Low BACK PAIN

Low back pain management.

1. LOW BACK PAIN Dr. SUMAN PAUL Department of Orthopaedics & Traumatology , Rajshahi Medical College Hospital

2. CONTENT Brief anatomy of the back Intro to Lower Back Pain Epidemiology Causes of LBP Presentation Ways of preventing LBP Treatment

3. THE BACK The back can be viewed as that region of the body from the occiput to the gluteal folds ( Olaogun , 1999) The back is composed of very sturdy bones and powerful muscles. The spine or the back bone is made up of 33 bones called vertebrae. 7 cervical, 12 thoracic and 5 lumbar vertebrae separated by 23 intervertebral discs.

4. LOW BACK PAIN Also known as lumbago (at times referred to as waist pain) is pain (as name implies) in the lower back (lumbar) region. Typically, the commonest area of back pain is the low back (lumbar region) and sometimes it spreads to the buttocks or thighs. WHY THE LOWER BACK? Lumbar region because: It bears most of the body’s weight Most movements of the spine occur there.

5. LOW BACK PAIN Most bouts of back pain ease quickly, usually within a week (acute back pain). When symptoms persist for several months (over 3 months) chronic back pain results. Back pain could be mechanical, pathologic or physiologic

6. FACTS:- Low Back Pain Second most common cause of missed work days Leading cause of disability between ages of 19-45 Number one impairment in occupational injuries

7. Referred LBP Is Remote From Source of Pain LBP may radiate into groin buttocks upper thigh (posteriorly) areas that share an interconnecting nerve supply Source of somatic referred pain is a skeletal or myofascial structure of the lumbar spine Source of visceral referred pain is within a body organ ovarian cysts may refer pain to low back cancer of head of pancreas can present as low back pain becoming excruciating at night

8. Muscular Pain Most back pains are caused by strain or sprain of the back muscles & ligaments Pain will be in discrete area & tender to touch It is of aching quality & may involve muscle spasm

9. EPIDEMIOLOGY Back pain, especially low back pain (LBP), most often affects people between the ages of 25 and 60 years and those aged between 50 and 60 years are likely to become disabled (Corbin et al, 2002). Up to 70%-85% of the population in the United Kingdom (UK) experience back pain at some point in their lives. In Ghana, over 60% of the adult population complains of back pain at one time or the other ( Osei , 2000). Out of the 424 patients who presented with various conditions at the Physiotherapy Department of KBTH, 54% were LBP cases (From June to August 2004).

10. Sources of LBP Damage to several structures in the low back can result in severe pain vertebrae thoracolumbar fascia ligaments joints specifically sacroiliac joint discs muscle Deyo RA, Weinstein JN. N Engl J Med . 2001;344:363 -370.

11. Non-Spinal Related Causes Bladder Infection Kidney Disease Ovarian Cancer Ovarian Cyst Testicular Torsion Fibromyalgia Pelvic Infections Appendicitis Pancreatitis Prostate Disease Gall Bladder Disease Abdominal Aortic Aneurysm

12. Spine Related Causes Arthritis Fibromyalgia Kyphosis Lordosis Rheumatoid Arthritis Ankylosing Spondylitis Arachnoiditis Bone Cancer Chiari Malformation Compression Fractures Discitis Epidural Abscess Facet Joint Syndrome Fixed Sagittal Imbalance Osteomyelitis Osteophytes Pinched Nerve Ruptured Disc Spina Bifida Spinal Cord Injury Spinal Tumor Spondylolisthesis Spinal Stenosis Spinal Cord Injury Spinal Tumor Sprain or Strain Synovial Cysts Wedge Fractures

13. LBP Psychological Factors Psychological factors that may contribute to or be caused by chronic LBP include depression anxiety post-traumatic stress disorder pre-existing disorders Physiotherapy department, TQMH

14. Social Issues May Contribute to Chronic LBP Job dissatisfaction/loss of ability to work Pursuit of disability compensation Substance abuse Family dynamics Financial issues Loss of social identity or context Loss of ability to participate in recreational activities

15. Diagnosis of LBP History Location Specific Point vs. Across Back Superficial vs. Deep Involve Any other region (lower extremity)

16. History Quality Dull Ache (tooth ache) Sharp/Stabbing Burning Tearing/Pop

17. History Quality/Severity Intermittent Constant Pain Scale 1-10

18. History Setting Time of day when worst/better After strenuous activity

19. History Aggravating/Relieving Factors What Makes Better What Makes Worse BEWARE OF THE PATIENT THAT SAYS NOTHING MAKES PAIN BETTER !

20. History Associated Manifestations Numbness Tingling(pins/needles) Burning Weakness Incontinence Falls

21. OBJECTIVE ASSESSMENT Musculoskeletal Examination Look pain behaviors–groaning, position changes, grimacing, etc atrophy, swelling, asymmetry, color changes Feel palpate area of pain for temperature, spasm, and pain provocation point palpation for trigger points/tender points Move active and passive flexion, extension, rotational, lateral bending leg raising

22. Examination Posture – change in lumbar lordosis , scoliosis Range of motion – flexion,extension , lateral flexion SLR – seated & supine, sciatic nerve stretch test Presence of paraspinal muscle spasm, trigger points Tender areas –facets, sacro -iliac joints Neurological deficit – Dermatomal hypo/hyperaesthesia Ability to rise from squatting position (L4),walk on heels(L5), walk on tip-toes (S1) Tendon reflexes – knee jerk(L4 root), ankle jerk(S1 root)

23. Neurologic Exam Determines Presence/Absence and Level of Radiculopathy and Myelopathy Motor elements muscle bulk/tone atrophy/flaccidity muscle strength coordination gait Sensory elements sensory deficits, eg , touch, position sense, temperature, vibration allodynia : light touch hyperalgesia : single or multiple pinpricks The exam should include

24. Diagnostic Studies Plain X-Ray MRI CAT Scan Myelogram Discogram Bone Scan Facet Block SI Joint Block EMG SSEP DEXAscan Bone Scan

25. Diagnostic Studies X-Ray taken to assess the structure of the spine and to determine the alignment of the vertebra

26. Diagnostic Studies MRI Extremely Sensitive for assessment of Soft tissue structures (nerves, disc) One of the most commonly ordered test to assess low back pain

27. Diagnostic Studies CAT Scan Most often used to assess bone structures of spine. Faster and cheaper than MRI Can be very effective tool when using reconstruction images or combined with other modalities

28. Diagnostic Studies Myelogram & Post CT myelogram consists of a series of plain xrays with a contrast agent injected into the thecal sac. The C.A.T. scan that usually follows the myelogram depicts this same anatomy from a C.A.T. scan perspective

29. Diagnostic Studies Myelogram & Post CT The injection of iodine based contrast into the thecal sac containing the nerves and/or spinal cord, promotes better definition of those structures than the images obtained on the regular C.A.T. scan. Cross-sections and reconstructions of the images in different planes (including 3-D) allows different perspectives on the anatomy. This test is often used to visualize the spinal cord and nerves in relation to the surrounding spine structures (bone, joint, disc, etc)

30. Diagnostic Studies Discogram Involves the injection of contrast material into the disc space Concordant vs. Discordant Pain…..?? Helpful in assessing discogenic pain VERY “ uncomfortable ” test

31. PREVENTION LIFTING Squat directly (by bending your knees) in front of any object to be lifted; rise, letting your legs and thighs do the work. Keep the object you’re lifting close to your body, and don’t twist. Never try to lift anything you can’t easily manage – get help! Never bend over without bending your knees. Avoid twisting the trunk whilst lifting Lift and move the trunk in a vertical plane first Turn to the desired direction with the legs afterwards

32. CORRECT WAY OF LIFTING

33. PREVENTION STANDING Standing for long periods of time can put a lot of stress on your back. If you must stand, occasionally shift your weight from one side to the other. Or, try propping one of your feet on a footstool six-to-eight inches high. Occasionally, tighten your abdominal muscles. This can enable you to keep your back straight

34. STANDING

35. WRONG RIGHT WRONG

36. CARRYING BACK-PACKS

37. PREVENTION SITTING Sit in firm seats with straight backs, keeping your back flat/straight with the knees bent to about 90º. Rest your feet flat on the floor or on a footstool. If you cannot get the chair you prefer, learn to sit properly on whatever chair you get. Throw head well back, then bend it forward to pull in the chin. This will straighten the back. Now tighten abdominal muscles to raise the chest. Check position frequently.

38. SITTING POSTURE

39. SITTING POSTURE

40. PREVENTION SLEEPING Sleep on a firm, flat mattress. It’s best to sleep on your side with your knees and hips bent and a pillow under your head, or on your back with pillows beneath your head and knees.

41. POOR SLEEPING POSITION

42. GOOD SLEEPING POSITION

43. EVEN BETTER

44. POOR SLEEPING POSITION

45. GOOD SLEEPING POSITION

46. EVEN BETTER

47. SOME GOOD AND BAD POSTURES

48. TREATMENT Medications/ Pharmacotherapy Physiotherapy Surgery

49. Pharmacotherapy Options* Antidepressants Anticonvulsants Muscle relaxants Opioid analgesics Corticosteroids NSAIDs Topical analgesics * Except for certain opioids, none of these agents are indicated for chronic LBP.

50. PHYSIOTHERAPY Exercise (stretching and strengthening of back extensors mainly) Thermotherapy; Heat application in chronic lower back pain using Infra-red, shortwave diathermy, hotpacks , etc Electrotherapy; Transcutaneous Electric Nerve Stimulation, Trabert , etc

51. Back Exercises Ankle pump Heel slides Abdominal contraction Wall squats Heel raises Straight leg raises Knee to chest stretch Hamstring stretch Exercises with swiss ball

52. Surgery 1. DECOMPRESSION of spinal nerves (BURST FRACTURE, Spinal stenosis, PID) 2. Fusion & Stabilization (Instrumentation) 3. Correction of deformity

53. DECOMPRESSION Surgery

54. FUSION Surgery

55. References MOB Olaogun (1999): Pathomenchanics and force analysis at the low back during physical tasks (JNMRT), vol 4 (7). Pp 7-11 Clark MA, Russell AM. Low back pain: a functional perspective. Thousand Oaks, CA: National Academy of Sports Medicine; 2002. Hodges PW. Core stability exercise in chronic low back pain. Orthopedic Clinics of North America. 2003;34:245-254. Kendall FB, McCreary EK. Muscle Testing and Function. 4 th ed. Baltimore, MD: Williams & Watkins; 1993: 215-226, 284-293.

56. Thank you……