- Back pain which as known as an ancient

LOW BACK PAIN curse,

is now known as the modern international
- Common problem epidemic.
- The kind of back pain that follows - 80% of the population is affected by this
heavy lifting or exercise too hard is symptom at some time in life.
often caused by muscle strain, but - Impairments of back and spine are ranked
sometimes back pain can be related as
to a disc that bulges or ruptures. If a the most frequent cause of limitation of
bulging or ruptured disc presses on activity
the sciatic nerve, pain may run from in people younger than 45 years of age. It
the buttock down one leg. This is was
called sciatica. believed that posture was responsible for
- Low back pain is a universal human most
experience—almost everyone has it cases.
at some point
- The lower back pain which starts PHYSIOLOGY
below the rib cage is called the Mechanical back pain:
lumbar region. Pain here can be This type of pain is often due to stress of
intense and is one of the top causes strain
of missed work. Fortunately, low to the back muscles, tendons, and
back pain often gets better on its ligaments
own. When it doesn’t, there an and is usually attributed to strenuous daily
effective treatment. activities, heavy lifting, or prolonged
standing
ETIOLOGY or sitting.
Degenerative/osteoarthritis: Intervertebral
Traumatic injury disk degeneration: occurs anteriorly at the
Lumbar sprain or strain disk
Postural strain level from repetitive microtrauma of
obesity primarily
poor health shearing forces
prior LBP Tears in the annulus are thought to be the
poor back endurance first
frequent moving or lifting >25 lbs anatomic sign of degenerative wear. When
manual jobs the
awkward posture annulus is weakened enough, typically
mental distress posterolaterally, the internal nucleus
sitting, standing or walking >2hrs per day pulposus
depression can herniate, however internal disk
disruption
EPIDEMIOLOGY can occur without herniation due to age and
repeated stresses acting on the spine that
causes the gelatinous nucleus to become 1. Radiography – Not very reliable as
more normal
fibrous over time findings are observed in 7 – 46%
2. Myelography – Inject dye into the spinal
Spondylosis canal and taking radiographs of the back. It
It is the degeneration of the intervertebral is
disc, an invasion procedure and no longer used
which is more evident in people in older today.
than 3. CT scan – Useful non-invasive but fails
45 years of age to
detect intraspinal lesions, arachnoiditis and
It represents a stress fracture of the pars scar from disc herniation.
interarticularis of the fifth lumbar vertebra 4. MRI – Helps to detect intraspinal lesions
Spinal stenosis but
Degenerative disk disease and narrowing of expensive and prohibited
the Investigations of Low Back Pain
intervertebral space 5. Discography – After identifying the disk
Spondylolisthesis correctly, through a needle, a radiopaque
It is bilateral spondylolysis of the lumbar dye
spine is injected into the space. This reproduces
that can lead to anterior slipping of the the pain experienced by the patient and is
vertebral body on its adjacent vertebra relieved by injecting xylocaine. This
confirms the diagnosis. It is a painful
PHARMACOLOGICAL procedure and introduce infection into the
Non-steroidal Anti-inflammatory Drugs disk. Hence, it is less practiced.
(NSAIDs) - it provide some improvement in
functionality and short-term relief in non- PT MANAGEMENT
radiculopathy-related CLBP
Myorelaxant drugs - are usually Acute Stage
prescribed, when low back pain is thought
to be of myofascial origin, and its Use of modalities, myofascial release, and
combination with acetaminophen and massage to
NSAIDs are frequently used in clinical decrease pain and swelling
practice. Kinesthetic training of neutral or functional
Antiepileptic drugs - Gabapentin and spinal posture
pregabalin are used as first- line therapy in nondestructive movements in the pain-free
the treatment of neuropathic pain, and are range
frequently prescribed in daily practice, as awareness and activation of deep
neuropathic mechanisms play a critical role segmental musculature
in the emergence of lumbosacral radicular basic functional training maneuvers
pain and neurogenic claudication.
Subacute Spinal Impairments: Controlled
DIAGNOSTIC TEST Motion Phase
signs and symptoms of the inflammatory relieve the symptoms by moving the fluid to
process are under reverse the
control and pain is no longer constant stasis
Poor neuromuscular control and
stabilization, poor postural Management Guidelines: Extension Bias
awareness and body mechanics, decreased
flexibility and Pts assume a flexed posture or a flexed
strength, and generalized deconditioning posture with
may be the lateral deviation of the trunk or neck
underlying impairments sustained or repetitive extension maneuvers
At this stage, use of modalities to modulate reduce or
pain is not relieve their symptoms
recommended. Emphasis is placed on Impairments: IV-disc lesion, fluid stasis, a
increasing patient flexion injury,
awareness of posture, strength, mobility, or muscle imbalances from a faulty flexed
and spinal control posture.
and their relationship to modulating pain.
Principles of Management
Chronic Spinal Impairments: Return to
Function Phase Effects of Postural Changes on IV Disc
Pressure
Impairments in strength, endurance, level of pressure:
neuromuscular control, least when lying supine
and skill are related to the functional goals increases by almost 50% while sitting with
of the individual hips and knees flexed
conditioning and spinal control during high- almost doubles if leaning forward while
intensity and sitting
repetitive activities are emphasized Sitting with a back rest inclination of 120°
and lumbar support 5 cm in
Extension bias-extension syndrome depth provides the lowest load to the disc
while sitting
symptoms are lessened in positions of
extension (lordosis). Principles of Management
Sustained flexed postures or repetitive
flexion motions - Effects of Bed Rest on the IV Disc
load the anterior disc region fluid When a person is lying down, compression
redistribution from the forces to the disc are
compressed areas and swelling and creep reduced
in the distended nucleus potentially can absorb more water
areas posterior or posterolateral IV disc to equalize pressures
lesions or injury to (imbibition)
the posterior longitudinal ligament. To avoid exacerbating symptoms, absolute
PT Treatment: repeated extension motions bed rest during the acute
and positions phase should be avoided
 7. Flexion in standing (hamstring stretching)
Principles of Management
Interventions to Manage a Disc Lesion in
Effects of Traction on the IV Disc Traction the Cervical Spine
may relieve symptoms
from a disc Herniated discs are most common between
Traction may relieve symptoms from a disc the C6 and C7
protrusion, although vertebrae
conflicting evidence as to whether traction in Acute Phase
general is beneficial Passive Axial Extension (Cervical
Retraction) Patient position
Indications, Precautions, and and procedure:
Contraindications
for Interventions: Extension Approach 10 to 20 minutes

Indications: Extension is used if pain and/or Flexion bias-flexion syndrome

neurological
symptoms centralize (decrease or move symptoms are lessened in positions of
more proximally) spinal
during repeated extension testing flexion and provoked in extension as in
maneuvers and cases
peripheralize (worsen) during flexion.1 when there is compromise of the facets, IV
CONTRAINDICATIONS: When there is an foramen, or spinal canal, as in bony spinal
acute disc lesion, any stenosis, spondylosis, and
form of exercise or activity that increases spondylolisthesis.
intradiscal
pressure, such as the Valsalva maneuver, Management Guidelines: Flexion Bias
active trunk flexion,
or trunk rotation, is contraindicated during Patients may present with a flexed posture
the protection and be unable to
phase of treatment. Any movement that extend because of increased neurological
peripheralizes the symptoms and
symptoms signals decreased mobility
patients may have a medical diagnosis of
Mckenzie method spondylosis or
spinal stenosis (central or lateral), an
1. Lying face down with UE on side extension load injury,
2. Lying face down in extension ( prone on or capsular impingement or swollen facet
elbow) joints, so
#1& 2 5-10 mins symptoms increase with extension
3.Extension in lying (prone on hands)
4. Extension in standing Indications and Contraindications for
5. Flexion in lying (knee to chest) Intervention: Flexion Approach
6. Flexion in sitting
Indications. Flexion is used if neurological a gentle bulging contraction of the multifidus
and/or pain muscle
symptoms are eased with flexion and
worsened with
extension positions or motions.
CONTRAINDICATIONS: Extension and
THR
extension with rotation Definition
positions, motions, and exercises are The hip region is located lateral and
anterior to the gluteal region, inferior to
contraindicated if
the iliac crest, and lateral to the obturator
neurological symptoms or pain worsen with foramen, with muscle tendons and soft
these motions tissues overlying the greater trochanter of
the femur. In adults, the three pelvic
William flexion exercise bones (ilium, ischium and pubis) have
fused into one hip bone, which forms the
1, Unilateral knee to chest superomedial/deep wall of the hip region.
2. Posterior pelvic tilt
Epidemiology
3. Bilateral knee to chest
4. Long sitting then reach the toes Female>Male
5. Iliotibial band stretch In 2003, 220,000 associated with THA,
6. stand to squat or stand to sit 36,000 revisions in the United States
1.4 million women and 1.1 million men are
living with THA in United States
Nonweight-bearing bias-traction
Caucasians had the highest annual age-
syndrome standardized rates of THA
symptoms are lessened when in: Japanese, Hispanics, Chinese and
Nonweight-bearing positions, such as when Filipino had lower rates compared to
lying down or in Caucasiansof the spine in the coronal
traction (aka frontal) plane.
spinal pressure is reduced by leaning on the
Etiology
upper
extremities (using arm rests to unweight the
• Osteoarthritis – most common
trunk), by
• Rheumatoid arthritis
leaning the trunk against a support
• Avascular necrosis
or when in a pool
• Hip fractures
symptoms worsen during standing, walking,
• Malignant bone tumors
running,
• Ankylosing Spondylitis
coughing, or similar activities that increase
(Magee 2008)
spinal pressure
Anatomy
Lumbar Region: Deep Segmental Muscle
Activation
• PELVIS
Kinesiological function:
“Drawing-in” maneuver is used to activate
-Supporting and transfering the weight
the TrA and
-Rotate during walking
-Providing a broad area for muscular -medially and inferiorly to the greater
attachment trochanter
-It is an attachment site for the iliopsoas
muscle

ANGLE OF INCLINATION

• By the age of 2 and throughout

adulthood, 125°
• At birth, usually 150°

• Coxa valga
• Coxa vara
• ILIUM
-more anterior and superior
ANGLE OF TORSION
-40% to the formation of the acetabulum
• Anterior superior iliac spine (ASIS)
• Infancy- 40°
• Posterior superior iliac spine (PSIS)
• Adulthood- 10° to 20°
• Anterior inferior iliac spine (AIIS)
• Anteversion
• Posterior inferior iliac spine (PIIS)
-“in-toeing”
• Results in joint congruency
• ISCHIUM
• Retroversion
posterior inferior bone of the pelvis
-“out-toeing” or lateral hip rotation during
-40% of acetabulum formation
standing and walking
• Ischial tuberosity
-weight-bearing prominence
HIP JOINT
• Ischial ramus
-extends medially
The hip joint or acetabulofemoral
articulation
• PUBIS
diarthrodial triaxial joint
anteroinferior portion of the pelvis
three degrees of freedom
-20% formation of acetabulum
The hip joint is a ball-and-socket joint
• symphysis pubis
RESTING: 30 FLEXION, 30 ABDUCTION,
• pubic tubercle
SLIGHT LATERAL ROTATION
CLOSE PACKED: FULL EXTENSION,
FEMUR
MEDIAL ROTATION AND ABDUCTION
CAPSULAR PATTERN: FLEXION,
Longest and strongest bone
ABDUCTION, MEDIAL ROTATION
GREATER TROCHANTER
-most palpable prominence
FORCES OF THE HIP
-provides the attachment for the gluteus
STANDING: 0.3* BW
medius and lateral rotator muscles
S IN ONE LIMB: 2.4-2.6*BW
-used in measuring leg length
WALKING: 1.3-5.8 BW
LESSER TROCHANTER
WALKING UPSTAIRS: 3*BW LEGG- LCP: Affects
RUNNING: 4.5+*BW CALVE pedia patients
PERTH (4-12 y/o)
HIP LIGAMENTS ES
DISEAS OA: affects
ILIOFEMORAL OR Y LIGAMENT OR E geriatrics
LIGAMENT OF BIGELOW patients
P: AIIS and iliac portion of acetabulum (usually 40 and
D: As a thickening of the anterior and above)
superior joint capsule
M: Hip extension, especially RA primary RA: localized ,
hyperextension; superior portion limits joints metacarpophal
adduction and lateral portion limits some affected angeal
lateral rotation; also limits pelvic posterior OA: systemic.
tilt Distal
interphalangeal
PUBOFEMORAL stiffness
P:Pubis (anterior aspect of superior ramus) RA: morning
and anterior-medial or pubic portion of stiffness
acetabular rim OA: evening
D: As a thickening of anterior and inferior stiffness
capsule
ACL/LC Inflammat ACL: ligament
M:Hip extension, abduction and lateral
L ory
rotation; also limits ipsilateral pelvic
Pain OA: joints
lateral tilt
Swelling

ISCHIOFEMORAL
P:Ischial portion of acetabulum rim and DIAGNOSTIC PROCEDURE
labrum, posteriorly and inferiorly • Medical History
D: As a thickening of posterior and lateral • Hip Examination
capsule • ROM
M: Hip extension, abduction and medial • MMT
rotation; limits hyperflexion; superior • Circulation
fibers limit extreme adduction (especially • Mobility & function
when hip is flexed); also limits ipsilateral • X-Rays
pelvic rotation • MRI

DIFFERENTIAL DIAGNOSIS TREATMENT

Technique & Treatment
• Approaches
SIMILARI DIFFERENCE
• Posterior
CONDIT TIES S
• Direct Anterior (DA)
ION
• Anterolateral (Watson-Jones)
• Direct Lateral (Hardinge)
 • Wound Closure extensor and hip abductors to elicit
muscle ctxn
Regain mobility and control of operated
PT TREATMENT extremity
• Active knee flexion and extension
MAXIMUM PROTECTION PHASE AFTER exercises while seated in a chair
THA • Active hip rotation in supine position
between external and internal
• Goals and interventions rotation to neutral
• Prevent vascular and • Active hip ROM (forward and
pulmonary complications backward pendular motion) in
• Ankle pumping standing position with knee flexed
exercise and extended and hands on a stable
• Deep breathing surface to maintain balance
exercise and • Bilateral closed-chain, weight
bronchial hygiene shifting balance activities, heel
Prevent postoperative dislocation or raises and mini squats
subluxation of operated hip • Hip hiking while bearing the
• Patient and caregiver education allowable amount on operated
about motion restrictions, safe bed extremity
mobility, transfers and precautions Prevent a flexion contracture of operated
during ADL hip
Achieve independent functional mobility
prior to discharge (Kisner and Colby)
• Initially use of walker or crutches
• Ascending and descending stairs
with assistive device, initially one
step at a time
• (Kisner and Colby)

• Maintain a functional level of

strength and muscular endurance in
upper extremities and nonoperated
LE
• ARROM in functional
movement patterns, targeting
muscle groups used during
transfers and ambulation with
assistive device
Prevent reflex inhibition and atrophy of
musculature in the operated limb
• Submaximal muscle setting
exercises of quadriceps, hip