LOW BACK PAIN Flashcards
LOW BACK PAIN
- Primary/Idiopathic or Secondary
- Classification based on the duration:
- Acute: 4 weeks
- Subacute: from 2 to 6 months
- Chronic: 6 months up
- Most important before starting rehabilitation: identify a diagnoses and whether there is spinal cord involvement
HISTORY
- Duration and kind of pain (dull, mechanical, spastic, neuropathic)
- Onset and age
- Other systemic symptoms (fever etc.)
- History of trauma or injuries
- Previous surgeries
RED FLAGS
- RED FLAGS – risk factors
- Back pain in children <18 y with considerable pain or onset >55 y
- History of violent trauma and mild trauma in an aged patient
- Constant progressive pain at night
- Diseases - History of cancer, HIV, Systemic illness -Persisting severe restriction of motion
- Drugs - Systemic steroids Drug abuse
- Symptoms - Weight loss, Intense pain or minimal motion, Structural deformity Difficulty with micturition, -Loss of anal sphincter tone or fecal incontinence; saddle anesthesia, Widespread progressive motor weakness or gait disturbance Inflammatory disorders (ankylosing spondylitis) suspected
YELLOW FLAGS
- Risk Factors – Chronization of ALBP and SALBP
Personal Age - Female gender, Minor ethnicity, Low income, Low education - Medical - High BMI, Previous surgery, Impairment, - Neurological deficit Radicular impingement
- Pain related – Duration, Intensity, Leg pain, Pain in lateral flexion and/or in flexion-extension, Difficulties in sitting
- Impairment disability related- High referred impairment, High functional limitation at 4 week, High disability (Roland-Morris, Oswestry, Sickness Impact Profile), Perceived risk of not recovering
Psychosocial, Work Related and Treatments
PHYSICAL EXAMINATION
-Inspection – position of patient, unusualities, straight leg test
- Inspection – position of patient, unusualities, straight leg test
- Palpation – vertebral structure provoking pain and the direct assessment of regional and segment motion
determine whether it originates in the nerve root
On one side of one of the lower limbs, generally radiating below the knee, down to the ankle and the foot
- Very often more intense than LBP
- Hypoesthesia or paraesthesia with the same distribution
• Positive signs of radicular irritation
• Motor, sensory, or reflex changes related to a single nerve root
DIAGNOSTICS
In absence of red flags no required within 30 days
X-rays – check for bony abnormalities, cost effective
Magentic Resonance Imaging - both soft and bone tissues allow it to be a more comprehensive tool for LBP
PSYCHOSOCIAL ASSESSMENT
To anticipate the risk factors that will be crucial in chronization of LBP
Persistent pain always entails a certain degree of disability
the impact of pain and disability on decreasing the quality of life depends more on their duration than their intensity.
Zung Scale
Oswestry LBP Disability Questionnaire
Roland-Morris Questionnaire
disability (Oswestry Questionnaire)
the quality of life (EuroQoL)
ACUTE LOW BACk PAIN
GOAL OF TREATMENT - The main objective and therapy in ALBP is, in fact, to reassure the patient and provide accurate preventive information
Pain Management
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Paracetamol
Benzodiazepines and other muscle relaxants (Eperisone)
Manipulations were shown to be more effective than placebo on pain in the short-term (within 6 weeks) but were not more effective on function
NO RELEVANT DATA: lumbar supports, massage, herbal, ice therapy
Multiform – appear suddenly, insidiously, or without an apparent cause
And vary in pain intensity and location or radiation
from the quantity of pain, it can last from several minutes to several weeks.
the level of pain has no correlation with the anatomical lesion and its recovery
Function-Oriented Rehabilitation Approaches
Exercises showed no effect in the first 2 weeks of LBP, but they were shown to be effective in SALBP in the occupational setting
No clear evidence yet to support
avoiding chronicity and regaining any fitness lost during the period of acute pain which may open the way to frequent relapses.
SUBACUTE LOW BACK PAIN
defined as pain or discomfort in the lumbar region, on one or both sides, eventually irradiating to the buttocks
lasting more than 1 month but less than 6 months
intermediate stage, being the passage between ALBP and CLBP.
Diagnosis is made by exclusion
Rule out Sciatica
Pain Management – same as ALP but add medications for neuropathic pain but should be imposed only when necessary
Biopsychosocial approach - biological, psychological, and social factors
Rehabilitation
combining educational, cognitive-behavioral, and physical exercise treatments according to the individual needs
First stage – needs educational intervention
Later stages - individual cognitive- behavioral
The psychological approach must be part of the treatment – support
CHRONIC LOW BACK PAIN
a pain with or without functional limitation in the posterior region, including the area between the inferior limit of the costal arch and the inferior buttock fold
lasts more than 6 months
Pain also leads to a peripheral and central sensitization that increases pain per se.
Pain can lead to a physical deconditioning, that is, the loss of fitness or dysfunction, meaning altered mobility, strength, endurance, and coordination
“Non-use syndrome”
TREATMENT: reducing actual disability and avoiding its progression through instruments to manage the problem (active approach by the patient) and control pain.
Patients should be grouped into low and high disability
Multi-disciplinary approach
From the start: inform the patient of his prognosis, realistic goals and improve quality of life
PAIN MANAGEMENT: when absolutely necessary!
the complete rehab package includes exercises (functional restoration) together with psychological (cognitive-behavioral) and social approaches to the patient that allows to achieve the best results.
Biopsychosocial inpatient approaches, cognitive behavioral approaches, exercises of different kinds, and educational interventions.
the choice of the more adequate depends on individual features of the single patient
High Disability - a cognitive behavioral approach with specific exercises, aimed at recovering the physical limitations of the back, improving function, and giving the patient the right coping strategies
Low Disability - back school in-group with exercises and education or individually design cognitive behavioral therapy
The best maintenance protocol is a physical activity, whether general or through specific machines.
EXERCISES:
Reducing symptoms
Regaining function, reducing disability and fears related to movement, and encouraging regular physical activity
Preventing relapse
functional rehabilitation approach = function more than pain: in fact results are best in the functionaldisability domains than on the pain itself that is in any case decreased.
COGNITIVE BEHAVIORAL APPROACH
biopsychosocial model
ability to modify wrong beliefs about health status and changing the perception of health
Physical dysfunction: It depends on an imbalance between the demands of physical ability and real body capacities that are not ready to provide the required performances.
Belief and coping: Human thought and the way of perceiving pain. Copers vs. Non-copers
Distress: Increased pain perception, emotional stimulus, psychological factors
Illness behavior: It is heavily conditioned from prejudices about the pathology, future treatments, and the ability of medical care to resolve the pain
Social relationship: Social networks such as family, friends, and colleagues can influence the emotional status, development of illness beliefs, and coping strategy
Operant treatment, which is based on the operant conditioning principles of Skinner and applied to pain by Fordyce consists of the positive reinforcement of healthy behaviors;
• Cognitive treatment, which aims to identify and modify the patient’s cognitions regarding his/her pain and disability;
• Respondent treatment, which aims to modify the physiological response system directly.
First Therapeutic Aim - forecast the positive effects of treatment results by acting on external events
allows the patient to move from a control pain model, typical of the acute phase while improving behavioral and functional ability through communication, education, and motivation, which are methodological instruments peculiar to the cognitive-behavioral model
COMMUNICATION – most important
EDUCATIONAL TOOLS
Accurate information for the patient in order to understand his situation
the information should include advice on how to manage pain, control catastrophism, and decrease avoidance behavior
Brochures, media and back schools
SECONDARY LOW BACK PAIN
Spinal diseases that are a cause of low back pain
SCIATICA
defined as a pain in the lower back and hip, radiating in the distribution of the sciatic nerve
irritation of the sensory root or dorsal root ganglion of a spinal nerve - When irritation arises, it causes ectopic nerve impulses, which are perceived as pain in the distribution of the axon.
Causes - between the intervertebral disk and the nearby neural structures is the origin of irritation, lumbar stenosis and tumors are other possible causes
SYMPTOMS
radicular pain: a deep, severe pain that starts low on one side of the back and then shoots down the buttock and leg when certain movements are attempted.
Radicular pain is perceived in the territory innervated by the affected nerve root in the lower extremity when L4/5/S1 nerve roots are involved, or in the anterior thigh when L2/3 are involved.
travels through the lower limb along a narrow band and perceived as sharp, shooting, or lancinating.
The pain is usually worse with prolonged sitting and standing.
Bending backward can also increase the pain.
The lumbar spine may present an altered range of motion with limited forward flexion and spasm of the paraspinal muscles.
Occasionally, the somatic pain can exist as a dull, aching pain
If axonal damage is severe - weakness in the leg or the foot may occur, leading to neurogenic claudication
cauda equina syndrome - bladder dysfunction with urinary retention or overflow incontinence, saddle anesthesia, and unilateral or bilateral leg pain and weakness
PHYSICAL EXAMINATION
Observe Gait - limping or coordination problems,
Range of Motion of the Spine - severe guarding of lumbar motion on all planes,
Palpation - vertebral point tenderness to palpation, or spinal-cord dysfunction
Compare both limbs and circumferential measurements - difference of more than 2 cm
Neurologic examination - sensory examination, testing for muscle strength and trophism, reflexes
Straight leg test – (Positive) reproduce leg pain by stretching the nerve roots
DIAGNOSTICS
Sciatica - imaging may be indicated if the results influence further management or infer the suspicion of an underlying disease
Diagnostic imaging may also be indicated in patients with severe symptoms who fail to respond to conservative care after 6 to 8 weeks.
X-ray – check for bony abnormalities
MRI – nerve roots and disc herniation
TREATMENT
Its goal is to remove Disc Herniation and eventually part of the disc or foraminal stenosis, thereby eliminating the suspected cause of the sciatica.
However it will not relieved the back pain
Cauda equina syndrome is an absolute indication for immediate surgery
Surgery - suitable for the small percentage of patients with uncontrolled pain or deteriorating neurologic symptoms.
REHABILITATIVE
Non steroidal anti inflammatory drugs
Steroids
Physical therapy and manipulation
Objective – avoid surgery, speed up the resorption process
one must avoid increasing pain and the problem itself
treatment combined with joint mobilization and/or active exercises performed in a pain-free way, looking for the centralization of symptoms so as to speed up the autonomous and spontaneous recovery of the situation
LUMBAR SPINAL STENOSIS
any type of narrowing of the lumbar spinal canal, causing compression of its content which causes direct mechanical compression on the neural elements or on their blood supply.
may occur at different places in the spinal canal, sometimes in more than one location at the same time
Central canal stenosis - the nerve roots in the cauda equina may be compressed.
Lateral recess stenosis and foraminal stenosis may cause compression of the nerve roots leaving the spine
The degenerative type - often due to arthritic changes: Disc degeneration, facet degeneration and hypertrophy, degenerative spondylolisthesis (SL) and ligamentum flavum hypertrophy, and calcification can cause LSS alone or in combination.
Congenital type may occur earlier in life and a result of congenitally anatomic changes or malformations, for example, an excessive scoliosis or excessive lordotic curvature.
Developmental - a condition in which the narrow spinal canal is caused by a growth disturbance of the posterior elements
LUMBAR STENOSIS
SYMPTOMS
Low back pain – indistinguishable from non LBP
Leg symptoms – due to radiculopathy an aching or sharp pain and/or symptoms of pain, burning, numbness, and paresthesia following a specific dermatomal distribution in one lower extremity – commonly L5
Neurogenic claudication - cramping, weakness, pain, numbness, and tingling in both extremities
PHYSICAL EXAMINATION
Same but take note of the exacerbation of pain upon extension and improvement in flexion – due to the central canal and foraminal dimensions increase in flexion and diminish in extension.
symptoms are provoked by the act of standing but relieved when the patient is seated
Observe gait – wide based
an abnormal Romberg test
thigh pain following 30 seconds of lumbar extension, and neuromuscular deficit
Treadmill walking
DIAGNOSTICS
CT Scan and MRI – both measure the antero-posterior diameter
ABSOLUTE STENOSIS - an anterior-posterior (AP) canal diameter of less than 10 mm
RELATIVE STENOSIS - whereas an upper limit of less than 13 mm
Electromyography and nerve conduction studies – differentiate other disorders
TREATMENT
The aim of the operation is to improve the quality of life, and surgical candidates include patients who have persistent severe leg symptoms and functional limitations.
Less aggressive surgical techniques that provide for adequate decompression - fenestration, laminotomy, selective decompression and laminarthrectomy
Relieves the leg symptoms but does not relieve the back pain
LUMBAR SPINE INSTABILITY and SPONDYLOLISTHESIS
Instability can be defined as an abnormal response to applied loads, characterized kinematically by abnormal movement in the motion segment beyond normal constraints
This abnormal movement can be explained in terms of damage to the restraining structures (i.e., facet joints, disks, ligaments, and muscles) that, if damaged or lax, will encourage altered equilibrium and thus instability.
It occurs in individuals older than 50 years, it occurs four times more frequently in women, and is most commonly seen at L4-5
SYMPTOMS
Non-specific low back pain and sciatica – most common
Spondylolisthesis - seen in people involved in repetitious alternate loading activities such as gymnastics, weightlifting, and football.
Involvement of the PARS INTERARTICULARIS
the translation of the lumbar segment had a greater influence than angulation on lumbar symptoms, and the combination of translation and angulation was associated with worse symptoms and the persistence of pain
A thorough physical examination
diagnostics
X-rays: to check for radiologic instability
anteroposterior, lateral, and flexion-extension radiographs
Standing lateral radiograph: the degree of slippage, slip angle, sacral inclination, sacrohorizontal angle, and lumbar index
Criteria for Lumbar Instability:
sagittal plane translation greater than 4.5 mm or greater than 15% of the vertebral body width,
sagittal plane rotation greater than 15 degrees at L1/L2, L2/L3 or L3/L4, greater than 20 degrees at L4/L5, or greater than 25 degrees at L5/S1
X-rays at Lumbosacral Junction
stability is dependent on the spatial orientation of L5 to the sacrum, lumbosacral angle, sacral slope, and pelvic incidence as well as an intact osteo-discal-ligamentous comple
CT scan and MRI - preoperative planning stage, for better defining both the bony and soft tissue anatomy, respectively.
TREATMENT
Indiciations for Surgery:
Patients with intolerable back and/or leg pain recalcitrant to a prolonged conservative treatment program
patients with a history of neurogenic claudication or vesicorectal symptoms deteriorated with poor final outcome
Persistence of symptoms and failure of non surgical treatment for at least 3 months
SURGERY
the mainstay of surgical treatment is decompression
The goals for decompression are to relieve radicular symptoms and neurogenic claudication
the goals for fusion are to relieve LBP by elimination of instability
goals for instrumentation are to promote fusion and to correct listhesis or kyphotic deformity
DIAGNOSIS
X-rays at Lumbosacral Junction
stability is dependent on the spatial orientation of L5 to the sacrum, lumbosacral angle, sacral slope, and pelvic incidence as well as an intact osteo-discal-ligamentous comple
CT scan and MRI - preoperative planning stage, for better defining both the bony and soft tissue anatomy, respectively.
TREATMENT
Indiciations for Surgery:
Patients with intolerable back and/or leg pain recalcitrant to a prolonged conservative treatment program
patients with a history of neurogenic claudication or vesicorectal symptoms deteriorated with poor final outcome
Persistence of symptoms and failure of non surgical treatment for at least 3 months
SURGERY
the mainstay of surgical treatment is decompression
The goals for decompression are to relieve radicular symptoms and neurogenic claudication
the goals for fusion are to relieve LBP by elimination of instability
goals for instrumentation are to promote fusion and to correct listhesis or kyphotic deformity
TREATMENT
REHABILITATIVE
According to Panjabi instability can happen:
the passive subsystem (e.g., ligaments, vertebrae, disks),
the active subsystem (musculature)
the neural subsystem (e.g., sensory receptors, cortical, and subcortical controls).
. The intervertebral neutral zone is the zone, within the “range of motion,” of high flexibility, laxity within which the spinal motion is produced with minimal internal resistance
Instability could be a result of tissue damage, making the segment more difficult to stabilize, insufficient muscular strength or endurance, or poor muscular control; instability is usually a combination of all three.
Insufficient muscular strength - The major source of spinal stability and the component that can be enhanced from a rehabilitation approach
Trunk stabilizing muscles are also defined as a core stabilizing system
Core musculature is required for the spine to move freely throughout its entire range of motion, and it also serves as a functional center of the kinetic chain by connecting the upper and lower extremities.
ACUTE PHASE – control pain by pharmacological treatment or physical modalities and some easy exercises to minimize pain, activity modification like lifting heavy load, avoiding spinal manipulation or traction
aerobic conditioning – swimming, walking, or stationary bicycling that promotes spinal flexion and avoid wear and tear associated with impact aerobic exercises such as running.
Rigid brace
an intensive continuous stabilizing program with a deep cognitive behavioral intervention.
Lumbar stabilization exercises aim at a sensorimotor reprogrammation of the spine stabilizer muscle intended to improve their motor control skills and delay of response, and consequently to compensate for weakness of the passive stabilization system.
Stiffness is achieved with specific patterns of muscle activity, which differ depending on the position of the joint and the load on the spine.
Core muscle endurance seems to be more important than total strength
First Stage - isometric transversus abdominis-multifidus co-contractions, while maintaining the spine in a static neutral position.
Second Stage - requires co-contraction in situation where patients feel “unstable,” experience or anticipate pain.
Third stage - includes functional demands of daily requiring a low degree of attention for adequate contraction
Neuromuscular control can be enhanced through a combination of joint stability (co-contraction) exercises, balance training, perturbation (proprioceptive) training, polymeric (jump) and also via wobble boards, roller boards, and physio-ball.
