PHYSİOPATHOLOGY AND REHABİLİTATİON OF CERVİCAL AND LOW BACK PAİN

1. PHYSİOPATHOLOGY AND REHABİLİTATİON OF CERVİCAL AND LOW BACK PAİN Dr. Pembe Hare Yiğitoğlu Near East UniversityFaculty of Medicine Department of PhysicalMedicineandRehabilitation 2012

2. Low back and neck pain are second only to the common cold as the most common affliction of mankind. • Low back and neck pain are symptoms, not diseases, and they have many causes.

3. The symptom of axial skeleton pain is associated with a wide variety of mechanical and systemic disorders. • Mechanical disorders cause the vast majority of low back or neck pain episodes. • Most of these mechanical disorders resolve over a short period of time.

4. Disordersaffectingthelowbackandneck • Mechanical • Rheumatologic • Endocrinologic/Metabolic • Neurologic/Psychiatric • Infectious • Neoplastic/Infiltrative • Hematologic • Referredpain

5. LOW BACK PAİN • Low back pain has become a leading cause of disability and loss of productivity. • It is extremely common.

6. About 40% of people say that they have had low back painwithin the past 6 months. • Studies have shown a lifetimeprevalence as high as 84%. • Most patients have short attacks of painthat are mild or moderate and do not limit activities.

7. Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) • Back pain in children <18 y with considerable pain or onset >55 y • History of violent trauma • Mild trauma in an aged patient • Constant progressive pain at night • History of cancer • Systemic steroids • Drug abuse, human immunodeficiency virus infection

8. Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) • Weightloss • Systemicillness • Persisting severe restriction of motion • Intense pain with minimal motion • Structuraldeformity • Difficultywithmicturition • Loss of anal sphincter tone or fecal incontinence; saddle anesthesia • Progressive motor weakness or gait disturbance

9. Red flags (Risk Factors for Secondary LBP Due to Important Pathologies) • Inflammatory disorders (ankylosingspondylitis) suspected • Gradualonset <40 y • Markedmorningstiffness • Persistinglimitation of motion • Peripheraljointinvolvement • Iritis, skin rushes, colitis, urethraldischarge • Familyhistory

10. Mechanicaldisorders of thelumbosacralspine • Back strain • Lumbar disc herniation • Lumbosacral spondylosis • Lumbar spinal stenosis • Spondylolisthesis • Scoliosis

11. Back strain • Backstrain is precededbysometraumaticeventthat can rangefromcoughingto lifting a heavyobject. • Musclestrain is acutebackpainthatradiatesuptheipsilateralparaspinousmuscles, acrossthelumbararea, andsometimescaudallytothebuttockswithoutradiationtothethigh. • No neurologicabnormalitiesarepresent.

12. Lumbar disc herniation • The disc's structure is composed of outer annulus fibrosusandinnernucleuspulposus. • Thenucleuspulposushave regions with highly hydrophilic. • The hydrated nucleus within the annulus acts as a shock absorber to cushion the spinal column from forces that are applied to the musculoskeletal system. • Nuclear material is normally contained within the annulus, but it may cause bulging of the annulus or may herniate through the annulus into the spinal canal.

13. Neurologic examination may reveal sensory deficit, asymmetry of reflexes, or motor weakness corresponding to the damaged spinal nerve root. • More than 95% of lumbar disk herniations occur at the L4–L5 and L5–S1 levels

14. Lumbosacral spondylosis • Osteoarthritis of the lumbosacral spine may cause localized low back pain. • Oblique views of the lumbar spine demonstrate facet joint narrowing, periarticular sclerosis and osteophytes.

15. Lumbar spinal stenosis • The narrowing of the spinalcanal that occurs in stenosis results from the degenerativechanges. • Neurologic claudication is the most common presentingsymptom of lumbarstenosis. • It is classically described as bilateral legpain initiated by walking, prolonged standing, and walkingdownhill (relative lumbar extension). • It is typicallyrelieved by sitting or bending forward.

16. Spondylolisthesis • Lumbar spondylolisthesisistheanteriordisplacement of a vertebral body in relationtotheunderlyingvertebra. • Spondylolisthesis usually is secondarytodegeneration of intervertebraldiscs. • The most common level affectedin a degenerative slip is the L4–L5 level.

17. Scoliosis • Scoliosis is a lateral curvature of the spine in excess of 10°. • Most commonly begins to develop in adolescent girls.

18. Cancer and Low Back Pain • The spine is the most common site for bonymetastases. • Vertebral body metastases are found inmore than one third of cancer patients. • The most commoncancers that involve the spine are • lung, • breast, • prostate, • renalcell.

19. Spinal Infections • Spinal infections include • osteomyelitis, • diskitis, • pyogenicfacet arthropathy, • epidural infections.

20. It is important to diagnose and treat spinal infections quickly • to preventincreased morbidity and mortality, • to prevent complicationssuch as epidural abscesses that can cause paralysis.

21. Spondyloarthropathies • Spondyloarthropathies are a group of diseases associatedwith the HLA-B27 allele. • They include • Ankylosing spondylitis, • Reactive arthritis, • Psoriatic arthritis, • Enteropathic arthritis, • Undifferentiated spondyloarthropathy.

22. Ankylosing Spondylitis • Ankylosing spondylitis is the prototype for the spondyloarthropathies. • It generally first presents with morning stiffness and a dullache in the low back or buttocks.

23. Rehabilitation • PatientEducation • Educationshouldinclude providing as much of an explanation as patientsneed in terms they can understand. • BackSchools • The term back school is generally used forgroup classes that provide education about back pain. • They include information about the anatomyand function of the spine, common sources of low backpain, proper lifting technique and ergonomic training, andsometimes advice about exercise and remaining active.

24. Exercise • Exercise results in positive outcomes in the treatment ofchroniclowbackpain. • The most effective exercise for lowback pain includes an individualized regimen learned andperformed under supervision that includes stretching andstrengthening. • Patients who have not tolerated land-based exercises areoften able to participate in pool exercises.

25. Medication • Nonsteroidal Antiinflammatory Drugs • Muscle Relaxants • Antidepressants (Tricyclic antidepressants) • Topical Treatments (Lidocaine patches, antiinflammatory creams)

26. Injections and Needle Therapy for Mechanical Low Back Pain • Myofascial Pain and Trigger Point Injections • Acupuncture • Steroid Injections and Other Spinal Procedures

27. Lumbar Supports • Superficial anddeep heat • Transcutaneous Electrical Nerve Stimulation • The stimulation of largeafferent fibers inhibits small nociceptive fibers, causingthe patient to feel less pain.

28. Lumbar epidural steroid injections have become a commonadjuvant for the treatment of lumbosacralradiculopathy. • Surgical management of lumbosacralradiculopathy isbest reserved for those patients who have • significant persistent symptoms despite 6 to 8 weeks of maximizedconservativemanagement, • neurologicprogressionor • caudaequinasyndrome.

29. CERVİCAL PAİN • The prevalence of neck pain with or without upper limb pain rangesfrom 9% to 18% of the general population. • One of three individuals can recall at least one incidenceof neck pain in their lifetime.

30. Mechanicaldisorders of thecervicalspine • Neck strain • Cervical disc herniation • Cervical spondylosis • Myelopathy • Whiplash

31. Neck strain • Neckstrain is rarelyassociatedwith a specifictrauma. • It is typicallytriggeredbysleeping in an awkwardposition, turningtheheadrapidly. • Physicalexaminationrevealslocaltenderness in theparacervicalmuscles, withdecreasedrange of motionandloss of cervicallordosis. • No abnormalitiesarefound on neurologicexamination.

32. Cervical disc herniation • Intervertebraldischerniation in thecervicalspinecausesradicularpainthatradiatesfromtheshouldertotheforearmtothehand. • Neurologicexaminationmayreveal • sensorydeficit, • asymmetry of reflexes, • motor weaknesscorrespondingtothedamagedspinalnerveroot.

33. Cervical spondylosis • Osteoarthritis of thecervicalspine • As thediscdegenerates, thearticularstructuresarebroughtclosertogether, thecervicalspinebecomesunstable. • Increasedinstabilityresults in osteophyteformation. • Plainradiographsshowtheintervertebralnarrowingandfacetjointsclerosis.

34. Myelopathy • Themostserioussequelae of cervicalspondylosis is myelopathy. • Thisdisorderoccurs as a consequence of spinalcordcompressionby • osteophytes, • ligamentumflavumor • intervertebraldisc.

35. Clinicalsymptomsincludeweaknessanduncoordination in thehands. • Inthelowerextremities, thisdisorder can cause • gaitdisturbances, • spasticity, • legweaknessand • spontaneouslegmovements.

36. Sensory deficits include decreased dermatomal sensation and loss of proprioception. • Hyperreflexia, clonus and positive Babinski’s sign are present in the lower extremities.

37. Whiplash • Whiplashinjuriesarecervicalhyperextensioninjuries of theneck. • Theyareassociatedwith motor vehicleaccidents. • Regardless of the direction of impact, whiplash is definedby the passive movement of the neck.

38. Muscular control tostabilize the cervical spine does not react quickly enoughto prevent injurious forces from occurring across the cervical functional spinal units.

39. The anterior disk, anterior longitudinalligament, posterior disk or annulus, and cervicalzygapophyseal joints are all at risk for injury during awhiplash event. • Injury also occurs to the cervicalsoft tissues, resulting in strain and sprain injuries.

40. The most commonly reported symptoms of whiplash injury includeneck pain and headaches, followed by shoulder girdlepain, upper limb paresthesias, and weakness. • Less commonsymptoms include dizziness, visual disturbances, and tinnitus.

41. Treatment • Patient education, activity modification, andrelief of pain are the initial treatment steps. • Nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen (paracetamol) aid in controllingpain.

42. Adjunct medications are often used in conjunction withantiinflammatory medications. These are: • muscle relaxants, • tricyclic antidepressants, • antiepileptics.

43. Physical modalities superficial anddeep heat, electrical stimulationcan be used in the treatment program. • Cervical traction applies a distractive force across the cervical intervertebral disk space.

44. Transcutaneouselectricalnervestimulation (TENS) can also be effective in modulating musculoskeletalpain. • Cervical orthoses function to limit painful range ofmotion and facilitate patient comfort during the acuteinjuryphase. • A soft cervical collar can be prescribed to reduce further neck strain.

45. Surgery • Indications for surgical treatment include • intractablepain, • severe myotomal deficit (progressive or stable), • progression to myelopathy.

46. REFERENCES • Physical Medicine & Rehabilitation • DeLisa’s Physical Medicine & Rehabilitation • Harrison’s Rheumatology • Primer on the Rheumatic Diseases