearm to the hand.
• Neurologic examination may reveal
• sensory deficit,
• asymmetry of reflexes,
• motor weakness corresponding to the damaged
  spinal nerve root.

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Cervical spondylosis

• Osteoarthritis of the cervical spine
• As the disc degenerates, the articular structures
  are brought closer together, the cervical spine
  becomes unstable.
• Increased instability results in osteophyte
  formation.
• Plain radiographs show the intervertebral
  narrowing and facet joint sclerosis.

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Myelopathy

• The most serious sequelae of cervical spondylosis
  is myelopathy.
• This disorder occurs as a consequence of spinal
  cord compression by
• osteophytes,
• ligamentum flavum or
• intervertebral disc.

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• Clinical symptoms include weakness and
  uncoordination in the hands.
• In the lower extremities, this disorder can cause
  
• gait disturbances,
• spasticity,
• leg weakness and
• spontaneous leg movements.

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• Sensory deficits include decreased dermatomal
  sensation and loss of proprioception.
• Hyperreflexia, clonus and positive Babinskis
  sign are present in the lower extremities.

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Whiplash

• Whiplash injuries are cervical hyperextension
  injuries of the neck.
• They are associated with motor vehicle accidents.
• Regardless of the direction of impact, whiplash
  is defined by the passive movement of the neck.

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• Muscular control to stabilize the cervical spine
  does not react quickly enough to prevent
  injurious forces from occurring across the
  cervical functional spinal units.

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• The anterior disk, anterior longitudinal
  ligament, posterior disk or annulus, and cervical
  zygapophyseal joints are all at risk for injury
  during a whiplash event.
• Injury also occurs to the cervical soft tissues,
  resulting in strain and sprain injuries.

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• The most commonly reported symptoms of whiplash
  injury include neck pain and headaches, followed
  by shoulder girdle pain, upper limb paresthesias,
  and weakness.
• Less common symptoms include dizziness, visual
  disturbances, and tinnitus.

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Treatment

• Patient education, activity modification, and
  relief of pain are the initial treatment steps.
• Nonsteroidal antiinflammatory drugs (NSAIDs) and
  acetaminophen (paracetamol) aid in controlling
  pain.

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• Adjunct medications are often used in conjunction
  with antiinflammatory medications. These are
• muscle relaxants,
• tricyclic antidepressants,
• antiepileptics.

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• Physical modalities superficial and deep heat,
  electrical stimulation can be used in the
  treatment program.
• Cervical traction applies a distractive force
  across the cervical intervertebral disk space.

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• Transcutaneous electrical nerve stimulation
  (TENS) can also be effective in modulating
  musculoskeletal pain.
• Cervical orthoses function to limit painful range
  of motion and facilitate patient comfort during
  the acute injury phase.
• A soft cervical collar can be prescribed to
  reduce further neck strain.

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• Surgery
• Indications for surgical treatment include
• intractable pain,
• severe myotomal deficit (progressive or stable),
• progression to myelopathy.

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REFERENCES

• Physical Medicine Rehabilitation
• DeLisas Physical Medicine Rehabilitation
• Harrisons Rheumatology
• Primer on the Rheumatic Diseases