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Low back ache
Capt Pramod
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Introduction
First, we will discuss the medical model:definition,
incidence,
aetiology,
diagnosis, and treatment.
Secondly we will look at prevention andthe Back Pain exercises
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IntroductionBack pain is one of the most commonailments of mankind. An estimated 80percent of people will experience backpain at some point in their lives, andslightly more men suffer from it than
women
Potent cause of absence from work
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What is spine, anatomically?
Bunch of joints (cushioned)
Designed for mobility and movement
Kinetic chain
Provide structural support for the upper body
Protection of the spinal cord
Shock absorber for the brain
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Lumbarvertebrae
Musclesof thepelvis
VertebraeDisk
SI JOINT
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Causes
Musculoskeletal
Degenerative
Rheumatic
Neoplastic
Referred
Infection
PsychologicalMetabolic
Traumatic
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Musculoskeletal
Ligamentous
Muscular
Facet jointSacroiliac strain
Prolapsed disc
FractureScoliosis
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Degenerative
Osteoarthritis
Spondylosis
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Rheumatic
Rheumatoid Arthritis
Ankylosing Spondylitis
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NeoplasticPrimarySecondary
Prostate
Lung
Renal
Breast
Thyroid
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Referred PainGynaecologicalRenal
Other abdominal
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Infection
TB
Osteomyelitis
Herpes Zoster
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Psychological
Depression
Malingering
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Metabolic
Osteoporosis
Pagets
Osteomalacia
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History
Sometimes a clear cause but often not
In a young, fit person then usually:
muscle or ligament strain
facet joint problem
prolapsed disc
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Muscle or ligament strain
Usually can give you the cause
Related to posture
EpisodicPain worse on movement, helped by rest
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Facet Joint
Sudden backache with a simplemovement I was just picking up a coin off
the floor
Often flexion with rotation
May have heard a click
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Prolapsed Disc
Shooting pain
Pain radiating downthe leg below the
kneeAggravated bycoughing/sneezing
Usually sudden onsetand often no trauma
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Red Flags in the History
Retention of urine or incontinence
Onset over age 55 or under 20
Symptoms of systemic illness - weightloss, fever
Morning stiffness
Severe progressive painA prior history of cancer
Intravenous drug use
Prolonged steroid use
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Examination
Observation
Palpation
MovementsStraight leg raising
Femoral stretch test
PowerSensation
Reflexes
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Dermatome
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Investigations
For simple backache, age 20-50
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Investigations
Plain x-ray with FBC and ESR to rule outtumour, infection if red flags suggest likely
If red flags present and plain x-ray normalthen bone scan, CT or MRI may still beindicated
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Imaging
Plain x-rays AP and lateral views
Oblique views
PA view of S.I. JointComputed tomography (with mylography)
MR imaging
Radioisotope scanningDiscography and facet joint arthrography
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Chronic low back pain
Pain that persists after 3 months
< 5% of patients with L.B.P develop
Ch.L.B.PMultiple factors Disc, facet joints, annulus fibrosis, ligaments
Psychosocial factorsSurgery is rarely helpful
Functional restoration programme
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Acute disc prolapse
Uncommon in very young and the very old
Nerve root pain follows the dermatome of
the involved nervePain is generally worse in the leg than inthe back
Exacerbation of leg pain by straining,sneezing or coughing
Localised neurological signs
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Cauda Equina Syndrome
Large midline discprolapse
Compresses several
nerve rootsSphincter disturbance
Saddle anaesthesia
Prompt surgicalintervention
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Treatment acute disc prolapse
Conservative
Bed rest for 48-72 hours
NSAIDs
Epidural steroids
85% relief rate
Surgical treatment
10-15% of patients ultimately require surgery More rapid relief but the ultimate end point is the same
regardless of treatment
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Spinal Stenosis
Commonest cause ofneurologic leg pain inolder patients
SymptomsNeurogenicclaudication -Vascular claudication
Treatment
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Spondylolysis
Spondylolysis
Also known as pars defect
Also known as parsfracture
With or withoutspondylolisthesis
A fracture or defect in thevertebra, usually in theposterior elementsmost
frequently in the parsinterarticularis
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Spondylolisthesis
Forward slippage of onevertebral body on another
Causes
Congenital Isthmic
Traumatic
Pathologic
Degenerative
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Spondylolisthesis
Forward slippage of onevertebral body on
another
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Discitis
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Spinal Deformity
Deformity may occur in either coronal or sagittal plane
Scoliosis - Lateral curvature of the spine
Structural
Nonstructural
Kyphosis - Sagittal plane deformity in the thoracic orthoracolumbar spine
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Scoliosis
Idiopathic Scoliosis
80% of all scoliosis
Adolescent - age 10 or overJuvenile - age 4 to 9
Infantile - age 3 or under
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Scoliosis - Cobb angle
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Adolescent idiopathic scoliosis
Structural scoliosis presenting at or about the onsetof puberty and before maturity
80 % of cases of idiopathic scoliosisMostly (90%) in girls
Predictors of progression
very young agemarked curvature
Risser sign
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Neuromuscular scoliosis
CausesPoliomyelitis
Cerebral palsy
SyringomyeliaFriedrichs ataxia
Muscular dystrophies
Typical paralytic curve is long, convex towards
the side with weaker muscles
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Kyphosis
Postural (Round back)
Compensatory
Structural
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Scheuermanns disease
Excessive thoracic kyphosis (Cobb angle >45with wedging of 5 or more) of at least 3
adjacent apical vertebrae and vertebral endplate irregularities
Aetiology unknown
Incidence 1% of general population
with slight femaledominance
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Scheuermanns disease
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Scheuermanns disease
Treatment
Orthotic treatment
Skeletally immature - Milwaukee brace(poor compliance)
Surgical
Severe deformity in skeletally mature
Severe deformity and neurologic signs
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S curvePOSTURE:
The neck has a slightnatural curve, which sitson top of the two curves inthe middle and lower back.
Correct posture maintainsall three curves andprevents undue stress and
strain by distributing bodyweight evenly
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STANDING POSTURE
In correct, fully erect posture,a line dropped from the earwill go through the tip of theshoulder, the middle of thehip, the back of the kneecap
and the front of theanklebone.
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SITTING POSTURE
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SITTING POSTURE
When sitting in anyposition, the threeback curves need tobe maintained.
If you cannot sitwithout slouchingforward or backward,you need to supportyourself with hands
and arms or leanagainst a wall orchair back.
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SITTING POSTURE
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SITTING POSTURE:
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LYING POSTURE:
Avoid proppinghead or upper body
up on an arm andhand.
Head shouldremain relaxed.Legs should betogether.
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Th 5 L f Lifti
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The 5 Ls of Lifting
L1, LoadAlways test the weight of the loadbefore lifting. get help.L2, Lungs, inhale,and as you lift, breath out
through pursed lips.L3, Leverload close to you body,thereby reducing the lever effect.
L4, LegsAlways use your legs and not yourback while lifting.L5, LordosisMaintain the hollow (S curve) inyour back throughout the lift.
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BackacheEXERCISES:
Cat Back
Fetal Position
Arm exercises
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Alternate LegSlides
Alternate LegRaises
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RELIEVE STRESS
Yoga
Meditation
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SURGERY
Only considered if:
Conservative management fails
Patient develops neurological deficits(weakness, numbness, change in reflexes)
Diskectomy
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Diskectomy
the removal of aherniated disk torelieve pressure on anerve root
Window in the lamina-retract nerve-removalof herniated discmaterial-healing by
scar tissue
Laminectomy
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Laminectomy
derived fromlamina (part of thespinal canal's bonystructure) and -ectomy (removal).
The operation isperformed torelieve pressure onone or more spinalnerve roots
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Posterior Lumbar Fusion
Posterior lumbar interbody fusion (PLIF)
Usually includes the use of screws/rods for stabilization until thefusion occurs
Bone graft
Cages
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Lumbar Arthroplasty
Total disc replacement (TDR)
DDD
Contraindicated for spondylolisthesis and
spondylolysis
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exercises to strengthen the core
Exercise 1 Hip Rolls:
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Exercise 1 Hip Rolls:
Stand back away fromyour support and standwith legs at shoulder-width apart.
Tighten your abdominalmuscles and put yourhands on your hips.
rotate your hips
clockwise 5 times, thenrotate them counter-clockwise 5 times.
Exercise 2 Waist Twists:
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Exercise 2 Waist Twists:
With your handsrelaxed at your sidesand with feet ashoulder-width apart,
simply start swingingyour arms right thenleft, patting both handson your lower back as
they reach around.
Simply do a count of10, and then relax. .
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Exercise 3 Knee Bends
gentle, relaxed kneebends, best to do themwith the assistance of a
chair, table or desk.Tighten your stomachmuscles and exhale whilebending your knees
. Inhale while standingup.
Do 10 of these to finishthis quick exercise circuit.
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Prevention is the key!
Proper posture and body mechanics Lifting technique
Activities modification
Workplace ergonomics evaluation; occupational specific
trainingLow impact exercises to strengthen the core Yoga, swimming
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Thou shalllearn
low backexercise
THANK YOU