pathology: chronic low back pain CLBP

yogabook / pathology / chronic low back pain CLBP

Definition

chronic low back pain CLBP is defined as back pain between the ribs and buttocks that lasts for at least 12 weeks or 3 months. The intensity of the pain can range from mild to a NRS 10 in the case of lumbago, although its chronic forms are usually somewhat less intense. The pain can be largely constant, but is more often dependent on movement and exertion. The progression over time is also variable, with less painful phases often alternating with more intense phases.
In addition to the pain, there is often also stiffness in the back, especially in the morning, which usually improves with movement. Restrictions in mobility are also common. There is often painful muscular hypertonicity somewhere in the autochthonous back muscles.

CLBP has increased by 100% in the last decade and is largely ethnicity dependent, slightly more pronounced in females. The prevalence is higher among those with a lower level of education, lower income and smokers. In „civilised countries“, most people are affected by CLBP at least once during their lifetime. Worldwide, CLBP is on average the second most important cause of incapacity for work and therefore also a major economic problem. In addition, CLBP can affect various aspects of life expression such as work, sport, leisure activities and social contacts. CLBP can weaken and later flare up again. The ability to walk, stand, lie down or hold the same position for long periods may be impaired.

Pain avoidance behaviour can lead to secondary disorders. With some causes, pain can radiate, particularly into the pore region and into one or both legs. More serious causes of CLBP include the following structural disorders:

  1. Cauda equina syndrome
  2. Tumours
  3. Morbus Bechterew (ankylosing spondylitis)
  4. Lumbar spinal canal stenosis, neuroforaminal stenosis
  5. Lumbar disc hernias (disc herniation)
  6. Lumbar vertebral body fractures
  7. spondylodiscitis
  8. Aortic aneurysms

Spondylolysis and spondylolisthesis are not necessarily among the causes of CLBP, as they are often asymptomatic.
In order to clarify CLBP, psychosocial aspects are also required as part of the medical history. The physical examination with functional tests and pain provocation tests is important, as is imaging if necessary to rule out more serious structural events.

A significant proportion of CLBP is functional in nature, with no correlates of structural changes detectable on imaging or in the laboratory. However, even minor changes in the back muscles can become symptomatic, both acutely and chronically, as shown by multifidus dysfunction, which is likely to be the underlying cause or contributory cause of many cases of CLBP.
Multifidus dysfunction is usually less severe compared to the above list:

  1. Facet joint dysfunctions
  2. ISG events such as ISG blockade, sacroileitis

Kidney stone disease are less likely to be CLBP, as they are usually highly acute, gallstone disease also less likely, as they tend to radiate to ventral/cranial. Sometimes menstruation or pregnancy in particular are also the cause of back pain. In the latter case in particular, the static changes in the body play an important role and often lead to significant functional complaints.

Passive or drug-based monotherapies are rarely successful. Successful therapy is usually multidisciplinary and includes physiotherapy, exercise therapy and regular exercises performed by the patient themselves, which are very valuable here. The proactive patient is in a much better position in terms of outcome and long-term prognosis.

Cause

  1. Causes of functional disorders
  2. Causes of structural disorders such as Morbus Scheuermann, Post-Scheuermann’s syndrome, intervertebral disc disease, see above

Predisposing factors

  1. Age (the incidence increases with age)
  2. BMI (if this is not based on a large muscle mass)
  3. Lifestyle deficiencies such as smoking, alcohol consumption, lack of exercise, lack of training stimuli
  4. Activities such as repetitive/frequent lifting and prolonged/frequent postures with a rounded back
  5. Various types of sport
  6. Mental health conditions, in particular depression

Diagnosis

  1. X-ray (spine), MRI
  2. EMG
  3. Blood laboratory for tendency to kidney stone disease and ankylosing spondylitis

Symptoms

  1. Back pain between ribs and buttocks, often load-dependent and posture-dependent, not necessarily constant over time, but more often of varying intensity
  2. Muscular lumbar back stiffness that improves with movement
  3. Restricted mobility, especially lumbar

Complications

  1. possible complication of the underlying disease

Therapy

  1. For functional disorders: Rest, NSAIDs if necessary, exercise therapy
  2. Avoid excessive rest and lack of exercise
  3. In the case of traumatic triggers, clarification and adequate treatment
  4. Only if necessary: muscle relaxants
  5. PT, especially KGG. Osteopathy
  6. Exercise therapy relapse prophylaxis, behavioural training/ergotherapy

DD

External links

  1. https://pmc.ncbi.nlm.nih.gov/articles/PMC9964474
  2. https://www.physio-pedia.com/Chronic_Low_Back_Pain

Asana practice and movement therapy

Chronic lower back pain can have many causes, including structural disorders in the lumbar region. These may require a different approach than purely functional disorders, which are often based on muscular imbalances or insufficiently strong muscles. In many cases of functional disorders, multifidus dysfunction is likely to be the cause. If scoliosis is present, e.g. due to a pelvic obliquity, the muscles on both sides of the body will be differently strong in different areas and under different levels of tone. Flexibility will also vary. In addition to treating the cause, such as an anatomical leg length difference or a functional leg length difference, it is also important to to put the muscles in a better condition so that the tone of no muscle is too high and the strength endurance of all muscles is sufficient. When choosing and performing strengthening exercises, it should be borne in mind that in most cases strength endurance is the much more important factor than maximum strength. Scolioses often show a clear difference in the body silhouette of both sides in lateral flexions of the spine. For example, if there is a left-convex lumbar spine scoliosis with a right-convex thoracic spine scoliosis, it is to be expected that lateral flexion in the lumbar region is much more difficult to the left, but is much more pronounced to the left in the thoracic spine. These disorders benefit most from customised therapy that addresses the areas of the spine differently, such as Schroth therapy. However, even a general isometric strengthening of the lateral flexor muscles at 0 degrees lateral flexion can have a very positive clinical effect, as it both reduces excessive tonus and strengthens underdeveloped muscles. In addition to the described shape anomaly of the spine in the frontal plane, deviations in the sagittal plane also frequently lead to chronic complaints in the lumbar region. Acquired damage to the spine, for example due to Morbus Scheuermann or Morbus Bechterew, very clearly predispose to complaints, in the first case they occur more frequently from around the age of 30. This is referred to as post-Scheuermann syndrome and is more pronounced in type 2 than in type 1, In ankylosing spondylitis, the entire back can be affected from the ISG region, and the tendency to contact hyperkyphosis of the thoracic spine may even need to be suppressed with pain medication. This requires a lot of spinal extensor training, both passive stretching training and strengthening of the extensor function of the autochthonous back muscles. In Morbus Scheuermann, hyperlordosis or steep positioning of the lumbar spine can also lead to significant symptoms, especially the latter due to hypertonicity of the lumbar musculature due to a hollow back. If the iliopsoas is involved as a shortened muscle in keeping the pelvis tilted forwards, this restriction in flexibility must be addressed.

The iliopsoas is a good example of how the muscles covering the hip joint can have an effect on the trunk and the lumbar spine area in particular. Of course, it is also important to check whether the hip extensors are sufficiently strong and not under too much tone.
Most of the functional complaints are likely to be localised in the autotonic back muscles themselves or sometimes also in the neighbouring quadratus lumborum. In most of these cases, strength training focussed on endurance is required. At the same time, a reduction in excessive tension can often bring significant relief from the symptoms. It should be noted that a large part of the autochthonous musculature not only serves the extensory function of the spine, but at least one other dimension of movement, so that combination movements will prove to be the more successful, especially combinations of flexion and rotation.

If pain radiates beyond the region of the lumbar spine towards the legs, this usually indicates a possibly structural disorder that requires clarification.
The development of this type of pain phenomenon is often caused by dispositional factors in the area of posture, sometimes also movement, especially sitting with a convexly curved lumbar spine, as well as carrying, holding or lifting movements with a curved back.