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 Table of Contents  
MISSION HOSPITAL SECTION
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 43-47

Approach to chronic low back pain in a Rural Mission Hospital: An audit report


1 Department of Physiotherapy, Christian Hospital Mungeli, Chhattisgarh, India
2 Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Deeptiman James
Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_40_17

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  Abstract 


Background: Challenging psychological and ergonomic burden demands a streamlined approach to Chronic low back pain (LBP) in rural population. Methodology: All patients with chronic LBP managed in the outpatient physiotherapy and occupational therapy clinic at the rural mission hospital from July 2015 to June 2016 were included in a retrospective chart audit. Patients' demographic data and diagnosis were statistically analyzed with t-test. Results: One hundred and fifty five patients were included in the study. 65 patients (42%) had mechanical LBP, 46 patients (30%) had chronic LBP with lumbar radiculopathy, 22 patients (14%) had discogenic chronic LBP, 15 patients (10%) had chronic LBP due to osteoporosis, 5 patients (3%) had chronic infective spondylitis and 2 patients (1%) had post-traumatic chronic LBP. 25 patients (16%) were less than 30 years old, 106 patients (68%) were between 30 and 60 years and 24 patients (16%) were older than 60 years. Higher incidence of mechanical chronic LBP was noted in younger group (t [129] = 1.36, P = 0.17) and higher incidence of chronic LBP with lumbar radiculopathy (t [129] =1.181, P = 0.239) was noted in middle aged patients, respectively. Gender prevalence of osteoporosis was statistically significant (t [153] =2.188, P = 0.03). Conclusion: Chronic LBP constituted 23% of all patients managed at the PT/OT outpatient clinic and mechanical chronic LBP was the most common diagnosis. Highest incidence of chronic LBP was noted in the middle aged 'working class' group of patients. Higher proportion of osteoporosis was detected among the female patients.

Keywords: Chronic low back pain, occupational therapy, physiotherapy


How to cite this article:
Paraseth TK, Gajendran M, James D. Approach to chronic low back pain in a Rural Mission Hospital: An audit report. CHRISMED J Health Res 2018;5:43-7

How to cite this URL:
Paraseth TK, Gajendran M, James D. Approach to chronic low back pain in a Rural Mission Hospital: An audit report. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 11];5:43-7. Available from: http://www.cjhr.org/text.asp?2018/5/1/43/223118




  Introduction Top


Low back pain (LBP) is one of the most common presenting complaints encountered in any outpatient clinic worldwide. Most people experience LBP during their lifetime. LBP can affect any age group across all genders and races. Intensity of pain may vary from mild or moderate to severe and can be debilitating, causing anxiety, and stress. Most cases of acute LBP are self-limiting and resolve with limited treatment intervention. However, patients with acute LBP can go on to develop chronic LBP. Chronic LBP is the most common cause of disability among people younger than 45 years and people aged 45–64 years develop disability frequently due to chronic LBP.[1] Chronic LBP is associated with frequent visit to orthopedics and physiotherapy and occupational therapy (PT/OT) outpatient clinics and can lead to the restriction of activities of daily living (ADL) and adversely affect the quality of life (QOL). Prompt and accurate diagnosis is necessary for alleviating symptom and prognosticating the outcome in patients.

Limited information is available regarding the prevalence and disease burden of chronic LBP in low and middle-income countries (LMICs).[2],[3],[4] Significant differences in lifestyle, occupational and recreational activities, health-seeking behavior, access to healthcare, and availability of resources between the urban and the rural populations in LMICs demands tailored treatment protocols for the two different population cohorts.[5],[6],[7] This audit was conducted with the aim to determine the prevalence, identify the etiology, and highlight PT/OT protocols for chronic LBP in a resource-limited health-care setup. This audit was carried out for a cohort of adult patients evaluated at a PT/OT outpatient clinic of a secondary level mission hospital in rural Central India.


  Methodology Top


A retrospective outpatient chart audit was carried out to assess the prevalence as well as classify patients presenting with chronic LBP at the PT/OT outpatient clinic at the rural mission hospital. All chronic LBP patients who were evaluated and treated in the outpatient clinic at the rural mission hospital from July 2015 to June 2016 were included in this study. They were classified into cohorts based on gender, age, and etiology.

Patient data were collected from the Doc 99 Hospaa3 HIMS software and from the outpatient clinic register. Radiographs of patients were verified using MedSynapse PACS software. All data were tabulated and analyzed with Word Excel 2010 software. T test was used for statistical analysis.


  Results Top


Six hundred and sixty patients underwent evaluation and treatment in the PT/OT outpatient clinic from July 2015 to June 2016. Out of which, 155 patients (23%) presented with chronic LBP. Eighty-nine patients (57%) were female patients, and 66 (43%) were male patients. They were categorized into six groups based on their diagnosis: discogenic pain secondary to degenerative disc disease without radiculopathy, chronic infective spondylitis, posttraumatic chronic LBP, lumbar radiculopathy, osteoporosis, and mechanical chronic LBP. In our audit cohort, 65 patients (42%) were diagnosed with mechanical LBP, 46 patients (30%) presented with lumbar radiculopathy, and 22 patients (14%) were diagnosed with discogenic chronic LBP. Fifteen patients (10%) had chronic LBP due to osteoporosis. Five patients (3%) were diagnosed with chronic infective spondylitis, and two patients (1%) had posttraumatic chronic LBP [Figure 1].
Figure 1: Etiological classification of chronic low back pain patients evaluated at the physiotherapy and occupational therapy outpatient clinic

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Among male patients with chronic LBP, six patients (12%) had discogenic chronic LBP without radiculoathy, two patients (4%) had chronic infective spondylitis, 17 patients (34%) patients had lumbar radiculopathy, one patient (2%) was osteoporotic, and the remaining 24 patients (48%) had mechanical chronic LBP [Table 1]. Among female patients, 16 patients (15%) had discogenic chronic LBP without radiculopathy, three patients (3%) had chronic infective spondylitis, two patients (2%) developed chronic LBP posttrauma, 29 patients (28%) had lumbar radiculopathy, 14 patients (13%) had osteoporosis, and 41 patients (39%) had mechanical chronic LBP [Table 1].
Table 1: Gender-specific distribution of chronic low back pain at the rural physiotherapy and occupational therapy clinic

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Our study population was subdivided into three age group-based cohorts [Table 2]. The first cohort included 25 patients (16%) who were below 30 years of age. The second and largest cohort of 106 patients (68%) were between the 30 and 60 years age and the third cohort included 24 patients (16%) who were more than 60 years old. In the younger age group (<30 years), four patients (16%) had chronic infective spondylitis, five patients (20%) had lumbar radiculopathy, two patients (8%) had osteoporosis, and 14 patients (56%) had mechanical LBP. In the second cohort (30–60 years), 17 patients (16%) had discogenic chronic LBP, one patient (1%) had chronic infective spondylitis, two patients (2%) had posttraumatic chronic LBP, 34 patients (32%) had lumbar radiculopathy, eight patients (8%) had osteoporosis, and 44 patients (41%) had mechanical chronic LBP. In the older age group (>60 years), five patients (21%) had discogenic chronic LBP without radiculoathy, seven patients (29%) had lumbar radiculopathy, five patients (21%) had osteoporosis, and seven patients (29%) had mechanical chronic LBP. Eighty-nine (57%) of our survey population were women. Gender prevalence of osteoporosis was statistically significant (t [153] =2.188, P = 0.03). Etiological factors identified in each of the three cohorts were analyzed. The second cohort from 30 to 60 years age group had a higher incidence of chronic LBP with lumbar radiculopathy (t [129] =1.181, P = 0.239). Similarly, a higher incidence of mechanical chronic LBP was noticed in the younger age group cohort (t [129] =1.36, P = 0.17). The proportions of discogenic chronic LBP without radiculopathy in the middle-aged cohort and the elderly cohort was not remarkably different (t [128] =0.59, P = 0.5563).
Table 2: Age-specific distribution chronic low back pain at the rural physiotherapy and occupational therapy clinic

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  Discussion Top


Chronic LBP constitutes a major public health problem worldwide and exhibits epidemic proportions. It affects nearly one in every ten person in the world each year and leads to significant discomfort as well as economic loss.[3],[8],[9] Recent surveys also indicate that chronic LBP results in restrictions of social and other activities and has substantial impact on ADL resulting in reduced QOL.[3],[9],[10] Chronic LBP exerts a significant ergonomic burden on the individual and the society. It causes loss of large number of work days and decreases individual's productivity.[5],[9] Chronic LBP manifests as physical as well as mental stress and is associated with clinical depression and anxiety. Stress related to persistent symptom commonly manifests as malaise, lethargy, depression, weight gain, and loss of self-esteem.[11]

The disease burden of the chronic LBP borne by the rural sector in LMICs has been seldom audited or documented.[2] Limited access to healthcare compounded by nonexistent medical insurance in rural areas result in cost burden of treatment directly affecting the patient who is already losing the days' income as he or she is not working due to illness.[12] This audit was carried out to identify and highlight the disease burden of chronic LBP in a health-seeking rural population in central India.

All patients who presented with chronic LBP at the PT/OT outpatient clinic in the rural hospital were evaluated with standard orthogonal (anteroposterior and lateral) radiographs of Lumbosacral spine and routine blood investigations including erythrocyte sedimentation rate and serum 25-hydroxyvitamin D assay. Diagnosis of discogenic and chronic infective spondylitis was augmented with outsourced magnetic resonance imaging. Pharmacological management of chronic LBP was augmented with assistive bracing, PT/OT administered at the rural mission hospital. Physiotherapy modalities included short-wave diathermy, interferential therapy, ultrasound therapy, moist heat application, intermittent lumbar traction, transcutaneous electric nerve stimulation, and isometric core strengthening exercises [Table 3]. Physiotherapy modalities were administered for variable durations as per patient compliance and requirements.
Table 3: Physiotherapy modalities for Chronic LBP

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OT interventions were tailored to help individuals to do their everyday task through the use of therapeutic activities that facilitate them to cope with their illness, disease, injury, or disability.[13] OT interventions administered at the rural mission hospital included learning or relearning of skills after injury or disability. Modification of work environment, postural and body mechanics training and energy conservation principles were individualized, age appropriated, and personal goal oriented. Repeated evaluations were carried out after therapeutic intervention to assess the outcomes and plan future goal [Table 4] and [Table 5].
Table 4: Occupational therapy modalities for chronic LBP

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Table 5: Energy conservation principles

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As our study included symptomatic health-seeking population, presenting for the evaluation of chronic LBP to the PT/OT outpatient clinic of the secondary level hospital; hence, the proportion of patients with chronic LBP was significantly high compared to other prevalence studies.[8],[9],[14] The study population was subdivided based on two major nonmodifiable risk factors for chronic LBP: Gender and age.[15] Postmenopausal osteoporosis predisposes additional risk of chronic LBP among female patients. Unnaturally high prevalence of hysterectomies reported among young women in Chhattisgarh resulting in iatrogenic osteoporosis, poor overall human development indices, and rampant malnutrition tend to accentuate the risks associated with female gender.[16],[17] Eighty-nine (57%) of our survey population were women. Our audit detected a statistically significant (t [153] =2.188, P = 0.03) gender prevalence of osteoporosis-related chronic LBP.

Age has a significant correlation between discogenic chronic LBP secondary to degenerative lumbar spondylitis with or without lumbar radiculopathy.[8] Two-thirds of the patients presenting with chronic LBP to our outpatient clinic (n = 106, 68%) belonged to the 30 to 60 years age group. This age group represents the working class in a rural population. While the audit report cannot be extrapolated to the general population, nevertheless this data reflect larger disease burden among the “working class age group.” The rural economy, as well as dependants, relies on the individual's productivity of the working class. Thus, chronic LBP does not only affect the individual alone but by decreasing his/her productivity and by levying additional financial burdens of treatment, chronic LBP directly affects the immediate dependents within the patient's family and indirectly affect the interdependent network of rural economy. Our audit showed a higher tendency of lumbar radiculopathy associated with chronic LBP in the second cohort (30 to 60 years age group) (t [129] =1.181, P = 0.239). Similarly, a higher tendency of mechanical chronic LBP was noticed in the younger age group cohort (t [129] =1.36, P = 0.17]. While no discogenic chronic LBP was detected in the younger cohort, the proportions of discogenic chronic LBP secondary to degenerative lumbar spondylitis in the middle-aged cohort and the elderly cohort was not remarkably different (t [128] = 0.59, P = 0.5563).

Tendency of higher prevalence of osteoporosis was detected in the third cohort (over 60 years of age) patients as compared to the younger patients (t [128] = 1.884, P = 0.06). Posttraumatic chronic LBP accounted for minor proportions of chronic LBP treated in outpatient clinic. A small but significant proportion of chronic infective spondylitis was detected, primarily among the younger population (t [129] =3.501, P = 0.006). A large proportion of mechanical chronic LBP was detected across both gender groups as well as across all three age-based cohorts. All symptomatic patients with nonspecific chronic LBP were collectively classified as mechanical LBP.


  Conclusions Top


We conclude that chronic LBP constitutes a significant (23%) presenting complaint among patients reporting at the PT/OT outpatient clinic of the rural mission hospital in Central India. Statistically, the significant higher proportion of osteoporosis was detected among the female population. More female patients presented with chronic LBP. While, mechanical chronic LBP was the most common diagnosis across all cohorts in this audit, interesting trends such as higher proportion of chronic LBP in the working class (30 to 60 years age cohort) and similar proportions of discogenic chronic LBP and degenerative lumbar spondylitis in the middle age and over 60 years cohorts were identified. Chronic infective spondylitis was an important differential diagnosis among the younger patient group.

We conclude that auditing the outpatient data can help streamline diagnostic workup and optimize treatment protocols in resource-limited centers such as mission hospitals.

Limitations

The findings of this audit cannot be extrapolated to the general population as the study population is not representative of the same. However, this audit highlights that symptomatic chronic LBP is prevalent among rural population and diagnosis and evidence-based multidisciplinary management of chronic LBP is feasible in rural health-care setup.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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