Management of Low Back Pain: Physiotherapy Approaches

Transcription

1 Management of Low Back Pain: Physiotherapy Approaches Professor Sunday R.A. Akinbo PhD, FWSPC, FPC Consultant Physiotherapist; Department of Physiotherapy Lagos University Teaching Hospital, Idi-Araba, Lagos Definition of Low Back Pain: Low back pain (LBP) is the pain usually felt at the lower aspect of the spine/back (Figures 1 and 2). It can be due to problems with the lumbar spine (lower back area), the discs between the vertebrae (backbone), the ligaments around the back and discs, the spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen (e.g. referred pain due to disease involving the prostate gland, bladder, uterus, kidney, lung, intestine etc), or the skin covering the lumbar area. Figure 1: Lower back area of the spine

2 Figure 2; Lumbar region (lower back) of the spine/back Causes (Aetiology) Low back pain (LBP) has a multitude of causes and it is often difficult to narrow down to a specific cause. There are a number of potential causes. These include: Common Causes Injury to the back muscles/ligaments e.g. acute strain or sprain. Intervertebral disc damage or degeneration. In some cases the disc can bulge or herniate. Facet joint degeneration and changes. Nerve irritation which can be caused by compression from any surrounding structure (most commonly a bulging disc), or from spread of inflammation from other structures e.g. inflamed facet joint. Referred pain such as endometriosis, hip joint pain, abdominal aortic aneurysm. Mechanical causes; such as prolapsed intervertebral disc or a growth. Vertebral fractures; such as those secondary to osteoporosis. Inflammatory diseases of the spine such as: o Ankylosing Spondylitis o Reactive Arthritis

3 o Enteropathic Arthritis Fibromyalgia Coccydynia (Tailbone pain) Osteoporosis/Osteopenia Sciatica pain, caused by irritation of the sciatic nerve Discogenic disease Rare Causes Malignancy; cancer (e.g. bony metastases, multiple myeloma) Infection (e.g. vertebral osteomyelitis, septic arthritis, spinal tuberculosis, discitis, epidural abscess) Vascular (e.g. abdominal aortic aneurysm, epidural hematoma, hemoglobinopathy) Rheumatologic (e.g. rheumatoid arthritis, ankylosis spondylitis, psoriatic arthritis, reactive arthritis) Lesions causing spinal cord or cauda equina compression (e.g. vehicle or motorcycle accident) Referral of pain from other structures e.g. ruptured aortic aneurysm or pancreatitis. Contributory or Predisposing Factors Heavy manual labor Tasks/work that involves long hours of standing and/or sitting (e.g long distant driving or desk jobs) Persistent stress and fatigue Obesity Chronic Smoking Older age; 40 years and above Female gender Sedentary lifestyle Psychological factors: anxiety, loneliness, and depression.

4 Epidemiology of Low Back Pain (LBP) How common is LBP? Pain is the most common reason for hospitalisation, surgery and work disability in United State 8 Low back pain is the most common of all chronic pain disorders. It occurs at all ages % adults will have LBP at some point in their lives 3. Most prevalent age is years 4. It affects 2/3 of population at any given time 5. Studies reveal that females are slightly more affected compared with male 6. In the US alone, the annual combined cost of back pain care is estimated at $50 billion, or about 35 billion in UK 7. Most cases of LBP in adults are traceable to age-related degenerative processes (osteoarthritis), physical loading, spinal muscle or ligamenteous injuries. The incidence of back pain has increased tremendously lately with the advent of desk-top computer, laptop, keyboard musical instruments and other related electrical gadgets 1. Symptoms of Low Back Pain The major symptom is pain that sometimes may radiate down either leg or both. The nature of the pain can be stabbing, shooting and soreness. Others are muscle ache and weakness, limited flexibility (stiffness) and limitation in the range of movement (ROM), inability to stand up straight or walk properly. Diagnosis of Low Back Pain The diagnostic difficulty of LBP is reflected in the many different philosophies and approaches to its diagnosis and treatment. This means that there are varying opinions on what causes LBP. It is estimated that only 15% of people have an accurate diagnosis of the cause of their back pain 11. Therefore proper and detailed clinical examination and evaluation are needed to detect the cause(s) in order to plan appropriate treatment. The inherent difficulty in the diagnosis of LBP has led health professionals to incorporate a much more holistic approach to it analysis in modern times, often incorporating psychological and social treatment components to the overall management 1. It also highlights the importance

5 of prevention which is the focus of many exercise programmes and training on correct lifting and ergonomics 4. Management of Low Back Pain The International Association for the Study of Pain (IASP) has emphasised the need for multidisciplinary management of patients with pain in general, and LBP specifically 9. Approaches to managing LBP include: 1 Physiotherapy 2 Surgery 3 Medication/Drugs 4 Psychotherapy Physiotherapy Management Historically, the use of physical agents (physiotherapy) to treat pain, specifically LBP and other impairments has been empiric 8. Developed countries have emphasised physiotherapy, pharmacological or surgical intervention and advanced anesthetic approaches 12. Psychological/behavioral and cognitive methods are being increasingly utilised as adjunct. Physiotherapy Approaches 1 Electrophysical/Electrotherapy Agents: Therapeutic Ultrasound (Phonophoresis) Short wave diathermy, Micro wave diathermy Intrasound therapy Transcutaneous Electrical Nerve Stimulation (TENS) Vacuum therapy Interferential Current/therapy (IFC) LASER therapy Magnetophoresis Neuromuscular Electrical Stimulation (Ionophoresis) Thermal therapy (IRR) and Heat packs 2 Cryotherapy and hydrotherapy

6 3 Cervical and Lumbar Traction Therapy (Spinal Immobilisation) 4 Therapeutic Exercise and Soft Tissue Manipulation (Massage) 5 Manipulative/Manual Therapy 6 Ergonomic and Back School approaches The department of physiotherapy at the Lagos University Teaching Hospital (LUTH) with five units; Cardiopulmonary Physiotherapy, Neuro-Physiotherapy & Mental Health, Orthopeadic & Sports Physiotherapy, Peadiatrics Physiotherapy, and Physiotherapy in Women s Health is well equipped with modern facilities (Figures 3 and 4), competent and dedicated staff to manage any case of LBP or any physiotherapy related conditions. But the best approach is prevention! REFERENCES 1) Akinbo SRA, MA Danesi, DA Oke, CB Aiyejusunle, AA Adeyomoye (2013). Comparison of supine and sitting positions cervical traction on cardiovascular parameters, pain and neck mobility in patients with cervical spondylosis. International Journal of Rheumatology; 8 (1). 2) Akinbo SRA, Esionye-Uzodimma NV, Odebiyi DO, Owoeye O (2012). Knowledge about psychosocial yellow flags in patients with low back and neck pain among physiotherapists in Nigeria- a cross-sectional Study. Journal of Physical Therapy; 5(2): ) Akinbo SRA, Owoeye OBA, Adesegun SA (2011). Comparison of the therapeutic efficacy of diclofenac sodium and methylsalicylate phonophoresis in the management of knee osteoarthritis. Turkish Journal of Rheumatology; 26(2): ) Akinbo SRA, Odebiyi DO, Osasan AA (2008). Characteristics of back pain among the commercial motor drivers and motorcyclists in Lagos, Nigeria. West African Journal of Medicine 27 (2): ) Akinbo SRA, Noronha CC, Oke DA, Okanlawon AO, Danesi MA (2006). Effect of cervical traction on cardiovascular and selected ECG variables of cervical spondylosis patients using various weights. Nigerian Postgraduate Medical Journal 13(2): ) Akinbo SRA, Alimi NO, Noronha CC (2004). Relationship between knee joint osteoarthritis and the quadriceps (Q)-Angle. South Africa Journal of Physiotherapy 60:

7 7) Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, Kvarstein G, Stubhaug A (2008). Assessment of pain. British Journal of Anaesthesia 101(1): ) Debono, DJ, Hoeksema, LJ, Hobbs, RD (2013). "Caring for Patients with Chronic Pain: Pearls and Pitfalls". Journal of the American Osteopathic Association 113 (8): ) IASP Taxonomy (2011)." International Association for the Study of Pain Welcome to IASP. < 14th June, ) Jordan R, Kruger M., Stewart A. and Becker P (2005). The association between low back pain, gender and age in adolescents. South African Journal of Physiotherapy 61 (3): ) Lamas D and Rosenbaum L (2012). Painful Inequities Palliative Care in Developing Countries. New England Journal of Medicine 366: ) May SJ (2001). Patient satisfaction with management of back pain (part 1). Physiotherapy 87: 4-9. Figure 3: Patient preparation before IRR session in LUTH Physiotherapy Dept

8 Figure 4: Patient receiving Functional Neuromuscular Electrical Stimulation in LUTH Physiotherapy Dept Common asked questions and answers about low back pain (LBP) 1 Can my foot wear aggravate my LBP? Yes. High heeled, ill fitted and tight shoes can seriously aggravate back pain because it negatively affects body stability on standing and walking 2 What are the daily activities that can aggravate LBP? Sitting in awkward position without seat back support, lifting/pushing of heavy object, standing or sitting continuously for more than 90 minutes, lack of rest after strenuous activity etc can worsen LBP 3 Is LBP hereditary? Yes, especially if the LBP is precipitated by obesity, and if obesity runs in the family 4 Can LBP be permanently cured? Yes; if experts are consulted on time before irreversible damage is done and appropriate treatment utilised.

9 5 What are the preventive measures against LBP? Maintain ideal body weight, engage in supervised aerobic exercise 2-4 times weekly, eat balanced diet, engage in regular medical check-up at least once a year, avoid lifting heavy objects.