Low back pain
Dr Wrishi Raphael
Last Wednesday night while carrying a bucket of water from the well, Hannah Williams slipped upon the icy path and fell heavily upon her back. We fear her spine was injured for though she suffers acute pain in her legs she cannot move them. The poor wild beautiful girl is stopped in her wildness at last- Francis Klvert 1874, clergyman and author.
Low back pain is a very common problem in general practice. The most common cause is minor soft tissue injury, but patients with this do not usually seek medical help because the problem settles within a few days. Most back pain in patients presenting to GPs is postulated to be due to dysfunction of elements of the mobile segment, namely the facet joint, the intervertebral joint (with its disc) and the ligamentous and muscular attachments.
Causes of low back pain
To develop a comprehensive diagnostic approach, the practitioner should have a clear understanding of the possible causes of low back and leg pain and of the relative frequency of their clinical presentations. The major causes of low back pain in several hundred
patients presenting to the authors general practice are summarized below:
Vertebral dysfunction
Lumbar spondylosis ( arthritis of the joints of the vertebrae )
Depression
Urinary tract infection
Spondylolisthesis (the forward displacement of a vertebra, especially the fifth lumbar vertebra, most commonly occurring after a fracture. )
Spondyloarthropathies ( the name for a family of inflammatory rheumatic diseases that cause arthritis )
Musculoligamentous strains/tears
Malignant disease
Arterial occlusive disease
As a General Practitioner certain serious disorders cannot be missed and must be reviewed with great care. Such symptoms and signs should alert the practitioner to a serious health problem and thus guide selection of investigations, particularly plain films of the lumbar spine.
a) Age 5O years or 20 years
b) History of cancer
c) Temperature 37.8C or 100.04F
d) Constant pain-day and night especially severe night pain
e) Unexplained weight loss
f) Symptoms in other systems, e.g. cough, breast mass
g) Significant trauma
h) Features of spondyloarthropathy, e.g. peripheral arthritis (e.g. age 40 years, night-time waking)
i) Neurological deficit
j) Drug or alcohol abuse
k) Use of anticoagulants
l) Use of corticosteroids
m) No improvement over 1 month
n) Possible Cauda Equina syndrome:
1) Saddle anaesthesia ( lack of sensation in buttock, perineum, back of thigh )
2) Recent onset bladder dysfunction/overflow incontinence
3) Bilateral or progressive neurological deficit
General aspects of management of back pain:
The aim of treatment is to reduce pain, maintain function and minimise disability and work absenteeism and importantly the risk of chronicity.
Advice to stay active. Evidence from randomized controlled trials confirms that, in people with acute low back pain, advice to stay active speeds symptomatic recovery, reduces chronic disability and results in less time off work compared with bed rest or usual care. Encourage the patient to stay at work or return early if possible.
The caring knowledgeable therapist.
Evidence supports the positive value of education and reassurance from a confident, supportive and knowing therapist.
Relative rest. For acutely painful debilitating back problems, 2 days of strict rest lying on a firm surface is optimal treatment. Resting for longer than 3 days does not produce any significant healing, and patients should be encouraged to return to activities of daily living as soon as possible.
Patient education. Appropriate educational material leads to a clear insight into the causes and aggravation of the back disorder plus coping strategies.
Heat. The application of heat in some form, including heat bags, hot flannels and similar methods, can be of benefit especially in the first 2- 4 weeks of acute low back pain.
Exercises. An early graduated exercise program as soon as the acute phase settles has been shown to promote healing and prevent relapses. All forms of exercise (extension, flexion and isometric) appear to be equally effective. Swimming is an excellent activity for back disorders. Studies support the use of exercises for chronic back pain rather than acute pain.
The writer can be reached at
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