Most problems involving the lower back in adults can be handled appropriately using a very simple approach. One good method for determining appropriate treatment is to identify the injured part of the back and determine how different positions affect the severity of symptoms. Each spinal segment consists of anterior and posterior elements which are affected by the position of the trunk and angular relationship of the vertebrae.
Back injuries most commonly involve either: a) the anterior elements
of the spinal segment (the vertebra and discs), b) the posterior elements
(the facet joints, spinal canal and foremen), or c) both the anterior and
posterior elements or the soft tissue structures around the spine.
Symptoms usually appear shortly after injury occurs, so the body positions
immediately preceding the onset of symptoms can provide clues as to the
diagnosis and the recommended therapeutic exercise program.
Problems involving the discs are particularly common in patients between
the ages of 18 and 50. They usually consist of tears in the annulus fibrosis.
Mechanisms of injury usually involve bending forward (in sitting or lifting
or falling on the buttocks). Re-creating the position in which the injury
occurred will increase symptoms such as back and/or leg pain, which will
help identify the root of the problem.
Another common back problem involves the facet joints or the foremen
in the posterior section of the segment. Symptoms may be triggered by bending
backwards (extension), walking, running, or a fall that causes a backward
bend. With these injuries, a person has difficulty standing and walking,
and feels better bending forward and sitting.
The third pattern of back injury may involve both the anterior and posterior
elements of the spine, or the soft tissue structures around the spine. In
either situation, there is no particular pattern of increased symptoms or
relief when sitting, standing or walking. Instead, the most comfortable
position is lying on the back with the knees bent, or lying on the side.
The basic rule for choosing an appropriate regimen is to reverse the
mechanism of the injury and avoid positions that increase symptoms, while
simultaneously strengthening the musculature that supports the spine.
Disc annulus tear, for example, would be treated by maintaining lumbar
lordosis and avoiding lumbar flexion . Exercise would strengthen the spinal
extensors. Appropriate injuries will respond immediately to these exercises,
and the injury can often be rendered symptom-free within 72 hours.
Treatment for injury or abnormality of the posterior elements involves
keeping the back in a bent-forward position or flattening the curve in the
back. This maneuver, called the pelvic tilt, teaches patients to strengthen
the appropriate muscles and loosen ligaments so that the lumbar curve can
be held in a more flattened position, even when the trunk as a whole may
not be bending in that direction.
For injury to the posterior and anterior elements of the spine or to
the soft tissues, the back is kept in a neutral position. The patient is
taught to strengthen the musculature in this position and to minimize motion
of the injured part of the back during daily activities.
We call these treatment strategies extension, flexion or neutral stabilization. The concept of stabilization was greatly popularized on the west coast by California physical therapists Michael Moore, Dennis Morgan and Eileen Vollowitz.
These treatment approaches are appropriate for over 90 percent of all
back patients. Weakness of the extremities, numbness, or bowel or bladder
dysfunction may mandate immediate consultation with a spine specialist physician. |
