THE ROLE OF

NEUROREHABILITATION IN
LOW BACK PAIN SYNDROME

Dr Handojo Pudjowidyanto, SpS

Normal Anatomy of the Functional Spinal Unit (L4-5) and Associated Neural
Structures

Rathmell, J. P. JAMA 2008;299:2066-2077.

 DEFINITION
 Low back pain is difined as pain
and discomfort, localised below
the costal margin and above the
inferior gluteal folds with or
without leg pain
 LBP Classification:
 Acute
 Chronic

Karnath, Bernard . Clinical Signs of Low Back Pain.

2003
 Etiology/Risk Factor
 4 % have compression fracture
 1 % have a tumor
 1%-3% have proplaps
Intervertebral disc
 Ankylosing Spondylitis and
infeksi spinal are loss common
 Heavy physical work; frequen
bending, twisting, or lifting and
prolonged static postures
including sitting.

McIntosh G dan Hamilton Hall. Low Back Pain (Acute) Clinical

 LBP Classification:
 Acute Low back pain : low back
pain persisting < 6 weeks
 Sub acute low back pain : low
back pain persisting between 6
and 12 weeks
 Chronic low back pain : low
back pain persisting for 12
weeks or more.

Burton AK et al. European Guidelines For Prevention In Low

Back Pain. 2004
DIFFERENTIAL DIAGNOSIS AND ACCOMPANYING
SIGNS OF LOW BACK PAIN
Pain-Spasm-Pain (Vicious cycle)
Pain-Spasm-Pain (Vicious cycle)

ISCHEMIA

SPASM PAIN
 MANAGEMENT LOW
BACK PAIN

RECOMMENDATION
OF AMERICAN
COLLEGE OF 7 recommendations.
PHYSICIANS AND
THE AMERICAN PAIN Take a look the 7Th
Recommendation
SOCIETY
 RECOMMENDATION OF AMERICAN COLLEGE OF PHYSICIANS AND
THE AMERICAN PAIN SOCIETY : TREATMENT OF LOW BACK PAIN

 Recommendation 7: For patients who do not

improve with self-care options, clinicians should
consider the addition of nonpharmacologic
therapy with proven benefits—for acute low back
Neuro- pain, spinal manipulation; for chronic or subacute
low back pain, intensive interdisciplinary
rehabilitation rehabilitation, exercise therapy, acupuncture,
massage therapy, spinal manipulation, yoga,
cognitive-behavioral therapy, or progressive
relaxation (weak recommendation, moderate-
quality evidence).

Chou R et all. Clinical Guidelines. Diagnosis and Treatment of Low Back

Pain: A Joint Clinical Practice Guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med.
2007;147:478-491.
 GUIDELINES EUROPEAN

 Exercise therapy
 Manipulation/mobilisation
 Physical modalities
 Back schools and brief educational
nterventions/advice to promote self-care
Neuro- (Consider back schools where information given
is consistent with evidence-based
rehabilitation recommendations for short-term (<6 weeks)
technique 
pain relief and improvements in functional status)
Cognitive-behavioural treatment for patients with
chronic low back Pain
 Multidisciplinary biopsychosocial rehabilitation
with functional restoration for patients with
chronic low back pain who have failed
monodisciplinary treatment options.
Prevention Strategies

 Exercise and
strengthening exercises
 Weight loss?
 Smoking cessation?
 Improvement of
strenuous and stressful
working conditions
 Back braces are
ineffective in prevention

14
 Posture

BIOMECHANICS
PROPER BODY MECHANICS
REHABILITATION OF LOW
BACK PAIN

 Keep moving. (only a few days rest at

most)
 Pain relief:
◦ Modalities
 Exercise
 Pool therapy: swimming
 Bracing
 Psychological intervention
 Proper Body Mechanic
MODALITIES
 Thermal modalities.
◦ Cold therapy: Cryotherapy, icing.
◦ Superficial Heating: Infra Red, Hot Pack
◦ Deep Heating: Ultra Sound, Short Wave,
Microwave Diathermy
 Electrotherapy
 Traction
THERMAL MODALITIES
 Cold therapy:
◦ Icing
◦ Cryojet
◦ Decrease pain in acute
condition
 Transcutaneus Electrical Nerve
Stimulation (TENS)

Mechanism of action TENS :
1. Gate control theory (Melzack and
Wall)
2. Endogenous opiate pain-control
theory
No Stimulation Modes Frequency (Hz) Pulse/Phase Amplitude (mA)
Duration
(us)
1 Conventional High Short Low
(High Rate) (50–100 Hz) (50 – 80 us) (10 – 30 mA)
To produce tingling

2 Acupuncture Like Low Long High

(Low Rate) (1 – 4 Hz) (150 – 300 us) (30 – 80 mA)
To produce visible
contraction

3 Burst Low Long High

(<10 Hz) (100 – 300 us) (30 – 60 mA)
To produce visible
contraction
THERMAL MODALITIES
 Superficial heating:
◦ Infra red
◦ Hot pack
 Decrease pain
 Improve blood flow
 Reduce spasm
DIATHERMY
controll Pain, edema and muscle spasm

1. Haemodinamik effects
vasodilatation
 improve tissue oxygenation
2. Metabolic effect
Improved enzym activity
3. Neuromuscular
decreased pain perception  comfort feeling
4. Soft tissue
improved flexibility
Diathermy

 Mechanisme of action coneversion

electromagnetic wave thermal
 Magnetic field induced eddy current on
the tissue.
 Frequency : 27,12 mHz
 Applicator : Inductive coil
 Duration : 20 minutes, 3 x / week
THERMAL MODALITIES

Deep heating: Ultra sound

diathermy
 traction
 Mechanical load force to the bodily axis
 Effects:
1. Elongation to decreased muscle spasme
2. Break pain – spasme – ischemia circle
3. In some degree re-allignment vertebral curve
4. Correct Intervetebral disc placement (in some
literature)
 Maintain Posture and
Exercise
1. Correct posture
2. Maintain moderate level of physical
activity can help maintain lean body
tissue
3. Exercise

Kisner Carolyn in
Therapeutic Exercise,
2002
 Spine Exercise
• Core Stabilization
The primary functions of the muscle of the trunk are to provide
the stabilizing force ( core stability) against the effect of grafity so
that up right posture can be maintained

Kinestatic training, stabilization exercise and functional activities

are integrated over core stabilization.
Kisner Carolyn in
Therapeutic Exercise,
2002
Kinestetic Training procedure
Goal : develop proprioceptive awareness of posture, positioning and
safe movement
Active control posture
Cervical Retraction : to decrease a forward head posture
• Lightly touch above the lip under the nose and ask
the patient to lift the head up and away
• Verbally reinforce the correct movement of tucking
the chin in and straightening the spine and draw
attention to the it feel

Scapular Retraction : to correct protacted scapula

• For tactile and proprioceptive cues, gently resist
movement of the inferior angle of the scapula
and ask the patient to pinch them together
• Patient imagine holding a quarter between the
shoulder blades.

Kisner Carolyn in
Therapeutic Exercise,
2002
BACK EXERCISE
BACK EXERCISE
Low Back Flexion
Exercises
 Hayden JA et al, 2005, systematic review:
◦ Exercise therapy that consists of individually
designed programs, including stretching or
strengthening, and is delivered with
supervision may improve pain and function in
chronic nonspecific low back pain.

Ann Intern Med 2005;142(9):776-85

 van Tulder MW et al, systematic review:
◦ Exercise therapy was more effective than usual
care by the general practitioner and equally
effective as conventional physiotherapy for
chronic low back pain.
◦ Exercises may be helpful for chronic low back
pain patients to increase return to normal daily
activities and work.

◦ Cochrane Database Syst Rev.2000;(2) :CD000335

 Degenerative disease of facet joint:
◦ Pain can be induced with lumbar extension
maneuvers
◦ Avoid sleeping in prone position
 Spondylolisthesis grade 1 and 2:
◦ Patients treated with flexion rather than
extension have shown to have less pain and
less need for use of back support.
 Degenerative disc disease:
◦ Avoid flexion exercise
 Lumbar Stretching
• Self stretching the lumbar erector
spinal muscle and soft tissue
posterior of the spine.
Duration : 10 Second
Frequency : 3 repetation

Kisner Carolyn in
Therapeutic Exercise,
2002
FELDENKRAIS
FELDENKRAIS
FELDENKRAIS
FELDENKRAIS
FELDENKRAIS
FELDENKRAIS
FELDENKRAIS
 Muscle Performance
Goal :
1. Activate and develop neuromuscular
control of spinal stabilization muscle
2. Develop strength and endurance in
the postural and stabilizing muscle.

Kisner Carolyn in
Therapeutic Exercise,
2002
BRACING

 Short term:
◦ May enhance the patient’s feeling stability and
prevent joint motion to decrease the patient’s
pain
 Long term:
◦ Deconditioning of the surrounding musculature,
contracture of the joint capsule and loss of
bone density
LUMBO-SACRAL ORTHOSE

◦ Take some of the load of the lower back

and support abdomen and improve
posture
◦ May result disuse atrophy, restrict
motion and decrease bone density
◦ Limit the use to intermittently several
hours a day.
 Conclusion
 Back pain is a clinical syndrome, with
many etiologies
 Pain is just one of chain link in Low back
pain vitious circle
 One of the recommendations in LBP
treatment is rehabilitation