Lower back pain is not an independent disease, but a symptom common to many diseases, and patients often present with this as the main complaint. The incidence of this disorder is very high, accounting for the highest number of surgical visits and 30% of rehabilitation visits. Lower back pain can be acute, most of them are chronic or persistent, accompanied by morphological changes and dysfunction of the lower back, which affects daily life, work and labor. In recent years, the cost of lower back pain has been increasing year by year in various countries. According to statistics, the annual cost of medical treatment for lower back pain in the United States is about $24 billion, and the annual loss is $50 billion when added to the impact of lost work, which shows that in addition to the pain caused to patients, this disease also causes significant losses to the country.
Over the years, the medical community has conducted a lot of research on the etiology, classification, diagnosis, treatment and prevention of lower back pain, but there are still many issues that lack a clear and consistent view. Therefore, the in-depth study of lower back pain remains one of the important tasks for practitioners of preventive, medical and rehabilitation medicine in the future. This chapter focuses on the rehabilitation of lower back pain caused by acute and chronic injuries and degenerative spinal pathologies.
I. Overview
Lower back pain is a group of diseases characterized by pain in the lower back, lumbosacral region and buttocks, which may or may not be accompanied by radiating pain in the lower extremities.
Etiology
1.Disorders of the spine itself
(1) Acute and chronic injury to the spine, such as lumbar disc herniation, fracture, spondylolisthesis, arch collapse, etc.
(2) degenerative osteoarthropathies such as spinal stenosis, spinal instability, small joint disorders, etc.
(3) Developmental abnormalities and postural disorders such as migrating vertebrae, scoliosis, flat feet, etc.
(4) spinal inflammation, tuberculosis, tumors.
(2) Intraspinal disorders such as inflammation, tumors, etc.
3, paraspinal myofascial disorders such as acute lumbar sprain, chronic strain, myofasciitis, supraspinous and interspinous ligament injuries, etc.
4.Sacroiliac joint disorders such as sacroiliac joint sprain, separation, tuberculosis, dense osteitis, etc.
5. Visceral diseases involved in painful diseases
(1) Gynecological disorders such as uterine and adnexitis, pelvic tumor, etc.
(2) Kidney disorders such as kidney stone, kidney tumor, renal prolapse, pyelonephritis, etc.
(3) Prostate disorders such as prostatitis, tumor, etc.
II. Rehabilitation problems
1.Pain
2.Functional disorders
3.Psychological disorder
4.Recurrent attacks
III. Rehabilitation treatment techniques and principles
Lower back pain is a common symptom of many diseases. First of all, it should be clarified what kind of disease is the cause of lower back pain. Some lower back pain is secondary to tumor, tuberculosis, septic inflammation, autoimmune diseases, as well as internal, external, gynecological and neurological diseases, which should be treated as the primary cause in time. Most of the lower back pain is caused by acute and chronic injury and degenerative changes of the spine, and is the main target of rehabilitation treatment. Such patients also need to have a clear etiology, detailed examination and correct treatment plan.
(I) Rehabilitation assessment
Patients with lower back pain mostly have different degrees of functional impairment, so detailed rehabilitation assessment should be done before, during and after treatment, including lumbar spine mobility measurement, lower limb sensory, reflex and muscle strength examination, gait analysis, ADL assessment, electrodiagnosis and electromyography, etc.
(II) Treatment principles
In the acute stage of the disease, the primary purpose is to eliminate or relieve pain, and for this purpose, necessary bed rest and various passive therapies such as lumbar spine traction, massage, electrotherapy, heat therapy, closure, medication, etc. are used. As the symptoms are relieved, the purpose of treatment turns to restoration of function, and the method also needs to turn to restoration of normal activities, local and systemic functional exercises in time.
(C) Methods and principles
1.Bed rest and restriction of physical activity Bed rest and restriction of physical activity are common measures in the early stage of acute attack of lower back pain, which can reduce the stress load of lumbar spine, relax the muscles, improve local blood circulation, reduce inflammation and edema and accelerate the repair of injury. Recent research results show that prolonged bed rest can delay functional recovery and cause disuse changes, so it is advocated to shorten the bed rest period. When resting in bed, it is not advisable to use too thick and soft mattresses, and different lying positions and postures can be used, subject to the patient’s comfort.
2.Lumbar traction has good effect on lumbar disc herniation, and is also effective for other lower back pain. Mechanism of action:: increase the vertebral space, reduce the internal pressure of the intervertebral disc, promote the retraction of the herniation; adjust the relationship between the nerve root and the herniation; improve blood circulation and relieve muscle spasm. There are many methods of lumbar spine traction, and the clinic mostly uses automatic traction bed lying traction. Traction weight is generally taken as 50% of its own body weight gradually increased to 80%, the lightest weight that can produce therapeutic effect is appropriate. Traction time of 30 min each time, 1 to 2 times a day.
3, Tui Na Chinese medicine Tui Na, also known as massage, is the theory of Chinese medicine organs and meridians as a treatment method. Tui Na is rich in techniques, such as rubbing, rubbing, kneading, pushing, rolling, one-finger meditation pushing, etc., which have different local effects on different depths of tissues; there are techniques such as pressing, pointing, taking, etc., which act on meridian points and play a long-distance therapeutic role; there are techniques such as rubbing, shaking, patting, etc., which play a role in relaxing muscles; there are also techniques such as shaking, wrenching, etc., which play a role in passive movement and rectification. Tui Na has a wide range of adaptability to different stages of lower back pain.
Mechanism of action
(1) TCM mechanism Pain is mainly due to the congestion of Qi and blood and the blockage of meridians, which is known as “pain if it does not pass”. Tui-na treatment can move the qi and blood, unblock the meridians and channels, so that the pain will not be painful.
(2) Modern medical mechanism Relax the muscles, relieve pain, improve the pain threshold and reset the bones. Some experiments found that the plasma norepinephrine and dopamine content decreased after massage, and the degree of decrease correlated with the degree of pain reduction.
4.Manipulation therapy Manual therapy is one of the common methods used by foreign physiotherapists to treat lower back pain. According to the intensity and location of treatment, manual therapy includes three techniques: massage, joint release and tui-na.
Manual therapy is suitable for most patients with lower back pain and is performed for 20 minutes at a time, requiring the patient to relax the area and cooperate with the treatment. Once a day, 10 times is a course of treatment.
5.Exercise therapy Patients with lower back pain often have reduced trunk muscle strength. Therefore, trunk muscle training should be an important part of the treatment of lower back pain and prevention of recurrent attacks. McKenzie et al. advocated focusing on extensor muscles, while Williams et al. advocated focusing on flexor muscles, and some advocated combining extensor and flexor training. As for the actual training effect, the reports are also inconsistent.
Training methods When developing a training program for trunk muscles in patients with lower back pain, it is advisable to consider both extensor and flexor muscles together. According to the results of muscle strength test, the weaker side can be focused on training; the arc of lumbar lordosis can also be taken into consideration, and when the lordosis is too small and needs to be increased, it is advisable to focus on extensor training. If the anterior convexity is too large and needs to be corrected and the angle of sacral anterior tilt reduced, it is necessary to focus on flexor training.
In the different stages of lower back pain, the training methods should be targeted.
①Acute lower back pain At this time, muscle spasm often causes changes in the curvature of the lumbar spine, which is a protective mechanism to reduce pain and should not be forcibly corrected.
② After spinal injury, intervertebral disc lesion or surgery This stage requires early abdominal back muscle training, but should not make the spine flexion or hyperextension, in order to prevent the intervertebral disc pressure increase due to the deformation of the vertebral space. Therefore, isometric contraction exercises of the abdominal and dorsal muscles or small-amplitude power exercises with the end point of restoring physiological curvature are appropriate.
③No nerve root irritation or when the symptoms of nerve root irritation are basically eliminated At this time, lumbar spine flexibility exercises should be performed to traction the contracted and adhered tissues and restore the lumbar spine mobility. The exercises include lumbar flexion and extension, left and right lateral bending and left and right rotational movements. The training should be carried out at a smooth and slow pace, with as large an amplitude as possible but without causing significant pain.
After the symptoms disappear, based on the above exercise therapy training, gradually increase the trunk force exercise and heavy lifting exercises to gradually rebuild the ability to engage in physical labor, also known as work strengthening exercises.
⑤After rehabilitation, increase aerobic training to correct the lack of exercise and enhance physical function.
6.Electrotherapy, hot and cold therapy can change tissue temperature, improve blood circulation and tissue metabolism, accelerate injury repair, and help reduce inflammation, swelling, relax muscles, raise pain threshold, directly or indirectly achieve the purpose of eliminating pain, which is widely used in the treatment of lower back pain. The more commonly used methods are medium-frequency electrotherapy, ion introduction, short-wave transheat, ultra-short wave, ultrasonic wave, microwave therapy, etc.
7.Pharmaceutical treatment Three types of pain-relieving drugs are commonly used in the treatment of lower back pain.
(1) Non-steroidal anti-inflammatory analgesics (NSAIDs) The main mechanism of action of NSAIDs is to inhibit the synthesis of prostaglandins, so that their sensitizing effect on tissues is reduced, and also to reduce the sensitivity of tissues to bradykinin, inhibit the release of histamine and reduce vascular permeability. In addition, these drugs have anti-inflammatory effects such as antipyretic, anti-swelling, and improvement of stiffness.The common side effects of NASIDs are gastrointestinal reactions, followed by toxic reactions to varying degrees on the hematopoietic system, kidney, and liver, as well as metabolic reactions. Among them, COX2 selective inhibitors have less adverse reactions. NSAIDs are commonly used for mild to moderate acute and chronic lower back pain. However, they are more effective for acute effects and less effective for chronic lower back pain.
(2) Adjuvant analgesics include antidepressants, antispasmodics, and anticonvulsants. The mechanism of action is still completely unknown, and the possible mechanisms are: blocking the reabsorption of neurotransmitter 5-hydroxytryptamine in the center, increasing the concentration of biogenic amines at the receptor site; strengthening the inhibition of stimulation of posterior horn upward injury; stabilizing the cell membrane potential, etc. The combination of this class of drugs with NSAIDs can enhance the analgesic effect.
(3) Narcotic analgesics Mostly used for acute lower back pain.
8.Closure therapy refers to the method of using a syringe to inject a closed drug into the diseased tissue or into the part related to the diseased tissue to treat the disease, and the drug used for closure therapy is called closure solution. The commonly used closed drugs for the treatment of lower back pain are mainly corticosteroids and local anesthetics.
The therapeutic mechanism is to use the anti-inflammatory, anti-toxic and anti-allergic effects of corticosteroids to reduce the pathological response of the body’s tissues to injurious stimuli, reduce the permeability of capillary walls and cell membranes, reduce inflammatory exudation and make local swelling subside; inhibit connective tissue proliferation and inhibit the release of histamine and other toxic substances. In addition, local anesthetics can stabilize the cell membrane of nerve fibers and inhibit the generation of action potentials, thus interrupting pain transmission.
Sealing therapy includes pressure pain point injection or posterior joint cavity, intra-neural foramen, lumbosacral canal epidural injection, etc. It is suitable for patients with lower back pain whose diagnosis is clear and other methods of treatment are not effective.
9.Psychotherapy Chronic lower back pain is clinically characterized by pain that persists and far exceeds the severity of the injury and the properties of the disease symptoms in the process of healing of all injuries, or basic healing, or chronic recurrence, and becomes a prominent pain problem, forming a pain syndrome. At this point, pain often loses its protective effect on the person and becomes a disaster.
Patients at this time have complex psychological and behavioral abnormalities, constantly complaining of pain, seeking medical help everywhere, often taking large amounts of analgesic drugs, and some even become addicted to them. For such patients, a diagnosis and assessment should be made including medical, psychological, physical and behavioral reactions to pain, and a comprehensive treatment plan including psychotherapy should be formulated.
IV. Rehabilitation treatment of common lower back pain
(A) Soft tissue lower back pain
Also known as non-specific lower back pain, it usually includes lower back pain caused by injury or inflammation of the muscles, ligaments, fascia and soft tissues around small joints in the lumbosacral region.
1.Clinical features The disease has no nerve root irritation symptoms, but there may be manifestation of posterior branch of lumbar nerve compression. Some cases have fixed pressure pain points, while some have vague symptoms and are difficult to locate. The diagnosis can be confirmed by general physical examination. x-ray examination can exclude tumor, tuberculosis, spinal inflammation and other organic lesions.
2, rehabilitation treatment The effect is good, 80% of patients in 2 to 4 weeks the pain disappears.
(1) Bed rest Short-term bed rest is required for those with significant symptoms in the acute phase. Recently, it is believed that the bed rest period should not exceed 2 days to avoid delaying functional recovery.
(2) Oral medication Oral non-hormonal anti-inflammatory analgesics are effective. When there is obvious muscle spasm, muscle relaxant can be added to eliminate the ischemic pain caused by muscle spasm.
(3) Physiotherapy, massage and acupuncture have good effect.
(4) Exercise can accelerate the recovery of activity and working ability. Some studies have reported that practicing aerobic gymnastics is more effective than simple low back exercises.
(5)Closure When the local pressure pain of the injury is obvious, local injection of corticosteroid can quickly stop the pain.
(B) lumbar disc herniation
Lumbar disc herniation is a syndrome caused by degeneration, rupture, and posterior protrusion of lumbar discs compressing the spinal cord or nerves. This disease is a common disease causing lower back pain and occurs mostly in young adults.
1, pathology and clinical characteristics of the normal human intervertebral disc begins to degenerate after the age of 30, its outer ring can become malleable, bulge or even rupture due to fibrous degeneration, the colloid nucleus pulposus protrudes and the adjacent nerve roots are stimulated or compressed, and typical symptoms such as low back pain and lower limb radiating pain occur. The protruding lumbar intervertebral disc compresses the nerve root, which can cause nerve inflammation and edema.
Since the nerve root is only wrapped by a membrane and not protected by the outer membrane of the nerve, it is easy to have micro-venous stasis, capillary congestion and accumulation of metabolites in the nerve after compression, so edema, ischemia and chemical stimulation of metabolites further aggravate the nerve root symptoms; on the contrary, after treatment, edema is eliminated, local blood circulation is improved, metabolites are eliminated, and nerve root symptoms can be relieved or eliminated. At this time, there may be no change in the morphology of the protruding nucleus pulposus on CT or MRI examination, indicating that mechanical compression of the protrusion is not the whole cause of the pathological changes.
2. Rehabilitation treatment
(1) Bed rest and restriction of activities lying down can reduce the pressure in the intervertebral disc to the lowest level, which is conducive to swelling reduction and symptom relief. Strict bed rest should not exceed 1 week. Excessive bed rest can cause muscle atrophy, osteoporosis and psychological disorders, which is not conducive to functional recovery. Since the force on the lumbar spine when standing is only higher than that in the lateral recumbent position and lower than that in the sitting position, it is advisable to alternate between standing and recumbent positions after getting up early.
When sitting, it is advisable to make the back of the chair tilt back about 20 degrees, relax the sitting back, and place a cushion behind the waist to maintain the physiological convexity of the lumbar spine, so as to minimize the pressure within the lumbar intervertebral disc. Note that the sitting position (such as soft sofa, etc.) that makes the lumbar vertebrae flexed as much as possible, so this position can make the intervertebral disc pressure higher than when standing nearly 1 times.
(2) Lumbar traction is more effective for those with nerve root irritation symptoms.
(3) massage and manipulation therapy massage has good effect on this disease. Its basic operations are.
① Push, roll and knead in the prone position to relax the muscles of the lumbar hip and the affected lower limb.
②Make the lumbar vertebrae produce posterior extension, lateral flexion, rotation, stretching techniques such as prone lumbar compression and extension, lateral lying lumbar lateral pulling; supine position affected limb pulling and stretching, etc.
③acupuncture point massage kidney Yu, lumbar Yang Guan, ring jump, Cheng Fu, Yin Men, Wei Zhong, Cheng Shan, take Achilles tendon, press Kun Lun and Xie Xi, etc.
④ Joint passive activities of the three large joints of the affected lower limb.
⑤ Relaxation of the muscles of the waist and hip and the lower limb on the affected side again.
(4) Exercise therapy Patients with lumbar synostosis commonly have weakness of the lumbar and abdominal muscles and impaired stability of the lumbar spine, resulting in delayed symptoms or easy recurrence. The compromise is that bed rest for 2-7 days is recommended during the acute phase, with elevated calves and relaxed psoas major muscles to fully reduce spinal stress.
After the initial remission of symptoms, it is advisable to start recumbent lumbar and abdominal exercises as soon as possible, but avoiding obvious flexion or hyperextension of the lumbar spine. When the symptoms further improve, then further lumbar and abdominal muscle training. In principle, the lumbar and abdominal muscles at the same time, in order to balance and enhance, but should be based on the lumbar vertebral curvature, the size of the sacral anterior tilt angle and lumbar back muscle and abdominal muscle strength compared to some weight. Abdominal and back exercises should be performed daily for at least 3 months, followed by appropriate consolidation exercises. Exercises to restore spinal mobility should be started after the nerve root symptoms disappear.
(5) Closure Corticosteroid epidural injection is indicated for those with significant pain and poor results of general treatment. Once a week, three times for a course of treatment.
(6) Other treatments Cold and heat therapy, electrotherapy, acupuncture, and medication can be used as appropriate.
(7) Minimally invasive treatment includes percutaneous puncture chemical nucleolysis, mechanical excision and suction, laser vaporization, arthroscopic surgery, etc. The indications should be strictly grasped.
The indications for surgical treatment are limited to: 2~3 months of regular non-surgical treatment cannot control the symptoms and the patient cannot tolerate them; symptoms of cauda equina damage such as urinary and fecal disorders and numbness in the saddle area.
(C) Spinal stenosis
1. Etiology Spinal stenosis is mostly caused by degenerative changes. Due to factors such as bulging disc, narrowing of the intervertebral space, spinal instability and slippage, thickening of the posterior joint capsule, thickening and bulging of the ligamentum flavum, and formation of bone redundancy, the space in which the cauda equina and nerve roots are located is relatively reduced, while mechanical stimulation and compression cause neuroinflammation, venous return obstruction, edema and other factors, which may be the pathophysiological basis for the occurrence of symptoms. There is a periodic increase in epidural pressure during walking, and the intermittent pressure on the nerve roots causes imbalance in nerve blood supply and nutrition, which may be the precipitating factor of intermittent claudication.
2. Clinical features Spinal stenosis is mostly seen in middle-aged and elderly people, typically manifesting as low back pain with intermittent claudication; more symptoms and fewer signs; straight leg raising is often negative, and symptoms are often aggravated when the lumbar spine is hyperextended and alleviated when the lumbar spine is slightly flexed; aggravated when standing and walking, especially when going downhill, and alleviated when sitting. The patient’s dorsalis pedis artery pulsation is normal, but the squat toe extensor muscle strength is reduced, which can be distinguished from vascular intermittent claudication.
3, rehabilitation treatment The purpose of treatment is to eliminate the pathophysiological mechanism and try to control the symptoms.
(1) Rest When the symptoms are significant, bed rest for 2-5 days can relieve the symptoms, but long-term bed rest is not recommended.
(2) Early lumbar and abdominal muscle exercises There are reports in the literature that the dural cavity pressure is reduced when the lumbar spine is flexed and increased when it is hyperextended, which is consistent with clinical symptoms being reduced when the lumbar spine is flexed and increased when it is extended, so it is appropriate to focus on abdominal and gluteal muscle exercises to reduce lumbar lordosis. Exercises to extend the lumbar spine may cause symptoms and should be performed with caution.
(3) Drugs Aspirin or other non-hormonal anti-inflammatory and analgesic drugs can be applied.
(4) Lumbar spine traction and massage therapy have been widely used in China, but their efficacy is not as certain as that of disc herniation, and their application value has not been clearly evaluated.
(5) Surgery Patients with severe symptoms and ineffective non-surgical treatment should be treated surgically.
(4) Degenerative lumbar spondylolisthesis
Degenerative lumbar spondylosis refers to the degenerative stenosis of the lumbar intervertebral disc, degenerative hyperplasia of the vertebral body edges and osteoarthrosis of the small joints due to degeneration. The disease is also clinically known as hypertrophic spondylitis because it is mainly characterized by hyperplasia of the vertebral body edges and hypertrophic changes of the small joints. It is also synonymous with lumbar osteoarthritis, hyperplastic lumbar spondylitis, senile lumbar spondylitis, deformational lumbar spondylitis, lumbar spondylolisthesis or bone spurs, etc.
The causal relationship between lumbar disc degeneration, vertebral body edge hyperplasia and osteoarthritis of the synovial joint is still unclear, and it is generally believed that the latter two are significantly associated with disc degeneration, as well as age, local pressure and trauma.
1. Clinical features are mainly low back pain, spinal deformation as well as tightness, pain and weakness in the lower limbs. It is generally believed that degenerative hyperplasia at specific sites can lead to low back pain, but the intrinsic link between early degenerative hyperplasia and low back pain is not clear. Although the bone lip is large, as long as it does not directly compress the nerves, it can stabilize the spine and thus may not produce pain.
It is easy to diagnose lumbar degeneration and hyperplasia on radiographs, but to determine whether a patient’s low back pain originates from degeneration, it must be combined with clinical, and sometimes oblique, functional, and other examinations for comprehensive analysis. Low back pain in this disease is also similar to soft tissue pain. It is also characterized by stiffness in the morning or after rest, which improves after activity. However, the pain site of this disease is mostly in the paraspinal area, and the pressure pain site is deep in, while soft tissue pain is easier to reach a clear pressure pain point early. The pain of this disease is mostly dissipated to the lateral side of the thigh and the front, producing less distribution according to nerve root segments; superficial closure is also not easy to stop the pain. This disease should also exclude lumbar disc herniation, vertebral tumor, tuberculosis and other diseases, and the pain site and degenerative vertebral body coincide to confirm the diagnosis.
2, rehabilitation treatment The degeneration and proliferation of the lumbar spine is a normal physiological process that increases with age. Therefore, asymptomatic or asymptomatic people do not need special treatment, but those with obvious symptoms should use rehabilitation therapy to reduce pain and maintain and restore the motor function of the spine.
(1) Exercise therapy is effective in the early stage and for those with little bone and joint changes, and can restore the mobility of the lumbar spine, but in acute pain should be suspended or reduce the amount of activity. Commonly used methods are medical gymnastics, taijiquan, taiji sword, etc.
(2) Heat therapy and electrotherapy Use electric excitation or induction electricity to release muscle spasm, but should be used with caution for hypertension. Infrared ray, ultra-short wave, heat bag, waxing therapy, ion introduction can relieve spasm and pain. Low-period waves can be used for myasthenia gravis.
(3) Massage and manipulation loosening can relieve muscle spasm and increase joint activity, avoid using strong manipulation plate pile, especially for those with heavy hyperplasia should not be applied.
(4). Acupuncture is suitable for those with lumbar muscle tension and pain limitation.
(5) Traction can reduce the internal pressure of the intervertebral disc, reduce joint friction and relieve muscle spasm. It is especially suitable for acute pain that cannot be treated by massage and manipulation. Continuous pelvic traction is preferred for degenerative pain to ensure that the patient gets rest without harming the soft tissues. Patients can also do self-gravity traction, which is suitable for those who are younger and in better health. The traction should be performed 2-3 times a day for 20 min each time.
(6) Oral medications Non-steroidal anti-inflammatory and analgesic drugs, such as Intazing, Oxytetracycline and Cilobal, should be used only when symptoms are obvious. Chinese herbal medicines should be effective in soothing the tendon and dispersing cold.
(7) Closure Those with obvious pain points can use local closure. For deep pain, long needles can be used to close the tissues around small joints. Epidural injection has a good pain relief effect, but should not be used for a long time.
(8) Brace Patients with back pain caused by spinal instability, lumbar brace can help stabilize the spine and reduce joint wear, but should not be worn for a long time, and should be used in conjunction with exercise therapy.
(E) Spondylolisthesis
Spondylolisthesis is a slippage of the upper vertebral body along the bevel of the upper edge of the lower vertebral body. The degree of slippage is generally divided according to the distance of forward slippage, with forward movement not exceeding 1/4 of the upper edge of the next vertebral body as degree I, 1/4 to 1/2 as degree II, 1/2 to 3/4 as degree III, and more than 3/4 as degree IV. Severe slippage can damage the cauda equina and cause paraplegia.
A few spinal slips are caused by lumbosacral dysplasia, and most are caused by lumbar isthmic fissure or degenerative changes in the intervertebral discs and small joints. The former is known as isthmic spondylolisthesis or true spondylolisthesis, which can develop to a more serious degree; the latter is known as degenerative spondylolisthesis or pseudospondylolisthesis, which generally does not exceed degree I.
(1) Sliding isthmic fissure The isthmic fissure is usually acquired and can be caused by fatigue fractures or acute fractures. The literature reports that 5% to 8% of adults have both sides of the isthmus, but about half do not develop spondylolisthesis and are asymptomatic, requiring no treatment. Non-surgical treatment is generally used for symptomatic degree I and II spondylolisthesis. Treatment methods include
① Short-term bed rest when pain is significant.
Some authors consider Williams gymnastics to be the cornerstone of the treatment of spondylolisthesis and must be practiced continuously over a long period of time.
Traction of the lower lumbar back muscles to reduce lumbar lordosis and sacral anteversion to improve the stability of the lower lumbar spine, control the slippage and improve symptoms. Some literature reports that 67%-78% of adolescent patients treated with this principle have good results.
④III-IV degree slippage generally requires surgery.
(2) Degenerative slippage is caused by degeneration resulting in thinning of the intervertebral disc, local relaxation of the anterior and posterior longitudinal ligaments, thinning of the articular cartilage of the posterior joint, and relaxation of the joint capsule, resulting in the superior vertebral body slipping forward and downward. It is not accompanied by an isthmic defect and is mostly seen in elderly patients. Slip does not exceed I degree, generally without surgical treatment, Williams gymnastics can be satisfactory results.
(F) Posterior joint syndrome
This disease is caused by abnormal movement of the joint surface on the basis of degenerative changes and instability of the posterior joint, which occurs when the back is suddenly extended or turned under weight. The typical symptom is persistent lower back pain, which is aggravated by extension, lumbar rotation or both, with morning stiffness. x-ray, CT or MRI examination may show increased posterior joint bone density, hyperplasia, joint cavity narrowing, instability, etc.
Rehabilitation treatment
①Bed rest In some cases, the pain can be relieved or disappeared after short-term bed rest and restriction of lumbar activities.
②Tui-na The use of special rehabilitation techniques can often receive immediate results. The operation is divided into three steps. First, kneading, rolling or pushing is applied to the painful point and its vicinity for 5-15 min to fully relax the spastic muscles. Then the spinal manipulation is performed so that the spinal mobility is close to normal. Finally, the finishing and relaxation techniques, including rolling, pressing, kneading and percussion, are performed for about 5 min.
Lumbar traction is also effective and is often performed in conjunction with tui na.
④Closure In some cases, if the pain is not satisfactorily relieved by the above manipulation, corticosteroids can be used for posterior lumbar joint and epidural injection to obtain better results.