Low back pain

low back pain - a relatively malaysian recent update

1. AN UPDATE LOW BACK PAIN

2. INTRODUCTION Is a MAJOR PROBLEM PATIENT: Cause How to deal with it O utcome UNKNOWN!

3. DOCTORS: Majority unknown cause Difficult to get working ‘cure’ SOCIETY: - Main cause of work disability

4. CAUSES - VERTEBRAL BONE DISC SOFT TISSUE Degeneration, Infection, Inflammation, Malignancy, Trauma

5. CAUSES – NON VERTEBRAL STRUCTURES NEAR TO LOW BACK: GIT GUT Pancreas Vascular Gynae

6. CAUSES – NON SPECIFIC Most common LBP cause Poorly localized Long periods of no pain May reduce with massage, chiropractic or acupuncture No spine pathology

7. Understanding symptoms Good interpretation of signs EVALUATION OF LBP Treatment strategy History Physical examination MAIN AIM – TO DETECT RED FLAGS AND YELLOW FLAGS

8. RED FLAGS Possible serious spinal pathology: Cauda Equina Syndrome Trauma or Tumor Infection (TB or pyogenic)

9. RED FLAGS - HISTORY

10. RED FLAGS – PHY. EXAM.

11. Psychosocial factors Increases risk of long term disability and work loss Interferes with patient recovery YELLOW FLAGS

12. YELLOW FLAGS – FACTORS

13. Whether more detailed assessment is needed Identifications of factors that may require specific intervention secondary prevention of chronic low back pain YELLOW FLAGS IDENTIFICATION– LEADS TO:

14. OTHER NEW METHODS IN IDENTIFYING RISK FACTORS OF LBP: Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) Core Outcome Measure Index DALLAS Pain Questionnaire (DPQ) STarT Back Screening Tool RISK FACTORS

15. INVESTIGATIONS Must always be correlated clinically and should not be interpreted on its own To rule out possible causes ( e.g : infection, degeneration) Specialized Ix ( e.g MRI) done when possible surgical intervention is required (through assessment of Hx and PE)

16. MANAGEMENT – ALGORITHM

17. PHARMACOTHERAPY: Based on type of pain Nociceptive – simple, COX-2 inhibitors Neuropathic – anticonvulsants, opioids MANAGEMENT

18. MANAGEMENT INFORMATION: To minimize effects of psychosocial risk factors To prevent progression to chronicity Provide info and evidence of psychosocial contribution in LBP E.g : the Back Book

19. THERAPEUTIC PATIENT EDUCATION: Self-sufficient in meeting challenges raised by disease Main goal – provide pt with skills they need Ensure they remain active longer Optimal disease control MANAGEMENT (updates)

20. FUNCTIONAL RESTORATION PROGRAM: Designed to improve physical, psychosocial and socioeconomic situation via active involvement of patient Multidisciplinary approach Delivered during 3 to 5 week hospital stay Physical retraining main component Work resumption – main goal MANAGEMENT (updates)

21. COGNITIVE-BEHAVIORAL THERAPY Based on idea that belief influences pain perception Methods include: Education and information Reframing of beliefs Acquisition of coping strategies Reassurance Positive self-affirmations Stress management MANAGEMENT (updates)