Background & Etiology
The lower back can be divided functionally and anatomically into three separate areas, the lumbar spine, the sacrum, and coccyx. The lumbar spine includes five lumbar vertebra (L1-L5), and five intervertebral discs.
The vertebra of the lumbar spine are the largest vertebra in the body because they carry the most weight and are subject to the greatest amount of stress. That being said, it is the area most frequently associated with back pain. The motions of the lumbar spine (in order of greatest to least) include flexion (bending forward), extension (bending backward), side bending, and rotation right and left (turning).
The two lowest levels (L4-L5) and (L5-S1) have the most flexion and extension motion stress, and the highest rate of injury. The intervertebral discs of these two levels also have the highest rate of disc degeneration and herniation. The L5 vertebra is the most common site of spondylosis and spondylolisthesis.
Each vertebral level of the spine consists of three joints. There is a joint between the bodies of two vertebra connected by an intervertebral disc, and two facet joints, which connect the vertebra. The facet joints are on the posterior aspect of the spine, one on each side. These three joints form a tripod system. The function of the facet joints is to provide support, stability and mobility to the spine. In addition to promoting mobility these joints also function to restrict excessive motion. This allows the spine to move with precision.
The facet joints are synovial joints, which have articular cartilage that covers the ends of the bones. The articular cartilage has a smooth and shiny surface, which allows the ends of the bones to slide freely over each other. In addition, each joint is surrounded by a protective sleeve of soft tissue called a capsule, and is lubricated by synovial fluid. Each joint can be a source of pain if irritated or inflamed
Degenerative joint disease
Arthritis is a noninfectious progressive disorder of the joints. The normal articular joint cartilage is smooth, white, and translucent. In early arthritis or joint degeneration, the cartilage becomes yellow and opaque with localized areas of softening and roughening of the surfaces. As degeneration progresses, the soft areas become cracked and worn, exposing bone under the cartilage. Eventually, osteophytes (spurs of new bone) covered by cartilage form at the edge of the joint. As mechanical wear increases, the cartilage cells are unable to repair themselves.
The majority of degenerative joint disease is the result of mechanical instabilities or aging changes within the joint.
Degenerative joint disease is a common cause of low back pain. The lumbar facet joints, like other synovial joints of the body, are susceptible to wear and tear, degeneration, inflammation and arthritic changes. Inflammation and degenerative changes to the facet joints may result in pain, loss of motion, and if severe encroachment or pinching of the nerve exiting the spinal column. Common causes of facet joint irritation include the following:
- Degeneration, arthritic changes, or general wear and tear of the joint over time.
- Disc degeneration may cause a loss of height between the vertebra placing a greater compression force on the posterior facet joints increasing and accelerating wear and tear on these joints.
- Extension (backward) motions can produce compression on the facet joints, which can lead to degenerative, and eventual arthritic changes.
- Sudden fall or trauma, like a motor vehicle accident, can result in a facet joint irritation, increasing and accelerating wear and tear on joints.
- Genetic factors can contribute to the likelihood of degenerative joint disease.
- Repetitive stress injuries like lifting or carrying heavy loads can cause facet joint irritation and degenerative joint disease.
The symptoms of degenerative joint disease will depend on the location of the joint and what structures are affected. Symptoms can vary from mild to severe and may mimic the symptoms of a disc problem:
- Pain in the back or radicular to the buttock, into the leg and extending down behind the knee, but barely in the front of the leg or in the foot.
- Pain and tenderness localized at the level of the involved facet joint.
- Muscle spasm and changes in posture in response to the injury.
- Loss of motion like the inability to bend backward, move sideways to the effected side, or stand erect for extended periods of time.
- Standing and walking can be difficult if the irritation is severe.
- Sitting is usually more comfortable.
- Loss of the normal lumbar curvature or lordosis.
- Development of stenotic-like symptoms.
- Stiffness in the joints following a period of rest.
- Pain with excess activity and relief with rest.
- Localized swelling at the joint level may be present.
Treatment of degenerative joint disease or injury will depend on the severity of the condition. When treating acute back problems:
- Rest: avoid the activities that produce the pain (bending, lifting, twisting, turning or bending backwards).
- Medication to reduce inflammation (anti-inflammatory drugs and pain medication).
- Ice in acute cases: apply ice to the lumbar spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Moist heat may be helpful to reduce pain and improve any feelings of stiffness.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative joint disease and improve joint mobility, spinal alignment, posture, and range of motion.
- Bracing or the use of supports may be necessary to reduce stress on the facet joints, muscles and lumbar spine.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Facet joint injections directly to the involved joint.
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function.
In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe
If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement, including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures.
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with facet joint injuries.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Condition
In the case of conditions that do not respond to conservative care, surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain
- Pain or nerve irritation that gets worse
- Associated disc involvement
If the symptoms of degenerative joint changes have compromised the nerves that exit from the intervertebral foramen, nerve root entrapment may occur. This causes radicular pain, weakness, and stenotic-like symptoms. In this case, surgery may be indicated to release entrapment and remove the degenerative changes that are compromising the nerve. One such procedure is called a Foraminotomy.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal Examination where the patient is put through a series of movements and tests to determine the most probable cause of the condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. An examination of the dynamic and static postures that may have caused or contributed to the back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for lumbar degenerative joint disease must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation, load and stress on the affected area. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.
Common Physical Therapy interventions in the treatment of lumbar degenerative joint disease include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the lumbar spine. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to restore joint mobility, range of motion, and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses placed on the spinal joints, discs, and back.
- Neuromuscular Re-education (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation of spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Most degenerative joint problems can be managed conservatively without surgery and return to normal function. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients need to continue with a regiment of stretching, strengthening and stabilization exercises. Use of proper mechanics, proper posture, body mechanics and awareness of the do’s and don’ts for a healthy back is necessary for a good long-term prognosis. The attitude of, “once you have a back problem, you have a back problem” goes a long way to preventing further injury. Treatment cannot reverse the degenerative changes that have occurred but can slow the progression and help manage and improve the quality of life.