Low Back Pain

ByDr Ajay Kumar

Understanding Back Pain

Back pain is actually very common—about three in four adults will experience back pain during their lifetime, especially low back pain.

Most back pain comes from sprains and strains caused by stressful movements, and with a bit of medical attention, those will get better.

Occasionally, back pain requires more demanding medical help and possibly even surgery.

But remember, even severe pain may not require severe treatment, so always check with your doctor.

Understanding (cont)

Back pain may be acute or chronic. Acute pain lasts four to six weeks chronic pain is persistent, long-term pain—

sometimes lasting throughout life. At times, people with chronic pain can also

have episodes of acute pain.

Understanding (cont)

Back pain comes in many forms. It may be sudden and sharp—or it may be

dull. Pain may occur with movement, and it may

even occur with coughing and sneezing. You may also have numbness in your legs.

(Leg symptoms are often referred to as sciatica caused by a pinched nerve.)

Understanding (cont)

It’s important to treat your back pain properly.

Seek medical attention if your back pain persists—and seek immediate attention if you have any of the emergency signs listed in the next slide

Warning Signs You Need Help

Pain is getting significantly worse Pain affects every day activities Severe symptoms Groin or leg weakness or numbness Arm or hand weakness, tingling, or numbness Loss of bowel or bladder control

Note: There are a variety of reasons for back pain. To get the best treatment, you first need to know the origin of the problem.

Causes

Most of our back troubles happen because of bad habits, generally developed over a long period of time:

poor posture; overexertion in work and play; sitting incorrectly at the desk or the steering

wheel; or pushing, pulling and lifting things

carelessly.

Causes (cont)

Sometimes, however, backache occurs for no apparent reason.

Nonspecific backache may develop from weakened muscles that cannot handle everyday walking, bending and stretching.

In other cases, the discomfort seems to come from -- or is aggravated by -- general tension, lack of sleep (see Insomnia) or stress.

Causes (cont)

A condition called fibrositis causes chronic backache from localized muscle tension, which may in turn be psychosomatic in origin.

Whether the muscle strain is from lifting heavy objects or from a sneeze makes little difference to the sufferer.

Causes (cont)

Pregnancy commonly brings on back pain, as the developing fetus, hormonal changes and attendant weight gain put new kinds of stresses on a pregnant woman's spine and legs.

Injuries from contact sports, accidents and falls can cause all manner of problems, from minor muscle strains to severe damage to the spinal column or the spinal cord itself.

Note

Sometimes the effects are immediate, but in many cases back problems develop over time.

The most common type of back pain comes from straining the bands of muscles surrounding the spine.

Although such strains can occur anywhere along the spine, they happen most often in the curve of the lower back; or at the base of the neck.

Types of Back Pain

IDIOPATHIC (Unknown cause) DISCOGENIC (de arrangement of inter vertebral disc) CANAL STENOSIS (narrowing of vertebral canal) SPONDYLOLYSIS (spondylitis / inflammation of

vertebra SPONDYLOLISTHESIS (forward displacement of a

vertebra over lower region) TUMORS OF SPINE FACET JOINT ARTHRITIS

SCIATIC NEUROPATHY- (DIABETIC, HERPES, PIRIFORMIS SYNDROME, TRAUMA TUMORS.)

SACROILIAC JOINT PAINSPINAL FRACTURES

Types of back pain

Understanding how pain is defined is important in order to learn how to better control it. For the purposes of research and medical practice, pain can be separated into three categories:Acute pain Chronic pain Neuropathic pain

Acute Pain

One common type of pain is acute pain, currently defined as pain lasting less than 3 to 6 months, or pain that is directly related to tissue damage.

This is the kind of pain that is experienced from a paper cut or needle prick. Other examples of acute pain include:

cont

Smashing one’s finger with a hammer. Touching a hot stove in that there is

immediate pain, withdrawal and then “slower” aching pain.

Labor pains. The pain during childbirth is acute and the cause is certainly identifiable.

As the acute pain goes longer it may develope into a chronic pain problem.

Chronic pain

There are at least two different types of chronic pain problems :-

Chronic pain due to an identifiable pain generator (e.g. an injury), and

Chronic pain with no identifiable pain generator (e.g. the injury has healed).

Chronic pain due to an identifiable pain generator

This type of chronic pain is due to a clearly identifiable cause.

Certain structural spine conditions (for example, degenerative disc disease, spinal stenosis )can cause ongoing pain until successfully treated.

These conditions are due to a diagnosable anatomical problem.

If the pain caused by these types of conditions has not subsided after a few weeks or months of conservative treatments, then spine surgery may usually be considered as a treatment option.

Chronic pain with no identifiable pain generator

This type of pain continues beyond the point of tissue healing and there is no clearly identifiable pain generator that explains the pain.

It appears that pain can set up a pathway in the nervous system and, in some cases, this becomes the problem itself.

In chronic pain the nervous system may be sending a pain signal even though there is no ongoing tissue damage.

cont

The nervous system itself misfires and creates the pain.

In such cases, the pain is the disease rather than a symptom of an injury.

cont

The term “chronic pain” is generally used to describe pain that lasts more than three to six months, or beyond the point of tissue healing.

Chronic pain is usually less directly related to identifiable tissue damage and structural problems.

Examples of chronic pain are: chronic back pain without a clearly determined cause, i.e failed back surgery syndrome (continued pain after the surgery has completed healed)

Neuropathic pain

Neuropathic pain has only been investigated relatively recently.

In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition.

With this type of pain, certain nerves continue to send pain messages to the brain even though there is no ongoing tissue damage.

Neuropathic pain (cont)

Neuropathic pain (also called nerve pain or neuropathy) is very different from pain caused by an underlying injury.

While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy.

Neuropathic pain could be placed in the chronic pain category but it has a different feel then chronic pain of a musculoskeletal nature.

Neuropathic pain (cont)

Neuropathic pain feels different than musculoskeletal pain and is often described with the following terms: severe, sharp, lancinating, lightning-like, stabbing, burning, cold, and/or ongoing numbness, tingling or weakness.

It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet.

Neuropathic pain (cont)

It’s important to understand neuropathic pain because it has very different treatment options from other types of back pain.

For example, opioids (such as morphine) and NSAID’s (such as ibuprofen, COX-2 inhibitors) are usually not effective in relieving neuropathic pain.

Treatments for neuropathic pain include certain medications, and nerve “block” injection.

Diagnostic and Test Procedures

Your doctor probably will test your range of motion and nerve function, and may use palpation to locate the area of discomfort. (Manual Muscle Testing)

Blood and urine tests will make sure the pain is not due to an infection or other systemic problem.

X-rays are useful in pinpointing broken bones or other skeletal defects, and can sometimes help locate problems in connective tissue.

cont

To analyze soft-tissue damage, computed tomography (CT) or magnetic resonance imaging (MRI) scans may be necessary.

X-rays and imaging studies are generally reserved for viewing direct trauma to the back, back pain with fever, or neurological abnormalities, such as extremity weakness or numbness.

To determine potential abnormalities that affect nerve and muscle stimuli, an electromyogram (EMG) can be useful.

Treatment

Because back problems occurs from a variety of causes, some of which may not be readily apparent, treatment goals are:

pain relief, rest and suitable restoration of movement.

Conventional Medicine

The basic treatment for relieving back pain and inflammation from strain or minor injury is immediate bed rest with an ice pack and aspirin or another nonsteroidal anti-inflammatory drug (NSAID).

After the inflammation subsides, applying heat can soothe and restore muscles and connective tissue.

Conventional Medicine (cont)

When back pain becomes truly immobilizing, the doctor will probably prescribe an appropriate prescription painkiller and possibly a muscle relaxant.

Some muscle relaxants, such as methocarbamol or cyclobenzaprine, can cause such side effects as nausea, disorientation and drowsiness.

Such medications usually are recommended for only a few days.

Conventional Medicine (cont)

To relieve inflammation and inhibit the patient's pain perception in severe cases, therapy may include an injection of a local anesthetic, such as lidocaine in combination with a corticosteroid, into the tissue around the affected area or into trigger points elsewhere in the body.

For relief of chronic back pain, low doses of antidepressant medications are sometimes prescribed.

Conventional Medicine (cont)

Long-term bed rest is no longer considered necessary for most cases of back pain.

Indeed, the lack of activity actually may contribute to recurring back problems.

In most cases, you will be expected to start normal, nonstrenuous activity within 24 to 72 hours, after which controlled exercise or physical therapy should begin.

Conventional Medicine (cont)

Physical therapy treatments may employ massage, ultrasound, whirlpool baths, Hot tubs, controlled application of heat and specifically tailored exercise programs to help patients regain full use of the back.

Conventional Medicine (cont)

In addition, some physicians -- especially those in sports medicine -- advocate using a transcutaneous electrical nerve stimulator (TENS).

Electrodes taped to the body carry a mild electric current that helps relieve pain.

After appropriate training, patients can a TENS on their own to help speed recovery of strained or moderately injured backs.

Conventional Medicine (cont)

Surgery for nonspecific backpain is a last resort.

In cases of persistent pain from extreme nerve damage, -- surgically severing (Rhizotomy) a nerve -- may be necessary to stop transmission of pain to the brain.

Rhizotomy can correct the symptoms caused by friction between the surfaces in a spinal joint, but it doesn't correct other problems, such as herniated disks.

Chiropractic

It is estimated that more people see chiropractors for back problems than for all other ailments combined.

Chiropractic spinal manipulation has been recognized by the U.S. Agency for Health Care Policy and Research as an effective therapy for acute low-back pain.

Chiropractic (cont)

Traditional chiropractic therapy relies on spinal manipulation to correct subluxations, or misaligned vertebrae, which may be responsible for problems anywhere along the spine.

By helping restore motion to poorly functioning vertebrae, chiropractic therapy diminishes the accompanying pain and muscle spasm.

Chiropractic (cont)

Chiropractors who use mixed therapies may rely on X-rays and other conventional diagnostic methods to treat back pain, combining spinal manipulation with muscle massage, ultrasound stimulation of deep tissue, nutritional recommendations and exercise.

For people wary of becoming dependent on painkillers and muscle relaxants for chronic back problems, modern chiropractic treatment offers a drug-free option to pain relief.

Other Spinal Manipulation

Osteopathic treatment is likely to combine drug therapy with spinal manipulation or traction, followed by physical therapy and exercise.

More and more doctors and physical therapists are using spinal manipulation techniques as part of back-pain therapy.

The U.S. Government has recognized spinal manipulation by osteopaths and chiropractors as being highly effective in treating many back problems.

Prevention

The most important preventive measure for lower-back pain is practicing good posture when standing and sitting.

First, analyze your posture by standing with your heels against a wall.

Your calves, buttocks, shoulders, and the back of your head should touch the wall, and you should be able to slip your hand behind the small of your back.

Prevention (cont)

Then step forward and stand normally: If your posture changes, correct it right away.

If you stand for long periods at work, wear flat shoes with good arch support and get a box or step about 6 inches high to rest one foot on from time to time.

Prevention (cont)

Your sitting posture may be even more important.

A good chair bottom supports your hips comfortably but doesn't touch the backs of your knees.

Your chair back should be set at an angle of about 10 degrees and should cradle the small of your back comfortably; if necessary, use a wedge-shaped cushion or lumbar pad.

Prevention (cont)

Your feet should rest flat on the floor. Your forearms should rest on your desk or work surface with your elbows almost at a right angle.

When you have to lift heavy objects, don't bend at the waist.

Prevention (cont)

Squat with your legs, keep your back upright as you grasp the object and stand upright again.

Let your legs do the lifting, not your back. A nonprescription back brace may also give

support and prevent back strain; its main benefit is that it won't let you bend

over at the waist. Long-term use can make you dependent on it and eventually may lead to weaker -- not stronger -- back muscles.

Prevention (cont)

Finally, ask your doctor or health club trainer about back strengthening exercises.

These stretching and strengthening exercises can alleviate chronic back pain and prevent future episodes of back pain.