This is a book written for physical therapists and physicians interested in the treatment of patients with low back pain. The author has brought nearly 50 years of clinical training and scientific evidence to write this book. According to a very well known physical therapist, this book is claimed to be a seminal book on low back pain, and according to Dr. Basmajian (Father of EMG Biofeedback) "it should strengthen the hands and minds of several branches of the healing professions while clearing the debris of dubious techniques." The book is about treatment of Mechanical Disorders of Lumbar Spine and mainly Intervertebral Disc Disorders by physical therapists using conservative techniques. The author is cognizant of the fact that patients who come to physical therapy should not be harmed by physical therapy, hence with this in mind, these gentle techniques are presented to the practicing physical therapist and the student alike. There are 9 chapters with two appendices and an index. The three anatomy chapters were co-authored with Dr. Arthur Nelson. The next few chapters are on sprains/strains, intervertebral disc conditions, spinal stenosis and disc degeneration, spondylolesthesis/spondylolysis and spondylosis. In addition to that, there are chapters on epidemiology, clinical evaluation, chronic low back pain, and physical therapy techniques. The main thrust in this book, is that all patients must be treated by proper clinical diagnosis based on pathophysiology using sensitive and specific tests and arriving at treatment techniques which are evidence based. This book is not for the believer and non-scientist, but to all those who profess to be physical therapists/scientists. This might be the only book written by two physical therapists for the treatment of patients suffering low back problems, with evidence to back it up.

Intervertebral Discs and Other Mechanical Disorders of the Lumbar Spine

Evidence-Based Conservative Management and TreatmentBy C.K. Fernando Arthur Nelson

iUniverse, Inc.

Copyright © 2009 C.K. Fernando
All right reserved.
ISBN: 978-1-4401-3451-7

Contents

Preface..............................................................iAbout the Authors....................................................ivDedication...........................................................vAcknowledgments......................................................viForeword.............................................................vii1. Epidemiology......................................................1Chapter 1 Notes......................................................82. The Vertebral Column..............................................12Chapter 2 Notes......................................................253. Muscles and Ligaments of the Lumbar Spine.........................27Chapter 3 Notes......................................................494. Joints of the Lumbar Spine........................................54Chapter 4 Notes......................................................745. Mechanical Disorders of the Lumbosacral Spine.....................79Chapter 5 Notes......................................................1466. Clinical Evaluation...............................................161Chapter 6 Notes......................................................1957. Chronic Low-Back Pain.............................................199Chapter 7 Notes......................................................2058. Physical Therapy Techniques.......................................208Chapter 8 Notes......................................................2319. A Plea for Progress...............................................239Chapter 9 Notes......................................................243Appendix A...........................................................244Appendix B...........................................................249Index................................................................251

Chapter One

Epidemiology

The study of how often a disease occurs and its distribution among various groups in the human population is essential in order to plan and evaluate strategies for prevention. And most importantly, epidemiology provides an understanding of the natural history of a disease so that treatments can be validated and their efficacy appraised.

Two relevant concepts are prevalence and incidence. Prevalence is a measure of the number of cases of a disease in a designated population at a particular time, while incidence is a measure of the rate at which new cases occur during a specified period. For instance, low back pain has a prevalence in a given year for a given population of approximately 5% while its incidence reportedly ranges from as low as 1 % to as high as 20% per year depending on the specific population surveyed.'

Many studies inform us regarding both prevalence and incidence. However some, rather than being purely scientific, are designed to increase or decrease payment by insurance companies.

To better understand the short-term and long-term results and aftermath of back pain, we need new methods of studying its course and improved data on outcomes. According to Saal, managed care of low back pain is based on the assumption that 90% of patients improve in 6-12 weeks. However, a natural history study by Van Korff found that 60-75% improve in one month, 33% repart intermittent or persistent pain at the end of one year, and 20% of patients describe substantial limitations at one year. The premise of the AHCPR guideline and managed care for back pain is not valid.

With these limitations in mind, a few natural studies of the lumbar spine, which are treated by physical therapists, are relevant. The National Health and Nutrition Examination (NHANE) surveyed 10,404 civilians, non-institutionalized adults in the U.S. Of these, 1,355 had low back pain lasting more than two weeks and 5% had chronic symptoms lasting more than six months. Extrapolating the 5% with back pain to the current U.S. population of over 280 million yields a total of over 14 million persons with chronic pain. Another 38,640,000 persons in the survey had sciatica and low back pain, yielding a lifelong prevalence of 13.8%.

Deyos states that when patients' low back pain and leg pain persists for four weeks: 4-5% have symptoms of spinal stenosis, 4% have compression fractures, and 1% have a primary metastasis tumor or osteomylitis; fewer than 1% have a visceral disease, a renal condition, an aortic aneurism or gynecological problems Most studies agree that the 10% of patients with chronic low back pain account for 80-90% of the costs of health care for back pain.

According to Nachemson, 85% of people with back pain lose fewer than seven days of work and account for about half the total workdays lost due to this malady. The other 15% of back pain sufferers stay at home for more than one month and account for the other half of workdays lost due to back pain. According to the National Health Interviews Survey of 30,074 workers in the U.S., about 22.4 million people, 17.6% of all U.S. workers, lost an estimated 149 million days from work as a result of back pain.

Definitions of Low Back Disorders

Low Back Pain. Unfortunately, the term low back pain is an inexact, catch-all category. Because the definition is not standardized, many studies of its prevalence, incidence and outcomes are not comparable. Adding to the confusion, studies performed for insurance purposes differ in methodology from those conducted for medical and scientific purposes. A better understanding of low back pain and its short-term and long-term outcomes must await more reliable data as our methods of studying the course of the disease improve.

Sciatica is pain along the route of the sciatic nerve, often appearing as a motor or sensory deficit such as tingling, burning, or pins and needles; the anterior primary rami of one or more roots of the sciatic nerve, usually the L5, S 1 and occasionally the S2, are involved. When the L4 and L3 nerve roots are involved, the femoral nerve is affected and the pain radiates down the anterior thigh.

The NHANE survey reported that 11 % of the population has sciatica. The number of persons who can expect to get sciatica at some time during their lives has been variously estimated from 40% of adults to 13.8% of women and 22.4% of men between 45 and 54 years of age.

Many studies show that sciatica is prevalent among those involved in heavy manual work. Recent Finnish studies of sciatica in male concrete workers revealed a high prevalence rate of 42% and for those over 45 years of age, 60%. Five years later, the lifetime prevalence had increased to 59% for all ages. i9 In the same studies, nurses and nurses' aides also showed high prevalence rates: 38% of nurses and 43% of nurses aides had experienced sciatica at least once. In contrast, only 5% of nursing school applicants, averaging 22.1 years of age reported a history of sciatica. A U.S. study found the highest prevalence of sciatica among adults 45 to 64 years of age.

Duration of Back Disease

In a survey of 10,404 non-institutionalized adults, 5% had backaches that had lasted for over six months. Applying this rate to the entire U.S. population of 280 million, we...