Lower back pain ( LBP ) is a common disorder involving muscles, nerves, and spine. Pain may vary from constant pain to sudden sharp feelings. Lower back pain may be classified by duration as acute (pain lasts less than 6 weeks), subchronic (6 to 12 weeks), or chronic (more than 12 weeks). This condition may be further classified by the underlying cause as a mechanical, non-mechanical, or referred pain. Symptoms of lower back pain usually improve within a few weeks from the time they start, with 40-90% of people actually improving for six weeks.
In most episodes of lower back pain, the underlying specific cause is not identified or even sought, with pain believed to be due to mechanical problems such as muscle or joint strain. If the pain does not go away with conservative treatment or if accompanied by a "red flag" such as unexplained weight loss, fever, or significant problems with feelings or movements, further testing may be needed to look for serious underlying problems. In most cases, imaging tools such as X-ray computed tomography are useless and carry their own risks. Nevertheless, the use of imaging in lower back pain has increased. Some lower back pain is caused by damaged intervertebral discs, and straight leg improvement test is useful to identify this cause. In those suffering from chronic pain, pain processing systems may fail to function, causing enormous pain in response to less serious events.
Initial management with non-drug-based care is recommended. NSAIDs are recommended if this is not effective enough. Normal activity should proceed as much as pain allows. Medicines are recommended for a very helpful period of time. A number of other options are available for those who do not improve with regular care. Opioids may be useful if simple pain medication is not enough, but they are generally not recommended because of side effects. Surgery may be of benefit to those suffering from chronic pain and disability or spinal stenosis. No clear benefits were found for other non-specific low back pain cases. Lower back pain often affects mood, which can be enhanced by counseling or antidepressants. In addition, there are many alternative therapeutic treatments, including Alexander's techniques and herbal remedies, but there is not enough evidence to recommend them with confidence. The evidence for chiropractic care and spinal manipulation is mixed.
Approximately 9 to 12% of people (632 million) had LBP at some point in time, and nearly 25% reported having it at some point during the one month period. About 40% of people have LBP at some point in their lives, with estimates as high as 80% among people in developed countries. The most frequent difficulty begins between 20 and 40 years. Men and women are equally affected. Lower back pain is more common in people aged 40-80 years, with the total number of affected individuals expected to increase as the population ages.
Video Low back pain
Signs and symptoms
In general presentation of acute lower back pain, pain develops after movement involving lifting, twisting, or bending forward. The symptoms can begin immediately after the movement or wake up in the next morning. Descriptions of symptoms can range from tenderness at some point to a spread of pain. It may or may not deteriorate with certain movements, such as lifting a foot, or a position, such as sitting or standing. Pain radiating to the foot (known as sciatica) may be present. The first experience of acute lower back pain is usually between the ages of 20 and 40. This is often the first reason someone sees a medical professional as an adult. Recurrent episodes occur in more than half of people with recurrent episodes that are generally more painful than the first.
Other problems can occur along with lower back pain. Chronic low back pain is associated with sleep problems, including more time needed to fall asleep, sleep disturbances, shorter sleep durations, and less satisfaction with sleep. In addition, the majority of those suffering from chronic low back pain show symptoms of depression or anxiety.
Maps Low back pain
Cause
Lower back pain is not a specific disease but a complaint that may be caused by a large number of problems that underlie various levels of seriousness. The majority of LBPs do not have a clear cause but are believed to be the result of less serious muscle or bone problems such as sprains or strains. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture and poor sleeping position can also cause lower back pain. The full list of possible causes includes many less common conditions. Physical causes may include osteoarthritis, degeneration of the disc between the spine or the herniation of the spine, the broken vertebrae (e) (as from osteoporosis) or, rarely, infections or spinal tumors.
Women may have acute lower back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids. Nearly half of all pregnant women report pain in the lower back or sacral areas during pregnancy, because of their posture changes and their center of gravity which causes muscles and ligaments.
Lower back pain can be broadly classified into four main categories:
- Musculoskeletal - mechanics (including muscle tension, muscle spasms, or osteoarthritis); herniated nucleus pulposus, herniated disk; spinal stenosis; or compression fracture
- Inflammation - HLA-B27 associated arthritis including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease
- Malignancy - bone metastases from the lung, breast, prostate, thyroid, among others
- Contagious - osteomyelitis; abscess
Pathophysiology
Back structure
The lumbar region (or lower back) consists of five vertebrae (L1-L5), sometimes including the sacrum. Among these vertebrae are the fibrocartilaginous disc, which acts as a cushion, preventing the spine from rubbing together while at the same time protecting the spinal cord. The nerves originate from and go to the spinal cord through specific openings between the vertebrae, providing the skin with sensations and messages to the muscles. Spinal stability is provided by the ligaments and back and abdominal muscles. Small joints called facet joints limit and direct the movement of the spine.
The multifidal muscle runs up and down along the back of the spine, and it is important to keep the spine straight and stable for many common movements such as sitting, walking and lifting. Problems with these muscles are often found in someone with chronic low back pain, because back pain causes people to use the back muscles incorrectly in trying to avoid pain. Problems with the multifidal muscle continue even after the pain disappears, and may be an important reason why the pain returns. Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program.
The intervertebral disk has a gelatin core surrounded by a fibrous ring. When under normal circumstances, uninjured, most of the disk is not served by the circulatory system or the nerves - blood and nerves just run out of the disc. Special cells that can survive without blood supply go directly to the inside of the disc. Over time, the disks lose the flexibility and ability to absorb physical strength. The decreased ability to handle physical strength increases pressure on other parts of the spine, causing the spinal ligaments to thicken and bone growth developing in the vertebrae. As a result, there is less space in which the spinal cord and nerve roots can pass. When the disk degenerates as a result of injury or disease, the disk arrangement changes: the blood vessels and nerves can grow into the inner parts and/or the herniated disk material can push directly on the nerve roots. Any of these changes can cause back pain.
Pain sensation
Pain is generally an unpleasant feeling in response to an event that is damaging or potentially damaging to body tissues. There are four major steps in the process of feeling pain: transduction, transmission, perception, and modulation. Nerve cells that detect pain have cell bodies located in the dorsal root ganglia and fibers that transmit these signals to the spinal cord. The process of pain sensation begins when the cause of the pain triggers the end of the sensory nerve cells right. This cell type converts the event into electrical signals by transduction. Some types of nerve fibers transmit electrical signals from the transduction cell to the posterior horn of the spinal cord, from there to the brainstem, and then from the brain stem to different parts of the brain such as the thalamus and limbic system. In the brain, pain signals are processed and given context in the process of pain perception. Through modulation, the brain can modify further nerve impulse delivery by reducing or improving the release of neurotransmitters.
Sections of pain sensation and processing systems may not function properly; creating pain when there is no outside cause, indicating too much pain from a specific cause, or indicating pain from a usually painless event. In addition, the pain modulation mechanism may not work properly. This phenomenon is involved in chronic pain.
Diagnosis
Because the back structure is very complex and reporting pain is subjective and influenced by social factors, the diagnosis of indirect waist pain. While most lower back pain is caused by muscle and joint problems, these causes must be separated from neurological problems, spinal tumors, vertebral fractures, and infections, among others.
Classification
There are a number of ways to classify low back pain without consensus that any method is best. There are three common types of lower back pain due to causes: mechanical back pain (including nonspecific muscle strain, herniated disc, compressed nerve root, degenerative disc or joint disease, and vertebral fractures), non-mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and infection), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysms, among others). Mechanical or musculoskeletal problems underlie most cases (about 90% or more), and most (about 75%) have no specific cause identified, but are thought to be caused by muscle tension or injury to the ligaments. Rarely, low back pain complaints are caused by systemic or psychological problems, such as fibromyalgia and somatoform disorders.
Lower back pain can be classified by signs and symptoms. Unstable diffuse pain in response to certain movements, and localized to the lower back without radiating out the buttocks, is classified as
Symptoms can also be classified by duration as acute, sub-chronic (also known as sub-acute), or chronic. The specific duration required to meet each of these is not universally agreed, but generally pain lasting less than six weeks is classified as acute , pain lasting six to twelve weeks is sub-chronic , and over twelve weeks is chronic . Management and prognosis may change based on the duration of symptoms.
Red flag
The presence of certain signs, termed red flags, indicates the need for further testing to look for a more serious underlying problem, which may require immediate or specific treatment. The presence of a red flag does not mean that there is a significant problem. It's just suggestive, and most people with red flags have no serious underlying issues. If there are no red marks, performing diagnostic imaging or laboratory testing within the first four weeks after the onset of symptoms has not been proven beneficial.
The usefulness of many red flags is less supported by evidence. The most useful for detecting fractures are: older age, corticosteroid use, and significant trauma especially if it produces skin signs. The best determinant of cancer presence is the same history.
With other causes put aside, people with non-specific lower back pain are usually treated symptomatically, without proper determination of the cause. Attempts to find factors that might complicate the diagnosis, such as depression, substance abuse, or an agenda related to insurance payments can help.
Testing
Imaging is indicated when there are red flags, sustained neurological symptoms that do not resolve, or ongoing or worsening pain. In particular, early use of imaging (either MRI or CT) is recommended for suspected cancer, infections, or cauda equina syndrome. MRI is slightly better than CT to identify disc disease; both technologies are equally useful for diagnosing spinal stenosis. Only a few useful physical diagnostic tests. Limb straightening tests are almost always positive in those who suffer from herniation. Lumbar provocative discography may be useful for identifying specific discs that cause pain in those with high chronic low back pain levels. Similarly, therapeutic procedures such as nerve blocks can be used to determine the source of specific pain. Some evidence supports the use of facet joint injections, transformative epidural injections and sacroilliac injections as diagnostic tests. Most other physical tests, such as evaluating scoliosis, muscle weakness or wasting, and reflex disorders, are not of much use.
A low back pain complaint is one of the most common reasons people visit a doctor. For pain that has lasted only a few weeks, the pain will likely subside by itself. Thus, if a medical history and a person's physical examination do not show a particular illness as the cause, the medical community advises against performing imaging tests such as X-rays, CT scans, and MRI. Individuals may want such tests but, unless there is a red flag, they do not need health care. Regular imaging increases costs, is associated with higher levels of operation without overall benefit, and the radiation used may be harmful to a person's health. Less than 1% of the imaging tests identify the cause of the problem. Imaging can also detect non-harmful abnormalities, encouraging people to request unnecessary or worried testing. However, MRI scans from the lumbar region increased by more than 300% among US Medicare recipients from 1994 to 2006.
Prevention
Exercise seems to be helpful to prevent lower back pain. Exercise may also be effective in preventing recurrence in those with pain that has lasted more than six weeks. Medium-firm mattresses are more useful for chronic pain than hard beds. There is little or no evidence that the back belt is more helpful in preventing low back pain than education on proper lifting techniques. Shoe soles do not help prevent lower back pain.
Management
Management of lower back pain relies on three general categories where the cause: mechanical problems, non-mechanical problems, or referred pain. For acute pain that only causes mild to moderate problems, the goal is to restore normal function, return the individual to the workplace, and minimize the pain. This condition is usually not serious, heals without much, and recovery is helped by trying to get back to normal activity as soon as possible within the pain limit. Providing individuals with coping skills through certainty of these facts is useful in speeding up recovery. For those with chronic or chronic low back pain, a multidisciplinary treatment program can help. Initial management with non-drug-based care is recommended, with NSAIDs used if this is not effective enough.
Physical management
Increased general physical activity has been recommended, but no clear association with pain or disability was found when used for the treatment of acute episodes of pain. For acute pain, low to moderate quality evidence supports walking. Treatment by McKenzie method is somewhat effective for recurring acute lower back pain, but its benefits in the short run do not seem significant. There is transient evidence to support the use of heat therapy for acute and sub-chronic lower back pain but little evidence for the use of either heat or cold therapy in chronic pain. Weak evidence suggests that the back belt can reduce the number of missed days of work, but nothing indicates that they will help with pain. The therapy of shock and shock waves does not appear to be effective and therefore is not recommended. Lumbar traction is less effective as an intervention for radicular lower back pain.
Exercise therapy is effective in reducing pain and improving function for those suffering from chronic low back pain. It also appears to reduce recurrence rates for six months after completion of the program and improve long-term function. There is no evidence that one particular type of exercise therapy is more effective than the other. The Alexander technique appears useful for chronic back pain, and there is tentative evidence to support the use of yoga. Transcutaneous electrical nerve stimulation (TENS) has not been found to be effective in chronic low back pain. The evidence for the use of shoe soles as a treatment can not be inferred. Peripheral nerve stimulation, minimally invasive procedures, may be useful in cases of chronic low back pain that do not respond to other measures, although the evidence supporting it is not conclusive, and ineffective for pain that spreads to the legs.
Drugs
Management of lower back pain often includes drugs for a useful duration. With the first episode of low back pain, hope is a complete drug; However, if the problem becomes chronic, goals may turn into pain management and function recovery as much as possible. Since pain medication is only effective, expectations about its benefits may differ from reality, and this can lead to decreased satisfaction.
The first usually recommended medication is NSAIDs (though not aspirin) or skeletal muscle relaxants and this is enough for most people. Benefits with NSAIDs; However, it is often small. High-quality reviews have found acetaminophen (paracetamol) to be no more effective than placebo in improving pain, quality of life, or function. NSAIDs are more effective for acute episodes than acetaminophen; However, they carry a greater risk of side effects including: kidney failure, heartburn and possibly heart problems. Thus, NSAIDs are the second choice for acetaminophen, recommended only when the pain is not handled by the latter. NSAIDs are available in several different classes; there is no evidence to support the use of COX-2 inhibitors over other classes of NSAIDs with respect to benefits. With respect to the safety of naproxen may be best. Muscle relaxants may be helpful.
If the pain is not adequately managed, the use of short-term opioids such as morphine may be beneficial. These drugs carry the risk of addiction, may have negative interactions with other drugs, and have a greater risk of side effects, including dizziness, nausea, and constipation. The effects of long-term opioid use for low back pain are unknown. Opioid therapy for chronic low back pain increases the risk of lifetime drug use. Specialist groups advise against the use of long-term opioids for chronic low back pain. By 2016, the CDC has released guidelines for the use of opioids prescribed in the management of chronic pain. It states that the use of opioids is not the preferred treatment when managing chronic pain because of the excessive risks involved. If prescribed, a person and his doctor must have a realistic plan to stop their use in the event of a greater risk than the benefit.
For elderly people with chronic pain, opioids may be used in those whose NSAIDs are at greatest risk, including those with diabetes, stomach or heart problems. They may also be useful for a select group of people with neuropathic pain.
Antidepressants may be effective for treating chronic pain associated with depressive symptoms, but they have the risk of side effects. Although gabapentin and carbamazepine antiseizure medications are sometimes used for chronic low back pain and can relieve sciatic pain, there is insufficient evidence to support its use. Systemic oral steroids have not been shown to be helpful in low back pain. Shared injections and steroid injections into the disc have not been found effective in those with persistent and non-radiant pain; However, they can be considered for those with persistent sciatic pain. Epidural corticosteroid injections provide short and questionable short-term improvement in patients with sciatica but do not have long-term benefits. There are also concerns of potential side effects.
Surgery
Surgery may be useful in those who have a herniated disk that causes pain that radiates to the feet, significant leg weakness, bladder problems, or loss of bowel control. It may also be useful in those with spinal stenosis. In the absence of this problem, there is no clear evidence of the benefits of surgery.
Discectomy (removal of some discs that cause leg pain) can provide pain relief more quickly than non-surgical treatment. Dysectomy has better results in one year but not in four to ten years. Less invasive microsysectomy has not been shown to produce different results than the usual discectomy. For most other conditions, there is not enough evidence to provide recommendations for surgical options. Surgical effects of long-term effects on degenerative disc disease are unclear. Less invasive surgical options have increased recovery time, but evidence of inadequate effectiveness.
For those with localized pain to the lower back due to disc degeneration, fair evidence supporting spinal fusion is similar to intensive physical therapy and slightly better than non-surgical low-intensity measures. Fusion may be considered for those with lower back pain from acquired spinal vertebra that do not improve with conservative treatment, although only a few of those with spinal fusion experience good results. There are a number of different surgical procedures to achieve fusion, with no clear evidence of someone better than others. Adding a spinal implant device during fusion increases the risk but does not provide any additional increase in pain or function.
Alternative medicine
It is unclear whether among those with alternative treatments of non-chronic back pain are useful. For chiropractic treatment or spinal manipulation therapy (SMT) it is unclear whether it improves results more or less than other treatments. Some reviews found that SMT results were similar or improved in pain and function compared to other interventions commonly used for short, medium, and long-term follow-up; other reviewers found it to be no more effective in relieving pain than inert intervention, false manipulation, or other treatments, and concluded that adding TPS to other treatments did not improve outcomes. National guidelines reach different conclusions, with some not recommending spinal manipulation, some describing manipulation as optional, and others recommending short courses for those who do not improve with other treatments. 2017 reviews recommend spinal manipulation based on low quality evidence. Manipulation under anesthesia, or medical assisted manipulation, does not have enough evidence to make a confident recommendation.
Acupuncture is no better than placebo, ordinary care, or false acupuncture for non-specific acute pain or sub-chronic pain. For those with chronic pain, this increases the pain a little more than no treatment and almost the same as the drugs, but it does not help with disability. The benefits of this pain are present only immediately after treatment and not in follow-up. Acupuncture may be a sensible method to try for those suffering from chronic pain that do not respond to other treatments such as conservative care and treatment.
Massage therapy does not seem to provide many benefits for acute lower back pain. The 2015 Cochrane Review found that for acute back pain massage therapy is better than no treatment for pain only in the short term. No effect to improve function. For chronic back pain massage therapy is no better than no treatment for pain and function, although only in the short term. The overall quality of the evidence is low and the authors conclude that massage therapy is generally not an effective treatment for low back pain.
Prolotherapy - the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body's healing response - has not proven effective by itself, although it may be beneficial when added to other therapies.
Herbal medicines, on the whole, are less supported by evidence. Herbal treatments Claw devil and white willow can reduce the number of individuals reporting high levels of pain; However, for those who consume painkillers, this difference is not significant. Capsicum, in the form of gel or plaster, has been found to reduce pain and improve function.
Behavioral therapy may be useful for chronic pain. There are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behavior and improve desired behavior; cognitive behavioral therapy, which helps people identify and correct negative thoughts and behaviors; and conditioning of respondents, who can modify one's physiological response to pain. Medical providers can develop an integrated program of behavioral therapy. Evidence is inconclusive whether stress reduction based on mindfulness reduces the intensity of chronic back pain or related disability, although it suggests that it may be useful in improving the acceptance of existing pain.
The provisional evidence supports neuroreflexotherapy (NRT), in which small pieces of metal are placed just below the skin of the ear and back, for non-specific back pain.
Prognosis
Overall, the results for acute hip pain were positive. Pain and disability usually increase rapidly in the first six weeks, with complete recovery reported 40 to 90%. In those who still have symptoms after six weeks, repairs are generally slower with only a small profit of up to one year. At one year, the level of pain and disability is low to a minimum in most people. Distress, previous lower back pain, and job satisfaction are predictors of long-term outcomes after episodes of acute pain. Certain psychological problems such as depression, or unhappiness due to job loss may extend the episode of back pain. After the first episode of back pain, recurrences occur in more than half of people.
For persistent low back pain, short-term results are also positive, with improvement in the first six weeks but little improvement afterwards. At one year, those with chronic back pain usually continue to experience moderate pain and disability. People at higher risk of long-term disability include those with poor coping skills or fear of activity (2.5 times more likely to have poor outcomes in one year), those with poor ability to cope with pain, functional impairment , poor general health, or a psychiatric or psychological component that is significant to pain (Waddell signs).
Epidemiology
Lower back pain lasting at least one day and limiting activity is a common complaint. Globally, about 40% of people experience LBP at some point in their lives, with estimates as high as 80% of people in developed countries. Approximately 9 to 12% of people (632 million) had LBP at some point in time, and almost a quarter (23.2%) reported having it at some point during the one month period. The most frequent difficulty begins between 20 and 40 years. Lower back pain is more common in people aged 40-80 years, with the total number of affected individuals expected to increase as the population ages.
It is not clear whether men or women have higher levels of lower back pain. The 2012 Review reported 9.6% rate among men and 8.7% among women. Other reviews in 2012 found higher rates in women than men, which reviewers say may be due to higher pain levels due to osteoporosis, menstruation, and pregnancy among women, or perhaps because women are more willing to report pain than men. It is estimated that 70% of women experience back pain during pregnancy with higher rates during pregnancy. Active smokers - and especially those who are teenagers - are more likely to have low back pain than former smokers, and former smokers are more likely to have back pain than those who never smoked.
History
Lower back pain has occurred in humans since at least the Bronze Age. The oldest known surgical treatise - Edwin Smith Papyrus, aged around 1500 BC - describes diagnostic and treatment for spinal spines. Hippocrates (about 460 BC - about 370 BC) was the first to use the term for sciatic pain and lower back pain; Galen (mid-active to the end of the second century AD) illustrates this concept in detail. Doctors until the end of the first millennium are not trying to re-operate and recommend waiting with caution. During the period of the Middle Ages, traditional medicine practitioners provided care for back pain based on the belief that it was caused by the spirit.
At the beginning of the 20th century, doctors thought lower back pain was caused by inflammation or damage to the nerves, with neuralgia and neuritis often mentioned by them in the medical literature at the time. The popularity of the proposed causes declined during the 20th century. At the beginning of the 20th century, American neurosurgeon Harvey Williams Cushing improved acceptance of surgical treatment for lower back pain. In the 1920s and 1930s, new theories about the cause arose, with doctors proposing a combination of nervous system and psychological disorders such as neurological weakness (neurasthenia) and female hysteria. Rheumatic muscle (now called fibromyalgia) is also quoted with increasing frequency.
Emerging technologies such as X-rays give doctors a new diagnostic tool, revealing the intervertebral disc as a source for back pain in some cases. In 1938, orthopedic surgeon Joseph S. Barr reported on cases of sciatica-associated disks increased or recovered by surgery. As a result of this work, in the 1940s, the vertebral disc model of lower back pain took over, dominating the literature until the 1980s, further assisting with the advent of new imaging technologies such as CT and MRI. Discussion eased as research showed disk problems to be a relatively rare cause of pain. Since then, doctors have realized that it is unlikely that a specific cause for low back pain can be identified in many cases and questioned the need to find one at all because most of the time resolve symptoms within 6 to 12 weeks without treatment.
Society and culture
Lower back pain results in large economic costs. In the United States, this is the most common type of pain in adults, responsible for the large number of missed work days, and is the most common musculoskeletal complaint seen in the emergency department. In 1998, was estimated to be responsible for $ 90 billion in annual healthcare costs, with 5% of individuals raising most (75%) of the cost. Between 1990 and 2001 there was more than double the increase in spine fusion surgery in the US, although in reality there was no change in indications for surgery or new evidence of greater utility. Further costs occur in the form of lost income and productivity, with low back pain responsible for 40% of all missed work days in the United States. Lower back pain causes disability in a greater percentage of labor in Canada, the UK, the Netherlands and Sweden than in the US or Germany.
Workers who experience acute hip pain as a result of work injuries may be required by their company to perform x-rays. As in other cases, testing is not indicated unless there is a red flag. The employer's concern about legal liability is not a medical indication and should not be used to justify medical testing if not indicated. There should be no legal reason to encourage people to perform tests that are not determined by health care providers.
Research
Total disk replacement is an experimental option, but there is no significant evidence to support its use of lumbar fusion. Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human growth factors, planted substances, cell therapy, and tissue engineering.
References
External links
- Back and backbone in Curlie (based on DMOZ)
Source of the article : Wikipedia
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