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

A meta-analysis of 45 trials was conducted by Searle et al. (2015) comparing different exercise interventions and their effect on LBP. They looked at strengthening, resistance, stability, coordination and cardiorespiratory exercise. The CASP tool (ref) has been used to critically appraise the methodological quality of this study.

This review is of high quality overall with only RCTs included, all of which were moderate to high quality. Some of the study limitations include the fact that it did not use any unpublished RCTs. Some RCTs could also not be translated into English and therefore were not included. There were also variations in programme intensity and duration, ranging from 1.5 weeks to 18wks duration. The paper also did not address other outcome measures such as quality of life, satisfaction and function which may effect depression and psychosocial wellbeing (ref) which could then have a carryover effect on reduction of pain.

The results cannot be directly applied to amputees as the participants were fully able and healthy. They were between 30 and 65 years of age which is not necessarily generalisible to all amputees. The included studies were carried out in a variety of settings different to the environment amputees will be in.

The results show that exercise has a beneficial effect on chronic low back pain when compared with other treatments. It is suggested that programs consisting of coordination/stabilisation and strength/ resistance exercises have a small but significant effect on reducing low back pain. Evidence states cardiorespiratory exercise has no effect on reducing low back pain. Only six out of forty five of the studies looked at cardiorespiratory exercise however. Also evidence suggests that LBP patients can have generally lower cardiovascular fitness and therefore may not have been able to tolerate training up to American College of Sports Medicine (ACSM) guideline. This may be a reason why the programmes were not effective. Other evidence suggests that cardiovascular exercise can decrease depression (Hurri et al., 1991).

Another recent Cochrane review found that exercise is an effective treatment of LBP, but no specific exercise programs showed a clear advantage (ref)

A further paper by Gailey et al. (2008) showed no preference for core stability or normal exercise in the management of LBP.

Trunk exercises for lower extremity amputees helps with the prevention of scoliosis development (Stolov et al, 1981). These were the early claims made my physicians in the 1980’s. However more recent research concluded that exercise is unable to stem the progression of scoliosis. the most recent Cochrane review in 2012 suggested that there was high quality evidence that exercise therapy alone has no benefit to the treatment of scoliosis.

A study conducted by tamanova, gruner and Lhotska in 2015 looked at specific exercise for lower back pain. This study found that application of the INFINITY method improves stabilization, centralization, postural correction of the body, and distribution of weight on the foot soles, and it fullyimproves the position of the centre of force. 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

Stretching 

A study conducted byGawda et al 2015 looked at the influence of the stretching therapyon the postural control strategy. They concluded that restrictions within the musculoskeletal system cause disorders in muscle synergies and that stretching therapy techniques improves the range of motion of the spine and reduces pain.

Cognitive Behavioural Therapy (CBT) and the psychosocial approach

Transcutaneous Electrical Nerve Stimulation (TENS)

A meta-analysis in 2004 by Milne et al. says TENS should not be used alone to treat chronic LBP.

The NICE guidelines for the management of general LBP suggest not to use TENS (Savigny et al., 2009). However research by Neil et al. (2015) on the pain management of amputees suggests the use of TENS on amputees with LBP. No evidence is given to show it’s clinical effectiveness

Acupuncture

A study by Manheimer et al. (2015) suggests acupuncture is effective in the management of LBP compared to no treatment or ‘sham acupuncture’, but no more effective than any other treatment. Another paper by Swathy et al. (2015) found acupuncture can be effective in LBP management showing no or minor adverse effects. This was not shown to be any more effective than other treatment however. Research by Neil et al. (2015) on the pain management of amputees suggests the use of acupuncture on amputees with LBP.

Manual Therapy  A recent 2013 systematic review conducted by Posadzki et al (2013) showed no evidence to support osteopathic manual therapy in the treatment of scoliosis in fully abled patients (Plaszewski and Saltikov, 2014). It must be presumed due to insufficient research that these outcomes would be similar if used as a treatment method on LLA with secondary scoliosis.

Electro Stimulation

Bayer in 1957 first introduced electro stimulation to scoliosis treatment claiming it increased activity at the paravertebral muscles at the convexity of the scoliosic curves, however he has since been proved wrong by recent research (Kolmel, 2012). Still, literature is conflicting regarding the topic however, hypersensitivity is almost always prevalent following amputation surgery (Meier and Carter, 2014). Therefore it clinicians would have to take into consideration tolerance levels before administering.

Bracing

Bracing is an important intervention when scoliosis is progressive and symptomatic and is most effective when treating thoracolumbar scoliosis (Frontero, Silver and Rizzo, 2015). Recommended guidelines for use state that the brace should be worn for 23 hours with an unpredictable time scope potentially ranging from months to years. (Skinner and Hurley, 2007). Bracing is used to facilitate a degree of sitting balance (Allam and Schwarbe, 2013) by improving posture, bracing allows patients scoliosis to become more functional day to day (Boos and Aebi, 2008). Balance impairments result in decreased function are common within LLA population, Ku et al 2014 identified increased postural sway due to uneven body weight distribution as a consistent issue facing lower limb amputees, following their systematic review on balance control.

Clinicians could discuss the possibility of bracing with their patients if they feel as though scoliosis was having a significant impact on their ADL’s secondary to balance issues. Despite individual RCT’s favouring the use of bracing as a treatment for scoliosis Plaszewski and Saltikov’s Non-Surgical Interventions for Adolescents with Idiopathic Scoliosis: An Overview of Systematic Reviews 2014 found that the most studies favouring bracing and physiotherapy management on the whole lacked a great deal of methodological quality. It can be presumed that the same conclusions can be made in transference to LLA patients, although further research into bracing to prevent scoliosis progression in LLA is needed

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