Tuesday, 26 November 2013

Chronic Low back pain – The Diagnosis and Complications

 Low back pain is a Musculoskeletal disorders (MSDs, affecting over 80% of the population in US alone some points in their life. Chronic LBP (pain has persisted for longer than 3 months(1) prevalence in older adults was significantly higher than the 21-to-44-year age group (12.3% vs. 6.5%, p < .001). Older adults were more disabled, had longer symptom duration, and were less depressed(2)..Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free(3).
III. Diagnosis
1. Health and family history and physical exam
If you are experience low back pain, a decrease in sensation, and weakness of the extremities, the diagnosis may include a complete family history including the prior and current illnesses and injuries and a physical exam include pressure on (palpate) the spine, which may cause tenderness over the affected area. The pain may radiate along the course of a rib to the anterior chest or abdomen. Gait and posture can be affected by disc herniation that causes spinal cord compression and are usually evaluated during the physical exam(24).
2. Other tests may include 
a. X ray
b. CT scan
c. MRI
d. Radiography of the spine
e. Etc.
But other suggested that immediate, routine lumbar spine imaging in patients with LBP and without features indicating a serious underlying condition(Red flags*) did not improve outcomes compared with usual clinical care without immediate imaging. Clinical care without immediate imaging seems to result in no increased odds of failure in identifying serious underlying conditions in patients without risk factors for these conditions. In addition to lacking clinical benefit, routine lumbar imaging is associated with radiation exposure (radiography and CT) and increased direct expenses for patients and may lead to unnecessary procedures. This evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in primary care patients with nonspecific, acute or subacute LBP and no indications of underlying serious conditions(25)(26). Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition(27).
IV. Complications
1. Mental health
found that adults aged 65 years and above with chronic impairing LBP had higher mental health scores, reported significantly less depression, and used less antidepression medication relative to the younger age groups, according to the study of a crosssectional, telephone survey of 5,357 households was conducted to identify 732 adults with chronic, impairing LBP(28).
2. Sleep disturbance, and interleukin-6
In adults with CLBP, poorer sleep quality was associated with higher IL-6 levels, and both sleep and IL-6 related to pain reports. Inflammatory processes may play a significant role in the cycles of pain and sleep disturbance. Clinical interventions that improve sleep and reduce concomitant inflammatory dysregulation hold promise for chronic pain management, according to the study by Rochester Center for Mind-Body Research, University of Rochester Medical Center(29).
Others suggested that The sleep of the patients with CLBP was significantly altered compared with that of the healthy controls, in proportion to the impact of low back pain on daily life(30).
3. Maladaptive movement and motor control impairments
Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of ‘non-specific CLBP’ that leaves a diagnostic and management vacuum. Dr. O’Sullivan P. said ” These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain”(31).
4. Somatic dysfunction (by the presence of any of 4 TART criteria: tissue texture abnormality, asymmetry, restriction of motion, or tenderness)
In a Cross-sectional study nested within a randomized controlled trial, by The Osteopathic Research Center, Fort Worth, demonstrated that somatic dysfunction, particularly in the lumbar and sacrum/pelvis regions, is common in patients with chronic LBP. Forthcoming extensions of the OSTEOPATHIC Trial will assess the efficacy of OMT according to baseline levels of somatic dysfunction(32).
5. Etc.
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Red flags*
Recent significant trauma, Milder trauma if age is greater than 50 years, Unexplained weight loss, Unexplained fever, Immunosuppression, Previous or current cancer, Intravenous drug use, Osteoporosis, Chronic corticosteroid use, Age greater than 70 years, Focal neurological deficit, Duration greater than 6 week(a)
(a) http://en.wikipedia.org/wiki/Low_back_pain 
(1) https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain
(2) http://jah.sagepub.com/content/22/8/1213.refs
(3) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2065872/
(24) http://www.mdguidelines.com/degeneration-thoracic-or-thoracolumbar-intervertebral-disc
(25) http://www.ncbi.nlm.nih.gov/pubmed/21214357.
(26)  http://www.ncbi.nlm.nih.gov/pubmed/11701101
(27) http://www.ncbi.nlm.nih.gov/pubmed/19200918
(28) http://jah.sagepub.com/content/22/8/1213.full.pdf+html
(29) http://www.ncbi.nlm.nih.gov/pubmed/21188850.
(30) http://www.ncbi.nlm.nih.gov/pubmed/18389288
(31) http://www.ncbi.nlm.nih.gov/pubmed/16154380
(32) http://www.ncbi.nlm.nih.gov/pubmed/22802542

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