Low_back_pain__overview in orthopaedics.

low back pain overview

1. EVALUATING PATIENT Aim of evaluation is to differentiate the severity RED FLAGS Severity YELLOW FLAGS

2. Age Pain History Duration Location Character Radiation – Buttock, thigh, – Calf, foot (sciatica*) Medical Illness Social and Psychological Issues Precipitating factors Previous Low Back Pain Previous Back Surgery Work and Lifestyle History Constitutional Symptoms Fever Night Sweats Weight Loss Neurological Symptoms Numbness including its distribution Weakness Bladder and bowel dysfunction (retention or incontinence) Aggravating factors Relieving factors Spinal Claudication HISTORY

3. Neurological Symptoms – Presence of saddle anaesthesia – Weakness of the leg or foot – Loss of bladder or bowel contro Cauda Equina Lesion or Cord compression Pain – Nerve root pain (Sciatica) – Unremitting night pain Nerve root compression Spinal infection or malignancy Constitutional Symptoms – Fever – Night sweats – Significant loss of weight Spinal infection Chronic spinal infection or malignancy Essential Questions

4. ESSENTIAL EXAMINATION Heel and Toe walking Significant muscle weakness if unable to perform this Cross Straight Leg Raising Prolapsed disc with significant nerve root impingement Muscle Strength – Big toe flexion and extension – Ankle flexion and extension Weakness indicatessignificant nerve root OR cord compression If loss of bladder/bowel control is present check perianal sensation and anal tone Saddle anaesthesia and/or lax anal tone indicates cauda equina lesion

5. Red Flags Types of Red Flags i . Cauda equina syndrome ii. Possible serious spinal pathology – trauma or tumour iii. Infection (e.g. TB, pyogenic abscess) History of trauma, cancer, osteoporosis, significant LOW, use of systemic steroids, HIV, Drug or Alcohol Onset of pain Age < 20yrs old or > 55yrs old Unrelenting night pain/ pain at rest Fever >24hrs Sudden unexplained Bowel or Bladder control Sudden onset of Bilateral leg weakness with gait disturbance Saddle numbness ( Perineum, Anus, Genitals) Physical examination: Fever ≥ 38°C Saddle anaesthesia Structural spinal deformity Severe restriction of lumbar flexion Widespread neurological deficit

6. Yellow Flags Factors that increase risk of long term disability A belief that back pain is harmful or potentially disabling 2. Fear avoidance behaviour and reduced activity levels 3. Tendency to low mood and withdrawal from social interaction 4. An expectation of passive treatments rather than a belief that active participation will help 5. Problems with claims and compensation 6. Past history of back pain, time-off, other claims 7. Problems at work, poor job satisfaction 8. Heavy work, unsociable hours 9. Overprotective family or lack of support Identification of yellow flags leads to a decision as to whether more detailed assessment is needed identification of factors that can be addressed by specific Interventions secondary prevention of chronic back pain

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

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

9. CORRECT WAY OF LIFTING

10. 8. Management of Low Back Pain “It is important to keep in mind that we are treating people and not spines” ~ Waddell 2004

11. 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

12. STANDING

13. WRONG RIGHT WRONG

14. CARRYING BACK-PACKS

15. 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.

16. SITTING POSTURE

17. SITTING POSTURE

18. 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.

19. POOR SLEEPING POSITION

20. GOOD SLEEPING POSITION

21. EVEN BETTER

22. POOR SLEEPING POSITION

23. GOOD SLEEPING POSITION

24. EVEN BETTER

25. SOME GOOD AND BAD POSTURES

26. TREATMENT Medications/ Pharmacotherapy Physiotherapy Surgery

27. 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.

28. 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

29. 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

30. 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.

31. Thank you……