Lumbalgia: Difference between revisions

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* Heat therapy is useful for back spasms or other conditions. A [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain <ref name=pmid16641776>16641776</ref>
* Heat therapy is useful for back spasms or other conditions. A [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain <ref name=pmid16641776>16641776</ref>


* Medications, such as [[muscle relaxants]]<ref name=pmid12804507>{{cite journal | author = van Tulder M, Touray T, Furlan A, Solway S, Bouter L | title = Muscle relaxants for non-specific low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD004252 | year = | id = PMID 12804507}}</ref>, [[narcotics]], [[Non-steroidal anti-inflammatory drugs|non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs)]]<ref name=pmid10796356>{{cite journal | author = van Tulder M, Scholten R, Koes B, Deyo R | title = Non-steroidal anti-inflammatory drugs for low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD000396 | year = | id = PMID 10796356}}</ref> or [[paracetamol|paracetamol (acetaminophen)]].
* Medications, such as [[muscle relaxants]] are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. <ref name=pmid12804507>{{cite journal | author = van Tulder M, Touray T, Furlan A, Solway S, Bouter L | title = Muscle relaxants for non-specific low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD004252 | year = | id = PMID 12804507}}</ref>, [[narcotics]], [[Non-steroidal anti-inflammatory drugs|non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs)]]<ref name=pmid10796356>{{cite journal | author = van Tulder M, Scholten R, Koes B, Deyo R | title = Non-steroidal anti-inflammatory drugs for low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD000396 | year = | id = PMID 10796356}}</ref> or [[paracetamol|paracetamol (acetaminophen)]]. A [[Cochrane Collaboration]] systematic review found that NSAIDs are effective for short-term symptomatic relief in patients with acute low back pain. Furthermore, there does not seem to be a specific type of NSAID which is clearly more effective than others. Sufficient evidence on chronic low back pain is still lacking.
 


* Exercises can be done the patient individually, or under supervision of a professional such as a [[physical therapist]]. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, a [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] found that exercises are effective for chronic back pain, but not for acute pain <ref name=pmid16034851>{{cite journal | author = Hayden J, van Tulder M, Malmivaara A, Koes B | title = Exercise therapy for treatment of non-specific low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD000335 | year = | id = PMID 16034851}}</ref>. One [[randomized controlled trial]] found that back-mobilizing exercises in acute settings are ''less effective'' than continuation of ordinary activities as tolerated <ref name=pmid7823996>{{cite journal | author = Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V | title = The treatment of acute low back pain--bed rest, exercises, or ordinary activity? | journal = N Engl J Med | volume = 332 | issue = 6 | pages = 351-5 | year = 1995 | id = PMID 7823996}}</ref>.
* Exercises can be done the patient individually, or under supervision of a professional such as a [[physical therapist]]. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, a [[meta-analysis]] of [[randomized controlled trials]] by the [[Cochrane Collaboration]] found that exercises are effective for chronic back pain, but not for acute pain <ref name=pmid16034851>{{cite journal | author = Hayden J, van Tulder M, Malmivaara A, Koes B | title = Exercise therapy for treatment of non-specific low back pain. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD000335 | year = | id = PMID 16034851}}</ref>. One [[randomized controlled trial]] found that back-mobilizing exercises in acute settings are ''less effective'' than continuation of ordinary activities as tolerated <ref name=pmid7823996>{{cite journal | author = Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V | title = The treatment of acute low back pain--bed rest, exercises, or ordinary activity? | journal = N Engl J Med | volume = 332 | issue = 6 | pages = 351-5 | year = 1995 | id = PMID 7823996}}</ref>.

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Lumbalgia is the medical term for the more common lay discription of low back pain or lower back pain. It is used to describe a symptom related to the lower section of the human spine. Persistant and recurring low back pain affects 60 - 80% of people at some stage in their life and is the most common reason for lost work.[1]

Low back pain varies in intensity, frequency, duration, and quality depending on the cause and stage of injury or illness as well as the time of day and activity level. It is considered either acute (of recent origin) or chronic (longer term) in nature, though these give little insight as to a particular cause of the pain. The degree of pain ranges from a mild annoyance that comes and goes to constant and totally disabling.

The majority of acute causes of low back pain are grouped as mechanical type injuries to the ligaments, muscles and joints that are responsible for the function of the vertebral column. The injury may be the result of one traumatic event or multiple, repetitive type traumas. If the cause of these mechanical conditions persist, the pain may develop into a chronic low back pain with a change in symptom quality and frequency depending on the type of structures that become affected, such as discs and nerves. These include diagnoses such as osteoarthritis, degeneration of the discs or a spinal disc herniation.

Some cases of low back pain are related to systemic conditions that affect other regions of the body such as rheumatoid arthritis or cardivascular disease, while a small percentage are caused by tumors (including cancer). There are psychological or emotional components of all disease and low back pain is no exception.

Etymology

"Lumbalgia" derives from the Latin "Lumbaris" referring to the lower or loin region of the body and "algia" is from the Greek "algos" for pain.

Background

The low back performs two major functions; to act as a weight bearing column that supports upright posture and to act as a conduit that protects the spinal cord and the tender nervous system that tranmits through it. As a supporting structure, it carries the weight of the upper torso including the head, arms, thorax, and abdominal contents. Impact forces from actions such as walking or jumping multiply these forces exponentially.

The structures of the adult low back consist of the lower five verterbae along with the ligaments, discs and muscles that support it. Together they are identified as the lumbar region of the spine. The range of movement that occurs at the lumbar level is responsible for the majority of the total range of motion necessary for bending. The lumbar spine sits atop the sacrum which is a wedge shaped bone that rests into a space formed by the left and right innominate bones. The innominates are divided into the ilium, ischium and pubis and, with its attached musculature, make up the pelvic girdle that acts to connect the leg to the torso. Together with the sacrum, the left and right innominates wrap around to the lower abdominal region, creating a "bowl" that supports the organs contained within the abdomen. The joint between the sacrum and each innominate (sacroiliac joint) allows for slight motion with walking and bending. The sacrum and innominates together with their supporting ligaments and muscles are referred to as the pelvis. The resulting circle-like formation is commonly called the pelvic ring. For the lay person, the combination of the lumbar and pelvic regions are effectively called the low back. Low back pain can be generated from injury to any or all of the joints, muscles, ligaments or nerves that make up the region as well as organs in the pelvic bowl that get their nerve supply from the low back.

For the purposes of understanding the causes of low back pain, it is important to note that all pain is a perception of the person that is experiencing it. These perceptions are the result of an intricate relationship between the nerve endings that monitor the condition of the tissues and send that information to the higher centers of the brain where the conscious perception actually occurs. The vast majority of the nerve endings are in the ligaments, muscle and outer layer of the disc tissues that support the boney structures. While bones have a thin 'skin' or periosteum that has a plentiful nerve supply, the bones themselves do not. This is also the case of the inner portions of the disc.

Causes

Possible causes of low back pain:

Diagnosis

Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms, such as sciatica, is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an MRI scan or x-ray [1].

Treatment

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. Only a minority (most estimates are 1% - 10%) require surgery.


  • Exercises can be done the patient individually, or under supervision of a professional such as a physical therapist. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration found that exercises are effective for chronic back pain, but not for acute pain [5]. One randomized controlled trial found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated [6].
    • Physical therapy and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine), often learned with the help of a health professional, such as a physical therapist. Physical therapy, when part of a 'back school', can improve back pain [7].
  • Massage therapy, especially from a very experienced therapist, may help. Acupressure or pressure point massage may be better than classic (Swedish) massage [8].
  • Acupuncture has a small benefit for chronic back pain. The Cochrane Collaboration concluded that "for chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and alternative treatments." [11]. More recently, a randomized controlled trial found a small benefit after 1 to 2 years [12].
  • Education, and attitude adjustment to focus on psychological or emotional causes (e.g. TMS)[13]. respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain [14].
  • Most people will benefit from assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc. Although this recommendation has not been tested, this intervention is a part of many 'back schools' which do help [7].

Surgery

There are a number of different types of spine surgery to treat a variety of back conditions. Surgery should be considered if a patient has a significant neurological deficit, or if they fail non-surgical therapy. There is particular concern if back pain is associated with loss of bowell or bladder function and may indicate Cauda equina syndrome or Conus medularis syndrome. Urgent surgical considerations are necessary for these conditions.

Regarding the role of surgery for failed medical therapy in patients without a neurological deficit, a [review http://www.cochrane.org/reviews/en/ab001352.html] by the Cochrane Collaboration concluded that "limited evidence is now available to support some aspects of surgical practice". The ongoing Spine Patient outcomes Research Trial (SPORT) is addressing the role of surgery [15]. Some of the more common forms of surgery are:

  • Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.
  • Laminectomy, removes a portion of the bone to relieve pressure on the spinal nerve from behind.

Treatments with uncertain or doubtful benefit

  • Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain" [2]
  • Bed rest is rarely recommended as it can exacerbate symptoms [18], and when necessary is usually limited to one or two days.

References

  1. ↑ Waddell G, Burton AK(2000) Occupational health guidelines for the management of low back pain at work: evidence review. London:Faculty of Occupational Medicine. PDF version
  2. ↑ 2.0 2.1 16641776 Cite error: Invalid <ref> tag; name "pmid16641776" defined multiple times with different content
  3. ↑ van Tulder M, Touray T, Furlan A, Solway S, Bouter L. "Muscle relaxants for non-specific low back pain.". Cochrane Database Syst Rev: CD004252. PMID 12804507.
  4. ↑ van Tulder M, Scholten R, Koes B, Deyo R. "Non-steroidal anti-inflammatory drugs for low back pain.". Cochrane Database Syst Rev: CD000396. PMID 10796356.
  5. ↑ Hayden J, van Tulder M, Malmivaara A, Koes B. "Exercise therapy for treatment of non-specific low back pain.". Cochrane Database Syst Rev: CD000335. PMID 16034851.
  6. ↑ Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V (1995). "The treatment of acute low back pain--bed rest, exercises, or ordinary activity?". N Engl J Med 332 (6): 351-5. PMID 7823996.
  7. ↑ 7.0 7.1 Heymans M, van Tulder M, Esmail R, Bombardier C, Koes B. "Back schools for non-specific low-back pain.". Cochrane Database Syst Rev: CD000261. PMID 15494995. Cite error: Invalid <ref> tag; name "pmid15494995" defined multiple times with different content
  8. ↑ Furlan A, Brosseau L, Imamura M, Irvin E. "Massage for low back pain.". Cochrane Database Syst Rev: CD001929. PMID 12076429.
  9. ↑ Assendelft W, Morton S, Yu E, Suttorp M, Shekelle P. "Spinal manipulative therapy for low back pain.". Cochrane Database Syst Rev: CD000447. PMID 14973958.
  10. ↑ Cherkin D, Sherman K, Deyo R, Shekelle P (2003). "A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.". Ann Intern Med 138 (11): 898-906. PMID 12779300.
  11. ↑ Furlan A, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. "Acupuncture and dry-needling for low back pain.". Cochrane Database Syst Rev: CD001351. PMID 15674876.
  12. ↑ Thomas K, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell M, Roman M, Walters S, Nicholl J (2006). "Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain.". BMJ 333 (7569): 623. PMID 16980316.
  13. ↑ Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. "Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among working age adults.". Cochrane Database Syst Rev: CD002193. PMID 12804427.
  14. ↑ Ostelo R, van Tulder M, Vlaeyen J, Linton S, Morley S, Assendelft W. "Behavioural treatment for chronic low-back pain.". Cochrane Database Syst Rev: CD002014. PMID 15674889.
  15. ↑ Birkmeyer N, Weinstein J, Tosteson A, Tosteson T, Skinner J, Lurie J, Deyo R, Wennberg J (2002). "Design of the Spine Patient outcomes Research Trial (SPORT).". Spine 27 (12): 1361-72. PMID 12065987.
  16. ↑ Nelemans P, de Bie R, de Vet H, Sturmans F. "Injection therapy for subacute and chronic benign low back pain.". Cochrane Database Syst Rev: CD001824. PMID 10796449.
  17. ↑ Yelland M, Mar C, Pirozzo S, Schoene M, Vercoe P. "Prolotherapy injections for chronic low-back pain.". Cochrane Database Syst Rev: CD004059. PMID 15106234.
  18. ↑ Hagen K, Hilde G, Jamtvedt G, Winnem M. "Bed rest for acute low-back pain and sciatica.". Cochrane Database Syst Rev: CD001254. PMID 15495012.

See also


External links

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