Low Back Pain
Caused by many musculoskeletal problems:
Acute lumbosacral strain
Unstable lumbosacral ligaments and weak muscles
Intervertebral disc problems
Unequal leg length
Frequent comorbidities:
Depressions, smoking, alcohol abuse, obesity, stress
Older patients may experience back pain with osteoporotic vertebral fractures,
osteoarthritis of the spine, and spinal stenosis
Higher areas of pain are associate with a higher level of disability
Other nonmusculoskeletal causes include:
Kidney disorders, pelvic problems, retroperitoneal tumors, abdominal aortic
aneurysms
Spinal column is a rod of rigid units, vertebrae, and flexible units, discs, held together by
facet joints, multiple ligaments, and paravertebral muscles
Flexibility while providing protection for the spinal cord
Spinal curves absorb vertical shocks from running and jumping
Abdominal and thoracic muscles work together when lifting to minimize stress on the
spinal units
Disuse weakens the supporting muscular structures
Intervertebral discs change in character with age:
Young: mainly fibrocartilage with gelatinous matrix; as we get older fibrocartilage
becomes dense and irregularly shaped
L4-L5-S1 are subject to the greatest mechanical stress and greatest
degenerative changes
Disc protrusion or facet joint changes can cause pressure on nerve roots
resulting in pain that radiates along the nerve
Typical patient reports acute or chronic (fewer than 3 months or longer without
improvement) and fatigue
Pain:
Radiating down the leg (radiculopathy: diseased spinal nerve root) or
sciatica: pain radiating from an inflamed sciatic nerve suggests nerve root
involvement
Patients gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory
perception may be affected
Physical exam may disclose greatly increased muscle tone of the back postural
muscles with a loss of normal lumbar curve and possible spinal deformity
Initial evaluation of acute low back pain includes focused history and physical exam;
observation of patient, gait evaluation, and neurologic testing
Suggest either lumbar strain or potentially serious problems: spinal fracture, cancer,
infection, rapidly progressing neurologic deficits
Red flags that trigger diagnostic procedures:
Suspected spinal infection
Severe neurologic weakness
Urinary or fecal incontinence
New onset of back pain in patient with cancer
Diagnostic Procedures:
X-ray of spine: may demonstrate fracture, dislocation, infection, osteoarthritis,
scoliosis
Bone scan and blood studies: may disclose infections, tumors, bone marrow
abnormality
CT scan: identifies underlying problems; obscure soft tissue lesions adjacent to
spinal column, and problems of discs
MRI: visualization of nature and location of spinal pathology
EMG and nerve conduction studies: evaluate spinal nerve root disorders
Myelogram: visualization of segments of spinal cord that may have herniated or
may be compressed; infrequently performed
Ultrasound: detecting tears in ligaments, muscles, tendons, and soft tissues in
the back
Medical management
Most back pain is self-limited and resolves within 4-6 weeks with pain meds, rest, and
avoiding strain
Initial assessment findings that indicate nonspecific back symptoms can rule out need
for diagnostic tests
Pain management focuses on relief of discomfort, activity modification, and patient
education
Presence of other medical problems has a higher cost, less favorable outcomes, and
more long-term disability
Non-pharmacologic interventions:
Thermal applications
Spinal manipulations
Lumbar support belts: not to treat but to prevent
Orthopedic shoe inserts: not to prevent but to treat
Cognitive-behavioral therapy: biofeedback
Exercise regimens
Physical therapy
Acupuncture
Massage
Yoga
Alterations of activity patterns: avoid twisting, bending, lifting, reaching
Change position frequently: sitting limited to 20-50 mins
Conditioning exercises for back and trunk muscles are begun after about 2
weeks to help prevent recurrence of pain
Nursing Assessment
Ask patient to describe discomfort (COLDSPA)
How it occurred
How the patient has dealt with the pain
Assess environmental variable, work situations, family relationships; assess the pain on
the patient’s emotional well-being
Observe patient’s posture, position changes, and gait; often movements are guarded;
sit or stand in an unusual position; may need assistance undressing
Assess the spinal curve, leg length discrepancy, pelvic crest and shoulder symmetry
Palpate paraspinal muscles and note spasm and tenderness
Notice any discomfort or limitations in movement
Evaluate nerve involvement by assessing deep tendon reflexes, sensations, and muscle
strength; back and leg pain on straight-leg raising suggest nerve root involvement
Nursing management
Relieve pain, improve physical mobility, use of back-conserving techniques of body
mechanics, improve self-esteem, and weight reduction (if necessary)
Assess patients response to pain meds; do not remain in bed, inactivity results in
deconditioning
Initiate exercise program after comfort is achieved; swimming, short walks; physical
therapist designs exercise program; may include hypertension exercises to strengthen
the paravertebral muscles, flexion exercises to increase back movement and strength,
and isometric flexion to strengthen trunk muscles; 30 mins daily and end with relaxation
Encourage patient to adhere to program; alternate activities if too much to do for
extended time; activities should not cause excessive lumbar strain or twisting
Back Muscles
Superficial
Latissimus Dorsi: extends, adducts, immediately rotates the humerus
External oblique: rotate the torso contralaterally
Internal: column rotation
Gluteus Medius: helps keep pelvis level when opposite leg is raised:
Trendelenburg test
Gluteus Maximus:
Deep tissue
Erector Spinae: act as main extensors of spinal column
Serratus Anterior: protracts and stabilizes the scapula; lesion will cause winging
of the scapula
Serratus Posterior: acts to depress the ribs
Nerve Cell
Nerves and motor nerves: innervate muscle movement
Nerve cells have a membrane potential; inside negative charge; outside positive charge;
membrane potential can change by sensory outside and chemicals released from
another nerve
Opens or close gates; changes permeability of inside of cell; depolarizes cell because
potassium and sodium enter cell making in positive
Nerve to nerve; send by neurotransmitters via axon
Presynaptic: if depolarization is great enough, nerve fires an action potential
Postsynaptic cell: if result is positive, fires another action potential
Travels down nerves, or target organ, or gland
May be inhibited: cell is hyperpolarized and prevents nerve from firing
Myelin covers nerves; if myelin is destroyed, transmission of action potential slows
because it has to travel all the way down the axon instead of using nodes to travel
through rapidly
Health Care of the Older Adult
Impaired mobility
Causes are many and varied
Strokes, parkinsons, diabetic neuropathy, cardiovascular compromise, osteoarthritis,
osteoporosis, sensory deficits
Older people should be encouraged to stay as active as possible
Bed rest should be minimalized
Perform ROM and strengthening exercises with unaffected extremities and passive
ROM on affected extremities
Frequent position changes