Low back pain in a Nutshell Paul Manjaly. Paul Manjaly

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1 Low back pain in a Nutshell Paul Manjaly Paul Manjaly

2 Pain: An unpleasant sensory and emotional experience which follows actual or potential tissue damage or is described in terms of such damage Unpleasant Sensory Emotional Damage

3 Introduction Low back pain is defined as pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain. LBP is the most common MSK pain and cost NHS millions and it affects 80% of the population(katz,2002,ehlrich & Wool & Pfleger,2003) Prevalence of back pain is between 30 to 60yrs of age Most acute LBP (80-90%) resolves within 2-3 months although recurrence is common (Hides et al., 1996)

4 Causes of Low back pain Disc Degeneration/ protrusion Spinal Stenosis Facet joint arthropathy Sprains & Strains Fractures Scoliosis Spondylolisthesis Arthritis

5 Characteristic of Low back pain Central or Paracentral low back pain with or with out leg pain Difficult to sit or stand or walk for long period due to pain Difficult to stand up from sitting Discomfort in lying or turning in bed Activity based with Varied its intensity Possible hyperactivity / spasm in paraspinal muscle

6 Mechanical LBP Results from an acute traumatic event or cumulative events such as lifting, twisting, fall, RTA, repetitive work, prolong sitting, sedentary lifestyle, work and posture etc. Chen at al (2007) based on a systematic study review suggested sedentary lifestyle such as prolong period of sitting is a risk factor for LBP but not leads to LBP Peng at al suggested overweight and obesity are risk factor for LBP but not a primary cause compared to persons of normal weight Rivinoja et al in 2008 and Yang and Haldeman in 2012 cohort study indicates smoking, alcohol use are risk factors for LBP

7 Non specific Low back pain Non-specific low back pain is defined as low back pain not attributed to recognisable cause or known specific pathology (e.g. infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome or cauda equina syndrome). If not treated appropriately, it will lead to CLBP. Optimal treatment for these patients remains a problem 10-40% become chronic and represent major cost burden (Dillingham, 1995; Croft et al., 1998) 85% of CLBP patients are without a detected patho-anatomical/radiological abnormality and hence diagnosed as CNSLBP (Waddell, 1987, 2004; Dillingham, 1995) CNSLBP has classified into 3 Movement control impairment subgroups (O Sullivan, 2005)

8 Subjective Assessment- Physio Onset ( any predisposing factors?) Site of pain ( is it dermatomal?) Aggravating factors such as sitting or walking etc Easing Factors Occupation and Hobby ( sedentary/active, manual ) PMH 24 hour pattern Cough/Sneeze Night pain

9 Objective Assessment Observation ROM Neurological examination plus UMN if appropriate SLR/ Slump test Clear above and below joints

10 Impression Mechanical LBP or NSLBP Disc with or with out radiculopathy Serious pathology such as Cauda equina or Red flags or Inflammatory Red flags (waddell 1999): Presentation age <20 years or onset >55. Violent trauma e.g. fall from height, RTA. Constant, progressive, non-mechanical pain Thoracic pain Previous history carcinoma, systemic steroids, drug abuse, HIV. Systemically unwell weight loss Persistent severe restriction of lumbar flexion Widespread neurology Structural deformity Night pain

11 Management Mechanical/ NSLBP- Education of condition, advice on posture, Medication, Exercise preference, keep moving for 4-6 weeks. If not improved then refer to PD / face to face physio progression of symptoms i:e single nerve root pathology or bilateral symptoms please refer to Ortho via CATS Symptoms of Cauda equina or redflags refer to A & E or discuss with on call Ortho doctor or follow the pathway If Inflammatory pathology identified please refer to Rheumatology CNSLBP- MDT/ CBT or Pain management team

12 Extensive pattern of CNSLBP

13 Summary Any questions?

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