Lumbar Segmental Rigidity: Can Its Identification With Facet Injections and Stretching Exercises Be Useful? Tom G. Mayer, MD, Richard Robinson, PhD, Pauline Pegues, RN, Sheri Kohles, PT, Robert J. Gatchel, PhD ABSTRACT. Mayer TG, Robinson R, Pegues P, Kohles S, Gatchel RJ. Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful? Arch Phys Med Rehabil 2000;81:1143-50. Objectives: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. Design: Preliminary 2-part study: (1) presentation of a technique for identifying lumbar segmental rigidity based on physical observation of the spine’s lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. Setting: An outpatient tertiary rehabilitation facility provid- ing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. Patients: Chronically disabled patients with lumbar spinal disorder (n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. Interventions: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1–4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. Main Outcome Measures: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. Results: Patients’ mobility improved significantly ( p  .01–.0001) across all 4 motions. A large majority (71%–97%) of individuals improved on motion. According to self-reports made over the postinjection period, most patients improved their disability (83%) and pain intensity (63%) ratings. Conclusions: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improve- ments in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticoste- roid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improve- ments cannot be determined from the present study, but warrants future investigation. Key Words: Disability; Injections; Lumbar vertebrae; Out- come assessment; Pain; Range of motion, articular; Rehabilita- tion.  2000 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation C HRONIC LOW BACK PAIN (LBP) is a major cause of disability in the United States. A single anatomic cause can rarely be identified. One cause that has garnered little attention, but should be considered, is segmental rigidity or hypomobility. Chronic posttraumatic pain arising from extremity synovial joints is frequently associated with persistent joint stiffness from capsular, ligamentous, or para-articular muscle and tendon contracture. Through stretching and activating physical train- ing, some pain may be relieved as stiffness improves. Without intervention, pain often persists and is particularly exacerbated by sudden joint movements beyond the restricted ‘‘frozen’’ range. Although interarticular or para-articular local anesthetic with corticosteroid may induce limited periods of pain relief, 1,2 beneficial outcomes may last longer if corticosteroid injections are accompanied by physical training to remobilize the affected joint. When a patient attains and retains full motion in an osteoarthritic joint, that patient may achieve prolonged pain relief. Because facets are diarthrodial joints, they may be expected to respond to the pathophysiology of stiffness and the rehabilitative techniques of motion restoration, much as extrem- ity joints respond. Lumbar spine physical examination rarely focuses on spe- cific intersegmental mobility deficits. Consequently, even if lumbar segmental rigidity is present and related to facet joint stiffness, the examiner may fail to note it. If one could observe lumbar segmental rigidity and make it the main criterion for prescribing an intervention of facet steroid injection under fluoroscopy combined with stretching exercises, one could then verify reduced segmental rigidity by measuring improvements in the patient’s inclinometric lumbar mobility. If reduced hypomobility also correlates with prolonged pain relief, chronic LBP might be treated with greater efficacy. This hypothesis may help identify a subgroup of facet syndrome patients whose characteristics may have affected the long-term outcomes of previous studies, 3-7 making the results inconclusive. Specific mobility deficits in lumbar spinal joints, particularly at the lower (2–3) levels, can be seen with reference to dependable anatomic landmarks in a patient who is bending laterally. Inclinometers have been used to document isolated regional lumbar sagittal and coronal motion for more than a decade. Improvements in inclinometric true lumbar motion correlated to pain report in chronically disabled industrial patients have been well documented. 8,9 Assisting patients to maximize mobility before they start a strength training program is a key principle of functional restoration. 10-13 Facet injections may therefore be an adjunct to overcoming segmental rigidity From the Departments of Orthopedic Surgery (Mayer) and Psychiatry and Rehabilitation Science (Gatchel), University of Texas Southwestern Medical Center; and the PRIDE Research Foundation (Robinson, Pegues, Kohles), Dallas, TX. Accepted January 31, 2000. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Tom G. Mayer, MD, 5701 MapleAve, #100, Dallas, TX 75235. 0003-9993/00/8109-5876$3.00/0 doi:10.1053/apmr.2000.9170 1143 Arch Phys Med Rehabil Vol 81, September 2000