The physiotherapy management of Lower Back Pain in amputees

 

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Introduction
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A previous Physiopedia page 'Lower Limb Amputees and Lower back Pain' (add hyperlink) 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, amputees 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 utilization [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
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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 the activity level for people with amputation [9].  Most amputees wear a prostheses for the majority of the day  [10] [11] [12] [13].

The presentation of at lest one gait deviation is common for the majority of prosthesis users as a result of improper prosthetic fit or alignment, lack of proper gait training, development of poor habits, or compensation for a secondary physical limitation [14]. 

Many amputees move the intact limb toward the midline while slightly increasing the external rotation of the lower limb as a compensation during gait [15]. They also tend to spend more time weight bearing on their intact limb in aim to protect the amputated limb and to avoid putting too much weight through a prosthesis that they don’t trust  [16] 16 [17] [18]18]
Due to increased weight bearing through the intact limb, the amputee will face biomechanical changes that can put pressure through joints and tissues, which could potentially result in LBP [13 27 28].

With a "good prosthetic fit," the forces acting across the joints of the contralateral limb of a person with transtibial amputation are not significantly greater than the forces acting across the joints of a person without amputation [29-31].

If the socket does not fit correctly or if the prosthesis is not aligned they may not be able to wear it due to pain. There is evidence that this can decrease a patient’s quality of life (QOL), therefore potentially being a yellow flag that could lead to depression and further influence chronic back pain for example (Ephraim et al., 2005).

There have been no studies looking directly at the effect of prothetic alignment and back pain (Gailley et al., 2008).

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). It is known that physical factors such as increased activity within the back muscles are closely related to psychosocial factors (Lewis et al, 2012), as well as LBP.  

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 (Isakov et al, 1992; Nadollek et al, 2002; Fernie et al, 1978). 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 (Jones et al, 1997; Isakov et al, 1992; Rossi et al, 1995). 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

Chronic Pain

Chronic pain is pain that has persisted for a period of a minimum of three months  (Merskey and Bogduk, 1994). incidence is common after procedures that involve major nerve injury or transection, such as amputation (Humble et al, 2015). Neuropathic changes are traditionally associated with chronic pain, whereas acute pain has been considered as a protective nociceptive process (Dworkin et al., 2007; Gray, 2008). Many lower limb amputees suffer from chronic pain, especially chronic low back pain (Kulkarni et al, 2005). Chronic pain is considered to be a complex biopsychosocial condition and a long-term multidisciplinary approach to management may be required for many cases (Humble et al, 2015). 


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[edit | edit source]

Exercise

General exercise management

Strengthening, resistance exercises and coordination an stabilisation are effective in reducing LBP generally. 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.

Scoliosis management

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

Treatment for anterior pelvic tilt can include gluteal bridges with isometric hip abduction using thera-band, activating gluteus maximus, hamstrings and erector spinae. A paper by Choi et al. (2015) showed a significant difference in the anterior pelvic tilt angle between isometric hip abduction using thera-band and with out theraband in favour of theraband

Stretching 

A study conducted byGawda et al 2015 looked at the influence of stretching therapy on the postural control strategy. They concluded that restrictions within the musculoskeletal system cause disorders in muscle synergies and that stretching therapy techniques improve the range of motion within the spine and in turn reduces pain. Cooper et al, 2015 also suggest that stretching is a beneficial treatment for tight hip flexors, which is a common occurance in amputees (Gailey et al, 2008).

Cognitive Behavioural Therapy (CBT) and the psychosocial approach

The implementation of cognitive coping strategies has a mediating effect on pain and depression (Hülsebusch et al., 2015) and has been used in the treatment of chronic LBP (Ehde et al., 2014). Cognitive behavioural therapy (CBT) can be helpful in treating pain or improving compliance with care, affecting the perception of pain (Hashmi et al., 2013). 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(Leeuw et al, 2007). In addition, exercise has been shown to produce changes in pain catastrophizing (Smeets et al. 2006), and appears to be as successful as interventions like CBT at addressing these factors (Mannion et al, 2001). It can also improve a patient’s outlook on life and the treatment they are receiving (Meichenbaum et al., 2009).

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

Clinical Bottom line

There is insufficient evidence in the area of lower back pain in lower limb amputee patients. Therefore in order to formulate a clinical bottom line, we interviewed Chris Walker, the senior Physiotherapist at the Nottingham City Hospital Mobility Centre.

It is important to approach lower back pain in amputees the same way as you would approach lower back pain with a fully abled patient. Gaining a full proof subjective history is fundamental in establishing the root cause of LLA LBP. Although the circumstances in which the pain arises can be completely variant, the principles to of assessment do not change.

Objectively, Analysis of patient gait and sitting posture can help to differentiate between a musculoskeletal structural issues or whether the patients are experiencing pain due hypersensitivity or psychosocial issues following their surgery. Proteases fitting can significantly influence upper chain biomechanics. Liaison with Occupational Therapy and Orthotics to make sure proteases are fitted correctly should be first port of call if a clinician suspects LBP as a result of lower limb biomechanical defects. If the patient mobilises with a walking aid, gait (with aid) should always be assessed in order to rule out inadequate usage of the aid as a cause of LBP. Considerations for the difficulties LLA patients may face when mobilising into different positions for assessment should also be made. Otherwise, clinicians should follow protocol for any standard LBP assessment.

From a management prospective, LLA’s benefit from the same treatments as fully abled patients would. A mixture of cardiovascular exercise, manual therapy, exercise prescription and sound education will almost always mediate LBP. Global exercise prescription is with a focus on core stability and balance/proprioception should be used early on from the rehabilitation process and throughout life in order to compensate for any atrophic deconditioning and maximise biomechanical advantage. A variety of cardiovascular, for example swimming or hydrotherapy and appropriate resistance training provides the patient with a personal, well round and comprehensive reconditioning programme in order to aid function. For fast working pain relief, TENS and acupuncture can be used.

Patients should be advised how to avoid the day to day exacerbation of musculoskeletal lower back pain. Patient should avoid prolonged sitting, however if the patient is unable to stand for a long period of time, regular transferees should be advised. The importance of quality of movement rather than quality should be stressed, if the patient uses a walking aid it is vital that it is used. Maintaining maximal function and encouraging patients to have a open minded, positive attitude to life following amputation will almost have a beneficial effect to comorbidities such as LBP.

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References

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  1. ↑ Mark LL, Latash S. Neurophysiological basis of movement. Illinois: Human Kinetics. 1998:81-97.
  2. ↑ Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, Robinson LR. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Archives of physical medicine and rehabilitation. 2000 Aug 31;81(8):1039-44.
  3. ↑ Kulkarni J, Gaine WJ, Buckley JG, Rankine JJ, Adams J. Chronic low back pain in traumatic lower limb amputees. Clinical Rehabilitation. 2005 Jan 1;19(1):81-6.
  4. ↑ 4.0 4.1 Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. Journal of rehabilitation research and development. 2008 Jan 1;45(1):15.
  5. ↑ Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Archives of physical medicine and rehabilitation. 2005 Oct 31;86(10):1910-9.
  6. ↑ Neil MJ. Pain after amputation. BJA Education. 2015 Jun 23:mkv028.
  7. ↑ Marshall HM, Jensen MP, Ehde DM, Campbell KM. Pain site and impairment in individuals with amputation pain. Archives of physical medicine and rehabilitation. 2002 Aug 31;83(8):1116-9.
  8. ↑ Marshall M, Helmes E, Deathe AB. A comparison of psychosocial functioning and personality in amputee and chronic pain populations. The Clinical journal of pain. 1992 Dec;8(4):351-7.
  9. ↑ Sherman RA. Utilization of prostheses among US veterans with traumatic amputation: a pilot survey. Journal of rehabilitation research and development. 1999 Apr 1;36(2):100-8.
  10. ↑ Pohjolainen T, Alaranta H, Kärkäinen M. Prosthetic use and functional and social outcome following major lower limb amputation. Prosthetics and orthotics international. 1990;14(2):75-9.
  11. ↑ Walker CR, Ingram RR, Hullin MG, McCreath SW. Lower limb amputation following injury: a survey of long-term functional outcome. Injury. 1994 Aug 31;25(6):387-92.
  12. ↑ Jones ME, Steel JR, Bashford GM, Davidson IR. Static versus dynamic prosthetic weight bearing in elderly trans-tibial amputees. Prosthetics and orthotics international. 1997 Jan 1;21(2):100-6.
  13. ↑ Burger H, Marincek CR, Isakov E. Mobility of persons after traumatic lower limb amputation. Disability & Rehabilitation. 1997;19(7):272-7.
  14. ↑ Nolan L, Wit A, Dudziñski K, Lees A, Lake M, Wychowañski M. Adjustments in gait symmetry with walking speed in trans-femoral and trans-tibial amputees. Gait & posture. 2003 Apr 30;17(2):142-51.
  15. ↑ Engsberg JR, Herbert LM, Grimston SK, Fung TS, Harder JA. Relation among indices of effort and oxygen uptake in below-knee amputee and able-bodied children. Archives of physical medicine and rehabilitation. 1994 Dec;75(12):1335-41.
  16. ↑ Silver-Thorn MB, Steege JW, Childress DS. A review of prosthetic interface stress investigations. Journal of rehabilitation research and development. 1996 Jul 1;33:253-66.
  17. ↑ Murray MP, Mollinger LA, Sepic SB, Gardner GM, Linder MT. Gait patterns in above-knee amputee patients: hydraulic swing control vs constant-friction knee components. Archives of physical medicine and rehabilitation. 1983 Aug;64(8):339-45.
  18. ↑ Engsberg JR, Lee AG, Tedford KG, Harder JA. Normative ground reaction force data for able-bodied and trans-tibial amputee children during running. Prosthetics and orthotics international. 1993 Aug 1;17(2):83-9.
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