Step by step understandable lower back pain consept

1. Low BACK PAIN
•1. LOW BACK PAIN Dr. SUMAN PAUL Department of
Orthopaedics & Traumatology, Rajshahi Medical College
Hospital
•2. CONTENT ¶Brief anatomy of the back ¶Intro to Lower
Back Pain ¶Epidemiology ¶Causes of LBP ¶Presentation
¶Ways of preventing LBP ¶Treatment
•3. THE BACK ¶ The back can be viewed as that region of the
body from the occiput to the gluteal folds (Olaogun, 1999) ¶
The back is composed of very sturdy bones and powerful
muscles. ¶ The spine or the back bone is made up of 33
bones called vertebrae. ¶ 7 cervical, 12 thoracic and 5
lumbar

2. vertebrae separated by 23 intervertebral discs.
•4. LOW BACK PAIN Also known as lumbago (at times

referred to as waist pain) is pain (as name implies) in the
lower back (lumbar) region. Typically, the commonest area

of back pain is the low back (lumbar region) and sometimes
it spreads to the buttocks or thighs. WHY THE LOWER

BACK? ¶Lumbar region because: ¶It bears most of the body’s
weight ¶Most movements of the spine occur there.
•5. LOW BACK PAIN ¶Most bouts of back pain ease quickly,
usually within a week (acute back pain). ¶When symptoms
persist for several months (over 3 months) chronic back pain
results. ¶Back pain could be mechanical,

3. pathologic or physiologic
•6. FACTS:- Low Back Pain ¶Second most common cause of
missed work days ¶Leading cause of disability between ages
of 19-45 ¶Number one impairment in occupational injuries
•7. Referred LBP Is Remote From Source of Pain ¶LBP may
radiate into • groin • buttocks • upper thigh (posteriorly)
areas that share an interconnecting nerve supply ¶Source of
somatic referred pain is a skeletal or myofascial structure of
the lumbar spine ¶Source of visceral referred pain is within a
body organ • ovarian cysts may refer pain to low back •
cancer of head of pancreas can present as low back pain
becoming excruciating at night

4. •8. Muscular Pain ¶Most back pains are caused by strain or
sprain of the back muscles & ligaments ¶Pain will be in
discrete area & tender to touch ¶It is of aching quality & may
involve muscle spasm
•9. EPIDEMIOLOGY ¶Back pain, especially low back pain
(LBP), most often affects people between the ages of 25 and
60 years and those aged between 50 and 60 years are likely
to become disabled (Corbin et al, 2002). ¶Up to 70%-85% of
the population in the United Kingdom (UK) experience back
pain at some point in their lives. ¶In Ghana, over 60% of the
adult population complains of back pain at one time or the
other (Osei, 2000). ¶Out of the 424 patients who presented
with various conditions at the Physiotherapy

5. Department of KBTH, 54% were LBP cases (From June to
August 2004).
•10. Sources of LBP ¶Damage to several structures in the low
back can result in severe pain • vertebrae • thoracolumbar
fascia • ligaments • joints • specifically sacroiliac joint • discs
• muscle Deyo RA, Weinstein JN. N Engl J Med.
2001;344:363-370.
•11. 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
•12. Spine Related Causes Arthritis Fibromyalgia Kyphosis
Lordosis

6. 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
•13. LBP Psychological Factors ¶ Psychological factors that
may contribute to or be caused by chronic LBP include •
depression • anxiety • post-traumatic stress disorder • pre-
existing disorders Physiotherapy department, TQMH

7. •14. Social Issues May Contribute to Chronic LBP ¶Job
dissatisfaction/loss of ability to work ¶Pursuit of disability
compensation ¶Substance abuse ¶Family dynamics
¶Financial issues ¶Loss of social identity or context ¶Loss of
ability to participate in recreational activities
•15. Diagnosis of LBP History Location Specific Point vs.
Across Back Superficial vs. Deep Involve Any other region
(lower extremity)
•16. History Quality Dull Ache (tooth ache) Sharp/Stabbing
Burning Tearing/Pop
•17. History Quality/Severity Intermittent Constant Pain Scale
1-10

8. •18. History Setting Time of day when worst/better After
strenuous activity
•19. History Aggravating/Relieving Factors What
Makes Better What Makes Worse BEWARE OF THE PATIENT
THAT SAYS NOTHING MAKES PAIN BETTER!
•20. History Associated Manifestations Numbness
Tingling(pins/needles) Burning WeaknessIncontinence Falls
•21. OBJECTIVE ASSESSMENT Musculoskeletal Examination
¶ Look • pain behaviors–groaning, position changes,
grimacing, etc • atrophy, swelling, asymmetry, color changes
¶ Feel • palpate area of pain for temperature, spasm, and
pain provocation • point palpation for trigger points/tender
points ¶ Move •

9. active and passive • flexion, extension, rotational, lateral
bending • leg raising
•22. Examination ¶Posture – change in lumbar lordosis,
scoliosis ¶Range of motion – flexion,extension, lateral flexion
¶SLR – seated & supine, sciatic nerve stretch test ¶Presence
of paraspinal muscle spasm, trigger points ¶Tender areas –
facets, sacro-iliac joints ¶Neurological deficit – • Dermatomal
hypo/hyperaesthesia • Ability to rise from squatting position
(L4),walk on heels(L5), walk on tip- toes (S1) • Tendon
reflexes – knee jerk(L4 root), ankle jerk(S1 root)
•23. Neurologic Exam Determines Presence/Absence and
Level of Radiculopathy and Myelopathy ¶ Motor elements •
muscle bulk/tone • atrophy/

10. flaccidity • muscle strength • coordination • gait ¶ Sensory
elements • sensory deficits, eg, touch, position sense,
temperature, vibration • allodynia: light touch •
hyperalgesia: single or multiple pinpricks The exam should
include
•24. Diagnostic Studies ¶Plain X-Ray ¶MRI ¶CAT Scan
¶Myelogram ¶Discogram ¶Bone Scan • Facet Block • SI Joint
Block • EMG • SSEP • DEXAscan • Bone Scan
•25. Diagnostic Studies X-Ray ¶ taken to assess the structure
of the spine and to determine the alignment of the vertebra
•26. Diagnostic Studies MRI ¶Extremely Sensitive for
assessment of Soft tissue

11. structures (nerves, disc) ¶One of the most commonly
ordered test to assess low back pain
•27. Diagnostic Studies CAT Scan ¶ Most often used to assess
bone structures of spine. ¶ Faster and cheaper than MRI ¶
Can be very effective tool when using reconstruction images
or combined with other modalities
•28. Diagnostic Studies Myelogram & Post CT ¶myelogram
consists of a series of plain xrays with a contrast agent
injected into the thecal sac. ¶The C.A.T. scan that usually
follows the myelogram depicts this same anatomy from a
C.A.T. scan perspective
•29. Diagnostic Studies Myelogram & Post CT The injection of
iodine based

12. contrast into the thecal sac containing the nerves and/or
spinal cord, promotes better definition of those structures
than the images obtained on the regular C.A.T. scan. Cross-
sections and reconstructions of the images in different planes
(including 3-D) allows different perspectives on the anatomy.
This test is often used to visualize the spinal cord and nerves
in relation to the surrounding spine structures (bone, joint,
disc, etc)
•30. Diagnostic Studies Discogram ¶Involves the injection of
contrast material into the disc space ¶Concordant vs.
Discordant Pain…..?? ¶Helpful in assessing discogenic pain
¶VERY “uncomfortable” test
•31. PREVENTION LIFTING ¶Squat


13. directly (by bending your knees) in front of any object to be
lifted; rise, letting your legs and thighs do the work. ¶Keep
the object you’re lifting close to your body, and don’t twist.
¶Never try to lift anything you can’t easily manage – get
help! ¶ Never bend over without bending your knees. ¶Avoid
twisting the trunk whilst lifting ¶Lift and move the trunk in a
vertical plane first ¶Turn to the desired direction with the
legs afterwards
•32. CORRECT WAY OF LIFTING
•33.
•34. PREVENTION STANDING ¶Standing for long periods of

time can put a lot of stress on your back. ¶If you must stand,
occasionally shift your

14. weight from one side to the other. ¶Or, try propping one of
your feet on a footstool six-to- eight inches high.
¶Occasionally, tighten your abdominal muscles. This can
enable you to keep your back straight
•35. STANDING
•36. WRONG RIGHTWRONG
•37. CARRYING BACK-PACKS
•38. PREVENTION SITTING ¶Sit in firm seats with straight

backs, keeping your back flat/straight with the knees bent to
about 90º. ¶Rest your feet flat on the floor or on a footstool.
¶ If you cannot get the chair you prefer, learn to sit properly
on whatever chair you get. ¶ Throw head well back, then
bend it

15. forward to pull in the chin. This will straighten the back. ¶
Now tighten abdominal muscles to raise the chest. Check
position frequently.
•39. SITTING POSTURE
•40.
•41.
•42.
•43. SITTING POSTURE
•44. PREVENTION SLEEPING ¶Sleep on a firm, flat

mattress. ¶It’s best to sleep on your side with your knees and
hips bent and a pillow under your head, or on your back with
pillows beneath your head and knees.

16. •45.
•46. POOR SLEEPING POSITION
•47. GOOD SLEEPING POSITION
•48. EVEN BETTER
•49. POOR SLEEPING POSITION
•50. GOOD SLEEPING POSITION
•51. EVEN BETTER
•52. SOME GOOD AND BAD POSTURES
•53. TREATMENT ¶Medications/ Pharmacotherapy
¶Physiotherapy ¶Surgery

17. •54. Pharmacotherapy Options* ¶Antidepressants
¶Anticonvulsants ¶Muscle relaxants ¶Opioid analgesics
¶Corticosteroids ¶NSAIDs ¶Topical analgesics * Except for
certain opioids, none of these agents are indicated for
chronic LBP.
•55. PHYSIOTHERAPY ¶Exercise (stretching and strengthening
of back extensors mainly) ¶Thermotherapy; Heat application
in chronic lower back pain using Infra-red, shortwave
diathermy, hotpacks, etc ¶Electrotherapy; Transcutaneous
Electric Nerve Stimulation, Trabert, etc
•56. Back Exercises ¶Ankle pump ¶Heel slides ¶Abdominal
contraction ¶Wall squats ¶Heel raises ¶Straight leg raises
¶Knee to chest stretch

18. ¶Hamstring stretch ¶Exercises with swiss ball
•57. Surgery 1. DECOMPRESSION of spinal nerves (BURST
FRACTURE, Spinal stenosis, PID) 2. Fusion & Stabilization
(Instrumentation) 3. Correction of deformity
•58. DECOMPRESSION Surgery
•59. FUSION Surgery
•60. References ¶ MOB Olaogun (1999):Pathomenchanics
and force analysis at the low back during physical tasks
(JNMRT), vol 4 (7). Pp 7-11 ¶ Clark MA, Russell AM. Low back
pain: a functional perspective. Thousand Oaks, CA: National
Academy of Sports Medicine; 2002. ¶ Hodges PW.

19. Core stability exercise in chronic low back pain. Orthopedic
Clinics of North America. 2003;34:245-254. ¶ Kendall FB,
McCreary EK. Muscle Testing and Function. 4th ed.
Baltimore, MD: Williams & Watkins; 1993: 215-226, 284-293.
•61. ¶Thank you……
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