Management of Low Back Pain

Basjiruddin A
Bagian Neurologi FK-Unand/R !R" M !jamil Padang
A#stract
Low Back Pain (LBP) is an extremely common problem that is often poorly managed. Most back pain is
simple and self limiting but its important to recognize that which is not. LBP means a pain or ache some
where between the bottom of the ribs at the back and the top of the legs.
!bout "#$ of people report back pain at some time in their life. %tandard management is rest and analgesic
medication causist of nonsteroidal anti inflammation drugs (&%!'(s) or acetaminophen. !n acti)e
rehabilitation programme uses exercise and grandual return to usual acti)ities.
&er)e blocks can be useful in a specific condition such as acute facet *oint pain. %urgery is referred for use
in patients with ser)e neurologic deficits and possibly those with se)ere symptoms that persist despite
ade+uate conser)ation treatment.
$ntroduction
Low back pain is an extremely common problem and is commonly treated by general
practitioners. 'n most cases are simple and self limited only and need conser)ati)e
therapy. ,owe)er the history and physical examination may elicit warning signals that
indicate the need for further work up and treatment
(-)
Particularly back pain is common symptom in industrialized nations that is responsible
for substantial morbidity impairment and disability. Low back problems ha)e been
leading reasons for patient )isits and health care costs despite measures to control access
to ser)ices and contain costs. ,ealth care costs and producti)ity losses most often
associated with chronicity may be in excess of ./# billion annually in the 0nite %tates
(1.2)
(isability is increasing greatly as can be seen from time off work. Looking at this trend
o)er the last decade the whole working population of the UK will be off sick by the year
2017. 3hus in spite of all our knowledge in spite of our health ser)ice and in spite of
research and e)idence4based medicine we seem to be getting things terribly wrong in
low back pain.
%&idemiolog' tud'
%howed that about "#$ of people report back pain at some time in their life. 'n )arious
studies between -/$ and 2#$ of people report some back pain or trouble on the day of
inter)iew and up to 5#$ report ha)ing had back pain in the last month. 'n the 0nited
6ingdom fifty per cent of attack settle more or less completely within four weeks but
-/$ to 1#$ of patients continue to ha)e symptoms for at least a year. %e)enty per cent of
people who e)er experience an attack will suffer three or more recurrences although
these may diminish o)er time. 3wenty per cent of people with back pain (i.e. /$ to -#$
of the population) will continue to ha)e some degree of back pain symptoms o)er long
periods of their life. 7our per cent of the population up to the age of 55 and / to 8$ of
those older will report back problems as a chronic sickness.
9n the other hand true ner)e root pain or sciatica affects only 2$ to /$ of people at
some time in their life.
(5)

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Simposium The adance management of low back pain from basic to clinic!
"adang# 17 $anuari 200%
3he pre)alence of LBP has )aried from 8: to 28 percent. Peak pre)alence is in the group
between 5/ and :# years of age although back pain is also reported by adolescents and
by adults of all ages.
(/)

LBP exists in e)ery culture and country. ;stimates by numerous in)estigators indicate
that at some point in their li)es "#$ of all human beings experience LBP.
Mechanical LBP becomes more pre)alent in countries with higher per capita income and
where more liberal policies and ade+uate funds pro)ide for compensation.
(5)
!uration of s'm&toms
LBP is classified into three categories based on the duration of symptoms<
4 !cute back pain is arbitrarily defined as pain that has been present for six weeks
or less
4 %ub acute back pain has a six4to -14week duration
4 =hronic back pain lasts longer than -1 weeks
0sing these three categories we can make predictions about prognosis. !t least :#$ of
patients with acute LBP return to work within one month and ># percent return within
three months with minimal inter)entions most patients impro)e in the first few weeks.
(-)

Mor#idit'
Morbidity of LBP in terms of lost producti)ity use of medical ser)ices and cost to society
is staggering. 3otal workers compensation costs for cases in the 0% amounted to 0%.
--5 billion making in the most costly ailment for working age adults and found that the
number of days of work lost each year due to LBP was rising. &o e)idence has been
found to indicate that these costs are declining.
(:)

*arning ign
;ffecti)e diagnosis and treatment of LBP can sa)e health care resources and relie)e
suffering in a multitude of patients.
(8)
3he )ast ma*ority of LBP cases in)ol)e a non4
specific etiology. ?@ellow flags? (including indi)idual psychosocial and occupational
factors are prognostic factors) for occurrence and chronicity of such non4specific LBP
whereas ?red flag? are signs or symptoms that ha)e come to be associated with specific
pathological causes of LBP.
3here are a number or warning signs which are factors which lead the doctor to arrange
for more rapid in)estigation and treatment than would otherwise be necessary. 3hey may
paint to something more serious going on than simple or mechanical back pain should
see the doctor soon <
4 @ounger than 1# or older than // which get LBP for the first time
4 Pain follows a )iolent in*ury
4 3he pain is constant and getting worse
4 Patients on long term steroid
4 3he pain in the upper part of the spine
4 Lost significant weight
4 =ontinue to ha)e great difficulty bending forwards
4 ! number problems in ner)ous system (eg numbness loss of power etc)
4 %tructural deformity of spine
(")
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3here are many factors related to pain perception on LBP patient such as central ner)ous
system plasticity endocrine immune and autonomic system acti)ity psychosocial and
health status factors medullary descending inhibition trauma on the )ertebrae etc.
'n the clinical practice the types of LBP could de)ided into <
4 Muscular spasm
4 Aadicular back pain
4 Pain of spine origin referred to the buttocks or legs
4 Local pain such ad compression of )isitation on sensory ner)e endings because of
fracture tears or stretching tumor infection
4 Aeferred pain abdominal or pel)ic )iscera
(>)
Manajemen
3he !merican Pain %ociety recommendations pro)ide and algorithm to facilitate
collection and interpretation of data during the first patient )isit and to categorized patient
into - of 2 general subgroups < (-) nonspecific LBP "/$ of patientsB (1) back pain
associated with spinal conditions such as spinal stenosis sciatica )ertebral compression
fractures B and (2) LBP specific causes such as cancer. 7or patients with non specific
LBP clinician should not routinely older imaging studies such as radiograph =3 scan or
MA'. 3hese tests should be use to e)aluated patients who ha)e se)ere or progressi)e
neurologic deficits or are suspected to ha)e cancer infections etc.
Most patients re+uire only symptomatic treatment for acute LBP. 'n fact about :#$ of
patients with LBP report impro)ement in 8 days with conser)ati)e therapy and most note
impro)ement within 5 weeks.
(-#)
Patient should be instructed to watch for worsening symptoms such as an increasing loss
of motor or sensory functions increasing pain and the loss of bladder or bowel function.
%hould any of these occur the patient should undergo further e)aluation and treatment
immediately with weekly follow4up. Patient should gradually return to their normal
acti)ities as tolerated. =ontinuing ordinary acti)ities within the limits permitted by pain
leads to a more rapid reco)ery than either bed rest or back4mobilizing exercise.
(--)
Patient with acute low back problems benefit from exercise programs if started early and
if the exercises cause minimal mechanical stress on the back.
3he goal of an exercise program is Cfirst to pre)ent debilitation related to inacti)ity and
Csecond to impro)e acti)ity tolerance and return patients to their highest le)el of
functioning as soon as possible.
&ew studies in the 0%! and the 06 ha)e delineated best practice in the management of
back pain and yet there is often resistance to accepting the ad)ice gi)en. ! plethora of
treatments exists and it is of historical note that &here many remedies e'ist# one can be
sure that there is no cure. (iagnostic triage needs to be carried out early in acute back
pain and serious and remediable pathology needs to be excluded or treated. 3reatment of
the remainder of patients re)ol)es around relief of pain and early mobilisation. 3his
patient needs to be reassured about the etiology and not turned into a chronic sufferer by
bad ad)ice. 3he good outcome needs to be stressed. 3he patient needs to be encouraged
to take personal responsibility for the continued management and pre)ention of further
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exacerbations and chronicity. 't can be explained that the outcome depends more on their
beha)ior than on medical treatment.
(-1)

3he basics of management include <
4 Aecognising and addressing any factors that may mitigate against a swift reco)ery
including negati)e attitudes and e)en compensation neurosis (yellow flags)
4 Planning a simple route for reco)ery with the patient being positi)e and
reassuring
4 Aecognition of those causes of back pain that are a cause for concern and taking
appropriate action (red flags)
4 Aelief of pain
4 !ddressing issues that may predispose to further episodes including poor practice
at work or poor ergonomics.
(-2)

'n ->>5 the =linical %tandards !d)isory Droup (=%!D) published a report on back pain
that almost completely in)erted current teaching and practice. 0ntil then ad)ice had been
to rest perhaps with a board under the bed or directly on a board and *ust lying flat was
the basis of management. 3hese new guidelines ad)ised that only in exceptional cases is
rest allowed and then for no longer than 5" hours. 3he principles of management were
changed to keeping the patient acti)e gi)ing analgesia as necessary to facilitate this.
!cti)e rehabilitation is the term to use.
(-2)

Acti,e Re-a#ilitation
%tandard management of back pain is rest and analgesic medication. this may go as far as
bringing a patient in for traction for 1 weeks although happily this practice is now dying
out. 3here is e)idence to suggest that this is counter4producti)e. 3here is no e)idence to
support the use of rest for simple backache for more than 2 days and the ill effects of
prolonged rest are well recognized. !cti)e rehabilitation should be distinguished from
specific back exercise. ;xercise are often recommended but the patient is told to stop if
pain is pro)oked. !n acti)e rehabilitation programme (!AP) uses exercises but the main
emphasis needs to be on restoring full function and regaining physical fitness based on
goal setting and a gradual increase in targets rather than on taking accord of the pain.
(-1)
Medication
3he most commonly prescribed medications for the treatment of chronic pain symptoms
are the nonsteroidal anti4inflammatory drugs (&%!'(s) which include among many
others aspirin ibuprofen (&aprosyn &aprelan !noprox). 't may take one or two weeks
before patients begin to notice a reduction in pain.
(-.:)

%creen for disease processes that should be considered in choosing medications for
patients such as peptic ulcer disease renal failureEinsufficiency diabetes or cardiac
disease. &%!'(s were found to be effecti)e for short4term symptomatic relief. &o
specific type was shown to be clearly more effecti)e than the others. &%!'(s augmented
with muscle relaxants are a standard medical prescription for LBP in the primary care
setting. 3hese agents should be prescribed on a scheduled basis rather than as needed for
optimal analgesia. Patients on combined &%!'(s and muscle relaxants report reduction
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of symptoms at - week which is less than when compared to either drug alone. 3he
optimum combination of &%!'(s and muscle relaxants remains to be determined.
(:)
=orticosteroid may play a role in the treatment of mechanical LBP with acute
radiculopathic features of radiating pain down one or both legs. !nticon)ulsants that
stabilize neural membranes ha)e been used for ad*unct analgesia of pain suspected to
come from neuropathic causes.
/ Acetamino&-en (3ylenol 3empra)
!cetaminophen acceptable for LBP inexspensi)e a)ailable efecti)e for mild to
moderate but for se)ere low back pain is +uestionable. 't is recomanded by the !P%
guideline as a first line pharmacological option for chronic LBP.f)
;)idence on paracetamol spesificcally for LBP is )ery limited.f). 3he maximum
ad)issed dose is 5 gEd (f) but for se)ere LBP is +uestionable. 3he prolonged use of high
dose may lead to li)er toxicity.(malang D wolf ;.;)idence informed management of
chronic LBP with non steroid and simple analgesic 3he spinal *ournal 1##"B "< -824
-"5)
/ NA$!s ha)e analgesic anti inflammatory and antipyretic acti)ities.
!spirin (!nacin !scriptin) effecti)e in most mechanical LBP cases dose< /##4-###
mg P9 +54:h
C Na&ros'n (&aproxen &aprelan) for relief of mild to moderate pain dose< /## mg P9
initially 1/# mg P9 +:4"h or /## mg P9 +-1h.
(:)
/ 0'cloo1'genase $$ (=9F4'') inhibitors although increased cost can be a negati)e
factor the incidence of costly and potentially fatal D' bleeds is clearly less with =9F4''
inhibitors than with traditional &%!'(s.
=elecoxib inhibits primarily =9F41. =9F41 is considered an inducible isoenzyme
induced during pain and inflammatory stimuli dose< -##41## mg P9 + -1h
=yclobenzaprine (flexiril) skeletal muscle relaxant that acts centrally dose< -# mg P9. tid
=elecoxib (celebrex) and meloxicam (mobic) are known as =9F41 (cyclooxygenase41)
inhibitors. %tandard &%!'(s block two prostaglandin4producing enzymes called
cyclooxygenase - and 1 (=9F4- and 1). the new drugs block =9F41 (responsible for
most inflammatory effects) but not =9F4- which normally protects the stomach.
%till long term side effects are unknown inhibiting =9F41 may ha)e some negati)es as
well as positi)e results had some ad)erse effects on kidney function particularly in
elderly people. 3hey may ha)e negati)e effects on pregnancy and fertility.
(-5)

7. &aproxen oraspirin may be the most appropriate &%!'( in patients at higher
cardio)ascular risk the latter because of its platelet inhibitors effects
(Gchou.A.Pharmacological management of low back pain. (rugs 1#-#8#(5)<2"845#1)
!lthough &%!'(s can work )ery effecti)ely against symptoms they often trigger
gastrointestinal problems such as upset stomachs ulcers and internal bleeding. &%!'(s
cal also increase blood pressure particularly among people already being treated for
hypertension. !bout -1$ to -/$ of elderly people take both an &%!'(s and an
antihypertensi)e drug. Piroxicam naproxen and indomethacin appear to pose the
greatest risk of high blood pressure.
Page 2 of ()
9ther side effects of &%!'(s include dizziness ringing in the ears headaches skin
rashes and possibly depression. %tudies ha)e appeared suggesting that high doses of
&%!'(s can damage cartilage. Because &%!'(s reduce blood clotting &%!'( users
scheduled for surgery should stop taking those drugs a week before the operation.
(-/)

9ne study ranked most commonly used &%!'(s to risk for ulcers and bleeding.
4 Lowest risk < nabumetone (Aelafen) etodolac salsalate and sulindac (clinoril)
4 Medium risk< diclofenac ()oltaren) ibupro)en (motrin rufen) aspirin naproxen
4 ,ighest risk< flurbiprofen (ansaid) piroxicam (feldene) fenoprofen indomethacin
(indocin) meclofenamate (meclomen).
(-/)
(rugs use to protect against &%!'( induced ulcers including the following <
4 Proton4pump inhibitors are the first choice for pre)enting ulcers in high risk
indi)iduals. such drugs include omeprazole lanzoprazole rabeprazole and
pantoprozole. 3hey may reduce &%!'( ulcer rates by as much as "#$
4 Misoprostol is a prostaglandin the protecti)e substance blocked by &%!'( use. 't
is used to pre)ent &%!'( induced ulcers both duodenal and gastric but is not
useful in healing existing ulcers.
(-5)
/ Muscle rela1ants" ! muscle relaxants agent eperisone hydrochloride has been recently
proposed as a muscle relaxant for the treatment of muscle contracture and chronic LBP as
it is de)oid of clinically rele)ant sedati)e effect on the central ner)ous system.
'ts mechanism of action is belie)ed to be blockade of sodium channels and similar
compounds are also reported to ha)e a marked effect on )oltage gated calcium channels.
;perison may exert spinal reflex inhibitory action predominantly )ia presynaptic
inhibition of transmitter release from the primary afferent endings )ia a combined action
on )oltage gate sodium and calcium channels.
(-:.-8)

! recent study presented by %artini % et al (1##") described that eperison had an
analgesic and muscle relaxant effect is patient with LBP. ;ffect of -# days of treatment
with eperison 2## mgEday in -## patients with LBP pro)ided a consistent beneficial
analgesic and muscle relaxant acti)ity. !ccording to the in)estigators the efficacy was
*udged to be good to excellent in 5-$ B moderate in 2:$ and mild to poor in only 12 $
of patients (all PH##-). 3hese suggest that eperison is a useful alternati)e for treatment
of LBP.
(-8)

Antide&ressants
%ome experts suggest that treating people with low back pain and depression for the
psychological condition may be more beneficial and cost4effecti)e than back treatments.
=ertain antidepressants called tricyclics can e)en be effecti)e pain killers in non(
depressed people with chronic back pain. 3hey include amitriptyline desipramine
(&orpramin) doxepin imipramine (3ofranil) amoxapine (!sendin) nortriptyline and
maprotiline (Ludiomill).
(-5)
Potent Pain Relie,ers
)pioids* 0nless the pain is )ery se)ere experts ad)ise against routinely prescribing pain
killers containing opioids (eg morphine codeine meperidine I(emerolJ oxycodone
Page 3 of ()
I9xycontinJ) or tramadol. 9pioids are mainstays for short4term treatment and no role in
the long4term care of patients with LBP. ! skin patch containing an opioid called
transdermal tentanyl ((uragesic) may relie)e chronic back pain more effecti)ely than
oral opioids. %ide effects for all opioids include drowsiness impaired *udgment nausea
and constipation. 9xycodone (9xycontin) dose< /4-# mg p.o.+ 54: h.
(-")
3he use of oppioids in the treatment of LBP should be limited to pain that is unresponsi)e
to alternati)e medication such as appropriated prescribed &%!'( or other analgesic are
contraindicated prolonged or repeated use of opioids is not necessary in most pattient
with acute LBP
%e)eral new abuse detterent and abuse rsistance for medications of oppioids are currently
under re)iew by the 7(! although none are not yet commercialy a)ailable .Khether
these formulations succeed in actually reducing opioid missuse and abuse in clinical
practice remains to he seen (=hoe A Pharmacological management of low back pain.
(rugs 1#-#< 8# (>)< 2"8.5# =)
!ntiepileptic medications
3here is insufficient e)idence to recomended antiepileptic medications for tretment of
non spesific low back pain. 9ne randomized trial in a mixed population of patients with
chronic low back pain with or without radiculopathy found topiramate moderately
superior to placebo for pain relief but only slightly superior for functional impro)ement .
9ther trial of anti epileptic drugs (gabapentin and topiramate) focused on patients with
radiculopaty or spinal stenosis with some trial showing no or small benefits.(>-4>5)
%ystemic corticosteroids are recomended in patients with nonspesific low back pain (>).
! randomized trial of pattients with acute non radicular low back pain foun no difference
in pain relief o)er - month between a single intramuscular in*ection of metylprednisolone
-:# mg and placebo (>/). 9ther trial of systemic corticosteroid that focused on patient
with sciatica also demonstrated to benefit.(>:4>")
$njections
'n*ection of different substances are sometimes used to treat low back pain caused by
ner)e impingement<
! one4time in*ection of a corticosteroid into the area around the spinal column may
short4cut sciatic pain until the body heals itself. =orticosteroids reduce inflammation
and are a temporary not permanent solution.
Local anesthetics.
,yaluronidase (an enzyme from mammalian testes that has been used for arthritis). 'n
one study about a +uarter of patients recei)ing hyaluronidase experienced significant
relief right after the treatment.
Botulinum. 'n*ections of botulinum toxin (Botox) in the lower back reduce muscle
spasm and relie)ed pain up to 5 months.
&er)e block. 3hese can be useful if the patient has a specific condition. 7or instance
facet *oint in*ection can be used for an acute facet *oint pain if this does not settle
rapidly with simpler techni+ues and time.
Page 4 of ()
;pidural in*ection of local anaesthetic and steroid ha)e been shown to be of some
efficacy in patients with simple back pain they are also more effecti)e if done under
F4ray control.
Permanent ner)e blocks should only be considered in chronic sufferers and then only
in carefully selected patients. Aecently the use of none of these substances cure the
problem.
(-")
&one of these substances cure the problem (only temporary)
Re-a#ilitation Program5
a" Physical 3herapy< 3he treatment program for mechanical LBP must ha)e specific
functional goals and can be outlined in the following : step<
-. =ontrol of pain and the inflammatory process. Pain treatment should be initiated
early and efficiently to gain control. 'ce transcutaneous electrical ner)e
stimulation (3;&%). ;xcessi)e bed rest leading to lumbar segment motion loss
of muscle strength.
1. Aestoration of *oint A9M and soft4tissue extensibility. ;xtension exercises may
reduce neural tension. 7lexion exercises reduce articular weight4bearing stress to
the facet *oints and stretch the dorsolumbar fascia.
2. 'mpro)ement of muscular strength and endurance. ;xercise training can begin
after the patient has passed successfully through the pain control phase.
5. =oordination retraining. (ynamic exercise in a structured training program
maximizes coordinated muscle group acti)ities that lead to postural control.
/. 'mpro)ement of general cardio)ascular condition. 'nitiate brisk walking
programs a+uatic acti)ities or use of stationary bicyclesE stair steppers.
:. Maintenance exercise programs
#" 3he main goal of physical therapy in acute back pain is not to increase strength
but to achie)e ade+uate pain control. ;xercise should begin with extension exercises
in the prone position as tolerated to prone lying with support.
c" 3he spine should be stabilized using strengthening of segmental muscles followed
by the prime mo)ers of the spine.
(-5)
6t-er 7reatment 8mani&ulation9 etc":5
%pinal manipulation has been shown in se)eral randomized trials to be beneficial.
%hoe insoles4o)er4the4counter foam or rubber inserts and custom4made orthotics4
may also be beneficial in some patients. %pinal traction biofeedback trigger4point
in*ections facet *oint in*ections and acupuncture are usually not helpful in the
management of acute low back pain. Patients with red flags noted at the initial
e)aluation may be candidates for immediate surgery.
(-)

Manual therapy consisting of manipulation was studied in sub*ects and was found
to attenuate alpha motoneuronal acti)ity as measured by the gastrocnemius muscle
, (,offmann) reflex. Manual therapy may cause short4term inhibitory effects to the
motor system and has been shown to be effecti)e as a treatment for acute LBP.
=linical trials do suggest the efficacy of manipulationB preliminary trials suggest
massage also may be helpful.
3raction facet in*ections and 3;&% appear to be ineffecti)e in randomized trials.
(-5.-")
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urgical $nter,ention 5 %urgical inter)entions for mechanical LBP are the last choice for
treatment. (iscectomies are performed in the 0% at a rate proportional to the number of
spine surgeons in the community. 3he 0% rate of surgeries is twice that of ;urope
=anada and !ustralia and / times the rate in the 06. Better results occur with open
excisions compared with percutaneous discectomies. Aesults were best there was no
workersL compensation or litigation in)ol)ed
0-ronic Low Back Pain
7alls into three broad categories< Cmonotherapies Cmulitidisciplinary therapy and
Creductionism. 7or chronic low back pain the situation is entirely different. By
definition this is pain that has persisted for longer than 2 months patients typically suffer
physical disabilities and psychological distress. 3hey may be unable to work and
depressed.
(-")

Monot-era&ies are inter)entions of a single particular kind that a medical practitioner
might prescribe as sole treatment. %ome might be used simultaneously but there is no
e)idence that such combinations are more effecti)e than monotherapies used alone.
(&%!'(s) may be of short4term benefit but no published data )indicate their long4term use
for chronic low back pain.
)pioids are more effecti)e than naproxen or placebo for relie)ing chronic low back pain
+ntidepressants are slightly more effecti)e than placebo for relief of chronic low back pain
)rthoses# transcutaneous electrical nere stimulation ,T-.S/# and electromyographic
biofeedback show no e)idence of efficacy.
Traction# acupuncture# magnet therapy# in0ections into trigger points# and hydrotherapy are
no more effecti)e than sham treatment placebo.
1assage is a relati)e newcomer as a scientifically tested treatment for chronic low back
pain
(-")

Multidisci&linar' t-era&'. 3his therapy comprises )arious combinations of
exercises education and beha)ioural therapy. Khen work4hardening is emphasised it
has been called functional restoration.Khile proponents of multidisciplinary therapy
ha)e published fa)ourable re)iews of its efficacy for chronic pain in general a re)iew
focusing on chronic low back pain was less encouraging. !lthough intensi)e
rehabilitation is more effecti)e than some other inter)entions outcomes are )ariable
and limited.
(-")

Reductionism describes the pursuit of a pathoanatomical diagnosis for chronic low
back pain with the )iew to implementing a target4specific treatment. 'n this regard it
differs from monotherapies and multidisciplinary therapy neither of which re+uires a
classical diagnosis to be established.
(-5)
Pursuing a diagnosis in most cases causes for chronic LBP cannot be found using
con)entional in)estigations. it should be considered that the degenerati)e changes and
conditions such as spondylolysis and spondylolisthesis are not )alid diagnoses of the
cause of pain as they are no more common in patients with pain than in asymptomatic
indi)iduals.
(-")

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%,idence-#ased &ractice &oints
4 3here is no e)idence of long4term efficacy for drug therapy with analgesics non4
steroidal anti4inflammatory drugs muscle relaxants or antidepressants for
treatment of chronic low back pain opioids are only partially effecti)e and do not
impro)e function
4 3ranscutaneous electrical ner)e stimulation electromyographic biofeedback
traction acupuncture magnet therapy and hydrotherapy are no more effecti)e
than sham therapy.
4 Khile exercise therapy is more effecti)e than other inter)entions.
4 %urgery is more effecti)e than physiotherapy but outcomes are modest.
4 Multidisciplinary therapy based on intensi)e exercises impro)es physical function
but has modest effects on pain.
(->)

Algorit-m for general &ractice management of c-ronic low #ack &ain
(-")
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Bogduk &. Management of chronic low back pain. MG! 1##5B -"#(1)< 8>4"2
Pre,ention
Aecurring back pain resulting from improper body mechanics or other non traumatic
causes is often pre)entable. ! combination of exercises that donMt *olt or strain the back
maintaining correct posture and lifting ob*ects properly can help pre)ent in*uries.
Many work related in*uries are caused or aggra)ated by stressors such as hea)y lifting
contact stress.
3he use of wide elastic belts that can be tightened to Npull inO lumbar and abdominal
muscles to pre)ent low back pain remains contro)ersial. ! landmark study of the use of
lumbar support or abdominal support belts worn by persons who lift or mo)e
merchandise found no e)idence that the belts reduce back in*ury or back pain.
!lthough there ha)e been anecdotal case reports of in*ury reduction among workers using
back belts many companies that ha)e back belt programs also ha)e training and
ergonomic awareness programs.
(-")
Puick tips a healthier back
7ollowing any period of prolonged inacti)ity begin a program of regular low impact
exercise. %peed walking swimming or stationary bike riding 2# minutes a day can
increase muscle strength and flexibility.
4 !lways stretch before exercise or other strenuous physical acti)ity
4 (onLt slouch when standing or sitting. Khen standing keep your weight balanced
on your feet.
4 !t home or work make sure your work surface is at a comfortable height for you
Page (( of ()
4 %it in a chair with good lumbar support and proper position and height for the
task.. 'f you must sit for a long period of time rest your feet on a low stool or a
stack of books
4 Kear comfortable low heeled shoes
4 %leep on your side to reduce any cur)e in your spine. !lways sleep on a firm
surface
4 (onLt try to lift ob*ects too hea)y for you. (o not twist when lifting
4 Maintain proper nutrition and diet to reduce and pre)ent excessi)e weight
especially weight around the waistline that taxes lower back muscles. ! diet with
sufficient daily intake of calcium posphorus and )itamin ( helps to promote new
bone growth.
(-")

0onclusion
LBP is a widespread and often chronic and debilitating problem
3he )ast ma*ority of LBP in)ol)e a nonspecific etiology.
LBP is classified into three categories based on the duration of symptoms< acuteB sub
acute B chronic.
Most patients re+uire only symptomatic treatment Q:#$ of patients impro)e in 8
days.
'maging studies are indicated for patients with se)ere or progressi)e neurologic
deficits sign of radiculopathy spinal stenosis or strong recommendation such as
underlying conditions
Khen pharmacotherapy is considered drugs of choice should be those with pro)en
benefits. !cetaminophen or &%!'(s are preferred first4line drugs and used together
with self care and back care education
7or acute pain muscle relaxants benzodiazepines or opioids may be considered.
'f not impro)e clinicians should consider adding nonpharmacologic modalities such
as spinal manipulation.
'f a warning sign (Nred flagO) has shown appropriate action must be taken need
referral to an orthopaedic neuro surgeon with an interest in back.
Reference
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Simposium The adance management of low back pain from basic to clinic!
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