LBP

• 80-90%
• Mechanical
• Non mechanical
• Age related, physical loading
• SIJ 18-30%
• Visceral
 Risk factor assessment
History
Age, weight
History
loss

Personal,
Family Medications
diseases
 Classification…..source of back pain

1-Visceral back pain

2-Neurogenic back pain
3-Vasculogenic back pain
4-Spondylogenic back pain
5- Psychogenic back pain
 Back pain
• Symptom not diagnosis
• Etiology = Mechanical , inflammatory ,
developmental , metabolic , Neoplastic etc
• Referred pain from Abdominal , pelvic etc

Important factor:
• Quality of pain
• Age of client
• Systemic complication
• Associated symptoms
 Effects of position
• Systemic pain is not relieved by recumbency
• Pain of metastasis progressive and continuous
when recumbent
• Fever indicate infection
• Pancreatic Neoplastic , ulcer , pancreatitis ….
Not relieved in any position
• Pain not relieved by rest or change position ,
not mechanical or neuro-muskeloskeletal
…..Red flag
 Night pain

• Long standing pain unaltered by positional

change …..tumor
• Systemic pain worse at night…. osteomyelitis
 Decision making process
• Client history
• Pain pattern /types
• Associated sign and symptoms
• Systems reviews
Viscerogenic Causes of Neck and Back Pain
Viscerogenic Causes of Neck and Back Pain
Viscerogenic Causes of Neck and Back Pain
Red Flags Associated with Back Pain of Systemic
Origin
 Head
• Evaluate pain and symptoms of the face, scalp, or
skull
• The brain itself does not feel pain because it has no
pain receptors
• Headache pain is related to pressure on other
structures:
– Blood vessels
– Cranial nerves
– Sinuses
– Membrane surrounding the brain
 Causes of Headaches
• Cancer
• Cardiovascular
– Ischemia (atherosclerosis; vertebrobasilar
insufficiency)
– Cerebral vascular thrombosis
– Arteriovenous malformation
– Subarachnoid hemorrhage
– Hypertension
– Hypoxia
 Causes of Headaches
• Pulmonary
– Obstructive sleep apnea
– Hyperventilation
• Gynecologic
– Pregnancy
– Dysmenorrhea
• Neurologic
– Post-seizure
– Cranial neuralgia (e.g., trigeminal, Bell's palsy,
– Brain abscess
– Hydrocephalus
S/S of Headaches
S/S of Headaches
S/S of Headaches
• Stress and inadequate coping are risk factors
for persistent headache
• Therapists often encounter headaches as a
complaint in:
– Post-traumatic brain injury
– Post-whiplash injury
– Post-concussion injury
• Migraine headaches are often accompanied
by:
– Nausea
– Vomiting
– Visual disturbances
• But the pain pattern is also often classic in
description
 Cervical Spine
• Neck pain is very common
– Mechanical causes
– Systemic causes
• Neck and shoulder pain and neck and upper
back pain often occur together making the
differential diagnosis more difficult
• Cervical myelopathy of mechanical or medical
cause may result in radicular symptoms
accompanied by:
– Weakness
– Coordination impairment
– Gait disturbance
– Bowel or bladder retention or incontinence
– Sexual dysfunction
 S/S of Cervical Myelopathy
• Wide-based spastic gait
• Clumsy hands
• Visible change in handwriting
• Difficulty manipulating buttons or handling coins
• Hyper-reflexia
• Positive Babinski test
• Urinary retention followed by overflow
incontinence (severe myelopathy)
• Vertebral artery syndrome caused by structural
changes in the cervical spine is characterized by:
– Patient turning the whole body instead of turning the
head and neck when attempting to look at something
beyond his or her peripheral vision
• Combined cervical motions such as extension,
rotation, and side bending cause:
– Dizziness
– Visual disturbances
– Nystagmus
 Thoracic Spine
• Thoracic pain can also be referred from:
– Kidney
– Biliary duct
– Esophagus
– Stomach
– Gallbladder
– Pancreas
– Heart
• Cardiac causes of thoracic back pain:
– Thoracic aortic aneurysm
– Angina
– Acute myocardial infarction
 Scapula
• Most causes of scapular pain occur along the
vertebral border and result from various
primary musculoskeletal lesions
• Scapular pain may due to:
– Cardiac Disorder
– Pulmonary Disorder
– Renal Disorder
– GI disorder
 Lumbar Spine, Sacrum/Sacroiliac
• Spondylo-arthropathy is characterized by:
– Morning pain accompanied by prolonged stiffness that
improves with activity
– Limitation of motion in all directions
– Tenderness over the spine and sacroiliac joints
• Polymyalgia rheumatica and fibromyalgia syndrome are
muscle syndromes associated with lumbo-sacral pain
• Fibromyalgia syndrome refers to a syndrome of pain
and stiffness that can occur in the low back and sacral
areas with localized tender areas
 CaudaEquinaSyndrome
• Low back pain
• Unilateral or bilateral sciatica
• Saddle anesthesia; perineal hypoesthesia
• Change in bowel and/or bladder function (e.g.,
difficulty initiating flow of urine, urine retention,
urinary or fecal incontinence, constipation, decreased
anal tone and sensation)
• Lower extremity motor weakness and sensory deficits
• Diminished or absent lower extremity deep tendon
reflexes
 Facet Joint Pain
• A fairly common cause of mechanical LBP.
• It features pain that has onset in minutes to
hours, lasts days to weeks, and is worse on
extension.
• Often associated with osteophytes that
accompany osteoarthritis.
 Spinal Stenosis
• Uncommon before age 60. Presents with pain in
both legs aggravated by walking, standing, or
extension and relieved by sitting or bending
forward.
• Also called neurogenic claudication, it must be
differentiated from vascular claudication.
• The latter presents with calf pain that comes on
after a specific amount of exercise and only
improves with rest, not with bending forward
 Fibromyalgia
• Women account for 75% of patients with
fibromyalgia.
• Symptoms persist for >3 months and are
worse in morning and at end of day.
• Patient suffers from severe fatigue,
widespread pain, difficulty sleeping, and often
anxiety/depression.
 Spondylolisthesis
• Slippage of L5 on S1.
• Represents 2% of back pain, but is more
common in athletes or in women over 40.
• Loss of lumbar lordosis is evident, and a step
over L5 is palpable. The back pain often
radiates into the knees.
Scheuermann's kyphosis
• It is significantly worse cosmetically and can cause pain.
• It is found mostly in teenagers and presents a significantly
worse deformity than postural kyphosis.
• A patient suffering from Scheuermann’s khyphosis cannot
consciously correct posture.
• Whereas in postural kyphosis the vertebrae and disks
appear normal, in Scheuermann’s kyphosis they are irregular,
often herniated and wedge shaped over at least three
adjacent levels.
• Fatigue is a very common symptom, most likely because of
the intense muscle work that has to be put into standing
and/or sitting properly. The condition seems to run in families.
 VBI
• Vertebrobasilar insufficiency (VBI)
• Beauty parlour syndrome (BPS)

• Due to decreased blood flow in the posterior circulation of

the brain. The posterior circulation supplies blood to
the medulla, cerebellum pons, midbrain, thalamus,
and occipital cortex (responsible for vision)
 Head neck and back

A 53-year-old postmenopausal woman with a history of breast

cancer 5 years ago with mastectomy presents with a report of
sharp pain in her mid-back. The pain started after she lifted her 2-
year-old granddaughter 3 days ago. Tylenol seems to help, but the
pain is keeping her awake at night. Once she wakes up, she cannot
find a comfortable position to go back to sleep. What are the red
flags? What will you do to screen for a medical cause of her
symptoms?
 Neck and Back Pain: Symptoms and
Possible Causes
• Back pain can be associated with:
– Distention or perforation of organs
– Gynecologic conditions
– Gastroenterologic disease
• Muscle spasm and tenderness along the
vertebrae may be elicited in the presence of
visceral impairment
– Spasm on the right side at the 9th and 10th costal
cartilages can be a symptom of gallbladder problems
– The spleen can cause tenderness and spasm at the
level of T9 through T11 on the left side
– The kidneys are more likely to cause tenderness,
spasm, and possible cutaneous pain or sensitivity at
the level of the 11th and 12th ribs.
 S/S Oncologic Spine Pain
• Severe weakness without pain
• Weakness with full range
• Sciatica caused by metastases to bones of pelvis, lumbar
spine, or femur
• Pain does not vary with activity or position(intense,
constant); night pain
• Skin temperature differences from side to side
• Occipital headache, neck pain, palpable external mass in neck
or upper torso
• Cervical pain or symptoms accompanied by urinary
incontinence
• Look for signs and symptoms associated with other visceral
 Cardiac causes of neck and back pain
• Angina
• MI
• AAA
• Rapid onset of severe neck or back pain
• Pain may radiate to chest, between the scapulae,
or to posterior thighs
• Pain is not relieved by change in position
• Pain is described as "tearing" or "ripping"
• Other signs: cold, pulseless lower extremities,
blood pressure differences between arms
Infectious Back Pain
 Key Points to Remember
• Pain associated with pleuro-pulmonary disorders
can radiate to: Anterior neck, Upper trapezius
muscle, Ipsilateral shoulder and Thoracic spine
• Clues to the possible involvement of the GI system:
Abdominal pain at the same level as back pain
occurring either simultaneously or alternately
• Percussion of the costovertebral angle resulting in
the reproduction of symptoms signifies: (X
Radiculitis, X Pseudorenal pain, X Has no
significance, ✔ Medical referral is advised
• A clinician will apply slow pressure over McBurney's
point and then quickly release. The presence of
severe pain when pressure is released is indicative
of a positive test and raises the suspicion for acute
appendicitis
• Murphy's sign is elicited in patients with acute
cholecystitis by asking the patient to take in and hold
a deep breath while palpating the right subcostal
area. If pain occurs on inspiration, when the inflamed
gallbladder comes into contact with the examiner's
hand, Murphy's sign is positive.
• Auto-splinting refers to lying on one side to
decrease respiratory movements; the client
will use auto-splinting when pain is induced by
lung excursion.
• Skin pain over T9 to T12 can occur with kidney
disease as a result of multi-segmental
innervation.
• Shoulder and back are the most common sites
of referred pain from systemic diseases
• To screen for back pain caused by systemic
disease:
1. Perform special tests (e.g., Murphy’s
percussion, Bicycle test)
2. Correlate client history with clinical
presentation and ask about associated signs
and symptoms
3. Perform a Review of Systems
• Always rule out trigger points as a possible cause of
musculoskeletal symptoms before referring the
client elsewhere.
• Muscle weakness without pain, without history of
sciatica, and without a positive straight leg raising is
suggestive of spinal metastases.
• When symptoms cannot be reproduced,
aggravated, or altered in any way during the
examination, additional questions to screen for
medical disease are indicated.
• Urinary incontinence with cervical pain
suggest of cord compression
• Pancoast’s tumors of the lung may invade the
roots of the brachial plexus causing
entrapment as they enlarge, appearing as pain
in the C8 to T1 region, possibly mimicking
thoracic outlet syndrome.
• Multiple myeloma is the most common
primary malignancy involving the spine often
resulting in diffuse osteoporosis and pain with
movement that is not relieved while the
person is recumbent.
 Guidelines for Physician Referral
• Back pain or symptoms that are not improving as expected,
steady pain irrespective of activity, symptoms that are
increasing, or the development of new or progressive
neurologic deficits such as weakness, sensory loss, reflex
changes, bowel or bladder dysfunction, or myelopathy.
• The ESR, serum calcium level, and alkaline phosphatase
level are usually elevated if bone cancer is present.
• Back pain in the presence of elevated alkaline phosphatase
levels can also indicate hyperparathyroidism, osteomalacia,
pregnancy, and/or rickets.
• Reproduction of pain or exquisite tenderness over the
spinous process(es) is a red-flag sign requiring further
investigation and possible medical referral.
• Back pain in children is uncommon and constitutes
a red flag finding, especially back pain that lasts
more than 6 weeks.
• Back pain accompanied by unexplained weight loss.
• Back pain accompanied by extreme weakness in the
legs, numbness in the groin or rectum, or difficulty
controlling bowel or bladder function
• Back pain that is relieved by sitting up and leaning
forward (pancreas)
 Case

• A 68-year-old accountant came to physical therapy as a self-

referral for low back pain (LBP). He reported slipping on a patch
of ice as the mechanism of injury. Symptoms were mild but
distressing to this gentleman. He reported pain as “sore” and
“aching” with any spinal twisting or side bending to the right. The
pain was present across the low back on both sides. The client
reported symptoms of stomach distress from time to time. He
attributed this to his trips overseas, eating foods from Ireland,
Scotland, Germany, and the Netherlands.
• Lumbar range of motion (ROM) was fairly typical of a nearly 70-
year-old man with most of his functional forward flexion from the
hips and thoracic spine. True physiologic motion in the lumbar
spine was negligible. Accessory spinal motions were also limited
globally. Active rotation and side bending were stiff and limited to
both sides, but only painful to the right.
• Neurologic screening exam was negative. The therapist did not ask
about the presence of any other symptoms of any kind anywhere
else in his body. No questions were asked about changes in the
pattern of his bowel movements or appearance of his stools.
• Given the examination results as tested, a conditioning exercise
program seemed most appropriate. The client began a stationary
bicycling program alternating with walking when the weather
permitted. He reported gradual relief from his symptoms and return
of motion and function to his previous levels.
• Four months later this same client reported another injury while
walking with subsequent back pain.

• The client’s age (over 50) is the first red flag. Back pain across both
sides can be considered bilateral and therefore a red flag until
further assessment is completed.
• Result: The key red flag in this case was alternating back
and abdominal pain at the same level. The client did not
see a connection between these two episodes of pain.
When his back hurt, he did not have any abdominal pain
and vice versa.
• The client was advised to see his regular physician for an
evaluation. He was diagnosed with colon cancer in
advanced stages and died 6 weeks later. Earlier detection
may have made a difference in this case, but the cyclical
nature of his presentation masked the true significance of
his symptoms.