The physiotherapy management of Lower Back Pain in amputees

 

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Top Contributors - Megan Clements, Lialle James and Thomas Lamb     

Introduction

A previous Physiopedia page titled Lower Limb Amputees and Low Back Pain addresses the epidemiology and aetiology of lower back pain (LBP) in the lower limb amputee population as well as some of the biomechanical and psychosocial elements that may cause or influence this pain.This page aims to provide an overview of possible physiotherapy interventions to decrease and manage LBP in amputees.

Limb amputations lead to a dramatic change in the biomechanical and neurophysiological relationships developed since birth[1]. As common as LBP is in the general population, lower limb amputees (LLA) seem to be at even greater risk for back pain. This problem however is rarely studied post amputation. Back pain has been reported to affect 52% to 89.6% of lower-limb amputees [2] [3]. This LBP can cause chronic disability [4]. The chronic LPB in amputees is not said to have any correlation to the time since amputation [5]. LBP could also be a pre-existing problem that surgery exacerbates. It may also occur as a result of prolonged bed rest post surgery but is more often encountered during the early rehabilitation phase during weight bearing on a prosthesis. Considerable bio-mechanical changes occur in the lower back and pelvis as a result of altered weight and force distribution and different muscle utilisation [6]. The pain is more likely to impair the patient than the amputation itself [7]. Marshall et al. found amputees with LBP have more disability than amputees without [8].

Given the high incidence of back pain within the Western hemisphere however, a number of the population of people with amputation may have suffered from back pain regardless of limb loss [4] .

Causes of LBP in amputees

Amputees may be at an increased risk of LBP because of factors irrelevant to the general population such as:

Poor socket fit and poor prosthetic alignment

A prosthesis is used to assist amputees with ambulation and the performance of activities of daily living. However, wearing an ill-fitting prosthesis can lead to complications affecting gait and activity level  [9].  Most amputees wear a prostheses for the majority of the day  [10] [11] [12] [13].

The presentation of at least one gait deviation is common in prosthesis users as a result of improper prosthetic fit or alignment, improper gait training, poor habit development, or as compensation for  secondary physical limitations [14]

Many amputees move the intact limb toward the midline while slightly increasing lower limb external rotation as a compensation during gait [15]. They also tend to spend more time weight bearing on their intact limb in order to protect the amputated limb and to avoid putting too much weight through a prosthesis that they don’t trust  [16] [17] [18]. This could be because of the prosthetic limb's lack of proprioception or pain secondary to infection, skin irritation, wounds or hypersensitivity [19]. Following these changes, the amputee may face biomechanical changes including increased lumbar side flexion that could put pressure through joints and tissues, potentially resulting in LBP [14] [20] [21][22].

In contrast it has been shown that when a prosthetic limb fits correctly, forces acting through the intact limb of an amputee are no greater than the forces through that of a person without amputation [23] [24].

There is evidence that not being able to wear a prosthesis can decrease the quality of life (QOL) of a patient, therefore potentially increasing the risk of yellow flags that could lead to depression and further influence chronic LBP [25].

Further studies need to be done looking directly at the effect of prothetic alignment and back pain however [4].


Figure 1: Examples of Prostheses
                                                                    Figure 1: Examples of different prostheses [26] 


Postural and muscle imbalances

Muscle imbalances have been reported in amputees, included muscle strength and length imalances and reduced muscle endurance [27]. In order to reach the degree of hip extension required for a normal step length, a compensatory anterior pelvic tilt has been described in amputees [28]. Day et al. showed that those with maximal anterior tilt have a significantly increased depth of lumbar lordosis [29]. An increased liklihood of back pain has been associated with this in amputees  [30]. These patients commonly present with tight back extensors and hip flexors and weak abdominals and hip extensor muscles. It is known that physical factors such as increased activity within the back muscles are closely related to psychosocial factors, as well as LBP [31]These muscle imbalances can also be caused by increased muscle tone which can arise as a result of stress [32].

Muscle imbalances can be seen through atrophy of the amputated side and overactivity of the intact limb. Atrophy of hip joint muscles has been reported in above knee amputees including decreased strength of gluteus maximus, hamstrings and adductor magnus in comparison to the intact side [33]. In below knee amputations, research has found a decreased quadriceps strength [34]


Wound .png
                                                                       Figure 2: An example of a stump wound [35]


Burke et al. was the first to report radiographic findings of the spine in people with LLA. They observed scoliosis in 43% of the subjects [36]. Research has suggested that even slight leg length discrepency (LLD) can cause scoliosis in the lumbar region [37].

As a compensation for postural changes and pain, an increased lateral pelvic tilt is often seen. This in turn can cause patients to side flex and rotate, potentially increasing chances of developing scoliosis [38]. A scoliotic back shows significant muscular imbalances with muscles on one side of the curve being over stretched and the muscles on the other side being very tight [39]


Leg-length discrepancy

Many amputees experience a degree of leg length discrepancy (LLD) following amputation, which can cause pelvic malalignment, deformation of musculoskeletal structures and can in turn lead to LBP [4]. Research has shown a significant association between a LLD of 6mm or more and LBP [40].


Chronic Pain

Chronic pain is pain that has persisted for a period of a minimum of three months  [41]. Incidence is common after procedures that involve major nerve injury or transection, such as amputation [42]. Neuropathic changes are traditionally associated with chronic pain, whereas acute pain has been considered as a protective nociceptive process [43]. Chronic pain is considered to be a complex biopsychosocial condition and a long-term multidisciplinary approach to management may be required for many cases [42].


Hypersensitivity 

Post surgery amputees often suffer from phantom limb pain and hyperanalgesia [44]. An increased activity in the primary somatosensory cortex has been observed and the cortical representation of the back has been shown to shift towards a more medial position in amputees with chronic LBP. This suggests not only enhanced reactivity but might indicate an expansion of the back representation into the neighbouring foot and leg areas of the cortex [45].


Homunculus lateral to medial.jpg
                                                               Figure 3: A map of the sensory homunculus [46]


Yellow Flags

Presence of psychosocial factors increases the risk of chronic LBP and disability [47]. Amputees face many psychosocial challanges and may therefore present with the following yellow flags:


  • Catastrophising [48]
  • Fear of movement and falling [49]
  • Depresssion and Anxiety [50]
  • Altered body image [51]

    Ephraim et al. found that the reporting of back pain in amputees was more likely to be 'extremely bothersome' in depressed patients as oppsed to 'bothersome' in non-depressed patients. Therefore suggesting depression heightens pain interpretation [25].

Management

There is limited evidence comparing specific treatments for LBP in amputees. The following section will utilise the general research available on how some of the problems that may lead to LBP could be overcome within this population.

Exercise

There is evidence to suggest that physical activity in general, regardless of it's nature, is effective in reducing LBP [52]. Sedentry behaviours such as sitting for long periods of time have been linked to LBP [53]. It can therefore be advised that amputee patients spend minimal time sat in wheelchairs for example. 

General exercise management

A meta-analysis of 45 trials was conducted by Searle et al. comparing different exercise interventions and their effect on LBP. They looked at strengthening, resistance, stability, coordination and cardiorespiratory exercise [54]. The CASP tool for reviews has been used to critically appraise the methodological quality of this study [55].

The review is of relatively high quality overall with only moderate to high quality RCTs included. Some of the study limitations are as follows:

  • The review did not use any unpublished RCTs.
  • Some RCTs could not be translated into English and therefore were not included.
  • There were variations in programme intensity and duration, ranging from 1.5 weeks to 18 weeks.
  • The paper did not address other outcome measures such as quality of life (QOL), satisfaction and function. This may effect depression and psychosocial wellbeing, which could then have a carryover effect on reduction of pain [56].
  • The results cannot be directly applied to amputees as the participants were fully able and healthy, ages ranging between 30 and 65 years of age (not necessarily generalisible to all amputees).
  • The included studies were carried out in a variety of settings different to the environment the amputees may be in.

The results show that exercise has a beneficial effect on chronic LBP when compared with other treatments. It is suggested that programs consisting of co-ordination, stabilisation, strength and resistance exercises significantly reduce LBP. It is stated that cardiorespiratory exercise has no effect on pain reduction. Only six out of forty five of the studies looked at cardiorespiratory exercise however. Moreover, LBP patients can have generally lower cardiovascular fitness and therefore may not have been able to tolerate training suggested by American College of Sports Medicine (ACSM) guidelines. This may be a reason why the programmes were not effective. Other evidence suggests that cardiovascular exercise can decrease depression which therefore may have a carryover effect on to pain [56].

A further meta-analysis showed short term effects on reduction of LBP in favour of core stability exercises in comparison to general exercises, however these improvements were not carried over long term [57]

It has been recomended in the literature that strength training should be undertaken regularly in order to avoid losing limb strength following amputaion, it's been suggested that a strengthening programme that targets both the residual and the intact limb be prescribed to this population. Nolan et al. stated that training twice a week for 10 weeks is sufficient to significantly improve hip strength in LLA, therefore decreasing stress on the back [27].

Postural Changes

A study conducted by Tomanova et al. looked at specific exercise for lower back pain. This study found that application of the INFINITY was most effective. The Infinity method is a special rehabilitation method which focuses on stabilization and strengthening of trunk muscles, dorsal and abdominal muscles, including the deep stabilisation system closely linked with diaphragmatic breathing. It activates subconscious and conscious setting of the postural system of the body, efficiently involves the stabilisation system of the spine. The method improves stabilisation, centralisation, postural correction of the body, distribution of weight on the foot soles and improves the position of the centre of force [58]. Due to the high prevalence of postural changes in LLA patients, this could be an effective exercise option of the clinician feels that postural deficits are the cause of the patients LBP.

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Walking amputee.jpg
                                                        Figure 4: An example of walking rehabillitation in an amputee [59]


Scoliosis management

Traditionally it was suggested that trunk exercises for LLAs helps with the prevention of scoliosis development [60]. More recently, a good quality Cochrane review proposed that exercise therapy alone has no benefit in scoliosis. This study however was carried out on adolescents which may not be generalisible to all patients. A recent systematic review showed no evidence to support osteopathic manual therapy in the treatment of scoliosis in fully abled patients [61].

 In 1957 Electrostimulation was first introduced to scoliosis treatment and was thought to increase activity at the paravertebral muscles at the convexity of the scoliosic curves, however this theory has since been challanged by recent research [62]. Still, literature is conflicting regarding the topic. 

Bracing may be effective when treating progressive thoracolumbar scoliosis [63]. Recommended guidelines for use state that the brace should be worn for 23 hours a day [64]. Bracing can be used to facilitate a degree of sitting balance [65]. Balance impairments resulting in decreased function are common within LLA population. 

Despite individual RCT’s favouring the use of bracing as a treatment for scoliosis, a systematic review by Plaszewski and Saltikov found that the most studies favouring bracing and physiotherapy management on the whole lacked a great deal of methodological quality [61]. There is a possibility that these treatments may benefit amputees with a scoliosis, although further research is needed.

Specific strengthening exercises

Following the potential that amputees may have increased anterior pelvic leading to LBP, it may be beneficial to strengthen around the core and pelvis. Treatments can include gluteal bridges, activating gluteus maximus, hamstrings and erector spinae. A paper by Choi et al., showed a significant difference in the anterior pelvic tilt angle between isometric hip abduction using thera-band compared to without thera-band. The results were in favour of theraband use [66]. Some examples of amutee hip and core stability execises can be viewed at the bottom of this page.


Strengthening.png

                                                           Figure 5: An example of hip strengthening exercises [67]

Stretching 

A study conducted by Gawda et al. looked at the influence of stretching on postural control. They concluded that restrictions within the musculoskeletal system can cause disorders in muscle synergies and that stretching improves the range of motion within the spine and in turn, reduces pain [68]. In addition, it is suggested that stretching is a beneficial treatment for tight hip flexors, which can coexist with LBP [69].

Cognitive Behavioural Therapy (CBT) and the psychosocial approach

The implementation of cognitive coping strategies has a mediating effect on pain and depression [70] . CBT has been sucessfully used in the treatment of chronic LBP and it can be helpful in treating pain or improving compliance with care, effecting the perception of pain [71]. It has also been shown to have an effect on chronic LBP disability by reducing psychological factors such as catastrophising, distress, fear and self efficacy [72]. In addition, exercise has been shown to produce changes in catastrophisation of pain [73]. It appears to be as successful as CBT at addressing these factors [74].  

Transcutaneous Electrical Nerve Stimulation (TENS)

A meta-analysis by Milne et al. says TENS should not be used alone to treat chronic LBP [75]. The NICE guidelines for the management of general LBP also advise not to use TENS alone [76]. However research by Neil et al. on the pain management of amputees suggests the use of TENS is effective [6]. Unfortunately no evidence is given to show it’s clinical effectiveness in terms of outcome measures. 

Acupuncture

An overview of seventeen systematic reviews on the use of acupuncture to treat LBP found that acupuncture was more effective when compared with a no treatment or sham acupuncture.  It also indicated that acupuncture plus an intervention is more effective than any other intervention alone. It states that frequency and needle placement needs to be stadardised in future treatment and research [77]Neil et al. suggests the use of acupuncture on amputees with LBP but again does not show statistical evidence of it's effects [6].

Acupuncture .jpg
                                                                              Figure 6: Low Back Acupuncture [78]


Clinical Bottom line

There is insufficient evidence for the treatment for LBP in lower limb amputees. Therefore in order to formulate a clinical bottom line, a consented video interview was conducted with Chris Walker, a senior Physiotherapist at Nottingham City Hospital Mobility Centre (see bottom of page). 

In the clinician's opinion, LBP in amputees is often treated and assessed in a similar way to able bodied patients. Gaining a thorough subjective history is fundamental in establishing the root cause of the pain. Although the circumstances in which the pain arises can vary, the principles of assessment do not change.

Objectively, analysis of patient gait and sitting posture can help to establish the main issues causing the LBP. Assessment should also consider musculoskeletal, neurological and psychosocial factors. Prosthesis fitting can significantly influence biomechanics. Liaison with Occupational Therapy and Orthotics to make sure prosthetic limbs are fitted correctly is paramount if problems are suspected. If the patient mobilises with a walking aid, gait (with the aid) should always be assessed in order to rule out incorrect use that could influence LBP. 

A combination of education, physical activity and specific exercises in conjunction with TENS or accupuncture may be appropriate to reduce LBP. This may help prevent deconditioning, pain and imbalance. Swimming or hydrotherapy is often effective in strengthening, relaxing, reducing pain and encouraging general fitness according to the clinican. 

According to the clinican patients should avoid prolonged sitting. If the patient is unable to stand for long periods of time, regular transfers are advised. The importance of quality of movement was also stressed, encouraging pacing and gradual exposure. Maintaining maximal function and encouraging patients to have a open minded, positive attitude towards treatment and life in general following amputation is key to their individual progress.

Video References

     


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