Deyo, MD, MPH, Weinstein, DO. Low back pain. NEJM. 2001; 344(5): 363-369. Early or frequent use of imaging (plain films, MRI, CT) is discouraged because disc & other abnormalities are common among asymptomatic adults. Degenerated, bulging, & herniated discs are frequently accidental findings, even among patients w/ Low Back Pain & may mislead to over diagnosis, anxiety, dependence on medical care, conviction about the presence of disease & unnecessary test or treatments. Sequential MRI studies reveal that the herniated portion of the disc tends to regress with time, with partial or complete resolution in 2/3ds of cases after 6 mo.

Deyo, MD, MPH, Weinstein, DO. NEJM. 2001; 344(5): 363-369. Differential Dx of LBP: Mechanical Back Pain: 97% (refers to anatomical or functional abnormality w/o malignant, neoplastic, or inflammatory disease.) Mechanical LBP or leg pain: lumbar strain, sprain (70%): DJD of discs & facets (10%); Herniated disc (4%); Spinal Stenosis (3%); Osteoporotic compression Fx (4%); Spondylolisthesis (2%); Traumatic Fx (<1%); Congenital disease (<1%) [severe kyphosis, severe scoliosis, transitional vert]; Spondylolysis, Internal disc disruption or discogenic LBP; Presumed instability. No mechanical Spinal Conditions: (about 1%): Neoplasia (0.7%); Infections (0.01%); Inflammatory Arthritis (0.3%): ankylosing spondylitis, psoriatic spondylitis, Reiter’s syndrome, inflame bowel dis, Scheuremann’s, Paget’s. Visceral Disease (2%): Disease of pelvic organs: prostatitis, endometriosis, Chronic PID; Renal disease; Aortic aneurysm; GI disease: pancreatitis, cholecystitis, penetrating ulcer.

Kader, MD et al. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clinical Radiology 2000;55:145-149. MRIs of 78 BP Pts (17-72 yrs) w/ or w/o leg pain were analyzed for lumbar multifidus (MF) atrophy, disc degen & N root compression. Multifidus atrophy was present in 80% of Pts w LBP & was bilateral in most cases & at L4/L5 & L5/S1 levels together. Muscle atrophy was more common in older Pts & females. The correlation between Multifidus atrophy & leg pain was significant. Atrophy of Multifidus may explain referred leg pain in the absence of other Multifidus abnormalities & should be assessed in MRIs of lumbar spine. Multifidus are innervated unisegmentally by the medial branch of t dorsal ramus. Multifidus wasting may be caused by the Lumbar Dorsal Ramus Syndrome: LBP w/ referred leg pain induced by irritation to structures innervated by the dorsal ramus nerve, (facet jts, MFs, interspinous ligs, or by myofascial injury) due to acute or chronic trauma wh initiates myofascial pain, spasm & ischemia. This triggers a self-sustained vicious cycle that promotes muscle atrophy.

Graves, PhD et al. Arch Phys Med Rehab 1994; 75: 210-15. Training w/o pelvic stabilization resulted in no improvement in strength of lumbar extensors. Training w pelvic stabilization showed significant improvement in lumbar extensor strength. The magnitude of improvement in the fully extended ROM was 120% at full extension to 42% at full flexion. This demonstrates the unique potential of the lumbar muscles to adapt to specific resistive exercise. Research suggests that large strength increases in the isolated lumbar extensor muscles are due to the fact that these muscles are initially very weak. Because lumbar extensors are rarely isolated during normal daily activities, they seldom encounter an overload stimulus required to gain strength. These muscles are weak before training because they exist in a state of chronic disuse. Trained lumbar extensors have a greater strength & would be able to handle greater external loads & be more resistant to fatigue.

Morton, PT, M Hth Sc. Manipulation in the treatment of acute low back pain. J Manual & Manip Ther 1999;7(4):182-189. Prospective study of 29 Pts w Acute Low Back Pain (4 wks or less) randomized to 2 treatment groups: Group 1) 15 subjects receive Spinal Manipulation & stabilization exercises (to contract multifidi & improve co-contractions between multifidi & abdominal muscles); 2) 14 subjects receive stabilization exercise program alone. Pts got Spinal Manipulation 2X/wk for total of 8 treatments. Post-Treatment assessment performed weekly for 4 wks, then w/o further spinal manipulation but continuing exercise program at 2 mo & 3 mo. Outcomes: ROM, Roland-Morris, VAS taken at initial visit, at the end of each week, at 2 & 3 mo. Results: Significant differences between groups appears at 1 wk for pain & ROM & at 4 wks for disability. All 3 outcomes increase further w time. Acute Low Back Pain Pts who receive Spinal Manipulation + exercise program improve to a greater extent than Pts who receive t exercise program alone. At 3 mos, Group 1 (Spinal Manipulation & exercise group) had a mean disability score on the Roland 90.3% less than exercise alone group. 11 of 15 Pts in Group 1 had no disability at 3 mo vs only 1 in 14 in Group II (exercise alone). At 3 mo Group 1 had a mean pain score 100% less than Group II. None of the 15 Pts in group 1 had pain at the end of 3 mo, vs 13 of 14 in group still had pain. At 3 mo, Group 1 had mean ROM 46.44% more than group II. Conclusions: Pts who receive Spinal Manipulation + exercise for Acute Low Back Pain will improve more & faster than Pts who receive exercises alone. The difference between the groups appears early. Spinal Manipulation also appears to be cost-effective.