Issue №5-22, 2023
Review
Low Back Pain: a New Comprehensive Pathogenetic Model Supporting Methods of Medical Rehabilitation
1 
Luigi Tesio
1Department of Neurorehabilitation Sciences, Istituto Auxologico Italiano, Milan, Italy
ABSTRACT
The pathogenesis of chronic low back pain remains elusive. It is still considered a «non-specific» condition, with severity loosely related to anatomical alterations of the lumbar spinal canal (e.g., disc herniation, spinal stenosis). Signs and symptoms may appear contradictory, such as pain aggravated by rest or spinal loading, opposite lumbar postures (flexed or extended) adopted by different patients, and others. Guidelines and reviews oscillate between a restrictive nerve compression model to large sets of epidemiologic factors (from lifestyle to chronic lumbar stress to genetic determinants). A new pathogenetic model is presented here, based on the variable interaction between three possible determinants: compression of nerve endings by disc herniation or arthritic spurs, engorgement of the epidural (Batson) venous plexus, and inflammation triggered by focal thrombophlebitis and fostered by fibrinolytic defects. Hence, the name Compressive-Venous-Inflammatory (CoVIn) is given to the model. Biological and clinical studies provide evidence for each of the three cited determinants. The integrated model explains many «unexplained» characteristics of LBP and provides a rationale for mechanical treatments targeting one or more of the three determinants. Active Lumbar Traction (auto-traction), water exercise, and Williams’ flexor exercises look highly consistent with the model, which can explain their effectiveness.KEYWORDS: low back pain, pathogenetic model, epidural venous plexus, active lumbar traction, balneotherapy, flexor exercises
Acknowledgments: The study had no sponsorship.
Conflict of interest:: The authors declare no apparent or potential conflicts of interest related to the publication of this article.
For citation: Tesio L. Low Back Pain: a New Comprehensive Pathogenetic Model Supporting Methods of Medical Rehabilitation.
Bulletin of Rehabilitation Medicine. 2023; 22(5): 83-92. https://doi.org/10.38025/2078-1962-2023-22-5-83-92
For correspondence: Luigi Tesio, E-mail: l.tesio@auxologico.it
Список литературы:
1. Cieza A., Causey K., Kamenov K., Hanson S.W., Chatterji S., Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020; 396(10267): 2006–2017. https://doi.org/10.1016/S0140-6736(20)32340-02. Balagué F., Mannion A.F., Pellisé F., Cedraschi C. Non-specific low back pain Epidemiology and natural history. The Lancet. 2012; (379): 482–491. https://doi.org/10.1016/s0140-6736(11)60610-7
3. Zampolini M., Bernardinello M., Tesio L. RTW in back conditions. Disability and Rehabilitation. 2007; 29(17): 1377–1385. https://doi.org/10.1080/09638280701314980
4. Brennan G.P., Fritz J.M., Hunter S.J. et al. Identifying Subgroups of Patients with Acute/Subacute «Nonspecific» Low Back Pain Results of a Randomized Clinical Trial. Spine. 2006; 31(6): 623–631.
5. Chiarotto A., Koes B.W. Nonspecific Low Back Pain. The New England Journal of Medicine. 2022; 386(18): 1732–1740. https://doi.org/10.1056/nejmcp2032396
6. Frymoyer J.W. Back Pain and Sciatica. The New England Journal of Medicine. 1988; (318): 291–300.
7. Hassan S., Nesovic K., Babineau J. et al. Systematic Review and Meta-Analysis Identifying chronic low back pain phenotypic domains and characteristics accounting for individual variation: a systematic review. Pain. 2023; 164(10): 2148–2190. https://doi.org/10.1097/j.pain.0000000000002911
8. Jackson C., Brown M. Is there a role for exercise in the treatment of patients with low back pain? Clinical Orthopaedics and Related Research. 1983; (179): 39–45.
9. Wike B. The neurology of low back pain. The Lumbar Spine and Back Pain. 1987: 265–339. 10. Mixter W.J., Barr J.S. Rupture of the Intervertebral Disc with Involvement of the Spinal Canal. The New England Journal of Medicine. 1934; 211(5): 210–215. https://doi.org/10.1056/NEJM193408022110506
11. Williams A.L., Murtagh F.R., Rothman S.L.G. et al. Lumbar disc nomenclature: Version 2.0. American Journal of Neuroradiology. 2014; 35(11): 2029. https://doi.org/10.3174/ajnr.A4108
12. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. Journal of Bone and Joint Surgery. 1954; 36B(2): 230–237.
13. Siebert E., Prüss H., Klingebiel R. et al. Lumbar spinal stenosis: Syndrome, diagnostics and treatment. Nature Reviews Neurology. 2009; 5(7): 392–403. https://doi.org/10.1038/nrneurol.2009.90
14. Kashima T.G., Dongre A., Athanasou N.A. Lymphatic involvement in vertebral and disc pathology. Spine. 2011; 36(11): 899–904.
15. Williams P.C. Lesions of the lumbosacral spine. Part II. Chronic Traumatic (postural). Destruction of the Lumbosacral Intervertebral Disc. Journal of Bone and Joint Surgery. 1937; 19(3): 690–703.
16. McKenzie R., May S. The Lumbar Spine Mechanical Diagnosis & Therapy. Spinal Publications New Zealand. 2003.
17. Hayden J.A., Ellis J., Ogilvie R. et al. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021; 2021(9). https://doi.org/10.1002/14651858.CD009790.pub2
18. Ostgaard H.C., Andersson G.B.J., Karlsson K. Prevalence of Back Pain in pregnancy. Spine. 1991; 16(5): 549–552.
19. Batson O.V. The function of the vertebral veins and their role in the spread of metastases. Annals of Surgery. 1940; 112(1): 138–149.
20. LaBan M.M. «Vespers Curse» night pain-the bane of Hypnos. Archives of Physical Medicine and Rehabilitation. 1984; 65(9): 501–504.
21. LaBan M.M., McNeary L. The clinical value of B-type natriuretic peptide (BNP) in predicting nocturnal low back pain in patients with concurrent lumbar spinal stenosis and cardiopulmonary dysfunction (Vesper’s Curse): a clinical case series. American Journal of Physical Medicine & Rehabilitation. 2008; 87(10): 798–802. https://doi.org/10.1097/PHM.0b013e318186b969
22. LaBan M.M., Kucway E.J. Aeolus myth: chronic obstructive lung disease and nocturnal lumbosacral pain in association with lumbar spinal stenosis and pulmonary hypertension. American Journal of Physical Medicine & Rehabilitation. 2003; 82(9): 660–664. https://doi.org/10.1097/01.PHM.0000083663.01028.9C
23. LaBan M.M., Wang A.M., Shetty A. et al. Varicosities of the paravertebral plexus of veins associated with nocturnal spinal pain as imaged by magnetic resonance venography: a brief report. American Journal of Physical Medicine & Rehabilitation. 1999; 78(1): 72–76. https://doi.org/10.1097/00002060-199901000-00019
24. Fast A., Weiss L., Parikh S. et al. Night backache in pregnancy. Hypothetical pathophysiological mechanisms. American Journal of Physical Medicine & Rehabilitation. 1989; 68(5): 227–229. https://doi.org/10.1097/00002060-198910000-00005
25. Rozen T.D., Devcic Z., Toskich B. et al. Nutcracker phenomenon with a daily persistent headache as the primary symptom: Case series and a proposed pathogenesis model based on a novel MRI technique to evaluate for spinal epidural venous congestion. Journal of the Neurological Sciences. 2022; 434. https://doi.org/10.1016/j.jns.2022.120170
26. LaBan M.M., Viola S.L., Femminineo A.F. et al. Restless legs syndrome associated with diminished cardiopulmonary compliance and lumbar spinal stenosis — a motor concomitant of «Vesper’s curse». Archives of Physical Medicine and Rehabilitation. 1990; 71(6): 384–388.
27. Tesio L. The cause of back pain and sciatica may be a venous matter, too. British Journal of Rheumatology. 1991; 30(1): 70–71.
28. Jayson M.I.V., Million R., Keegan A. et al. A fibrinolytic defect in chronic back pain syndromes. The Lancet. 1984; (13): 1186–1187.
29. Pountain G.D., Keegan A.L., Jayson M.I. Impaired fibrinolytic activity in defined chronic back pain syndromes. Spine. 1987; 12(2): 83–86. https://doi.org/10.1097/00007632-198703000-00002
30. Klimiuk P.S., Pountain G.D., Keegan A.L. et al. Serial measurements of fibrinolytic activity in acute low back pain and sciatica. Spine. 1987; 12(9): 925–928. https://doi.org/10.1097/00007632-198711000-00014
31. Cooper R.G., Freemont A.J., Hoyland J.A. et al. Herniated intervertebral disc-associated periradicular fibrosis and vascular abnormalities occur without inflammatory cell infiltration. Spine. 1995; 20(5): 591–598. https://doi.org/10.1097/00007632-199503010-00016
32. Goupille P., Jayson M.I., Valat J.P. et al. The role of inflammation in disk herniation-associated radiculopathy. Seminars in Arthritis and Rheumatism. 1998; 28(1): 60–71. https://doi.org/10.1016/s0049-0172(98)80029-2
33. Tesio L., Raschi A., Meroni M. Autotraction treatment of low-back pain in pregnancy: a pilot study. Clinical Rehabilitation. 1994; (8): 314–319.
34. Groen R.J.M., Groenewegen H.J., Van Alphen H.A.M. et al. Morphology of the human internal vertebral venous plexus: A cadaver study after intravenous Araldite CY 221 injection. The Anatomical Record. 1997; 249(2): 285–294. https://doi.org/10.1002/(sici)1097-0185(199710)249:2<285::aid-ar16>3.0.co;2-k
35. LaBan M.M., Wilkins J.C., Wesolowski D.P. et al. Paravertebral venous plexus distention (Batson’s): an inciting etiologic agent in lumbar radiculopathy as observed by venous angiography. American Journal of Physical Medicine & Rehabilitation. 2001; 80(2): 129–133. https://doi.org/10.1097/00002060-200102000-00010
36. Bozkurt G., Cil B., Akbay A. et al. Intractable radicular and low back pain secondary inferior vena cava stenosis associated with Budd-Chiari syndrome: endovascular treatment with cava stenting: case report and review of the literature. Spine. 2006; 31(12): E383–E386. https://doi.org/10.1097/01.brs.0000219516.54500.97
37. Epstein B.S. Low back pain associated with varices of the epidural veins simulating herniation of the nucleus pulposa. The American Journal of Roentgenology Radium Therapy and Nuclear Medicine. 1947; 57(6): 736–740.
38. Parke W.W. Role of Epidural and Radicular Veins in Chronic Back Pain and Radiculopathy. Arthroscopic and Endoscopic Spinal Surgery. 2005: 151–165. https://doi.org/10.1385/1-59259-904-4:151
39. Chung S.S., Lee C.S., Kim S.H. et al. Effect of low back posture on the morphology of the spinal canal. Skeletal Radiology. 2000; (29): 217–223.
40. Knutsson F. Volum-und formvariationen des wjrbel-kanals bei lordosierung bzw. kypho-sierung und ihre bedeutung fur die myelographische diagnostik. Acta Radiologica. 1942; 23(5): 431–443. https://doi.org/10.3109/00016924209135629
41. White A.A., Panjabi M.M. Clinical Biomechanics of the Spine. 2nd ed. Lippincott, Willians & Wilkins. 1990.
42. Demaerel P., Petré C., Wilms G. et al. Sciatica caused by a dilated epidural vein: MR findings. European Radiology. 1999; 9(1): 113–114. https://doi.org/10.1007/s003300050640
43. Bursalı A., Akyoldas G., Guvenal A.B. et al. Lumbar epidural varix mimicking disc herniation. Journal of Korean Neurosurgical Society. 2016; 59(4): 410–413. https://doi.org/10.3340/jkns.2016.59.4.410
44. Kamogawa J., Kato O., Morizane T. Three-dimensional visualization of internal vertebral venous plexuses relative to dural sac and spinal nerve root of spinal canal stenosis using MRI. Japanese Journal of Radiology. 2018; 36(5): 351–360. https://doi.org/10.1007/s11604-018-0725-4
45. Lind G. Auto-Traction Treatment of Low-Back Pain and Sciatica. University of Linkoping. 1974.
46. Natchev E. A Manual on Auto-Traction Treatment for Low-Back Pain. Tryckeribolaget i Sundvall AB. 1984.
47. Tesio L. Autotraction treatment for low-back pain syndromes. Critical Reviews in Physical and Rehabilitation Medicine. 1995; 7(1): 1–9.
48. Tesio L., Merlo A., Raschi A. Active Lumbar Traction. Scientific review. Manual. Treatment guidelines. Ricerca in Riabilitazione. 1996; (1): 27–45.
49. Gillstrom P., Ehrnberg A. Long-term results of autotraction in the treatment of lumbago and sciatica. Archives of Orthopaedic and Trauma Surgery. 1985; 104(5): 294–298. https://doi.org/10.1007/bf00435945
50. Larsson U., Choler U., Lidstrom A. et al. Auto-traction for treatment of lumbago-sciatica. 1980: 791–798.
51. Tesio L., Merlo A. Autotraction versus passive traction: an open controlled study in lumbar disc herniation. Archives of Physical Medicine and Rehabilitation. 1993; (74): 871–876.
52. Gillström P., Ericson K., Hindmarsh T. Autotraction in lumbar disc herniation — A myelographic study before and after treatment. Archives of Orthopaedic and Trauma Surgery. 1985; 104(4): 207–210. https://doi.org/10.1007/BF00450211
53. Tesio L., Luccarelli G., Fornari M. Natchev auto-traction for lumbago-sciatica: effectiveness in lumbar disc herniation. Archives of Physical Medicine and Rehabilitation. 1989; (70): 831–834.
54. Ljunggren A.E., Weber H., Larsen S. et al. Autotraction versus manual traction in patients with prolapsed lumbar intervertebral discs. Scandinavian Journal of Rehabilitation Medicine. 1984; 16(3): 117–124.
55. Bonaiuti D., Gatti R., Raschi A. et al. Manual autotraction: preliminary study on the effectiveness of a new device for back pain treatment. Eura Medicophys. 2004; (40): 75–81.
56. Andersson G.B.J., Schultz A.B., Nachemson A.L. Intervertebral disc pressures during traction. Scandinavian Journal of Rehabilitation Medicine. 1983; 15(9): 88–91.
57. Donelson R., Long A., Spratt K. et al. Influence of Directional Preference on Two Clinical Dichotomies: Acute Versus Chronic Pain and Axial Low Back Pain Versus Sciatica. PM&R. 2012; 4(9): 667–681. https://doi.org/10.1016/j.pmrj.2012.04.013
58. Waller B., Lambeck J., Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clinical Rehabilitation. 2009; (23): 3–14.
59. Maccarone M.C., Magro G., Albertin C. et al. Short-time effects of spa rehabilitation on pain, mood and quality of life among patients with degenerative or post-surgery musculoskeletal disorders. International Journal of Biometeorology. 2023; 67(1): 29–36. https://doi.org/10.1007/s00484-022-02381-4
60. Karagülle M., Karagülle M.Z. Effectiveness of balneotherapy and spa therapy for the treatment of chronic low back pain: a review on latest evidence.
Clinical Rheumatology. 2015; 34(2): 207–214. https://doi.org/10.1007/s10067-014-2845-2
61. Baena-Beato P.Á., Artero E.G., Arroyo-Morales M. et al. Aquatic therapy improves pain, disability, quality of life, body composition and fitness in sedentary adults with chronic low back pain. A controlled clinical trial. Clinical Rehabilitation. 2014; 28(4): 350–360. https://doi.org/10.1177/0269215513504943
62. Risch W.D., Koubenec H.J., Beckmann U. et al. The effect of graded immersion on heart volume central venous pressure pulmonary blood distribution and heart rate in man. Pflügers Archiv: European Journal of Physiology. 1978; 374(2): 115–118. https://doi.org/10.1007/BF00581289
63. Epstein M. Renal effects of head-out water immersion in humans: a 15-year update. Physiological Reviews. 1992; 72(3): 563–621.
64. Grossman E., Goldstein D.S., Hoffman A. et al. Effects of water immersion on sympathoadrenal and dopa-dopamine systems in humans. American Journal of Physiology. 1992; 262(6-2): 993–999.
65. O’Hare J.P., Heywood A., Summerhayes C. et al. Observations on the effect of immersion in Bath spa water. British Medical Journal. 1985; 291(6511): 1747–1751. https://doi.org/10.1136/bmj.291.6511.1747
66. Yamazaki F., Endo Y., Torii R. et al. Continuous monitoring of change in hemodilution during water immersion in humans: effect of water temperature.
Aerospace Medicine and Human Performance. 2000; 71(6): 632–639.
67. Pechter U., Maaroos J., Mesikepp S. et al. Regular low-intensity aquatic exercise improves cardio- respiratory functional capacity and reduces proteinuria in chronic renal failure patients. Nephrology Dialysis Transplantation. 2003: 624–625.
68. Pechter U., Raag M., Ots-Rosenberg M. Regular aquatic exercise for chronic kidney disease patients: a 10-year follow-up study. International Journal of Rehabilitation Research. 2014; 37(3): 251–255. https://doi.org/10.1097/MRR.0000000000000063
69. Fort S., James J.Y., Srivastava E.D. et al. Water Immersion for Treatment of Ascites in Chronic Liver Disease. Physiotherapy. 1981; 77(8): 571–572.
70. Moini Jazani A., Nasimi Doost Azgomi H., Nasimi Doost Azgomi A. et al. Effect of hydrotherapy, balneotherapy, and spa therapy on blood pressure: a mini-review. International Journal of Biometeorology. 2023; 67(9): 1387–1396. https://doi.org/10.1007/s00484-023-02512-5
71. Katz V.L., Rozas L., Ryder R. et al. Effect of daily immersion on the edema of pregnancy. American Journal of Perinatology. 1992; 9(4): 225–227. https://doi.org/10.1055/s-2007-994776
72. Epstein M., Norsk P., Loutzenhiser R. et al. Detailed characterization of a tank used for head-out water immersion in humans. Journal of Applied Physiology. 1987; (63): 869–871.
73. Williams P.C. Lesions of the lumbosacral spine. Part I. Acute traumatic destruction of the lumbosacral Intervertebral Disc. Journal of Bone and Joint Surgery. 1937; 19(2): 343–363.
74. Elnaggar I.M., Nordin M., Sheikhzadeh A. et al. Effects of Spinal Flexion and Extension Exercises on Low-Back Pain and Spinal Mobility in Chronic Mechanical Back Pain Patients. Spine. 1991; 16(8): 967–972.
75. Dydyk A.M., Amit S. Williams Back Exercises. StatPerls Publishing. 2023.
76. Benoist M., Ficat C., Baraf P. et al. Postoperative Lumbar Epiduro-Arachnoiditis: Diagnostic and Therapeutic Aspects. Spine. 1980; 5(5): 432–436.
©
This is an open article under the CC BY 4.0 license. Published by the National Medical Research Center for Rehabilitation and Balneology.
