CHRONIC BACK PAIN

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A. IntroductionAnatomy:• Spine

• Vertebral arch composed of

Cervical (7 vertebrae)

Thoracic (12 vertebrae)

Lumbar (5 vertebrae)

Sacrum (5 vertebrae)

Coccyx (3-5 vertebrae)

Pedicles

Transverse process

Articular process

Lamina

Spinous process

Sources: Southern California Orthopaedic Institute (SCOI) & The Orthopaedic Knowledge Network

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• Intervertebral disc made up of 2 parts:

• A fibrous ring• Functions: -to stabilize the disc-to make sure spine can rotate properly- resist compression or other stresses put on spine

• pulpy interior that consist of water, collagen & proteoglycans.• functions: - To help transmit stress & weight placed on the vertebrae during any movement & activity

Source: Neuro Spinal Hospital – understanding Spinal Anatomy: Intervertebral Disc

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Function:Limits extension. Reinforces anterior portion of annulus fibrosusRegion: axis to sacrum well developed in lumbar& thoracic

Function:Limits flexionRegion: axis to sacrum

Function:Limits lateral flexionRegion:Primarily lumbar

Function: Limits flexion especially in lumbar regionRegion: axis to sacrum

Function: Limits flexionRegion: Thoracic & Lumbar

Function:Limits flexionRegion: primarily lumbar

Function: to strengthen the joint & give extra support

• Ligaments

Source: The Orthopaedic Knowledge Network & Kinesiology: Scientific Basis Human Motion

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• Facet joint or zygapophyseal joint

Source: The Orthopaedic Knowledge Network

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• Muscles

1. Superficial group

Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf

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2. Intermediate group

Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf

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3. Deep group

Source: http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf

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• Abdominal muscles & hip muscles

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• Nerve

Source: TheSpineClinic.com

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Definition:

Chronic Back Pain“The term chronic back pain is used to describe pain

that occursbetween the lower costal margins and the gluteal folds

thatpersists for >3 months.”

(Jackson, M.A. & Simpson, K.H., Continuing Education inAnaesthesia, Critical Care & Pain | Volume 6 Number 4

2006)

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Risk factors1.Occupation2.Age3.Alcohol & drug abuse4.Family history5.Gender6.Level of activity (physical fitness)7.Obesity8.Poor posture & alignment9.Previous back injury10.Psychological, social & spiritual factors11.Smoking12.Sports13.Other factors – spinal condition

Source: http://www.healingchronicpain.org/content/backpain/pfactors.asp

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Etiology

Mechanical

Non-mechanical

Neurological

Biomechanical

Psychological

Strain Structura

l problem

Ankylosing Spondylitis Neoplasms InfectionsArtherosclerosisDisease of the viscera

Cauda equina syndromeShingles

Poor posture/ movement pattern/ everday activities/  Pre-

existing depression, anxiety & stress, together with lack of effective coping skills

Source: http://www.healingchronicpain.org/content/backpain/pfactors.asp & http://www.medicalnewstoday.com/articles/172943.php

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Pathophysiology

Decrease bone strength & muscle elasticity and tone

Dics thinner – diminishes dics flexibility

Decrease shockabsorbing capabilities

•Thickening of the ligament•Boney growth on the vertebral surfaces- Decrease space between the vertebra & the space that spinal cord & nerve roots pass.•Stress on the tissue and joints surrounding• Extruding disc material – impinged the nerve root.

If left untreated -> repeatedly sent pain signals affect the CNS, it will make it more sensitive;even the gentle touch will can be very painful.

Keep on degenerate due to aging

Increase stress on the spine

Aging

Source: Patricia T. Alpert, Management of Chronic Pain, published on 3 October 2013

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Sign & Symptoms• Pain – sharp, shooting, stabbing, burning, achy,

numbness, electrical, and/or tingling.• Localized to particular area or radiating down to the

lower extremities.• Aggravated by movements – leg raises, sitting, or

standing too long• Limited flexibility or range of motion of the back• Muscles aching

Source: Patricia T. Alpert, Management of Chronic Pain, published on 3 October 2013 & http://www.mayoclinic.org/diseases-conditions/back-pain/basics/symptoms/CON-20020797

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Doctor’s Management

Noninvasive pain management

Invasive pain management

No drugs pain management:Physical therapy/ physiotherapyBehavioral modificationPharmacologic pain management:AnalgesicsNSAIDsMuscles relaxantNarcotic medicationsAntidepressants & anticonvulsantsNeuromodulating medications

Injections / blocksProlotherapyRadiofrequency radioablationSurgically implanted electrotherapy devicesImplantable opioid infusion pumps

Source: http://www.spine-health.com/treatment/pain-management

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Physiotherapy’s Management

Advice and early activity (recent research indicates that one of the most important treatment for low back pain is movement).

Joint mobilisation/manipulationMcKenzie therapyGeneral strengthening and stretching exercisesSpecific stabilization exercisesErgonomic advicePostural advicePain relief techniques including electrotherapy devices

Source: http://www.rafflesmedicalgroup.com/ImgCont/323/physio-back-pain.pdf

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ReferencesBooks 1. Hislop, H.J. & Montgomery, J. (2007). Daniels and Worthingham’s Muscle

Testing Techniques of Manual Examination. (8th ed.). Philadelphia: Saunders Elsevier.

2. Kisner, C. & Colby, L.A. (2007). Therapeutic Exercise . (5th ed.).Philadelphia, Pennsylvania: F.A. DAVIS COMPANY.

3. Petty, N.J. (Ed.). (2011). Neuromusculoskeletal Examination and Assessment (3rd ed.). Edinburgh: Churchill Livingstone Elsevier

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Online articles:1. Southern California Orthopaedic Institute. Anatomy of the spine. Retrieved from

http://www.scoi.com/spine.php2. Muscles of the back. (n.d.). Retrieved from

http://musom.marshall.edu/anatomy/grosshom/allppt/pdf/Muscles%20of%20Back%20Lectureff.pdf

3. The Orthopaedics Knowledge Network. (2013). Spine anatomy. Retrieved from http://www.orthopaedicsone.com/display/Main/Spine+anatomy

4. Neuro Spinal Hospital. Understanding Spinal Anatomy: Intervertebral Discs. (n.d.). http://www.nshdubai.com/intervertebral-discs

5. Dr. Bruce McFarlane. (2010). Notes on Anatomy and Physiology: The Intervertebral Discs. Retrieved from http://ittcs.wordpress.com/2010/06/01/anatomy-and-physiology-the-intervertebral-discs/

6. Low Back Pain: Predisposing Factors. (2011). Retrieved from http://www.healingchronicpain.org/content/backpain/pfactors.asp

Online Journals 1. O’ Sullivan, P. B. (2002). The Effect of Different Standing and Sitting Postures on

Trunk Muscle Activity in a Pain-Free Population.2. Aspden R. Review of the functional anatomy of the spinal ligaments and the

lumbar erector spinae muscles. Clin Anat 1992;372–87:3. Gauvin, M.G., Riddle, D.L. & Rothstein, J.M. (1990). Reliability of clinical

measurement of forward bending using modified FTF method. Journal of the American Physical Therapy Association. PHYS THER. 1990; 70:443-447.

4. Jackson, M.A. & Simpson, K.H. (2006). Chronic Back Pain. Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 4 2006. doi:10.1093/bjaceaccp/mkl029.

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