The physiotherapy management of Lower Back Pain in amputees

 

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Top Contributors - Megan Clements, Lialle James and Thomas Lamb     

Introduction

The previous Physiopedia page 'Lower Limb Amputees and Lower back Pain' (add hyperlink) adresses 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 (Latash, 1998). As common as LBP is in the general population, amputees seem to be at even greater risk for back pain. Back pain has been reported to affect 52% to 89.6% of lower-limb amputees (add 3 ref) This LBP can cause chronic disability (Gailey et al 2008). The chronic LPB in amputees is not said to have any correlation to the time since amputation (Ephraim et al., 2015). 

It is often not the amputation that primarily impairs the patient, but rather the pain (Marshall 2002). Marshall et al. (1992) found amputees with LBP have more disability than amputees without.

Given the high incidence of back pain within the Western hemisphere, a number of the population of people with amputation may be predisposed to LBP regardless of limb loss. (Gailey, 2008).

Causes of LBP in amputees

Lower limb amputee patients often have co-morbidities following surgery (Stolov and Clowers, 1981).

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

Muscle imbalance</u

Postural changes and scoliosis</u

Burke et al. (1978) was the first to report radiographic findings of the spine in people with lower-limb amputation (LLA). They observed scoliosis in 43% of the subjects.

Leg length discrepancy, insufficient use and inadequate fitting of prostheses can lead to abnormal gait and asymmetrical posture causing increased anterior pelvic tilt. To reduce pain, patients often acquire a compensatory scoliosis (Meier and Carter, 2014). 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 (Hawes, 2003). 

Leg-length discrepancy
Muscle imbalance 
General deconditioning
Hypersensitivity 
Yellow Flags

Management 

Poor socket fit and poor prosthetic alignment
Postural changes and scoliosis
Leg-length discrepancy
Muscle imbalance
General deconditioning
Hypersensitivity
Yellow Flags

Exercise

Stretching 
Cognitive Behavioural Therapy (CBT) and the psychosocial approach

Transcutaneous Electrical Nerve Stimulation (TENS) Acupuncture Manual Therapy 

Case Study

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References

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