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Referred and Interactive Low Back Pain
Low back pain can cause and can be caused through the interaction of multiple sites of dysfunction.
"the last straw to break the camels back" may be the cause of 'overuse, abuse, misuse and disuse'
The physiotherapist needs to apply clinical reasoning to ascertain the "cause of the cause" so that treatment is meaningful and time effect.
This example demonstrates the frequent referral of 'somatic pain' into the limbs.
Central neurophysiological mechanisms suggest a role for the physiotherapist in identifying the source of symptoms.
Additionally, the physiotherapist is required to make realistic prognosis based on the 'stage, severity, stability, and irritability' of the dysfunction'
Connell AT (2008) Concepts
for assessment and treatment of anterior knee pain related
to altered spinal and pelvic biomechnics: a case report.
Manual Therapy, 13, 560-563
This author used 3 sessions
of treatment to the T10/11, T11/12, T12/L1 and L5/S1 to
improve the ROM and ability to squat in a patient with
anterior knee pain.
Grindstaff TL et al (2009) Effects of lumbopelvic
joint manipulation on quadriceps activation and strength
in healthy individuals. Manual Therapy, 14, 415-420.
These investigators
found a significant increase in the ability to produce
quadriceps force (+3%) and activation (+5%) immediatley
following lumbopelvic joint manipulation
Green A and Perry (2008)
An investigation into the effects of a unilaterally
applied lumbar mobilisation technique on peripheral
sympathetic nervous system activity in the lower limbs.
Manual Therapy, 13, 492-499.
These investigators examined
45 healthy naive males and performed a unilateral
Posteroanterior technique to the zygopophyseal joint
of L4/5 and recorded skin conductance in the lower
limb using a randomized control trial. They found
mobilsations at 2Hz resulted in side-specific peripheral
SNS changes in the lower limbs. In their review
they suggested that it is the oscillatory component
of the mobilisation which has the greatest effect
on the SNS (Gebber et al 1999, Kenny et al 1991,
McGuiness et al 1997). The effect reported was 13.5%
(+/- 20.25). Proposed mechanisms were direct stimulation
of the SNS ganglion, soft tissue joint receptor
reflexes, myogenic reflexes and descending modulatory
responses.
Bialosky JE et al (2009) The mechanisms
of manual therapy in the treatment of musculoskeletal
pain: a comprehensive model. Manual Therapy, 14, 531-538.
Their review concluded that the
result of a mechanical input from joint mobilisations
produced a cascade of peripheral and central nervous
system responses which provide an explanation for
immediated and lasting clinical outcome.
van Vliet PM & Heneghan (2006)
Motor control and the management of musculoskeletal
dysfunction. Manual Therapy, 11, 208-213.
Feedforward mechanisms, an essential
element to motor control, are altered in neurologically
intact patients with chronic neck and low back pain
and be the result of cortical neuroplasticity.
Wallwork TL et al (2009) The effect
of chronic low back pain on size and contraction of
the lumbar multifidus muscle. Manual Therapy, 14,
496-500.
Results showed a significantly
smaller cross sectional area of the multifidus muscle
for the subjects with CLBP as well as reduced percent
thickness contraction.
Green A & Dolan KJ (2006). Lumbar
spine reposition sense: the effect of a 'slouched'
posture.
Following 300secs of slouch the
lumbar spine demonstrated a reduced ability to reposition
sense. An increase in reposition error by more than
2.35degrees and less than 5.48degrees was found.
O'Sullivan et al (2006). The relationship
between posture and back endurance in industrial workers
with flexion-related low back pain.
LBP subjects had significantly
reduced back muscle endurance. LBP subjects sat
with less hip flexion suggesting increased posterior
pelvic tilt in sitting. LBP subjects postured their
spines significantly closer to their end of range
lumbar flexion in 'usual sitting' than healthy controls.
Hodges P & Gandevia SC (2000)
Activation of the human diaphragm during repetitive
postural task. Journal of Physiology, 522.1, 165-175
They concluded that the activity
of the phrenic motoneurones is organised such that
it contributes to both posture and respiration during
a task which repetitively challenges trunk posture.
Cowan et al (2004) delayed onset of
transverse abdominus in long-standing groin pain.
Med Sc Sp Ex.
They found that the onset of
transverse abdominus was delayed in individuals
with long standing groin pain.
Abt JP et al (2007) Relationship between
cycling mechanics and core stability. J strength and
Conditioning Research, 21(4), 1300-1304
Core fatigue resulted in altered
cylcing mechnics (frontal and saggital plane knee
motion and frontal plane ankle motion) which may
increase the risk of injury as the knee joint is
exposed to greater stress. von Banchet GS et al
(2009).
Gisela Segond von Banchet,
Michael K. Boettger, Nadja Fischer, Mieczyslaw Gajda,
Rolf Bräuer, Hans-Georg Schaible (2009) Experimental
arthritis causes tumor necrosis factor-?-dependent infiltration
of macrophages into rat dorsal root ganglia which correlates
with pain-related behavior. Pain, 145, 151-159.
After peripheral nerve damage
macrophages infiltrate the dorsal root ganglia
(DRG) in which cell bodies of lesioned neurons
are located. However, infiltration of macrophages
into the DRGs was also reported in complete
Freund’s adjuvant (CFA)-induced inflammation
raising the question whether CFA inflammation
induces nerve cell damage or whether peripheral
inflammation may also trigger macrophage
infiltration into DRGs. Related questions
are, first, which signals trigger macrophage
infiltration into DRGs and, second, is macrophage
infiltration correlated with pain-related
behavior. Using the rat model of unilateral
antigen-induced arthritis (AIA) in the knee
we found a massive infiltration of ED1+
macrophages into the ipsi- and contralateral
lumbar DRGs but not into thoracic DRGs.
At no time point of AIA DRG neurons showed
expression of activating transcription factor-3
(ATF3) indicating that macrophage infiltration
is not explainable by nerve cell lesions
in this model. During AIA, lumbar but not
thoracic DRGs exhibited a bilateral de novo
expression of vascular cell adhesion molecule-1
(VCAM-1) which is known to be involved in
macrophage infiltration. Tumor necrosis
factor-? (TNF-?) neutralization with etanercept
or infliximab treatment after induction
of AIA significantly reduced both macrophage
infiltration and VCAM-1 expression. It also
decreased mechanical hyperalgesia at the
inflamed joint although the joint inflammation
itself was barely attenuated, and it reduced
mechanical hyperalgesia at the non-inflamed
contralateral knee joint. Thus, bilateral
segment-specific infiltration of macrophages
into DRGs is part of an unilateral inflammatory
process in peripheral tissue and it may
be involved in the generation of hyperalgesia
in particular on the non-inflamed side.
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liability, negligence, or from any use of any methods, products, instruction,
or ideas contained in the material in this and it's related websites.
Because of rapid advances in the medical sciences, the author recommends
that there should be independent verification of diagnoses and exercise
prescription. The information provided on Back in Business Physiotherapy
is designed to support, not replace, the relationship that exists between
a patient/site visitor and their treating health professional.
Copyright Martin Krause 1999 - material is presented as a free educational
resource however all intellectual property rights should be acknowledged
and respected
