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Approach to Low Backache
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Transcript of Approach to Low Backache
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APPROACH
TO LOW
BACKACHE
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BASICS
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The back is composed
of : Vertebrae. Muscles.
Ligaments. Intervertebral disc. Nerves.
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DEFINITIONS
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Between the lowestribrease of thebuttocks
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RISK FACTORS
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Modifable risk a!ors"
Improper lifting techni!ues or liftinge"cessivel# heav# loads.
$oor posture while sitting or standing%twisting% vibration.
&trenuous ph#sical activit#.
$s#chological causes like an"iet# ordepression.
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&itting or standing for long periods oftime.
'riving long distances.
(besit#.
&moking.
No# $odifable risk a!ors"
)emale gender.
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CLASSIFICATION
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CLASSIFICATION OF LOW BACK PAIN%%%%D&RATION
*cute +,- months duration &ub acute +,- months duration hronic - months duration
/ecurrent /ecurring after a pain,freeinterval
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LASSIFICATION OF LOW BACK PAIN
Mechanical Low Back $ain:
*natomical deformit#. )unctional *bnormalit#.
Non Mechanical Low Back $ain:
In0ammator#
Infectious. In1ltrating. Traumatic.
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Ca'ses o Lo( Bak A)e
&pinal causes
ongenital
In0ammator# Infectious In1ltrating Traumatic.
Non &pinal auses
Metabolic auses
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ASSESSMENTTAKIN* THE
HISTOR+
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2I&T(/3:
Location of s#mptom The duration of s#mptom Mechanism or onset of s#mptom The character or description of the
pain: mechanical% radicular% claudicant%non,speci1c./elieving or e"acerbating factors.
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RED FLA* SI*NS
Indicate need for earl# diagnostic
testing.
Less than 4+ or older than 5+% with
back pain for the 1rst time. Trauma. The pain is constant and gettingworse. $ain is worse at ni ht or when su ine.
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RED FLA* SI*NS,Co#!
&teroid use)ever and weight loss. Neurological signs such asweakness% numbness% saddleanesthesia or bowel6bladderincontinence.
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S-i#al ra!'re&igni1cant trauma$rolonged glucocorticoiduse*ge 5+ #ears
I#e!io# or a#er2istor# of cancer
7ne"plained weight lossImmunosuppressionIn8ection drug useNocturnal pain*ge 5+ #ears
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Ca'da e.'i#a s/#dro$e7rinar# retention(ver0ow incontinence)ecal incontinenceBilateral or progressive motor de1cit
&addle anesthesia
S-o#d/loar!)ri!isMarked morning sti9ness in the back that
lasts -+ minLow back pain that improves with activit#but not rest*lternating buttock pain
*ge ;+ #ears
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$23&I*L
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Look for scoliosis% k#phosis% 0attening of thelumbar curve or e"aggeration of lumbar
lordosis.
$alpate the spinous processes for tendernessIf present% this is suggestive of spinal fracture
or infection.
$alpate the paravertebral muscles for spasm%hardening% trigger points. This helps to rule
out root levels of d#sfunction.
(N &T*N'IN@:
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The patient is made to e"tend and 0e"their back% side bend% and rotate to assesstheir range of motion.
Increased discomfort with h#pere"tensionis noted with facet 8oint involvement.&pinal stenosis relieved with forward
0e"ion.
>ith 'isc disease lateral 0e"ion is oftenpreserved%
whereas forward 0e"ion is not.
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A+ toe raises or toe walking will test plantar0e"ion and calf muscles innervated b# &A.
2eel walking or heel raises test ankle andtoe dorsi0e"or muscle strength innervated b#L5 and some L; nerve roots.
&ingle s!uat and rise tests the !uadriceps%mostl# innervated b# L; nerve root.
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(N &ITTIN@T)e S!rai0)! Le0 Raise implies signi1cantnerve root irritation when positive.
2ave the patient raise each thigh o9 thetable against #our resistance.2ave the patient e"tend as well as 0e" the
lower legs against resistance
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$atellar re0e" tests L- L;.
*chilles re0e" tests mostl# &A% Babinski orplantar re0e" helps to di9erential aspinal cord lesion upward toe suggests
a lesion above LA.
'orsi0e"ion of the foot tests L5 and someL;.
Cnee e"tensor strength tests L4,L;.
&kin testing for sensation to rule outnumbness and parasthesias should be
performed.
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Modi1ed &chober Test
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In0ammator# vs. MechanicalBack $ain
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DThink (utside the BackE/enal diseasesFp#elonephritis% renal stones% renal
abscessG
$elvic diseases F$I'% endometriosis% prostate
enlargementG
@astrointestinal disease Fcholec#stitis% ulcer%cancerG
/etroperitoneal diseases.
*bdominal *ortic aneur#sm.
2erpes Hoster infection.
'iabetic radiculopath#
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Therap#: Non,speci1c
LB$N&*I'&Muscle rela"ants&pinal manipulation6 $h#siotherap#Fe9ects
limitedG/apid return to normal activities*void heav# lifting% trunk twisting% vibrations
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Therap#: hronic LB$&urger# is often dicult to e"plainIntensive e"ercises help Fhard to maintainG*nti,depressant therap# useful if depressedLong term opioids not recommended/eferral to pain centerMassage therap# is promising
Therapeutic goals optimiJe dail# function
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THANK +O&