Lower back pain:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
1999
|
| Schriftenreihe: | Neurologic clinics
17,1 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | X, 196 S. Ill., graph. Darst. |
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| 650 | 4 | |a Back Pain | |
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Datensatz im Suchindex
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| adam_text | LOWER BACK PAIN
CONTENTS
Preface ix
Scott Haldeman
Low Back Pain: Current Physiologic Concepts 1
Scott Haldeman
It is clear that low back pain is not a simple process that can be
explained on purely anatomic, biomechanical, orneurophysiologic
theories. The intimate relationship of these processes have to be
considered. Each of the potential biomechanical stresses influence
the different spinal structures in different ways, depending on the
forces applied and the structure being affected. The biomechanical
response to the trauma caused by these forces may be immuno
logic, inflammatory, or neurochemical, depending on the struc¬
tures being traumatized. Once a nociceptive process is underway,
it is greatly influenced by the spinal cord and the brain. Only by
following this process through its various steps can a clinician be¬
gin to formulate an understanding of the mechanisms involved in
the genesis of low back pain.
The Clinical Relevance of Biomechanics 17
Malcolm H. Pope and James W. DeVocht
Most neurologists are familiar with biomechanics but may be un¬
sure of the relevance of this field to their practice. Actually those
involved in musculoskeletal problems are undoubtedly using bio¬
mechanical principles. This article is limited to the spine, but the
basic principles of biomechanics are applicable to other parts of the
body. In this article, we describe the spine and trunk as a biome¬
chanical organ, the biomechanical principles behind back injuries
and their importance, the role of biomechanical issues in pain, the
utility of clinical tests based on biomechanical principles, the effects
of aging, and the future directions in spine biomechanical research.
NEUROLOGIC CLINICS
Differential Diagnosis: A Reasonable Clinical Approach 43
Rand Swenson
The reasonable clinical approach to the patient who has low back
pain includes a search for any of the red flags that would prompt
consideration of additional diagnostic testing for serious underly¬
ing disease. The common patterns of back pain would be explored
in an effort to categorize the patient s symptoms and to begin for¬
mulation of a diagnostic impression. Re evaluation of the patient
in light of his response (or lack of response) to these measures is
an essential component of the clinical assessment. Finally, some
consideration must be given to the various biopsychosocial factors
that may affect prognosis, particularly in patients who have more
chronic pain and disability related issues.
Clinical Neurophysiologic Studies: Which Test Is Useful
and When? 65
Catherine Lomen Hoerth and Michael J. Aminoff
Neurophysiological studies test the integrity of nerve roots and
nerves at different points from the spinal cord to the periphery.
EMG is the most sensitive neurophysiological test for evaluating
patients with radiculopathy, providing information on diagnosis,
location, and prognosis. F wave and H reflex studies may be ab¬
normal, but the information that they provide is nonspecific and
usually redundant because the needle examination is abnormal
anyway. Somatosensory evoked potentials are less sensitive and
specific than EMG for diagnosing a radiculopathy, but uncom¬
monly may be the only abnormality. Magnetic stimulation, para
spinal mapping, and cervical root stimulation are investigational
techniques of uncertain utility.
Physical Therapy: Exercises and the Modalities:
When, What, and Why? 75
Margareta Nordin and Marco Campello
This article reviews the evidence for using modalities and/or ex¬
ercise treatment in patients with nonspecific low back pain. Poor
evidence of efficacy exists for the use of modalities in this patient
group. Exercises are beneficial for patients with subacute and
chronic nonspecific low back pain. Further studies are needed for
type, frequency, duration, and intensity of exercises.
Spinal Manipulation: Current State of Research
and Its Indications 91
Gert Bronfort
Based on the most recent and comprehensive systematic reviews,
there is moderate evidence of short term efficacy for spinal manip
ulation in the treatment of both acute and chronic low back pain.
There is insufficient data available to draw conclusions regarding
the efficacy for lumbar radiculopathy. The evidence is also not con¬
clusive for the long term efficacy of spinal manipulation for any
type of low back pain.
Surgery: Indications and Options 113
Hamilton Hall
The challenge is to better define the present role of spine surgery
and more completely understand its realistic benefits and conse¬
quences. In spite of modern sophistication, spine surgery can still
accomplish only the same two broad objectives, decompression
and fusion, that have been possible for more than a century. Never
vague or tentative, surgery has its place in the narrow spectrum of
cases with clearly established, well circumscribed, structural pa¬
thology unresponsive to nonsurgical treatment and producing sig¬
nificant persistent disability. Identifying valid indications and op¬
tions within the plethora of choices requires knowledge of what is
available, what can actually be accomplished, and what limitations
apply.
Rehabilitation: What Do We Do with the Chronic Patient? 131
Tom G. Mayer
Neurologists are often called on to see patients who have low back
pain presenting with significant chronicity and disabling pain.
Even in situations of chronic low back pain, it has been estimated
that a structural diagnosis is made only 60% of the time. Even when
a physical diagnosis is made in these cases, it may be irrelevant to
the primary causes of persistent pain and disability. This article is
designed to point out that, when nonstructural factors are ade¬
quately rehabilitated, even in a worst case occupational injury co¬
hort, remarkable outcomes can be anticipated irrespective of the
structural pathology, patient age, or postoperative impairment.
Psychosocial Issues: Their Importance in Predicting
Disability, Response to Treatment, and Search
for Compensation 149
Robert J. Gatchel and Margaret A. Gardea
The conceptualization of pain and its progression into chronic
disability has evolved from unidimensional models to more inte
grative, biopsychosocial models that take into account the many
biological, psychosocial, social, and economic factors that may
significantly contribute to the low back pain experience. This chap¬
ter reviews various studies that have demonstrated our growing
understanding of these complex, interactive processes in helping
to predict those who develop chronic disability as well as those
who respond best to treatment attempts. Further, we examine the
issue of compensation and how it too is intricately intertwined with
the other variables contributing to lower back pain disability.
Disability: How Successful Are We
in Determining Disability? 167
T. S. Carey
Individuals who have severe back pain have trouble bending, may
not be able to put on their shoes, have difficulty in ambulation, and
may not be able to clean their own houses. What distinguishes
these individuals with low back pain from those afflicted with
other conditions (i.e., congestive heart failure, metastatic cancer,
symptomatic acquired immune deficiency syndrome) is prognosis.
Back pain essentially never shortens life. Acute back pain has a
very benign prognosis, with more than 90% of the individuals re¬
turning to functional status equivalent to their baseline status
within 3 months of the onset of pain. Patients who have chronic
back pain have a significantly worse prognosis, but most cohort
studies show that substantial numbers of chronic back pain pa¬
tients improve over time with supportive therapy.
Perils, Pitfalls, and Accomplishments of Guidelines
for Treatment of Back Problems 179
Stanley J. Bigos
Science should be the basis for guidelines. As a result of the Flexner
Report in 1911, we now live in an era where randomized trials are
available. Statistical methods can truly be applied to evaluate the
reliability of data published in the literature. The result is that we
can now demand more from future publications and allow for a
better evaluation of the mistakes or bias that can distort validity,
applicability, and reliability. The importance of this methodology
is to reduce misunderstandings by patients, clinicians, manufac¬
turers, and government agencies about issues important to patient
care.
Index 193
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