My Spine World

1.How big a burden is Low back pain?

Low back pain (LBP) is a common musculoskeletal condition worldwide. A systematic review of studies reporting incidences of LBP, conducted in Canada, United Kingdom (UK), Denmark, Israel and Kuwait, suggested an annual incident estimate of 1.5–36% for LBP

 The annual estimate of new incidences of LBP was reported to range from 6.3% to 15.4% in these countries.

 A recent large survey, conducted in the UK with 15,000 people with LBP, reported a one-month prevalence rate of 28.5% for this condition. Incidences of severe LBP were shown to increase with age, with these incidences peaking in the 41–50 age group.

A systematic analysis for the Global Burden of Disease Study 2013 ranked LBP as the leading cause of years lived with disability.

The global economic burden of LBP is also high. A systematic review on the global cost of LBP, between 1997 and 2007, estimated the annual cost of illness to range from US$1.2 billion to US$25 billion.

With the pandemic situation abating, more data is emerging about a worsening situation with respect to back pain. Singapore is no different.

2. Every one experiences Low back pain at some point I their life. When should one consult a doctor or be worried about their back pain?

Let’s try and define an acute and chronic low back pain.

Recent evidence has questioned the prevailing belief that acute LBP resolves within 3 months. A systematic review indicated that 2% to 48% (median, 26%) of patients with acute LBP in primary care settings transition to chronic LBP.

In my opinion, if your back pain lasts more than two weeks and keeps you from participating in normal, daily activities, see your family doctor. If your pain is severe, you should see a doctor sooner. You should seek urgent medical care if you have “red flags”

• Fever associated with back pain
• Back pain after trauma
• Loss of bladder or bowel control
• Loss of strength in your arms and legs
• Unexplained weight loss associated with back pain

Also, always be more cautious if you have special risk factors for cancer, infection, or fractures that may affect the spine.

3. We know that Chronic low back pain is more problematic to manage .

How do you manage a patient with acute pain, to prevent it from being a chronic one?

A good question. I think the medical personnel who is reading this should pay special attention.

A systematic review indicated that 2% to 48% (median, 26%) of patients with acute LBP in primary care settings transition to chronic LBP. That’s a big number.

In a recent inception cohort study  conducted alongside a multisite, pragmatic cluster randomized trial and published in 2020 (JAMA), Adult patients with acute LBP were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months. 

They found that patient demographic and clinical factors associated with the chronic LBP transition included:

• Obesity
• Smoking
• Insurance coverage
• LBP with leg pain
• Baseline disability- the worse the pain more chance that you can develop chronic pain and Diagnosed depression/anxiety.

The role that these factors play in the transition to chronic LBP cannot be ignored;

however, many of these factors are difficult to change or nonmodifiable altogether. The study demonstrate that independent of these factors, exposure to non-concordant processes of care during the early phase of treatment was associated with developing chronic LBP. 

What are these non-concordant processes?

•  In brief, any prescriptions that included opioids were considered non-concordant.
• Additionally, prescriptions that included benzodiazepines and/or systemic corticosteroids alone without the presence of nonsteroidal anti-inflammatory drugs or short-term skeletal muscle relaxants were considered non-concordant.
• Non-concordant diagnostic imaging consisted of an order for lumbar radiograph or computed tomography/magnetic resonance imaging (CT/MRI) scan.
•  Non-concordant medical subspecialty referral included referrals to nonsurgical or surgical specialties (e.g.  orthopaedists, neurologists, neurosurgeons, or pain specialists). 

Early exposure to guideline non-concordant care was significantly and independently associated with the transition to chronic LBP after accounting for patient demographic and clinical characteristics, such as obesity, smoking, baseline disability, and psychological comorbidities.

3. How common is chronic low back pain in Singapore and are there any hurdles to low back pain management locally?

In a recent epidemiological study, LBP was ranked as the leading cause of years lived in disability in Southeast Asian countries, such as Indonesia, Malaysia, Philippines and Vietnam. Work-related LBP’s Daily Adjusted Life Years (DALYs) lost in Southeast Asia, after taking socioeconomic situations into consideration, was still found to be higher here than in other parts of the world.

Acute low back pain is estimated to affect up to 80% of the adult population in Singapore, leading to significant anxiety and debilitation in patients. It most commonly affects adults aged between 30 and 40 years.

Its interesting to note certain points that was published in a Singapore study a few years ago. I will mention a few points here:

• Majority of patients (59.6%) were aged between 30-50 years old. Sixty-six percent were engaged in occupations that involved sustained postures.
• Majority of patients (91.5%) had minor/no trauma in association to the onset of their symptoms.
• Although majority of patients (64.9%) did not take any time off work to manage their LBP, a total of 640 days were lost off work due to LBP.
• Majority of patients (93.6%) underwent radiological investigations.
• There was a significant relationship between earlier onset of therapy and better functional improvement on the PSFS (r= -0.299, p = 0.026).
• It is notable that 75.5% of these patients presented with recurring LBP .

Challenges to tackling backpain in Singapore?

Challenges are many .I will quote a few :

Non-concordant practices.

As mentioned before non-concordant practices would lead to higher incidence of chronic low back pain and in turn higher cost. Lack of awareness among patients, primary care physician and even specialists is definitely a challenge. The fact that an overwhelming order of radiographic investigations ordered is an example.

A review of clinical practice with regards to ordering radiological investigations may be required to minimise radiation exposure and increase cost effectiveness.

Pandemic and work from home practices .

Rising obesity

A recent survey, conducted between July 2019 to March 2020 from a representative sample of residential addresses, tracks the health and risk factors, as well as lifestyle practices of Singaporeans and permanent residents aged between 18 to 74  found that  during the period of 2019 to 2020, 10.5 per cent of Singapore residents were obese.

This is the same obesity level as in 2010.

In comparison, the crude prevalence of obesity was 8.6 per cent in both 2013 and 2017, when data on obesity was collected.

5. The COVID-19 pandemic and the extended lockdown are associated with numerouschanges in behaviour and lifestyles, especially with most of them working from home.

Do you see an increase in CLBP cases during the COVID-19 pandemic?

Yes. Universally .

A significant increase in LBP prevalence and intensity during the COVID-19 pandemic compared to the pre-pandemic period. This may be explained by the reduced rate of physical activity and the prolonged sitting time without appropriate ergonomic supports during remote working. In addition, psychological implications of social isolation, including loneliness, pain catastrophizing, somatization, and the incremented risk of anxiety and depression, may further boost such a condition.

Therefore, workplace interventions in the “home office” setting as well as psychological support for individuals affected by LBP are strongly advised as long as the COVID-19 pandemic persists.

6. What lifestyle modifications do you suggest for people who are working from home?

Ok. Here are the key points.

Don’t Be a Slouch

Easier said than done! The aim of our body is to maintain balance and to achieve centre of gravity. Slouching is common because the natural tendency is to have the head forward due to its weight and the body follows. It adds to the stress on your spine. That puts a strain on the bones, muscles, and joints you need to hold your backbone in place.

Slouching also reduces the space for your lungs to breathe and gives less space for your intestines. In other words, your intestines and your lungs don’t work well, and you end being fatigued early.

 Now… how do you prevent it?

It can be done in 5 easy steps

1. Always be conscious of your posture.
2. Keep a reminder if you have to on your phone or any smart devices. A 30 minute is a good idea to check on your posture. Take breaks.
3. When you sit, make sure your head is over your shoulder. One way is to have your earlobes in line with your shoulder
4. Sit all the way back in your chair. Place a small, rolled-up towel or lumbar cushion behind your mid-back to protect your spine’s natural curve.
5. Bend your knees at a right angle and keep them the same height, or a bit lower than your hips. Place your feet flat on the floor.

Make the changes you require to do these postural adjustments.

Deskercises that will help you to straighten up and feel better.

There are 2 types of exercises :

1. Tucks – Chin tucks, Shoulder tucks
2. Stretches- Ear to shoulder stretch ,Roof to chest stretch, Chest stretch, Chin to shoulder stretch

• Chin tucks- Pull your chin towards your spine. You will feel the muscles in the back of your neck working slightly. Hold for 5 seconds and keep breathing. Do 10-15 at a time.
• Shoulder tucks- Your shoulder blades together, down and back. You will feel the muscles in the upper back working. Hold for 5 seconds and keep breathing. Do 10-15 times.
• Ear to shoulder stretch-Sit up straight and tilt your head to one side so your ear goes towards your shoulder. This will stretch the opposite side neck muscles. Hold for 30-60 seconds on each side.
• Roof to chest stretch-Sit up straight and look at the roof and then slowly bend your neck down towards your chest. At the bottom of the movement you will feel a stretch in the back of your neck. Hold this for 30-60 seconds.
• Chest stretch-Stand in a doorway and put both hands on either side of the door about head level. Lean forward until you feel a light stretch in your chest. Hold about 30 seconds and do 2-3 times.
• Chin to shoulder stretch-Sit up straight. start by looking directly in front and slowly look to the side as if you are looking over your shoulder. You will feel the same side muscles stretching. Hold about 30 seconds and do 2-3 times. Repeat on the opposite side.

https://www.myspineworld.com/6-important-steps-for-you-to-attain-the-best-posture/

Beware of text neck

 

On your smart devices all day? Take a minute to stretch your neck.

When you tilt your head down to check messages it really strains your spine. Over the course of a day or year , that can add up. 

 Remember when you bend down the  front of the cervical spine ( that is  your neck) area will eventually kyphose or bend forward.

 Also, remember that your neck should be curved backwards than forwards. It will also stretch your trapezius muscle that connects your neck with the shoulder blades and you will end up with a stiff neck and upper backaches.

Here are 4 tips for you for that pain in the neck :

• Bring the screen to eye level so your head is not slouched forward or too high. Instead, keep a neutral spine so your ear is in line with your shoulders.
• Take phone breaks, water breaks, tea brakes, or any break.. as long as you get to ditch your smart devices. Even 5 minutes every hour will do.
• Did you know that there is an app for text neck?! There are text neck apps that offers “immediate real time feedback” about your posture (indicated by a green or red light). There’s also an optional vibration or beep reminder to tell you when you’ve lapsed back into bad habits.
• Do 20 minutes of exercises mentioned above or modalities like yoga.

https://www.myspineworld.com/5-tips-for-you-to-get-rid-of-tech-neck-syndrome/

 Do your daily core

Too many pounds around your belly puts added stress on your back. You need strong muscles to support your spine. Period.

A well-designed workout plan will keep your body and spine in tip-top shape. And that’s important. Do these and you will find yourself reaping the windfall for not only your back but in a lot other areas as well.

7. It is well-known that use of opioid pain treatments is associated with drug dependence.What is the status in Singapore? Any risk factors that one should look for?

Ok .This one is for the health care professional who deals with back pain.

There are enough and more studies out there that shows the connection between illicit drugs and prescription opioids among patients with chronic low back pain. Subjects who had ever used illicit drugs were more likely to have an active prescription for opioid analgesics: 22.5 percent versus 15 percent. Current illicit drug users were also more likely to have an opioid prescription, although that difference was not statistically significant.

Prescription opioids are widely used by patients with chronic low back pain, raising concerns about addiction, misuse, and accidental overdose. Previous studies have found that people with a history of illicit drug use are more likely to misuse prescription opioids.

The guidelines from the Ministry of Health states :

Initiating Opioid Therapy in General First Line Treatment for Acute and Chronic pain Opioids should not be prescribed as the first-line treatment for acute and chronic pain. Instead, the following pharmacological and non-pharmacological modalities should be considered, unless contraindicated:

Pharmacological: Paracetamol, non-steroidal anti-inflammatory drugs (“NSAIDS”) including Cox-II inhibitors and anti-convulsants (e.g. gabapentinoids) when indicated.  For acute neuropathic pain, anti-convulsants, tricyclic antidepressants (“TCA”), e.g. amitriptyline, and serotonin-norepinephrine re-uptake inhibitors (“SNRI”), e.g. duloxetine, may be more effective.

 Non-pharmacological: Exercise, physical therapy, acupuncture, relaxation exercises, cognitive behavioural therapy and heat/cold therapy.

Identifying Risk Factors and Patient Factors Before Initiating Opioid Therapy.Medical practitioners should identify and weigh the risk factors for opioid abuse and addiction, before initiating opioid therapy.

MONITOR FOR SIGNS OF :

• Borrowing or stealing of drugs.
• Repeatedly seeking drugs from other providers or emergency departments via doctor-hopping, forging prescriptions or reporting multiple episodes of loss or theft of prescription drugs.
•  Requests for specific drugs, especially a preference for immediate release over sustained-release medications, not following prescribed dose and schedule, multiple unauthorised dose increases or pushing for higher dose of opioids.
•  Non-compliance with non-pharmacological components of pain treatment (e.g. physiotherapy, psychological therapy).
• Showing up only for medication appointments (e.g. misses, cancels, or no-shows at other appointments).
•  Concurrent use of illicit drugs (e.g. heroin, cocaine, methamphetamine, marijuana, others), alcohol or tobacco.
• Past history of abuse of prescription medications or illicit drugs.
•  Positive urine drug test for illicit drugs or unauthorised drugs.
•  Deterioration of function at work, in the family or socially.

8. In your opinion, what can be done to prevent/overcome drug dependence inpatients with CLBP?

Goal of treatment should focus on return to function and not just relief of symptoms.

If you are prescribing drugs , follow the guidelines or Who pain ladder and do not start with the strong opioids.

A wide variety of treatment options are available for the management of Chronic low back ache.

• Opioids, especially long-term use of strong opioids, should not be prescribed as a first line treatment due to its potential side effects and risk of misuse.
• Initiation of strong opioids, especially when patients have multiple presentations, should be done together with a dedicated multi-disciplinary pain management team, preferably with the inclusion of a pain specialist.
•  A thorough evaluation, including an assessment for risk of opioids, should be done before the initiation of strong opioids. It is recommended that the prescriber clearly documents the roles and responsibilities of both patient and the prescriber.
• Patients with chronic pain receiving strong opioids should be reviewed at a frequency of once every 3 to 4 months if the opioid dose is stable, and more frequently if the titration of opioids are required.

9. What is your key takeaway message to CLBP patients?

PREVENTION IS THE KEY.

Prevention of aggravation is equally important.

1.Activity modification and physical therapy

• Exercise regularly to keep muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
• Use ergonomically designed furniture and equipment at home and at work. Make sure work surfaces are at a comfortable height.
• Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. Put your feet on a low stool or a stack of books when sitting for a long time.
• Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting. 
•  Wear comfortable, low-heeled shoes.
• Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface

2.Reduce dependency on drugs/painkillers

3.Do your daily core 

https://www.myspineworld.com/18-back-pain-exercises-for-you-to-bounce-back/

4.Diet

Maintain a healthy weight and eat a nutritious diet with sufficient daily intake of calcium, phosphorus, and vitamin D to promote new bone growth.

5.Quit smoking.

Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.

https://www.myspineworld.com/smoking-kills-your-back/

6.Mindfulness and Meditation

Chronic back pain is straining both physically and emotionally. To manage the frustration, irritability, depression and other psychological aspects of dealing with chronic pain, meditation, yoga, tai chi and other cognitive and relaxation strategies may help to keep your mind from focusing on pain

7.Know your alternative treatments

Acupuncture, massage, biofeedback therapy, laser therapy, electrical nerve stimulation and other nonsurgical spine treatments can also make a difference for chronic back pain.

You would have noticed that I have not mentioned surgery anywhere in this conversation. That is something that is beyond the scope of this talk and one should talk to your spine/ pain specialist!

References:

1. Goh MR, Po IYY, Olafsdottir K. Low Back Pain in Changi General Hospital: An Observational Study. Proceedings of Singapore Healthcare. September 2010:175-182.

• Stevans JM, Delitto A, Khoja SS, Patterson CG, Smith CN, Schneider MJ, Freburger JK.Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care. JAMA Netw Open. 2021 Feb 1;4(2):e2037371.