Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lower Back Pain When You Bend Forward? Here’s how you should manage.

Lumbar pain during flexion movement  is one of the commonest symptoms that we all face in our routine practice. There are a number of clinical reasoning processes, which need to be considered.

Much of the literature focuses on the changes in intra-discal pressure associated with spinal flexion. Which indicate that spinal flexion pain is associated with increased disc strain.  In order to strengthen the hypothesis of disc related flexion pain the clinician needs to establish other components of discogenic characteristics to support the hypothesis.

Here are some few things to remember when patient come with lower back pain.

  1. Observe everything, from entering into our examination room, starting with the client rising from a chair.
  2. History – link injury mechanisms, pain mechanisms with specific activities and past exercise regimens. Is there any “red flags” appear or not .
  3. Perform provocative tests – what loads, postures and motions exacerbate, what are relieving factors and what are aggravating factors? This needs to be address.
  4. Perform functional screens and tests – Are there perturbed postural, motion and motor patterns?
  5. If the clinical picture is complex and beyond your comfort zone, develop a referral relationship with a competent corrective exercise specialist.

It is not a matter of client performing an exercise – it is a matter of the client performing the exercise with perfection.

Observation Point:

  • Look for a dysfunctional movement pattern
  • Not able to hip hinge properly.
  • Allow the lower lumbar spine to flex forward.
  • Look for the patient get up from their seat
  • Do they difficulty to maintain neutral spine or bend forward into flexion as they arise?
  • Do they have pain while getting up from chair?
  • In the treatment room, watch them take off their shoes.
  • Ask patient to pick object from floor and observe behavior pattern of movement.
  • Look for fear or uncertainty at the prospect of bending forward.

Physical examination :

This is the main part one should find out what exact pathology it is.

  • Positive straight leg raise. Often you’ll see more subtle findings than in classic sciatica. They may experience more tightness in the back of the leg on one side or the other. They may experience buttock pain. I prefer the sitting straight leg raise. If needed, add foot dorsiflexion, have the patient bend forward, and/or add a Valsalva maneuver.
  • One of Comerford’s tests for flexion control is called the waiter’s bow. Briefly teach the patient to bend forward while maintaining the spine in neutral. Stand to the side and watch them do this. Do they do it well or do they lose neutral? For tactile feedback, place your index finger horizontally on the sacrum, and the other hand’s index finger just above, across the L5 spinous process. Now have the patient bend forward using the waiter’s bow. Do your fingers separate? Recheck between L5 and L4. If your fingers are separating, the patient’s lumbar spine in moving into flexion. It means that even when they are trying to, they cannot control flexion. See pictures below.

  • Palpate the interspace for tenderness. Place the patient prone with a pillow under their abdomen, so the lumbar spine is in slight flexion. Apply deep digital pressure to the interspinous spaces and the inferior spinous process, pushing simultaneously posterior to anterior and inferior to superior. I start with L5-S1 and work upward to at least L3-4. Is the interspace tender? Ask them to rate the tenderness on a 1-3 scale: 1-mild, 2-moderate or 3-severe. (I used to think this was the ideal test, but it is not always positive, even in those I know have flexion intolerance. Maybe it represents increased inflammation in those with flexion intolerance.)
  • Repeated end-range loading of extension This can be done prone or standing. Does this relieve or centralize their pain?
  • If they are not in acute pain, you can do repeated end-range loading of flexion, either from standing or in a long sit posture. Ask them to slump forward. Does this aggravate their pain; does this elicit increased buttock or leg pain, or sensory changes?
  • Palpate the lower lumbar paraspinal muscles. In disc-related pain, a discrete area will often feel atrophied, often unilaterally. There is often a divot, a hole, a small area of atrophy, at the level of the disc injury. As chiropractors, we are much more used to getting information on the restricted side, rather than the side that is moving too much.

 Unlock the mystery of pain

  • Treatment of flexion-intolerant pain is primarily self-care. Yes, your soft-tissue work and mobilizations can help, but self-care is primary and essential. There is no magic you can do that will override what the patient is doing 24/7. You have to teach them to move differently to solve flexion-intolerant pain. According toStuart McGill, “The first step in any exercise progression is to remove the cause of the pain, namely the perturbed motion and motor patterns.”9
  • There are two components of self-care. First, have them quit doing stupid stuff that is reinjuring them over and over. Totally stop the sit-ups and crunches. They cannot do yoga-style prolonged flexion. Pilates is not much effective as it often uses too much uncontrolled flexion. Don’t assume the patient knows this; they likely don’t. If they are sitting too much and for too long, help them figure out how to change that habit via frequent breaks and/or by utilizing a standing workstation.
  • Second, train them to move differently.
  • Yes, they need to strengthen their inhibited core muscles, but they need start with these simple movements, done precisely.

References

  1. Yin-gang Zhang, Tuan-mao Guo, Xiong Guo, Shi-xun Wu. Clinical diagnosis for discogenic low back pain.Int J Biol Sci, 2009;5(7):647-658.
  2. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode of low back pain.Spine, 1996;21(23):2763-2769.
  3. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain.Spine, 1993;19(2):165-172.
  4. O’Sullivan P, Twomey L, Allison G, et al. Altered patterns of abdominal muscle activation in patients with chronic low back pain.Aust J Physio, 1997;43:91-98.
  5. MacDonald D, Moseley GL, Hodges PW. People with recurrent low back pain respond differently to trunk loading despite remission from symptoms.Spine, 2010 Apr 1;35(7):818-24.
  6. Gibbons SGT, Comerford MJ. Strength versus stability. Part 1: Concept and terms.Orthopaedic Division Review. March / April: 2001:21-27.
  7. Liebenson C. “Flexion Intolerant Back” (10-minute video). Toronto, Ontario, 2011; filmed and edited by Phillip Snell.
  8. McGill S. “Designing Back Exercise: From Rehabilitation to Enhancing Performance.” (Guide to training the flexion-intolerant back.)

 

Courtsey : http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=56837

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