Monday, 9 February 2015

(First edited)) Most Common Diseases of Ages of 50 Plus - Musculoskeletal disorders (MSDs) -Chronic Lower Back Pain

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By Kyle J. Norton
Health article writer and researcher; Over 10.000 articles and research papers have been written and published on line, including world wide health, ezine articles, article base, healthblogs, selfgrowth, best before it's news, the karate GB daily, etc.,.
Named TOP 50 MEDICAL ESSAYS FOR ARTISTS & AUTHORS TO READ by Named 50 of the best health Tweeters Canada - Huffington Post
Nominated for shorty award over last 4 years
Some articles have been used as references in medical research, such as international journal Pharma and Bio science, ISSN 0975-6299.

Chronic Lower Back Pain

Low back pain is a Musculoskeletal disorders (MSDs) of degenerative disc disease, with pain persisted for longer than 3 months, affecting over 80% of the population in US alone some points in their life. Chronic LBP prevalence in older adults was significantly higher than the 21-to-44-year age group and inflicted more disabled, longer symptom duration, etc.(2). The unique impact of CLBP is unknown(3).

I. Signs and symptoms
1. Movement-evoked discomfort(4)
2. Hypersensitivity to cold stimuli(4)
3. Morning stiffness, as a result of inflammation due to aging causes of degenerated discs(5)
4. Sleep interruptions due to pain
5. Higher compressive axial and tensile radial strains(6)
6. Depression, anxiety disorders and adjustment disorders
In the study of 127 patients suffering from chronic back pain in multimodal inpatient pain therapy who were assessed by a psychologist, showed that there was a high prevalence of depression, anxiety disorders and adjustment disorders in patients with chronic back pain(7).
7. Pain interfered with daily living, depressive, and quality of life(8).
8. Diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain
due to chronic osteoarthritis (OA) pain and chronic low back pain (LBP)(9).
9. Metabolic syndrome
The prevalence of metabolic syndrome among chronic lower back pain patients was 36.2% (30.2% male, 38.6% female), according to Seoul Medical Center(9a)
10. Etc.

II. Causes of chronic back pain
1. Trochanteric bursitis 

Trochanteric bursitisis a clinical condition simulated major hip diseases and low back pain, it may also be mimic nerve root pressure syndrome(10).

2. Spinal stenosis
Aging population with spinal stenosis are at the higher risk of developing low back pain(11).

3. Chronic compression of the dorsal root ganglion (CCD) is associated with  Chronic Low back pain(12).

4. Cauda equina syndrome (CES)
Although each type of CES has different typical signs and symptoms, low back pain may be the most significant one, accompanied by sciatica, lower extremities weakness, saddle or perianal hypoesthesia, sexual impotence, and sphincter dysfunction(13).

5.  “Wear and tear” and “disc space loss” are associated with the development of Chronic Low back pain as a result of a progressive loss of structural integrity(14).

6. Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM)
Although Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM) are only poorly correlated with clinical pain, they all demonstrate abnormalities of muscles, ligaments, or joints(15).

7. Spondylitis
Spondylitis is associated with low back pain(16).

8. Extracellular matrix protein SPARC (Secreted Protein, Acidic, Rich in Cysteine) 
SPARC-null mice display behavioral signs consistent with chronic low back and radicular pain that attribute to intervertebral disc degeneration(16b). According to McGill University,  human subjects with back pain exhibit signs of disc degeneration and increased methylation of the SPARC promoter, in transient transfection assays(16a).

8. Etc.
III. Risk factors 
1. Aging
Elder is at higher risk  of chronic back pain due to discs degeneration(17a).

2. Repetitive bending and lifting can usually lead to severe back pain and sciatica over a period of 30 years as a result of ‘Annulus-driven’ disc degeneration involved a radial fissure and/or a disc prolapse(17).

3. An increased risk for incident chronic LBP if exposed twice to awkward postures(18).

4. Sex, race and Lumbar symptoms
a. Back and spine impairments were more common in women than in men, and
b. Chronic LBP  is more common among white people  than black people (38·7).
c. Lumbar symptoms were 2·86 times more likely than thoracic symptoms to become chronic(19).

5. Smoking
The prevalence of chronic LBP was 23.3% in daily smokers and only 15.7% in non-smokers. Back pain treatment programs may benefit from integrating smoking habit modification(20).

6. Psychiatric disorders are associated to the increased risk of transition to chronicity in men with first onset low back pain(21).

7. Alcohol dependency
Alcohol consumption appears to be associated with complex and chronic LBP only and in people with alcohol consumption dependence(22).

8. Others
Occupational factors, including presence of multiple functional symptoms, disease-related factors, onorganic disease, pain in the legs, significant disability at onset, a protracted initial episode, multiple recurrences,   a history of low back pain, spinal condition, etc. are all associated with higher risk to develop chronic back pain(23).

9. Etc.

IV. 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.
Clinicians should refrain from routine, immediate lumbar imaging as it does not improve clinical outcomes, in primary care patients with nonspecific, acute or subacute LBP and no indications of underlying serious conditions, experts suggested (25)(26)(27).

V. Complications
1. Mental health
 Adults aged 65 years and above with chronic impairing LBP had higher mental health scores, according to the study of a crosssectional, telephone survey of 5,357 households(28).

2. Sleep disturbance, and interleukin-6
Inflammatory processes may play a significant role in the cycles of pain and sleep disturbance. In adults with CLBP, poorer sleep quality was associated with higher pro inflammatory cytokine(IL-6) levels(29). The sleep of the patients with CLBP was significantly altered compared with that of the healthy population(30).

3. Maladaptive movement and motor control impairments
 Chronic low back pain (CLBP) disorders are more likely present with mal-adaptive primary physical and secondary cognitive compensations(31).

4. Somatic dysfunction (by the presence of any of 4 TART criteria: tissue texture abnormality, asymmetry, restriction of motion, or tenderness)
Somatic dysfunction in lumbar and sacrum/pelvis regions, is common in patients with chronic LBP, according to study(32).

5. Etc.

VI. Prevention
1. Weight loss Weight loss is associated chronic low back pain and cardiovascular risk factors, according to the study by Natural Wellness and Pain Relief Centers of Michigan(33).

2. Tai Chi
Ancient health art of Tai Chi may contribute to chronic pain management in 3 major areas: adaptive exercise, mind-body interaction, and meditation. Tai Chi seems to be an effective intervention in osteoarthritis, low back pain, and fibromyalgia(34).

3. Moderate alcohol consumption and quit smoking
Alcohol dependency and smoking are the risk factors of chronic low back pain.

4. Moderate exercise
Moderate exercise are associated to reduced risk of chronic low back pain as it increases oxygenation and blood circulation in the body(35).

5. Avoid recurrent Low back injure
Recurrent Low back injure and injure which has been not treated well may come back to haunt you when you get older, according to traditional Chinese medicine.

6. Yoga 
According to a randomized control single blind active study in an residential Holistic Health Centre in Bangalore, India, assigned 80 patients (37 female, 43 male) with CLBP, seven days intensive residential Yoga program showed to reduce pain, anxiety, and depression, and improved spinal mobility(36).

7. Healthy diet including calcium and vitamin D can prevent osteoporosis causes of chronic low back pain.

8. Etc.

VII. Treatments
A. In conventional medicine perspective

A.1. Non surgical treatment
1. Exercise therapy
Exercise therapy is the most widely used type of conservative treatment for low back pain as it improved post-treatment pain intensity and disability, and long-term function(38). The therapy is effective for chronic but not for acute low back pain, some study suggested(37). Impairment-based manual therapy and exercise directed at the hip joints, showed effectively in improvements in pain, function, and disability in patients with CLBP(39).

2. Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a beneficial treatment for chronic nonspecific back pain, as its improvements in a wide range of relevant cognitive, behavioral and physical variables, according to the study by Uni Health, Uni Research, Bergen, Norway(40).

3.   Medication
The range of regularly prescribed pharmacological agents to treat Chronic Low back pain extends from nonopioids (paracetamol, NSAIDs, and COX-2 inhibitors) to opioids, antidepressants and anticonvulsants(42).

3.1. Non-steroidal anti-inflammatory drugs (NSAIDs)
Transdermal fentanyl significantly improved visual analog scale scores and Oswestry Disability Index scores in 73% of patients, especially those with specific low back pain awaiting surgery(43).
Side effects include  nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, drowsiness, etc.

3.2. Opioids 
Tapentadol’s μ-opioid agonism shows a greater contribution to analgesia in acute pain with fewer adverse events. Noradrenaline reuptake inhibition shows a greater contribution in chronic neuropathic pain models, according to the study by Johns Hopkins University School of Medicine(44)
Side effects include Nausea, dizziness, constipation, CNS sedation, etc.

3.3. Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are a class of medication used as antidepressants in the treatment of depression, anxiety disorders, and some other disorders. According to study, visual analog scale scores were similar in patients taking versus those not taking SSRIs/SNRIs throughout the study(45).
Side effects include  nausea/vomiting, drowsiness, headache, bruxism, tinnitus, extremely vivid or strange dreams, dizziness, fatigue, etc.

3.4. Anticonvulsants 
Anticonvulsants benzodiazepines, the medication used in the treatment of epileptic seizures has been used as adjunctive medications for acute low back pain, with high incidence of sedation(46).
Side effects are not limited to dependency, rebound anxiety, memory impairment, discontinuation syndrome, muscle weakness, dizziness, mental confusion, depression, etc.

3.5. Antispasmodic drug
Eperisone had an analgesic and muscle relaxant effect in patients with LBP.  The drug may represents a valuable alternative to traditional analgesics and muscle relaxants for the treatment of LBP, according to the study by Service of Rehabilitation and Functional Reeducation, S. Orsola-Malpighi Hospital, Bologna(47).
Side effects are not limited to redness, itching, urticaria, edema, rash, pruritus, sleepiness, insomnia, headache, nausea and vomiting, anorexia, abdominal pain, etc.

4. Injection
In the comparison of the clinical effectiveness of FJ injections (FJI) and  denervation in patients with chronic low back pain, found that the FJ injections (FJI) is usually the first choice should be for treatment of Chronic LBP patients. If pain reoccurs after a period of time or injection is not effective, FJ radiofrequency (FJRF) procedure should be used for replaced treatment(47a).

5. Others
According to Avalon Health Solutions, beside conventional medicine, use of alternative treatments included: chiropractor, OA 11%, CLBP 34%; physical therapy, 20% in both groups; transcutaneous electrical nerve stimulations (TENS), OA 14%, CLBP 22%; acupuncture, hydrotherapy, massage therapy, and biofeedback, <3%(48).
Multidisciplinary rehabilitation program and oral drug treatment and oral drug treatment alone, improve most domains of quality of life in chronic low back pain patients in the 6-month period(49).
Biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises, showed  a long-term improvements in pain and disability scores(50).

A.2.  Surgical treatments
Most patients with back pain will not be beneficiary from surgery as it is only performed when conservative treatment is not effective in reducing pain or  if anatomic abnormalities consistent with the distribution of pain are identified. The most common types of low back surgery include
1. Microdiscectomy
Many patients may be symptomatic following LMD, significant disability and dissatisfaction are uncommon. Female sex, young age, lack of exercise, and chronic preoperative LBP may predict a worse outcome. Disc collapse is a universal finding, particularly at L4-L5. Neither DSC nor Modic changes seem to affect patient outcome, according to the retrospective cohort study of patients who underwent LMD in 2004-2005(51).

2. Discectomy(SD)
Recurrent or persistent low back pain (LBP) after surgical discectomy (SD) for intervertebral disc herniation has been well documented(52).

3. Laminectomy is a most minimally invasive surgical procedure removed a portion of the vertebral bone called the lamina, through a small skin incisions(53).

4. Spinal fusion is a surgical procedure to join two or more vertebrae,  either from the patient (autograft) or a donor (allograft), for stimulation of natural bone growth.
According to study, no subset of patients with chronic LBP could be identified for whom spinal fusion with a predictable and effective treatment(54). The surgical procedure showed a strong evidence in support the treatment of back pain caused by fractures, infections, progressive deformity, or instability with spondylolisthesis(57). Spinal fusion may be effective than standard rehabilitation for improving pain in people with chronic non-radicular low back pain, but it is no better than intensive rehabilitation with a cognitive behavioural component(56) but associated with a 16% pooled rate of early complication(55)

5. Etc.

B. In herbal medicine perspective
 Moderate evidences suggested the use of  Salix alba (White willow bark) for short-term improvements in pain acomparable to medication for daily doses standardized to 120 mg or 240 mg salicin with an additional trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib(58).

C. In traditional Chinese medicine perspective 
1. Acupuncture
 Acupuncture needling showed effectively in treatment for patients of chronic low back pain, according to the study of a total of 640 participants (160 in each of four arms) between the ages of 18 and 70 years of age who have low back pain lasting at least 3 months recruited from integrated health care delivery systems in Seattle and Oakland(59). Patients with chronic low back pain with severe baseline dysfunction had mau be also beneficary in most short-term benefit from acupuncture, according to the study of Characteristics of patients with chronic back pain who benefit from acupuncture(60).

2. Herbs
2.1. Traditional Chinese medicine interprets chronic lower back pain as of results of
(1) “Qi and/or Blood StagnationÈ with symptoms of piercing pain; activity limited by feeling of local heaviness, lumbar and flank stiffness with bending limitation and purple tongue, etc.;

(2) “Cold/Damp,” with symptoms of Cold/Damp pain, pallid face and greasy coating, etc.

(3) Kidney Deficiency,” with symptoms of dull pain and recurrent vague pain.

(4) “Warmth/Heat,” with symptoms of purple tongue, yellow tongue coating, and burning pain(61).

2.2. Herbal formulas (Please consult with your traditional Chinese medicine practitioner before applying)
a. Shen Tong Zhu Yu Wan (Shen Tong Zhu Yu Pian), a Chinese herbal formula, used to treat shoulder pain, pain in the arm, lumbago, pain in the leg or pain in the entire body due to obstruction of the flow of Qi and blood in channels. promotes blood circulation and Qi, removes blood stasis and obstruction in the channels, alleviates blood-arthralgia and pain.
b. Ingredients
 Radix Gentianae Macrophyllae (Qin Jiao), Rhizoma Chuanxiong (Chuan Xiong), Semen Persicae (Tao Ren), Flos Carthami (Hong Hua), Radix Glycyrrhizae (Gan Cao), Rhizoma Et Radix Notopterygii (Qiang Huo), Resina Commiphorae (Mei Yao), Radix Angelica Sinensis (Dang Gui), Rhizoma Cyperi (Xiang Fu), Radix Achyranthis Bidentatae (Niu Xi), Phertima (Di Long), Rhizoma Wenyujin Concisa (Jiang Huang), Rhizoma Corydalis (Yan Hu Suo)(61a).

2. Liu Wei Di Huang Wan (Kidney Yin deficiency)
a. Liu Wei Di Huang Wan can replenish Yin due to the Yin insufficiency of the kidney, the innate foundation of all organs with respect to the Yin-Yang principles, Qi essence etc.
b. Ingredients
Radix Rehmanniae Preparata (Shu Di Huang), Fructus Corni Officinalis (Shan Zhu Yu), Cortex Moutan Radicis (Mu Dan Pi), Rhizoma Dioscoreae Oppositae (Shan Yao), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Alismatis Orientalis (Ze Xie)(61b).

3. Jin Kui Shen Qi Wan (Kidney Yang deficiency)
a. Jin Kui Shen Qi Wan can replenish Yang due to the Yang insufficiency of the kidney, the innate foundation of all organs with respect to the Yin-Yang principles, Qi essence etc.
b. Ingredients
Radix Rehmanniae Preparata (Shu Di Huang), Fructus Corni officinalis (Shan Zhu Yu), Rhizoma Dioscoreae Oppositae ((Shan Yao), Cortex Moutan Radicis (Mu Dan Pi), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Alismatis Orientalis (Ze Xie), Cortex Cinnamomi Cassiae (Rou Gui), Radix Aconiti Lateralis Preparata (Zhi Fu Zi), Radix Achyranthis Bidentatae (Niu Xi), Radix Polygoni Multiflori (He Shou Wu), Fructus Lycii Chinensis (Gou Qi Zi),  Fructus Schisandrae Chinensis (Wu Wei Zi(61c).

D. TCM and conventional medicine baclofen 
Acupuncture and acupuncture + baclofen which is used as a muscle relaxer ufor treatment tof muscle symptoms , showed a significantly higher reduction and improvement in a Visual Analogue Scale (VAS) and Roland Disability Questionnaire (medical questionnaire, RDQ) score in patient with chronic lower back pain, according to a randomised controlled clinical trial(62)

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