Back pain - Chronic low back pain - Treatment and management

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Chronic low back pain

Home > Back pain - Chronic low back pain - Treatment and management

Lower back pain is a common health problem and nearly 80% of adults experience it at some point in their life. Low back pain is a skeletomuscular disorder and it is considered chronic if it persists for more than twelve weeks. Without proper treatment the pain tends to become chronic.

Most of the causes of chronic low back pain (CLBP) are neuromusculoskeletal disorders like wrong posture, sprain in the lower back muscles, strain of soft tissues, slipped disc (herniated, or ruptured disc), sciatica ( sciatic neuritis) degenerative discs, spinal stenosis, fractures, trauma, skeletal irregularities, scoliosis, kyphosis, lordosis, osteoarthritis and osteoporosis.

Chronic lower back pain treatment options

image of lumbar region
site of chronic low back pain

The options are physical, medical, and surgical methods. The focus is on causative factors, relevant pathoanatomy and pain generators and their alleviation and removal. Generally the options are non-invasive methods like initial rest, medication and exercise. In the case of traumatic injury, structural damage or structural irregularities surgical options may be resorted to.

Bed rest for chronic LBP

Immediate bed rest for less than two days helps in the lessening of chronic pain and inflammation. However bed rest for longer period does not have increased benefits. Prolonged bed rest can be counterproductive. In fact prolonged bed rest can have deleterious effects by weakening the supportive muscles and leading to progressive hypo mobility of joints and prolonged recovery.

Physio-therapeutic treatments

Physiotherapy comprises a mixture of any of the methods like interferential treatment, laser, lumbar supports, shortwave diathermy, therapeutic ultrasound, hot/cold packs, traction, transcutaneous electrical nerve stimulation (TENS), massage and mobilization Though there may be marginal momentary reduction in low back pain there are no long term positive effects and advantages.

Exercise treatment

Exercises aimed at strengthening, endurance and flexibility
show lasting improvement in chronic low back pain reduction and function. These exercises do not require expensive training equipment. Muscle strengthening, muscle conditioning, aerobic, flexion, Alexander Technique and McKenzie exercises may be tried as per the preference of both the patient and therapist.

Chiropractic spinal manipulation and spinal mobilization

Manual treatment comprises spinal manipulation and spinal mobilization  The spinal manipulation is small amplitude high velocity thrust technique. It is usually a rapid movement beyond the movement range of the affected back joint. The patient has no control over the manipulation and the technique is prone to complications if done by persons lacking expertise.

Spinal mobilization is use of passive low-velocity movements to give mobility to a joint. Excluding movements that would further strain the lower back, mobilization within the limits of low back pain aids recovery. Mobilization techniques show improvement in pain reduction, motor activity and sympathetic nervous system activity. As the patient has control over the movement, this technique is considered as far safer to manipulation technique.

Pharmacological treatments for chronic LBP

Non Steroidal Anti Inflammatory Drugs (NSAIDs) are widely prescribed for their pain-killing potential and also for their anti-inflammatory action. The side-effects of NSAIDs are gastrointestinal complications like irritation, gastric ulcers and intestinal bleeding. Some NASIDs like rofecoxib have serious long-term effects like increases cardiovascular risk. Hence for long term use individual case has to be monitored.

Noradrenergic and noradrenergic-serotonergic antidepressants have been found to be moderately effective in reducing chronic pain in CLBP patients and quite effective when used as co-medication with NSAIDs. In patients with kidney diseases, glaucoma, chronic obstructive pulmonary disease and heart failure antidepressants should be avoided. Pregnant patients with chronic pain should not be given antidepressants without closely monitoring their health.

Opioid are short-term treatment for pain and disability in chronic low back pain. Weak opioid are prescribed only for short-term treatment as there is the risk of development of dependence and addiction. To avoid addiction, slow release opioid can be given.

Muscle relaxants like benzodiazepines are used for the short-term reduction from pain. However they have the side effects like allergy, addiction, drowsiness, dizziness and impaired liver function in the long run.

Capsicum pain plasters have capsaicin from chilli peppers which reduces low back pain. Hence application of capsicum pain plasters is an effective short-term treatment for CLBP.

Surgical treatments

Surgery for pain reduction is resorted to when all other conservative treatments have become ineffective in reducing of pain.
Surgical treatments for chronic low back pain include lumbar microdiscectomy, discectomy (involving partial or complete excision of an intervertebral disk), laminectomy (removal of portion of the vertebral bone called the lamina), foraminotomy (performed to reduce the symptoms of nerve root compression), disc replacement surgery or spinal fusion.

Spinal fusion surgery is considered in case of degenerative disc disease, facet joint degeneration or spinal instability and it aims at obtaining solid fusion of two or more affected vertebrae to give stability. As spinal fusion surgery has high rate of complications it may be performed only if the CLBP persists for more than two years and also in case of failed conservative treatments and severe pain.
 

Other alternative treatments

Back school is a combination of education and skill program aimed to lower the chronic LBP. There are some short-term positive results. However there may not be any long-term benefit.
Brief educational interventions to promote self treatment by the patient can be given by the physiotherapist or physician to reduce disability and sickness. Brief educational interventions should provide reassurance and positive messages that encourage the patient to return to normal activities.
Cognitive-behavioral treatment methods are effective for chronic pain, functional status and behavioral outcomes.
Intensive multidisciplinary biopsychosocial rehabilitation treatment program consisting of combination of physical, pharmacological, vocational, and behavioral components are very effective in alleviating the chronic LBP and improving the functionality, especially in patients who have failed mono-disciplinary treatment options.
Neuro-Reflexotherapy has been effective in the treatment of chronic low back pain. Short-term treatment can be taken up to lower chronic pain.
Percutaneous electrical nerve stimulation (PENS) are effective in reduction of chronic low back pain.

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Image source:
http://en.wikipedia.org/wiki/File:Lumbar_region_in_human_skeleton.svg
Image author: LadyofHats Mariana Ruiz Villarreal
License: public domain

References:
1.http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
2.Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults. Cochrane Database Syst Rev. 2003;(2):CD002193.
3.http://www.musculoskeletalnetwork.com/pain/content/article/1145622/1507555
4.http://www.backpaineurope.org/web/files/WG2_Guidelines.pdf

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Chronic low back pain - Treatment

Back pain from heavy backpacks - Prevent back pain in children

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Back pain from heavy backpacks

Home > Knee pain remedies > Prevent back pain in children - Back pain from heavy backpacks.

Back pain is becoming a common health problem in children and carrying heavy backpacks increases the risk many fold. To prevent the risk of chronic back pain, children must be taught not to get backpacks heavy and also shown the correct way of carrying them. Any persistent back pain complained by children, even without lifting anything heavy, should be evaluated by medical professional, as it could be due to some serious health issue with muscles or vertebrae in the back or internal organs.

Health risks in carrying heavy backpacks

Initially the back pain due to strain of back muscles could be of short duration, which can be resolved with rest and reduced activity. Apart from straining the muscles of the back, neck and shoulder, carrying heavy backpacks prevents proper development of still-forming bones and muscles in children. Carrying heavy weight can put unnatural heavy stress on the young vertebral column and rib cage. Prevent distortion of the natural curve of the middle and lower back as otherwise it can lead to chronic pain and scoliosis.

Illustration of lumbar region
lower back pain

There are conflicting views by the medical community to prevent the possibility of development of back pain in children due to carrying heavy backpacks. Our common sense should prevail and we have to prevent the risk and pain involved in their carrying disproportionate amounts of heavy weight.

What experts say about heavy backpacks.

American Chiropractic Association (ACA), an association of health care professionals concerned to diagnosis treat and prevent of disorders of the neuromusculoskeletal system, has offered certain tips and advice on the use of heavy backpacks by children at http://www.acatoday.org/content_css.cfm?CID=65.

Skaggs DL el al, (of Children's Orthopaedic Center, Children's Hospital Los Angeles, and the Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA), in a population-based study of a sample of 1540 school-goers aged 11-14 years, have arrived at certain findings. They found that back pain is associated with use of a heavy backpack and that it is more prevalent in younger children and in girls. Their carrying heavy weights seemed to be directly proportional to the likelihood of back pain.

Paloma Rodríguez-Oviedo et al in their short research report (2011) concluded that carrying heavy backpacks increases the risk of back pain and possibly the risk of back pathology. The prevalence of school children carrying heavy backpacks is extremely high. Educational activities should be implemented in this age group to prevent them from carrying heavy weights.

Tips to prevent back pain in children from heavy backpacks.

• Backpack must not be heavy and the overall weight of the backpacks must not exceed the 10% of the body weight of the children.
• Heavy backpacks make the children to bend forward to support the weight on their back instead of shoulders.
• Weight must be evenly distributed on both the shoulders by proper strapping.
• Multiple dividers help in keeping the books in place prevent abrupt shifts disturbing the balance.
• Placing heavy books closer to the back distributes the weight to shoulders.
• A padded back is more comfortable and prevents poking by notebook edges, pens, pencils and rulers.
• The straps must be adjustable, padded, wide and placed apart to prevent pinching or squeezing of the shoulder or neck region.
• Tight and narrow straps dig into shoulders and neck, pinch nerves and prevent proper blood circulation.
• Both the shoulder straps should be used to prevent disproportionate shift of heavy weight to one side.
• Carrying the bag by hand or using one shoulder strap can lead to posture problems and scoliosis.
• Children must be encouraged to wear waist belt, as it helps in even distribution of weight.
• The correct size of the bag is of importance to prevent stuffing and making it heavy.
• Low hanging backpack makes the user to lean forward shifting the weight to back.
• It should be strapped so that it does not hang more than 3-4 inches below the waistline.

Although roller packs are comfortable, they become a bother while lugging them on stairs and also can become a tripping hazard to other students. Introduction of e-textbooks and educational software may reduce the burden and prevent back pain in children by not requiring to carry heavy backpacks.


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Prevent back pain in children due to heavy backpacks.

References:
1. American Chiropractic Association (ACA) topic on how to prevent carrying heavy weight by schoolgoers. (http://www.acatoday.org/content_css.cfm?CID=65).
2. Skaggs DL, Early SD, D'Ambra P, Tolo VT, Kay RM. Back pain and backpacks in school children. J Pediatr Orthop. 2006 May-Jun;26(3):358-63. PMID:16670549.
3. Paloma Rodríguez-Oviedo1, Alberto Ruano-Ravina2,3, Mónica Pérez-Ríos2, Francisco Blanco García4, Dorotea Gómez-Fernández1, Anselmo Fernández-Alonso1, Isabel Carreira-Núñez1, Pilar García-Pacios1, Javier Turiso5. Short research report. School children's backpacks, back pain and back pathologies. Arch Dis Child doi:10.1136/archdischild-2011-301253.