4. Physical therapy. Physical therapists who specialize in back problems (e.g., those involved in "back-hardening" programs) can make a major contribution to therapeutic success.
D. Invasive intervention should be contemplated when there is a failure of conservative therapy and there is a radiographically demonstrable anatomic defect that could explain the pain, or when malignancy or infection cannot be excluded with noninvasive techniques. The timing of surgery is critical; it should rarely be performed before 2 months of conservative therapy (except in circumstances noted above that require urgent intervention, such as persistent or worsening neurologic deficit). However, a delay of more than 6 months can lead to the development of a chronic pain syndrome and decrease the likelihood of a good surgical outcome. Types of surgical intervention include the following:
1. Laminectomy or hemilaminectomy. Removal of all or part of the lamina while preserving the apophyseal joints, or in the case of spinal stenosis, trimming the joints to decompress the neural tissues.
2. Laminotomy or hemilaminotomy. An opening is created in the lamina without its being totally removed.
a. Standard surgical approach.
b. Fiberoptic scope.
4. Spinal fusion. This is performed when instability is present, usually in combination with one of the above operations.
E. Chronic pain arises from a failure of standard therapy, and patients with this problem are a very difficult group to treat. A subset of this group has fibromyalgia, and these patients are identified by poor sleep, fatigue, and widespread pain and tender points. They may respond well to low doses of tricyclic antidepressants at bedtime (e.g., begin 10 mg of amitriptyline nightly, and escalate the dose by 10 mg once weekly to 50 to 70 mg nightly). In general, however, these patients are best managed by a multidisciplinary approach that combines psychosocial evaluation with one or more of the modalities discussed above.
VI. Rehabilitation and exercise Flexibility and strengthening exercise is frequently recommended for patients with low back pain, although objective data supporting benefits are sparse. Nonetheless, there are some basic principles regarding rehabilitation in these patients that should be followed. Physical therapists are helpful in instructing patients in these programs.
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Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.