LOW BACK
ACHE AND
SCIATICA
Spinal pain is multifaceted- involving
 Structural
 Biomechanical
 Biochemical
 Medical
 Psychosocial influences
 Tr...
 LBA is defined as chronic (cLBA) after 3
months because most connective tissues
heal within 6-12 weeks, unless
pathoanat...
 SCIATICA- leg pain that is localised in the
distribution of one or more lumbosacral
nerve roots, typically L4-S2, with o...
RISK FACTORS
 Men=women
(>60 years: women> men)
 Sciatica –fourth and fifth decades of life
 Extreme height
 Cigarette...
CLINICAL EVALUATION
 HISTORY
-characterization of pain as mechanical-
most often aggravated by static loading of
the spin...
PHYSICAL EXAMINATION
 Complete inspection- limb length
discrepancy and pelvic obliquity,scoliosis,
postural dysfunction w...
 SLRT with patient supine-ipsilateral leg pain
between 10 and 60 degrees- positive
SLRT that produces pain in the opposit...
Mechanical/activity- related
causes of LBP
 Discal and segmental degeneration- may include
facet arthropathy from osteoar...
Disorders associated with non
mechanical LBA
 Neurological syndromes
 myelopathy from intrinsic or extrinsic
processes
...
 Systemic disorders
 Neoplasms
 Infections
 Metabolic bone diseases
 Vascular disorders
 Referred pain
 Gastro inte...
DIAGNOSTIC STRATEGIES
 PLAIN XRAYS(AP/LATERAL) OF LUMBAR SPINE-
indicated for patients older than 50 years
 CT SCANNING-...
NON OPERATIVE TREATMENT
 NSAIDS
 Muscle spasmolytics
 Neuropathic pain analgesics
 Antidepressants(TCA)
 Opiod analge...
 3 phases depending upon the duration of
symptoms:
 PRIMARY
Passively applied physical therapy during the
acute phase of...
 TERTIARY
When spinal pain persists into the chronic
phase, therapeutic interventions shift from
rest and applied therapi...
 Elimination of activity of positive
biomechanical loading can only be
achieved by BEDREST.
 Bedrest is usually consider...
 Topical treatment is drug delivery over or
onto the painful site.
 The medication is deivered through the
skin to a sha...
SPINAL INTERVENTIONAL
PROCEDURES
Local anaesthetics, corticosteroids or other
substances may be directly injected into
pai...
 Epidural injections, epidural adhesiolysis are
also other methods
 Intradiscal ElectroThermal Therapy (IDET)
Is a minim...
SURGERY
 The benefit of lumbar spine surgery is not
controversial in many clinical circumstances
like major trauma, chron...
 PHYSICAL THERAPY FOR THE SPINE CAN BE
DIVIDED INTO PASSIVE AND ACTIVE THERAPIES:
 Passive therapy includes ultrasound, ...
 Traction is a long endured medical
prescription for LBP and is incorporated
into a variety of methods to treat
condition...
THANK YOU!
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Low back ache and sciatica

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Low back ache and sciatica

  1. 1. LOW BACK ACHE AND SCIATICA
  2. 2. Spinal pain is multifaceted- involving  Structural  Biomechanical  Biochemical  Medical  Psychosocial influences  Treatment is often difficult/ineffective
  3. 3.  LBA is defined as chronic (cLBA) after 3 months because most connective tissues heal within 6-12 weeks, unless pathoanatomic instability persists.  cLBA is the most common cause of disability in adults younger than 45 years.  LBA is the most expensive benign condition in industrialized countries.
  4. 4.  SCIATICA- leg pain that is localised in the distribution of one or more lumbosacral nerve roots, typically L4-S2, with or without neurological deficit.  Non specific radicular pattern- when dermatomal distribution is unclear
  5. 5. RISK FACTORS  Men=women (>60 years: women> men)  Sciatica –fourth and fifth decades of life  Extreme height  Cigarette smoking  Morbid obesity  Weakness of trunk extensor muscles compared with flexor strength– sciatica  Occupational risk factors- heavy physical work, lifting, prolonged static work postures, simultaneous bending and twisting, exposure to vibration
  6. 6. CLINICAL EVALUATION  HISTORY -characterization of pain as mechanical- most often aggravated by static loading of the spine, long- lever activities and levered postures. Pain relieved by rest. Non mechanical pain- r/o serious causes like infection and cancer.
  7. 7. PHYSICAL EXAMINATION  Complete inspection- limb length discrepancy and pelvic obliquity,scoliosis, postural dysfunction with forward leaning head and shoulders, accentuated kyphosis.  Any soft tissue abnormalities and tenderness to palpation should be noted.  palpation of lumbar paraspinal, buttock and other regional muscles- note areas with superficial and deep muscle spasms.
  8. 8.  SLRT with patient supine-ipsilateral leg pain between 10 and 60 degrees- positive SLRT that produces pain in the opposite leg carries a high probability of disc herniation- investigate  Reverse SLRT  Neurological evaluation is performed to determine the presence or absence of and levels(if present ) of radiculopathy or myelopathy.
  9. 9. Mechanical/activity- related causes of LBP  Discal and segmental degeneration- may include facet arthropathy from osteoarthritis  Myofascial, muscle spasm or other soft tissue injuries and/or disorders  Radiographic spinal instability with possible fracture or spondylolisthesis- may be due to trauma or degeneration  Fracture of bony vertebral body or trijoint complex- may not reveal overt radiographic instability  Spinal canal or lateral recess stenosis  Arachnoiditis, including postoperative scarring
  10. 10. Disorders associated with non mechanical LBA  Neurological syndromes  myelopathy from intrinsic or extrinsic processes  Lumbosacral plexopathy esp from diabetes  Neuropathy including the inflammatory, demyelinating type- eg. Guillan Barre syndrome  Myopathy  Dystonia
  11. 11.  Systemic disorders  Neoplasms  Infections  Metabolic bone diseases  Vascular disorders  Referred pain  Gastro intestinal disorders  Genitourinary disorders  Gynaecological disorders
  12. 12. DIAGNOSTIC STRATEGIES  PLAIN XRAYS(AP/LATERAL) OF LUMBAR SPINE- indicated for patients older than 50 years  CT SCANNING- effective when the spinal and neurological levels are clear and bony pathology is suspected.  MRI- useful when the spinal and neurological levels are unclear and a pathological condition of disc or spinal cord is suspected.  MYELOGRAPHY –useful in elucidating nerve root pathology  EMG/SSEP
  13. 13. NON OPERATIVE TREATMENT  NSAIDS  Muscle spasmolytics  Neuropathic pain analgesics  Antidepressants(TCA)  Opiod analgesics
  14. 14.  3 phases depending upon the duration of symptoms:  PRIMARY Passively applied physical therapy during the acute phase of soft tissue healing(<6 week)  SECONDARY Spine care education Active exercise programs during the subacute phase between 6-12 weeks with physical therapy-driven goals to achieve preinjury levels of physical and psychological deconditioning and disability.
  15. 15.  TERTIARY When spinal pain persists into the chronic phase, therapeutic interventions shift from rest and applied therapies to active exercise and physical restoration. Therapeutic injections, manual therapy and other externally applied therapies should be used adjunctively to reduce pain so that strength and flexibility can continue.
  16. 16.  Elimination of activity of positive biomechanical loading can only be achieved by BEDREST.  Bedrest is usually considered an appropriate treatment for acute backpain.
  17. 17.  Topical treatment is drug delivery over or onto the painful site.  The medication is deivered through the skin to a shallow depth <2cm and acts locally without producing systemic side effects.  Bisphosponates (palmidronate) have recently attracted attention as a potential new treatment for mechanical spinal pain involving discal and radicular structures.
  18. 18. SPINAL INTERVENTIONAL PROCEDURES Local anaesthetics, corticosteroids or other substances may be directly injected into painful soft tissuess, facet joints or epidural spaces. Local injections into paravertebral soft tissues, specifically into myofascial trigger points are widely advocated. Intra-articular facet blocks are also advocated. Medial branch blocks have been used for both diagnostic and therapeutic purposes.
  19. 19.  Epidural injections, epidural adhesiolysis are also other methods  Intradiscal ElectroThermal Therapy (IDET) Is a minimally invasive technique in which the annulus is subjected to thermo-modulation, thereby reducing the nociception reduced by mechanical loading of a painful disc.
  20. 20. SURGERY  The benefit of lumbar spine surgery is not controversial in many clinical circumstances like major trauma, chronic or complicated spinal infection etc  Moden suregery for LDD and sciatica are characterised by small incisions, minimal blood loss and early hospital discharge with post- operative convalescence lasting only a few weeks.
  21. 21.  PHYSICAL THERAPY FOR THE SPINE CAN BE DIVIDED INTO PASSIVE AND ACTIVE THERAPIES:  Passive therapy includes ultrasound, electric muscle stimulation, traction, heat and ice and manual therapy, were appropriate for short term treatment for acute backpain or acute exacerbation of a chronic backpain,  Corsets and braces are long used adjuncts for treatment.
  22. 22.  Traction is a long endured medical prescription for LBP and is incorporated into a variety of methods to treat conditions of the spine.  Education/ cognitive behavioural therapy.  Exercise
  23. 23. THANK YOU!

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