Low Back Pain.pptx

Overview of low back pain

1. Low Back Pain Dr Sushil Kumar Nayak Asst. professor Dept. of PMR

2. Low back pain is a symptom, not a disease, and has many causes.

3. Pain between the costal margin and the gluteal folds. Prevalence in India- Annual- 51% Lifetime- 66% Prevalence of low back pain in India: A systematic review and meta-analysis - Gautam M Shetty   1   2   3 ,  Shikha Jain   2 ,  Harshad Thakur   4 ,  Kriti Khanna   2

4. Acute- an episode resolves in <6wks Subacute - persisting for 6wks- 12wks Chronic- persistent for >12wks.

5. Biomechanics of Lumbar Spine Dichotomous role in terms of function, which is strength coupled with flexibility. Supports and protects (strength) the spinal canal contents (spinal cord, conus , and cauda-equina ). Provides inherent flexibility by allowing us to place our limbs in appropriate positions for everyday functions.

6. The strength of the spine results from the size and arrangements of the bones, ligaments and muscles. The inherent flexibility results from three-joint complex of vertebral segment. And the typical lordotic framework of the lumbar spine.

7. vertebrae Body Neural Arch Posterior Elements

8. Intervertebral Disc Secondary cartilaginous joint, or symphysis Internal Nucleus pulposus and the Outer Annulus fibrosus .

9. Nucleus pulposus It consists of water, proteoglycans , and collagen. The nucleus pulposus is 90% water at birth.

10. Annulus fibrosus concentric layers of fibers at oblique angles to each other, which help to with-stand strains in any direction. The outer fibers have more collagen and less proteoglycans and water than the inner fibers.

11. The main function of the intervertebral disc is shock absorption. Posterolateral disc herniations the most common. The activity of the lumbar muscles correlates well with intradiscal pressures.

12. Zygapophyseal Joints Paired synovial joints with a synovium and a capsule. The lumbar zygapophyseal joints lie in the sagittal plane and thus primarily allow flexion and extension.

13. Ligaments Longitudinal ligaments and the Segmental ligaments. Longitudinal ligaments- Anterior(ALL) and Posterior(PLL) ALL resists extension, translation, and rotation. PLL resists flexion. ALL is twice as strong as PLL.

14. Segmental ligaments Ligamentum flavum Supraspinous , Interspinous , and Intertransverse

15. Muscles Muscles with Origins on the Lumbar Spine Abdominal Musculature Thoracolumbar Fascia Pelvic Stabilizers

16. The posterior muscles include the latissimus dorsi and the paraspinals . The anterior muscles include psoas and Quadratus lumborum .

17. Abdominal Musculature The superficial abdominals include the rectus abdominis and external obliques . The deep layer consists of internal obliques and the transversus abdominis .

18. Pelvic Stabilizers Also known as “Core muscles” . Indirect effect on the lumbar spine, even though they do not have a direct attachment to the spine

19. Nerves

20. Potential Pain Generators of the Back Aging Spine: A Degenerative Cascade- ( Kirkaldy -Willis et al.) Centralization and Pain Psychosocial Factors and Low Back Pain Depression, Anxiety, and Anger Patient Beliefs About Pain and Pain Cognition.

21. Management History & Examinations Investigations, if needed.

22. Red flags

23. Yellow flags

24. Back pain greater than Leg pain Nonspecific LBP. Lumbar Spondylosis . Lumbar Disc Disease- Degenerative disc disease, Internal disk disruption, and Disc herniation .

25. Treatment Reassurance and Patient Education Back Schools Medication- Nonsteroidal Anti-inflammatory Drugs. Muscle Relaxants. Antidepressants. Anticonvulsants.

26. Exercises Physical modalities- TENS Manual massaging

27. Lumbar spondylolysis Spondylolisthesis Spondyloarthropathies Spinal infection Cancer pain

28. Leg Pain Greater Than Back Pain Lumbosacral Radiculopathy

29. Lumbar Spinal Stenosis • Congenital • Achondroplasia or dwarfism • Idiopathic • Acquired • Degenerative • Iatrogenic or postsurgical • Traumatic • Combined

30. Mechanical compression of the nerves can occur as a result of central canal narrowing, lateral recess narrowing, and Intervertebral foraminal narrowing

31. Symptoms Neurologic claudication B/L LL Initiated by walking, prolonged standing, and walking downhill, relieved by sitting or bending forward. Radicular pain in specific dermatome. Forward-flexed posture.

32. Treatment Oral medications, Epidural steroids, and Comprehensive functional Exercise program. flexion-based lumbar stabilization exercises. Bracing with an abdominal corset might be beneficial for overweight patients with a protuberant abdomen

33. Surgical indication- Intractable pain resistant to nonoperative management, profound or progressive neurologic deficit, or lifestyle impairment. Mode- Decompressive Laminectomy

34. Non-lumbar Spine Causes of Radicular Leg Symptoms Joint Disorders- SI joint, Hip joint Soft Tissue Disorders- Piriformis syndrome Greater Trochanteric Pain Syndrome Iliotibial Band Syndrome. Vascular Disorders- Vascular claudication Peripheral Neuropathy

35. Low Back Pain in Pregnancy Two categories-with low back pain and those with pelvic girdle pain i.e. below iliac crest pain. estimated the prevalence of low back pain in pregnancy at 49% to 76%. Risk factors- History of previous back pain, Previous pregnancy-related back pain, and Low back pain during menses.

36. Can begin at any time during the pregnancy and generally reaches a peak at 36 weeks. Improved by 3 months postpartum. Etiology- Altered hormonal influence and/or Increased biomechanical strain. Management- Individualised rehab with respect to weeks of gestation.

37. Pediatric Low Back Pain • Nonspecific • Spondylolysis with or without spondylolisthesis • Lumbar disk herniation • Slipped vertebral apophysis • Scheuermann disease • Discitis • Vertebral osteomyelitis • Neoplasm • Rheumatic disease • Somatization

38. Backpack & Backache Carrying a greater than 7.5% to 15% of the wearer’s body weight increases the metabolic demands over what is required to move a person’s body weight alone. The general recommendation for a child’s backpack weight is limited to 10% of body weight. Mackenzie WG, Sampath JS, Kruse RW, et al: Backpacks in children, Clin Orthop409:78–84, 2003

39. Ergonomic modifications The science of applying physical and psychological principles within an environment to increase both productivity and well-being.

40. Good sitting posture

41. Dynamic sitting Involves the used of both active and passive implements to encourage regular movement of the trunk and lower extremities in a seated position. O'Sullivan, K., O'Keeffe, M., O'Sullivan, L., O'Sullivan, P. and Dankaerts , W. (2012)  The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics  55(8): 898-908.

42. Movement Breaks For those individuals who are in a seated position for prolonged periods of time. Short, regular breaks of standing from a seated position. heahan , P., Diesbourg , T. and Fischer, S. (2016)  The effect of rest break schedule on acute low back pain development in pain and non-pain developers during seated work.  Applied Ergonomics 53: 64-70.

43. Thank you