What are the important facts about low back pain? No
definitive etiology is found in about 85% of the patients. 90% of patients with
a single episode of low back pain return to work within 6 weeks, and most
patients get better with time. The history of low back pain is the single most
important factor predicting future occupational low back pain. Low back pain is
the second most common cause of work absenteeism. Persistent back pain more
than 6 months constitutes more than 4% of the cases. Disability is closely
linked to compensation and litigation. The least amount of pressure on the disc
is measured with the person lying supine. The highest disc pressure is measured
while sitting and 20 degree forward leaning with 20 kg load in the arm. By
keeping the weight of the load close to the body, this reduces the compressive
forces being placed on the lumbar spine. Yoga activities and exercises
performed during sitting probably have less pressure being placed on the discs.
What are the physical factors that lead to low back pain? Lifting heavy
objects. Holding the load close to the body is important to reduce the
compressive forces being placed on the lumbar spine. Cigarette smoking is another factor. Nicotine
causes disc degeneration, it interferes with the vascularity of the spine and
the nutrition of the discs. Operating motor vehicles, prolonged sitting, lack
of fitness, operating vibrating tools also contribute to low back pain. Sports
related activities can lead to low back pain. One example includes golf. Pain results from twisting and excessive
forward bending and overarching of the spine during the swing. At the age of 40, the average person loses
50% of their rotational movement of the spine. It is important to perform
stretching and warmups before starting the game. Another example of a sport
related activity leading to low back pain is horseback riding. Vibration caused
by horseback riding increases the load on the discs. The back muscles work
constantly to keep you posture straight. Caring for horses could be bad for the
back due to the bending and the lifting associated with their care. The
etiology of low back pain. Virtually any structure in the spine and close to
the spine can hurt, causing what seems to be low back pain. These structures
include facet joints, intervertebral discs, spinal canal/nerve roots,
sacroiliac joints, muscles, ligaments, nerves, hip joint/piriformis syndrome,
and trochanteric bursitis. Red flags for cancer include patients over the age
of 50, pain at rest and at night, unexplained weight loss, history of cancer,
bone destruction involving the pedicle in pathognomonic. Look for the winking
owl sign of the vertebrae. The red flags for infection include diabetes
mellitus, intravenous drug abuse, fever, urinary tract infection, and previous
surgery on the spine. The physical examination includes the initial assessment,
focus on the red flags such as fractures, tumor, infection, or cauda equina
syndrome. Symptoms and signs of cauda equina syndrome are back pain more than
leg pain, bladder or bowel disturbances, bilateral leg pain and weakness,
saddle anesthesia (rectal and genital area sensory changes). In the absence of
red flags, imaging studies are usually not helpful in the first 4-6 weeks. It
is hard to explain to the patient why you did not get an x-ray, although not
getting and early x-ray is a good patient care, but it may lead to suboptimal
patient satisfaction. Intensive work-up may not be necessary in the early
stages of routine low back pain. Conservative treatment of low back pain
include anti-inflammatory medication and muscle relaxants which are usually
helpful, and a soft brace or corset. Physical therapy is an important aspect of
the treatment and should be done as soon as pain control is achieved. The
combination of physical therapy and return to work is important. If a patient
sustained chronic, disabling occupational low back pain without any intensive
rehab, there is a 50% chance of going back to work if the person is out of work
for 6 months. The chance of returning to work drops to 20% if the person is out
of work for 1 year. The chance of returning to work is almost none if the
person is out of work for 2 years. It is important to do therapy and encourage
the patient to go back to work. The best treatment for acute low back pain is
to continue with the ordinary daily activities within the limits permitted by
the pain. The best treatment for low
back pain is for the patient to go back to work.
