Patients guidebook for low back pain Low BackPain : The Disease BurdenLow back pain is the commonest symptom reported in anorthopedic out patient department.
With 80%-90% of the general populationfacing the problem at some point in their lives, it significantly affects DALYi.e disablility adjusted life year of the population as a whole. Low back achealso accounts for the commonest cause of disability in population below 45years of age , thus affecting the major workforce group. Apart from thedisability burden Low Back Pain significantly contributes to the financialburden , accounting for almost 20-40 billion USD per year.
Types of BackPain Common types of back pain include: • Acute back painAn episode of sudden onset pain usually associated withbending the back with a jerk or lifting heavy objects. Most common cause ofacute back pain is a strain or sprain of the muscles or the ligamentssupporting the lower back. The pain, although is predominantly experienced inlower back region but spreading to thebuttocks or front and back of thighs is not uncommon and many sufferers alsoexperience spasms. This kind of pain generally responds to rest and musclerelaxants which should be followed by gradual muscle stretching and strengtheningexercises of the back. • Chronic persistent back pain This type of back pain follows an indolent course graduallyincreasing in intensity. When back pain persists beyond four to six weeksdespite rest, physical therapy and analgesics, further medical evaluation maybe required.
This pain is often originating from the joints between thevertebrae, discs or supporting muscles of the back. In a few cases, cancer oran infection may be found. Causes ofLow Back Pain The spine is made upof a number of special type of bones also called the vertebrae. These vertebraehave a cushion between each vertebrae called the intervertebral disc and areconnected to each other by very strong ligaments and joints also called facetjoints. Lumbar spine or the lower back is the most commonly affectedpart of the spine as it bears the maximum part of the body weight. One of themost common causes of low back pain is overstreching i.
e strain or sprain ofthe muscles or ligaments supporting the lower back. Muscles and ligaments canbe injured by incorrect posture while lifting weights or even sitting andstanding in a particular posture for a long duration. Lack of exercise leads toweakness of abdominal and lower back muscles which thus become prone to injury.Engaging in sports that involve actions such as push and pull without adequatemuscle training and warming up eg.
Weightlifting, boxing, gymnastics mayincrease the risk of a injury to the lower back. Other causes of lowback pain include: • Obesity • “Slipped” disc, caused when a disc betweenvertebrae bulges past the bones and presses against a nerve• Osteoporosis (deteriorationof the quality of bone leading to thinning of the bone) · Canal stenosis i.e compression of the spinalcord due to overgrowth of supporting ligaments and joints• Osteoarthritis,a breakdown of the tissues or bones of the joint between the two vertebrae• Fibromyalgia, withpainful tender or trigger points, among other symptoms • Trauma frominjury due to an accident or fall that causes a fracture or soft tissue injury • Other seriouscauses such as cancer or infection Low Back Pain : Management Prevention of low back pain by careful modification ofactivities of daily living and adequate strengthening of lower back and abdominalmusculature is of utmost importance for the management of low back pain. Thecommon old notion of advising rest in every cause of back pain is not advisableany more as it may even worsen the pain. Staying highly active and continuingyour day to day activities while avoiding overexertion is the best way to dealwith the common causes of low back pain.
How to keep your back healthy ?Spine health is not just a few do’s and dont’s at the workplace but a round the clock process. We have tried to elaborate a few healthy practicesto be kept in mind while performing the activities of daily living aimed tomaintain the spine healthy. PostureThecorrect sitting and standing posture during day to day life is of utmostimportance to prevent early degeneration of spine , thus leading to low backpain • Support your backOne of the most common causes of sittingrelated back pain is lack of adequate support to your lower back.
Make surethat your lower back is well supported specially for students and in jobsinvolving long sitting hours. Addition of a lumbar support is advisable. Acorrectly adjusted chair will reduce the strain on your back. Adjustable chairswhich allow adjusting the height, back position and tilt are very useful. Yourknees should be bent lesser than 90 degrees and feet resting flat on theground. Use a footrest, if it feels necessary. • Take regular breaksAvoid sitting in the same position for long hours.
Practice the rule of 10 mins of walking after every 50 minutes of sittingwherever and whenever practicable. Sitting in the same position for longperiods puts excessive stress on a certain set of muscles of the back withoutallowing adequate rest. Make sure you change your posture as often as ispracticable so that the fatigued muscles get adequate time to recover whileother muscles take over. Frequent short breaks are better than fewer long ones. • Ensure the seat is firmSitting on a soft couch or a sagging chair exerts highlevels of stress to the back although itmay feel comfortable. A firm seat giving support to the lower back will notjust reduce the stress levels on the lower back but also help maintain the spinalcurvature thus, improving the sitting posture.
• Posture tips forlaptop usersAlthough laptopsbeing portable and light provide a ton of benefits but the very same qualitiesof a laptop promotes poor posture and harmful practices eg. using a laptopwhile lying down on a bed or a sofa. Wherever possible use a detachablekeyboard and mouse so the laptop can be put on a height and the screen kept ateye level. Using your keyboard on a stable base where there is support for yourforearms and elbows is advisable rather than keeping your elbows in your lap. Adopt good sitting posture with lower back support, and ensureother desk equipment like stationary, telephone etc. is within reach to avoid excessive bending ofyour back to reach them. • Avoid wrong sittinghabitsWrongsitting habits are generally adopted to compensate for inappropriate chairsize, shape, support or tilt.
Habits such as sitting with a foot kept under thebuttock, sitting on the edge of the seat in order to allow your feet touch thefloor or sitting with your feet dangling to be able to reach the back rest forsupport should be avoided. • Standing posture Standingposture is as important as sitting posture. Humans being bipedal are more proneto spinal degeneration as lower back bears the major weight of the body. Whilestanding excessive stooping as commonly seen in tall individuals or excessivearching of the back should be avoided as shown in the figure below.
Lifting and handling weightsLifting of heavy weights with an incorrect posture is one ofthe commonest causes of low back pain. Learning and applying thecorrect method for lifting loads can help prevent injury to the back and thus,avoid back pain. The important points have been discussed here. • Think before youliftPlanning thelift especially when the load is heavy is advisable. Your physical limitsshould be kept in mind while making a lift. Divide heavy loads into multiplesmaller loads if possible. Remove distractions, such as plastic wrappers ordiscarded papers from around the load.
For long lifts, such as from floor toabove shoulder height, resting the load mid-way on a table or bench to change toa more suitable grip over the load.• Correct position while liftingBend yourknees to go down, not your back. While making the lift make sure you raise theload and straighten your legs simultaneously. If you straighten your legs beforestarting to raise the load you will bend the back further which may leadto injury to the lower back.Also, makesure your feet are wide apart with one foot slightly forward as shown in the figure tomaintain balance. Avoid wearing heels while lifting load off the ground.
• Keep the load close to the waistThe farther the load is from the body, moreis the force on the lower back. Hold the weight as close to the waist for aslong as possible while lifting to minimize the strain applied on the back.Also, try keeping the heaviest side of the weight closer to the body. Avoidtwisting, turning or leaning sideways while lifting heavy weights. If you wantto turn, move your feet. • Avoid jerks Jerky movements are always difficult to control. Avoid jerkingor snatching the load as this increases the risk of injury. Back care in bedroomOnethird of our average lives are spent in bed.
A healthy bed is an absolutenecessity for a healthy back. • Know when to change the mattress You should always keep in mind the quality ofthe mattress you sleep on and know when to change it. Although a soft and saggymattress may feel comfortable to sleep on but one should be ready to change themattress: – if it is more than 6-8 years old- the mattress has become saggy, too soft or uneven – if springs are felt protruding out – you wake up with pain or stiffness in your back orneck • Mattress should be adequately firmThe firmness of the mattress should always bekept in mind while buying a new mattress. To find the rightdegree of firmness, lie down on the mattress with your back straight and askyour friend to insinuate his hand under the curve in your lower back. If the hand can not be insinuated , the bedis too soft; if its very easy to insinuate, the bed is too hard.
It should alsobe kept in mind NOT to put a new mattress on an old one. It is bound to adoptthe shape of the old mattress and will be no better for your back. Exerciseto keep your back healthyA series of exercise routines can be followed to keepyour back muscles strong and healthy, thus preventing the occurrence of lowback pain.
Also, these exercises help reduce any lower back pain includingtension, stiffness and soreness. Start the routine gently without putting anyexcessive amount of stress or pressure on your back. Gradually stretch yourlimits and see how far you can go in each position without feeling pain.
• Bottom to heels stretchStretches and mobilises the spine Start position: Begin from kneel down position such that knees and hands are rightbelow your hips and shoulders respectively. Look straight ahead and avoidlocking of the elbows. Action: Gradually bend your knees further in order totake your bottoms backwards till they reach your ankles. Hold the stretch for one deep breath and return to the startingposition. Repeat: 8 to 10 times.
Tips: Ensure proper breathing in and out along with the stretch. Do NOT overstretch. Stop the routine if you experience pain while doing the same. • Knee rollsStretches and mobilises the spineStart position: Begin by lying downflat on your back with knees kept together, bent to 90 degrees and both feetflat on the ground. Keep your upper body relaxed and both arms spread wideapart. Action: Keeping the upper body stable, roll both yourknees to one side followed by your pelvis.
Hold the stretchfor one deep breath, return to the starting position followed by repeating thestretch to the opposite side.. Repeat: 8 to 10 times,alternating sides. Tips: Do NOT overstretch. Keep a firm cushion or a book under your head. • Back extensionsStretches and mobilises the spine backwardsStart position: Begin by lying on a firm surface on your stomach, with elbows bentand palms flat on the ground as shown in the image. Keep your shoulders,back and neck stretched and straight. Action: keeping Keeping yourshoulders,back and neck straight, push your hands down, straighten the elbowsto 90 degrees and arch your back up.
Breathe in, feel the stretch in yourabdominal muscles and hold for one deep breath and return to start position Repeat: 8 to 10 times. Tips: Don’t bend your neck backwards. Keep your hips and lower abdomen fixed to the ground. • Pelvic tiltsStretches and strengthens the lower backStart position: Begin by lying down flat on your back. Place a firm cushion orbook under your head. Bend your knees to 90 degrees and keep your feet flat onthe floor and hip-width apart.
Upper body should be relaxed. Action: Gently contract your lower back muscles ,tilting your pelvistowards your heels. Feel the arching of your lower back.
Hold the same for onedeep breath and return to the starting position. Repeat: 10to 15 times. Tips: Don’t press down through the neck, shoulders or feet.
Don’t lift the hips above the ground • Partial CrunchesStretches and strengthens the lower back andabdominal muscles Start position: Begin by lying down flat onyour back with knees kept together, bent to 90 degrees and both feet flat onthe ground. Keep your hands behind yourneck or arms crossed over the chest. Action: Use the abdominal muscles to raise upper half body offthe floor while lower back is still resting on the floor. Breathe out asyou raise your shoulders. Hold for 3 seconds, then slowly lower back down tothe starting position. Repeat 8 to 12 times.
Tips:• Don’t pull yourbody up by the strength of your arms. • Your feet andlower back should remain in contact with the floor at all times • Bird DogStretches and strengthens the lower back andabdominal muscles. This exercise is a greatway to learn stabilization of lower back during synchronous mobilization ofarms and legs Start position: Begin from kneel down position such that knees and hands areright below your hips and shoulders respectively. Look straight ahead andmaintain the arch of the back.
Action: Tighten your stomach muscles. Lift and extend oneleg behind you and stretch the opposite side arm forwards. Keep hips level.Hold for 3-4 secs, and then switch to the other leg. Repeat:8 to 12 times for each leg try to lengthen the time you hold each lift.
Tips: • While doing this stretch, keep the lower back muscles taut and preventsagging of the arch.• Raise the limbs only to a height where the lower back position can bemaintained. Exercisesto be avoided in low back pain Although exercises are good for low back pain but it should always be rememberedthat some exercises may do more harm than good, more so in a setting of lowback pain. Mild discomfort that you feel in the beginning should disappear in3-4 days as the muscles gain strength and flexibility. If the pain in yourlower back increases while doing a particular type of stretching exercise withtime, or in a particular session of exercise you feel pain persisting beyond 15mins you should stop immediately and contact a doctor.
Some exercises may causeexcessive stretching of the muscles and ligaments of the spine and in turnaggravate the pain. A few of the exercises to be avoided in low back paininclude • Standing toetouches • Sit ups • Leg lifts Low Back Pain : The ‘RED FLAG’ signs Most of the patients with low back pain respond to gentleback stretching and strengthening exercises and over the counter analgesics (NSAIDS) spontaneously in 2-4weeks. The ‘red flag’ signs are ominous signs which may suggest a seriousunderlying pathology and thus, should be reported to a specialist as soon aspossible. A list of ‘Red Flag’ signs has been given here under. Progressive weakness of lower limb ( feeling of heaviness, frequent falls , paralysis) Recent bowel or bladder dysfunction Loss of sensation over buttocks and surrounding region Tingling or numbness over any part of lower limb Traumatic onset Age > 50 Male with diffuse osteoporosis or compression fracture Cancer history Insidious onset and persisting for more than 4-6 weeks No relief at bedtime or worsens when supine Fever, weight loss, loss of appetite, night sweats Hx UTI/other infection, IV drug use, TB exposure Immune suppression, Steroid use history Previous surgery Treatment with the specialistOnce you consult a specialist you may be advised to run aseries of diagnostic tests including blood investigations, X-rays and MRIstudies.
Further treatment is carried out after a diagnosis is established. Thespectrum of treatment ranges over conservative management with analgesics,interventional treatments for pain management or surgery in a few patients.Conservative Care:For the management of moderate to severe strains andsprains, the treatment strategy may be divided in two phases. The first phaseis aimed at reducing pain and spasm and may involve rest, locally appliedanalgesic creams, rubs and sprays, oral muscle relaxants or some physicaltherapy in the form of diathermy or interferential therapy. Once the patient ispain free, the second phase comes into play to tackle the residual stiffness inorder to achieve pre injury range of motion.
It also aims at strengthening thelower back musculature. Most people experience a full recovery within a periodof 2 weeks. If symptoms continue for more than 2 weeks, further investigationis warranted.Even in degenerative spine disorders or a slipped discdisease the first preference in most cases is to give a trial of physicaltherapy and specific set of exercises with a physiotherapist for 4-6 weeks.Most exercise programs can be carried out at home without special equipment.
Patientswho do not respond to physical therapy and drugs require additional treatment.InterventionalTreatments :For a small percentage of patients, back pain remainschronic, persistent and disabling. For people, with no response to physicaltherapy and analgesics more intensive treatment may be needed. A few of thecommon interventional treatments that you may be advised depending on yourdisease include:• Nerve root blocks and injections • Radiofrequency ablation• Facetal blocks – injection into the joints betweenyour vertebrae• Epidural injectionsSurgery :For patients who do not respond to the above methods andpatients with crippling pain or ‘red flag’ signs surgery may be the onlyoption.