News Category: Lumbar Spine

Back pain is an old problem that’s been with us from the beginning of time. Solomon once said, “There’s nothing new under the sun.” It’s a good thing he wasn’t talking about treatment for this problem, because he would have been wrong. Doctors, researchers, and scientists continue to move forward with new studies everyday.

This study involved placing a spacer between the bones of the spine. This oval-shaped implant is made of titanium and is used to treat painful lumbar stenosis. Stenosis in the low back is a narrowing of the opening for the spinal nerve roots. Pain, numbness, and weakness in the legs occur when there is pressure on these nerves as they leave the spinal column.

Patients with stenosis often get relief by bending forward. This position opens the space for the spinal nerves. It’s usually difficult to stand up straight with this condition. The implant holds the spine in a slightly forward bent position. This relieves the symptoms of stenosis while allowing the patient to stand up straighter.

The spacer also decreases pressure on the discs between the spine bones (vertebrae). The load is transferred from the disc to the vertebrae. This occurs at the level where the implant is placed. No changes occur in the discs above or below the spacer. This is important because other studies have shown that increased pressure on a disc can cause damage.

Low back pain is tricky to treat. For some patients, low back pain goes away on its own. Other patients never get better, forcing them to quit their jobs. Doctors would love to be able to predict which of their patients will have the hardest time returning to their jobs. That would allow the health care team to create a treatment plan designed to help patients get back to work. The savings in health care, lost days of work, and workers’ compensation insurance would be substantial.

Many researchers have tried to identify tests that help doctors predict the outcomes of low back pain–without much success. But these authors seem to be onto something. They worked with 253 patients with low back pain. All the patients had been out of work for at least four weeks because of a low back injury at work. All were covered under the workers’ compensation system in Canada. The patients went through a series of physical tests. Doctors also noted how they reacted to pain. The patients filled out surveys about their general health, home and work life, depression, anxiety, and pain. The same tests and surveys were repeated after three days and again after three months.

The authors found several factors that were related to the patients’ ability to return to work:

Back problems often start early in life. Young people with back pain are likely to have similar problems later in life. Preventing back problems is a major goal of physical therapists.

A physical therapist in Denmark studied back pain in military recruits. Two groups of soldiers were followed. One group had no intervention. The second group was given back care instruction and one exercise to do twice daily. This exercise is called passive prone extension (PPE).

Prone extension is done by lying face down on the floor. The arms are used to press the upper body off the floor but without lifting up the hips. The muscles of the low back and buttocks are kept relaxed during the movement. PPE is used in the treatment of back problems. This is the first study to see if these exercises can actually prevent back pain.

The results after almost a year were good. Only one-third of the exercise group reported any back problems. This compares to one-half of the group that did nothing. The cost to prevent one soldier from getting back pain was nine dollars. This is much less than the cost to treat back pain.

Passive prone extension may be a useful tool in preventing back pain. It may work best in a military setting where the exercises are done daily. Left on their own, soldiers reported it was difficult to do the exercises daily for a year. Adults in the general population are even more unlikely to follow a daily exercise program.

If you could look into the future, what would you want to know? People with low back pain might ask, “What treatment will work best for me?” Physical therapists may be the first to answer.

A group of military-based physical therapists studied the benefits of spinal manipulation. They found five factors that may predict who gets relief from back pain using manipulation. Patients in the study had low back, buttock, and/or leg pain. No one with symptoms of pressure on the nerves took part in the study.

The five factors included:

Pregnant and having back or pelvic pain? You’re not alone. One third of all women have back or pelvic pain in the last two months of pregnancy. The cause of this pain remains unknown, but physical therapists are studying the problem.

Back pain and pelvic pain used to be thought of as one problem. In the last 20 years, it’s been recognized that these are probably two separate conditions. Treatment is based on the actual cause, so this distinction is important.

Pelvic pain is four times as common as low back pain. There are three joints in the pelvic area. More problems occur when all three joints are involved. Women who have this type of pain can lose the ability to do routine activities. This kind of disability takes longer to overcome after delivery. Women with only one painful pelvic joint seem to recover more quickly.

Therapists in Denmark have found a way to use the patient’s history and physical exam to classify back and pelvic pain during pregnancy. This will help researchers report their findings in the same way. Common results will lead to more specific treatment. This is important because back and pelvic pain are two different conditions in these patients.

In patients with low back pain, fear is a bad thing. Doctors know that patients who are especially afraid of their back pain tend to have a harder time getting better.

In this study, researchers were trying to find a way to predict which patients would have the hardest time going back to work. Their study group was patients who had low back pain that occurred on the job. The only factor that really predicted which patients would have a hard time was–you guessed it–fear. The workers who were most afraid that their jobs would cause them back pain were also the most likely to be on sick leave four weeks after their injury. 

The researchers used a specific type of survey called the Fear-Avoidance Beliefs Questionnaire to rate patients’ fear. They suggest that this survey could help doctors target which patients might need more help getting over their fear–and getting back to work.

Medical and health treatments are based on scientific studies. One study is never enough to prove anything. And everyone takes notice when researchers get different results.

A new study repeating the work of another physical therapist has been reported. Therapists are looking for ways to test the sacroiliac joint (SIJ). It’s not enough to know there’s an SIJ problem. Finding out the exact problem is necessary. This helps therapists decide which treatment is best in each individual case.

Therapists want to find four tests that can be trusted to show what’s wrong with the SIJ. The four tests have been studied by one group and now repeated by another. In both studies, the four tests were done in the same way and in the same order. However, in the second study, different therapists using the same tests got different results.

Before therapists can treat the SIJ, the exact problem must be identified. Valid and reliable tests to give this information haven’t been found yet. Therapists need to find one or more tests that give the same result each time they are given. This means a patient with an SIJ problem could see any therapist and get the same answer about what’s wrong. It also means the best treatments will be used. More studies are needed to discover the most accurate tests for SIJ problems.

Half or more of all women who are pregnant have low back and pelvic pain sometime during the nine months. For some women, pain continues after the pregnancy ends. Doctors aren’t sure if these are two different problems or just a continuation of the first painful episode.

This pain syndrome isn’t understood very well. Does it have a specific cause? Is it muscle weakness or loss of muscle bulk? In many patients, pain occurs when the hip muscles are tensed. It would be helpful if the painful symptoms could be described or measured in the same way from patient to patient. Tests to measure the severity of the problem are being studied.
One test checks the strength of the hip muscles. The hip adductors are the muscles that bring the legs together. The strength of these muscles goes down as back and pelvic pain go up. According to a study in the Netherlands, hip adduction strength can be used to measure the severity of pelvic pain after pregnancy.

From this study, it is clear that muscle weakness is not the cause of the back and pelvic pain. Instead, weakness of the hip adductor muscles is caused by less ability to use the muscles. The strength of the muscles is a gauge of the severity of the disease. As the patient gets better, the muscles get stronger.

Using muscle strength as a guide to disease status is helpful to doctors. This gives a measure that can be used instead of the patient’s opinion or the doctor’s overall impression. This is a good starting point for future research about the cause of pain after pregnancy.

What’s the most common medical condition seen by primary care doctors? Hint: It’s the same problem that causes most work absences and forces early retirement. The answer is low back pain. With so many people affected, what’s the best treatment advice?

Researchers compared two treatment ideas. The first is staying active versus bed rest. The second is staying active versus exercise. Pain levels, activity levels, and absence from work were used as measures of outcome for each treatment.

Advice to stay active was no better or worse than advice to rest or exercise. Staying active or exercising didn’t cause any more pain or problems. Patients are encouraged to be as active as possible, as early as possible. Staying in bed slows down healing and many other body functions.

People with acute back pain are best advised to stay as active as possible. It won’t make the problem any worse, and it will avoid the dangers of too much inactivity.

We know that our joints move and have a certain range of motion. The nerves and their coverings also move and have some flexibility. This is most obvious when nerve tissue gets stiff or bound down. Painful symptoms are the result.

Physical therapists are health care specialists who work with bones, muscles, nerves, and other soft tissues. When a patient has back pain or back and leg pain, the therapist tests joint range of motion and nerve tissue motion. The amount of movement and flexibility in the nerve tissue is called neural tension.

Therapists have one test in particular for neural tension in the low back and legs. This is called the slump test. The patient sits up straight in a chair with back, legs, and feet supported. The therapist presses down through the top of the patient’s head as the patient relaxes the neck, shoulders, and low back.

The test is continued as the patient tucks the chin into the chest and slumps while straightening the knee. The final step is for the patient to pull the toes toward the face with the knee still straight. The therapist releases the pressure and the patient sits back up. The therapist looks for a change in symptoms during and after the test.

A positive slump test brings on the patient’s back and leg symptoms. It can also be a positive test if the patient can’t straighten the leg fully. Both of these findings suggest increased neural tension as a possible cause of painful symptoms. False positives are common, so therapists use other tests to confirm these results.

The slump test is also a form of treatment. The therapist knows how to use this same test position to help stretch the nerve tissue. It must be done slowly and carefully over several weeks’ time. Warm-up exercises and stretches must be done first. Therapists are studying who is helped the most by this treatment. The results will be reported in the coming months and years.

Exercise has proven over and over to work for low back pain. It decreases symptoms, increases strength and endurance, and improves mental and emotional outlook. Researchers are rolling up their sleeves to find out exactly what exercise works and what doesn’t.

High-tech exercise equipment can increase strength and improve symptoms. However, this equipment is expensive, and it isn’t always easy to use. Exercises without equipment or with low-tech equipment also improve back muscle endurance. The down side is that patients who are in very poor shape or just out of surgery may not be able to do these safely.

A new piece of equipment has been developed to offer a safe, low-tech way to strengthen the back. It’s called a variable-angle Roman chair (VARC). The person stands on a small platform with the stomach and waist supported. The chest and back can move forward to a bent and seated position or be extended at different angles to an upright position.

The VARC can be set to exercise the back muscles through a full range of motion. Different handholds along with different chair angles are used to increase the level of resistance. For example, the least resistance occurs in a nearly standing position with the hands behind the back. The most resistance is given while going from a seated position to standing with the hands behind the head.

Healthy volunteers used the VARC three times a week for eight weeks. They did one set of 15 to 25 repetitions of back extension exercises. At the end of the training, there was an increase in endurance of the back muscles. No increase in strength was measured. This is just the start of some very important studies. Finding easy-to-use and inexpensive back strengthening equipment is the goal.

Sciatica, shooting pain down the leg, can be caused by piriformis syndrome. The piriformis is a muscle that crosses over the same passageway as the sciatic nerve. The term “syndrome” means there is a cluster of findings with the problem. In this case, the findings might include pain in the buttocks, pain down the leg, difficulty walking, and pain made worse by stooping or lifting.

Piriformis syndrome is one cause of sciatica, but what causes piriformis syndrome? There are many possible causes reported. Most are based on single cases. The two causes seen on a regular basis are falling on the buttocks and childbirth.

True piriformis syndrome may be caused by injury to the piriformis muscle. Early diagnosis and treatment works best. Treatment consists of physical therapy and antiinflammatory drugs. If left too long, surgery may be needed. After surgery, patients have prompt relief of sciatica. There may be some problems that persist, but most people are able to eventually able to return to work.

When piriformis syndrome doesn’t get better with treatment, surgery may be advised. The muscle is released from the bone and allowed to reattach with less tension in the muscle. This is a simple treatment that typically works well for the few people who need it.

Low back pain is a common problem. It comes and goes for many sufferers, and it can require many visits to the doctor. Sometimes the best approach is to wait it out, taking simple steps to help manage pain and discomfort. But this type of practical information may not always come across during a brief visit with the doctor. Brochures are one possible way to help patients handle their own low back pain successfully.

In this case, the brochure was developed by asking patients what information they wanted. Patients and doctors had some different ideas about what information was important. The brochure included simple facts about the spine and ways to relieve back pain. It also discussed the importance of staying active and gave tips for the chores and movements of daily life. There was advice on exercise and on where to learn more. Doctors gave out the brochure with the message that it could help patients take control of their pain.

Over the next two and a half years, researchers went to patients’ homes. They found that the group who had gotten the brochure had developed some better habits for taking care of their backs. Both groups had about the same back function. But patients who got the brochure tended to be less anxious and felt more in control of their back pain. Studies like this help fine-tune treatment methods for patients with low back pain.

New and better technology is changing how low back surgery is done. Improved surgical tools are being used with an operating microscope with good results during surgery for spinal stenosis. Spinal stenosis in the low back is a narrowing in the opening where the nerve roots exit the spinal canal.

Surgery to relieve the pressure on the spinal nerves is one treatment option. Part of the bone on either side of the spinal column is removed. This is called a laminectomy. When both sides of the bone are cut out, the operation is called a bilateral laminectomy.

With this new equipment, doctors can do the operation on both sides with one incision. This is called a unilateral approach. The microscope goes into the back on one side of the spine and then can be angled to allow the surgeon to operate on the other side. The operation takes about 90 minutes and is done on an outpatient basis. This saves time and money. There isn’t much blood loss, and there are very few problems after surgery.

Doctors prefer not to make more than one incision into the body during an operation. Combining a microscope with specialized surgical equipment, doctors can perform the same operation on both sides of the spine with one incision. This simplifies the laminectomy operation. The patient usually goes home the same day and gets quick pain relief with few problems.

There is one question that researchers around the world keep asking: “What causes back pain?” They ask this about those millions of cases of back pain each year that have no obvious medical or disease-related cause. We call this type of back pain mechanical.

Mechanical back pain is so common, it is estimated that 80 percent of the people in the western world will have at least one episode in their lifetime. Is it caused by too much curve in the lower back or not enough curve? Is it weak stomach muscles or too much sitting? What about muscle tightness? Muscle weakness? Every possible cause is being considered.

Physical therapists often treat mechanical back pain. Therapists around the world have joined the search for the cause. A group of therapists in Iran studied 600 adults. They divided them into four groups including two groups (men and women separately) without back pain and two groups with back pain.

Twelve different factors were examined. Length and strength of stomach, leg, and back muscles were measured. The position of the pelvis and low back curve were part of the study. Differences in leg length were measured. The position of the feet was examined. All of these variables were compared from group to group.

When all was said and done, only muscle weakness was linked to low back pain. The size of the low back curve, the height of the foot arch, the length of the legs, and other factors weren’t noteworthy. The authors suggest that increased activity and endurance exercises continue to be the number one choice in treating mechanical low back pain.

Anyone who’s had a disc removed knows the disappointment of waking up after the operation with pain. Going into surgery with hopes of immediate pain relief isn’t always realistic. It may take time for the body to recover from the pain response that started long before surgery.

A disc that protrudes out of its normal space is called a herniated disc. Herniated discs release chemicals that cause pain. Pressure from the disc on a nearby nerve root may cause other symptoms, such as numbness, tingling, or weakness. This pressure also sets up an inflammatory response in the nerve root. Swelling occurs with inflammation, and this causes more pain.

Doctors are looking for ways to reduce the pain right after disc removal. Steroid medicine is one method. Steroids are powerful anti-inflammatory agents. Steroids reduce the swelling around the nerve root. Less swelling and less pressure means less pain. These drugs can be put directly into the bloodstream with an IV or into the muscle by injection. Some doctors have tried injecting steroids into the spinal canal, the opening for the spinal cord.

A new method of steroid application has been reported. A group of doctors in Israel soaked sponges with a steroid and placed these on the nerve root during surgery. The sponges were left in place when the operation was over.

Patients with this type of steroid application had less back pain in the first two weeks after the operation, compared to patients who didn’t receive the steroid. There was no difference in pain levels a year after surgery, however. This was based on patients’ reports of back pain.

Chronic low back pain of unknown cause occurs around the world. Despite painful and limiting symptoms, spine damage is not always found. X-rays and other imaging studies often appear normal. This kind of back pain is called nonspecific. It is likely that there are soft tissue, psychological, and social factors involved in nonspecific back pain.

A new treatment using vibration exercise (VbX) is ready for use. It is being tried in sports, geriatrics, and rehabilitation. It works by setting off muscle reflexes. These reflexes activate and strengthen the muscles.

Ironically, vibration is a risk factor for back problems. Workers who are exposed to whole-body vibration often have work-related back pain. VbX is different from industrial vibration, however. It is applied for no more than seven minutes at a time. The intensity is lower, and the patient is in a standing posture with knees slightly bent.

Researchers in Germany tested VbX against another kind of back treatment. The second type of treatment is exercise called isodynamic lumbar extension. These exercises are done on a machine that gives resistance to the movement. Resistance can be applied to different muscles and in different motions.

Both vibration and lumbar extension worked equally well in reducing pain. Both groups increased their back range of motion right after treatment and six months later. Only the lumbar extension group had less psychological depression after treatment. The reason for this isn’t known. In practical terms, the VbX device takes up less space and may be better for clinics where space is an issue.

The straight leg raise test has been around since 1880. It is used as a way to look for back pain caused by the disc pressing against the spinal nerves. The test is done with the patient lying on his or her back. The examiner lifts one of the patient’s legs without help from the patient. The leg is kept straight at the knee.

This is called a passive straight leg raise (PSLR). The test is stopped when the patient feels back or leg pain. This is considered by some examiners to be a positive PSLR. If there isn’t any pain or symptoms during this test, it is considered a negative PSLR.

The basic PSLR test can be done with slightly different variations. Sometimes ankle motion (up or down) is added. The patient may be asked to lift the head and bend the neck forward. Other testers turn or rotate the hip in. Another variation elevates the leg with the knee bent. Symptoms of back or leg pain occur only when the knee is straightened. This is known as the Lasègue’s sign or Lasègue’s test.

Just exactly what a positive test tells the examiner is questionable. Some studies show that the PSLR position pulls on the sciatic nerve, causing pain. Others suggest that the test shows inflammation of the spinal nerves as they leave the spinal cord and travel down the spine. Some use the test to show that a disc is pressing on the spinal nerve.

A worldwide review of studies on the PSLR test was done by a group of doctors in Ireland. Studies from 1989 to 2000 were included. Researchers wanted to know what changes have occurred with this test since its use began in 1880. They also looked to see how the test is used and what its results mean.

They found that the basic test remains unchanged after more than 100 years of use. However, there are as many ways to view the results as there are examiners. In other words, a positive test means something different to nearly each person using the test.

One use the PSLR has is to predict results after disc surgery. A positive PSLR four months after surgery is a sign of poor recovery. A negative PSLR (no pain or symptoms when the straight leg is elevated) predicts an excellent outcome.

More research is needed to clear up other uses and meanings of this test. Differences according to age and gender remain unknown. The effect of psychosocial factors is also unknown. A negative PSLR may actually give more helpful information than a positive result.

Many comedians have pretended to lift a box that looks heavy to get a laugh. The box turns out to be light, and the jokester falls over. This may be funny on the stage, but it’s a serious problem for workers. People who lift and handle items for a living are called manual material handlers (MMHs). Back injury is their number one enemy.

Lifting a load of unexpected or unknown weight is dangerous. The lifter may think it weighs more than it does. Getting the body ready to lift an object depends on knowing how much the item weighs. Using more force than is needed to move materials can increase the risk of falling backwards. The same risk applies to unstable loads or loads that shift suddenly, such as liquids.

MMHs must prepare their bodies each time they lift an object. The muscles and body posture are part of this preparation phase of lifting. Keeping the center of gravity steady is an important part of keeping balance without falling over.

Bending the trunk closer to the object lowers the center of gravity. This is called the stoop method of lifting. Stooping or bending over to lift puts greater strain on the low back. It’s easier to keep balance with the stoop method compared to the squat method of lifting.

Scientists are studying ways to prevent injuries for MMHs. More research is needed to mimic actual work settings. This will provide helpful information for different jobs where varying loads are lifted.

In an effort to help patients with low back pain, scientists are studying how the spine moves. We know that patients with chronic low back pain have reduced motion in the spine. New three-dimensional (3D) equipment is allowing researchers to study patterns of motion.

Now that we know “how much” the spine moves, the next step is to find out “how” it moves. The “how” of spine movement is referred to as patterns of motion. Three directions of motion were studied: bending forward and back, bending to the side, and turning or rotating to one side.

In the normal, healthy spine, the spine moves through each of these motions. Some movement patterns occur at the same time. For example, bending to the side also causes the joint to turn, or rotate. This pattern of two motions together is the same for everyone who doesn’t have back pain.

In patients with chronic low back pain, it seems that there are up to three different ways to do each motion. There may be side bending and rotation to the same side or side bending with no rotation at all. Only a small number of patients with back pain have the normal side bending with rotation to the opposite side. 

This new information will help doctors connect the patient’s symptoms with back function. It may be possible for doctors to listen to patients’ symptoms and know what changes in motion are occurring inside the spine. Surgery to fuse the spine may be needed, but the hope is to find a treatment that will restore normal motion.