Therapeutic management for Low Back Pain By Dr Arman MD (Course) Physical Medicine & Rehabilitation, Dhaka Medical College, Bangladesh.

1. Therapeutic management for
Low Back Pain
Dr. SM Arman Hossain
MD Resident (Phase-A)
Physical Medicine And Rehabilitation
Dhaka Medical College
Olive Unit, Rheumatology, BSMMU

2. Low Back Pain
Pain that occurs in an area with boundaries between the
lowest rib and the crease of the buttocks

3. Low Back Pain
• most common musculoskeletal complaint worldwide
• 85 percent of all people experiencing LBP during their
lifetimes
• Increasing incidence between age 35- 55 yrs
• 90% resolve within 4 to 6 weeks

4. Anatomy of Lower back
• Lumbar Vertebrae
• Sacrum
• Coccyx
• Ilium
• Sacro-iliac Joint

5. Anatomy of Lower back
pars interarticularis
Lumbar vertebrae

6. Anatomy of Lower back
Intervertebral Disc

7. Disc Problems

8. Anatomy of Lower back
Soft tissue (Muscles)
• Psoas Major/minor
• Quadratus lumborum
• Intertransversalis
• Multifidus
• Erector spinae

9. Anatomy of Lower back
Soft tissue(Ligaments)
• Anterior longitudinal
ligament
• Posterior longitudinal
ligament
• Interspinous ligament
• Supraspinous ligament
• Ligamentum flavum

10. Classification of LBP
LBP Dutation
Acute < 6 Weeks
Sub-acute 6 - <12 weeks
Chronic 12 or >12 weeks
Recurrent having previous episodes with pain free
intervals

11. Treatment of Acute LBP
• Analgesics (Acetaminophen, NSAIDs, Opioids)
• Activity(Should continue their usual activity within the
limits permitted by pain)
• Cold Packs or Heat(Recommend for first 72 hours)
• Multidisciplinary Treatment Programs

12. Treatment of Sub-acute & chronic LBP
• Pharmacological (Acetaminophen, NSAIDs, Opioids)
• Psychological (Watch out for mood disturbances, substance
use, behavioral problems): Low dose antidepressant have a
small to moderate effect
• Procedural (Epidural Steroid Injections)
• Physical
• Rehabilitation

13. Exercise-based therapy for low back pain
Goals of Exercise-based therapy for low back pain
• To stress both damaged and healthy supporting tissue to
promote tissue repair
• Improves structural impairments in our spine and pelvis
• Relieves pain or modifies our current pain experience
• Return us to our normal activities as quickly as possible

14. Therapeutic exercises for nonspecific chronic LBP(NCLBP)
90/90 rest position
• The 90/90 rest position for patients with low back pain is
achieved by lying on a flat surface and flexing both hips and
knees to 90 degrees.

15. Therapeutic exercises for nonspecific chronic LBP(NCLBP)
Posterior pelvic tilt
• The posterior pelvic tilt is a basic maneuver in back
rehabilitation. The abdominal and gluteal muscles are
contracted to flatten the lumbar spine. This position is held for
5 to 10 seconds and can be repeated frequently.

16. Therapeutic exercises for nonspecific chronic LBP(NCLBP)
Abdominal curl
• This exercise strengthens abdominal muscles. It should be
performed on a firm surface with knees bent.
• The subject raises the trunk no more than 6 inches from the
surface. Arms may be folded across chest or stretched forward
as shown.
• Hold position for ten to 20 seconds and breathe. Repeat 6 to 10
repetitions

17. Therapeutic exercises for nonspecific chronic LBP(NCLBP)
Single knee to chest
• Lie on your back with your knees bent and your feet flat on the
floor
• Bring one knee to your chest, keeping the other foot flat on the
floor
• Relax and lower the knee to the starting position
• Repeat 2 to 4 times with each leg

18. McKenzie Method
• It is a philosophy of active patient involvement and education
for back, neck and extremity issues
• The goal of McKenzie Method is to centralize the pain or
move the pain from the leg into the low back
• Useful In-
- Lumber radiculopathy
- HNP/Lumber Disc prolapse
- Recurrent or chronic back pain

19. Exercise 1: Lie Prone
• Lie prone, arms down the side of body, face turned to either
side
• Take a few deep breaths and then mentally relax the muscular
tension from the lumbar area completely for 2-3 minutes
• Done at beginning and end of each exercise session

20. Exercise 2: Prone on Elbows (Elbow drop)
• Now move further into spinal extension by placing elbows
under the shoulders
• Take some deep breaths and continue to mentally relax all the
lumbar muscles
• Stay in this position 2-3 minutes
• Always follows: Lie in Prone, done once per session
• Useful for more severe low back pain

21. Exercise 3: Prone on Hand (Lumbar Extension in Lying)
• Put hands under shoulder and straighten the elbows and push
the upper body up as far as pain permits
• Mentally relax the pelvis, hips and legs and let the back sag
• After 1-2 seconds, return to the elbows position
• Can be held longer if pain is centralizing
• Move through each repetition smoothly 10 times and each time
try to raise the upper body a bit higher until the back is
extended as much as possible and the arms are straight

22. Exercise 4: Standing Back Extension
• With feet slightly apart, hands on the low back with
fingers pointed down & towards the spine (fingers
should touch at the sacrum). Thumbs point forwards
• Keeping your knees straight with hands acting as a
fulcrum, bend backwards at the waist(trunk extension)
• Hold the position 1-2 seconds
• As with exercise 3, smoothly repeat the motion and
try to increase the range of extension with each rep

23. Exercise 5: Flexion in Supine (Knee to chest)
• Supine with bent knees and feet on floor/bed
• Bring knees to the chest
• Gently bring both knees to the chest with arms(as can tolerate)
• Breathe out as pull knees to chest
• Hold knees to chest 1-2 seconds, then return to supine with bent knees
• Do NOT raise the head or straighten legs during this exercise

24. Exercise 6: Flexion in Sitting
• Only start this exercise after complete at least one week of Exercise #5:
Flexion in Supine
• Less risk of re-injury in supine versus sitting
• Sit on the edge of a chair with knees and feet more than shoulder width
apart and let the hands
• Hang down to the floor between the legs
• Bend forwards at the trunk to touch the floor
• Return immediately to the starting position.
• Do reps smoothly and rhythmically, going
further down each time as can tolerate

25. Exercise 7: Flexion in Standing
• Only start this exercise after complete at least two weeks of Exercise #5:
Flexion in Supine
• Less risk of re-injury in sitting rather than standing
• For the first three pain-free months, do NOT
do this during the first four hours of your day
• Stand with feet shoulder width apart and bend
forward at the trunk, running hands down legs
towards the ground
• Return immediately to the starting position.
• Do reps smoothly and rhythmically, going
further down each time as can tolerate

26. Exercises: What to Look For
• Exercising Correctly if:
- Pain centralizes and decreases
- ROM increases
• Exercising Incorrectly if:
- Pain moves away from the spine or increases (or stays the
same)
- ROM decreases

27. NASS Guideline
National Ankylosing Spondylitis Society (NASS) recommend
some exercise which is useful in different disease associated with
low back pain like –
- Ankylosing Spondylitis
- Lumber Spinal Stenosis

28. 1. Exercises in lying
• Starting position: Lying on your back, both knees bent, feet
on floor
• Bridging: Lift your hips off the floor as high as possible, hold
for 5 seconds and lower slowly

29. 1. Exercises in lying
• Spinal Rotation: Lift your arms up in front towards the
ceiling, with fingers linked
• Take your arms to the right as far as possible while taking your
knees to the left as far as possible. Turn your head to the same
side as your arms. Repeat to the opposite side

30. 2. Exercises in 4 point kneeling
• Starting position: Kneel on all fours. Keep your hands
shoulder width apart and directly under your shoulders. Keep
your knees hip width apart and directly under your hips
• Cat Stretch (spinal flexion & extension): Keeping your
elbows straight throughout, tuck your head between your arms
and arch your back as high as possible

31. 2. Exercises in 4 point kneeling
• Superman Stretch (spinal extension):
Keeping your head looking forward, raise your right arm
forwards as you raise your left leg backwards to be parallel with
the floor. Hold for 5 seconds. Return to all fours and change to
raising your left arm and right leg

32. 3. Chair Exercises in sitting
• Starting position: Sit on a stable kitchen/dining
room chair with your feet on the floor, hooked
around the legs of the chair
• Spinal side flexion: Place your hands by your
sides. Hold the back of the chair with your left hand.
Bend sideways as far as possible, without bending
forwards, reaching your right hand towards the floor.
Repeat to the opposite side

33. 3. Chair Exercises in sitting
• Spinal Rotation: With your hands clasped on your forearms at
shoulder level, turn your upper body to the right as far as
possible. Repeat to the opposite side

34. 3. Chair Exercises in sitting
• Neck Rotation: Hold the sides of the chair seat. Turn your
head to the right as far as possible without letting your
shoulders turn. Repeat to the opposite side

35. 4. Leg Stretches
• Hamstring stretch: Stand facing a kitchen chair, with a
padded seat for comfort. Place your right heel on the seat,
keeping the knee straight, and reach forwards as far as possible
with both hands towards your foot. Feel the stretch at the back
of your right thigh. Hold for 6 seconds. Relax
• Repeat twice, stretching a little further each time. Relax
• Repeat with the opposite leg

36. 4. Leg Stretches
• Hip flexor stretch
Face the side of the chair and hold the
chair back with your right hand
Bend your right knee and place your
right shin on the seat

37. 4. Leg Stretches
• Place your left foot forward as far as possible
• Now place both hands behind your back. Bend
Your left knee as much as possible, keeping your
head up and your back straight
• Feel the stretch at the front of your right hip
• Hold for 6 seconds. Relax
• Repeat twice, stretching a little further each
time. Relax
• Turn round to face the other side of the chair
• Repeat with the opposite leg

38. 5. Posture Stretch
• Stand with your back to the wall, shoulders and
buttocks against the wall and heels as close to
the wall as you can. Tuck your chin in and push
the back of your head towards the wall. Keep
your shoulders down
• Stretch up as tall as possible without lifting
your heels. Hold this position. Raise your right
arm forwards and upwards while keeping your
elbow straight, your upper arm close to your
ear and your thumb towards the wall. Lower
and repeat with opposite arm

39. Clearing up the terms
Spondylosis
Degenerative joint disease affecting the vertebrae and
intervertebral disc
Spondylolysis
Fracture in pars interarticularis
Spondylolisthesis
condition in which a fracture of the pars interarticularis
causes one vertebral body to slip forward on top of the
vertebral body below it.

40. Spondylolysis & Spondylolisthesis

41. Therapeutic exercises specific for Spondylolysis & Spondylolisthesis
Following are specific
exercises for Spondylolysis &
Spondylolisthesis patients.
Performing technique of these
exercises are discussed
previously.

42. Therapeutic exercises & ADL for nonspecific LBP
• Patient should remain active- movement helps to relieve
muscle spasms and prevents loss of muscle strength
• Bed rest may be necessary for a short period of time, generally
no more than one day
• Using a heating pad can help with low back pain during the
first few weeks. It is not clear if cold packs help as well.
• Should avoid prolonged standing or sitting, heavy lifting, and
twisting
• While standing at work, stepping on a block of wood with one
foot (and periodically alternating the foot on the block) may be
helpful.

43. ADL for nonspecific LBP
Body Mechanics
• Push vs. Pull
• Keep Work Within “Strike Zone”
• Keep Load Close To Body
• Use Abdominal Bracing
• Team Work vs. Mule Work

44. ADL for nonspecific LBP
Sitting Posture
• As you sit down, you should pull these sit bones away from each
other.
• Your pelvis should be tucked into the back of the chair and slightly
tilted forward.
• Distribute weight evenly between both buttock cheeks and ensure
that you do not lean to one side
• Your upper back should remain up right. Do not hunch your back!
Don’t be lazy! Sit up straight!

45. ADL for nonspecific LBP
Sleeping posture
• Bed rest may be necessary for a short period
of time, generally no more than one day
• If back pain is severe, the most comfortable
position may be to lie on the back with a
pillow behind the knees and the head and
shoulders elevated
• or to lie on the side with the upper knee bent and a pillow
between the knees

46. ADL for nonspecific LBP
Proper Lifting Technique
• Wide base of support
• Feet shoulder width apart
• Back straight
• Head and shoulders up
• Bend at hips and knees - NOT BACK!
• Keep load close to body
• Tighten stomach muscles
• Use leg, hip and buttock muscles
• Breathe out with lift

47. Therapeutic exercises for nonspecific LBP
Aerobic exercise
• Bicycling, swimming, treadmill walking, and elliptical trainers
• Simplest and most readily available form of exercise
• Decreased pain intensity and improve the physical functioning
over time in patients with chronic LBP
Aquatic exercise
• The aquatic exercise is well suited for many soft tissue
conditions, including low back pain.

48. Therapeutic exercises for nonspecific LBP
Pilates
• Technique of exercise that focuses on performing controlled
movements of the whole body
• Start with the center or core (back and abdomen) and flow
outward towards the limbs
• Proponents report useful health benefits including body
alignment, breathing, strength, coordination and balance
• This form of exercise can be adapted to treat LBP

49. Therapeutic exercises for nonspecific LBP
Yoga
• Yoga refers to spiritual and physical practices that promote
controlled breathing, specific stretches, body positions, and
meditation
• Associated with small improvements
in pain
• The effect did not reach the
pre specified threshold for clinically
meaningful improvement

50. Therapeutic exercises for nonspecific LBP
Tai Chi
• Chinese martial art practiced for both its defense training and its
health benefits
• mind-body exercise therapy that has been used to manage
chronic pain conditions

51. How do we take care of our back?
• Body Mechanics
• Proper Lifting Techniques
• Maintain safe postures
• Keep physically fit
• Good nutrition
• Stretch and exercise

52. There are 1440 minutes in every
day...Schedule 30 of them for
physical activity

53. Thanks for your patience listening