Low back pain syndrome and associated conditions
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Low Back Pain Syndrome and Associated Conditions. Developed for OUCOM CORE by Craig Warren, D.O. Edited by Mindy Ford, D.O. and the CORE Osteopathic Principles and Practices Committee. Low Back Pain. Annual US prevalence is 15-20%

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Low back pain syndrome and associated conditions l.jpg

Low Back Pain Syndrome and Associated Conditions

Developed for OUCOM CORE

by Craig Warren, D.O.

Edited by Mindy Ford, D.O.

and the

CORE Osteopathic Principles and Practices Committee

Low back pain l.jpg
Low Back Pain

  • Annual US prevalence is 15-20%

  • 2nd most common symptomatic reason for visits to primary care physicians.

  • 90% of all episodes will resolve within 6 weeks regardless of treatment

  • 90% of all persons disabled for more than 1 year will never work again without intense intervention

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Low Back Pain

  • Most common cause of disability in people younger than 45.

  • 1% of U.S. population is chronically disabled due to back problems.

  • 1% of U.S. population is temporarily disabled due to back problems.

Definitions l.jpg

  • Acute LBP: Back pain <6 weeks duration

  • Subacute LBP: back pain >6 weeks but <3 months duration

  • Chronic LBP: Back pain disabling the patient from some life activity >3 months

  • Recurrent LBP: Acute LBP in a patient who has had previous episodes of LBP from a similar location, with asymptomatic intervening intervals

Origins of low back pain l.jpg

Referred pain from visceral disease

Non-activity related:




Acquired defects

Intra-spinal lesions

Metabolic disorders

Activity related spinal disorders:

Disco dural or disco radicular



Non-organic causes

Origins of Low Back Pain

Initial assessment l.jpg

Focused HxCC, PMHx, FMHx, PE

Be aware of Red Flags

Findings that suggest a serious underlying pathology

Refer to chart on next slide

In absence of Red Flags, imaging studies and further testing not helpful in first 4 weeks.

Initial Assessment

Differential diagnoses l.jpg

Aortic Aneurysm


Bony metastasis

Vertebral Osteomyelitis

Epidural abscess


Pelvic pathology

Abdominal pathology

Herniated disc

Compression fracture

Rheumatoid arthritis

Degenerative joint Disease


Ankylosing spondylitis

Cauda equina syndrome


Strain/ sprain

Differential Diagnoses

Viscerosomatic considerations l.jpg

10% Medical Cause





Primary cancer metastatic to bone


90% Musculoskeletal Cause

Somatic Dysfunction

Postural Decompensation

Viscerosomatic Considerations

Symptoms of benign lbp l.jpg

Dull and achy quality

Diffuse aching with associated muscle tenderness

Exacerbated with movement

Relieved with rest in recumbent position

No radiation, paresthesias

No dermatomal pattern

Pt. is able to find a position of comfort

DTR are within normal limits

Symptoms of Benign LBP

General considerations l.jpg
General Considerations

  • The history is of vital importance.

  • Go slowly, be patient. Listen to the patient.

  • Goal is to ascertain the cause for low back pain.

  • Somatic dysfunction is not a cause for low back pain.

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Important aspects of the history

  • Age of patient

  • Daily activities

  • Symptoms:

    • Pain, paresthesia, radiation, weakness

    • Influence of posture/activity

    • Bowel/bladder incontinence

    • Saddle anesthesia

    • ROS, including constitutional, possibly gastrointestinal, gynecologic

Pain history l.jpg
Pain History

  • Localization:

    • Where does it hurt? central, unilateral, bilateral

    • Does the pain go anywhere? upper lumbar, lower lumbar, gluteal, perineal, legs

  • Onset:

    • When did the pain start? days, weeks, months, years

    • How did the pain start? suddenly, gradually

  • Severity:

    • 0-10 Scale: Current? Average? Worst?

Pain history14 l.jpg
Pain History

  • Evolution:

    • How has the pain changed over time?

  • Relationship to activity:

    • What postures or movements worsen the pain?

    • Does it hurt to cough or sneeze?

    • Does the pain wake you at night?

    • What makes the pain better?

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General Impression

Is there a problem?

What regions exhibit a problem?

Osteopathic Exam

  • Diagnostic Characteristics

  • What

    • What are the specific characteristics of the identified segment(s)?

Screening l.jpg

  • Appropriate screening includes the following the regions

    • Thoracic

    • Lumbar

    • Sacral

    • Pelvic

    • Lower extremities

Physical exam l.jpg



Range of motion




Toe raise

One legged Extension

Inspection: for deviation, scoliosis, muscle wasting. Skin/hair changes

ROM: range, pain, deviation, painful arc.

Toe raise: neurological testing, motor, S1/2

One leg extension: loading of pars interarticularis

Physical Exam

Physical exam18 l.jpg


Muscle strength

Sensory testing

Plantar reflex

Sacroiliac joint


Hip joint


Dural tension signs


Sacroiliac screening

Hip screening

Dural tension signs L4-S2



Patellar Reflex

Achilles reflex

Muscle strength

Neurological testing


Motor L2-S2

Sensory L2-S2


Physical Exam

Physical exam19 l.jpg


Dural tension signs

Femoral stretch


Spinous processes

Interspinous ligaments

Iliolumbar ligaments

Sacroiliac ligaments

Neurological testing

DTR S1/2

Motor L2/3, S1/2

Dural tension signs L3 nerve root

Palpation: of osseous and ligamentous structures.

Physical Exam

Lbp osteopathic considerations l.jpg
LBP – Osteopathic Considerations

  • What will be your highest yield regions?

    • How does previous trauma influence these regions?

  • Which 1 or 2 of the aspects below has the greatest influence on the patient complaint?

    • Pain

    • Hyper-sympathetic influence

    • Parasympathetic influence

    • Fluid Congestion

  • Devise a focused examination based on the patient’s complaint

    • What are your expected findings?

    • Your expected palpatory findings (TART/STAR) ?

    • What are the acute or chronic aspects?

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LBP – Osteopathic Considerations

  • Propose an appropriate differential diagnosis

  • Devise an appropriate treatment plan based on musculoskeletal components involved in the patient complaint

    • What are the dose and frequency considerations?

    • What are the OP – IP – ER considerations?

  • Devise an appropriate manipulative approach or technique w/indications and contraindications

    • How are you going to talk to your patient about their complaint?

    • How will you communicate your findings, diagnosis, and treatment to your preceptor?

Treatment sequence l.jpg
Treatment Sequence

  • Leg restrictors

  • Pubes

  • Superior innominate Upslip (shear)

  • Lumbar Spine

  • Sacrum

  • Innominate

  • Iliopsoas

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Sequence Rationale

  • Leg restrictor muscle problems will affect the bony attachments of the innominate, sacrum, and pelvis

  • Treatment of the innominate, sacrum or pelvis will not be as effective without treating leg muscles first

  • Articular dysfunction will return more rapidly if muscular problem not resolved during treatment

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Treatment Techniques

  • Techniques that could be used include:

    • Direct techniques:

      • HVLA

      • Muscle Energy

      • Articulatory

    • Indirect techniques:

      • Strain Counterstrain

      • Functional Methods

Met lumbar fr l s l seated technique l.jpg
MET – Lumbar – FRLSLSeated Technique

  • Patient seated:

    • left hand holding right shoulder

    • Pt’s right arm dropped at the side

  • Operator:

    • straddles pt’s left knee & left hand grasping the pt’s right shoulder

    • Control the pt’s left shoulder with the left axilla

    • Right middle finger monitors the L4-5 interspinous space

    • Right index finger monitors the left transverse process of L4

  • Localization:Trunk Translation Anterior to Posterior to introduce L4-5 Flexion

Greenman, English 2nd ed., p.282

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MET – Lumbar – FRLSLSeated Technique

  • Pt side bends left against operator resistance

  • Isometric contraction, relax, reposition, repeat until sidebending & rotation resolution

  • Forward bend the pt (to fully open zygapophysial joints) while maintaining right rotation

  • Pt attempts extension

  • Pt cooperation: Ask the pt to reach for the floor to help introduce right sidebending & rotation

Greenman, English 2nd ed., p.282-3

Met lumbar fr l s l lateral recumbant technique l.jpg
MET – Lumbar – FRLSLLateral Recumbant Technique

Fine tune extension by moving shoulders posterior to feather edge of L4 movement

Maintain shoulders perpendicular to table for right sidebending

Fine tune extension by moving shoulders posterior to feather edge of L4 movement

Fine tune extension from below via the lower extremities

Met lumbar fr l s l lateral recumbant technique29 l.jpg
MET – Lumbar – FRLSLLateral Recumbant Technique

  • LE abduction enhances R SB from below & sets pt up for ME effort – adduction

  • Repeat

  • Pt reaches behind under guidance to grasp side of table; this enhances right rotation & sidebending

  • Left hand cephalad translation to barrier; (for right sidebending)

  • Right elbow resists pt attempt to turn left

  • Repeat

Greenman, English2nd ed.,p.292

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Neutral Technique Slide

Neutral SRRL

Notice the physician’s right arm under the pt’s right axilla – allows easy sidebending left.

Physician’s Left Thumb palpates the posterior transverse process.

Slide31 l.jpg

References l.jpg

  • Ward, R.C., Foundations for Osteopathic Medicine, 1997, Williams and Wilkins, Baltimore, MD: 337-345, 591-592, 583.

  • Acute Low Back Pain, MCARE Guidelines, 2005, http://mcare.org/media/pdf_autogen/cpg_lowbackpain_mcare05.pdf