Incidence and demography of low back pain in physiotherapy OPD a retrospective data driven analysis and review of literature about suggested strategies for low back pain management.

1. INCIDENCE AND DEMOGRAPHY OF
LOW BACK PAIN
IN PHYSIOTHERAPY OPD
(A RETROSPECTIVE DATA DRIVEN ANALYSIS)
&
REVIEW OF LITERATURE ABOUT
SUGGESTED STRATEGIES
FOR LOW BACK PAIN MANAGEMENT
Presented By –
Dr. Ravi Kumar
Tiwari
(Physiotherapist)

2. INTRODUCTION TO LBA [1]
• The low back pain (Lumbago) is the greatest public health
problem worldwide and fifth most common reason for
physician visits.
• According to the European Guidelines, low back pain is
defined as pain and discomfort, localized below the costal
margin and above the inferior gluteal folds, with or without
leg pain (Sciatica).
• Depending upon duration LBA is categorized in 3 subtypes
1. Acute :- less than 6 weeks
2. Sub-acute :- 6 and 12 weeks
3. Chronic :- 12 weeks or more

3. LBA Incidence and prevalence
• LBA affects nearly 60-80% of people throughout their
lifetime.
• Lifetime prevalence are as high as 84% in the adult
population. [3]
• The point prevalence of low back pain (LBP) in 2017 was
estimated to be about 7.5% of the global population.
• Estimates of recurrence at 1 year range from 24% to
80%.

4. Demographic pattern of LBA
 In 2019 the highest of LBP were observed in United States,
whereas the lowest were observed in India. [3]
 The prevalence of back pain was respectively, 69.5%, 64.8%,
40.6% 36.2% and 19.8% in Nepal, Bangladesh, Pakistan, Sri
Lanka and India. [4]
 Lack of physical activity is considered as one of the major
cause for such a high percentage of lower back pain in all the
above countries. [4]
 According to ICMR report, nearly about 8% people of all
states of India (F>M) yearly lived with Disability due to low
back pain. [4]

5. Age and gender in LBA
• 23% of the world’s adults suffer from chronic low
back pain. [3]
• The incidence of low back pain is highest in the
third decade.
• Overall prevalence increases with age until the
60–65 year age group and then gradually declines.
• Annual rate of adolescents suffering from back
pain is 11.8% to 33%. [4]
• The overall incidence is higher among females as
compared to males.

6. Causes of LBA
• Multifactorial etiology of LBA.
• Most acceptable Bio-Psycho-Social Model of
LBA.[7]
• Biological model - 85-95% of people presenting to
primary care providers do not have a specific
identifiable pathoanatomical origin for their pain
(Non specific LBA).Some of the specific identifiable
causes of LBA are Osteoporotic fractures,
inflammatory spondylo-arthropathies, infections
and malignancy. (Red flags)
• Psycho-social model - Low educational status,
unemployment, low income, stress, anxiety,
depression, job dissatisfaction, low levels of social
support in the workplace and occupational factors
(Yellow flags)

8. Impact of LBA
• Low back pain has an enormous impact on
individuals, families, communities,
governments and businesses throughout the
world.
• Low back pain (LBP) is a major health
problem, having a substantial effect on
peoples' quality of life and placing a significant
economic burden on healthcare systems and,
more broadly, societies.
• Financial impact of LBA[7]
• Total cost = Direct cost + Indirect cost .[8]

9. COST OF TREATMENT / LOSS OF
PRODUCTIVITY
 Over 80% of the total costs attributable to LBP are due to
indirect costs such as loss of productivity and disability
payments. [7]
 Non-adherence to LBP treatment guidelines is possibly
associated with increased direct healthcare costs. [7]
 Patients who obtain early imaging or surgery for LBP
without exhausting conservative therapies account for a
disproportionate amount of total costs associated with
LBP.
 The identified evidence suggests that combined physical
and psychological treatments are likely to be cost
effective options for LBP. [7]

10. Investigations / Imaging in LBA[5]
• Early Imaging in form of X-ray or MRI is required only for
limited number of cases showing red flag signs.
• Red flags are patient signs, symptoms or history that
indicate possible serious pathology and hence support
the decision to image the lower back. It includes -
1. Recent significant trauma
2. Age <20 or >55 years
3. Radiculopathy, Bladder or bowel dysfunction, severe or
progressive sensory or motor disturbance.
4. History of malignancy, Pain worse at night or at rest with
fever/ chills/ fatigue/ unexplained weight loss.
5. Thoracic pain.

11. Yellow flags for LBA[5]
• These are psychosocial factors that although are not
associated with serious organic pathology but indicate an
increased likelihood of chronic back pain and resultant
long term disability and potential loss of work. It includes -
1. A belief that pain and activity is harmful or severely
disabling.
2. The expectation that passive treatment rather than active
participation will help.
3. Fear-avoidance or sickness behavior.
4. Low mood and Social withdrawal
5. Poor job satisfaction, Lack of social support and
Financial problems

12. ACTUE LOW BACK PAIN MANAGEMENT
• Ensure clinical assessment including history taking,
physical examination, and neurological tests to
recognize radicular features or red flag signs. Patient
should also be screened for presence of psycho-
social risk factor. [11]
• Pharmacological therapies include NSAIDS and
weak opioids for brief periods. [11]
• Self management can include self -exercise and
education. [11]
• Primary conservative physical treatment may include
exercises, superficial heat, and manual therapy. [11]
• Guidance to return to normal activities. [11]
• Progress should be reviewed in 7-14 days. [11]

13. CHRONIC LOW BACK PAIN MANAGEMENT
• Exercise therapy has become a first-line treatment and
should be routinely used. No evidence available to show
that one type of exercise is superior to another . [11]
• Non – pharmacological and non – invasive management is
recommended for CLBA. [11]
• Passive physical therapies (massage, spinal mobilization ,
acupuncture, and spinal manipulation) are not usually
endorsed or are optional for patient not responding to basic
treatment. [11]
• The review of literature about management of chronic LBA
is compiled including conservative, pharmacological,
invasive and surgical methods of treatment.

14. Summary of treatment in chronic low
back pain (CLBP)[10]
• Conservative treatments: CBT, supervised exercise
therapy, brief educational interventions, and
multidisciplinary (bio-psycho-social) treatment,
Back schools and short courses of manipulation/
mobilization. Electrotherapy alone has been found
not to be very effective.
• Pharmacological treatments: The short term use of
NSAIDs and weak opioids can be recommended for
pain relief. Antidepressants, muscle relaxants for
pain relief can be used but . Gabapentin is not
recommended.

15. Cont.
• Invasive treatments: Acupuncture, epidural
corticosteroids, intra-articular (facet) steroid
injections, local facet nerve blocks, trigger
point injections, RFA are not recommended
for nonspecific CLBP.
• Surgery for nonspecific CLBP is not
recommended unless 2 years of all other
recommended conservative treatments –
including multidisciplinary have failed.

16. Effectiveness Acute LBA Chronic LBA
Beneficial Stay active, NSAIDs Exercise therapy,
multidisciplinary treatment
Trade off Muscle relaxants Muscle relaxants
Likely to be
beneficial
Spinal manipulations, CBT,
Multidisciplinary treatment
program (Sub acute phase)
Analgesics, acupuncture,
antidepressants, NSAIDs, Back
school, CBT, Spinal
manipulation
Unknown Analgesics, Acupuncture, Back
school, epidural steroids
injections, Lumbar support,
Massage, TENS, Traction,
thermotherapy, EMG Bio feed
back.
Epidural steroids injections,
local injections, Lumbar
support, Massage, TENS,
Traction, EMG Bio feed back.
Unlikely to be
beneficial
Specific back exercises -
Ineffective or
Harmful
Bed rest Facet joint injections
Rx for acute and chronic LBA

17. Articles in favour of Electrotherapy in
LBA Rx
• In a new systematic review, electrotherapy was found to
reduce fear-avoidance beliefs with moderate-quality
evidence.
• The guideline prepared by the American College of
Physicians (ACP) endorses superficial heat therapy,
stating that this recommendation is based on a Cochrane
review showing moderate-quality evidence on short
duration of pain control with superficial heat, compared to
oral placebo. [10]
• In a study from Turkey, PT treatment (hot pack, ultrasound
and TENS) added to exercise and medical therapy in
patients with CLBP were found to have a more positive
effect on pain and functional status than exercise and
medical treatment alone and this effect continued for up to
year. [12]

18. Articles in favour of
Exercise therapy in LBA Rx [11]
 The English guideline states that spinal
manipulation and massage can be only applied
with an exercise program.
• The Danish, United States of America, and the
United Kingdom Guidelines recommend the use
of exercise on its own, or in combination with
other non-pharmacological therapies.
• Exercise alone or in combination with education
has shown moderate-quality evidence that this is
effective for prevention of LBP.

19. Use of LS Corset in LBA [12]
• Another controversial approach in the treatment
of CLBP is the use of corsets.
• The use of a corset in addition to NSAIDs was
found to be more effective on pain and functional
status in the short term, compared to the use of
NSAIDs alone in a study from Turkey.
• A lumbosacral corsets were found to be superior
to elastic braces.

20. Take away message
 Continuation of the activity and active participation of the patient in the
treatment constitute the first steps of all current treatment
recommendations.
 The aim of physical treatments is to improve function and prevent
disability from getting worse. There is no evidence available to show
that one type of exercise is superior to another.
 Patients with low back pain can be triaged using a clinical assessment
. This should include history-taking, physical examination, and
neurological tests to recognize radicular features.
 With low back pain, patients should be screened for 'red flags' to
exclude serious pathologies, and diagnostic tests (such as imaging)
are carried out if suspected.
 Active strategies such as exercise are related to decreased disability.
Passive methods (rest, medications) are associated with worsening
disability, and are not recommended.
 In chronic low back pain, the physical therapy exercise approach
remains a first-line treatment, and should routinely be used.

21. Abstract
• Introduction – LBA is one of the commonest problem responsible for
years lived with disability world wide. LBA can occur without any
identifiable cause and thus the Bio-psycho-social model helps in
understanding the contributing factors and management of LBA.
• Aim of study : To evaluate the incidence and demographic pattern of
LBA in Physiotherapy OPD of Dr. B.R.A.M. Hospital, Raipur and
suggest the most appropriate and evidence-based strategies of LBA
management.
• Methods :
• Part 1- Patient data was collected from the PT OPD register year
(2021) Retrospective data driven analysis from patient cluster
• Part 2- In order to understand if there is any correlation of LBA with
Occupation of the patient, a pilot study was done for 15 days (March
2022).
• Part 3 – In order to identify the most appropriate approach for LBA
management online search of research articles, review was done using
PubMed, Google Scholar, and The Review of literature is compiled for
conclusion.

22. DATA COLLECTION
 OUT OF TOTAL 3581 ANNUAL (2021)OPD PATIENTS, 982
PATIENTS HAD LBA i.e. 27.42% .
 55% WERE MALE AND 45% WERE FEMALE.

23. DATA COLLECTION - AGE AND GENDER

24. DATA COLLECTION AND INTERPRETATION
 37.78% - Young adult age group (18-35)
 45.11% - Middle aged adult (36-55)
 17.10% - Old aged adult (<55).

25. CORRELATION OF LBA WITH OCCUPATION
(Pilot study for 15 days in month of March 2022)

26. DISCUSSION
• Wide variation in the management approach of LBA including
Physiotherapy treatment has been observed though the
bottom line is that non-pharmacological conservative
measures are most appropriate way of managing LBA
particularly Chronic nonspecific LBA.
• Electrotherapy have poor evidence of managing LBA in long
term though it can help in preparation of patient for exercises.
• Patient education and active therapy in form of exercises
should be considered as main line of treatment for LBA
patients without any complications.
• Medical professionals should be well equipped with
knowledge of red and yellow flag signs, indication for imaging.
• This study can be extended by evaluating the role of specific
physiotherapeutic approaches for long term relief in LBA.

27. Conclusion
• Though research articles are not in favour of
Physiotherapy as a recommended standalone
therapy for managing LBA, but based upon
Bio-psycho-social model which emphasises on
multidisciplinary therapy, physiotherapeutic
interventions give reasonably good results in
managing LBA particularly Non-specific
Chronic LBA.

28. Thank you

29. REFERENCES
1. Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group.
2004: 1-53.
2. The Global Burden of Low Back Pain – (IASP) International Association for study of Pain.
3. Epidemiological trends of low back pain at the global, regional, and national levels
Linfeng Wang1, Hong Ye1 · Zhichao Li2 Chengwu Lu1, Jian Ye1· Mingxin Liao1 ·
Xiaojie Chen1
4. Epidemiology of low back pain: A literature review -Arumay Jana and Dr. Asish Paul.
5. Red and yellow flags for guiding imaging of lower back pain – Dr Daniel Bell.
6. Essentials of Orthopaedic and applied Physiotherapy : Jayant joshi and Prakash kotwal
7. Cost-effectiveness of non-invasive and non-pharmacological interventions for low back pain: a
systematic literature review -LazarosAndronis, Philip Kinghorn, SuyinQiao, David GT
Whitehurst, Susie Durrell, Hugh McLeod ,-Applied health economics and health policy 15 (2),
173-201, 2017.
8. A systematic review of low back pain cost of illness studies In the United States and
internationally :Simon Dagenais, DC, PhD*, Jaime Caro, MDc, Scott Haldeman, DC, MD, PhD.
9. The European LBP Guidelines (Airaiksinen et al 2006; Van Tulder et al 2006).
10. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice
Guideline From the American College of Physicians ,Amir Qaseem, MD, PhD, MHA, Timothy
J. Wilt, MD, MPH, Robert M. McLean, MD, and Mary Ann Forciea, MD,For the Clinical
Guidelines Committee of the American College of Physicians.
11. Physical Therapy Approaches in the Treatment of Low Back Pain – Edward A. Shipton.
12. Pharmacological and non-pharmacological treatment approaches to chronic lumbar back pain –