Lumbar Facet Joint Pain
Research has shown that Physiotherapy treatment can greatly improve function and mobility and decrease the pain associated with facet joint injuries of the lumbar spine in the acute, sub-acute and chronic phases.
The Low Back Pain Position Statement, published by the Australian Physiotherapy Association, examines current research in this area.
Lumbar facet joint pain can present as an acute joint sprain (most common in the sporting population, particularly golf and tennis) but is more often a chronic problem associated with degenerative changes occurring at the facet joints at a specific level over time. A chronic lumbar disc injury places more stress on the facet joints at that level, leading to increased wear and tear. Osteo-arthritis of the facet joints is the most likely cause of the problem if there has been gradual onset with low back stiffness in the mornings.
These patients may have local low back aching but the pain can refer into the buttock, the hips, and even as far as the knee. The pain is diffuse and difficult to localise, but may be sharp with certain movements.
Pain is aggravated by extension, walking, prolonged standing, end-of-range flexion and side flexion activities. There may even be pain as the patient moves from flexion to extension, such as when getting up out of a chair.
Pain is often eased by sitting down in a supportive chair after prolonged standing (flexion of the lumbar spine) and by gentle movement and exercises. The OA facet joints stiffen easily, particularly in the mornings, and “warm up” with gentle movement. Often the aching is worse again at the end of the day.
Distal pain is not easily reproduced with palpation. Locally however the facet joint may be tender on palpation and there may be a feeling of stiffness and swelling of the joint when it is mobilised. There may be generalised tenderness and tightness in the muscles of the lower back and buttocks.
Physiotherapy treatment includes joint mobilisations or manipulations of the injured facet, as well as joint mobilisations at levels of the spine above and below to improve general spinal mobility and take pressure off the injured segment. Exercises to mobilise, strengthen and support the lumbar spine are commenced and stretches to improve muscular flexibility of the lumbo-pelvic region are also encouraged. Dry needling may be a useful adjunct. The physiotherapist may also mobilise the hip to take pressure off the lower back, and patient education is also essential.
Treatment for lumbar facet joint pain, should include physiotherapy with other conservative treatment options amongst a multidisciplinary team (cognitive behaviour therapy, pharmacological treatment and if necessary a psychological evaluation). Physiotherapy should include: exercise therapy, rehabilitation and manual medicine.
Intra-articular corticosteroid injections:
This is a controversial treatment due to uncontrolled studies showing temporary benefits. Lilius et al. performed a large study of 109 participants and found no difference between intra-articular saline (salty water) injection, intra-articular corticosteroid injection and a local anesthetic. Another study by Carette et al. found an improvement of 10% for the saline injection and 22% for the corticosteroid injection at the 6 months follow up.
There is little value with intra-articular corticosteroid injections for patients who do not have confirmed facet joint pain. Confirming facet joint pain is most accurately done with a diagnostic block procedure.
Radiofrequency (RF) treatment: This is a procedure that may recommended for patients who have chronic lower back pain, which includes a confirmed positive diagnostic block test.