Low back pain
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
 Aim: At the end of this presentation, the participants will
have knowledge on the management of low back pain.
 Objectives: At the end of this session, the trainees should;
• be able to discuss the prevalence of disc mediated low back
pain and current techniques for diagnosis
• be able to develop a structured approach to history taking
and physical examination in patients with low back pain
• be able to review the major types of mechanical back pain,
and describe common etiologies
• be able to explain the difference between simple and
complex low back pain
• be able to describe emerging interventional and biological
therapies to treat low back pain
Timing Definitions
• Acute LBP lasts for < 6 weeks
• Sub-acute LBP lasts for 6-12 weeks
• Chronic LBP lasts for > 12 weeks
• Acute & Sub-acute account for 90% of LBP
Epidemiology
• 75% of adults will experience LBP at some point in their
lives
• 5th most common cause of all physician visits
• Peak incidence 20-40 years old; More severe in older
patients
• 85% of patients have no definitive anatomic cause or
imaging finding
• Most cases are self limited with serious problems in < 5%
• Most common cause of work-related disability for
individuals < 45 years old
• Low back pain among Saudi school workers in
Jeddah
• The results of this study show
• a prevalence of 26.2% with low back pain
• Saudi medical journal 1998
• A response was obtained in 5,743 (97.4%). Their
mean age was 34.14 ± 15.16 (range 16-99). Back
pain was reported by 1,081 (18.8%), wherein
499 (8.8%) were men, and 574 (10%) were
women. Back pain was more prevalent in
married (23.3%) individuals than unmarried
(6.4%).
• How common is back pain in Al-Qaseem regoin
• Saudi Med J 2003
Causes of back pain
LBP: Risk Factors
• Heavy lifting and twisting
• Obesity
• Poor physical
fitness/conditioning
• History of low back
trauma
• Psychiatric history(chronic
LBP)
The European guidelines also classify acute back pain into three
categories. These are1:
 Serious spinal pathology
•
– This includes infection, malignancy, fracture, and inflammatory causes such
as ankylosing spondylitis
 Nerve root pain
– The sciatic nerve becomes trapped or irritated either in the lumbosacral
spine or the muscles of the lower back or buttock, if they go into spasm
secondary to pain
– It may take up to two months for the patient's symptoms to resolve
 Non-specific low back pain
– This is back pain that is not due to either serious spinal pathology or nerve
root pain
– It is often triggered by a minor sprain or strain of the back
– Pain may be mechanical - worsened by certain movement or postures
– Pain usually improves within two weeks.
When you assess patients who present with back pain you •
should:
• Rule out serious pathology by asking about red flags
• Ask about nerve root pain
• Examine all patients - usually a brief examination is
sufficient
• Examine other joints close to the back such as the hip joint
for pain
– Pain can be referred from the hip joint to the back.
Red Flags
•
•
•
•
•
•
•
•
Retention of urine or incontinence
Onset over age 55 or under 20
Symptoms of systemic illness - weight loss, fever
Morning stiffness
Severe progressive pain
A prior history of cancer
Intravenous drug use
Prolonged steroid use
yellow flags
• An inappropriate perception of back pain
– The belief that back pain is harmful and disabling
– The belief that passive activity such as bed rest is
better than staying active
• Lack of support at home and social isolation
• Mental health problems such as depression,
anxiety, and stress
• Problems at work such as job dissatisfaction
• Claims for compensation and benefits.
Examination
•
•
•
•
•
LOOK
FEEL
MOVE
STRAIGHT LEG AND FEMORAL STRETCH TEST
POWER,TONE,SENSATION + REFLEXES
LOOK
• Examine standing-look for deformity such as
increased or decreased lordosis, obvius
scoliosis, soft tissue abnormalities eg. Hairy
patch, scars
FEEL
• Spinous processes and paraspinal tissues for
any local tenderness or spasm
• Palpate vertebral column for point
tenderness
MOVE
• Flexion-try to touch toes with your legs straight and
note how far eg. To knees,ankles, mid shin
• Extension-straighten up and lean back as far as you
can
• Lateral flexion-reach down to each side touching
the outside of each leg and record amount of
flexion
• rotation
Straight Leg Raising L4,5,S1
Power/tone/sensation/reflexes
• Power-grade 0-5, test all joint movements
• Tone- should include anal tone esp. if red
flags
• Sensation- esp. perineal/perianal
• Reflexes-knee L3,4 ankle L5,S1 plantar S1,2
Motor Testing
Deficit should align with areas of
pain
• Toe Walk tests calf muscle
(S1)
• Heel Walk tests ankle and
toe dorsiflexion (L4, L5)
• Single squat and rise (L4)
• Ankle Jerk (S1)
• Knee Jerk (L4)
Sensory Tests
Deficits should align with areas
of pain
• Light touch on
– Medial foot (L4)
– Dorsal foot (L5)
– Lateral Foot (S1)
When to Image
•
•
•
•
Consider in all ages if any trauma
Consider in older adults with any falls
Pain not improved over 4 to 6 weeks
If there is a history of chronic steroid use or
osteoporosis
• If there are any “Red Flags” and suspicion for
cauda aquina, infection, cancer
How to image
• X-ray
– Fracture, tumour, infection
• CT
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–
–
–
Suspect disc herniation that is being considered for surgery
Detail an unstable fracture
Clarify abnormality seen on bone scan
If spinal stenosis suspected & want to localize pathology
• MRI
– Extent of tumour
– Recurrent or unremitting post surgery radicular pain
– Cauda equina
Management of LBP
•
•
•
•
•
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Keep moving! (only a few days rest at most)
Heat/cold
Decrease bending and lifting
Frequent position changes
NSAID/Acetaminophen
Low impact aerobic exercise
– Walking, swimming
• Education regarding proper lifting, bending techniques
• Progression of more specific strengthening exercise
– Core muscles
• Gradual progression back to normal activity
Treatment Options for
Mechanical LBP
 Scheduled oral NSAIDS are recommended; there is strong
evidence that they significantly reduce pain
 For NSAIDs – remember ease of use and cost – none more
effective than another
 Tylenol avoids the GI and renal issues found with NSAIDS,
however some studies found it less effective for pain than
NSAIDS
 May need opioids for severe pain; side affects include
drowsiness and addiction; administer for 1-2 weeks only
Treatment Options
• Strong evidence that muscle relaxants such
as Flexeril, Soma or Skelaxin are helpful
– most beneficial in first one to two weeks of
treatment
– most effective when combined with NSAIDS
– side affects include drowsiness and dizziness –
evaluate risks vs. benefit
Treatment Options
• Superficial heat therapy has been helpful in
reducing LBP – provides muscle relaxation and
analgesia
• Evidence to support use of ice is inconclusive
• Physical Therapy appears to be helpful in subacute LBP
– 2-6 sessions
– Beneficial for pateint education and activating
exercise programs
Treatment Options
• Epidural steroid injections may be helpful in
patients with radiculopathy who do not
respond to 6 weeks of conservative
treatment
– should be preceded by MRI or CT
– recommendation is 1-3 injections
– most effective when combined with medication
and physical therapy
Treatment Options
• Bedrest is not recommended, there is strong
evidence to stay active, however activity may
need to be modified
• If bedrest is necessary for severe pain, it
should not last longer than 2-3 days
• There is insufficient evidence to support
massage
• There is mixed evidence on efficacy of
acupuncture
Treatment options
• Some evidence that spinal manipulation
results in short-term improvement in pain
but is less effective than usual methods
(analgesics, muscle relaxants, PT)
• “Back schools”, lumbar supports, traction and
ultrasound have not been shown to be
effective
Treatment Options
• Despite the high rate of spinal surgery,
evidence shows only a small number of
patients have improvement
Summary of treatment recommendations
Van Tulder M and Koes B. Low back pain (acute & chronic). Clinical Evidence 2006
Effectiveness
Acute low back pain
Chronic low back pain
Beneficial
Advice to stay active, NSAIDs
Exercise therapy, intensive
multidisciplinary treatment
programmes
Trade-off
Muscle relaxants
Muscle relaxants
Likely to be beneficial
Multidisciplinary treatment
programmes (for subacute low
back pain), spinal manipulation
Analgesics, acupuncture,
antidepressants, back schools,
behavioural therapy, NSAIDs,
spinal manipulation
Unknown
Analgesics, acupuncture, back
schools, behavioural therapy,
electromyographical
biofeedback, epidural steroid
injections, lumbar supports,
massage, multidisciplinary
treatment (for acute low back
pain), temperature treatments,
traction, TENS
Electromyographical
biofeedback, epidural steroid
injections, local injections,
lumbar supports, massage,
traction, TENS,
Unlikely to be
beneficial
Specific back exercises
—
Ineffective, or harmful
Bed rest
Facet joint injections
3
WHO's three step ladder to
use of analgesic drugs
www.who.int/cancer/palliat
ive/painladder
2
1
Complications
• Development of chronicity and depression
• Disability and loss of employment
• CAUDA EQUINA SYNDROME- when disc
material is pushed into the spinal canal and
compresses the bundle of lumbar and sacral
nerve roots. Permanent neurological
sequelae can occur if not treated as
emergency
Prognosis
• In one month, 35% have no symptoms
• In 3 months, 85% have no symptoms
• In 6 months, 95% have no symptoms
• Remember, the etiology of LBP is usually not
identified (85%) but almost all patients get
better!
When to refer
Referrals
• Not improving in 4 to 6 weeks
• Deficit in more than one root
• Progressive root loss
• Loss of bladder and/or bowel function
• Red flag suggesting fracture, tumour, infection
– Get imaging & refer to spine surgeon
Who to refer to?
Referrals
• Joint inflammation and/or other joint involvement
– Order baseline labs & refer to rheumatologist
• UMN symptoms & signs
– Refer to neurologist and/or spine surgeon
• Persistent LBP
– Refer to physiatrist or spine surgeon
• Spinal stenosis suggested
– Refer to physiatrist or spine surgeon
• Chronic pain syndrome features
– Multidisciplinary pain clinic referral
Denniston PL, ed. Official Disability Guidelines. 11th ed.
Encinitas,Calif.: Work Loss Data Institute, 2005.
Who needs Surgery?
• Unstable Spine
Acute fractures with Neurologic deficit.
• Severe Stenosis
– After failure of aggressive non-operative tx.
• Tumor?
• Progressive Neurologic deficit
Thank you