LOW BACK PAIN. Practice Report.

Transcription

1 LOW BACK PAIN Practice Reprt.

2 Practice Reprt LOW BACK PAIN Lw back pain is mst cmmnly related t acute r chrnic strain f the jints and sft tissues that supprt the spinal clumn. Cmmn causes f acute back pain include disc injuries and strain invlving ligaments, tendns, r muscles supprting the spine. Cmmn causes f chrnic back pain include muscle spasm, arthritis, stensis, and ther degenerative changes. Lumbar Disc Disease Discs act like shck absrbers between the mvable bny segments f the spine. These discs can be strained t the pint where they bulge, prtrude, r rupture int spaces where the spinal crd r spinal nerves are affected. If the inner gel-like substance f a disc extrudes thrugh a crack in its utside wall and int the surrunding sft tissue, the result is ften severe pain and inflammatin. Acute vs. Repetitive Muscle Strain Individual differences in spinal cntur, pelvic size and symmetry, and cnnective tissue elasticity make sme peple mre susceptible t repetitive strain than thers. Every muscle has a tendn f rigin and a tendn f insertin. The way these tendns attach t bne and jint structures determines the kind f mvements prduced by that muscle. In a repetitive strain situatin, micr-injuries t strained tendns can evlve int persistent pckets f inflammatin. Small tendn fibers r ligaments attached t bnes in the lwer spinal clumn may tear resulting in bleeding, swelling and tenderness at the site f injury. This type f muscletendn-ligament strain can be the acute result f a specific incident f bending, twisting, r lifting, an injury incurred playing sprts, r an accident f sme kind. In such cases, patients ften describe feeling like smething gave way in their lwer back, fllwed by radiating pain (ften extending t the buttcks, the hip girdle muscles, and back f the thighs). In bth acute and repetitive frms f strain, tendn r ligament irritatin causes the muscle t g int what s called reactive spasm. If the prblem cntinues, the muscle may g int what s called trigger pint spasm Keith Berndtsn, MD 1

3 Trigger pint spasms are the mst difficult type f spasm t treat. If a muscle remains in a state f reactive spasm lng enugh, the mtr neurn that cntrls cntractin and relaxatin f its muscle bundles may get irritated and stuck in a make the spasm even tighter mde. Chrnic trigger pint spasm leads t chrnic myfascial changes in which muscle fibers waste away frm pr circulatin and are replaced by cllagen. This can spread t ther muscles in the area, creating a chrnic reginal myfascial pain syndrme. Trigger pints feel like rpes r knts under the skin. When pressed they can be extremely tender. Trigger pint pain is ften described as a claw dug int a muscle. When a chrnic reginal myfascial pain syndrme spreads t invlve the right, left, upper, and lwer regins f the bdy, the cnditin becmes assciated with interrupted sleep and daily fatigue. If physical examinatin reveals widespread trigger pints (knts) in additin t multiple tender pints (withut knts) in classic lcatins, the cnditin can be called fibrmyalgia. Bth fibrmyalgia and chrnic reginal myfascial pain syndrmes can be debilitating t the pint f interfering with activities f daily living. Risks fr Chrnic Lw Back Strain The lwer back carries all the weight f the trs, and is the mst frequently injured area f the spine. What puts individuals at risk fr lw back pain may include excess bdy weight, nutritinal deficiencies, smking, diabetes, pr muscle tne r lw muscle mass, pr psture, hyper-stretchy ligaments, imprper heavy lifting, pr sleeping psitin, and stress. The effects n quality f life range frm mild t severe. Pinpinting the surce f back pain can be a challenge. If smene reprts chrnic lw back pain in a setting where physical examinatin and imaging studies cannt accunt fr the pain, the pain is ften linked t psychlgical stress. Persistent stress is knwn t amplify the perceptin f pain. In cases f benign persistent lw back pain, psychscial stress predicts a higher likelihd f lw back pain-related disability. 1 Chrnic lw back pain f uncertain cause that is resistant t cnventinal therapies may be mre amenable t integrative therapies and a mind-bdy apprach. In patients with lw back pain fr at least 6 weeks, thse wh received naturpathic care ver a threemnth perid had better utcmes at less cst than thse wh received nly patient educatin and usual care. 2 Ptentially Threatening Frms f Back Pain If the pain is cnstant and unrelenting even with rest r when trying t sleep, r a specific spinal bne seems unusually tender, imaging may be needed t rule ut a serius prblem such as a fracture, tumr, infectin, abdminal artic aneurysm, kidney disease, pelvic inflammatin r tumr, r metablic bne disease such as Paget s Disease r steprsis Keith Berndtsn, MD 2

4 If a nerve rt is invlved yu may reprt a sharp, stabbing, shting pain, the sensatin f pins and needles in the leg, r even weakness f ne r mre muscles invlve in walking. This raises the pssibility f acute r chrnic radiculpathy fancy names fr nerve rt injury r irritatin. Depending n severity, this type f back pain may warrant nerve studies and/r the higher reslutin imaging prvided by an MRI scan. Spinal stensis is an age-related degenerative change in the bnes that make up the spine that results in pain invlving bth legs that gets wrse with walking. The pain can be felt in the upper and/r lwer legs. Sufferers ften find that they can nly take s many steps befre having t sit and rest, which relieves the pain. Smetimes bending slightly frward will reduce pain r allw mre walking distance befre pain starts. An MRI scan is that standard test fr diagnsing this cnditin. Arthritis Ostearthritis is an age-related degenerative change in the sft tissue structures that supprt nrmal jint mvement. Weakened supprt allws excessive play in the jint, resulting in micr-tears and pckets f inflammatin t advanced r numerus fr the immune and hrmnal systems t cntrl and repair. The spinal clumn has ver 200 pints f articulatin that culd be affected by cumulative wear and tear accmpanied by pckets f inflammatin. Uncntrlled inflammatry stearthritis is a serius chrnic pain cnditin that warrants an integrative apprach t assessment and treatment. Ankylsing spndylitis, arthritis f the spine gives rise t inflammatin f the spine and lwer back jints. One early symptm f this cnditin is mrning back stiffness. We advise ur patients nt t get t hung up n diagnstic labels. Our gal is t understand hw each persn became plagued by lwer back pain, and t develp an integrative care plan that is tailred t the uniqueness f that persn s health situatin. Imaging Studies fr Lw Back Pain Evidence indicates that dctrs shuld nt be ding rutine X-rays, CT scans, r MRI scans fr acute lw back pain, r fr lw back persisting fr less than 6 weeks, unless they suspect a ptentially serius underlying cnditin. 3 Ding a series f X-rays, a CT scan, r an MRI scan as a reflexive rutine fr cases f acute r lw back pain des nt imprve clinical utcmes cmpared t usual care unless there are grunds t suspect that a ptentially serius cnditin is causing the prblem. Unless there is reasnable cncern abut a ptentially threatening cause, rutine imaging studies fr acute and sub-acute (nset less than 6 weeks earlier) cases f lw back pain generate pintless expsure t radiatin (in the case f x-rays and CT scans), and pintless expense (in all cases) Keith Berndtsn, MD 3

5 If significant lw back pain persists withut imprvement beynd 6 weeks despite usual care, r if the pain gets prgressively wrse despite usual care, imaging studies shuld be cnsidered. The cnventinal medical apprach: Histry investigates the nature f an injury r repetitive strain, and explres general health status. Physical exam invlves fcused examinatin f nerve and jint functin, muscle spasm, and tender spts. Bld tests and imaging studies are smetimes run t lk fr signs f inflammatin r infectin. Imaging and electrphysilgical studies may include: X-rays prvide detailed infrmatin abut bne structures. They help assess the severity f degenerative changes in the lumbar spinal segments and the sacriliac jints. Muscle ultrasund t assess sft tissues fr evidence f trauma r chrnic inflammatry changes. CT scans prvide a higher reslutin imaging f bnes than X-rays. MRI scans prvide high reslutin images f bne and sft tissue, making them especially valuable when cncerned abut ptentially serius disc r nerve prblems. Nerve cnductin studies and electrmygraphy can help determine whether nerve injury exists, and if s, lcalize the injury t ne r mre specific spinal nerve rts. Treatment emphasizes prescriptin drugs fr pain, and/r md. Cmmnly prescribed drugs include: Pain relievers: nn-steridal anti-inflammatry drugs (NSAIDs) such as naprxen (e.g., Aleve) r ibuprfen (e.g., Advil) are ften prescribed first. If these are nt effective, a dctr may prescribe a shrt-acting narctic analgesic such as tramadl (e.g., Ultram) r hydrcdne with acetminphen (e.g., Vicdin). If back pain becmes chrnic and shrtacting narctic analgesics are needed several times per day t cntrl pain, a dctr may prescribe a lng-acting narctic analgesic such as Oxycntin. Muscle relaxants (such as cyclbenzaprine r carisprll) are als used fr pain related t spasm ften with little thught given t underlying reasns r perpetuating factrs fr muscle spasm. If primary care advice desn t help, referrals may be made t a rheumatlgist, physiatrist, neurlgist, neursurgen, and/r rthpedic specialist Keith Berndtsn, MD 4

6 The integrative medical apprach: Histry investigates the nature f an injury r repetitive strain, and explres general health status frm a systems bilgy perspective. Physical exam invlves fcused examinatin f nerve and jint functin, muscle spasm, and tender spts, while taking int accunt physical signs f underlying metablic imbalance. Physical exam is fcused n tender pints, bld pressure, nutritinal status, muscle tne and reflexes, skin tne, sinuses, thrat, lymph ndes, inflammatin znes, and any ther areas warranted based n the histry. Hyper-stretchy cnnective tissue is als f interest because it predispses t excess strain and premature stearthritic changes. Bld testing may lk fr signs f txicity, inflammatin, r infectin, but may als lk fr markers f neurhrmnal imbalance, nutritinal deficiency, r ther frms f metablic imbalance, t assess a persn s capacity fr a balanced interplay f damage cntrl and restratin systems. Treatment may include prescriptin r ver-the-cunter medicatin, but it emphasizes lifestyle changes and natural therapies and is fcused n restring balance t the metablic systems that, based n histry r exam, appear t have lst their functinal integrity. They include yur systems fr: Digestin and assimilatin f nutrients (ability t break dwn and absrb gd things while keeping bad things ut f the system). Micrcirculatin f bld and lymph (ability t mve xygen and nutritin in, and trash water ut, f tissue znes). Detxificatin (txin detectin, handling, and eliminatin). Restratin (hrmne and neurtransmitter balance). Inspiratin (cnscius and uncnscius brain effects n behavir). Physical therapy, chirpractic adjustment, massage therapy, prper stretching, and exercises t imprve the strength and resilience f the lwer back and hip muscles prduce the best results when attentin is als being paid t issues invlving assimilatin, circulatin, detxificatin, and restratin systems, as well as the critically imprtant desire t get well. Mind-bdy therapy are part f a panel f treatment ptins that include ther mind-bdy techniques fr managing stress: Addressing ptentially maladaptive psychlgical defenses. Learning techniques fr quieting the mind and bdy at will. Meditative practices including cntemplative prayer, yga, and Tai Chi. Varius stretching and breathing rutines Keith Berndtsn, MD 5

7 At nebdymind.cm, we view back pain the same way we view everything else: as a multidimensinal metablic rehabilitatin prject that applies specifically t yu, and that is amenable t sme degree t prper self-care. Our system f self-assessment and care is cnsistent with an emerging understanding f the rigins f chrnic illness that is based n systems bilgy research. We believe that wise self-care methds shuld be part f any plan t get key yur bdily systems wrking better tgether as a team. In sme cases, a well-placed injectin r a carefully executed invasive prcedure will fix the prblem. In mst cases, a metablic rehabilitatin mdel will help the back pain patient achieve mre effective results. An integrative apprach t back pain lks at the unique big picture fr each patient, and cntinually adjusts itself t achieve better results by restring functinal integrity t metablic systems that have fallen ut f balance. References: 1. Discgraphic, MRI and psychscial determinants f lw back pain disability and remissin: a prspective study in subjects with benign persistent back pain. Spine J Jan-Feb;5(1): Cst-effectiveness f naturpathic care fr chrnic lw back pain. Alternative Therapies in Health and Medicine. 2008;14(2): Imaging strategies fr lw-back pain: systematic review and meta-analysis. Lancet Feb 7;373(9662): Keith Berndtsn, MD 6