Chapter 41

Low Back Pain Comorbidities

Depression, smoking, alcohol abuse, obesity, and stress are frequent comorbidities

Hammer Toe

Hammer toe is a flexion deformity of the interphalangeal joint, which may involve several toes Treatment consists of conservative measures: wearing open-toed sandals or shoes that conform to the shape of the foot, carrying out manipulative exercises, and protecting the protruding joints with pads. Surgery (osteotomy) may be used to correct a resulting deformity.

Osteomyelitis is classified as

Osteomyelitis is classified as: Hematogenous osteomyelitis (i.e., due to bloodborne spread of infection) Contiguous-focus osteomyelitis, from contamination from bone surgery, open fracture, or traumatic injury (e.g., gunshot wound) Osteomyelitis with vascular insufficiency, seen most commonly among patients with diabetes and peripheral vascular disease, most commonly affecting the feet

Assessment of a patient who is using pain medication for lower back pain

The nurse assesses the patient's response to analgesic agents. As the acute pain subsides, medication dosages are reduced.

How should a patient with lower back pain get out of bed

The nurse instructs the patient to get out of bed by rolling to one side and placing the legs down while pushing the torso up, keeping the back straight

When is back pain considered to be chronic

With back pain, chronic pain is considered to last 3 months or longer without improvement.

Ganglion

a collection of neurologic gelatinous material near the tendon sheaths and joints—appears as a round, firm, cystic swelling, usually on the dorsum of the wrist. It frequently occurs in women younger than 50 years (Grossman & Porth, 2014). The swelling is locally tender and may cause an aching pain. Treatment may include aspiration, corticosteroid injection, or surgical excision

contracture

abnormal shortening of muscle or fibrosis of joint structures

Carpal Tunnel Syndrome

compression of the median nerve as it passes between the ligament and the bones and tendons of the wrist. It frequently occurs in women between 30 and 60 years of age. Commonly caused by repetitive hand and wrist movements, it is also associated with rheumatoid arthritis, diabetes, acromegaly, hyperthyroidism, or trauma patient experiences pain, numbness, paresthesia, and, possibly, weakness along the median nerve distribution (thumb, index, and middle fingers). Night pain and/or fist clenching upon awakening is common. A positive Tinel sign helps identify patients requiring intervention

sequestrum

dead bone in abscess cavity

radiculopathy

disease of a spinal nerve root, often resulting in pain and extreme sensitivity to touch. The patient may report pain radiating down the leg,

Involucrum

new bone growth around a sequestrum

Callus

A callus is a thickened area of the skin that has been exposed to persistent pressure or friction. Faulty foot mechanics usually precede the formation of a callus. Treatment consists of eliminating the underlying causes and having a painful callus treated by a podiatrist. A keratolytic ointment may be applied and a thin plastic cup worn over the heel if the callus is on this area.

corn foot

A corn is an area of hyperkeratosis (overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of a congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is most frequently involved, but any toe may be involved. Corns are treated by a podiatrist by soaking and scraping off the horny layer, by application of a protective shield or pad, or by surgical modification of the underlying offending osseous structure.

What position when laying down should be avoided in a patient with lower back pain?

A prone position should be avoided because it accentuates lordosis.

Benign Bone Tumors

Benign tumors of the bone and soft tissue are more common than malignant primary bone tumors. Benign bone tumors generally are slow growing, well circumscribed, and encapsulated; present few symptoms; and are not a cause of death. Benign masses include osteochondroma, enchondroma, bone cysts, osteoid osteoma, rhabdomyoma, and fibroma.

Conservative treatment for Bursitis and Tendonitits?

Conservative treatment includes rest of the extremity, intermittent ice and heat to the joint, and NSAIDs to control the inflammation and pain. Most tendon and bursal inflammatory problems are self-limiting; as they go away on their own with or without therapy

Post Op care for a Patient Undergoing Surgery of the Hand or Wrist

Hourly neurovascular assessment of the exposed fingers for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion. Dressings provide support but should be nonconstrictive. Intermittent use of ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control edema. Unless contraindicated, active extension and flexion of the fingers to promote circulation are encouraged, even though movement is limited by the bulky dressing. Generally, pain and discomfort can be controlled by the use of oral analgesic agents To control swelling that may increase the patient's discomfort, the nurse instructs the patient to elevate the hand to heart level with pillows. If the patient is ambulatory, the arm is supported in a conventional sling with the hand elevated at heart level

Impingement syndrome

Impingement syndrome is a general term that describes impaired movement of the rotator cuff of the shoulder. usually occurs from repetitive overhead movement of the arm or from acute trauma resulting in irritation and eventual inflammation of the rotator cuff tendons or the subacromial bursa as they grate against the coracoacromial arch. Early manifestations of this syndrome are characterized by edema from hemorrhage of these structures, pain, shoulder tenderness, limited movement, muscle spasm, and eventual disuse atrophy. Medications used to treat early impingement syndrome include oral NSAIDs or intra-articular injections of corticosteroids. Application of superficial cold or heat may subjectively improve patients' symptoms; however, a therapeutic exercise program is required to improve outcomes, including reduction of pain and improved shoulder function

Morton neuroma

Morton neuroma (plantar digital neuroma, neurofibroma) is a swelling of the third (lateral) branch of the median plantar nerve Microscopically, digital artery changes cause an ischemia of the nerve within the third intermetatarsal (web) space. The result is a throbbing, burning pain in the foot that is usually relieved with rest and massage.

Acute Back Pain Medical Managment

Most back pain is self-limited and resolves within 4 to 6 weeks with analgesics, rest, and avoidance of strain. Management focuses on relief of discomfort, activity modification, and patient education. Nonprescription analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain, but no one medication is considered superior to another Opioid medications are indicated only short term for acute moderate to severe cases of low back pain, except in older adults, those with kidney disease, or those who must avoid chronic NSAID exposure because of its adverse gastric effects. Systemic corticosteroids and acetaminophen (Tylenol) are not effective in alleviating low back pain Effective nonpharmacologic interventions include thermal applications (hot or cold) and spinal manipulation (e.g., chiropractic therapy). Lumbar support belts are not recommended to treat acute low back pain but may be marginally effective devices for preventing low back pain in occupational health settings (MQIC, 2016a).

Low Back Pain

Most low back pain is caused by one of many musculoskeletal problems, including acute lumbosacral strain, unstable lumbosacral ligaments and weak muscles, intervertebral disc problems, and unequal leg length. Generally, back pain due to musculoskeletal disorders is aggravated by activity, whereas pain due to other conditions is not. The patient's gait, spinal mobility, reflexes, leg length, leg motor strength, and sensory perception may be affected

osteomalacia

Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone. As a result, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures. On physical examination, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait. The major defect in osteomalacia is a deficiency of activated vitamin D, which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. A nutritious diet is particularly important in older adults. Adequate intake of calcium and vitamin D is promoted. Because sunlight is necessary for synthesizing vitamin D, patients should be encouraged to spend some time in the sun, for at least 10 minutes and up to an hour daily

Osteomyelitis

Osteomyelitis is an infection of the bone that results in inflammation, necrosis, and formation of new bone.

Paget Disease

Paget disease (osteitis deformans) is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. Because the diseased bone is highly vascularized and structurally weak, pathologic fractures occur. Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain Paget disease is insidious. Some patients do not experience symptoms but only have skeletal deformity. The condition is most frequently identified on x-ray studies performed during a workup for another problem.

Patient at risk for Osteomyelitis

Patients who are at high risk for osteomyelitis include older adults and those who are poorly nourished or obese. Other patients at risk include those with impaired immune systems, those with chronic illnesses (e.g., diabetes, rheumatoid arthritis), those receiving long-term corticosteroid therapy or immunosuppressive agents, and those who use IV drugs

Pes cavus

Pes cavus (clawfoot) refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot . The shortening of the foot and increased pressure produce calluses on the metatarsal area and on the dorsum of the foot

Pes planus

Pes planus (flatfoot) is a common disorder in which the longitudinal arch of the foot is diminished. It may be caused by congenital abnormalities or associated with bone or ligament injury, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis.

Plantar fasciitis

Plantar fasciitis, an inflammation of the foot-supporting fascia, presents as an acute onset of heel pain experienced with the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon.

Body Mechanics

Practice good posture Avoid twisting, lifting above waist level, and reaching up for any length of time Push objects rather than pull them Keep load close to your body when lifting Lift with the large leg muscles, not the back muscles Squat while keeping the back straight when it is necessary to pick something up off the floor Bend your knees and tighten abdominal muscles when lifting Avoid overreaching or a forward flexion position Use a wide base of support

Malignant Bone Tumors

Primary malignant musculoskeletal tumors are relatively rare and arise from connective and supportive tissue cells (sarcomas) or bone marrow elements (multiple myeloma; see Chapter 34). Malignant primary musculoskeletal tumors include osteosarcoma, chondrosarcoma, Ewing sarcoma, and fibrosarcoma. Soft tissue sarcomas include liposarcoma, fibrosarcoma of soft tissue, and rhabdomyosarcoma.

Risk factors for osteoporosis

Small-framed women are at greatest risk for osteoporosis. Men have a greater peak bone mass and do not experience a sudden midlife estrogen reduction. It is believed that both testosterone and estrogen are important in achieving and maintaining bone mass in men Risk for osteoporosis rises with increasing age for both genders Alcohol intake of 3 or more drinks daily Current use of tobacco products Family history History of bone fracture during adulthood Inactive or sedentary lifestyle Inadequate calcium and vitamin D intake Low body mass index Malabsorption disorders (e.g., eating disorder, celiac disease, bariatric surgery) Men older than 60 years of age Women who are postmenopausal Prescribed corticosteroids (e.g., prednisone) for longer than 3 months

Metastatic Bone Disease

The most common primary sites of tumors that metastasize to bone are the kidney, prostate, lung, breast, ovary, and thyroid (Coleman et al., 2014). Metastatic tumors are most frequently found in the skull, spine, pelvis, femur, and humerus and often involve more than one bone (polyostotic)

Most patients need to alter their activity patterns to avoid aggravating the pain. What should they do an avoid ?

They should avoid twisting, bending, lifting, and reaching—all of which stress the back. The patient is taught to change position frequently. Sitting should be limited to 20 to 50 minutes based on level of comfort. Absolute bed rest is no longer recommended; typical activities of daily living (ADLs) should be resumed as soon as possible.

Chronic Pain Managment

Tricyclic antidepressants (e.g., amitriptyline [Elavil]) and the dual-action serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine [Cymbalta]) or atypical anticonvulsant medications (e.g., gabapentin [Neurontin], which is prescribed for pain from radiculopathy) are used effectively in chronic low back pain. Systemic corticosteroids and acetaminophen (Tylenol) are not effective in alleviating low back pain Cognitive-behavioral therapy (e.g., biofeedback), exercise regimens, spinal manipulation, physical therapy, acupuncture, massage, and yoga are all effective nonpharmacologic interventions for treating chronic low back pain

Strategies for Preventing Acute Low Back Pain Prevention

Weight reduction as needed: Modify diet to achieve ideal body weight Avoid high heels Walk daily and gradually increase the distance and pace of walking Avoid jumping and jarring activities Stretch to enhance flexibility. Do strengthening exercises

Physical Examination of a patient suffering of lower back pain.

assesses the spinal curve, any leg length discrepancy, and pelvic crest and shoulder symmetry The nurse palpates the paraspinal muscles and notes spasm and tenderness. When the patient is in a prone position, the paraspinal muscles relax and any deformity caused by spasm can subside The nurse asks the patient to bend forward and then laterally, noting any discomfort or limitations in movement.

osteoporosis

degenerative disease of the bone characterized by reduced mass, deterioration of matrix, and diminished architectural strength.The bones become progressively porous, brittle, and fragile. They fracture easily under stresses that would not break normal bone. This occurs most commonly as compression fractures of the thoracic and lumbar spine, hip fractures, and Colles fractures of the wrist Peak adult bone mass is achieved between the ages of 18 and 25 years in both women and men and is affected by genetic factors, nutrition, physical activity, medications, endocrine status, and general health Primary osteoporosis occurs in women after menopause (usually by age 51) and in men later in life, but it is not merely a consequence of aging. Failure to develop optimal peak bone mass and low vitamin D levels contribute to the development of osteopenia without associated bone loss. increased calcium and vitamin D intake, participation in regular weight-bearing exercise, and modification of lifestyle (e.g., reduced use of caffeine, tobacco products, carbonated soft drinks, and alcohol) are interventions that decrease the risk of fractures and associated disability later in life

Osteoporosis is diagnosed by

dual-energy x-ray absorptiometry (DEXA), which provides information about BMD at the spine and hip Baseline DEXA testing is recommended for all women older than 65 years, for women who are postmenopausal older than 50 years with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of osteoporosis

nursing goals for the patient with lower back pain

include relief of pain, improved physical mobility, the use of back-conserving techniques of body mechanics, improved self-esteem, and weight reduction (as necessary)

bursitis

inflammation of a fluid-filled sac in a joint Bursae are fluid-filled sacs that prevent friction between joint structures during joint activity and are painful when inflamed Bursitis and tendonitis are inflammatory conditions that commonly occur in the shoulder

tendonitis

inflammation of muscle tendons Bursitis and tendonitis are inflammatory conditions that commonly occur in the shoulder

sciatica

inflammation of the sciatic nerve, resulting in pain and tenderness along the nerve through the thigh and leg pain radiating from an inflamed sciatic nerve

Hallux valgus (bunion)

is a deformity in which the great toe deviates laterally There is also osseous enlargement (exostosis) of the medial side of the first metatarsal head, over which a bursa may form (secondary to pressure and inflammation). Acute bursitis symptoms include a reddened area, edema, and tenderness. Factors contributing to bunion formation include heredity, ill-fitting shoes, osteoarthritis, and the gradual lengthening and widening of the foot associated with aging. Treatment depends on the patient's age, the degree of deformity, and the severity of symptoms

osteopenia

low bone mineral density

Loose Bodies

may occur in a joint space as a result of articular cartilage wear and bone erosion. These fragments can interfere with joint movement ("locking the joint"). Loose bodies are removed by arthroscopic surgery if they cause pain or mobility issues.

Nursing Assessment of Lower Back Pain

nurse asks the patient to describe the discomfort (e.g., location, severity, duration, characteristics, radiation, and weakness in the legs) Descriptions of how the pain occurred If back pain is a recurring problem, information about previous successful pain control methods helps in planning current management. Information about work and recreational activities helps identify areas for back health education. nurse assesses environmental variables, work situations, and family relationships as stress and anxiety can cause lower back pain The nurse should observe the posture and movements of the patient during the assessmet.

Dupuytren disease

results in a slowly progressive contracture (i.e., an abnormal shortening) of the palmar fascia that causes flexion of the fourth, fifth, and, sometimes, middle finger, rendering these fingers more or less useless associated with arthritis, diabetes, gout, cigarette smoking, and alcoholism, and inherited Symptoms:dull and aching discomfort, morning numbness, and stiffness in the affected fingers. This condition starts in one hand, but eventually both are affected. Finger-stretching exercises or intra-nodular injections of corticosteroids may prevent contractures.