LVS-Syndrome

Synonyms in a broad sense

Back pain, lumbar vertebral syndrome, lumbago, chronic back pain, chronic complaint about lumbar back pain, lumbar vertebral pain English: lower back pain

Introduction

This article was written primarily from the physiotherapeutic / physical therapeutic view point. The term LVS syndrome does not describe any independent clinical picture that can be traced to a particular anatomical or morphological event, but rather is a collective description (syndrome) for different illness indications (symptoms). The primary symptom of the LVS syndrome is local back pain, related to the lumbar vertebrae.

If patients complain about back pain, generally the complaints deal with the region of the lumbar vertebrae. A majority of all adults has already gained experience with the subject “back pain”. Nearly everyone has suffered at least once in his life from some type of back pain. Hardly any other orthopedic clinical picture has experienced such a rapid increase in the past few years as the number of patients with back pain that required therapy. Pains in the region of the lumbar vertebrae (LVS) can be roughly differentiated into two main sectors, acute and chronic back pain.

Acute LVS syndrome

Acute complaints with LVS syndrome:

A major portion of these complaints result from a herniated disc (prolaps). In fact, the majority of herniated discs are discovered in the region of the lumbar vertebrae (LVS).

While herniated discs still occur quite frequently in the region of the cervical vertebrae (CVS), they are extremely rare in the region of the thoracic vertebrae (TVS).

Many patients with a sudden (acute) back pain are initially worried that a herniated disc could be cause of their complaint. The clinical picture is widely „known“ and it is classified as serious and dangerous – not entirely unjustly. Little is known about other illnesses, which can lead to an acute LVS syndrome or to a so-called „lumbago“. Perhaps the term „blockage“is known in a broad sense. Under this term, patients usually understand an acute back pain, which can lead to limited physical movement and stress.

Characteristic indications for the existence of a herniated disc of the lumbar vertebrae are:

• A strong back pain that extends into the leg (lumbar sciatica), which often reaches the foot.
• Intensification of pain by sneezing, coughing of pressing.
• The leg pains are stronger than the back pains.
• Unpleasant sensations arise (paresthesia; e.g. prickling skin, scurrying ants) or reduced sensations (hypesthesia; e.g., as if the foot were packed in cotton“) in the region of the leg.
• Paralysis exists or a loss of power in certain muscle groups (impeded toe or heel extension).
• Loss of control in urination or bowel movement (incontinence).

In each instance, a doctor (orthopedist) should be consulted if uncertainty exists regarding the cause of the illness.

Therapy of acute LVS syndrome

Many patients are unaware that a significant reduction of their pain can be achieved through physiotherapeutic measures even in the acute phase of a herniated disc.

The physiotherapeutic treatment with a herniated disc is primarily directed according to the acute pain of the patient as well as to the stage of the illness.

During the acute phase, the major emphasis of the therapy should be directed toward rapidly reducing the pain. The characteristic pains of a herniated disc emerge due to pressure that is exerted on nerve roots of the spinal column, which emerge in the intervertebral foramen. Within the scope of the physical therapy, the initial attempt will thus be made to reduce this pressure via targeted positioning or mobilization techniques as well as by manual therapeutic techniques.

The graduated positioning

A quite simple positioning exercise, which often causes a significant pain reduction, is the so-called LVS syndrome graduated positioning. Hereby the patient lies on his back; his legs are laid on a foam plastic cube, whereby the hip and knee joints should constitute an angle that is approximately 90°. The positioning angle of the leg can be varied, according to the most comfortable position of the individual. Some patients prefer a somewhat flatter position, e.g. in which a wool blanket can be placed under the lower leg. By contrast, the reclining surface should be hard. The aim of this “entlordosaged” position (compensating the hollow of the back) is to relieve the lumbar vertebrae and to expand the intervertebral foramen (neuroforamen) for constricted nerve roots. This positioning can be supplemented by applying warmth locally, whereby one places a flat warm bottle or a warm towel beneath the lumbar vertebrae, of course without creating a new position of the hollow of the back. This positioning is very suitable for self-treatment in the acute pain phase.

The sling table

An even more effective positioning exercise, which employs the same effect as the graduated positioning, is suspending the pelvis and legs in a so-called sling table. Treatment with a sling table is offered primarily by physiotherapeutic clinics or by the physical therapy departments in hospitals. The pelvis and legs are fixed in this particular device by a special system of straps and held in the above-mentioned position. By means of the sling construction, a certain degree of „weightlessness“ is simulated and the relief of the vertebral disc structures often results in a significant improvement of pain relief.

The traction treatment

An additional, effective physiotherapeutic treatment method of a herniated disc (prolaps) is the traction treatment (stretching treatment). Thereby tension is exerted on the spinal column manually in a longitudinal direction (by the physical therapist) or on a Schlingen table by supplemental weight. By means of this regulated tension, one attempts to minimally separate the vertebrae and to relieve the affected discs and nerve roots. However, this should only be performed by a qualified physical therapist, who can suitably adjust the intensity of the traction to the respective situation.

Physical therapy

Among physical therapeutic measures, the application of warmth (thermotherapy) offers promise of pain relief in the acute phase, since relief of the frequently painfully cramped musculature is achieved by the effect of a fango pack or other means of warming. Massage therapy is often not recommended in the acute phase of complaints of a herniated disc, since an additional irritation of the affected nerve structure can occur through the intensive handling techniques. In addition, the possibilities of traditional Chinese medicine (TCM) can be exhausted. The best known aspect of the TCM is certainly the acupuncture; however the Moxa therapy (burning off of herbal medicine on acupuncture sites) or foot sole reflex therapy can also be applied successfully.

The physical therapeutic treatment of a herniated disc of the cervical vertebrae in the acute phase strongly resembles that of the physical therapy for the CVS syndrome.

Muscle training

In the subacute phase (the strongest, immobilizing pains have been overcome) of a herniated disc, a targeted muscle training of the abdominal muscles (stomach and back muscles) is one of the most important aspects of physical therapy. The above-mentioned therapeutic methods and medical treatment are primarily symptom-orientated. By contrast, a persistent and preventive therapy effect is only achieved by a well-performed callisthenic training and by learning daily routines that are suitable to proper back posture. If thereby in the past few years more value has been given to, training back and abdominal muscles, a trend reversal has become evident more recently. Newer concepts ignore the aspect of training abdominal muscles even more and they clearly place their emphasis on training the back musculature. Thus it is quite reasonable, after a herniated disc, to exercise the rotation movements of the spinal column (in defined timely intervals). However, more complex exercises, for example such as rotation components of the spinal column, should only occur under technical guidance in a physiotherapeutic clinic or a fitness studio with proper physiotherapeutic supervision, since more damage can be done than improvement can be achieved by improper training. Training with barbells is also becoming ever more prevalent.

Simpler, but nevertheless effective exercises, can however be performed well at home even without extensive technical expertise and devices. Thus for example, exercises on a quadruped platform are quite suitable, in order to strengthen the entire back musculature. Thereby it is primarily important to pay attention to a good starting position. Thus, the complete musculature of the spinal column should be stabilized, in order to avoid evasive movements.

Manual therapy

An additional, important clinical picture, which very often leads to an acute LVS syndrome, is the „blockage“ of one or several vertebral joints. A blockage, designated in medical terminology as segmental articular dysfunction, describes the temporary movement disruption of a joint. Patients classically report a sudden, lumbago-type of back pain upon acute blockage of a vertebral joint, which leads to the immediate secession of all activities. Movements are barely or no longer possible at all. The cause of such a blockage is often the sudden lifting of heavy objects; but sometimes also it is simply an unfortunate movement in a bent position. Within a very short time, the musculature surrounding the lumbar vertebrae becomes enormously tense, as an indication that the body is attempting to immobilize the movement segment (the blocked vertebral joint) that is causing the pain. But blockages can also run a course that is less dramatic. Then patients rather complain about an unspecific back pain or they have the impression that „something is crooked“.

Therapeutic treatment methods aim to restore the physiological (natural) speculum of the joint and to free the blocked vertebrae from its quandary.

The treatment methods that are most often applied, in order to achieve this goal, are the manipulation and mobilization techniques. Both techniques are components of manual therapy. With the manipulation techniques, targeted, rapid impulses are set in the region of the blockage. The populace knows this technique as the classical „setting something right“.

The mobilization techniques are muscular-energy techniques, which function without rapid impulses and which utilize the patient’s own muscle power, in order to free the blocked vertebral joint.

In Germany, the „setting right of a blocked spinal column“ is restricted to doctors with a special, additional training (osteopathy / manual therapy). On the basis of more limited possibilities for complications, mobilization techniques are performed to an equal degree by physicians and physiotherapists, who have been trained in the manual therapy; both techniques are well suited to the same extent to resolve a blockage with the appropriate application.

Chronic LVS syndrome

Chronic complaints with LVS syndrome

Clinical pictures such as the following fall under this subject complex:

• Osteochondrosis = Combined illness of disc and vertebrae within the scope of (degenerative) modifications that are caused by attrition.
• Spondylarthritis = Arthritis of the vertebral joint (facet syndrome)
• Minor herniated disc (disc prolaps)
• Protrusion of intervertrebral disc (protrusion)
• Spinal column stenosis = Constriction of spinal column due to attrition
• Spondylolisthesis / Spondylolysis = Shift of vertebra forward/ to the side
• Scoliosis = Curvature of the spine to the side
• Muscular insufficiency = Weakness of the back musculature
• Chronic muscle tension = Painful hardening of muscles/ cramps
• Osteoporosis = Bone degeneration
• Vertebral fracture = Broken spine, usually caused by osteoporosis

etc.

The majority of these clinical pictures can be compiled under the designation degenerative illnesses of the spinal column. The a.m. clinical pictures can occur in connection with each other or as an individual malady. Especially with severe, modifications of the spinal column that are caused by degeneration, a differentiation of the cause of pain is very difficult. For detailed information about the individual clinical pictures, please follow the link.

The application of physiotherapeutic measures is quite successful in the treatment of LVS syndrome and it is routinely used in hospitals at least. .

Therapy of chronic LVS syndrome

Applications of warmth

Therapy with different warming methods (thermotherapy) serves to relax muscles and to promote blood circulation and thereby to improve metabolism. Warmth causes a beneficial increase of the blood circulation in the connective tissues that are treated, with a limiting penetration depth of approximately 3 cm. An increased metabolic activity leads to a removal of „waste products“ and relaxation of tense tissue, whereby a reduction of pain is achieved. A strong penetration effect on the spinal column itself does not occur; the penetration depth is too small thereto. Applications of warmth are available in different manners. The hot roll is a very successful example. Hereto a hand towel is used that is rolled in a special manner. Hot water is poured into this towel. Subsequently, the most painful portions of the body are dabbed with this towel. An application with moist heat is regarded to be more pleasant by most patients; in addition, it offers a soothing influence on the general condition. There is no counter-indication to daily application of the thermotherapy, except if skin irritation or circulatory problems arise (e.g. a decrease in blood pressure), which however seldom occurs. The optimal duration of a single application lies between approximately 20- 40 minutes.

Packing with natural mud or fango is recommended with these illnesses. Fango packs are used almost exclusively in special health resorts, since the time requirement thereto is quite extensive. Fango can be used repeatedly; therefore, disinfection at high temperatures is required for hygienic reasons. By contrast, natural mud packs are one-time products; they are applied to the skin and brought to the desired temperature with special warming cushions. Both procedures are not suitable for self-application, since the instrumental complexity is quite extensive.

An old house remedy is very suitable for usage at home. It is a warm therapy with the aid of unpeeled potatoes. After cooking, these are cut into pieces and placed in a cotton cloth; subsequently, the cloth is laid onto the region of pain. The starch that is contained in the potatoes should assist the body to remove “waste products“ from the musculature and to activate the body’s own healing process.

Massage techniques

In contrast for example to an acute herniated disc, the massage therapy is absolutely advisable with degenerative illnesses of the spinal column. In addition to the classical message, the underwater massage is especially suitable, which however is no longer available in many physical therapy clinics, since the costs and material expense is too great and it is not reimbursed in the required extent by the health benefit funds. However, some massage clinics and hospitals with their own departments for physical therapy still have the required equipment for the underwater massage.

With the underwater massage (UWM), the patient lies in a large tub; the message pressure is applied by the treating therapist with the aid of a water hose. The back muscles are massaged by means of circulating movements.

The hedgehog-ball massage is suitable for self-therapy. Hereby, one rolls a knobbed ball over the painful musculature. Naturally it is ideal, if a second person undertakes this, since many sites on the back are difficult to reach by ones self; others cannot be reached at all.

As with every massage therapy, the intensity of this application depends on the individual and it is directed toward ones own feeling of well-being. .

Applications of current Direct current increases the reactive and functional ability of motor nerves.

With iontophoresis, galvanic, direct current is used to introduce medicines via the skin, According to the medicine that is introduced, the effect reduces pain, inhibits inflammation and/ or promotes blood circulation. .

Diadynamic stimulation with direct current and components of impulse current promote blood circulation and cause a reduction of pain.

Low frequency ultra-stimulating current cases a strong reduction of pain and increase of blood circulation. The pain reduction usually occurs directly during the treatment. .

The interference current therapy is especially recommended. Thereby, two middle-frequency currents are introduced beneath the skin into the body. In the depth of the musculature and in the region of the vertebral disc, low-frequency currents are created, which lead to a good pain-relieving effect.

The impact of the transcutaneous electrical nerve stimulation (TENS) is based on the therapy principal, that pain-receptive cells are blocked on one hand by low-frequency impulse and direct current; on the other hand, a pain-relieving effect occurs via nerve cells of the spinal cord. Overall, the TENS varies widely in effect from patient to patient. But an advantage of the TENS device is that it can be procured via subscription for self-treatment at home. The application occurs several times per day for one to several hours.

Daily routines that are suitable for proper back posture

Since most illnesses of the spinal column are degenerative in nature, and a causal therapy (healing) is usually not possible, prophylactic measures for preventing a deterioration of the finding or for avoiding a recurrence of the complaint receive special consideration.

Therefore, a daily routine that is suitable for back posture must be observed for patients with a LVS syndrome. It is known from experimental observation, that upon raising a load with the back alone, very high pressure is exerted on the vertebral discs of the lumbar vertebrae. With muscle weakness or a previously damage back, this can lead to an acute LVS syndrome („lumbago“).

Learning and integrating the rules of the back training as well as the consequent implementation in daily life are imperative. We also know that the daily life in our professions sometimes requires bodily stress, which seem to be unavoidable. But even minor modifications in behavior can exhibit appreciable effects that protect our backs. Thus for example, the conscious implementation of the abdominal press (abdominal musculature) upon lifting heavy loads appreciably reduces the stress on the spinal column.

Improvement of the environment Many back complaints can already be minimized by a few simple modifications in the private and professional environment. Thus the working place and the movement behavior should be analyzed for „back friendliness“. An ergonomic formed, office chair that can be elevated should be self-evident for activities that are primarily done while sitting. With increasing frequency, desks are being used that can be elevated. By modifying the elevation of the work surface and the possibility to work while standing, working at a desk can be done in a manner that is more protective to the back. Actually, a frequent position change is something, by which one can relieve his back quite well. The frequently-taught upright sitting posture is not as good as many believe, if one maintains this position over a long period. Pressure measurements have shown that a very large stress is exerted on the vertebral discs of the LVS through the straight, obligatory position. .

Good, targeted exercises can be included into the daily working schedule, which can be performed at the work site without devices and space requirements. With a thoughtful mixture of strengthening and relaxing exercises, a significant improvement of the complaint can be achieved in a short time, e.g. 10 minutes of the lunch break. .

A device, which is absolutely recommended for domestic use, is the large gymnastic ball, also called sitting ball. These balls can be procured in different sizes. Adults should routinely select a ball with a diameter of approximately 65 cm. Merely sitting on this device offers a good training effect, since it promotes dynamic sitting. While sitting on this ball, the musculature is continuously activated, in order to balance the smallest modification of position, since a quiet, rigid sitting is not possible. Thereby, sitting on the ball trains the complete abdominal musculature. Furthermore, the gymnastic ball offers a multitude of relaxation and training possibilities, to which we will make further reference in another paper.

LVS syndrome and sport Fundamentally it must be noted that moderate sport exercise is welcome for nearly all back complaints. Especially after a herniated disc, following a proper recovery phase, movement is one of the most important pillars of the physiotherapeutic rehabilitation. But also with all other forms of chronic back pain, the retention of the mobility of the spinal column as well as general body fitness are of great significance. By means of appropriate body building, the body will be enabled to encounter and to direct the dynamic forces that occur daily in a controlled manner, and to secure the subsequent braking actions in a protective manner. A recognized possibility of controlled body building is the „Kieser Training“, by which one is trained on special equipment according to a training plan under supervision. But a normal fitness studio with physiotherapeutic supervision is very suitable to achieve positive training effects in a short time.

Naturally, better and less suitable types of sport types exist for patients with back pain. Thus for example, a recently operated or conservatively treated patient with a herniated disc should not begin to play golf again too early. Especially with this type of sport, the extreme rotation movement of the upper body, with the golf club as an additional lever, cause severe pressure and other heavy stress on the entire back and especially on the lumbar vertebrae. This effect is made even more detrimental through a golf technique that is imperfectly performed. For the same reason, tennis, especially if it is played in competition, does not belong to the category of sports that are recommended. Here also considerable rotation stress of the spinal column occurs, combined with the overextension of the spinal column with each serve. The vertebral disc and the spinal column are hereby put under great stress. Furthermore, so-called contact sports must be dealt with caution, in which injuries occur through body contact with a competitor, such as soccer or handball.

By contrast, endurance sports are especially protective for the back, such as walking, Nordic walking and also moderate jogging. These types of sport have the common advantage, that they stress the spinal column to a minimal extent and that they cause a continuous change between stress and relief of the spinal column by means of the regular movement processes. This is advantageous for the nourishment situation of the spinal column, because spinal column tissues are not perfused with blood; the provision of nutrients for the tissues only occurs via this change between stress and relief. Swimming is also a sport, which is well suited for patients with an LWS syndrome; however, new evidence exists for this topic. For a long time the technique of back-swimming was favored, but the training effect with regard to strengthening the back muscles is rather minimal. A significantly greater effect is offered by breast-swimming, but it can only be recommended if one can master the technique properly. With a poor swimming technique, the cervical vertebrae are especially exposed to significant stress.

Exercise treatments according to the Pilates technique have been proven to be worthwhile, especially for people with spinal column complaints. All Pilates exercises begin with the establishment of a basic tension of the abdominal musculature. This tension, the so-called „powerhouse“, should be maintained throughout the entire exercise phase. The deep muscle layers will thereby be activated and the participant develops a significantly better body posture by means of regular exercise. The greatest difference versus conventional training schedules is that the Pilates method has a comprehensive approach. Thus, elements from Yoga are also applied, for example. .

Medicinal therapy Especially in acute painful phases, pure physiotherapeutic and physical therapies are often not sufficient. The application of a supplemental, medicinal therapy is needed here. This should always be discussed with the treating physician! Undesired side-effects and complications can thus be minimized and eventual incompatibilities/ contra-indications can be discussed.

Suitable medicines for the therapy of LVS syndrome are:

• NSAR
• Ibuprofen
• Diclofenac
• Celebrex
• Paracetamol
• Novalminsulfon
• Tramadol
• Valoron
• Katadolon
• Devil’s claw

The following have a muscle-relaxing effect:

• Tetrazepam (e.g... Musaril®)
• Mydocalm
• Diazepam (e.g... Valium®)

You can receive detailed information from our description of the medicines.