By Dr. Yoon Jeon. MChiro, MB, BSc, Dip.TCM, PGCert.
A 44 year-old office worker, presented to the clinic complaining of low back pain for more than 10 years. The pain comes and goes and was usually mild dull aching, but it is continually last one months and getting worse. He denied any bladder or bowel changes. The pain became worse as the day goes by and by the afternoon, He finds that walking, standing and even lying down is almost impossible to perform due to intensive pain. He also reported no other associated sign & symptoms such as leg pain, numbness or weakness.
On the physical examination, tenderness over Lumbar paraspinal muscles (Low Back Muscles), restricted painful L4/5 (Lower back joint) on springing & motion palpation are noted, but Lumbar AROM (Low back movements) is pain free and full except lumbar extension leading to the pain on L4 (Lower back region) bilaterally. It indicates the facet lesion (Spinal joints) is also suspected. In orthopaedic tests, supported Adam’s test and Adam’s test both cause mild ache pain on bilateral L3/4 region, it may indicate a lumbar lesion rather than Sacroiliac joint (Pelvic joint). Bilateral Yoeman’s causing bilateral L4/5 aching pain suspects a lumbar facet or lumbar sprain/strain. In addition, Fabere, Laugerre’s and hip stress test rule out of a hip joint pathology. Right - Strait Leg Raise (the mild painful on right L4/5 at 80 degree) and SMR (Sensory-Motor-Reflex) test: Ve- rules out of neurogenic pathology.
Overall, the lumbar myofacial pain syndrome with associated lumbar facet dysfunction is most likely suspected. The quadratus lumborum (QL) is the most frequent muscular cause of low back pain and may account for over 30% of musculoskeletal pain complaints seen by manual practitioners (J. Travell & D. Simons, 1992). And lumbar facet dysfunction also seems to account for a significant number of low back complaints (Souza, 2001).
Chiropractic Spinal Adjustment / Manipulation
Lunmar Facets Mobilization
Dry needling (Acupuncture)
Self-home Stretching Exercises.
Intensive course of spinal manipulation is commonly highly effective for the lumbar facet syndrome. (Cook, J. 2004). Mobilisation of the patient should be of benefit, and long term bed rest and inactivity must be prevented. Putting a Acupuncture needle into a spasmed muscle causes the muscle to relax. This can be seen with an electromyogram. (Cummings & White, 2001) Extension exercises may reduce neural tension. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia. Exercise training can begin after the patient has passed successfully through the pain control phase. The key is to attain adequate musculoligamentous control of lumbar spine forces to minimize the risk of repetitive injury to the intervertebral discs, facet joints, and surrounding structures. Start with isometrics, then progress to isotonic exercises with effort directed at concentric strengthening. A home programe is developed within the tolerance and ability of the patient in order to encourage continued exercise after discharge. (Von Korff, M. & Moore, J.C. 2001). Also the rehabilitation also be considered with a regular treatment, because of his chronic condition and improvement of muscular strength and endurance.
The patient came back 3 days later and reported significant improvement in the pain & the movements although he got still pain with back movements. On the third visit, he still reported improvement and demonstrated better ability to his daily activities. At the following treatment, he reported that his low back pain was almost gone. He was seen two more times over a month and reported only an occasional mild low back aching. He was last seen for this complaint 3 months after onset and was asymptomatic.
Cook, J. (2004) The orthopaedic lecture note.