Blogs Details

Lower back pain

Public Health
13-Sep-2017
Blogs Detailed

The low back pain in the young and middle-aged people is characterized by “so-called low back pain,” or non-specific low back pain in which the cause is difficult to identify, that is more common compared with other age groups. These people must maintain a high degree of activity of daily life at the time when the ageing-related changes in the lumbar spine and tissues surrounding the lumbar spine start to occur, thus creating a gap between social needs and physical capabilities.

 

Nonspecific low back pain must often be diagnosed based on exclusion, and it is important in particular to differentiate serious diseases such as spinal tumour and infectious spine diseases. The onset of nonspecific low back pain involves various factors, and socio-psychological factors may also be involved as an important cause, besides structural and physiological abnormalities in the lumbar region

 

The frequency of low back pain increases as age advances, and its prevalence in the elderly population of age 40 and older is as high as 20 to 40%. On the other hand, the prevalence of low back pain is about 10 to 25% in the age group from the late teens to age 40.People in this age group are highly active in daily life and are exposed to various stresses. Due to these circumstances, therefore, low back pain in this age group is characterized by non-specific low back pain without any clear-cut diagnosis being specified.

 

Low back pain from the lumbar spine can be classified into the following three categories:

(1) Nonspecific low back pain,

(2) Radicular pain, and

(3) Pain due to serious spinal lesions

Low back pain whose cause is difficult to identify is called nonspecific low back pain, and in young and middle-aged people it is characterized by more frequent nonspecific low back pain, compared with other age groups.

 

Pathology-  

Acute low back pain often occurs due to injury related elements such as minor change of body position, lifting something carelessly in a half sitting position.Also, small repeated movements, which even patients themselves do not notice, sometimes cause acute low back pain.

On the other hand, chronic low back pain is often due to structural or physiological fragility in the lumbar part. These cause pain in the lumbar spine and surrounding tissues, which is the pathology of nonspecific low back pain.Nonspecific low back pain does not involve nerve root symptoms or cauda equina symptoms, nerves other than spinal nerve roots, which are sinuvertebral nerve, grey rami, medial branches, and lateral branches, are considered to be related to nonspecific low back pain.

 

Diagnosis

An important point in diagnosis is to differentiate a serious disease without missing it. Serious spinal diseases are spinal tumour and infectious spinal diseases. As diseases in other fields besides orthopaedics, a lesion in an organ that exists in the retroperitoneum (kidney, urinary duct, and pancreas), or a lesion in the uterus or the ovary in a female patient, can be accompanied by low back pain. Serious diseases include a malignant tumour in the above mentioned retroperitoneal organs, abdominal aneurysm, and metastasis of gastrointestinal cancer to the lumbar spine. These diseases should be kept in mind while making a differential diagnosis.

 

History taking-

It is important to ask for details on the onset of the low back pain, and about the presence of disorders in regions other than the lumbar region, such as the abdomen, reproductive organs, and urinary organs.In particular, confirmation of the presence of low back pain at rest is important.When low back pain is present regardless of rest or movement, it should be considered diseases of internal organs.

When pain is present in a lower limb in addition to low back pain, there is a high possibility of radicular pain instead of nonspecific low back pain. Also, as to chronic low back pain, it is important to ask patients’ social background, such as the family environment, employment status, and the kind of work. Regarding the medical history, it is necessary to confirm history.of injuries, subscribed steroids, the presence of motor palsy, etc.

Physical findings- 

It is important to examine not only the lumbar region but also the entire body. Locally, root symptoms and cauda equina symptoms should be checked. Tests should be conducted on muscle strength of the lower limbs, deep tendon reflexes, perception disorder, and the straight leg raising (SLR) for assessing the tension state of nerve roots.

Tests-

Imaging and Blood tests are only useful to rule out any specific cause for the back pain.

Treatment for Acute Non-Specific Low Back Pain

Symptomatic therapies are the mainstay of treatment, such as local heating/cooling, administration of analgesics, or nonsteroidal anti-inflammatory drugs (NSAIDs).

Conventionally, rest has been considered the best measure for an attack of acute low back pain. Currently, however, giving guidance onto continuing normal activities as much as possible, though a few days’ rest may be necessary in some cases, is said to prevent the acute pain from becoming chronic and eventually to speed up social rehabilitation.  It is now also said that long-term bed rest causes chronic disorder and makes rehabilitation more difficult.

Therefore, it is not necessary to force bed rest, unless the patient is in severe pain. When bed rest is needed, a posture to reduce lumbar lordosis should be taken. In either a supine position or a lateral decubitus position, the patient should rest with the hip joints and knee joints bent. In the supine position, a pillow or the like is needed under the knees.

It is reported that 80 to 90% of acute nonspecific low back pain usually heals within six weeks. Because low back pain is a self-limited disease, if the symptom does not improve even after three or four weeks, further tests are needed to check for a potentially serious disease and to find out the cause of the pain.

Treatment for Chronic Non-Specific Low Back Pain-

Generally, low back pain that lasts more than three months is called chronic low back pain. Specifically, the causes are considered to be a weakness of the lumbar spine and muscles surrounding the lumbar spine, which maintain alignment (position and compatibility) of the entire spine, resulting in failure to maintain appropriate posture, instability of the lumbar spine, and excessive burden on muscles and fascia surrounding the lumbar spine.

Also, risk factors for making acute nonspecific low back pain chronic can be socio-psychological issues, such as complaints at work, financial problems, and legal problems, even more than clinical factors.Therefore, the treatment that includes guidance on daily life and psychological approaches is needed.

 

Guidance of daily life/Life style Modification-

A-When lifting a heavy object, the load to the posterior lumbar spinal soft tissues should be reduced by bringing the object as close to the body trunk as possible and shortening the distance between the lumbar part to the object.

B-For a type of job that requires sitting for long hours, it is recommended to make the knee height higher than the buttock height, or to sit with the knees crossed, to reduce lordosis of the lumbar spine.

C-In a standing posture, a footstool should be used to prevent excessive lordosis and to reduce muscle fatigue, because this can reduce lordosis of the lumbar spine and the burden on lumbar muscles by keeping the pelvis horizontal.

 At any rate, the basic caution is to avoid keeping any one posture for long hours.

 

Drug Treatment-

NSAID and muscle relaxant for short duration.Insufficient sleep leads to unhealthy feeling, which can sometimes prolong the period of low back pain. Adequate sleep at night is important, and administration of a sleeping pill is also important if there is a sleep disorder.

Physiotherapy-

Not clear if they are effective for chronic back pain and if they change its natural course.

Exercise -

The purposes of exercise for low back pain are:

 (1) improvement of improper posture,

 (2) strengthening of the abdominal muscles and muscles of the back, and

 (3) acquiring flexibility of the soft tissues.

Special Therapy-

Nerve blocks if the cause is identified.For example, if blocking of posterior medial branches seems effective for chronic low back pain, it is necessary to consider percutaneous cauterization, etc., of their nerve, as a choice of the treatment

 

Conclusion-

Nonspecific low back pain involves many factors. Not only structural and physiological abnormalities in the lumbar region but also socio-psychological factors can be a major cause. Complex factors comprising of obesity, overwork, lack of exercise, and mental stress can induce low back pain as a complaint.Since nonspecific low back pain in young and middle-aged people must often be diagnosed by exclusion, a solid differential diagnosis should be performed. In my view, in responding to, the complaint of low back pain, tackling this disease by grasping the whole picture of the patient’s life, from the standpoint of a living function-related disease, instead of merely providing anti-inflammatory analgesics, leads to early social rehabilitation.

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