24 January 2014

Low Back Pain

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hi I'm dr. Mike Evans and today we're

talking about low back pain a problem that people often take care of themselves but even then it's still one of the top two reasons people visit doctors and responsible for up to 40% of all missed work days okay let me begin by giving you a bit of a mixed message for most of us back pain is actually not a quote disease it's more part of the normal experience since we've walked on two legs spinal structures such as bones ligaments discs joints and nerves interacted marvelous ways to support us to do the million things we do with our backs but occasionally this backfires and gives us what we call mechanical back pain the severity of the pain which which can be extremely but always reflect the seriousness of the underlying problem and the vast majority gets better by itself without medical intervention on the other hand we know that while it does get better thirty percent of you have a recurrence in six months and forty percent within a year if this sounds familiar it may be helpful to stop seeing your recurrent back pain is discrete event and and more is a chronic vulnerability that you need

to create what I call a back resilience plan maybe learn some lessons from people who manage their chronic disease as well they build a support team and reach out early when there's a problem they make small changes and they focus on basics like managing stress getting quality sleep and keeping up so let's start with the pain itself let's keep it simple and talk about two patterns first is what we call back dominant pain most commonly this pain radiates down the back to our butt and or around the hips some patients just have pain in the back and others can sometimes feel the pain all the way down the leg but it's a back pain that is dominant most of these patients get relief or aggravation of pain with particular movements or positions for example when they arch backwards or bend forwards typically this kind of back pain comes and goes or it comes in spasms as you move in fact back dominant pain is a good pain because there's no damage to the nerves or spinal cord and and no surgery is needed the second pattern is leg dominant pain and there are two common presentations the first typically comes from a disc problem that puts pressure

on the nerves in your back and it travels down the legs this is often referred to as sciatica when this nervous compressed or irritated we get pain down the leg anywhere from below the buttock to the foot there may be pain in the back as well but this time the leg pain is dominant it's a constant pain but tends to feel better when we lie down sciatica often gets better by itself but we may need to give you special advice there or medications and sometimes imaging especially if there are thoughts of surgery so it's a good idea to talk to your care team if you have sciatica the second presentation is a leg pain that predictably comes only when you stand or walk or run and is relieved when you bend forward and especially when you sit the pain can be anywhere in the leg and patients describe a gradual worsening or or heaviness in the legs as they walk which causes them to stop the medical term for this leg pain is neurogenic claudication and it typically happens to people over 60 and is caused by significant narrowing or or what we call stenosis of the spinal tunnel containing the nerves when this gets

severe makes it hard for your nerves to keep up with your activity now pain predominantly in the back especially if it is intermittent or short lasting is almost always benign but it's good to quickly review what we call red flags science that you may need more investigation the first red flag is a sudden change in your normal bowel or bladder control or numbness around the groin and rectal area which makes us think something might be pressing on the spinal nerves there the second red flag wonders whether infection is the source of your back pain so for example if you have a sustained fever if you're an IV drug user if you have a weakened immune system or at high risk for urinary or other infections the third red flag is about your risk for fracture in your back so if your pain started with a big fall or a car accident or perhaps your bones are brittle because of osteoporosis the fourth red flag is wondering whether cancer might be involved so if you have a history of cancer particularly in the prostate breast or lung and your pain is constant lasting weeks even when lying down or at night or you have other insidious

symptoms such as unexplained weight loss you need to follow this up and finally there's back pain that comes from diseases that cause lots of information such as ankylosing spondylitis now this is rare but when we look at people with chronic back pain it can be seen in as many as one in 20 it tends to start when people are younger say ages 15 to 35 they have night pain and lots of morning stiffness lasting over an hour but this gets better with movement after red flags the next question we often get in clinic is should I have an x-ray or a CT scan or MRI so if you have a red flag or considering surgery for constant leg pain imaging may be an excellent idea but less than five and a hundred patients will actually have a red flag so does having an x-ray help for the other 95 the answer is no professor richard deo and his group calculated that only one and 2500 back x-rays show an important finding okay you say so not too helpful but what's the harm well there's a radiation there's wasted time and money but it's more than that one famous study mr IED 98 people with healthy backs and no back pain and found

disc problems and two-thirds of them the problem with this is that it turns out your outlook or your attitude is actually very important to outcomes and low back pain what we don't want is people saying to themselves oh I have back disease so I better stop exercising or every time they feel a twinge they feel they have a quote illness this brings us to the next type of flags what we call yellow flags these four flags predict an increase risks is somebody's acute low back pain will become chronic number one is the belief that back pain is harmful or potentially severely disabling secondly is fear and avoidance of activity or movement because of back pain when I think of these two risk factors I actually think of a trial done with baggage handlers and maintenance workers at an airport we're in bad shape from back pain and have been off work for a month dr. Bart stall and his colleagues in Maastricht a beautiful town in the Netherlands divided these workers with severe low back pain into two groups the first group received usual care the second group received the same but we're also slowly exposed to more and more

activity and exercise and we're conditioned to understand that they can function normally despite the presence of some back pain with their activity in other words the investigators helped them overcome yellow flag number one the belief that all back pain is harmful and that opened the door to overcome yellow flag number to reducing avoidance of activity it was mind over matter if the worker didn't mind some pain the back pain actually didn't matter the third yellow flag was a tendency towards low mood and isolation which is so true of all chronic diseases and the fourth yellow flag was a strong expectation that passive rather than active treatments will help believing you just need to sit there and have therapists work on you rather than owning the fact that it's not just a therapist that need to do the work you do too so now you know what to watch for let's end with what works for back pain let's start with movement until the late 1990s advice to rest was a common treatment approach for low back pain the exact nature of the rest varied but often a man stayin in bed full time what we know now is that this actually

makes people worse sometimes people with back pain do have to rest so for example with more severe sciatica but people who don't move at all do worse motion is lotion and over-the-counter medications can really help and I think why the key ways these work is to reduce pain so that you can keep moving other things have demonstrated effectiveness for pain relief include spinal manipulation typically by a chiropractor or an osteopath massage and even acupuncture these therapies combined with exercise can be considered active therapies and are often done by your local physiotherapist some exercise strategies may be effective once your pain is reduced like Pilates or yoga to improve your core or trunk strength but the benefits are hard to prove in research trials treatments like spinal manipulation or acupuncture should not be done indefinitely most of the trials maxed out at eight to ten sessions and often less if they don't work for you initially more treatments will unlikely benefit to other approaches that have been proven to work especially for more chronic back pain our cognitive behavioral therapy changing the way you

think and therefore behavior on low back pain and being taken care of by what we call a multidisciplinary team a team with different skill sets we see this often in medicine complex problems seem to rarely find a solution in one place okay let's step back and summarize first you need to know that the prognosis for acute low back pain is excellent only about one-third of patients with back pain seek medical care so most improve on their own over time up to 90% of patients we do see with acute low back pain recover the first episode may be brief or last several weeks but it does go away unless they're red flags these people do fine by acknowledging the pain but not focusing on it by keeping moving and perhaps having some active therapy but there's no need for x-rays or other imaging generally less is more with this type of back pain although there is less high-quality data to support this many patients often respond to small changes such as modifying their workstations taking breaks from sitting or improving their posture for those with chronic or recurrent pain the outlook is still good primary care samples suggest that 1/3 of

patients are substantially improved after just a few weeks and 2/3 after a few months but with recurrent or chronic back pain we both need to work a little harder to get you better as I mentioned earlier seeing this vulnerability and developing a resilience plan for your back that might include yoga or pilates or specific exercises have fit with your back pain pattern walking reconsidering your attitudes and having some people you can turn to early for active therapy can all help so in the end back pain is actually not that much different than a lot of things in life your mindset and daily habits are critical and so is self-knowledge trying to feel the treatments we've discussed knowing what works for you knowing red flags and when you need to seek care and finally understand that movement is medicine thanks and take care you