This is a book written for physical therapists and physicians interested in the treatment of patients with low back pain. The author has brought nearly 50 years of clinical training and scientific evidence to write this book. According to a very well known physical therapist, this book is claimed to be a seminal book on low back pain, and according to Dr. Basmajian (Father of EMG Biofeedback) "it should strengthen the hands and minds of several branches of the healing professions while clearing the debris of dubious techniques." The book is about treatment of Mechanical Disorders of Lumbar Spine and mainly Intervertebral Disc Disorders by physical therapists using conservative techniques. The author is cognizant of the fact that patients who come to physical therapy should not be harmed by physical therapy, hence with this in mind, these gentle techniques are presented to the practicing physical therapist and the student alike. There are 9 chapters with two appendices and an index. The three anatomy chapters were co-authored with Dr. Arthur Nelson. The next few chapters are on sprains/strains, intervertebral disc conditions, spinal stenosis and disc degeneration, spondylolesthesis/spondylolysis and spondylosis. In addition to that, there are chapters on epidemiology, clinical evaluation, chronic low back pain, and physical therapy techniques. The main thrust in this book, is that all patients must be treated by proper clinical diagnosis based on pathophysiology using sensitive and specific tests and arriving at treatment techniques which are evidence based. This book is not for the believer and non-scientist, but to all those who profess to be physical therapists/scientists. This might be the only book written by two physical therapists for the treatment of patients suffering low back problems, with evidence to back it up.

Intervertebral Discs and Other Mechanical Disorders of the Lumbar Spine

Evidence-Based Conservative Management and TreatmentBy C.K. Fernando Arthur Nelson

iUniverse, Inc.

Copyright © 2009 C.K. Fernando
All right reserved.
ISBN: 978-1-4401-3451-7

Contents

Preface..............................................................iAbout the Authors....................................................ivDedication...........................................................vAcknowledgments......................................................viForeword.............................................................vii1. Epidemiology......................................................1Chapter 1 Notes......................................................82. The Vertebral Column..............................................12Chapter 2 Notes......................................................253. Muscles and Ligaments of the Lumbar Spine.........................27Chapter 3 Notes......................................................494. Joints of the Lumbar Spine........................................54Chapter 4 Notes......................................................745. Mechanical Disorders of the Lumbosacral Spine.....................79Chapter 5 Notes......................................................1466. Clinical Evaluation...............................................161Chapter 6 Notes......................................................1957. Chronic Low-Back Pain.............................................199Chapter 7 Notes......................................................2058. Physical Therapy Techniques.......................................208Chapter 8 Notes......................................................2319. A Plea for Progress...............................................239Chapter 9 Notes......................................................243Appendix A...........................................................244Appendix B...........................................................249Index................................................................251

Chapter One

Epidemiology

The study of how often a disease occurs and its distribution among various groups in the human population is essential in order to plan and evaluate strategies for prevention. And most importantly, epidemiology provides an understanding of the natural history of a disease so that treatments can be validated and their efficacy appraised.

Two relevant concepts are prevalence and incidence. Prevalence is a measure of the number of cases of a disease in a designated population at a particular time, while incidence is a measure of the rate at which new cases occur during a specified period. For instance, low back pain has a prevalence in a given year for a given population of approximately 5% while its incidence reportedly ranges from as low as 1 % to as high as 20% per year depending on the specific population surveyed.'

Many studies inform us regarding both prevalence and incidence. However some, rather than being purely scientific, are designed to increase or decrease payment by insurance companies.

To better understand the short-term and long-term results and aftermath of back pain, we need new methods of studying its course and improved data on outcomes. According to Saal, managed care of low back pain is based on the assumption that 90% of patients improve in 6-12 weeks. However, a natural history study by Van Korff found that 60-75% improve in one month, 33% repart intermittent or persistent pain at the end of one year, and 20% of patients describe substantial limitations at one year. The premise of the AHCPR guideline and managed care for back pain is not valid.

With these limitations in mind, a few natural studies of the lumbar spine, which are treated by physical therapists, are relevant. The National Health and Nutrition Examination (NHANE) surveyed 10,404 civilians, non-institutionalized adults in the U.S. Of these, 1,355 had low back pain lasting more than two weeks and 5% had chronic symptoms lasting more than six months. Extrapolating the 5% with back pain to the current U.S. population of over 280 million yields a total of over 14 million persons with chronic pain. Another 38,640,000 persons in the survey had sciatica and low back pain, yielding a lifelong prevalence of 13.8%.

Deyos states that when patients' low back pain and leg pain persists for four weeks: 4-5% have symptoms of spinal stenosis, 4% have compression fractures, and 1% have a primary metastasis tumor or osteomylitis; fewer than 1% have a visceral disease, a renal condition, an aortic aneurism or gynecological problems Most studies agree that the 10% of patients with chronic low back pain account for 80-90% of the costs of health care for back pain.

According to Nachemson, 85% of people with back pain lose fewer than seven days of work and account for about half the total workdays lost due to this malady. The other 15% of back pain sufferers stay at home for more than one month and account for the other half of workdays lost due to back pain. According to the National Health Interviews Survey of 30,074 workers in the U.S., about 22.4 million people, 17.6% of all U.S. workers, lost an estimated 149 million days from work as a result of back pain.

Definitions of Low Back Disorders

Low Back Pain. Unfortunately, the term low back pain is an inexact, catch-all category. Because the definition is not standardized, many studies of its prevalence, incidence and outcomes are not comparable. Adding to the confusion, studies performed for insurance purposes differ in methodology from those conducted for medical and scientific purposes. A better understanding of low back pain and its short-term and long-term outcomes must await more reliable data as our methods of studying the course of the disease improve.

Sciatica is pain along the route of the sciatic nerve, often appearing as a motor or sensory deficit such as tingling, burning, or pins and needles; the anterior primary rami of one or more roots of the sciatic nerve, usually the L5, S 1 and occasionally the S2, are involved. When the L4 and L3 nerve roots are involved, the femoral nerve is affected and the pain radiates down the anterior thigh.

The NHANE survey reported that 11 % of the population has sciatica. The number of persons who can expect to get sciatica at some time during their lives has been variously estimated from 40% of adults to 13.8% of women and 22.4% of men between 45 and 54 years of age.

Many studies show that sciatica is prevalent among those involved in heavy manual work. Recent Finnish studies of sciatica in male concrete workers revealed a high prevalence rate of 42% and for those over 45 years of age, 60%. Five years later, the lifetime prevalence had increased to 59% for all ages. i9 In the same studies, nurses and nurses' aides also showed high prevalence rates: 38% of nurses and 43% of nurses aides had experienced sciatica at least once. In contrast, only 5% of nursing school applicants, averaging 22.1 years of age reported a history of sciatica. A U.S. study found the highest prevalence of sciatica among adults 45 to 64 years of age.

Duration of Back Disease

In a survey of 10,404 non-institutionalized adults, 5% had backaches that had lasted for over six months. Applying this rate to the entire U.S. population of 280 million, we would expect over 14 million persons to have chronic low back pain.

In the same survey, 1,355 individuals had low back pain that had lasted more than two weeks and an additional 161 had sciatica along with low back pain, making the total prevalence of low back pain 14.5%, and of sciatica, 1.5%.

Van Korff found that 60-75% of patients improve in a month; after a year, 33% report persistent or intermittent pain and 20% report substantial limitations. The managed care system for primary care of back pain is based on the premise that 90% of patients improve in 6-12 weeks (42-84 days). So it appears that the guidelines of the Agency for Health Care Policy and Research (AHCPR) are based on an invalid premise according to Saal.

Disability Due to Back Pain

Although psycho-social factors may still be modifiers of pain, mechanical or idiopathic low back pain is likely to have its origins in pathology. The National Health Interview Survey of 30,074 workers (1995) indicated that 17.6% of all workers in the U.S., over 22 million people, lost an estimated 149 million work days because of back pain. Nachemson states that 15% of patients with low back pain miss more than a month of work and that these 15% account for half of the total number of workdays lost as a result of back pain. According to this author, the remaining 85% lose a median of fewer than seven days of work.

Risk Factors for Backache

Frequent lifting of heavy objects and twisting are risk factors for U.S. men 20-64 years of age. Kelsey, in a 1984 study, found other contributory factors to be time spent riding in motor vehicles (vibrations to the spine) and smoking.

Heavy manual labor, lifting, twisting, driving (whole body vibration), monotonous work, low job satisfaction, poor physical fitness and smoking all are commonly related to back pain.

Some clinicians regard sitting as a risk factor. Sitting exerts more pressure on the disc at L3 than does standing, however the load is static and small compared to the amount required experimentally to cause damage. Bigos found none of the studies on effects of sitting to be scientifically acceptable.

Surgery

A revealing study shows that the number of back surgeries increased by a surprising 49% during the period from 1979 to 1987. At the same time, the non-surgical hospitalizations for low back pain decreased by 33%. The number of surgical procedures varied according to the region: in 1987, there were 77 surgeries per 100,000 adults in the northeast and 146 per 100,000 adults in the south. The authors attributed the discrepancy to cultural differences and patterns of practice.

During a later period, from 1987 to 1990, Taylor et al. found an alarming rise in surgical interventions: surgeries for low back pain increased by 55%; fusions increased by 100%, from 13 to 26 per 100,000 adults and the more common surgical procedures also increased by 47% - from 89 to 131 per 100,000 adults. At the same time that the number of surgeries rose, non-surgical hospitalizations decreased from 402 per 100,000 in 1979 to 150 per 100,000 in 1990.

In 1990, the most recent year for which comparisons are available, the U.S. led thirteen other industrial nations in the number of surgeries for back pain with a rate 40% higher than any other country. Again, the ever increasing numbers of surgeries are explained as due to cultural differences and practice patterns. These differences may well be inadequate therapy during the acute stages and of ineffective or even harmful non-surgical treatments such as mobilization, manipulation and unproven techniques of cults newly popular in the U.S.

Waddell, in a study that focuses mainly on the timing of surgical referrals and imaging, indicates that for the 1-2% of patients who need surgery this is important. But as reported by Marcus in the Wall Street Journal in 2003, for the 95% or more with simple strains, sprains and nonspecific backache, surgery is inappropriate and can initiate or speed up the onset of arthritis.

Saal, in his 1996 presidential address to the North American Spine Society, pointed to flourishing fellowships with a "fix-it paradigm:" if disc excision doesn't work, there is fusion, and if that doesn't work, there is fusion revision with hardware and interbody grafts, and if that fails, the hardware can be removed and other options explored. More recently, Frymoyer decried the initial enthusiasm for new fusion techniques; inevitably, the realization follows that these procedures do not solve the problems of disabilities. He laments, "When will we ever learn?"

Another reason for the increase in spinal surgery may be the transfer of executive management of physical therapy to major corporations. This creates a conflict of interest for surgeons in their employ, since the more procedures they perform, the more their incomes increase. The Wall Street Journal of April 8, 2003, reported that Health South, a rehabilitation company based in Alabama, had revenues of 4.4 billion dollars in 2002. With 1700 facilities and 203 surgical centers, they had 900,000 surgical cases, and the revenue for the surgical centers for that year was 1 billion dollars. Health South had 3500 physician partners who received 49% of profits each quarter from the surgical center revenues. The physicians limited physical therapy patients to 14 visits, after which other treatment options such as epidural shots or surgery were initiated.

This method of operation is standard for all other publicly held rehabilitation corporations in the country. The American Physical Therapy Association is aware of this practice and is taking steps to curb these abuses.

What patients with back pain need is relief of pain, information, counsel, rehabilitation and preparation for going back to work. Clearly, the situation calls for a return to conservative standards of basic physical therapy practice: careful clinical evaluations including a complete history as in allopathic medical practice, diagnoses according to accepted pathology based criteria, and fundamental, tried and true treatments that do no harm to the patient and are appropriate to the diagnosis.

Chapter Two

The Vertebral Column

The vertebral column, or spine, is the central structural pillar of the body. Viewed from either the front or the back, it is straight. Viewed from the sagittal plane, it has four curves, two convex - the thoracic and the sacral, which bend back - and two concave - the cervical and the lumbar, which bend forward. In the cervical region, the vertebral column supports the head. In the lumbar region, it supports the entire trunk and this region is most frequently involved in backache.

Besides supporting the body, the vertebral column protects the spinal cord within the vertebral canal. See Figure l.

Functional Components of the Vertebral Column

The vertebrae, 33 bones stacked one on top of another, are similar in size and shape, the exception being the lumbar vertebrae, which are massive in comparison to the others. Between the vertebrae, cushioning them, are the intervertebral discs, which account for as much as a third of the height of the vertebral column. The discs, along with muscles and ligaments, connect the vertebrae to form a stable, strong and flexible column.

The central portions of the vertebrae are called the vertebral bodies. Located behind them is the vertebral arch, which form a passageway, the vertebral foramen or spinal canal, which houses and protects the spinal cord. The spinal cord begins immediately behind and below the foramen magnum and ends at L1-L2 level as the conus madullaris. See Figure 2.

The Vertebrae

The 33 vertebrae - 7 cervical, 12 thoracic, S lumbar, 5 fused sacral and 4 coccygeal, are similar in basic design, but they increase in size and mass from the first cervical down to the last lumbar.

Structurally, a typical vertebra consists of two major parts:

1) The vertebral body. The anterior part is largest. It is wider than it is tall, cylindrical in shape and composed of cancellous bone covered by a thin shell of cortical bone. McBroom found that the vertebral cortices provided for only 10% of the total compressive load carried by the vertebrae. In Osteoporosis, due to the loss of the horizontal trabecule, the vertical traberculae beams are weakened and hence the vertebral bodies are weakened. The superior and inferior surfaces of vertebral bodies, the end plates, are slightly concave.

2) The vertebral arch, the posterior part, a horseshoe-shaped projection, is attached to the vertebral body by two pedicles. Two laminae are situated posterior amid articular processes. The spinous process is posterior, attached at the midline, and the transverse processes are attached near the articular processes.

Intervertebral discs connect the vertebral bodies to each other. In addition, the articular process situated above one body, called a superior articular process, and the articular process situated beneath the body, called an inferior articular process, join to form a facet joint, or zyga pophysial joint. In this way, the vertebral bodies are joined in a column, forming a strong pillar to support the head and trunk.

Lumbar Vertebrae

Since the most common disorder of the spine is low back pain, the principle focus of this book is on the lumbar spine. The lumbar vertebrae support the entire trunk, as mentioned, and are massive compared to the other vertebrae. Their bodies are about 5 cm wide from side to side and 2 to 3 cm deep from front to back. Their lamina is broad, short and strong and their pedicles are very strong.

Largest in the lumbar region, the vertebral canal is approximately triangular, or trefoil shaped and decreases in size in the thoracic region, and is smallest in the cervical region.

The spinous process of a lumbar vertebra is thick and broad. The facets on the superior articular processes are concave and directed medially backward. The facets on the inferior processes are convex and directed laterally forward. The inferior and superior facets on the pedicles of adjacent vertebrae form the facet joints, which allow flexion, extension and side-to-side bending. If they allow any rotation at all, it is very minimal. Lumbar vertebrae have long and thin transverse processes.

The vertebral body L-5 is wedge-shaped, making it higher anteriorly than posteriorly. The basic design of vertebrae from C3 through LS is similar, but from LI through LS their size and mass increase to accommodate the increased compression loads to which they are subjected.

The Intervertebral Discs

The intervertebral discs account for up to 33% of the height of the vertebral column and aid in load-bearing and shock absorption. Their geometry and physiological condition largely determine the biomechanical functioning of the vertebral column. A disc is composed of upper and lowers cartilaginous end plates and, sandwiched in between, a cartilaginous annulus fibrous with a gelatinous center, the nucleus pulpous.

(Continues...)

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