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Low Back Ache for General Practitioners

This is just a collection of slides arranged to give an useful to talk about Low back pain to a group of medical practitioners. Hope you will find it useful.

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Low Back Ache for General Practitioners

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  1. Low Back ACHE

  2. Learning Objectivesin this talk • General Knowledge (facts, stats, etiology, definition) • Clinical Examination • Diagnostic Tests • Treatment Options

  3. 8 out of 10 adults will experience low back pain at some point in their lives. Source: American Academy of Orthopedic Surgeons, www.orthoinfo.aaos.org.

  4. According to a recent study in the Scandinavian Journal of Rehabilitative Medicine, nearly 51% of school children suffered from low back pain. • Significant risk factors included age, gender, amount of time spent in front of the TV, and involvement in competitive sports.

  5. Is Back Pain a Problem? In the US • Back pain is the most frequent cause of activity limitation in people younger than 45 years old • Fifteen million American adults currently suffer lower back pain • Second leading symptomatic cause for physician visits • Third most common cause for surgical procedures • Fifth most common reason for hospitalization

  6. Is Back Pain a Problem at Work? Absences from Work In 1999, back pain accounted for 40 percent of absences from work, second only to the common cold. Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. AM J Public Health. 1999;89:1029-1035.

  7. COST • Low-back pain (LBP) is the most common condition leading to workers' compensation claims associated with time loss (i.e., injuries sufficiently severe to lead a worker to miss days from work • Americans spend at least $90 billion each year on back pain • Each year, Americans lose 93 million days of work, at a cost of $11 billion, due to low back injuries. They spend another $5 to $24 billion in direct medical expenses

  8. Adding Up The Numbers Perspective….. A billion dollars is more than 10,000 dollars a day for 300 years! Now Multiply That By 90!

  9. Acute Back Pain is a chronic, relapsing/remitting Illness • Von Korf, Spine 1996: 1/3 of primary care patients who presented with acute back pain reported back pain on at least 50% of the days of the year at 1 and 2 year follow-up. Von Korf M 1996 Spine; 21(24):2833-37

  10. Acute Back Pain is a chronic, relapsing/remitting Illness Screened Cochrane data base, Medline, and EMBASE for back pain literature on the general population with at least 12 month follow-up. • 62% had pain at 12 months after onset • 60% had > 2 relapses • 33% had relapses of work absence Haestbaek L Eur Spine J 2003

  11. General Aspects Regarding Back Pain Three facts that should help frame our approach from here forward (evidence follows): • Low back pain is recurrent in 33-70% of patients1,2 Expectations fail to reflect this: Patients want a cure, physicians pursue it, yet many times there is none • Psychosocial issues often contribute to, and many times are the main cause of disability • Physical therapists are a vastly underutilized yet readily available resource. 1. Von Korf, Spine 1996 21(24):2833-37; 2. Haestbaek L European Spine Journal 2003 Apr;12(2):149-65

  12. Psychosocial issues are important in determining who goes to the doctor for help with back pain Prospective study looked for medical and psychosocial factors that predict onset of new chronic back pain in asymptomatic volunteers. Found that only psychosocial factors, especially poor coping skills, Predict future chronic back pain. Poor coping skills increase the odds of future back pain by 3 fold. Carragee EJ Spine 2005 May 15;29(10):1112-7

  13. The patient’s psychosocial issues are the leading cause of failure of back pain treatment Anxiety, Depression, and amount of time off work were the primary determinants of failure to return to work in a program designed to treat employees off work due to low back pain. Watson P European J Pain 2004 Aug; 8:359-69

  14. Psychosocial factors that predict poor outcome for treatment of back pain • Motivation for self-care • Depression • Job satisfaction • Job stress • Support of significant other/marital stress • Secondary gain • Maladaptive thinking and coping styles • History of physical or sexual abuse • Multiple somatic complaints PSYCHOSOCIAL FACTORS IN PAIN, Gatchel and Turk, Eds

  15. Low Back Pain Defined • Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal hernia or the genital region • A variety of symptoms may exist in the presence of back pain. There may be a tingling or burning sensation, a dull aching, or sharp pain. Weakness in the legs or feet may also exist. • There won't necessarily be one event that actually causes low back pain.

  16. There are different types of pain. These differences are important to understand as they help determine the cause and the best treatment options. Source: Back.com, www.back.com.

  17. Pain may be felt as a dull ache or pressure. This is characteristic of an injury to the nerves, causing spasms in the muscles, that results in muscular aches and pains. Source: Back.com, www.back.com.

  18. Some pain may be felt as a “burning” or “stabbing” pain. This is usually caused by damage to nerve tissue. Source: Back.com, www.back.com.

  19. ACUTE PAIN Can be sharp and severe. It may go away on its own or with the application of ice or heat. If it fails to go away, it can develop into chronic pain. Source: Back.com, www.back.com.

  20. CHRONIC PAIN Is pain of long duration. It may be on and off. Due to its long term nature, it usually indicates underlying damage to the structure of the back. This could be damage to the nerves, discs, or muscles. Source: Back.com, www.back.com.

  21. Anatomy

  22. Sources of pain

  23. Neurogenic • Tension • Irritation • compression

  24. Arise from ventral root and gray rami communicants near DRG • Innervates PLL,ant dura,post annulus,blood vessels • ALL,lat & ant annulus –sympathetics • SP.VIP,CGRP

  25. Gray Rami Communicantes

  26. Discogenic pain Disc herniation Annular tear Sinuvertebral nerve Decrease pH within a deg disc –irritate the nerve root

  27. Radiculopathy Mechanical deformation-intraneural tissue reactions Nerve roots –no effective blood nerve barrier --lack epineurium Inflammation with mechanical compresion

  28. Anatomy

  29. FACET JOINT PAIN Innervated by medial branches of dorsal primary rami Facet capsule-contains encapsulated,non encapsulated & free nerve endings Mechanoreceptors-inflamation sensitizes these to movements of facet jt Nociceptors-unmyelinated & plexiform fibres sensitizes to chemical or mechanical stimulus

  30. Mechanism Injury to articular cartilage as in OA DEGEN changes of facet jt-static n dynamic compression of nerve root-lateral recess stenosis Blockage of facet by synovial fold

  31. Now that you know about the types of pain which are Discogenic, Radicular, Neurogenic, Facet joint origin. Let’s look at some of the more common causes of low back pain.

  32. 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

  33. 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

  34. 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

  35. LOW BACK PAIN • Congenital- Spina bifida, Listhesis, Hemivertebra Sacralisation • Traumatic - Fractures, Lig injuries, LS strain, Ruptured disc • Inflammatory-TB, Pyogenic, Brucellosis, RA, Anks spond • Degenerative- DDD, Spondylosis, Senile osteoporosis • Neoplastic - Primary Secondary

  36. APPROACH to aPatient with BACK PAIN

  37. Clinical Examination Listen Look Feel Move X-Ray Special Tests

  38. HISTORY • Pain - Commonest symptom • Site of pain - Superficial or Deep, • Axial • Radicular involving limbs • combination of both • Acute Pain - strains, sprains • Chronic Pain - degenerative conditions • a/c on chronic

  39. History Aggravating/Relieving Factors What Makes Better What Makes Worse BEWARE OF THE PATIENT WHO SAYSNOTHINGMAKES PAIN BETTER!

  40. Onset,Duration,Progression • Acute onset – fall,lifting weights, sports injury • Insidious onset with rapid progression-infection, path #, tumours 1* 2* • Referred pain-pancreatitis,aortic aneurysm,pelvic and rectal conditions

  41. Nature and intensity of pain • Discogenic- focal, aching in nature, increased with activity causing axial loading, decreased with rest • Facetal pain-pain on extension of spine • Degenerative-Pain and stiffness in morning • Inflammatory-prolonged pain with stiffness > 1hr • Tumour/infection- Night Pain unrelieved by rest

  42. Neurogenic pain-radicular claudicaton • Radicular • thoracic spine-band like along the rib • Lumbar spine-radiates into the lower limb • L3-4-Anterior thigh • L5- Dorsum of foot, 1 web space • S1-Buttock/posterior thigh

  43. Neurogenic claudication • Diffuse pain n numbness • Progressive loss of walking ability/forward stooping walking • Symptoms produced by activities causing extension of spine, relieved by flexion • To r/o vascular claudication

  44. Neurogenic vs Vascular

  45. LBA • Occupational history-return to heavy physical work may not be possible • Family n social history- assess pts resources and support for treatment plan • Other systems assessment-CVS,PULMO,GI ,GU,ENDO

  46. Look from front/back &sides • Level of shoulders • iliac crest-pelvic obliquity-LLD,Spine • Coronal plane-scoliosis • Sagittal plane-Kyphosis/lordosis • Angular kyphus • Knuckle-1 vertebra • Gibbus-2 vertebra • Round kyphus- > 2 vertebra • Overall spinal balance

  47. INSPECTION • Gait • Antalgic one leg-nerve root irritation, muscle weakness • Sciatica :walk with hip more extended & knee more flexed • High stepping : foot drop -to clear the ground • Spastic: drags the foot

  48. Inspection • Trendelenburgs : L5 - abductor lurch • S1- Extensor lurch & toes walking not possible • L4- Heel walking not possible

  49. The plumb line

  50. Sciatic list Lateral Shoulder disc Medial Axillary disc

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