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 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)

usually attributable to musculoligamentous injuries or age-related degenerative disease in intervertebral disks and facet joints Sprain – torn or detached ligament Strain – torn muscle Radiculopathy – pain & neurological deficit caused by injury to a nerve root (radix=root) Sciatica – pain that radiates down posterior or lateral leg; a type of radiculopathy Spinal Stenosis – narrowing of the spinal column resulting in compression of the nerve root; often resulting in pain or numbness in legs Degenerative Disk Disease – gradual degeneration of the disk between vertebrae, due to loss of fluid and tiny cracks, part of normal aging process Compression Fracture – fracture that collapses a vertebrae Spondylolisthesis - anterior or posterior slipping or displacement of one vertebra over another

Serious spinal pathology 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 Knowing the prevalence of various etiologies of back pain, looking for “red flag” findings B=bowel or bladder dysfunction A=anesthesia C=constitutional symptoms/malignancy K=chronic diseases P=paresthesia A=age>50 I=infection, IV drug use N=neuromotor deficits History Questions and DDX

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. You can approach the subject of yellow flags by asking patients the following: Have you had time off work because of back pain? What do you think is the cause of the back pain? What do you think will help the pain? How does your employer respond to your back pain? Do you plan to return to work? You can help patients who are at risk of developing chronic back pain by: Offering information and reassurance about acute back pain Correcting misconceptions - for example that bed rest is better than staying active Treating mental health problems such as depression Avoiding passive treatments such as bed rest Encouraging active treatment such as a gradual return to normal activities Setting realistic goals Offering an exercise programme to patients who have sub-acute back pain - pain that lasts between six and eight weeks Consider referral to a back school Back schools educate patients about back care, how to avoid back pain, and exercises that can strengthen the back. A recent Cochrane review showed that back schools in the workplace can help patients with chronic low back pain.

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 The straight leg raise test is highly suggestive of nerve root pain. Patient lies flat with both legs straight raise 1 leg till limited by pain or tight hamstring-slightly lower leg to provide relief then increase tension on nerve by dorsiflexion of foot-this will aggravate or elicit pain radiating down the raised leg if there is nerve root irritation, the pain will be relieved by flexion of the knee SLR-measure angle off couch for each leg Flip test-patient sitting with legs over edge of couch and knees flexed, straighten knee as if to perform ankle jerk, no pain if functional overlay

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 Toe Walk tests calf muscle (S1) 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 Light touch on Medial foot (L4) Dorsal foot (L5) 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 CT MRI Fracture, tumour, infection 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 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 sub-acute 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

Non-specific low back pain 23/04/2017 Non-specific low back pain 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 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 National Prescribing Centre

Pain overview - Approaches 23/04/2017 Pain overview - Approaches WHO's three step ladder to use of analgesic drugs www.who.int/cancer/palliative/painladder 3 2 1 National Prescribing Centre

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 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 Severe Stenosis Tumor? Acute fractures with Neurologic deficit. Severe Stenosis After failure of aggressive non-operative tx. Tumor? Progressive Neurologic deficit

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