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ABSTRACT
The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient’s low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.
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No potential conflict of interest was reported by the author(s).
Correction Statement
This article has been corrected with minor changes. These changes do not impact the academic content of the article.
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Notes on contributors
Douglas Creighton
Dr. Doug Creighton holds certifications in two different systems of manual therapy. He has been in clinical practice since 1985, and a full-time faculty member at Oakland University since 1998. His teaching responsibilities are spread across both the entry-level and post-profession programs. He teaches across both the basic science and orthopedic curriculum including musculoskeletal Imaging, Arthrology, a cadaver-based anatomy course, which looks at joint surface shape and orientation, capsular anatomy, and in-depth exploration of degenerative changes including chondral defects, arthritic and spondylotic hypertrophy, and degenerative disc narrowing. He is also responsible for an orthopedic Examination and Therapeutic Exercise course. His post-professional teaching occurs in Oakland University's orthopedic manual physical therapy program where he provides both didactic and residency-based education. He has published work related to radiological confirmation of lumbar foraminal opening with therapeutic positioning, diagnostic ultrasound imaging of vertebral artery blood flow during upper and lower cervical manual therapy interventions, and various levels of research which has looked at both manual and exercise intervention for orthopedic pain and motion impairments.
David Fausone
Dr. David Fausone is an assistant professor at Oakland University. Dr. Fausone graduated from Oakland University with a Bachelor’s Degree in Health Sciences, Master’s and Doctoral Degrees in Physical Therapy and a Doctor of Science with concentration in Physical Therapy. He holds certifications in Orthopedic Manual Physical Therapy (OMPT) and Teaching and Learning for Rehabilitation Professionals. He has been in clinical practice since 2003, and a faculty member at Oakland University since 2016. His teaching responsibilities are within the entry level program, focusing primarily on functional, gross and neuroanatomy. His research currently focuses on anatomical variation and patterns of degeneration in the cervical and lumbar spine.
Brian Swanson
Dr. Brian T. Swanson is an Associate Professor at the University of Hartford. He serves as Chair of the Department of Rehabilitation Sciences, Director of the Doctor of Physical Therapy Program, and co-Director of the University of Hartford/HHCRN orthopedic physical therapy residency program. He is a board certified orthopedic clinical specialist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists. Dr. Swanson’s research interests include validating tests and measures in orthopedic manual physical therapy, developing a further understanding of the mechanisms of manual physical therapy interventions, and evidence-based practice/research methodology.
William Young
William Young is a current doctor of physical therapy student and graduate assistant. His primary area of clinical interest is orthopedic spine management and his research interests currently focus on the investigation of degenerative spinal disorders.
Spencer Nolff
Spencer Nolff is a current doctor of physical therapy student and graduate assistant. His primary area of clinical interest is orthopedics and sports physical therapy and his research interests currently focus on the investigation of degenerative spinal disorders.
Amanda Ruble
Dr. Amanda Prahl (Ruble) is a 2022 graduate of the Oakland University Doctor of Physical Therapy Program, and holds a certification in LSVT BIG. She currently works as an outpatient physical therapist at the Detroit Medical Center Rehabilitation Institute of Michigan at Huron Valley Sinai Hospital. Dr. Prahl (Ruble) clinical interests include orthopedic and sports rehabilitation as well as treating patients with Parkinson’s Disease.
Noraan Hassan
Dr. Noraan Hassan is a 2022 graduate of the Oakland University Doctor of Physical Therapy Program and is currently in full-time clinical practice
Emily Soley
Dr. Emily Soley is a 2022 graduate of the Oakland University Doctor of Physical Therapy Program. She is currently practicing as an outpatient orthopedic physical therapist at Corewell Health. Her clinical interests include sports rehabilitation and orthopedic manual therapy.