Anda di halaman 1dari 32

THE PATHO-MECHANICS

OF
LOW BACK PAIN

Hadi Kurniawan
Dept. of Physical Medicine & Rehabilitation
Panti Wilasa “Dr. Cipto” Hospital
Semarang
INTRODUCTION

• Low back pain (LBP) is a common


medical problem
• ± 84% chance of a person having LBP
pain during his or her lifetime, with a
prevalence of about 18%
• A significant portion of the problem (pain
& disability) is of mechanical origin
• Thus, an understanding of functional
anatomy, biomechanics and patho-
mechanics (changes in the normal
biomechanical function of the spine as
the result of trauma or disease) of the low
back (lumbosacral spine) can help in
determining and managing the problems
The Scope of biomechanics & Patho-mechanics in LBP

Functional anatomy
Static Spine
– Physiological curve (relationship to
the plumb line of gravity)
– Lumbo-sacral angle
– Posture
Dynamic spine/ Kinetic spine
 Movement of functional unit
 Movement of total lumbar spine
 Lumbar pelvic rhythm

Abnormal functional deviation

Pain / Impairment & Disability


Functional Anatomy

The Spine
Anatomically:
 33 vertebrae: cervical (7), thoracal
(12), lumbar (5), sacrum (5, fused),
cocygeal (4, fused)
 Increased in size distally
 Most massive in the lumbosacral
region  weight-bearing capacity

Functionally:
 An aggregate of superimposed
segments  functional units (FU)
 FU: 2 adjacent vertebral bodies +
intervertebral disk
 FU: anterior & posterior segments
Functional Anatomy

Functional Units

Anterior Weight-Bearing Portion:


 Supporting
 Weight-bearing Structure
 Shock-absorbing
 Flexible

Posterior Gliding Guiding Portion:


 Non-weight-bearing structure
 Protect neural structures
 Paired posterior articular joints
(facet joints)  direct the
movement of the unit (flexion –
extension)
Functional Anatomy

Posterior Functional Units

Intervertebral disk:
 Composed of a central
nucleus (pulposus) enclosed
within an annulus (fibrosus)
 A hydrodynamic elastic
structure
 “Shock absorbers”
 Innervation (-) / aneural

Annulus Nucleus structure


Fibrosus pulposus

Anterior
Functional Anatomy

Functional Units

Ligaments
Functional Anatomy

Functional Units

Ligaments:
 Intervetebral disk reinforce &
protected by the longitudinal
ligaments (anteriorly &
posteriorly)
 There is inadequacy of the
posterior longitudinal ligament
in the lower lumbar segment

Posterior longitudinal ligament
Decreasing the protective effect
in the L4, L5, and S1 region
Functional Anatomy

Functional Units

4 groups of Muscles:
 Extensors  Erector spinae muscles  main
 Flexors supportive muscles
 Lateral flexors
 Rotators
Functional Anatomy

Functional Units

Flexors Extensors
LBP: Biomechanical & Patho-Mechanical Aspect

“Specific”
± 5 – 6%

Tumors/ cancers

Infections

± 10 %

Rheumatics
Pancreatitis,
Nephrolithiasis,
etc

Fractures

Osteoporosis
 ± 4%
Mechanical
 ± 80% The American College of Physicians and The American Pain Society, 2007
LBP: Biomechanical & Kinesiology Aspect

A. Static LBP

LBP

B. Kinetic/ Dynamic LBP

LBP
Static Spine: Physiologic Curves

• 4 natural curves in the spine

• Provide architectural strength and


support (“coiled spring”)

• Distribute the vertical pressure

• Balance the weight of the body

• A neutral position (balance within


CoG)  strongest & most balanced
position  energized economically
with minimal wear & tear
Center of Gravity
(CoG)
Static Spine: Posture

 In neutral position & the balance


within the center of gravity (CoG) 
the spine constitutes a good posture
 Good posture:
 Aesthetically / cosmetically
 Functionally effective  minimal
energy expenditure, fatigue free
 Good balance
 Less stress on the joints, muscles,
& ligaments
Center of Gravity
(CoG)  Good posture must be hold while
standing, sitting or lying down
Static Spine: Posture
Static Spine: Posture
Static Spine: Poor/ Faulty Posture

A faulty relationship of the various parts of the body while


standing/ sitting

 Lumbosacral angle
 Lumbar Lordosis
Shifting of CoG

Sprain/ strain of muscles & ligaments
Facet joints compression

Pain
Static Spine: Poor/ Faulty Posture

Lumbar
Hyperlordosis
Static Spine: Poor/ Faulty Posture
Body Weight
Prolonged Overstretches
of posterior tissues
Flexed Posture

Overstretches of
joint capsules

Disk material compressed


posteriorly
Kinetic Spine

Lumbosacral spine movement:


 Well integrated & controlled
 Aggreate of movement of each FU
 Within guidance of posterior segment
 Limitation by constraints of the ligaments, joints capsules, and the
muscular fascial tissues
Kinetic Spine

Intervertebral disk:
 Permit compression  allowing flexion, extension, lateral flexion,
and rotation
 Lateral flexion & rotation occur simultaneously  limited in ROM
by the elasticity of the annular colagen fibers
 The nucleus deforms to allow all of the motion  reamins wihin the
container of the annulus fibrosus
Kinetic Spine

Flexion:
 Initiated by the kinetic action of the
abdominal muscles as the main flexor of
the trunk
 Muscles of the back (erector spinae)
actively conracts (eccentrically) 
provide smooth & controlled movement
and prevent falling
 Total ROM of flexion of lumbosacral
spine:  450  75% occuring at L5-S1 &
L4-5
 For additional forward flexion a
simultaneous rotation of the pelvis must
occur  “lumbar pelvic rhythm” 
allowed for a total 800 of flexion
Kinetic Spine

“Lumbar Pelvic Rhythm”


Kinetic Spine

Extension:
 Main extensor  erector spinae muscles
 Limited by mechanical approximation of
the facet joints structure
Kinetic LBP

LBP

Kinetic LBP implies irritation of pain sensitive tissues by


movement of the lumbosacral spine.
Pain can originate in one of three basic manners:
 Normal stress on unprepared normal low back
 Abnormal stress on a normal low back
 Normal stress on abnormal low back
Tissue Sites of LBP

(+)

(+)

(–)

(+)
Pathophysiology of Mechanical LBP
Pain
Sustained isometric
Mechanical stress or isotonic Ischemia &
(overuse) contraction of the metabolites
muscles
Nociceptors

Endorphin

Inhibition
Pain

Segmental
spinal reflexes Spasm
Disuse
ROM 

Limited functional activity


Clinical Presentation

• Dull aching pain


• Diffuse (low back – gluteal region)
• Various intensity
• Increases with activity, lifting,
prolonged sitting or standing, and
walking.
• Limited ROM
• Antalgic posture/ functional
scoliosis
• Neurologic symptoms (-)
• Radiologic: structural/ anatomical
abnormality (-)
Therapeutic Approach
The objectives of treatment
• Alleviation of pain
• Restoration of mobility
• Minimizing residual impairment & disability
• Prevention of recurrences
• Intervention of progression into chronic pain & disability

Treatment
• Bed rest
• Pharmacologic
• Physical medicine modalities
• Rehabilitation exercises
• Education: proper body mechanics
(PBM)
• Surgical
Summary
• Clinically LBP is evaluated and categorized, on the basis of
biomechanical and pathomechanical aspects of the
lumbosacral spine, as static and kinetic or dynamic LBP.
• Static LBP is LBP that occurs in certain static positions,
without movement, whether sitting or standing. Caused by
deviation of attitude or posture.
• Kinetic LBP occurs due to movements that do not follow the
normal mechanism of the lumbosacral spine.
• Understanding lumbosacral spine as a functional
mechanical structure is the basis for evaluating the
pathomechanism of LBP and provides benefits for
determining and overcoming various problems related to
LBP, including determining a diagnosis and making an
appropriate management programs.