LOW BACK PAIN

Low back pain (LBP) will afflict some 90% of people over their lifetime. Most LBP responds to conservative management, however the pathophysiology is poorly understood and a precise diagnosis is difficult.

DIFFERENTIAL DIAGNOSIS:

• Intervertebral disc disease (herniation-degeneration)
• Osteoarthritis (spine and facet joints)
• Osteoporosis
• Spondylolisthesis
• Spinal stenosis (congenital or acquired)
• Inflammatory disease
• Fractures or trauma
• Infiltrative disease (infection or malignancy)
• Scar tissue formation
• Muscle strain or spasm
• Psychogenic pain

HISTORY:

• Pain (onset, duration, location and radicular)
• Occupational and recreational activity
• Neurologic symptoms (sensory, motor, radiation)
• Psychosocial factors

CLINICAL FINDINGS:

• Neurologic examination (gate, walking on toes and heels, muscle strength,  tendon reflexes, sensation; touch, pinprick, vibratory)
• Posture, range-of-motion, muscle flexibility
• Point tenderness (spine, muscles, tendons, sacroiliac joints)
• Pelvic pain (perianal sensory loss, pelvic visceral dysfunction loss of anal tone)

TESTS:

• Radiographs reveal (fractures spondylolysis, degeneration, lytic lesions)
• Bone scan (inflammation and infiltration)
• CT scan 
• MRI (can give myelogram-like information)
• Electromyography (EMG) (peripheral nerve function)
• Myelogram (recommended only when MRI not available)
• Spinal endoscopy diagnostic (scare tissue formation; nerve root inflammation and entrapment; abnormal disc etc.) 
• Blood tests ( Sedimentation rate, screens for inflammation and chronic infection, rheumatologic disease)

MANAGEMENT:

Management includes medication, physical therapy, exercise, epidural steroid injections (ESI), spinal endoscopy, and lastly surgery (1to 3%)

Pharmacologic Therapy

• Nonsteroidal anti-inflammatory medication (use on regular basis)
• Acetaminophen (use on regular basis)
• Antidepressants (Amitriptyline etc..)
• Anticonvulsants ( Carbamazine, Gabapentin, etc.) for neuropathic pain.
• Epidural Steroid Injections (ESI)
• Spinal endoscopy with lysis of adhesions and application of medication
• Oral steroids (short term)
• Narcotics (for severe pain and short term)

Physical Modalities

• Physical Therapy

• Therapeutic exercise

• Passive 
• Active
• Resistive
• Mobilization

• Thermotherapy

• Moist heat
• Ultrasound

• Electrotherapy

• Electrical therapy
• Ionophoresis

• Rehabilitation Program

• Back Strengthening 
• Conditioning

Activity  - Rest only short term up to 48 hours. Low Back Pain Exercises (important)

• Goals of Exercise

• Decrease pain
• Stretching muscles
• Improve posture
• Increase strength
• Decrease mechanical stress
• Stabilizing segments
• Improve mobility
• Improve general fitness

• Indications

• Acute low back pain
• Pain associated with posture
• As part of general rehabilitation
• Fibrositis or fibromyalgia syndrome
• Chronic low back pain

• Types of exercise

• Mobility and strengthening

• Low back stretch
• Full spinal stretch
• Heel cord stretch
• Hamstring stretching
• Hip flexor stretching
• Back rotation

• Flexion exercises

• Knee to chest
• Curl-up

• Extension exercises

• Prone semi push-up
• Standing backward bending

Patients should take an active part in their rehabilitation and "control their pain not let pain control their lives". Patient education should include reassurance by physician, family and friends. The patient should modify the  workplace to relieve back stress. If over weight, should be encourage to return to normal weight, stop smoking, resolve psychosocial problems and engage in a lifelong fitness program.