Back Education Program

Welcome to the Back Education Program.  This is a program being created by the students in the School of Physical Therapy at Bellarmine University in Louisville KY for successful completion of their Capstone. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Hannah Anderson, Dan McCoy, Rebecca Porter and Millie Ware 

Top Contributors - <img _fck_mw_template="true" _fckrealelement="1" _fckfakelement="true" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" class="FCK__MWTemplate"> - Elaine Lonnemann (Advisor)

An Evidence-Informed Back Education Program

About Low Back Pain

Are you experiencing low back pain? You are not alone! Look at these statistics...

• As many as 80% of Americans have symptoms of low back pain during their lifetime
• Low back pain is the leading cause of injury and disability for those younger than 45 years old                 (pic)
• Each year, approximately $26 billion dollars are spent in the United States for the treatment of low back pain

Is pain always bad? No. Pain is a warning sign to our body that something is not physiologically correct. We feel pain when there is structural damage, sign of an infection, a previous structure has been reinjured, etc. Pain is a helpful indicator for us to get treatment to heal our bodies.

Before you are able to truly understand back pain, it is important to know your body's anatomy. 

Your spine is made up of 33 small bones called vertebrae. Together, they form what is know as the vertebral column. There are 7 vertebrae in the cervical region which is your neck; 12 vertebrae in the thoracic region which is your upper back; 5 vertebrae in your lumbar spine which is your lower back; and 5 sacral vertebrae and 4 coccyx which are located below that.

(pic)

Between each of the vertebrae is a disc that acts as a cushion and a shock absorber. These intervertebral discs are made up of two parts-- the nucleus pulposis and the annulus fibrosis. The nucleus pulposis is in the middle of the disc and is jelly-like due to its large water content; it is composed of up to 80% water!. The annulus fibrosis surrounds this nucleus and so forms the outer part of the disc. These discs play an important role in keeping the back healthy! For more information on these discs, click (have link). 

(pic)

Other important parts of the spine:

(pic with arrows -- spinal cord, facet, foramen, nerves, include the cauda equina)

Your spine has three natural curves that begin to develop from the moment a baby starts to lift his/her head and gravity begins to work on the body. The curves keep the spine from being completely rigid and help the spine to tolerate a little bit more compression. To understand the normal curves of a spine, there are 2 terms you need to know—lordosis and kyphosis. Lordosis is when the spine curves inward and a kyphosis is when the spine curves outward.   The cervical portion of the spine is in a lordosis, the thoracic portion is in a kyphosis, and the lumbar spine is in a lordosis. These nice curves of the back increase the load bearing capacity of the spine.

(pic)

The spine has 4 main motions—forward bending, backward bending, sidebending, and rotation. These motions can also be coupled. For instance, you can have forward bending with rotation or backward bending with sidebending. Below, we demonstrate these motions and report typical lumbar spine active range of motion. 

Forward bending (flexion): 60 degrees'''''' (pic)'

Backward bending (extension): 25 degrees (pic of ourself)

Lateral flexion (sidebending): 25 degrees to each side (pic of ourself)

Rotation: 30 degrees to each side (pic of ourself)

An example of coupled motion: Forward bending with coupled rotation (pic of ourself)

Many muscles work together to help make these spinal motions possible! These back muscles can be classified into three different layers-- superficial, intermediate, and deep.

Superficial Layer:

Muscle	Origin	Insertion	Action
Trapezius	Medial 1/3 of nuchal line; external occipital protuberance; nuchal ligament; C7-T12 spinous processes	Lateral third of clavicle; acromion; spine of scapula	Upper fibers: scapular elevation; Lower fibers: scapular depression; middle fibers: scapular retraction
Latissimus dorsi	T6-T12 spinous processes; thoracolumbar fascia; iliac crest; inferior ribs	Intertubercular sulcus of humerus	Extends, adducts, and medially rotates humerus, shoulder girdle depression
Rhomboid major	T2-T5 spinous processes	Medial border of scapula from base of the spine to inferior angle	Scapular elevation and inferior rotation; stabilizes scapula to thoracic wall
Rhomboid minor	Nuchal ligament and C7-T1 spinous processes	Base of scapular spine	Scapular elevation and inferior rotation; stabilizes scapula to thoracic wall
Levator scapulae	C1-C4 transverse process, posterior tubercles	Medial border of scapula superior to base of spine	Elevation and downward rotation of scapula

 

Intermediate Layer:

Muscle	Origin	Insertion	Action
Serratus posterior inferior	T11-12 spinous processes	Inferior borders of 8th-12th ribs near the angle	Elevate ribs
Serratus posterior superior	Nuchal ligament and C7-T3 spinous process	Superior borders ribs 2-4	Elevate ribs

About Neck Pain

Prevalance

• Neck pain reported to be 2nd most common musculskeletal disorder that leads to disability and injury claims
• 2002: 13.8% of population > 18 years old in U.S. reported neck pain

Risk factors for neck pain:

• Working at a desk that is ill fitting to your body
• Working at a computer for long periods of time
• Sitting with bad posture for long periods of time
• Working on above head activities (i.e. painting) for long periods of time

Classifications of Neck Pain:

Cervical Hypomobility

• Loss of ROM/flexibility
• No symptoms beyond the shoulder
• Sudden onset- sudden awkward movements can theoretically cause entrapment of the facet joint meniscus

Gradual onset- joint stiffness can come from osteoarthritic changes, adaptive shortening of connective tissues, or adhesions after trauma to spinal segments 

Cervical Radiculopathy

• Disorder of the spinal nerve root caused by disc herniation or other space-occupying lesion (i.e. spondolytic spurs or cervical osteophytes)
• Usually present with pain in the neck and in one arm, loss of motor function, or reflex changes in affect nerve root distribution
• Most common cause is foraminal encroachment of the spinal nerve secondary to decreasing disc height and degenerative changes to the uncovertebral and facet joints

Cervical Instability

• Remote history of trauma
• Symptoms occur with sustained weight-bearing posture and relieve from non-weight bearing position
• Hypermobility with lose end feels
• Poor strength of deep cervical muscles
• Aberrant movement with AROM

Acute Pain (whiplash)

• Recent history of trauma
• Referred symptoms into upper quarter
• Poor tolerance to most interventions
• High pain a disability scores

Cervicogenic Headache

• Unilateral headache with onset proceeded by neck pain
• Triggered by neck movements or positions
• Pain elected by pressure on posterior neck especially at upper cervical joints

Why Does My Back hurt?

Pain Science

What can I do about my Low Back Pain?

For Physical Therapists: What subjective and objective information should you be collecting when treating a patient with low back pain? The following classification system by Stanton et al. will lead you to which treatment a patient would benefit from.

Manipulation or Mobilization Category

Subjective: 

1). Symptoms < 16 days

2). Symptoms not below knee

3). Not afraid to work (FABQ < 19)

Objective:

1). Lumbar hypomobility

2). Hip internal rotation > 35 degrees for at least one hip

Stabilization Category

Subjective:

1). Age < 40 degrees

Objective:

1). Average straight leg raise > 90 degrees

2). Abberant movement present

3). (+) prone instability test

Specific Exercise Category

Subjective: 

1). Symptoms distal to buttocks

Objective: 

1). Pain centralizes with a specific movement (can be flexion or extension)

Traction Category

Subjective:

1). Symptoms distal to buttocks

Objective:

1). Pain peripheralizes with a specific movement (can be flexion or extension)

2). (+) Crossed straight leg raise