The physiotherapy management of Lower Back Pain in amputees

 

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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.

Back pain is a very common yet under recognized and seldom studied post-amputation pain problem. Back pain can arise de novo after amputation or pre-exist and be exacerbated by loss of a limb. Back pain may also occur as a result of prolonged bed rest after surgery but is more frequently 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 utilization.

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

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 (Lowe, 2008). Day et al. showed that those with maximal anterior tilt have a significantly increased depth of lumbar lordosis (ref). An increased liklihood of back pain has been associated with amputees with lumbar lordosis (Morgenroth, 2010) Those with a lumbar lordosis commonly present with tight back extensors and hip flexors and weak abdominals and hip extensor muscles. These muscle imbalances can also be caused by increased muscle tone which can arise as a result of stress (Norris, 1995).

Muscles 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 (Jaegers et al 1995) including decreased strength of gluteus maximus, hamstrings and adductor magnus in comparison to the intact side. due to weak hip extensors in above knee amputees, often patients present with overactive back extensors (Friel et al 2005). In below knee amputations, research has found a decreased quadriceps strength (Sherk et al 2010).

Postural changes and scoliosis

Burke et al. (1978) was the first to report radiographic findings of the spine in people with 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. Amputees often stand with a greater sway and weighbear more heavily through their intact limb (ref). This can be as a result of the prosthetic limb's lack of proprioception or pain resulting from the prostheses from complications such as infection, skin irritation wounds and hypersensitivity (ref). Even slight leg length discrepency can cause scoliosis in the lumbar region (Raczkowski, 2009)

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 roatate, therefore potentially resulting in future 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

Many amputees experience a degree of leg length discrepancy (LLD) following aputation, which in turn can lead to LBP (Gailey et al, 2008). Research has shown a significant association between a LLD of 6mm or more and LBP  (Rannisto 2015) leg length descrepancy can lead to a abnormal alligmnet of the plevis causing one leg to appear longer or shorter than the other (Lowe, 2008)''

Movement impairment could potentially predispose to abnormal tissue loading and deformation of musculoskeletal structures and contribute to on-going LBP and disability seen in the population.

• Increased lumbar spine extension during walking with an above knee amputation compared to non-disabled controls and increased pelvic tilt caould lead to increased LBP

General deconditioning
Hypersensitivity 

In addition to the increased activity in primary somatosensory cortex, the cortical representation of the back had shifted towards a more medial position in the chronic back pain group. This suggests not only enhanced reactivity but might indicate an expansion of the back representation into the neighboring (foot and leg) area.
Flor, H., Braun, C., Elbert, T. and Birbaumer, N., 1997. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience letters, 224(1), pp.5-8.
In essence the cortical changes involve a compensatory migration into the representation of the absent limb from adjacent regions of the somatosensory cortex.
Yellow Flags

• Catastrophising (Whyte, 2004)
• Fear of movement and falling (Fritz, 2001; Vlaeyen, 2000)
• Depresssion and Anxiety (Mickchnie, 2014)
• Altered body image (Zidarov, 2009)
  
  
  Presence of these psychosocial factors increases the risk of future chronic LBP and disability (Picavet et al., 2002)
  Ephraim et al. (2005) found that the reporting of back pain was more likely to be extremely bothersome in depressed patients as oppsed to 'bothersome' in non-depressed patients. Therefore suggesting depression heightens pain interpretation. 

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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