INTRODUCTION
Low back pain is one of the most common problems people have. Low back
problems affect the spines flexibility, stability ,and strength ,which can cause pain
discomfort and stiffness1 .Lower back pain means a back pain roughly between the
bottom of the ribs and the top of the legs at the back. The pain often radiates to the
buttocks and sometimes further down the leg and even to the foot. When back pain is
combined with pain into the leg, travelling down below the knee, it is referred to as
sciatica, because the nerve roots of the sciatic nerve at the back are being irritated by
pressure on it2. There are many mechanisms of back pain, but the most common one
is called mechanical back pain or vertebral dysfunction. Vertebral dysfunction occurs
due to malalignment between the lumbar vertebrae at the facet joints and or
intervertebral discs3.Approximately 80% of individuals will experience an episode of
lower back pain at some time during their life. Lower back pain is the fifth leading
reason for patients visiting a doctor and the leading cause of work related disability.
However, the underlying cause is usually not serious and may not even be identified
by the doctor. Lower back pain is most common in patients between the ages of 20
and 40 years, but can be more severe and disabling in elderly patients. Men and
women are equally affected by lower back pain but the underlying causes of the pain
may differ. For example, women suffer back pain during pregnancy and menstruation
or from conditions such as osteoporosis or osteoarthritis, which are correspondingly
more common in females. Men may be more likely to suffer lower back pain
secondary to trauma from sporting or labour intensive work activities.
Lower back pain is not common in children and when present is more likely to
represent a serious underlying pathology such as maliganancy or infection.
SIGNS AND SYMPTOMS
Low back pain is usually caused by and injury strain from lifting, twisting or
bending4. However, in rare cases low back pain can be a sign of a more serious
condition, such as an infection, a rheumatic or arthritic condition, or a tumor. A
ruptured or bulging disk, the strong, spongy gel filled cushions that lie between each
vertebra and compression fractures of the vertebra caused by osteoporosis can also
cause low back pain. Arthritis can cause the space around the spinal cord to narrows,
leading to pain.
Symptoms of low back pain may include5:
-Tenderness, pain and stiffness in the lower back.
-Pain that spreads into the buttocks or legs.
-Having a hard time standing up or standing in one position for a long time.
-Discomfort while sitting.
-Weakness and tired legs while walking.
Most commonly, diagnoses of acute painful spinal conditions are nonspecific, such as
neck or back strain, although injuries may affect any of several pain-sensitive
structures, which include the disk, facet joints, spinal musculature, and ligamentous
support.[6,7] The origin of chronic back pain is often assumed to be degenerative
conditions of the spine; however, controlled studies have indicated that any
correlation between clinical symptoms and radiological signs of degeneration is
minimal or nonexistent.[6,7,8,9,10,11]Inflammatory arthropathy, metabolic bone conditions,
and fibromyalgia are cited in others as the cause of chronic spine-related pain
conditions.[6,7]
Although disk herniation has been popularized as a cause of spinal and radicular pain,
asymptomatic disk herniations on computed tomography (CT) and magnetic
resonance imaging (MRI) scans are common.[11, 12, 13, 14] Furthermore, there is no clear
relationship between the extent of disk protrusion and the degree of clinical
symptoms.[15] Degenerative change and injury to spinal structures produce lower back
and leg pain that vary proportionally. A strictly mechanical or pathoanatomical
explanation for LBP and sciatica has proved inadequate; therefore, the role of
biochemical and inflammatory factors remains under investigation. In fact, this failure
of the pathological model to predict back pain often leads to an ironic predicament for
the patient with LBP.
Sciatica describes leg pain that is localized in the distribution of one or more
lumbosacral nerve roots, typically L4-S2, with or without neurological deficit.[6,7]
However, physicians often refer to leg pain from any lumbosacral segment as sciatica.
When the dermatomal distribution is unclear, the descriptive phrase nonspecific
radicular pattern " has been advocated. When initially evaluating a patient with lower
back and leg pain, the physician must first determine that pain symptoms are
consistent with common activity-related disorders of the spine resulting from the wear
and tear of excessive biomechanical and gravitational loading that some traditionally
describe as mechanical.[7, 16]
Mechanical lumbar syndromes are typically aggravated by static loading of the spine
(eg, prolonged sitting or standing), by long lever activities (eg, vacuuming or working
with the arms elevated and away from the body), or by levered postures (eg, bending
forward).[7, 16] Pain is reduced when the spine is balanced by multidirectional forces
(eg, walking or constantly changing positions) or when the spine is unloaded (eg,
reclining). Mechanical conditions of the spine, including disk disease, spondylosis,
spinal stenosis, and fractures, account for up to 98% of LBP cases, with the remaining
ones due to systemic, visceral, or inflammatory disorders.[17]
Mechanical versus nonmechanical spinal disorders
Mechanical syndromes






Diskal and facet motion segment degeneration
Muscular pain disorders (eg, myofascial pain syndrome)
Diskogenic pain with or without radicular symptoms
Radiculopathy due to structural impingement
Axial or radicular pain due to a biochemical or inflammatory reaction to spinal
injury
Motion segment or vertebral osseous fractures


Spondylosis with or without central or lateral canal stenosis
Macroinstability or microinstability of the spine with or without radiographic
hypermobility or evidence of subluxation
Nonmechanical syndromes



Neurologic syndromes
o Myelopathy or myelitis from intrinsic/extrinsic structural or vascular
processes
o Lumbosacral plexopathy (eg, diabetes, vasculitis, malignancy)
o Acute, subacute, or chronic polyneuropathy (eg, chronic inflammatory
demyelinating polyneuropathy, Guillain-Barre syndrome, diabetes)
o Mononeuropathy, including causalgia (eg, trauma, diabetes)
o Myopathy, including myositis and various metabolic conditions
o Spinal segmental, lumbopelvic, or generalized dystonia
Systemic disorders
o Primary or metastatic neoplasms
o Osseous, diskal, or epidural infections
o Inflammatory spondyloarthropathy
o Metabolic bone diseases, including osteoporosis
o Vascular disorders (eg, atherosclerosis, vasculitis)
Referred pain
o Gastrointestinal disorders (eg, pancreatitis, pancreatic cancer,
cholecystitis)
o Cardiorespiratory disorders (eg, pericarditis, pleuritis, pneumonia)
o Disorders of the ribs or sternum
o Genitourinary disorders (eg, nephrolithiasis, prostatitis, pyelonephritis)
o Thoracic or abdominal aortic aneurysms
o Hip disorders (eg, injury, inflammation, or end-stage degeneration of
the joint and associated soft tissues [tendons, bursae, ligaments])
.
RISK FACTORS
Risk factors for back pain include age, smoking, being overweight, being female,
being anxious or depressed, and either doing physical work or sedentary work
LBP is most prevalent in industrialized societies. Genetic factors that predispose
persons of specific ethnicity or race to this disorder have not been clearly identified
with respect to mechanical, diskogenic, or degenerative causes. Men and women are
affected equally, but in those older than 60 years, women report LBP symptoms more
often than men. The incidence of LBP peaks in middle age and declines in old age
when degenerative changes of the spine are universal. Sciatica usually occurs in
patients during the fourth and fifth decades of life; the average age of patients who
undergo lumbar diskectomy is 42 years.
Epidemiological data suggest that risk factors, including extreme height, cigarette
smoking, and morbid obesity, may predispose an individual to back pain. However,
research studies have not clearly demonstrated that height, weight, or body build are
directly related to the risk of back injury. Weakness of the trunk extensor muscles,
compared with flexor strength, may be a risk factor for sciatica. Fitness may be
correlated with the time to recovery and return to work after LBP; however, in
prospective studies controlled for age, isometric lifting strength and the degree of
cardiovascular fitness were not predictive of back injury.
Occupational risk factors are difficult to define because exposures to specific
causative influences are unclear, mechanisms of injury may be confusing, and the
research supporting these findings is variable and conflicting for most environmental
risks. Furthermore, job dissatisfaction, work conditions, legal and social factors,
financial stressors, and emotional circumstances heavily influence back disability.
Although many experts agree that heavy physical work, lifting, prolonged static work
postures, simultaneous bending and twisting, and exposure to vibration may
contribute to back injuries, the medical literature provides conflicting support for most
of these proposed risk factors.
DIAGNOSIS OF LOWER BACK PAIN.
Diagnostic Strategies
As indicated in the last section, unrelenting pain at rest should generate suspicion of
cancer or infection. The appropriate imaging study is mandatory in these cases and in
cases of progressive neurological deficit. Plain anteroposterior and lateral lumbar
spine radiographs are indicated for patients older than 50 years and for those with pain
at rest, a history of serious trauma, or other potential conditions (eg, cancer, fracture,
metabolic bone disease, infection, inflammatory arthropathy). The yield for
discovering a serious condition with radiography outside these parameters is minimal,
and the cost savings are substantial.
When LBP and sciatica persist into the subacute phase (pain lasting 6-12 wk),
appropriate consultation and diagnostic imaging should be considered. Referring the
patient to a physician with expertise in spinal disorders may be the most appropriate
procedure for initial evaluation as opposed to relying on expensive diagnostic testing.
CT scanning is an effective diagnostic study when the spinal and neurological levels
are clear and bony pathology is suspected.
MRI is most useful when the exact spinal and neurologic levels are unclear, when a
pathological condition of the spinal cord or soft tissues is suspected, when
postoperative disk herniation is possible, or when an underlying infectious or
neoplastic cause is suspected.
Myelography is useful in elucidating nerve root pathology, particularly in patients
with previous lumbar spinal surgery or with a metal fixation device in place. CT
myelography provides the accurate visual definition to elucidate neural compression
or arachnoiditis when patients have undergone several spinal operations and when
surgery is being considered for the treatment of foraminal and spinal canal stenosis.
Acute pain 18less than two weeks that is not sinister requires no investigations.
Screening tests [indicated in chronic back pain longer than 3 months]
-Plain X rays
-Urinalysis.
-ESR- a marker of inflammation.
-Alkaline phosphatase- a liver enzyme also produced by bone that may be elevated in
bone resorptive diseases.
-Prostatic specific antigen a good marker for prostate cancer.
NUTRITION AND DIETARY SUPPLEMENTS.
There is no special diet for back pain but you can help your body in good shape by
eating a healthy diet with lots of fruits vegetables and whole grains. Choose foods that
are low in saturated fat and sugar19. Drink plenty of water. Foods that are high in
antioxidants [such as green leafy vegetables and berries] may help fight inflammation.
Avoid caffeine and other stimulants alcohol and tobacco. Exercise moderately at least
30 minutes daily 5 days a week. These supplements may help fight inflammation and
pain20
-Omega -3 fatty acids, such as flaxseed and fish oils, 1-2 capsules or 1 tablespoonful
olive oil daily, to help decrease inflammation.
-Glucosamine/ chrondroitin, 500-1500 mg daily.
In some but not all studies glucosamine and chondroitin have helped relieve arthritis
pain. It has not been studied specifically for low back pain.
-Methylsulfonylmethane [MSM] 3000mg twice a day, to help prevent joint and
connective tissue breakdown. In some but not all studies MSM has been shown to
help relieve arthritis pain.
-Bromelain 250mg twice a day .This enzyme that comes from pineapples reduces
inflammation.
HERBS.
Herbs are generally available as standardized dried extracts21 pills, capsules or tablets,
teas or tinctures liquid extracts [alcohol extraction unless otherwise noted].
HYDROTHERAPY
Contrast hydrotherapy.alternating22 hot and cold, may help.
TREATMENT
Nonoperative Treatment
Support for Nonsurgical Treatment
Doubt remains regarding the relative efficacy and cost-effectiveness of surgical versus
nonsurgical treatment approaches. An important longitudinal study was performed by
Henrik Weber, who randomly divided patients who had sciatica and confirmed disk
herniations into operative and nonoperative treatment groups.[23] He found
significantly greater improvement in the surgically treated group at 1-year follow-up;
however, the 2 groups showed no statistically significant difference in improvement at
4 to 10 years.[23] Two prospective cohort studies compared the surgical and
nonsurgical management of lumbar spinal stenosis and sciatica due to lumbar disk
herniation.[24, 25] The results and conclusions were similar in both studies. For patients
with severe symptoms, surgical treatment was associated with greater improvement
and satisfaction. This distinction persisted, but diminished over time.[24, 25, 26]
The recent and very ambitious Spinal Patient Outcomes Research Trial (SPORT) had
been hoped to significantly clarify the surgical versus nonsurgical issues. So far, with
data analyzed for 2- and 4-year follow-ups, finding definitive answers in this study is
difficult, though they contain a large amount of interesting information. For disk
herniation, the major conclusion at 4 years was that nonoperative treatment or surgery
led to improvement in intervertebral disk herniation. But surgery may have a slight
benefit.[27, 28] For spondylolisthesis, the 2- and 4-year as-treated analysis showed an
advantage to surgical therapy.[29, 30] Likewise, for spinal stenosis, the 2-year analysis
showed somewhat more improvement for surgery.[31]
With regard to cost effectiveness, the surgical costs were rather high, though not
completely out of the range of other medical treatments. For lumbar disk herniations,
1 quality-adjusted life year (Qaly) cost about $70,000. For stenosis and
spondylolisthesis the costs per Qaly were $77,000 and $116,000, respectively.[32, 33] A
significant general problem with the SPORT data is that there was so much switching
between treatment groups that intention-to-treat analysis (the usual criterion standard)
was impossible. Therefore as-treated analyses were used. As the SPORT analyses
continue beyond the 2- to 4-years, additional information or more definitive changes
between groups may be identified. But lack of an intention-to-treat analysis will
probably complicate definitive conclusions. Hopefully, future studies and newer
treatments may someday provide clearer answers.
The rationale for nonoperative treatment of diskal herniation has been supported by
clinical and autopsy studies, which demonstrate that resorption of protruded and
extruded disk material can occur over time.[34, 35] Other studies have correlated MRI or
CT improvement with successful nonoperative treatment in patients who have lumbar
disk herniations and clinical radiculopathy.[35, 36, 37] The greatest reduction in size
typically occurred in patients with the largest herniations. Recent uncontrolled studies
have shown that patients who have definite herniated disks and radiculopathy and
satisfy the criteria for surgical intervention can be treated successfully with aggressive
rehabilitation and medical therapy. Good to excellent results were achieved in 83% of
cervical and 90% of lumbar patients.[38, 39]
In general, nonoperative treatment can be divided into 3 phases based on the duration
of symptoms. Primary nonoperative care consists of passively applied physical
therapy during the acute phase of soft-tissue healing (< 6 wk). Secondary treatment
includes spine care education and active exercise programs during the subacute phase
between 6-12 weeks with physical therapy—driven goals to achieve preinjury levels
of physical function and a return to work. After 12 weeks, if the patient remains
symptomatic, treatment focuses on interdisciplinary care using cognitive-behavioral
methods to address physical and psychological deconditioning and disability that
typically develops as a result of chronic spinal pain and dysfunction.[40]
When spinal pain persists into the chronic phase, therapeutic interventions shift from
rest and applied therapies to active exercise and physical restoration. This shift is
primarily a behavioral evolution with the responsibility of care passed from doctor
and therapist to patient.[6, 41] Bed rest should be used sparingly for chronic spinal pain
to treat a severe exacerbation of symptoms. Therapeutic injections, manual therapy,
and other externally applied therapies should be used adjunctively to reduce pain so
that strength and flexibility training can continue. When spinal pain is chronic or
recurrent, traction or modalities, such as heat and ice, can be self-administered by
patients for flare-ups to provide temporary relief.[6, 41]
Rational physical, medical, and surgical therapies can be selected by determining the
relevant pathoanatomy and causal pain generators. Acute spinal injuries are first
managed by the elimination of biomechanical stressors, using short-term rest,
supplemented by physical and pharmacological therapies aimed directly at the
nociceptive or neuropathic lesion(s).
The paradigm that best represents the elimination of activity or causative
biomechanical loading is bed rest. Bed rest is usually considered an appropriate
treatment for acute back pain. However, 2 days of bed rest for acute LBP has been
demonstrated to be as effective as 7 days and resulted in less time lost from work.[42]
Furthermore, prolonged bed rest can have deleterious physiological effects, leading to
progressive hypomobility of joints, shortened soft tissues, reduced muscle strength,
reduced cardiopulmonary endurance, and loss of mineral content from bone.[6, 19, 10] For
these reasons and because inactivity may reinforce abnormal illness behavior, bed rest
is usually avoided when treating chronic spinal conditions.[6,19,10]
Oral Pharmacology
Rational pharmacology for the treatment of spinal pain is aimed at causative
peripheral and central pain generators, determined by the types of pain under
therapeutic scrutiny (eg, neuropathic and/or nociceptive), and modified additionally to
deal with the evolving neurochemical and psychological factors that arise with
chronicity. In general, the published research for evaluating the efficacy of medication
in treating neck and back pain has demonstrated faulty methodology and inadequate
patient/subject description.[43] However, medication continues to be used as adjunct to
other measures because of anecdotal reports, perceived standards of care, and some
supportive clinical research.
Some authors contend that analgesics like acetaminophen are a reasonable first step
for the treatment of cLBP[44, 45] , although others disagree and advocate its use only
when treating acute LBP.[46] There is evidence that acetaminophen has a similar
efficacy to nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with acute
LBP; however, little direct evidence exists regarding the efficacy of acetaminophen in
cLBP.[47] The possible beneficial effects of long-term acetaminophen use must be
weighed against potential adverse hepatic and renal effects.[48]
There is strong evidence that both traditional and cyclooxygenase-2-specific NSAIDs
are more efficacious than a placebo for reducing LBP in the short term, although the
effects tend to be small.[47] One small randomized study suggested that the NSAID
diflunisal had a greater efficacy than acetaminophen.[49] In addition, their findings
demonstrate that the various NSAIDs are, on average, equally efficacious.[50]
Gastrointestinal, renal, and potential cardiac toxicities must be considered with longterm NSAID use.[47] .
During the acute phase following biomechanical injury to the spine, where there are
no fractures, subluxation, other serious osseous lesions, or significant neurological
sequelae, mild narcotic analgesics may assist patients in minimizing inactivity and
safely maximizing the increase in activity, including prescribed therapeutic exercises.
NSAIDs and muscle spasmolytics used during the day or at bedtime may also provide
some benefit.[6, 41]
The best available evidence advocates the use of an antidepressant, analgesic, or both
for chronic back pain. When starting a new medication, patients should be educated as
to why a medication is chosen and its expected risks and benefits. Patient preferences
concerning medications should be considered, especially after they are informed of
potential risks. When anxiety lingers regarding the risks or side effects of a
medication (eg, NSAIDs or muscle relaxants), a short trial of the medication at a low
dosage over 3-4 days can be effective for assessing the patient's tolerance and
response to the drug, as well as alleviating patient and physician concerns. Most
patients require medications in relatively high therapeutic ranges over a protractile
period of time.[51]
Patients may be resistant to multiple therapeutic approaches and may require more
individualized medication combinations, including other analgesics. Pooled data from
large groups of patients have shown that no one medication in any of the various drug
classes provides more benefit to the patient than another.[51] Furthermore, predicting
which patient will respond best to which medication within that class is impossible.
Better studies with greater numbers of patients and longer follow-up times are needed
to better compare classes of medications, including simple analgesics, muscle
relaxants, and NSAIDs.[45]
In many cases back pain will get better with self care .You should see your doctor if
your pain doesn’t get better within 72 hours. You can lower your risk of back
problems by exercising, maintaining52 a healthy weight, and practicing good posture
Learning to bend and lift properly, sleeping on a firm mattress, sitting in supportive
chairs, and wearing low- heeled shoes are other important factors.
Although you may need to rest your back for a little while, staying in bed for several
days tends to make back pain worse. For long term back pain your doctor may
recommend stronger medications physical therapy or surgery. Most people will not
need surgery for back pain. Medications used to treat low back pain include53
nonsteroidal anti inflammatory drugs [NSAIDs] such as ibuprofen [Motrin, Advil]
and naproxen [Aleve], muscle relaxants such as carisoprodol [Soma], and steroids as
prednisone.
Education/cognitive behavioral therapy
Although back schools to educate and train patients have been popular internationally,
they have been ineffective as preventive measures. However, back schools have had a
94-96% rate of patient satisfaction. In a prospective randomized clinical trial to
compare exercise alone with back-school education plus exercise, the back-school
group had significant improvements in pain and disability. Furthermore, at 16 weeks,
the exercise-only group had reverted to their original level of disability, whereas the
back-school group had continued improvement. Other studies have shown that
patients with LBP who participate in back schools return to work earlier, seek less
follow-up medical attention, and have less frequent episodes of pain than other
patients.[54]
Swedish-style back schools generally provide education and information about LBP
problems, ergonomic instruction, and back exercises. For cLBP, the evidence is
somewhat conflicting, but there is some evidence overall that back schools may be
effective in improving short-term pain and functional outcomes, but not long-term
outcomes.[55, 56] Previous systematic reviews that are available for evaluating back
schools largely included multidisciplinary interventions where back schools played a
minor role. Most studies included various types of physiotherapy including exercise,
massage, electrotherapy, thermotherapy, and other modalities, which makes it
difficult to evaluate the effectiveness of back schools alone. One high-quality study
showed evidence that back schools contributed significantly to overall outcomes only
when offered between weeks 4 and 16 of treatment following onset or injury.[57]
Brief education is defined as advice given verbally or nonverbally after consultation
and usually involves only short contact with healthcare professionals through patientled self-management groups, educational booklets, and online discussion groups.
These interventions often encourage self-management, assist in staying active, and
reduce potential concerns about LBP. Two high-quality reviews reported that adding
exercise, stabilization exercises, and manipulation was not cost-effective in patients
with cLBP. In at least 2 of the included trials, differences seemed evident between the
placebo, which was deduced from clinical examination and advice, and education via
a back book that was emailed to the participant (nocebo). Observed results
demonstrated positive effects from active contact.[57]
Behavior caused by a fear of movement is commonly observed in people with cLBP
who have been warned that a "wrong movement" may cause severe pain and
prolonged disability. There are no systematic reviews or meta-analyses to determine
the evidence-based support for training patients to better manage fear-avoidance.
Nevertheless, high-quality studies have suggested that cognitive intervention,
education, and exercises that reduce pain-related fear are likely cost-effective and
vital in returning patients with cLBP to engaging in low levels of physical activity,
including work.
Studies have reported that fear-avoidance beliefs were reduced following exercises
and brief education, suggesting the importance of this intervention as a key factor for
reduction of pain-related fear. A study in patients with acute pain suggests that fearavoidance training should be offered to those with high pain scores and fearavoidance beliefs.
More studies are warranted to compare the cost-effectiveness of brief education, by a
physician or a physical therapist (or both), with back schools. On the basis of
empirical data, the authors of this article do not recommend back schools at this time,
but according to at least 1 high-quality study, back schools warrant more research.
The authors recommend brief education to reduce sick leave. Back books or internet
discussions cannot be recommended as an alternative to other treatments. Fearavoidance training should be incorporated into rehabilitation programs as an
alternative to spinal fusion, but more research is warranted to clarify the indications
and most effective components of the intervention.[57]
Cognitive behavioral therapy is used to modify maladaptive responses to chronic pain.
There is evidence that behavioral therapy can improve short-term pain and functional
outcomes compared with those receiving no treatment. Behavioral treatments seemed
to have similar outcomes to exercise when they were directly compared.[47, 56]
Exercise
Exercise is widely used to treat LBP, but again, research studies without
methodological flaws that support this therapeutic approach are limited. Furthermore,
the specific exercise interventions used to treat cLBP are often heterogeneous, and
little evidence supports one particular approach over another. In a pooled metaanalysis of a variety of exercise interventions, there was strong evidence of a fairly
sizable short-term improvement in pain when patients used exercise therapy compared
with no treatment. There was a smaller, but still significant, improvement from
exercise compared with other conservative treatments. Improvements were
additionally seen in functional outcomes.[47]
Lumbar extensor strengthening exercises describes a supervised progressive
resistance exercise (PRE) program with isolation and intensive loading of the lumbar
extensor muscles. This type of therapy can be performed through a variety of physical
activities including directed physical exercise; aquatic rehabilitation; directional
preference exercises (eg, McKenzie approach); flexibility exercises (eg, yoga);
stabilization exercises (ie, low-load targeted strengthening of the core trunk muscles
with the lumbar spine in a close-packed posture with all components of the rejoin
complex engaged; Pilates and general strengthening exercises, preferably with a
reduced gravity load across the lumbar spine).
A recent systematic review of the best available evidence for lumbar extensor
strengthening exercises was performed by Mooney et al in 2008. The authors
examined various lumbar extensor strengthening devices and protocols including both
high-tech and lower-tech approaches. The specific muscles targeted included the
lumbar erector spinae (including iliocostalis lumborum and longissimus thoracis) and
multifidi muscles. Some techniques specifically isolated these muscle groups, while
others sought to improve trunk extension as a compound movement by including the
action and strengthening of both the lumbar extensors and hip girdle extensors (eg,
buttocks and hamstring muscles). This type of preferential strengthening enhances the
spine's capacity to act as a crane.
This intervention's theoretical mechanism of action is likely related to the
physiological effects of conditioning the lumbar spine muscles through progressive
tissue resistance or enhancing the metabolic exchange of water and nutrients to the
lumbar disks (and muscles) through repetitive motion. These strengthening exercises
may also use psychological mechanisms that force improvements such as retaking the
locus of control and reconditioning the mind to offset fear-avoidance.
Current evidence suggests that short-term lumbar strengthening administered alone is
more effective than either no treatment or most passive modalities for improving pain,
disability, and other patient-reported outcomes with cLBP. However, no clear benefit
of lumbar extension exercises can be demonstrated relative to similar exercise
programs when looking at the long-term effects on pain and disability. However,
lumbar extensor strengthening exercises administered with co-interventions are more
effective than those other exercises (eg, stabilization, no treatment, or just passive
modalities) administered alone with respect to improving lumbar muscle strength and
endurance.
This improvement of strength and endurance in the isolated lumbar extensor muscles
with cLBP through safe, gradually loaded, and measurable PREs that include lumbar
dynamometer machines appears to be the best option. Roman chairs and benches are
viable options, whereas floor or stability ball exercises are not recommended without
supervision. Higher-quality RCTs with a larger sample size and well-defined patient
groups followed for the long-term are necessary to determine more accurate
recommendations in this regard.[58]
Dynamic lumbar stabilization exercises (LSEs) are widely accepted as being
effective. This technique begins with the spine placed in a neutral position, which is
defined as the posture of least pain, biomechanical stress, and potential risk for injury.
The patient is taught to maintain this position while the surrounding muscles
isometrically brace the spine. The extremities can then be moved in patient positions
ranging from supine to standing by using no resistance other than the weight of the
arms and legs or by adding free weights, weight machines, or functional activities.
A 2008 evidence-informed evaluation of the available evidence suggests that LSEs
are effective at improving pain and function in a heterogeneous group of patients with
cLBP. However, strong evidence coexists that this treatment is no more effective for
back pain than less specific exercises. There is moderate evidence that LSEs are no
more effective than manual therapy in the same population.
Only 3 studies were deemed eligible for this review, and only 2 of those were highquality. Although the theoretical and experimental bases for considering this type of
exercise training seem relatively sound, study participants were heterogeneous.
Therefore, no specific subgroup of patients could be identified that may be more
responsive to this type of exercise. Until further data become available, LSE training
should be considered a useful tool for the management of cLBP, but must be
prescribed on a case-by-case basis.[59]
Sertpoyraz et al compared isokinetic and standard exercise programs for cLBP. Pain,
mobility, disability, psychological status, and muscle strength were measured. Forty
patients were randomly assigned to a program that took place in an outpatient
rehabilitation clinic. The results showed no statistically significant difference in effect
between the 2 programs.[60]
EPIDEMIOLOGY OF LOW BACK PAIN IN AFRICA
The health of Africans is of global concern, as improvement in health outcomes observed in
most Western countries over the past few decades has not been achieved in Africa [61].
This has been attributed more recently to the negative impact of the HIV and AIDS
epidemic, reflecting both the focus shift of health interventions, and funding directions in
health research [61]. Africa accounts for about 14% of the world's population, and it is
also the poorest continent, bearing about 40% of the global burden of disease [61,62]. A
positive causal relationship between income and health is well recognized internationally,
in which a higher income promotes good health by the economical ability to access clean
water and sanitation, good nutrition and good quality health services [62]. Lack of access
to these resources consequently predisposes communities to a greater prevalence of
disease and disability [63]. Socioeconomic constraints in Africa therefore underpin the
higher prevalence of many diseases and disabilities [61,62].
The global prevalence of general disability is highest in sub-Saharan Africa [64]. The
etiology of disability is multi-factorial and varies between different parts of the world
[64]The most apparent difference in disability prevalence is between the developed and
developing worlds [65], with the most frequent cause of disability being musculoskeletal
disorders [66]. The difference in disability prevalence between the developed and
developing worlds is one example of global differences in health. Musculoskeletal disorders
accounts for about 4.3% of disability life adjusted years (years living with disability) in the
developed world, whilst it is reported as accounting for approximately 1% in the
developing world [61]. Pain and loss of function associated with musculoskeletal conditions
primarily leads to disability [67]. The four major musculoskeletal conditions leading to
disability include osteoarthritis, rheumatoid arthritis, osteoporosis and low back pain (LBP)
[67].
LBP is the most prevalent musculoskeletal condition and the most common cause of
disability in developed nations [67]. The lifetime prevalence of LBP (at least one episode of
LBP in a lifetime) in developed countries is reported to be up to 85% [68]. LBP results in
significant levels of disability, producing significant restrictions on usual activity and
participation, such as an inability to work [69]. Furthermore, the economic, societal and
public health effects of LBP appear to be increasing. LBP incurs billions of dollars in medical
expenditures each year [70] and this economic burden is of particular concern in poorer
nations such as Africa, where the already restricted health care funds are directed toward
epidemics such as HIV and AIDS [68].
A review of research publications on LBP suggests that most research has been conducted
in the developed world, where little racial heterogeneity exists [71]. Racial, economic and
social homogeneity is not a feature of Africa, a developing country. It is logical, therefore,
to argue that genetic diversity, and differences in social structure and economics between
the developed and developing nations, may underlie reported differences in the prevalence
of LBP [66]. Other African-specific factors such as the HIV and AIDS epidemic, types of
work tasks and poor nutrition may also influence LBP prevalence among Africans [61].
The literature on the epidemiology of LBP is accumulating, but for the most part, studies
are restricted to high-income countries, therefore little is known about the epidemiology of
LBP in the rest of the world [72]. In developed countries such as the United States of
America (USA) and Australia, LBP prevalence ranges from 26.4% to 79.2% [73,74]. There
appears to be a general (albeit anecdotal) assumption that LBP prevalence in Africa is
lower than that reported in the developed nations [75-77]. A systematic review into the
global prevalence of LBP by Walker in 2000, identified that of the 56 included studies, only
8% were conducted in developing countries, with only one study conducted in Africa [68].
The lack of information on the prevalence of LBP in developing countries is therefore a
significant shortcoming [68,77], particularly as it is predicted that the greatest increases in
LBP prevalence in the next decade will be in developing nations [66]. Understanding
prevalence and causality of LBP in developing nations such as Africa may assist
understanding of global LBP causes and management [68,77], and will determine whether
the factors differ in socio-cultural characteristics [77].
To our knowledge, no systematic review reporting on the prevalence of LBP on the African
continent exists. The aim of this review was therefore to systematically appraise peerreviewed published disease prevalence studies conducted on the African continent, in order
to ascertain whether LBP is of concern among Africans, as it is globally. This review
considered the methodological quality of the relevant literature in order to identify
opportunities for improvement in research practices, as well as to establish a way forward
for high quality research in this area in Africa.
This is the first known systematic review to report on the findings of LBP prevalence and
LBP risk factors among African populations. A global review published in 2000 suggested
that only one African study was available for inclusion [68]. This current review reports a
much larger group of relevant African studies (most published since 2000), of which 67%
were methodologically sound. This review indicates that there is little difference in the
prevalence of LBP among Africans compared with the prevalence of LBP in developed
countries. The earliest publication in this review was written in 1990, which may indicate
that LBP prevalence may be a relatively recent and emerging problem in Africa [78]
However this may also be an indication that publishable LBP research has only received
resource support since the early 1990s, reflecting constraints on health research resources
available on the African continent for orthopaedic research, as a result of urgent research
into other health threats such as HIV/AIDS.
The most common population group studied was "workers". This finding is plausible given
that there is a lack of legislation to support workers suffering from LBP to ensure that they
receive optimal rehabilitation and support. In contrast, in western societies, legislation to
promote spinal health protects workers from lumbar spine injury or pain is in place and is
monitored by government bodies [79]. The lack of best practice rehabilitation methods for
LBP which could prevent chronic pain and disability is evident in the reports of the most
common treatment methods reported in the African research to treat LBP. Despite the
increasing scientific evidence from meta-analyses that active rehabilitation involving
exercise is most effective in reducing disability and LBP recurrence [80,81], the most
common forms of management identified in this review were rest and analgesics. Well
designed prevalence studies into African LBP, coupled with intervention studies to test the
effectiveness of high quality interventions should be undertaken to inform and transform
labor legislation policies to ensure better support for workers suffering from LBP.
'School scholars' were the second most common group studied by African researchers. This
is viewed as a positive step, particularly with respect to setting the scene for primary
prevention of LBP. The results of this review indicate that there is reason for concern
regarding LBP prevalence in adolescents. Of further concern is that a "history of LBP" as
reported in many western societies as a causal agent of LBP, may also be an important
predictor of LBP among Africans. This implies that much LBP experienced by young people
may manifest into chronic LBP in adulthood. Chronic LBP is costly to manage due to
recurrent and debilitating nature of the condition. The findings of this review indicate that
primary prevention should be considered an African priority due to the already constrained
economic resources for overall health care [63,65,68]. Another factor that may be
increasing the prevalence of LBP among young African people is the widespread
introduction of information technology systems in African schools. For instance, in the
Western Cape of South Africa, all or most schools will probably be equipped with computer
laboratories by the year 2012 for curriculum delivery in an attempt to compensate for the
increasing shortage of school educators. While the use of technology may be best practice
for educating young people, it also introduces the likelihood of young people developing
poor postural habits unless they are specifically instructed otherwise. The school setting
may therefore be appropriate to teach young people good spinal health habits, and future
research should incorporate spinal health promotion strategies for schools in Africa.
The mean LBP point prevalence among the African adolescents was 12% and among the
African adults 32% (range 10% to 59%). This finding negates any assumptions that LBP
point prevalence is lower in the developing world than developed societies, as the range of
LBP point prevalence among western societies is also reported to range between 12% and
33% [68,82]. This revelation supports the findings of the global burden of disease studies
which predict that the greatest increases in LBP prevalence will be in developing nations
[66]. Unfortunately, the data obtained from the studies included in this review is
insufficient to ascertain the trend of LBP over more than 2 decades, as the earliest
methodologically acceptable study reporting point prevalence was published in 1993 [83].
However, with over 80% of the included studies published after the year 2000, there will
be the capacity in a few years time to predict African LBP prevalence trends with some
certainty.
The one-year LBP prevalence among Africans ranged from 14% to 72%. The one-year
prevalence among Western societies is reported to be between 20% and 62% [68].
Therefore it appears that the one-year prevalence estimated among Africans correlates
with the one-year LBP prevalence in Western societies. Similarly, comparable findings were
observed for lifetime prevalence estimates as African lifetime prevalence ranged from 28%
to 74%, whilst lifetime prevalence in Western societies ranged from 30% to 80%[82].
Advances in technology and the mechanization of industries in African countries may
therefore be reflected in the high one-year and lifetime prevalence of LBP among Africans,
reported in the past decade of research. However, there is insufficient data on rural
populations as only three [84,85,46] of the 18 methodological acceptable studies provided
data exclusively on rural populations. The prevalence reported in these studies is
comparable to reported urban population prevalence, and may reflect that the considerable
physical activities required for rural (farming) activities may be a risk factor for LBP [84,85
,46]. The study by Omokhodion (2004) illustrates that farming activities increase the odds
of suffering LBP by four, compared with individuals not exposed to farming activities [76].
These findings related to one-year and lifetime prevalence, and further illustrates that LBP
among all Africans is of concern. Further research into the most effective strategies to
manage and prevent LBP is warranted.
The mean response rate to the African studies included in this review was 88%, which
correlates with the mean response rate of 81% reported in the systematic review by
Walker [68]. The reason for poor response rates in six [75,87-90,91] of the African studies
was often cited as incomplete questionnaires, and this may be because the questionnaire
content and language was not culturally acceptable. One critical area to be addressed by
African researchers is to ensure that data collection tools are valid for specific target
populations, and are reliably answered.
The findings of this review indicate that the prevalence of LBP among Africans may be
comparable to that reported in research undertaken in developed nations. Therefore
further research into the identification, prevention and best practice management of LBP is
also necessary in African countries. Furthermore, there is a clear mandate for African
researchers to improve the methodological quality of their LBP epidemiological studies,
considering the reliability and validity of measurement instruments, and agreeing on a
standard definition of the condition. Possible limitations to this study could be that certain
African journals were inaccessible on electronic databases, as they were published locally,
were only available in the specific African country and not obtainable in South Africa. There
was difficulty contacting the researchers and libraries in these countries.
CONCLUSIONS
Most back pain can be prevented by keeping your back muscles strong and making
sure you practice good mechanics. Chronic low back problems can interfere with
everyday activities, sleep and concentration. Severe symptoms may affect mood and
sexuality. Chronic pain is also associated with depression, which can in turn make
chronic pain worse. The challenge for the future will involve the search for the best
therapeutic intervention
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