I. Epidemiology of low back pain in the elderly
Low back pain (LBP) is a group of syndromes, which is a symptom name rather than a disease name. It is a group of diseases characterized by low back pain and is divided into acute and chronic. The incidence is higher in the elderly. Many local and systemic diseases can present with low back pain, but clinically it is mostly caused by intraspinal canal diseases, extraspinal canal diseases, spinal degeneration and acute and chronic injuries; it is the most common complaint symptom in rehabilitation, orthopedics and neurology clinics, and at the same time, it is also a very common occupational disease. Its etiology is extremely complex, and there are many factors affecting it, so it is quite difficult to diagnose and treat. In developed countries, its prevalence can be as high as 60%?80%, and it is the second most common syndrome after upper respiratory tract disorders. About 97% of the causes of lower back pain are mechanical, 1% are non-mechanical, and 2% are visceral disease. The prevalence of low back pain in the United States is second only to upper respiratory tract infections, and the prevalence of low back pain in China is 11.5%, which is the first among orthopedic patients, and the trend is increasing in recent years.
Anatomy, physiology and pathology
The main tissues that constitute the lumbar region are lumbar fascia, muscles, lumbar vertebrae and their connections and intra-vertebral canal tissues. The muscles are the dynamic structure of the lumbar spine, and the cooperative action of each muscle produces flexion, extension, lateral bending and rotational movements. The fascia is the fixation and protection device for the muscles, and the lumbar vertebrae and their connections are the important components of the spine and the pillars of the lumbar tissues.
The lumbar and sacral vertebrae are the most weight-bearing parts of the body, and they transfer the weight of the body above the waist and the stresses generated by movement to the pelvis and lower extremities. The lumbar spine is also the more active part of the human spine, with movement in the form of flexion, extension, left and right lateral bending and rotation. These two factors determine that the lumbar spine is the most vulnerable part of the injury, especially chronic strain lesions.
When standing, the disc is subjected to greater pressure by the weight of the upper part of the body and the contraction force of the muscles of the lumbar back and abdomen that maintain the posture of the trunk, and the lower the disc is, the greater the pressure. Therefore, the incidence of lumbar disc herniation is highest in the lumbar 4-5 and lumbar 5-sacral 1 discs, reaching more than 90%.
When the human body bends over, the intervertebral space narrows in front and opens up at the back, so the pressure on the fibrous ring is greater, and the fibrous ring is weaker on the back side, so the nucleus pulposus protrudes more to the back.
As the intervertebral disc is often subjected to extrusion, twisting and other actions and the accumulation of minor injuries, the fibrous ring and the nucleus pulposus gradually undergo degenerative changes, manifesting as reduced water, increased protein, reduced sugar, reduced tension, weakened elasticity, increased brittleness and thinning of the intervertebral disc. Due to the high pressure on the intervertebral disc and the large range of activities, when the disc metamorphoses and the elasticity of the fibrous ring is weakened, the fibrous ring is destroyed and the nucleus pulposus protrudes by the action of sudden and large external forces or repeated strain. The herniated nucleus pulposus stimulates or compresses the nerve root and dural sac, and corresponding neurological symptoms such as lumbar and leg pain and numbness appear. Therefore, lumbar disc herniation is often caused by certain injuries on the basis of degenerative changes in the intervertebral disc.
III. Diagnosis and rehabilitation assessment
The diagnosis is mainly based on the complaints, the nature of pain, physical examination, the location of pressure points found by palpation, the presence or absence of hard nodes, striae and pain provoking points in the pressure area, the abnormalities of muscle strength and superficial skin sensation, etc., combined with imaging examinations such as X-ray, CT and MRI examinations. Other auxiliary examinations include EMG (electromyography), motor evoked potentials, balance test, etc. Rehabilitation assessment: the pain level, muscle strength, lumbar mobility, lumbosacral curvature, impact on work and life, etc. can be assessed. Single assessment (MMT, ROM-T, ADL-T) or comprehensive assessment can be performed.
Rehabilitation treatment for low back and leg pain
Understand the general principles of rehabilitation treatment, and at the same time should learn to make differential diagnosis of several common types of lower back pain.
Through treatment, the activity of the nociceptive modulation system in the body is stimulated, thereby suppressing pain. For example, transcutaneous electrical nerve stimulation for analgesia, etc.; drugs and surgery to block the production, transmission and perception of nociceptive impulses; reduction of pressure on the intervertebral disc to promote the reduction and return of protrusions, release of nerve root compression or promotion of inflammatory edema to subside and release of adhesions. Later on, the stability of the spine is enhanced and the motor function of each axis of the spine is restored to consolidate the therapeutic effect and reduce recurrence. Psychological support to reduce pain exacerbation. See Table 1 below for several common types of lower back pain and their differentiation.
V. Rehabilitation of lumbar intervertebral disc herniation
This section introduces the types and clinical manifestations of lumbar intervertebral disc herniation; focuses on understanding the rehabilitation treatment methods for acute and chronic phases.
(I) Classification and clinical manifestations
Lumbar disc herniation is a syndrome caused by degeneration of the intervertebral disc, rupture of the annulus fibrosus and protrusion of the nucleus pulposus to irritate or compress the nerve root, and is one of the most common causes of lumbar leg pain. Depending on the location and degree of lumbar disc herniation, the clinical manifestations vary and are usually divided into.
1, central type: the disc protrudes in the midline, compressing the cauda equina, and the symptoms are more severe.
2. Lateral type: The herniated disc is located in the small intervertebral joint area and its lateral side, compressing the dural sac and nerve roots.
3.Posterior lateral type: The herniated disc is located on the side of the midline and compresses the ipsilateral nerve root.
The disease can have a variety of clinical manifestations depending on the site of the herniated nucleus pulposus, the size, the length of the disease and individual differences. The main clinical manifestations are: lumbar pain, radiating pain in the lower limbs, numbness and abnormal sensation in the lower limbs, difficulty in walking, muscle paralysis and atrophy, and manifestations of cauda equina syndrome.
(B) Rehabilitation assessment and treatment
Rehabilitation assessment includes assessment of daily living ability, assessment of spinal morphology, assessment of muscle strength, assessment of spinal mobility, electromyographic determination of the spine, and scoring system for lumbar pain, etc.
The treatment of lumbar disc herniation is divided into non-surgical treatment and surgical treatment. Non-surgical treatment is an important method of rehabilitation, and about 90% or more of patients have their symptoms relieved or cured by non-surgical treatment.
Non-surgical therapy can change the relationship between the protrusion and the compressed nerve root, correct the lumbar spine misalignment and release the adhesion of the nerve root, which is conducive to the recovery of the lesion and is the treatment of choice for this disease. Non-surgical treatment includes lumbar traction, physiotherapy, massage, acupuncture, body therapy, manual repositioning, painful point closure, epidural injection, chemical lysis of the nucleus pulposus and other methods. If conservative treatment is ineffective for more than six months and affects daily life and workers, surgical treatment can be performed.
Acute stage rehabilitation treatment
1, rest and braking on a hard bed: when lying down, the internal pressure of the disc is the lowest, and the muscles are relaxed, which is conducive to the reset of the protrusion and the repair of the disc, and usually the pain can be relieved. Away from the bed can be used to protect the lumbar circumference. Bed generally use hard board bed, take free position, need about 3 weeks.
2, lumbar traction: through traction, it can make the lower vertebrae separate, the vertebral space increases, thus generating negative pressure, and make the posterior longitudinal ligaments tense, all of which help the herniated material to return, so that the spastic muscles relax. Treatment of lumbar intervertebral disc herniation is effective.
3, short-wave therapy: electrodes placed in the front and back of the waist opposite or the waist and the affected side of the calf juxtaposition, warm heat, 20 minutes each time, l to 2 times a day.
4.Medium frequency electrotherapy: electrodes and placed in the lower back, 20 minutes each time, 1～2 times a day.
5.Ultrasonic therapy: lower back and posterior side of the affected limb, contact movement method, 0.8 to 1.5W/cm2, 10-20 minutes each time, once a day.
6.Application of waist circumference: After the symptoms are reduced, you can get up and move around, but you should not stand for too long or walk long distances. Wearing a lumbar girth to protect the waist helps to reduce pain so as to facilitate activities away from bed, and is used until symptoms are significantly reduced when removed, and should not be applied for a long time.
7.Tui-na: generally use non-anesthesia tui-na technique, combined with rectification techniques. The herniated nucleus can be returned to the nerve root; the nerve root adhesions can be loosened so that the herniated nucleus can be moved out of contact with the nerve root; the herniated nucleus can be crushed so that its contents can escape and enter the epidural cavity to release the compression on the nerve root.
8, other therapies: epidural injection of steroids has a significant role in inhibiting the inflammatory response of the compressed nerve roots, which can be helpful in relieving pain that is difficult to control.
Chronic phase rehabilitation therapy
1.Lumbar spine traction and physical therapy: the same methods as in the acute stage.
2.Tui-na: Stronger posterior lumbar reach method is required. The patient is in prone position, and first the lumbar muscles are relaxed by pushing, kneading and rolling, then the therapist holds the patient’s knees of both lower limbs with one arm and lifts the lower body, and presses the sacrum with the palm of the other hand, one lift and one press makes the lumbar elastic passive back extension. Rotation and other manipulative treatments can also be selected according to the patient’s condition.
3.Lumbar back muscle strength training.
(1)Angling chest: take the prone position, support the bed with both hands, lift the head first, while the supporting hands gradually support the upper body, and extend the head back as far as possible to make the chest angling, try to make the lower abdomen close to the bed, if necessary, with the help of external force to fix the pelvis to do the above action, after each action lie flat for a short rest, repeat 10-20 times.
(2) swallow position: take the prone position, both hands and upper arms back, trunk and lower limbs are simultaneously force back, the knee can not be flexed, so that it becomes an anti-bow, in this position as much as possible to maintain a while, lie down for a short rest and then do, repeat 3 to 10 times.
(3) stretching: take a standing position, legs apart and shoulder width, both hands hold the waist, the body to do backward stretching action, and gradually increase the magnitude, restore rest and then do, repeat 10 ~ 20 times.
Surgical treatment
Suitable for those who are not effective in non-surgical treatment or have frequent attacks, but need early intervention rehabilitation before and after surgery. Pre-surgical rehabilitation
1.Bed rest, physiotherapy, traction treatment, the same method as in the acute stage.
2.Waist brace Wear the same method as above.
3.Position training Prone training should be performed before surgery, and prone position should be taken for posterior surgery to facilitate the completion of surgery.
4, bed feeding and defecation training Posterior surgery non-internal fixation patients, postoperative bed rest for 3 to 4 weeks, therefore, preoperative bed defecation, eating adaptation training must be carried out. Postoperative posterior surgery patients should reduce the forward flexion of the waist; anterior surgery patients should reduce the movement of lumbar back extension, and bone fusion patients should start the training of lumbar activities after the bone healing.