Transcript Low Back Pain

Low
Back Pain
By
Dr Ajay Kumar
Understanding Back Pain
Back pain is actually very common—about three
in four adults will experience back pain during
their lifetime, especially low back pain.
Most back pain comes from sprains and strains
caused by stressful movements, and with a bit of
medical attention, those will get better.
Occasionally, back pain requires more
demanding medical help and possibly even
surgery.
 But remember, even severe pain may not require
severe treatment, so always check with your
doctor.
Understanding (cont)
Back pain may be acute or chronic.
Acute pain lasts four to six weeks
chronic pain is persistent, long-term pain—
sometimes lasting throughout life.
At times, people with chronic pain can also
have episodes of acute pain.
Understanding (cont)
Back pain comes in many forms.
It may be sudden and sharp—or it may be
dull.
Pain may occur with movement, and it may
even occur with coughing and sneezing.
You may also have numbness in your legs.
(Leg symptoms are often referred to as
sciatica caused by a pinched nerve.)
Understanding (cont)
It’s important to treat your back pain
properly.
Seek medical attention if your back pain
persists—and seek immediate attention
if you have any of the emergency signs
listed in the next slide
Warning Signs You Need Help
Pain is getting significantly worse
Pain affects every day activities
Severe symptoms
Groin or leg weakness or numbness
Arm or hand weakness, tingling, or numbness
Loss of bowel or bladder control
Note: There are a variety of reasons for back pain.
To get the best treatment, you first need to know
the origin of the problem.
Causes
Most of our back troubles happen because of
bad habits, generally developed over a long
period of time:
poor posture;
overexertion in work and play;
sitting incorrectly at the desk or the steering
wheel;
or pushing, pulling and lifting things
carelessly.
Causes (cont)
Sometimes, however, backache occurs for no
apparent reason.
Nonspecific backache may develop from
weakened muscles that cannot handle
everyday walking, bending and stretching.
In other cases, the discomfort seems to come
from -- or is aggravated by -- general tension,
lack of sleep (see Insomnia) or stress.
Causes (cont)
A condition called fibrositis causes chronic
backache from localized muscle tension,
which may in turn be psychosomatic in origin.
Whether the muscle strain is from lifting
heavy objects or from a sneeze makes little
difference to the sufferer.
Causes (cont)
Pregnancy commonly brings on back pain, as
the developing fetus, hormonal changes and
attendant weight gain put new kinds of
stresses on a pregnant woman's spine and
legs.
Injuries from contact sports, accidents and
falls can cause all manner of problems, from
minor muscle strains to severe damage to the
spinal column or the spinal cord itself.
Note
Sometimes the effects are immediate, but in
many cases back problems develop over
time.
The most common type of back pain comes
from straining the bands of muscles
surrounding the spine.
Although such strains can occur anywhere
along the spine, they happen most often in
the curve of the lower back; or at the base of
the neck.
Types of Back Pain
 IDIOPATHIC (Unknown cause)
 DISCOGENIC (de arrangement of inter vertebral disc)
 CANAL STENOSIS (narrowing of vertebral canal)
 SPONDYLOLYSIS (spondylitis / inflammation of
vertebra
 SPONDYLOLISTHESIS (forward displacement of a
vertebra over lower region)
 TUMORS OF SPINE
 FACET JOINT ARTHRITIS
SCIATIC NEUROPATHY- (DIABETIC,
HERPES, PIRIFORMIS SYNDROME,
TRAUMA TUMORS.)
SACROILIAC JOINT PAIN
SPINAL FRACTURES
Types of back pain
Understanding how pain is defined is
important in order to learn how to better
control it. For the purposes of research and
medical practice, pain can be separated
into three categories:
Acute pain
Chronic pain
Neuropathic pain
Acute Pain
One common type of pain is acute pain,
currently defined as pain lasting less than 3 to
6 months, or pain that is directly related to
tissue damage.
 This is the kind of pain that is experienced
from a paper cut or needle prick. Other
examples of acute pain include:
cont
Smashing one’s finger with a hammer.
Touching a hot stove in that there is
immediate pain, withdrawal and then “slower”
aching pain.
Labor pains. The pain during childbirth is
acute and the cause is certainly identifiable.
As the acute pain goes longer it may
develope into a chronic pain problem.
Chronic pain
There are at least two different types of
chronic pain problems :Chronic pain due to an identifiable pain
generator (e.g. an injury), and
Chronic pain with no identifiable pain
generator (e.g. the injury has healed).
Chronic pain due to an
identifiable pain generator
This type of chronic pain is due to a clearly
identifiable cause.
Certain structural spine conditions (for example,
degenerative disc disease, spinal stenosis )can
cause ongoing pain until successfully treated.
These conditions are due to a diagnosable
anatomical problem.
 If the pain caused by these types of conditions has not
subsided after a few weeks or months of conservative
treatments, then spine surgery may usually be considered
as a treatment option.
Chronic pain with no identifiable pain
generator
This type of pain continues beyond the
point of tissue healing and there is no
clearly identifiable pain generator that
explains the pain.
It appears that pain can set up a pathway
in the nervous system and, in some cases,
this becomes the problem itself.
In chronic pain the nervous system may be
sending a pain signal even though there is
no ongoing tissue damage.
cont
The nervous system itself misfires and
creates the pain.
In such cases, the pain is the disease
rather than a symptom of an injury.
cont
The term “chronic pain” is generally used to
describe pain that lasts more than three to six
months, or beyond the point of tissue healing.
Chronic pain is usually less directly related to
identifiable tissue damage and structural
problems.
Examples of chronic pain are: chronic back
pain without a clearly determined cause, i.e
failed back surgery syndrome (continued pain
after the surgery has completed healed)
Neuropathic pain
Neuropathic pain has only been investigated
relatively recently.
In most types of neuropathic pain, all signs of
the original injury are usually gone and the
pain that one feels is unrelated to an
observable injury or condition.
With this type of pain, certain nerves continue
to send pain messages to the brain even
though there is no ongoing tissue damage.
Neuropathic pain (cont)
Neuropathic pain (also called nerve pain or
neuropathy) is very different from pain
caused by an underlying injury.
While it is not completely understood, it is
thought that injury to the sensory or motor
nerves in the peripheral nervous system can
potentially cause neuropathy.
Neuropathic pain could be placed in the
chronic pain category but it has a different
feel then chronic pain of a musculoskeletal
nature.
Neuropathic pain (cont)
Neuropathic pain feels different than
musculoskeletal pain and is often described
with the following terms: severe, sharp,
lancinating, lightning-like, stabbing, burning,
cold, and/or ongoing numbness, tingling or
weakness.
It may be felt traveling along the nerve path
from the spine down to the arms/hands or
legs/feet.
Neuropathic pain (cont)
It’s important to understand neuropathic pain
because it has very different treatment
options from other types of back pain.
For example, opioids (such as morphine) and
NSAID’s (such as ibuprofen, COX-2
inhibitors) are usually not effective in relieving
neuropathic pain.
Treatments for neuropathic pain include
certain medications, and nerve “block”
injection.
Diagnostic and Test
Procedures
Your doctor probably will test your range of
motion and nerve function, and may use
palpation to locate the area of discomfort.
(Manual Muscle Testing)
Blood and urine tests will make sure the pain
is not due to an infection or other systemic
problem.
X-rays are useful in pinpointing broken bones
or other skeletal defects, and can sometimes
help locate problems in connective tissue.
cont
To analyze soft-tissue damage, computed
tomography (CT) or magnetic resonance
imaging (MRI) scans may be necessary.
X-rays and imaging studies are generally
reserved for viewing direct trauma to the
back, back pain with fever, or neurological
abnormalities, such as extremity weakness or
numbness.
To determine potential abnormalities that
affect nerve and muscle stimuli, an
electromyogram (EMG) can be useful.
Treatment
Because back problems occurs from a variety
of causes, some of which may not be readily
apparent, treatment goals are:
pain relief,
rest and
suitable restoration of movement.
Conventional Medicine
The basic treatment for relieving back pain
and inflammation from strain or minor injury is
immediate bed rest with an ice pack and
aspirin or another nonsteroidal antiinflammatory drug (NSAID).
After the inflammation subsides, applying
heat can soothe and restore muscles and
connective tissue.
Conventional Medicine (cont)
When back pain becomes truly immobilizing,
the doctor will probably prescribe an
appropriate prescription painkiller and
possibly a muscle relaxant.
Some muscle relaxants, such as
methocarbamol or cyclobenzaprine, can
cause such side effects as nausea,
disorientation and drowsiness.
Such medications usually are recommended
for only a few days.
Conventional Medicine (cont)
To relieve inflammation and inhibit the
patient's pain perception in severe cases,
therapy may include an injection of a local
anesthetic, such as lidocaine in combination
with a corticosteroid, into the tissue around
the affected area or into trigger points
elsewhere in the body.
For relief of chronic back pain, low doses of
antidepressant medications are sometimes
prescribed.
Conventional Medicine (cont)
Long-term bed rest is no longer
considered necessary for most cases of
back pain.
Indeed, the lack of activity actually may
contribute to recurring back problems.
In most cases, you will be expected to
start normal, nonstrenuous activity within
24 to 72 hours, after which controlled
exercise or physical therapy should begin.
Conventional Medicine (cont)
Physical therapy treatments may
employ massage, ultrasound, whirlpool
baths, Hot tubs, controlled application of
heat and specifically tailored exercise
programs to help patients regain full use
of the back.
Conventional Medicine (cont)
In addition, some physicians -- especially
those in sports medicine -- advocate using a
transcutaneous electrical nerve stimulator
(TENS).
Electrodes taped to the body carry a mild
electric current that helps relieve pain.
After appropriate training, patients can a
TENS on their own to help speed recovery of
strained or moderately injured backs.
Conventional Medicine (cont)
Surgery for nonspecific backpain is a last
resort.
In cases of persistent pain from extreme
nerve damage, -- surgically severing
(Rhizotomy) a nerve -- may be necessary to
stop transmission of pain to the brain.
Rhizotomy can correct the symptoms caused
by friction between the surfaces in a spinal
joint, but it doesn't correct other problems,
such as herniated disks.
Chiropractic
It is estimated that more people see
chiropractors for back problems than for all
other ailments combined.
Chiropractic spinal manipulation has been
recognized by the U.S. Agency for Health
Care Policy and Research as an effective
therapy for acute low-back pain.
Chiropractic (cont)
Traditional chiropractic therapy relies on
spinal manipulation to correct subluxations, or
misaligned vertebrae, which may be
responsible for problems anywhere along the
spine.
By helping restore motion to poorly
functioning vertebrae, chiropractic therapy
diminishes the accompanying pain and
muscle spasm.
Chiropractic (cont)
Chiropractors who use mixed therapies may
rely on X-rays and other conventional
diagnostic methods to treat back pain,
combining spinal manipulation with muscle
massage, ultrasound stimulation of deep
tissue, nutritional recommendations and
exercise.
For people wary of becoming dependent on
painkillers and muscle relaxants for chronic
back problems, modern chiropractic treatment
offers a drug-free option to pain relief.
Other Spinal Manipulation
Osteopathic treatment is likely to combine
drug therapy with spinal manipulation or
traction, followed by physical therapy and
exercise.
More and more doctors and physical
therapists are using spinal manipulation
techniques as part of back-pain therapy.
The U.S. Government has recognized spinal
manipulation by osteopaths and chiropractors
as being highly effective in treating many
back problems.
Prevention
The most important preventive measure for
lower-back pain is practicing good posture
when standing and sitting.
First, analyze your posture by standing with
your heels against a wall.
Your calves, buttocks, shoulders, and the
back of your head should touch the wall, and
you should be able to slip your hand behind
the small of your back.
Prevention (cont)
Then step forward and stand normally: If your
posture changes, correct it right away.
If you stand for long periods at work, wear flat
shoes with good arch support and get a box
or step about 6 inches high to rest one foot
on from time to time.
Prevention (cont)
Your sitting posture may be even more
important.
A good chair bottom supports your hips
comfortably but doesn't touch the backs of
your knees.
Your chair back should be set at an angle of
about 10 degrees and should cradle the small
of your back comfortably; if necessary, use a
wedge-shaped cushion or lumbar pad.
Prevention (cont)
Your feet should rest flat on the floor. Your
forearms should rest on your desk or work
surface with your elbows almost at a right
angle.
When you have to lift heavy objects, don't
bend at the waist.
Prevention (cont)
Squat with your legs, keep your back upright
as you grasp the object and stand upright
again.
Let your legs do the lifting, not your back.
A nonprescription back brace may also give
support and prevent back strain;
its main benefit is that it won't let you bend
over at the waist. Long-term use can make
you dependent on it and eventually may lead
to weaker -- not stronger -- back muscles.
Prevention (cont)
Finally, ask your doctor or health club trainer
about back strengthening exercises.
These stretching and strengthening exercises
can alleviate chronic back pain and prevent
future episodes of back pain.