MANAGEMENT OF ACUTE

MUSCULOSKELETAL PAIN
FOCUS ON LOW BACK PAIN

 ACUTE PAIN SYNDROME

Muscle Tendon Ligment

Skin/subcutan strain tendinitis sprain Bone

Abscess,bruise ischemic avulsion fracture

ACUTE PAIN SYNDROME

Joint
arthritis Postoperative

Vascular Visceral Cancer

PAD angina
 DEFINITIONS
I. Low Back Pain
Pain between lowest ribs angle and
lumbosacral.

2. Acute LBP : < 6 week

Subacute LBP : 7 - 12 weeks
Chronic LBP : > 13 weeks
 LOCALIZATION OF PAIN

I. LOCAL
2. RADICULAR
Radiating to leg and foot
3. LOCAL AND RADICULAR
4. REFERRED PAIN
 STRATEGIES IN THE
MANAGEMENT OF LBP
I. What Structures involved ?
2. Underlying Pathylogy?
3. Diagnostic Work-up
4. Therapeutic Options
 I. WHAT STRUCTURES
INVOLVED (1)
I. Pain - sensitive structures
- Skin, Subcutaneous tissues
- Joint, Capsule, Facet Joint
- Anterior and Posterior Longitudinal
ligament
- Sacraoiliac Ligament
- Vertebral Periosteum
- Muscle, Fascia, Tendon, Aponeurosis
- Outer layer of anulus fibrosus
- Duramater
- Blood Vessel
 I. WHAT STRUCTURES
INVOLVED (2)

2. Less - Pain - Sensitive

Structures
- Intervertebral Disk
- Ligamentum Interspinosus
- Ligamentum Flavum
- Inner Layer of Anulus Fibrosus
 II. UNDERLYING
PATHOLOGIES (1)
Classification :

1. Soft tissue strain (90%)

2. Structural Deformity (9%)
3. Systemic Pathology (1%)
Cellis RM. Medicine International 1998;42:82-87)
 II. UNDERLYING
PATHOLOGIES (2)
Approach to Diagnosis :
Based on Pain Distribution
1. Local pain
2. Ischialgia
3. Pain Radiating to Anterior Thigh
4. Pain Radiating to Posterior Thigh
 II. UNDERLYING
PATHOLOGIES (3)
I. Local low back pain
a. Strain
Ligament injury, Anulus Fibrosus
Tearing, Muscle Fibre Disruption,
Muscle spasm, muscle exhaustion.
b. Vertebra
Spondylolysis, Spondylolisthesis,
Facet Syndrome, Spondylitis, Fracture,
Metastatic Tumor.
 II. UNDERLYING
PATHOLOGIES (4)
I. Local low back pain
c. Joint
Sacroilitis
d. Viscera (referred pain)
Aortic aneurysm, gastrointestinal,
urogenital and pancreatic
disorders.
 II. UNDERLYING
PATHOLOGIES (5)
2. Ischialgia
- Pain radiating along the course
of N. Ischiadicus on the limb ex-
tends below the knee.
- Causes: HNP, Spinal stenosis, tumor,
lymphomatous/carcinomatous
meningitis, epidural abscess.
 II. UNDERLYING
PATHOLOGIES (6)
3. Pain Radiating to Anterior Thigh
- Coxitis, hernia anguinalis
- Upper lumbar radiculopathy

4. Pain Radiating to Posterior Thigh

- Myofascial, gluteal, and pyriformis
syndromes.
 PROBLEMS OF LBP
CLINICAL CATEGORY ETIOLOGY_____

Potentially serious Tumor,infection,

Spinal pathology conus cauda
syndrome,fracture______
Ischialgia compression,inflammation
___________________________________________
Nonspecific LBP 85%
Neither serious pathology
nor ischialgia___________
 RED FLAGS

RED FLAGS are physical symptom and sign

indicating serious pathology underlying
the pain.
 YELLOW FLAGS

YELLOW FLAGS are psychosocial disorders

as risk factors for the development of
chronic low back pain.
PATHOLOGY RED FLAGS___________
Cancer & Infection Age >50 or <20
History of Ca,
Unexplained weight loss,
UTI, IV drug abuse,
intractable LBP.________
Fracture Age > 70
Trauma, long-term steroid
Conus cauda Urinal retention/overflow
syndrome incontinence,
Saddle anesthesia,
Progressive paraplegia
DIAGNOSTIC WORK-UP IN LBP (1)

I. History
II. Physical Examination
1. General
2. Neurologic
a. routine
b. specific
III. Investigational
DIAGNOSTIC WORK-UP IN LBP (2)

I. History
1. Nature, Course, Site,
Extension of Pain
2. Past Medical History
3. Family History
4. Psychogenic
5. Red Flags
DIAGNOSTIC WORK-UP IN LBP
(3)

II. Physical Examination

1. General
Spine, Lumbar Muscle, Posture, Gait,
Sitting, Tenderness, Range of
Movement
DIAGNOSTIC WORK-UP IN LBP
(4)

III. Physical Examination

2. Neurological
a. Routine
Motor, Sensory and Autonomic Systems
b. Specific
* In Radiculopaty
- Posture, Gait, Lasegues Test,
Bragards Test, Contralateral
Lasegues Test, Valsalva
Diagnostic Work-Up in LBP (5)

* In Join Pain
- Patricks FABER test: HIP and
Sacroiliac Joints
- Inverse Patricks test: Sacroiliac Joint

3. Red Flags
 DIAGNOSTIC WORK-UP IN LBP
(6)

III. Investigational Examination

1. Neurophysiologic
EMG, SSEP
2. Imaging
Plain Photo, Myelography, CTScan, MRI
USG Abdomen / Pelvis
3. Laboratory
Spinal Fluid, Blood, Urine
 THERAPEUTIC OPTIONS

1. SEVERE ACUTE PAIN

Start with high dose, then lower
gradually.
ANALGESIC DOSING LADDER

2. CHRONIC PAIN / CANCER PAIN

Analgesic agent and its strength are
chosen coresponding to pain intensity in
stepwise manner.
WHO ANALGESIC LADDER
1. ANALGESIC DOSING LADDER
WHO ANALGESIC LADDER
Freedom from pain
Opioid for moderate to severe pain Step 3
+/- Adjuvant
Persisting Pain
Opioid for mild to moderate pain Step 2
+/- Non opioid , +/- Adjuvant

Persisting Pain
Step 1
Non opioid +/- Adjuvant
TREATMENT OF ACUTE LOW
BACK PAIN (I)
I. Conservative
1. Bed Rest
- in severe pain
- 2-4 days followed by gradual mobilization
2. Physical Treatment
- First 2 weeks mild exercise (swimming,
cycling, walking)
- After 2 weeks: exercise of back and
abdominal muscles.
- TENS, traction, ice/hot pack, diathermy,
ultrasound, corset, brace.
TREATMENT OF ACUTE LOW
BACK PAIN (2)

I. Conservative
3. Pharmacotherapy
- Analgesic: Paracetamol, NSAID, Opioid
- Muscle Relaxant
- Steroid: oral, epidural
4. Education
- Posture, Sitting, Weight Lifting
 TREATMENT OF ACUTE LOW
BACK PAIN (3)

II. Surgical

Indication and Method based

on underlying pathology
 CLASSIFICATION OF NSAID
Based on COX Selectivity
1. Standard NSAID
- Inhibition of COX-1 > COX-2
- NSAID COX-1(aspirin,piroxicam,diclofenac)
2. Preferential COX-2
- Inhibition of COX-2 >> COX-1
- Meloxicam, Nimesulide, Etodolac.
3. Selective COX-2
- Inhibition of COX-2.
- Celecoxib, Rofecoxib, Valdecoxib,
Parecoxib,
Lumiracoxib.
 MECHANISM OF ACTION OF NSAID
I. COX-1 INHIBITOR
Homeostatic Stimulus (hormone, GF)

Cell membrane phospholipid cNOS NO
PLA 2
Arachidonic Acid
NSAID(-)-------> COX-1 (constitutive)
(COX 1-I) PGG2
Endoperoxidase
PGH2
Isomerase & syntethase
___________________ _____
| | | | |
PGD2 PGE2 PGF2 PGI2 TXA2
-kidney - endothel -platelet
-vascular - gaster
COX-1 function: physiologic process of organs
(house keeping)
 MECHANISM OF ACTION OF NSAID
II. COX-2 INHIBITOR
INFLAMMATORY STIMULUS
(Endotoxin,cytokine (IL1,TNF),Mitogen)iNOS------NO

Phospholipid (cell membrane) inflammatory cell |

----PLA 2 (macrophage,synoviocyte tc.) |
Arachidonic Acid |
--- COX-2 (+)--------Inflammatory mediator
|
PGs (PGE2) (Protease,cytokine,PAF) |
| (-) |_____(+)
_________________________|
|___NSAID (COX-2 Inhibitor)