AN UPDATE

LOW BACK PAIN

INTRODUCTION

Is a MAJOR PROBLEMPATIENT:- Cause- How to deal with it- Outcome

UNKNOWN!

DOCTORS:- Majority unknown cause- Difficult to get working

‘cure’

SOCIETY:- Main cause of work disability

CAUSES - VERTEBRAL

BONE

DISC

SOFT TISSUE

Degeneration, Infection, Inflammation, Malignancy, Trauma

CAUSES – NON VERTEBRAL

STRUCTURES NEAR TO LOW BACK:- GIT- GUT- Pancreas- Vascular- Gynae

CAUSES – NON SPECIFIC

- Most common LBP cause- Poorly localized- Long periods of no pain- May reduce with massage, chiropractic

or acupuncture- No spine pathology

- Understanding symptoms

- Good interpretation of signs

EVALUATION OF LBP

Treatment strategy

- History- Physical examination

MAIN AIM – TO DETECT RED FLAGS AND YELLOW FLAGS

RED FLAGS- Possible serious spinal

pathology:- Cauda Equina Syndrome- Trauma or Tumor- Infection (TB or pyogenic)

RED FLAGS - HISTORY

RED FLAGS – PHY. EXAM.

- Psychosocial factors

- Increases risk of long term disability and work loss

- Interferes with patient recovery

YELLOW FLAGS

YELLOW FLAGS – FACTORS

- Whether more detailed assessment is needed

- Identifications of factors that may require specific intervention

- secondary prevention of chronic low back pain

YELLOW FLAGS IDENTIFICATION– LEADS TO:

OTHER NEW METHODS IN IDENTIFYING RISK FACTORS OF LBP:

- Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ)

- Core Outcome Measure Index

- DALLAS Pain Questionnaire (DPQ)

- STarT Back Screening Tool

RISK FACTORS

INVESTIGATIONS- Must always be correlated

clinically and should not be interpreted on its own

- To rule out possible causes (e.g: infection, degeneration)

- Specialized Ix (e.g MRI) done when possible surgical intervention is required (through assessment of Hx and PE)

MANAGEMENT – ALGORITHM

1)PHARMACOTHERAPY:• Based on type of pain• Nociceptive – simple, COX-2 inhibitors• Neuropathic – anticonvulsants, opioids

MANAGEMENT

MANAGEMENT

2) INFORMATION:• To minimize effects of

psychosocial risk factors• To prevent progression to

chronicity• Provide info and evidence

of psychosocial contribution in LBP

• E.g: the Back Book

3) THERAPEUTIC PATIENT EDUCATION:

• Self-sufficient in meeting challenges raised by disease

• Main goal – provide pt with skills they need

• Ensure they remain active longer• Optimal disease control

MANAGEMENT (updates)

4) FUNCTIONAL RESTORATION PROGRAM:• Designed to improve physical, psychosocial

and socioeconomic situation via active involvement of patient

• Multidisciplinary approach• Delivered during 3 to 5 week hospital stay• Physical retraining main component• Work resumption – main goal

MANAGEMENT (updates)

5) COGNITIVE-BEHAVIORAL THERAPY• Based on idea that belief influences

pain perception• Methods include:• Education and information• Reframing of beliefs• Acquisition of coping strategies• Reassurance• Positive self-affirmations• Stress management

MANAGEMENT (updates)