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Low back pain


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Low back pain

  2. 2. INTRODUCTION • Low back pain or lumber pain is a common disorder involving the muscles and bones of the back (musculoskeletal disorders). • It affects about 40% of people at some point in their lives. • Low back pain (often abbreviated as LBP) may be classified by duration as acute (pain lasting less than 7 weeks), or chronic (more than 7 weeks). • It is a worldwide problem
  3. 3. CONT’D
  4. 4. EPIDEMIOLOGY • 60 – 90% of adults experience back pain at some point in their life. - incidence age 35- 55 y.o. - 90% resolve in 6 weeks - 7% become chronic - M/ F equally affected • 5th Leading reason for medical office visits • 2nd to respiratory illness as reason for symptom-related MD visits • #1 Cause and #1 Cost of work related disability
  6. 6. • The structures surrounding and supporting the vertebrae can be sources of low back pain • The lumbar (or lower back) region is made up of five vertebrae (L1-L5), sometimes including the sacrum. • In between these vertebrae are fibrocartilaginous discs, which act as cushions, preventing the vertebrae from rubbing together while at the same time protecting the spinal cord. • Stability of the spine is provided by the ligaments and muscles of the back and abdomen. Small joints called facet joints limit and direct the motion of the spine. • The muscles run up and down along the back of the spine, and are important for keeping the spine straight and stable during many common movements such as sitting, walking and lifting. • A problem with these muscles lead to the LBP. The problem with the muscles continues even after the pain goes away, and is probably an important reason why the pain comes back. • An intervertebral disc has a gelatinous core (pulposus) surrounded by a fibrous ring (annulus)
  7. 7. CAUSES OF LOW BACK PAIN There are many potential causes of LBP back pain. Physical, chemical and emotional stressors all contributing factors, while some of the more common predisposing factors include: Postural alterations (forward head carriage, rounded shoulders etc) Lack of muscle tone Excessive weight Emotional stress can trigger back pain Traumas such as accidents, knocks and falls Pregnancy increases the mechanical load on the back and pelvis, and woman are especially prone to back pain later on in their pregnancy.
  8. 8. OTHER CAUSES INCLUDE • Disc Herniation Tears in the annulus Herniation of nucleus pulposus Most common manifestaion of chronic LBP
  9. 9. Poor lifting techniques especially whilst bending and rotating the low back
  10. 10. DISC DEGENERATION With age and repeated efforts, the lower lumbar discs lose their height and water content (“bone on bone”) Abnormal motion between the bones leads to pain
  12. 12. PHYSICAL EXAMINATION • Fever – possible infection • Vertebral tenderness - not specific and not reproducible between examiners • Limited spinal mobility – not specific (may help in planning P.T. • If sciatica or pseudoclaudication present – do straight leg raise • Positive test reproduces the symptoms of sciatica – pain that radiates below the knee (not just back or hamstring) • Ipsilateral test sensitive – not specific: crossed leg is insensitive but highly specific • L-5 / S-1 nerve roots involved in 95% lumbar disc herniations
  13. 13. SYMPTOMS OF LOW BACK PAIN • There are many different types of symptoms associated with back pain. Back pain may be localised in the low back or it can radiate into the buttocks, groin or legs. • Patients often report pain to be: • Sharp • Aching • Dull • Stiff • Stabbing • Shooting or Electrical
  14. 14. TYPES OF LBP • Acute LBP • Chronic LBP Acute LBP This is associated with some types of activities that can cause undue stress on the tissue of lower back. Include o Prolong standing o Weight lifting o Pregnancy e.t.c • There may be RADICULOPHATY also knwn as SCIATICA
  15. 15. DIAGNOSIS OF ACUTE LBP STRAIGHT LEG RAISE TEST The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30 and 70 passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain
  16. 16. TRATMENTS FOR ACUTE LBP • NSAIDS • Muscle relaxants • Spinal manipulation • Delay referral until pain persists >3 weeks • 50% will improve b/f this time period • Avoid heavy lifting, trunk twisting, vibrations • Alternative Tx: acupuncture and massage • Surgery- ineffective unless: • sciatica, pseudoclaudication, spondylolisthesis
  17. 17. CHRONIC LBP • Chronic LBP is the pain of the lower part of the back that last for three(3) month without improvement. Causes • Degenerative dx of the disc • Occurring after injury • Obesity • Systemic dx like
  18. 18. MANAGEMEENT OF CHRONIC LBP • Conservative treatment which include; • Rest • TENS • NSAID • Muscle relaxant • Physical therapy • If conservative rx is not successful, the following surgical interventions may be needed; • Lamilectomy • Discpectomy • Spinal fusion with or without instrumentation
  19. 19. DIAGNOSIS OF CHRONIC LBP Straight leg raised test X-ray for Low Back Pain Several conditions can affect the low back. The following conditions should be assessed using x- ray; o Altered spinal curvature o Disc Disease o Osteoarthritis (Degenerative Joint Disease) o Arthritis o Osteoporosis o Soft tissue calcifications o Congenital anomalies o Tumur o Fractures o Dislocations
  20. 20. ABDOMEN, X- RAY, ANTEROPOSTERIOR VIEW 1. 1st Lumbar vertebra 2. 2nd Lumbar vertebra 3. 3rd Lumbar vertebra 4. 4th Lumbar vertebra 5. 5th Lumbar vertebra 6. T12 7. Twelfth rib 8. Sacroiliac joint 9. Sacrum 10. Sacral foramen 11. Ilium 12. Pelvic brim 13.Superior ramus of pubic bone 14. Pubic symphysis
  21. 21. CT SCAN • Shows bone (e.g., fractures) very well • Good in acute situations (trauma) • Sagittal reconstruction is mandatory • Soft tissues (discs, spinal cord) are poorly visualized • CT-myelogram adds contrast in the CSF and shows the spinal cord and nerves contour better
  22. 22. MRI Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan 1. Vertebral body 2. Spinal cord 3. Conus medullaris 4. Intervertebral disc 5. Filum terminale (internum) 6. Subarachnoid space
  23. 23. THERAPY: CHRONIC LBP • Intensive exercises help (hard to maintain) • Anti-depressant therapy useful if depressed • Long term opioids – not recommended • Referral to pain center • Massage therapy is promising • Therapeutic goals – optimize daily function
  24. 24. NURSING MANAGEMENT OF PATIENT WITH LBP • Maintain proper alignment • Flat bed rest • Assurance and explanation • Watch for headache • Health education • Physical therapy • Nutrition
  25. 25. PREVENTION • Effective methods to prevent low back pain have not been well developed. • Medium-firm mattresses are more beneficial for chronic pain than firm mattresses. • Exercise is important for preventing back pain. Through exercise you can: Improve your posture Strengthen your back and improve flexibility Lose weight Avoid falls • It is also very important to learn to lift and bend properly.
  27. 27. REFERENCES • Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M Low back pain evidence review. Royal College of General Practitioners, 1999. • Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491. • Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463-472. • Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1078-1093. • Chou R, Loeser JD, Owens DK, Rosenquist RW, et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009;34:10660-1077. • Jani P, Battaglia M, Naesch E, Hammerle G, Eser P, et al. A randomised controlled trial of spinal manipulative therapy in acute low back pain. Ann Rheum Dis. 2009;68:1420-1427.
  28. 28. Thank you