LOW BACK PAIN
It is a common disorder involving muscles, nerves and bones of the back. Men and women are equally affected by low back pain, which may vary from dull aching pain that develops gradually to sudden, sharp or persistent pain felt below the waist. There are various causes of LBP, most common is mechanical and Ankylosing spondylitis and degenerative.
ANKYLOSING SPONDYLITIS (AS):
It is one of the most common causes of low back pain. It mainly affects the spine and sometimes also affects the joints of both upper and lower limb, also may involve eyes, intestine and skin. It is mostly seen in early 20s with a male predominance. If patient has AS with HLAB27 positve, then his family members are at higher risk.
If only the spine is involve then it is known as axial spondyloarthrits. And if there is involvement of arms and legs then it is known as peripheral spondyloartritis.
CAUSES of AS is mainly hereditary, associated with HLAB27 gene, other factors are environmental. It may also be associated with Uveitis causing red eye, Inflammatory bowel disease (Ulcerative colitis & Crohn’s disease).
DIAGNOSIS: is based on clinical history and radiological findings.
History includes low back pain either acute or chronic with increase pain and stiffness in the morning (>30min). Pain decrease with activity and increase with rest. On clinical examination faber’s test (leg flexed, abducted and externally rotated—pain on sacroiliac (SI) bone) will be positive. X-ray of pelvis will show changes in SI joints and if disease is chronic then hip damages may also be seen.
TREATMENT: Includes physiotherapy, NSAIDs, Corticosteroids, DMARDs and Biologics.
For Axial AS, Initial therapy includes physiotherapy for spinal extension and mobility, NSAIDs (Etoricoxib, Naproxyn etc) or Steroids and Vitamin D and calcium supplements. If patients did not improve with above line of treatment for at least 3-6 months and if disease activity is still high then next treatment option will be Biologics ( Adalimumab, Rituximab). But treatment with biologics is very expensive so only few patients will choose it. Before starting it, they have to screen for tuberculosis and other viral disease (HIV, HCV, HBsAG). If patients could not afford biologics, then treatment can be done with high dose of NSAIDS/Steroid and DMARDs (methotrexate) and regular physiotherapy.
For Peripheral AS, NSAIDS/Steroid, Physiotherapy and DMARDs (Sulfasalazine). If did not improve with this therapy then Biologics is the only option.
Patients are ask to come for regular follow up to look for disease activity which can be monitored by ASDAS (Ankylosing Spondylitis Disease Activity Score), and BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), also have to monitor for any side effects of the drug.
Patients are counseled to do regular exercise (physiotherapy) but should avoid heavy ones and asked to stop smoking, as Smoking aggravates spondyloarthritis.
Pain, fatigue and stiffness, these symptoms may come on & off or sometimes continues. Despite these, some patients may have normal life and lead a productive life with the available treatments.
Mechanical back pain:
Any type of back pain which occurs as a result of abnormal stress or strain on the muscles of vertebral column. It is most commonly due to bad habits such as, poor posture, incorrect bending and heavy lifting. It is also the most common cause of work related disability.
Most common region for mechanical back pain is L1-L5, because these levels absorbs and distribute most of the body’s weight. Both men and women are equally affected.
Symptoms may vary from simple back pain to severe which increase or get worse with activity. Pain may be radiating, sometimes associated with tingling and burning sensation either to single or bilateral.
Diagnosis can be done by clinical, radiological investigations and MRI can be done to rule out other causes eg. degenerative disease and/or nerve entrapment.
Treatment can be done by regular physiotherapy as directed by physical therapist, NSAIDS, and muscle relaxant. Bed rest should be avoided, if possible. Most of the cases are self limited and resolves with little interventions.
Avoidance of bad posture and patient education regarding avoidance of aggravating movements, decreasing weight and returning to normal activity as soon as possible are also very beneficial.