Back pain and regional disorders
November 28, 2012: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.
Update:
Diagnostic criteria for neurogenic claudication—enhanced based on recent evidence reviews.
Intervention recommendations for nonspecific low back pain—based on review of national guidelines for management of low back pain published in 2010.
Prevalence, risk factors, classification, and intervention recommendations for neck pain—based on findings from the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders, published in 2008.
Low back pain
Over 70% of people in industrialized countries suffer from low back pain at some time, and it is one of the leading reasons for visits to physicians. Risk factors include heavy physical work, smoking, stress, depression, and job dissatisfaction. In more than 90% of cases the exact anatomical source of back pain cannot be determined, and the preferred diagnostic label is ‘nonspecific low back pain’.
‘Red flags’ is the term used for the presence on history of any of the following: age over 50, fever, weight loss, significant trauma, previous history of neoplasia, use of corticosteroids, drug or alcohol abuse, neurological symptoms and signs, night pain, morning stiffness, and the persistence of pain after 1 month of conservative therapy. Such red flags suggest the possibility of serious disorders, e.g. neoplasia, infection, fracture, or inflammatory spinal disease.
Investigation and management: investigation should be restricted to patients with red flags, with MRI the best imaging modality for the diagnosis of lumbar disorders. In the absence of red flags, patients with acute low back pain should be reassured and encouraged to remain active: simple analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and spinal manipulation may help for pain relief.
The early recognition of psychosocial risk factors, or ‘yellow flags’, is important to identify patients who are at higher risk of progressing towards chronic low back pain. Cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, multidisciplinary treatment, and short courses of manipulation/mobilization can each be recommended in patients with nonspecific chronic low back pain, but the condition is often refractory.
Other regional disorders
Neck pain—the clinical approach should follow the same principles as described for low back pain.
Regional musculoskeletal pain disorders—painful conditions affecting a specific region of the body are extremely common. Various pains have been described affecting the shoulder, elbow, wrist and hand, hip, knee, ankle, and foot regions. Most of these can usually be identified by a careful history and directed physical examination. The principles of management include temporary rest, analgesics or NSAIDs, local corticosteroid injections, thermal modalities, orthotics, and graded flexibility and strengthening exercises.
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