Mechanical Low Back Pain: Clinically Relevant Anatomy

Mechanical low back pain
Mechanical low back pain is the general term that refers to any type of back pain caused by strain on muscles of the vertebral column and abnormal stress.
[1]
Mechanical pain is the general term that refers to any type of back pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating and incorrect bending and lifting motions
Clinically relevant anatomy
Bony: at each level of the vertebrae theres a 3-joint complex, namely 2 facet joints and a disc interposed between 2 vertebra. Joint inflammation and degeneration is caused by rotational load of the facet joints and the disc weight-bearing transfers. The nucleus of the disc, facet joint capsule, anterior and posterior longitudinal ligaments, muscles, .. are the causes of the most pain. There are 2 important muscular groups: The anterior group: abdominal and psoas muscles.
[2] [2] [2]
The posterior group: erector spinae, profundi and intersegmental muscles.
Epidemiology/etiology
Mechanical low back pain is defined as pain secondary to:

[3][4]
Traumatic injury Lumbar sprain or strain: degenerative disease, discs, facet joints, diffuse idiopathic skeletal hyperostosis[[|]] Spondylolysis, Spondylolisthesis Disc Herniaton Spinal stenosis Osteoporosis with Compression fracture (Lumbar compression fracture) Congenital disease: severe Kyphosis, severe Scoliosis Paget's Disease
The surrounding ligaments, muscles and facet joints may become irritated and inflamed. People with mechanical back pain experience pain primarily in the lower back, the pain can also radiate to the knees, thighs or buttocks. This is called sciatica, namely nerve pain from irritation of the sciatic nerve.
[3]
There are 3 types of mechanical low back pain:
Acute Subacute Chronic
Characteristics/clinical presentation
This low back pain is usually aggravated by:

[3]
Long levered activities Lifting heavy objects Levered postures (bending forward) Static loading of the spine (prolonged sitting or standing)
Diagnostic procedures
Its difficult to reliably identify by diagnostic testing. These typically involve processes in the muscles and/or ligaments.
[4]
Differential diagnoses

Discogenic back pain Cauda Equina Syndrome Fracture (compression, spinosus process, stress fractures of pars) SI dysfunction Non-back pain infection (AAA, Pancreatitis, posterior penetrating ulcer and pyelonephritis) Metastatic disease (prostate, renal cell, thyroid, breast)
Examination

Paraspinal muscle tenderness No bony tenderness Back pain with passive knee-to-chest stretch Limited ability to forward bending as a resullt of limited ROM Muscle spasm Negative discogenic exam
[2] [2] [1] [2] [1] [2]
[1] [2]
Physical therapy management

The conservative treatment in the initial phase is ice massage followed by passive knee-to-chest stretch (one leg at a time then both legs together). Also daily walks followed by stretching, electrical stimulation and iontophoresis are recommended in this phase. Its important to identify possible causes and to correct harmful activities and attitudes, to avoid further back pain problems.
[2] [3]
In the second phase its necessary to continue the pain management and to be alert for red flags. The rehabilitation program exists out of stretching of the hamstrings
and back (knee-chest), strengthening of back flexors and extensors and core strengthening.
[2]
Patients should be taught several correct and comfortable positions and postures (during sleeping, sitting, lying, standing, walking and lifting techniques) that are safe for the spinal structures.
[3]
References
1. Moffett J.K. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ.1999;319:279-83 (Level of evidence 1B) 2. The little black book of sports medicine. By Thomas M. Howard.2006 .p.156-157 3. Ruth L. Solomon John. Preventing dance injuries. 2005. p.93 4. Atlas S.J. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120-131 (Level of evidence 1A) - See more at: http://www.physio1.0 1.1 1.2 1.3 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3.0 3.1 3.2 3.3 3.4 4.0 4.1
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Chronic back pain

1)Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine. Back pain may have a sudden onset or can be a chronic pain; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may radiate into the arms and hands as well as the legs or feet, and may include symptoms other than pain. These symptoms may include tingling, weakness or numbness. Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.[1] The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, all of which are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.[2] Back pain is usually defined as either acute or chronic. Doctors may diagnose low back pain as acute if it lasts less than a month. Most cases clear up in a few days without medical attention, although recurrence after a first attack is common. If the pain persists for over 3 months, it is considered chronic back pain, this constitutes only 1% to 5% of back pain cases.
2)
Classification
Back pain can be divided anatomically: neck pain, middle back pain, lower back pain or tailbone pain.
By its duration: acute (less than 4 weeks), subacute (4 12 weeks), chronic (greater than 12 weeks).
By its cause: nonspecific back pain, back pain with radiculopathy or spinal stenosis, and back pain associated with [3] another specific cause (such as infection or cancer). Non specific pain indicates that the cause is not known [4] [5] precisely but is believed to be due from the soft tissues such as muscles, fascia, and ligaments. Back pain is classified according to etiology in mechanical or nonspecific back pain and secondary back pain. Approximately 98% of back pain patients are diagnosed with nonspecific acute back pain which has no serious underlying pathology. However, secondary back pain which is caused by an underlying condition accounts for nearly 2% of the cases. Underlying pathology in these cases may include metastatic cancer, spinal osteomyelitis and epidural abscess which account for 1% of the patients. Also, herniated disc is the most common neurologic impairment which is associated with this condition, from which 95% of disc herniations occur at the lowest two lumbar [6] intervertebral levels.

Mechanical Low Back Pain: Clinically Relevant Anatomy

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Mechanical low back pain

Clinically relevant anatomy

The posterior group: erector spinae, profundi and intersegmental muscles.

There are 3 types of mechanical low back pain:

Acute Subacute Chronic

Physical therapy management

Chronic back pain

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