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Monday, 25 November 2013

Chronic Low back pain – The Causes

Low back pain is a Musculoskeletal disorders (MSDs, affecting over 80% of the population in US alone some points in their life. Chronic LBP (pain has persisted for longer than 3 months(1) prevalence in older adults was significantly higher than the 21-to-44-year age group (12.3% vs. 6.5%, p < .001). Older adults were more disabled, had longer symptom duration, and were less depressed(2)..Many older adults remain quite functional despite CLBP, and because age-related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain-free(3).
A. Causes of chronic back pain
1. Trochanteric bursitis 
Trochanteric bursitisis a clinical condition which simulates major hip diseases and low back pain, it may also mimic nerve root pressure syndrome(10).
2. Spinal stenosis
Spinal stenosis of aging population is at the higher risk of developing low back pain(11)
3. Chronic compression of the dorsal root ganglion (CCD) is associated with  Chronic Low back pain(12)
4. Cauda equina syndrome (CES)
In the study to review the literature on the clinical progress in cauda equina syndrome (CES), including the epidemic history, pathogenesis, diagnosis, treatment policy and prognosis, showed that each type of CES has different typical signs and symptoms. Low back pain may be the most significant symptoms, accompanied by sciatica, lower extremities weakness, saddle or perianal hypoesthesia, sexual impotence, and sphincter dysfunction(13).
5.  “Wear and tear” and “disc space loss” are associated with the development of Chronic Low back pain as a result of a progressive loss of structural integrity(14).
6. Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM)
Patients with OA, LBP, and FM frequently demonstrate abnormalities of muscles, ligaments, or joints, the severity of such changes is only poorly correlated with clinical pain. Importantly, many patients with these chronic pain disorders show signs of central sensitization and abnormal endogenous pain modulation, according to the study by the Division of Rheumatology and Clinical Immunology, University of Florida(15)
7. Spondylitis
Spondylitis is associated with low back pain(16)
8. Extracellular matrix protein SPARC (Secreted Protein, Acidic, Rich in Cysteine) 
Study of Alan Edwards Centre for Research on Pain, McGill University showed that aging mice develop anatomical and behavioral signs of disc degeneration and back pain, decreased SPARC expression and increased methylation of the SPARC promoter. In parallel, human subjects with back pain exhibit signs of disc degeneration and increased methylation of the SPARC promoter. Methylation of either the human or mouse SPARC promoter silences its activity in transient transfection assays(16a). Other study found that SPARC-null mice display behavioral signs consistent with chronic low back and radicular pain that we attribute to intervertebral disc degeneration(16b).
8. Etc.
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Sources
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Red flags*
Recent significant trauma, Milder trauma if age is greater than 50 years, Unexplained weight loss, Unexplained fever, Immunosuppression, Previous or current cancer, Intravenous drug use, Osteoporosis, Chronic corticosteroid use, Age greater than 70 years, Focal neurological deficit, Duration greater than 6 week(a)
(a) http://en.wikipedia.org/wiki/Low_back_pain 
(1) https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain
(2) http://jah.sagepub.com/content/22/8/1213.refs
(3) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2065872/
(10) http://www.ncbi.nlm.nih.gov/pubmed/15587030
(11) http://www.ncbi.nlm.nih.gov/pubmed/22828693
(12) http://www.ncbi.nlm.nih.gov/pubmed/23054639
(13) http://www.ncbi.nlm.nih.gov/pubmed/19493474
(14) http://www.ncbi.nlm.nih.gov/pubmed/20838269
(15) http://www.ncbi.nlm.nih.gov/pubmed/21833699
(16) http://www.ncbi.nlm.nih.gov/pubmed/21952186
(16a) http://www.ncbi.nlm.nih.gov/pubmed/21867537
(16b) http://www.ncbi.nlm.nih.gov/pubmed/20714283