low back pain - a relatively malaysian recent update

1. AN UPDATE

2. INTRODUCTION
Is a MAJOR PROBLEM
PATIENT:
- Cause
- How to deal with it
- Outcome
UNKNOWN!

3. DOCTORS:
- Majority unknown cause
- Difficult to get working ‘cure’
SOCIETY:
- Main cause of work disability

4. CAUSES -VERTEBRAL
BONE
DISC
SOFT TISSUE
Degeneration, Infection, Inflammation, Malignancy,Trauma

5. CAUSES – NONVERTEBRAL
STRUCTURES NEARTO
LOW BACK:
- GIT
- GUT
- Pancreas
- Vascular
- Gynae

6. CAUSES – NON SPECIFIC
- Most common LBP cause
- Poorly localized
- Long periods of no pain
- May reduce with massage, chiropractic or
acupuncture
- No spine pathology

7. - Understanding symptoms
- Good interpretation of signs
EVALUATION OF LBP
Treatment
strategy
- History
- Physical examination
MAIN AIM –TO DETECT RED FLAGS ANDYELLOW FLAGS

8. RED FLAGS
- Possible serious spinal pathology:
- Cauda Equina Syndrome
- Trauma orTumor
- Infection (TB or pyogenic)

9. RED FLAGS - HISTORY

10. RED FLAGS – PHY. EXAM.

11. - Psychosocial factors
- Increases risk of long term
disability and work loss
- Interferes with patient
recovery
YELLOW FLAGS

12. YELLOW FLAGS – FACTORS

13. - Whether more detailed assessment is needed
- Identifications of factors that may require
specific intervention
- secondary prevention of chronic low back pain
YELLOW FLAGS IDENTIFICATION–
LEADSTO:

14. OTHER NEW METHODS IN IDENTIFYING RISK
FACTORS OF LBP:
- Orebro Musculoskeletal Pain Screening
Questionnaire (OMPSQ)
- Core Outcome Measure Index
- DALLAS Pain Questionnaire (DPQ)
- STarT Back Screening Tool
RISK FACTORS

15. INVESTIGATIONS
- Must always be correlated clinically
and should not be interpreted on its
own
- To rule out possible causes (e.g:
infection, degeneration)
- Specialized Ix (e.g MRI) done when
possible surgical intervention is
required (through assessment of Hx
and PE)

16. MANAGEMENT – ALGORITHM

18. 1)PHARMACOTHERAPY:
• Based on type of pain
• Nociceptive – simple, COX-2 inhibitors
• Neuropathic – anticonvulsants, opioids
MANAGEMENT

19. MANAGEMENT
2) INFORMATION:
• To minimize effects of
psychosocial risk factors
• To prevent progression to
chronicity
• Provide info and evidence of
psychosocial contribution in LBP
• E.g: the Back Book

20. 3) THERAPEUTIC PATIENT EDUCATION:
• Self-sufficient in meeting challenges raised
by disease
• Main goal – provide pt with skills they need
• Ensure they remain active longer
• Optimal disease control
MANAGEMENT (updates)

21. 4) FUNCTIONAL RESTORATION PROGRAM:
• Designed to improve physical, psychosocial
and socioeconomic situation via active
involvement of patient
• Multidisciplinary approach
• Delivered during 3 to 5 week hospital stay
• Physical retraining main component
• Work resumption – main goal
MANAGEMENT (updates)

22. 5) COGNITIVE-BEHAVIORALTHERAPY
• Based on idea that belief influences pain
perception
• Methods include:
• Education and information
• Reframing of beliefs
• Acquisition of coping strategies
• Reassurance
• Positive self-affirmations
• Stress management
MANAGEMENT (updates)