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20-September-2008 10:21:21 - Back pain To meet 's quality standards, this article or section may require cleanup because it is in a list format that may be better presented using prose. You can help by converting this section to prose, if appropriate. ing help is available. March 2008 Back pain Classification and external resources Different regions curvatures of the vertebral column ICD-10 M54. ICD-9 724.5 DiseasesDB 15544 MeSH D001416 Back pain also known dorsalgia is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine. The pain may have a sudden onset or can be a chronic pain; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck and might radiate into the arm and hand, in the upper back, or in the low back, and might radiate into the leg or foot, and may include symptoms other than pain, such as weakness, numbness or tingling. Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain also called lumbago is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.1 The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities. Contents 1 Associated conditions 2 Underlying causes 3 Treatment 3.1 Conservative treatment 3.2 Surgery 3.3 Emerging treatments 3.4 Treatments with uncertain or doubtful benefit 3.5 Clinical Trials 4 See also 5 References 6 External links Associated conditions Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause: Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs. Severe back pain such as pain that is bad enough to interrupt sleep that occurs with other signs of severe illness e.g. fever, unexplained weight loss may also indicate a serious underlying medical condition. Back pain that occurs after a trauma, such as a car accident or fall may indicate a bone fracture or other injury. Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention. Back pain in individuals with a history of cancer especially cancers known to spread to the spine like breast, lung and prostate cancer should be evaluated to rule out metastatic disease of the spine. Back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months. A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease may not be more prevalent among those in pain than among the general population, and that the mechanisms by which these conditions might cause pain are not known.2345 Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.67 A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.891011 Underlying causes Muscle strains pulled muscles are commonly identified as the cause of back pain, as are muscle imbalances. Pain from such an injury often remains as long as the muscle imbalances persist. The muscle imbalances cause a mechanical problem with the skeleton, building up pressure at points along the spine, which causes the pain. Another cause of acute low back pain is a meniscoid occlusion. The more mobile regions of the spine, such as the facet joints, have invaginations of their synovial membranes that act as a cushion to help the bones move over each other smoothly. The synovial membrane is well supplied with blood and nerves. When these become pinched or trapped sudden severe pain may result. The pinching causes the membrane to become inflamed, causing greater pressure and ongoing pain. Symptoms include severe low back pain that may be accompanied by muscle spasm, pain with walking, concentration of pain to one side, but no radiculopathy radiating pain down buttock and leg. Relief should be felt with flexion bending forward,and exacerbated with extension bending backward. When back pain lasts more than three months, or if there is more radicular pain sciatica than back pain, a more specific diagnosis can usually be made. There are several common causes of back pain: for adults under age 50, these include spinal disc herniation and degenerative disc disease or isthmic spondylolisthesis; in adults over age 50, common causes also include osteoarthritis degenerative joint disease and spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease1. Non-anatomical factors can also contribute to or cause back pain, such as stress,12 repressed anger,13 or depression. Even if there is an anatomical cause for the pain, if depression is present it should also be treated concurrently. New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patients that have no radiographic abnormalities. See Posterior Rami Syndrome. Treatment The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better. Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition acute or chronic is also a determining factor in the choice of treatment. Only a minority of back pain patients most estimates are 1% - 10% require surgery. Conservative treatment Heat therapy is useful for back spasms or other conditions. A meta-analysis of studies by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.14 Some patients find that moist heat works best e.g. a hot bath or whirlpool or continuous low-level heat e.g. a heat wrap that stays warm for 4 to 6 hours. Cold compression therapy e.g. ice or cold pack application may be effective at relieving back pain in some cases. Use of medications, such as muscle relaxants,15 narcotics, non-steroidal anti-inflammatory drugs NSAIDs/NSAIAs16 or paracetamol acetaminophen. A meta-analysis of randomized controlled trials by the Cochrane Collaboration found that injection therapy, usually with corticosteroids, does not appear to help regardless of whether the injection is facet joint, epidural or a local injection.17 Accordingly, a study of intramuscular corticosteroids found no benefit.18 Exercises can be an effective approach, particularly when done under supervision of a licensed health professional. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, one study found that exercise is also effective for chronic back pain, but not for acute pain.19 Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.20 Physical therapy and exercise, including stretching and strengthening with specific focus on the muscles which support the spine, often learned with the help of a health professional, such as a physical therapist. Physical therapy may be especially effective when part of a 'work hardening' program, or 'back school'.21 Massage therapy, especially from an experienced therapist, may help. Acupressure or pressure point massage may be more beneficial than classic Swedish massage.22 Body Awareness Therapy such as the Feldenkrais Method has been studied in relation to Fibromyalgia and chronic pain and studies have indicated positive effects.23. Organized exercise programs using these therapies have been developed. Manipulation, as provided by an appropriately trained and qualified chiropractor, osteopath, physical therapist, or a physiatrist. Studies of the effect of manipulation suggest that this approach has a benefit similar to other therapies and superior to placebo.2425 Acupuncture has some proven benefit for back pain.2 Education, and attitude adjustment to focus on psychological or emotional causes26 - respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.27 Surgery Surgery may sometimes be appropriate for patients with: Lumbar disc herniation or degenerative disc disease Spinal stenosis from lumbar disc herniation, degenerative joint disease, or spondylolisthesis Scoliosis Compression fracture Emerging treatments Vertebroplasty involves the percutaneous injection of surgical cement into vertebral bodies that have collapsed due to compression fractures. This new procedure is far less invasive than surgery, but may be complicated by the entry of cement into Batson's plexus with subsequent spread to the lungs or into the spinal canal. Ideally this procedure can result in rapid pain relief. The use of specific biologic inhibitors of the inflammatory cytokine tumor necrosis factor-alpha may result in rapid relief of disc-related back pain. 28 Treatments with uncertain or doubtful benefit Injections, such as epidural steroid injections and facet joint injections, may be effective when the cause of the pain is accurately localized to particular sites. The benefit of prolotherapy has not been well-documented.1729 Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain14 Bed rest is rarely recommended as it can exacerbate symptoms,30 and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain. Electrotherapy, such as a Transcutaneous Electrical Nerve Stimulator TENS has been proposed. Two randomized controlled trials found conflicting results.3132 This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS.33 In addition, spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain. Inversion therapy is useful for temporary back relief due to the traction method or spreading of the back vertebres through in this case gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang 90 degree and noticeable benefits can be observed at angles as low as 10 to 45 degrees.citation needed Clinical Trials There are many clinical trials sponsored both by industry and the National Institutes of Health. Clinical trials sponsored by the National Institutes of Health related to back pain can be viewed at NIH Clinical Back Pain Trials. See also Failed back syndrome Low back pain Posterior Rami Syndrome Tension myositis syndrome Upper back pain References ^ A.T. Patel, A.A. Ogle. Diagnosis and Management of Acute Low Back Pain. American Academy of Family Physicians. Retrieved March 12, 2007. ^ Borenstein DG, O'Mara JW, Boden SD, et al 2001. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. The Journal of bone and joint surgery. American volume 83-A 9: 1306-11. PMID 11568190. ^ Savage RA, Whitehouse GH, Roberts N 1997. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 6 2: 106-14. PMID 9209878. ^ Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS 1994. Magnetic resonance imaging of the lumbar spine in people without back pain. N. Engl. J. Med. 331 2: 69-73. doi:10.1056/NEJM199407143310201. PMID 8208267. ^ Kleinstück F, Dvorak J, Mannion AF 2006. Are structural abnormalities on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?. Spine 31 19: 2250-7. doi:10.1097/01.brs.0000232802.95773.89. PMID 16946663. ^ White AA, Gordon SL 1982. Synopsis: workshop on idiopathic low-back pain. Spine 7 2: 141-9. doi:10.1097/00007632-198203000-00009. PMID 6211779. ^ van den Bosch MA, Hollingworth W, Kinmonth AL, Dixon AK 2004. Evidence against the use of lumbar spine radiography for low back pain. Clinical radiology 59 1: 69-76. PMID 14697378. ^ Burton AK, Tillotson KM, Main CJ, Hollis S 1995. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine 20 6: 722-8. doi:10.1097/00007632-199503150-00014. PMID 7604349. ^ Carragee EJ, Alamin TF, Miller JL, Carragee JM 2005. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. The spine journal : official journal of the North American Spine Society 5 1: 24-35. doi:10.1016/j.spinee.2004.05.250. PMID 15653082. ^ Hurwitz EL, Morgenstern H, Yu F 2003. Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA Low-Back Pain Study. Journal of clinical epidemiology 56 5: 463-71. doi:10.1016/S0895-43560300010-6. PMID 12812821. ^ Dionne CE 2005. Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings. Journal of clinical epidemiology 58 7: 714-8. doi:10.1016/j.jclinepi.2004.12.005. PMID 15939223. ^ At the Root of Back Pain. WholeHealthMD. ^ McGrath, Mike 2004-11-03. When Back Pain Starts in Your Head: Is repressed anger is causing your back pain?. Prevention.com. Rodale Inc.. Retrieved on 2007-09-12. ^ a b French S, Cameron M, Walker B, Reggars J, Esterman A 2006. A Cochrane review of superficial heat or cold for low back pain.. Spine 31 9: 998-1006. doi:10.1097/01.brs.0000214881.10814.64. PMID 16641776. ^ van Tulder M, Touray T, Furlan A, Solway S, Bouter L 2003. Muscle relaxants for non-specific low back pain.. Cochrane Database Syst Rev: CD004252. doi:10.1002/14651858.CD004252. PMID 12804507. ^ van Tulder M, Scholten R, Koes B, Deyo R 2000. Non-steroidal anti-inflammatory drugs for low back pain.. Cochrane Database Syst Rev: CD000396. doi:10.1002/14651858.CD000396. PMID 10796356. ^ a b Nelemans P, de Bie R, de Vet H, Sturmans F 1999. Injection therapy for subacute and chronic benign low back pain. Cochrane Database Syst Rev: CD001824. doi:10.1002/14651858.CD001824. PMID 10796449. ^ Friedman B, Holden L, Esses D, Bijur P, Choi H, Solorzano C, Paternoster J, Gallagher E 2006. Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain. J Emerg Med 31 4: 365-70. doi:10.1016/j.jemermed.2005.09.023. PMID 17046475. ^ Hayden J, van Tulder M, Malmivaara A, Koes B 2005. Exercise therapy for treatment of non-specific low back pain.. Cochrane Database Syst Rev: CD000335. doi:10.1002/14651858.CD000335.pub2. PMID 16034851. ^ Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V 1995. The treatment of acute low back pain--bed rest, exercises, or ordinary activity?. N Engl J Med 332 6: 351-5. doi:10.1056/NEJM199502093320602. PMID 7823996. ^ Heymans M, van Tulder M, Esmail R, Bombardier C, Koes B 2004. Back schools for non-specific low-back pain.. Cochrane Database Syst Rev: CD000261. doi:10.1002/14651858.CD000261.pub2. PMID 15494995. ^ Furlan A, Brosseau L, Imamura M, Irvin E 2002. Massage for low back pain.. Cochrane Database Syst Rev: CD001929. doi:10.1002/14651858.CD001929. PMID 12076429. ^ Gard G 2005. Body awareness therapy for patients with fibromyalgia and chronic pain.. Cochrane Database Syst Rev. PMID 16012065. ^ Assendelft W, Morton S, Yu E, Suttorp M, Shekelle P 2004. Spinal manipulative therapy for low back pain.. Cochrane Database Syst Rev: CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. ^ Cherkin D, Sherman K, Deyo R, Shekelle P 2003. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.. Ann Intern Med 138 11: 898-906. PMID 12779300. ^ Sarno, John E. 1991. Healing Back Pain: The Mind-Body Connection. Warner Books. ISBN 0-446-39320-8. ^ Ostelo R, van Tulder M, Vlaeyen J, Linton S, Morley S, Assendelft W 2005. Behavioural treatment for chronic low-back pain.. Cochrane Database Syst Rev: CD002014. doi:10.1002/14651858.CD002014.pub2. PMID 15674889. ^ Uceyler N, Sommer C. Cytokine-induced Pain: Basic Science and Clinical Implications. Reviews in Analgesia 2007;92:87-103. ^ Yelland M, Mar C, Pirozzo S, Schoene M, Vercoe P 2004. Prolotherapy injections for chronic low-back pain.. Cochrane Database Syst Rev: CD004059. doi:10.1002/14651858.CD004059.pub2. PMID 15106234. ^ Hagen K, Hilde G, Jamtvedt G, Winnem M 2004. Bed rest for acute low-back pain and sciatica.. Cochrane Database Syst Rev: CD001254. doi:10.1002/14651858.CD001254.pub2. PMID 15495012. ^ Cheing GL, Hui-Chan CW 1999. Transcutaneous electrical nerve stimulation: nonparallel antinociceptive effects on chronic clinical pain and acute experimental pain. Archives of physical medicine and rehabilitation 80 3: 305-12. doi:10.1016/S0003-99939990142-9. PMID 10084439. ^ Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S 1990. A controlled trial of transcutaneous electrical nerve stimulation TENS and exercise for chronic low back pain. N. Engl. J. Med. 322 23: 1627-34. PMID 2140432. ^ Khadilkar A, Milne S, Brosseau L, et al 2005. Transcutaneous electrical nerve stimulation TENS for chronic low-back pain. Cochrane database of systematic reviews Online 3: CD003008. doi:10.1002/14651858.CD003008.pub2. PMID 16034883. External links Marma Therapy in back pain due to disc prolapse Back and spine at the Open Directory Project Handout on Health: Back Pain at National Institute of Arthritis and Musculoskeletal and Skin Diseases Back pain, on Medline plus, a service of the National Library of Medicine v d e Pain and nociception Head and neck Jaw and mouth pain Odynophagia , temporal arteritis Ear pain otalgia, otitis media, otitis externa Eye pain glaucoma Head pain headache, migraine, tension headache, cluster headache, cerebral aneurysm, sinusitis, meningitis Neck pain atypical myocardial infarction Thorax Back pain upper back pain, lower back pain, spinal disc herniation, degenerative disc disease, coccydynia Breast pain perimenstrual, breast cancer Chest pain myocardial infarction, gastroesophageal reflux disease, pancreatitis, hiatus hernia, aortic dissection, asymptomatic pulmonary embolism, Tietze's syndrome Shoulder pain right side - cholecystitis Abdominal pain Left and right upper quadrant peptic ulcer disease, gastroenteritis, hepatitis, pancreatitis, cholecystitis, atypical myocardial infarction, abdominal aortic aneurysm, asymptomatic gastric cancer Left and right lower quadrant appendicitis, ulcerative colitis, Crohn's disease, ectopic pregnancy, endometriosis, pelvic inflammatory disease, diverticulitis, urolithiasis, pyelonephritis, colorectal cancer Limbs Arms myocardial infarction, left arm Legs deep vein thrombosis, peripheral artery occlusive disease, claudication, spinal disc herniation, sciatica Joints Small joints osteoarthritis, rheumatoid arthritis, systemic lupus erythematosis, gout, pseudogout Large joints septic arthritis, hemarthrosis, osteonecrosis Back joints ankylosing spondylitis, inflammatory bowel disease Other psoriatic arthritis, Reiter's syndrome Musculoskeletal Delayed onset muscle soreness, Myalgia, Physical trauma Other/unspecified pain Allodynia, breakthrough pain, chronic pain, congenital insensitivity to pain, congenital insensitivity to pain with anhidrosis, hyperalgesia, hyperpathia, neuralgia, pain asymbolia, pain disorder, paroxysmal extreme pain disorder, phantom pain, referred pain Related concepts Anterolateral system, gate control theory of pain, pain management anesthesia, cordotomy, pain scale, pain threshold, posteromarginal nucleus, substance P, OPQRST v d e Diseases of the musculoskeletal system and connective tissue M, 710-739 Arthropathies Arthritis Septic arthritis - Reactive arthritis - Rheumatoid arthritis - Psoriatic arthritis - Felty syndrome - Juvenile idiopathic arthritis - Still's disease - crystal Gout, Chondrocalcinosis - Osteoarthritis Heberden's node, Bouchard's nodes - Monoarthritis/Polyarthritis Specific joints shoulder Winged scapula - elbow Cubitus valgus, Cubitus varus - hand Wrist drop, Boutonniere deformity, Swan neck deformity hip Protrusio acetabuli, Coxa valga, Coxa vara - leg Foot drop, Flat feet, Club foot, Unequal leg length - patella Luxating patella, Chondromalacia patellae - foot Bunion/hallux valgus, Hallux varus, Hallux rigidus, Hammer toe general terms Valgus deformity, Varus deformity Other Hemarthrosis - Arthralgia - Osteophyte - Hypermobility Systemic CT disorders vasculitis: Arteritis Polyarteritis nodosa, Takayasu's arteritis, Temporal arteritis - arterioles/capillaries Wegener's granulomatosis, Kawasaki disease, Churg-Strauss syndrome, Microscopic polyangiitis hypersensitivity/autoimmune: Hypersensitivity vasculitis - Goodpasture's syndrome - Systemic lupus erythematosus Drug-induced - Dermatomyositis Juvenile dermatomyositis - Polymyositis - Scleroderma - Sjögren's syndrome - Behçet's disease - Polymyalgia rheumatica - Eosinophilic fasciitis Dorsopathies spinal curvature Kyphosis, Lordosis, Scoliosis - Scheuermann's disease - Spondylolysis - Torticollis - Spondylolisthesis Spondylopathies Ankylosing spondylitis, Spondylosis, Spinal stenosis - Schmorl's nodes - Degenerative disc disease - Coccydynia - Back pain Radiculopathy, Neck pain, Sciatica, Low back pain Soft tissue disorders Muscle Myositis Pyomyositis - Myositis ossificans Fibrodysplasia ossificans progressiva Synovium and tendon Synovitis/Tenosynovitis Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome - Irritable hip - Ganglion cyst Bursa Bursitis Olecranon, Prepatellar, Trochanteric - Baker's cyst Fascia/fibroblastic Fasciitis Plantar fasciitis, Nodular fasciitis, Necrotizing fasciitis - Dupuytren's contracture - Fibromatosis Shoulder lesions Adhesive capsulitis - Rotator cuff tear - Subacromial bursitis Enthesis Enthesopathies Iliotibial band syndrome, Achilles tendinitis, Patellar tendinitis, Golfer's elbow, Tennis elbow, Metatarsalgia, Bone spur, Tendinitis Other, NEC Muscle weakness - Rheumatism - Myalgia - Neuralgia - Neuritis - Panniculitis - Fibromyalgia Osteopathies disorders of bone density and structure: Osteoporosis - Osteomalacia - continuity of bone Pseudarthrosis, Stress fracture - Monostotic fibrous dysplasia - Skeletal fluorosis - Aneurysmal bone cyst - Hyperostosis - Osteosclerosis Osteomyelitis - Avascular necrosis - Paget's disease of bone - Algoneurodystrophy - Osteolysis - Infantile cortical hyperostosis Chondropathies Juvenile osteochondrosis Legg-Calvé-Perthes syndrome, Osgood-Schlatter disease, Köhler disease, Sever's disease - Osteochondritis - Tietze's syndrome - Relapsing polychondritis See also congenital Retrieved from http://en..org/wiki/Back_pain Categories: Pain | Nociception | Sensory systemHidden categories: Cleanup from March 2008 | Articles with sections that need to be turned into prose | All articles with statements | Articles with statements since August 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Þ‹Þ¨ÞˆÞ¬Þ€Þ¨Þ„Þ¦Þ?Þ° Español Français Italiano Nederlands Português This page was last modified on 12 August 2008, at 15:30
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