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BACK PAIN

EPIDEMIOLOGY
Back pain occurs at any age
Half of the population will report back pain over a 12 month
period
Overall prevalence increases with age until 60-65 then
gradually decreases
Non-specific low back pain is estimated at 60-70% in
industrialized countries
Low back pain is the single leading cause of disability worldwide, according to
the Global Burden of Disease 2010.

http://www.who.int/medicines/areas/priority_medicines/BP6_24LBP.pdf
http://www.aafp.org/afp/2007/1115/p1497.html#sec-1

ANATOMY
The low back architecture consists of:

Vertebral bodies: the bones of the spine


Vertebral discs: cushions between the bones
Cartilage: lines the bones that connect with other bones
(i.e. spine to ribs)
Supportive structures surrounding the spine: muscles,
tendons (connecting muscle to bone), ligaments
(connecting bone to bone)

ACUTE VS CHRONIC
Acute Back Pain - pain that typically lasts for less
than 3 to 6 months and is usually more sharp and
severe than chronic back pain. The pain usually
gradually dissolves as the injuries tissues heal.
Chronic Back Pain- pain that lasts for more than 3
months where the pain can become progressively
worse and recur intermittently, outlasting the usual
healing process.

TYPES OF BACK PAIN


Mechanical
Musculoskeletal
Pathological

MECHANICAL LOWER BACK PAIN


When there is abnormal stress and strain on
muscles of the vertebral column.
Typically, mechanical pain results from bad habits,
such as poor posture, poorly-designed seating, and
incorrect bending and lifting motions.
This type of back pain typically gets better without
intervention

MECHANICAL BACK PAIN


- Generally attributed to acute traumatic event; but may also
include cumulative trauma as an etiology
- < 45 yrs, mechanical LBP represents the most common
cause of disability and is generally associated with a workrelated injury.
- > 45 years, mechanical LBP - third most common cause of
disability, and a careful history and physical examination are
vital to evaluation, treatment, and management

TYPES OF MECHANICAL PAIN


Muscle strain
Ligament sprain
Arthritis
Degenerative
InstabilitySpondylolysis/spondylolisthesis

SPONDYLOLYSIS/SPONDYLOLIST
HESIS

http://www.spine-health.com/video/lumbar-herniateddisc-video

PATHOLOGICAL
Back pain that is caused by an underlying condition
or disease examples of common diseases resulting
in back pain include.
Osteoporosis
Cancer
Spinal cord infection (eg. Tubercolosis)
Pagets disease
Multiple sclerosis

MUSCULOSKELETAL
Most episodes of lower back pain are caused
by damaged to the muscles and/or
ligaments in the low back. This results in a
Strain
Types of strain:Muscular and lumbar
Fractures
Dislocation

VIDEO
http://www.spine-health.com/video/lower-back-strainvideo

RECURRENT BACK PAIN


A newer outlook on back pain must now be
adopted.
Discrete events vs chronic vulnerability
Explore ways to overcome chronic back pain

RISK FACTORS
Being overweight
Smoking
Being pregnant
Long-term use of medication that
weaken bones. Eg corticosteroids
Being stressed/ depressed.

EXAMINATION AND INVESTIGATIONS


History and Physical Examination (limited ROM)
Local examinations (remember to check for
GIBBUS)
Neurological examination (anal tone/perianal
sensation, dermatome and myotome)
Ask about radiating pain to legs or hips (Sciatica)

GIBBUS

WARNING SIGNS ( RED FLAGS)


Sudden change in bladder or bowel control (suspicious of
something compressing these areas)
Infection (fever, iv drug user, immuno-compromised)
Risk of fracture. (trauma, accident, osteoporosis)
Cancer (Hx of cancer in breast lung or prostate) with long lasting
pain and weightloss.
Diseases that cause inflammation (ankylosing spondylitis, this is
associated with night pain and morning stiffness)

YELLOW FLAGS
Screen with Chronic BP
A belief that back pain is harmful or potentially severely
disabling
Fear-avoidance behaviour (avoiding a movement or activity
due to misplaced anticipation of pain) and reduced activity.
Tendency to low mood and withdrawal from social interaction
Expectation of passive treatment(s) rather than a belief that
active participation will help.
Poor job satisfaction and hx of time-off
Overprotective family or lack of support

NVESTIGATIONS
X-Ray (look for loss of lumbar lordosis, reduced disc space, deformity,
fracture, osteoporosis)
Blood investigations (Complete blood count, Liver function test,
Kidney function test, Erythrocyte sedimentation rate)
Computo tomography scan
Magnetic resonance imaging
Bone density test
Bone scan

MULTIDISCIPLINARY APPROACH TO
TREATMENT OF BACK PAIN
GP

Exercise
Instructor

Massage
Therapist &
Acupuncture

Specialist
BACK PAIN

Pharmacist

Imaging
Dept.

Surgeon

http://www.cochrane.org/CD000963/BACK_multidisciplinary-treatment-for-back-pain

MANAGEMENT & TREATMENT OF RECURRENT


BACK PAIN
Self reliant attitude must be adopted and
patient must be educated that their health
rest in their own hands.
Support teams that manage chronic back
pain. Work on small changes
Emphasis on stress management, getting
quality sleep and staying active.

NON- DRUG MEASURES FOR


MUSCULOSKELETAL PAIN
Bed rest - not recommended in mx of lower back
pain
Physiotherapy
Hydrotherapy
Back exercise - stretching/walking/swimming
Modification of daily activity
Hot and/or cold compresses
Education on postures and trigger factors

DRUG THERAPY
Paracetamol
- 1st line therapy for managing acute lower back pain
- Insufficient dosing can lead to the perception of
ineffectiveness.
- Regular use of appropriate doses (1g four times daily
regularly) provides effective relief of mild to moderate pain
- Paracetamol + codeine/ tramadol remain third-line therapy
(Consider adverse effects and drug interaction potential)
NB - Evidence for the efficacy of NSAIDs in low back pain is
limited. Due to their common adverse effects, they should not
replace paracetamol as first-line therapy.

NSAIDS
NSAIDs are second-line therapy due to their common adverse
effects and limited evidence for efficacy in low back pain.
COX-2 selective NSAIDs - not more effective than conventional
NSAIDs, have the same range of adverse effects as
conventional NSAIDs
NB: Before prescribing conventional or COX-2 selective NSAIDs,
- review the patients risk of developing hypertension, heart
failure, peptic ulcer or renal impairment. Patients considered at
risk should be assessed and monitored prior to prescribing and
during therapy

EDUCATION IS KEY!
As a GP your role is to educate and work WITH your
patients to overcome any obstacles in the way of
their care.
They must adopt a mind over matter attitude.
Exercise is essential. If they conditioned to slight
pain during exercise then the back pain didnt
matter.
Overcoming yellow flag 1 opens the door to
overcoming the rest.
Active management vs passive management.

WHAT WORKS?
Motion is lotion!
Movement is medicine!
In association with NSAIDS can help
pain and keep person moving.
This is contraindicated in patients with
severe scatica

ALL THAT ACTIVITY BOY DOC? WHAT ELSE IS


THERE THAT CAN HELP?
Spinal manipulation (specifically by chiropractor)
Massage
Acupuncture
There is no substitute for exercise these activities
COMBINED with exercise is known as active
therapy!
Yoga, pilates, swimming, walking/ jogging.

THE GP MAY REFER PATIENT FOR - SURGICAL


TREATMENT
Indications include
-pain
-evidence of neurological defect
-cauda equina syndrome
-Spinal instability
-life altering deformity