Deterrence/Prevention
Back schools and other training programs that are not job specific have not been shown to be effective statistically; however, programs that integrate job requirements into training programs show statistically significant results.
Complications
IDD, or incompetent disk disease, may account for 39% of all cases of chronic LBP. Alterations in the internal structure and metabolic functions of the disk account for associated symptoms.
-
IDD most commonly occurs after significant trauma (eg, sudden or unexpected lifting, forces transmitted through the disk secondary to high-speed accidents, substantial axial load). Some individuals develop IDD in the absence of a known inciting event. For inexplicable reasons, a small number of individuals with insidiously progressing degenerative disk disease develop IDD.
-
The major clinical characteristic is a deep-seated spinal ache. IDD typically worsens over several months after onset and is aggravated by activities that increase compressive forces on the spine. No explanation of why such activities cause pain is accepted widely, though several theories exist. One is possible leakage of disk catabolites, which may create adverse reactions in the regional nerves around the disk and spinal canal and/or produce constitutional disturbances mediated by the immune system.
Adams and colleagues have proposed an appealing biomechanical model, suggesting that creep leads to concentrated areas of stress in the annulus.
-
Results from in vivo stress profilometry led to the postulation that biomechanical changes due to degeneration may transmit excess force to the vertebral endplate and that shear stress develops in the disk because of anisotropic force concentration. The result is that the annulus functions as a mechanical support rather than a retaining membrane.
-
Combining these postulates with results of previous intradiskal pressure studies leads to a potential explanation of why patients with IDD frequently have predictable symptoms and examination findings. That is, patients often indicate that their symptoms do not improve rapidly with rest but that unloading the spine may ameliorate them.
-
Partial pain relief is achieved by resting in the lateral decubitus position, that is, the supine position with knees and hips flexed, and changing from unsupported to supported sitting. Symptom exacerbation occurs with positions or maneuvers that load the spine.
Patients frequently describe increased symptoms during prolonged sitting and lumbar flexion, and lumbar flexion, especially with rotation. Aerobic and anaerobic deconditioning, resulting from prolonged inactivity, leads to complaints of frequent fatigue, weight gain, and soft tissue tightness.
-
Some patients experience weight loss, but, in clinical experience, this tends to be the exception.
-
Some patients describe extremity or perineal pain.
-
An insidious history is typical and peripheral symptoms fluctuate directly with intensity of back pain.
-
Radicular complaints are rarely confused with these somatically referred symptoms.
-
A deep aching pain, a sense of weakness without corroborative objective evidence, and a feeling of heaviness are experienced commonly.
-
Lower-extremity symptoms may involve the thigh, lower leg, and/or foot.
Some depression is common. When one assesses patients with IDD, make a critical assessment of psychological factors, particularly when surgical intervention is considered.
-
Physical findings consistent with IDD syndrome, which are not found in every case, include provocation of back pain with pelvic rocking, straight leg raise, partial forward flexion in the standing position with the knees extended, pressure application over the intervertebral disk space, and sustained hip flexion.
-
These provocative maneuvers should not be accompanied by exorbitant demonstrations of perceived pain. Such overt pain behavior should alert the clinician to possible psychosocial issues.
Partial pain relief is achieved by reducing axially transmitted forces. Although the patient is sitting at the edge of the bed, ask him or her to shift his or her weight to the hands by lifting the buttock slightly off the bed. ROM testing of the lumbar spine leads to commonly observed findings.
Performing standing forward flexion with or without simultaneous trunk rotation with the knees fully extended is painful, whereas extension may provide symptom reduction.
-
In some instances, peak pain intensity is described during the return to the neutral position from the terminally flexed position. When this occurs, patients commonly use their hands to apply force to the anterior thigh, reducing the intensity of the pain associated with this task. Such symptom and examination findings are generally accepted but not proven by scientific study.
-
In 1 study of the components of history or physical examination that were predictive of IDD, none could be identified. Results of another study suggest that using a McKenzie approach can reliably differentiate diskogenic from nondiskogenic pain.
Patient Education
An education-based paradigm for the patient with LBP can be inexpensive, beginning with providing reassuring information to patients.
-
Seeds of the educational approach exist in back schools, functional restorative programs, and innovative prevention and rehabilitation strategies.
-
LaCroix found that 94% of patients with a good understanding of their condition returned to work, whereas only 33% of patients with poor understanding of their condition returned to employment.
-
Reassurance that activity is helpful promotes return to function.
For excellent patient education resources, see eMedicineHealth's patient education articles, Low Back Pain, Lumbar Laminectomy, and Chronic Pain.
