Low Back Pain

Abstract: Low back pain (LBP) is a musculoskeletal disorder, affecting humans from adolescent to adult age. It is a health and socio-economic problem worldwide. The cause and contributing factors to LBP are multifactorial resulting in different approaches for its management. The attitudes and beliefs of patient with LBP, play an important role in the whole process of pain management. Negative attitudes and beliefs may lead to fear -avoidance behaviour, resulting into pain chronicity and disability. Thus, this study aimed to identify the attitudes and beliefs among patients with LBP, attending physiotherapy treatment in Malawi. Queen Elizabeth and Kamuzu Central hospitals were selected as study settings. A quantitative cross-sectional survey was done, using a self-administered questionnaire, employing a convenience sampling method. Twelve statements about attitudes and beliefs on LBP were adopted from the Back Beliefs Questionnaire (BBQ) and from the Survey of Pain Attitudes (SOPA). The SPSS (version 19.0) was used for data capturing and analysis. Descriptive and inferential statistics were used to summarize data. The Chi-square test was used to determine any association between variables and the Alpha level of significance was set at 0.05. All ethical issues were sought and adhered to throughout the study period. The results showed that out of 205 participants, with mean age of 47.74 years, (SD=13.29), female constituted 53.2% of the sample. More than half (67%) of all participants portrayed negative attitudes and beliefs about their LBP. We concluded that, majority of patients with LBP in Malawi hold negative attitudes and beliefs about their pain. Therefore, patient health education is needed to change these attitudes and beliefs if recovery and treatment goal are to be achieved.

Improved understanding of low back pain and its management are identified as key components of care by both patients and healthcare professionals. This guideline emphasises the importance of patient choice, which can only be exercised effectively if people have an adequate understanding of the available options. Extensive research literature addresses the education of adults using a wide variety of techniques, but studies of patient education for people with low back pain have focused almost exclusively on written

In sources used for collating this report low back pain is often embedded in data relating to “back pain”, “musculoskeletal disorders” or “chronic pain”. I have sought to refer to the most recent data available, but the numbers vary due to the time of publication of the report, the time span and the geographical area the data is collected from, the purpose of the report, and how “low back pain” is situated in the field of musculoskeletal disorders. Most of the figures published have been estimates. Therefore it has not been possible to come up with any definite figures for low back pain and its economic cost to the NHS and the society more generally. This report should be taken as illustrative of the seriousness of the condition and the extent of its impact on the NHS, the workforce and the society more generally.

(continued on next page) LOW BACK PAIN; MECHANICAL Background This case definition was developed by the Armed Forces Health Surveillance Center (AFHSC) for the purpose of epidemiological surveillance of a condition important to military-associated populations. In the U.S. Armed Forces, low back pain is among the most frequent causes of medical visits and lost- duty time. Back problems have also been the leading causes of medical evacuations from Iraq and Afghanistan. 1 This case definition is used to identify cases of mechanical low back problems defined as local or radicular pain associated with conditions of the sacrum or lumbar spine and unrelated to major trauma, neoplasms, pregnancy, infectious or inflammatory causes. 2

Arthritis—The spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include reactive arthritis (Reiter's disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Each of these diseases can lead to low back pain and stiffness, which is typically worse in the morning. These conditions usually begin in the second and third decades of life. They are treated with medications directed toward decreasing the inflammation. Newer biologic medications have been greatly successful in both quieting the disease and stopping the progression.

Imaging in Low Back Pain Haider N. Al-Tameemi Abstract Medical imaging plays an important role in the evaluation of low back pain (LBP). The choice of certain radiological method over other depends on many factors like patient’s presentation, presence of contraindication, availability, relative cost of the test, and the expected impact of the results on management. Radiological evaluation helps the physician reach the most likely cause of LBP, con- firm the provisional diagnosis, provide alternative one, or narrow the differential diagnosis. Plain X-ray radiograph is useful in initial general assessment. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of LBP because of elegant demonstration of anatomical details and many patholo- gies. Computerized tomography (CT) can provide high-resolution images of the bony structures and is particularly invaluable in trauma. Other imaging modalities are rarely used usually as problem-solving or in selected conditions. For example, sonography may have a role in the evaluation of soft tissue lesions and the sacroiliac joints. Angiography is useful for vascular evaluation. Isotope imaging may be used in the elucidation of of hidden cause of pain (tumors or fracture). Conventional myelography and discography are virtually obsolete in current clinical practice because of the presence of much safer and accurate new modalities. Finally, inter- ventional radiology has an increasing role in treating certain conditions.

3. Is the peridural membrane of the spine a potential source of low back pain? In this chapter results of the research presented in this thesis will be discussed. At the center of this investigation is the method of epiduroscopy. Epiduroscopy is relatively new, generally difficult to perform and largely unexplored. A systematic approach to epiduroscopy, in which information obtained through epiduroscopy was correlated with known clinical and basic scientific facts, has markedly improved the ability to reliably evaluate the spinal canal and its contents. Using this newly acquired knowledge, it has become clear that observations do not always support conventional theory of the pathogenesis of low back pain. In fact, several findings have not been described at all. To express results of innovative research in conventional terms is difficult and not always possible. Use of terms as defined in the introduction may help avoid some of the confusion. Of course, caution should be taken with conclusions presented in this thesis because large controlled studies or replicative studies by other investigators have not been done. However, even though rigorous scientific support is lacking at this time, results of this research may open up pathways to a better understanding of the pathophysiology and hence treatment of back pain.

Heritability for migraine has been estimated at 35% (Stam et al., 2010), 55% for menstrual pain (Treloar et al., 1998), and 33% to 50% for low back pain (Bengtsson & Thorson, 1991 Battié et al., 2007). The main aim in pain genetics, however, is to identify the actual genes and gene polymorphisms that influence the pain pathways. Linkage and association studies have attempted to identify specific genes that affect the peripheral nervous system through the voltage-gated sodium channels on the one hand and genes that affect the central nervous system and modulate sensory-discriminatory and affective-evaluative elements of pain perception that affects the central nervous system on the other (for an extensive overview, see Foulkes & Wood, 2008). Many candidate genes have been proposed, but the effects of these genes are small and even together, if true, explain only a fraction of the heritability involved. A possible explanation for this is the complexity of pain as a phenotype. Measurement of the pain experience plays an important part in this. In human studies, three single-nucleotide polymorphisms (SNPs) have been proposed to impact pain perception: COMT Val158Met (rs4680), BDNF Val66Met (rs6265), and OPRM A118G (rs1799971). COMT Val158Met is a gene polymorphism that alters the activity of the COMT enzyme, which degrades catecholamines, such as dopamine, epinephrine, and norepinephrine (Nackley et al., 2006). It has been demonstrated that Met/Met homozygotes have decreased mu-opioid system activation in response to pain (Zubieta et al., 2001, 2003); however, further replication is required. Brain-derived neurotrophic factor (BDNF) is a neurotrophin that supports the growth, differentiation, and survival of neurons in both the peripheral and the central nervous system. BDNF is released when nociceptors are activated and is involved in the activity-dependent pathogenesis of nociceptive pathways, which may lead to chronification of pain (Merighi et al., 2008; Sen et al., 2008). One piece of genetic variation within the BDNF gene is a valine-to-metionine substitution at codon 66 (Val66Met), resulting in reduced secretion of the BDNF protein and impaired BDNF signaling. The Met carriers are believed to be more sensitive to pain; however, here, replication in large and systematic studies is also required.

1. Brisby H. J Bone Joint Surg Am 2006;88 (Suppl 2):68–71; 2. McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006; pg 1032; 3. Freynhagen R, Baron R. Curr Pain Headache Rep 2009;13:185–90 Example of co-existing pain: herniated disc causing low back pain and lumbar radicular pain

As many as 90 percent of persons with occupational nonspecific low back pain are able to return to work in a relatively short period of time. As long as no “red flags” exist, the patient should be encouraged to remain as active as possible, minimize bed rest, use ice or heat compresses, take anti-inflammatory or analgesic medications if desired, participate in home exercises, and return to work as soon as possible. Medical and surgical intervention should be minimized when abnormalities on physical examination are lacking and the patient is having difficulty returning to work after four to six weeks. Personal and occupational psychosocial factors should be addressed thoroughly, and a multidisciplinary rehabilitation program should be strongly considered to prevent delayed recovery and chronic disability. Patient advo- cacy should include preventing unnecessary and ineffective medical and surgical interventions, prolonged work loss, joblessness, and chronic disability. (Am Fam Physician 2007;76:1497-1502, 1504. Copyright © 2007 American Academy of Family Physicians.)

What is Chronic Pain? Low back pain is considered to be chronic if it has been present for longer than three months. Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe.

• Low back pain worse with rest • Unexplained weight loss In the presence of “Red Flags”, especially for tumour or infection, the use of other imaging studies such as bone scan, CT or MRI may be clinically indicated even if plain X-rays are negative.

Pregnancy-related low back pain is a common complaint among pregnant women. It can potentially have a negative impact on their quality of life. The aim of this article is to present a current review of the literature concerning this issue. By using PubMed database and low back pain, pelvic girdle pain, pregnancy as keywords, abstracts and original articles in English investigating the diagnosis treatment of back pain during pregnancy were searched and analyzed. Low back pain could present as either a pelvic girdle pain between the posterior iliac crest and the gluteal fold or as a lumbar pain over and around the lumbar spine.

429, 2011. Key words: herniation; intervertebral disk displacement; geriatrics; outcomes L ower extremity pain in the setting of low back pain affects 12% of older men in the community-based pop- ulation 1 and 21% of older adults in retirement communi- ties. 2 Lumbar disk herniation (LDH) is a common cause of these symptoms and most typically manifests as a lumbo- sacral radicular syndrome: a combination of one or more of radicular pain, paresthesia, sensory changes, motor weak- ness, and impaired reflexes in the distribution of one or more lumbosacral spinal nerve roots in the lower extremity. 3,4 A classical dichotomy has been prominent in spine care whereby LDH is considered a clinical entity common mainly to younger adults, with a shift to a predominance of degen- erative lumbar spinal stenosis (LSS) in older adults. 5 The view that LDH is rare in older adults is echoed in scientific reports and textbooks of spine care, 6–9 but other reports caution that LDH in older adults is more common than pre- viously believed. 10–12 The prevalence of LDH in older adults is of particular importance because the outcomes with non- surgical treatment of LDH are favorable in the majority of individuals, 13 whereas dramatic improvements in LSS with nonsurgical treatment are seen less commonly. 12

Abstract: Adolescent low back pain (ALBP) is a common form of adolescent morbidity which remains poorly understood. When attempting a meta-analysis of observational studies into ALBP, in an effort to better understand associated risk factors, it is important that the studies involved are homogenic, particularly in terms of the dependent and independent variables. Our preliminary reading highlighted the potential for lack of homogeneity in descriptors used for ALBP. This review identified 39 studies of ALBP prevalence which fulfilled the inclusion criteria, ie, English language, involving adolescents (aged 10 to 19 years), pain localized to lumbar region, and not involving specific subgroups such as athletes and dancers. Descriptions for ALBP used in the literature were categorized into three categories: general ALBP, chronic/recurrent ALBP, and severe/disabling ALBP. Whilst the comparison of period prevalence rates for each category suggest that the three represent different forms of ALBP, it remains unclear whether they represented different stages on a continuum, or represent separate entities. The optimal period prevalence for ALBP recollection depends on the category of ALBP. For general ALBP the optimal period prevalence appears to be up to 12 months, with average lifetime prevalence rates similar to 1-year prevalence rates, suggesting an influence of memory decay on pain recall.

Testing the validity and reliability: To explore the validity and reliability of the LBPRS-Ar, the questionnaire was administered to 65 patients with low back pain. Eligibility Criteria for patients were: age more than 18 years, a written consent of the patient, and low back pain lasting more than 3 months. Patients were excluded if they had severe lumbar radiculopathy, low back pain related to vertebral fracture, back surgery, cognitive impairment, infectious disease, neurological deficits, cancer, or other systemic diseases with possible effect on the musculoskeletal system.

araja University, Kanpur, India About 80 percent of adults experience low back pain at some point in their lifetimes. It is the most related disability and a leading contributor to missed work days. Vast majority re mechanical in nature. In many cases, low back pain is associated with spondylosis, a term that refers to the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older. Recurring back pain resulting from improper body mechanics is often preventable and minimized by avoiding movements that jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-

Abstract Low back pain (LBP) is primarily managed in general practice and commonly underestimated or misdiagnosed by physicians. This article presents comprehensive review for diagnosis and evalu- ation of LBP according to current clinical studies guidelines. Our objectives are to define LBP, to establish how to take a detailed history and how to physically examine it in order to enable physi- cians to make an appropriate differential diagnosis for LBP, and to identify relevant investigations and referrals of patients with LBP. The article first offers a quick description of inflammatory back pain then discusses the importance of screening red flag patients with LBP and the importance of its early detection. Finally, we summarize how to outline a primary plan for managing and treating LBP. The article is prepared in the format of question and answer to make it targeted and accessi- ble.

As mentioned, most back pain in athletes is soft-tissue related; therefore, treatment of the majority of back disor- ders should be aimed at functional rehabilitation in order to minimize downtime and deconditioning. In this con- text, George and Delitto [24•] outline a treatment-based classification system for the management of low back pain. They specifically describe modalities for alleviating acute and chronic low back pain in athletes in order to return the athlete to daily training schedules and prevent recurrence of low back injury. Patients initially avoid activity follow- ing a back injury. However, long periods of inactivity must be discouraged in order to minimize loss of strength and flexibility. Bed rest is occasionally required but must be limited to 24 to 36 hours. Activities of daily living should be performed and walking should be recommended. Ice and nonsteroidal anti- inflammatory medication s (NSAIDs) will help with initial inflammation. Narcotic medications should be avoided. Stretching exercises should begin when acute pain and spasm subside, and usually within 48 to 72 hours of the injury. Hamstring flex- ibility must be attained. Strengthening exercises are initi- ated at 1 to 2 weeks following the injury. Flexors or extensors should be strengthened according to the specific diagnosis. For example, flexion exercises should be empha- sized in patients with spondylolysis, spondylolisthesis, and facet joint disorders. Athletes with herniated discs must build up the extensors. With soft tissue strains, both flexors and extensors should be strengthened in order to achieve the appropriate balance between the two. Rehabilitation advances as symptoms subside. When the athlete has attained normal strength, normal flexibility, and is pain- free, return to competition is allowed. The athlete is encouraged to maintain a strength and flexibility program after symptoms resolve in order to prevent recurrence of back pain.

4. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.