Back pain - Chronic low back pain - Treatment and management

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Nutrition, Health & Wellness

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

Chronic Sinusitis Treatments - Balloon Sinuplasty

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Nutrition, Health & Wellness

Chronic Sinusitis Treatments

Home > MRI uses, benefits and health risks > Balloon sinuplasty treatment for chronic sinusitis

Chronic sinusitis refers to persisting inflammation of the sinuses and its treatment with recently developed balloon sinuplasty appears promising. Endoscopic balloon sinuplasty procedure is similar to angioplasty and is less invasive than conventional surgical treatments for chronic sinusitis aka chronic rhinosinusitis (CRS).

Balloon sinuplasty procedure for sinusitis treatment helps in improving the normal drainage of the sinus cavities. drainage passages are widened and enlarged  with a small, flexible endoscopic balloon catheter. Unlike the conventional surgical treatment for chronic sinusitis, balloon sinuplasty procedure does not involve bone and tissue removal and has a shorter recovery period.

Picture of a flexible endoscope
attribution: de:Benutzer:Kalumet

What is chronic sinusitis?

• There are small paranasal cavities in the skull on the facial region and they are lined by mucus membrane and are filled with air. 
• Mucus is discharged from these cavities into the nasal passage through ostia (opening). 
• Sinusitis is the chronic inflammation of these cavities. 
• The primary cause of chronic sinusitis is nasal inflammation blocking the mucus drainage, leading to infection, inflammation and pain in these cavities. 
• If the sinusitis persists for more than twelve weeks, it is considered chronic.
• Untreated acute sinusitis can become chronic.

Triggers and predisposing factors for chronic sinusitis.

The predisposing factors and triggers of sinusitis are:

• allergies to environmental pollutants,
• common cold,
• Cystic fibrosis,
• asthma,
• inflammatory disorders,
• seasonal temperature changes,
• viral, bacterial and fungal infections, 
• defective structure of nasal passage like deviated septum,
• nasal polyps blocking the mucus drainage and
• gastroesophageal reflux disease (GERD).

Conventional treatments for chronic sinusitis

Sinusitis is a much prevalent illness, affecting individuals of all age groups. Treatment with anti-inflammatory medicine, painkillers and antibiotics are considered for sinusitis.

Nasal sprays and drops: Saline nasal sprays, corticosteroid nasal sprays or corticosteroid nasal drops are recommended by physicians to clear the blocks of ostia and also to reduce inflammation in the early stages of chronic sinusitis.
Though nasal sprays containing Zinc compounds have been used successfully for sinusitis, FDA has advised against their use. The zinc nasal compounds can damage the sense of smell by permanently damaging the smell nerve endings.

Steam inhalation treatment: Breathing steam has been found useful in treatment of sinusitis controlling inflammation and opening up the blocked ostia.

Antimicrobial treatment: The physician may consider treatment with antibacterial (amoxicillin, doxycycline or trimethoprim-sulfamethoxazole) or antifungal preparations (amphotericin B) if an infection is the cause of chronic sinusitis.

Nasal irrigation: Flushing out the nasal passage with sterile saline water with the help of bulb syringes or neti pots help in relieving the pressure, blockage and pain.

Surgical options

For patients with chronic sinusitis if the response to conventional treatment is not satisfactory, there are two surgical options available.

Functional endoscopic sinus surgery (FESS): FESS is the conventional surgical treatment involving removal of bone and/or tissues to make wide passage for the cavity to drain. This surgical procedure requires hospitalization, rest and a long recovery period.

Balloon sinus dilation (BSD) or balloon sinuplasty: This procedure introduced in 2005 is the latest non invasive method for the treatment of chronic sinusitis. The advantage of BSD lies in minimal anesthetic use, short procedure time and fast return to normal activities.

Equipment for balloon sinuplasty: A flexible endoscope (Rhinoscope or Nasoscope), guide catheter, balloon catheter and irrigation catheter are used while performing this procedure.

Balloon sinuplasty procedure

Ct scan and endoscopic visualization is done prior to sinuplasty.
With endoscopic visualization a guide catheter is introduced into sinus opening.
Once access to the ostium of the cavity under treatment is located, a balloon catheter is positioned into the blocked ostium.
Balloon sinuplasty catheter is inflated for short duration with predetermined pressure.
The sinuplasty balloon is deflated and the catheter is removed after treatment.
If irrigation system incorporated into the balloon sinuplasty catheter, irrigation is activated to flush out the mucus and pus, if any.
If the balloon sinuplasty catheter is not equipped with irrigation system, a separate irrigation catheter has to be inserted to flush out the cavity of its accumulated mucus.

When sinusitis becomes chronic, it is very difficult to avoid recurrences. Taking preventive measures and also early treatment with balloon sinuplasty will go a long way in alleviating the severity of chronic sinusitis.


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