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LOW BACK PAIN in PRIMARY CARE Bennet Davis, MD Integrative

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LOW BACK PAIN in PRIMARY CARE Bennet Davis, MD Integrative Pain Center of Arizona PART I Very brief review of impressive epidemiologic statistics General comments ... – PowerPoint PPT presentation

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Title: LOW BACK PAIN in PRIMARY CARE Bennet Davis, MD Integrative


1
LOW BACK PAIN in PRIMARY CARE
  • Bennet Davis, MD
  • Integrative Pain Center of Arizona

2
  • PART I
  • Very brief review of impressive epidemiologic
    statistics
  • General comments regarding back pain
  • Evaluation of back pain, whether acute or chronic
  • Warning signs for immediate referral
  • General management, according to duration of
    symptoms
  • 0-8 weeks
  • PART II
  • General management, according to duration of
    symptoms
  • 8 weeks - 6 months
  • Greater than six months
  • Common diagnoses in chronic low back and leg pain

3
Is This Really A Problem?
  • 80 0f adults in industrial countries have at
    least one episode of disabling back pain.

Bonica 1980
4
Is This Really A Problem?
  • 80 0f adults in industrial countries have at
    least one episode of disabling back pain.
  • By the 3rd decade 50 of people have experienced
    an episode of LBP that required alteration in
    activity.

Leboeuf-Yde 1998
5
Is This Really A Problem?
  • 80 0f adults in industrial countries have at
    least one episode of disabling back pain.
  • By the 3rd decade 50 of people have experienced
    an episode of LBP that required alteration in
    activity.
  • In spite of optimal management 5 of acute back
    pain progresses to a chronic and disabling
    endpoint.

Spengler 1986
6
Is Back Pain a Problem?
  • 86 million Americans suffer from chronic pain
  • 66 million are partially disabled
  • There are 65,000 cases of pain related permanent
    disability diagnosed each year.
  • 8 million are totally disabled from back pain

Medical Data International 1998
7
Is Back Pain a Problem?
  • Pai found in 20041 that in the U.S.
  • low back pain was the
  • Second leading symptomatic cause for physician
    visits
  • Third most common cause for surgical procedures
  • Fifth most common reason for hospitalization
  • .

1. Pai S, Sundaram LJ. Low back pain an economic
assessment in the united states. Orthop Clin N
Am. 2004351-5.
8
Is Back Pain a Problem, At Work?
  • Back pain is the most common reason for filing
    workers compensation claims1
  • From an economic perspective, the average cost
    of a workers compensation claim for low back
    pain was 8,300, which was more than twice the
    average cost (4,075) for all compensable claims
    combined2

1. Guo HR, Tanaka S, Halperin WE, Cameron LL.
Back pain prevalence in US industry and estimates
of lost workdays. AM J Public Health.
1999891029-1035. 2. Pai S, Sundaram LJ. Low
back pain an economic assessment in the united
states. Orthop Clin N Am. 2004351-5.
9
  • Is Back Pain a Problem at Work?

Absences from Work
  • In 1999, back pain accounted for 40 percent of
    absences from work, second only to the common
    cold.

Guo HR, Tanaka S, Halperin WE, Cameron LL. Back
pain prevalence in US industry and estimates of
lost workdays. AM J Public Health.
1999891029-1035.
10
General Aspects Regarding Back Pain
Three facts that should help frame our approach
from here forward (evidence follows)
  • Low back pain is recurrent in 33-70 of
    patients1,2
  • Expectations fail to reflect this Patients want
    a cure, physicians pursue it, yet many times
    there is none
  • Psychosocial issues often contribute to, and many
    times are the main cause of disability
  • Physical therapists are a vastly underutilized
    yet readily available resource.

1. Von Korf, Spine 1996 21(24)2833-37 2.
Haestbaek L European Spine Journal 2003
Apr12(2)149-65
11
Evidence base for these statements Acute Back
Pain is a chronic, relapsing/remitting Illness
  • Von Korf, Spine 1996 1/3 of primary care
    patients who presented with acute back pain
    reported back pain on at least 50 of the days of
    the year at 1 and 2 year follow-up.

12
Evidence base for these statements Acute Back
Pain is a chronic, relapsing/remitting Illness
  • Screened Cochrane data base, Medline, and
  • EMBASE for back pain literature on the
  • general population with at least 12 month
  • follow-up.
  • 62 had pain at 12 months after onset
  • 60 had gt 2 relapses
  • 33 had relapses of work absence

13
Evidence base for these statements Psychosocial
issues are important in determining who goes to
the doctor for help with back pain
  • Prospective study looked for medical and
    psychosocial factors that predict onset of new
    chronic back pain in asymptomatic volunteers.
  • Found that only psychosocial factors, especially
    poor coping skills, Predict future chronic back
    pain. Poor coping skills increase the odds of
    future back pain by 3 fold.

14
Evidence base for these statements The
patients psychosocial issues are the leading
cause of failure of back pain treatment 1
  • Anxiety, Depression, and amount of time off
  • work were the primary determinants of failure
  • to return to work in a program designed to
  • treat employees off work due to low back
  • pain.

15
Evidence base for these statements The patients
psychosocial issues are the leading cause of
failure of back pain treatment 2
  • Prospective study looked at factors that
    predicted
  • failure of medical therapy plus stabilization
    training
  • and manual therapy in a national health service
  • database over 5 years.
  • Depression, anxiety, generalized somatic
    complaints, poor life control topped the list
  • Concluded Psychosocial differences seem to be
    the important determinants for treatment outcome

16
Evidence base for these statements Psychosocial
factors that predict poor outcome for treatment
of back pain
  • Motivation for self-care
  • Depression
  • Job satisfaction
  • Job stress
  • Support of significant other/marital stress
  • Secondary gain
  • Maladaptive thinking and coping styles
  • History of physical or sexual abuse
  • Multiple somatic complaints

17
Evidence base for these statements Does any
evidence show that treatment of Psychosocial
factors is and effective way to treat back pain?
YES
  • Randomized trial of Cognitive Behavioral Therapy
    (CBT) vs. patient education 243 patients with
    acute or subacute back pain1
  • Both reduced sick days compared to controls, but
    9 fold less sick days in the CBT group at 1 year.
  • Randomized trial of spinal fusion vs. CBT plus
    exercise for chronic low back pain2
  • Equal improvement, no difference in outcome at 1
    year.

1Linton SJ Spine 2000 Nov 125(21)2825-31 2Brox
JI Spine 2003 Sep 128(17)1913-21
18
The evidence is clear that optimal treatment of
back pain includes evaluating the patient for
psychosocial factors and treating them when
found and when they are refractory to treatment
we should anticipate poor outcomes from medical,
physical therapy, and surgical treatment.
19
We rarely do so, however. No wonder back pain
treatment outcomes are poor in this country! No
wonder research shows that increasing numbers of
surgeries and other medical treatments have had
little impact on the incidence of back-related
disability.
20
New Topic Duration of symptoms
It is generally useful to break back pain into
three categories according to duration of
symptoms
  • Less than eight weeks duration
  • Eight weeks-six months duration
  • Greater than six months duration

21
General management, according to duration of
symptoms 0-8 wks 8 wks-6 mo gt6 mo
  • Most people recover from an acute episode within
    8 weeks
  • Conformity The NASS guidelines define the
    initial phase of care as lasting about 8
    weeks1
  • Patients remaining symptomatic after six months
    have a poor prognosis for significant improvement2

1Phase III Guidelines for Multidisciplinary Spine
Specialists, North American Spine Society,
2000 2Mayer TG, pg 3-9 in Contemporary
Conservative Care for Spine Disorders
22
0-8 weeks 8 weeks 6 months
23
0-8 weeks Overview
  • A specific anatomic diagnosis is usually not
    necessary, perhaps impossible
  • Diagnostic efforts are directed at identifying
    those who have diagnoses that require urgent
    referral
  • Use both pain and function as your measure of
    disease severity and as endpoints for therapy.
  • Patients with significant functional impairment
    need to be flagged for more aggressive symptom
    palliation
  • Screen for predictors of chronicity
  • Physicians role palliate symptoms to support
    spontaneous recovery
  • Patient education is key

24
Diagnoses we dont want to miss
  • Tumor (of bone or viscera)
  • Infection
  • Fracture
  • Any process resulting in severe compromise of
    nervous tissue
  • Systemic illnesses affecting joints
  • Leaking abdominal aortic aneurysm

25
How not to miss them History the nine red pain
flags
  • Prominent neurological symptoms of weakness,
    numbness, loss of bowel or bladder control,
    difficulty walking
  • Pain is much worse at night
  • Fever
  • Other constitutional symptoms that always worry
    us
  • Patient cannot sit or stand due to pain

26
The nine red flags on history 2
  • Pain following a fall in the elderly or in a
    patient at risk for osteoporosis
  • Leg pain is much worse than back pain
  • History of cancer in the last five years,
    particularly breast, lung, prostate,thyroid,
    renal
  • Polyarthralgias

27
Historical aspects that increased suspicion for
infection
  • Recent IV drug abuse
  • Immunosuppression
  • Diabetes

28
Things we don't want to miss physical exam
  • Neurological signs such as
  • loss of reflex in the area of pain
  • profound focal weakness
  • profound diffuse proximal weakness
  • upgoing toes
  • clonus at the ankle
  • hyperreflexia
  • patulous sphincter tone

29
Things we dont want to miss physical exam 2
  • The patient cant walk or sit due to back or leg
    pain.
  • Severe pain with movement when it has lasted for
    more than one week history
  • Severe muscle spasm when it has lasted more than
    one week on history
  • Extreme and localized tenderness to percussion
    over the spinous processes or other bony
    prominences
  • Joint effusions, redness, synovial bogginess,
    tenderness

30
0-8 weeks Where to start after conditions
requiring immediate referral are ruled out?
  • Evaluate functional impact of pain, measure the
    disability
  • Understand what your patient wants from you, and
  • Manage expectations
  • Tune treatment to your patients needs

31
Why is function and degree of disbility worth
quantifying and following over time?
  • It is our blood pressure for chronic pain
  • Disability - impairment of function due to pain -
    is what we are treating
  • Pain and disability are not the same thing

32
PATHOANATOMIC LESION PAIN DISABILITY
SOCIAL FACTORS
CULTURAL FACTORS
PSYCHOLOGICAL FACTORS
COGNITIVE FACTORS
33
  • Measure disability
  • Evaluate the cause of disability
  • Treat the cause of the disability

Concept
PATHOANATOMIC LESION PAIN DISABILITY
SOCIAL FACTORS
CULTURAL FACTORS
PSYCHOLOGICAL FACTORS
COGNITIVE FACTORS
34
Measuring disability Brief Pain Inventory, etc.
  • How well do you sleep?
  • Good fair poor very poor
  • Do you miss any work because of pain?
  • days per month
  • How much time on a typical day do you spend
    down because of pain?
  • Rate your mood
  • Good fair poor very poor

35
What is the evidence that pain and disability are
not well correlated (that factors other than pain
are important in producing disability)?
In a formal study of the correlation between pain
and disability, the relationship was week, with
correlation coefficient of 0.3-0.4
36
Measuring disability
The key question is not Is this activity
painful? The key question is Are you restricted
in this activity, and how much so?
37
Functional impairment Disability consequent to
pain
The 6 major areas of function worth quantifying
  • Impairment of work life
  • Impairment of recreational activity
  • Impairment of social activity
  • Impairment of sleep
  • Impairment of sex life
  • Patient specific disability

38
Decision Making The Patients basis
  • Function at work
  • Function at home
  • Social function
  • Recreational function

39
  • I cant lift my grandchild
  • I cant make it through a day at work
  • I have to sleep in a recliner, cant join my
    spouse in bed
  • I cant sit through a game of cards

40
Decision Making The Physicians basis
  • Symptom driven
  • Limited to Pathoanatomy
  • Bio-reductionist model
  • Bio-medical model

41
For Example
  • This is a patient with
  • Chronic back pain
  • Due to degenerative disc disease

42
What does research say about how often physicians
ask about the patients function?
  • 76 audiotaped primary care back pain visits
  • 13.2 asked if the patient had taken time off
    work for back pain
  • 14.5 asked if back pain interferes with work
  • 10.5 asked if back pain interferes with social
    activities
  • 19.7 asked if back pain interferes with
    activities such as driving, walking, etc.

43
How does this compare to the patients
perspective?
  • 74 of patients indicated that they had
    significant interference with work, 42 rated
    this as gt 7/10.
  • 83 of patients rated receiving information on
    what could be done to return to normal activities
    as quickly as possible as very/extremely
    important

44
0-8 weeks Where to start after conditions
requiring immediate referral are ruled out?
  • Evaluate functional impact of pain, measure the
    disability
  • Understand what your patient wants from you, and
  • Manage expectations
  • Tune treatment to your patients needs

45
Patients rated the following as either very
important or extremely important
  • 85 how to manage back pain
  • 83 how to reduce back pain without prescription
    drugs
  • 81 what they can do to get back to usual
    activities
  • 76 how to prevent a recurrence of back pain

46
Patients rated the following as either very
important or extremely important
  • 76 understand the likely course of back pain
  • 68 receive a medical diagnosis
  • 52 received reassurance that there is no
    serious disease

47
Patients rated the following as either very
important or extremely important
  • 35 receive a prescription medication to relieve
    back pain
  • 34 get an x-ray or other diagnostic test
  • 30 get a referral to physical therapy
  • 27 get a referral to a specialist

48
0-8 weeks Identify early predictors of chronicity
  • Identify unrealistic expectations, such as
    complete cure.
  • 51 of patients expect this
  • Identify the patients motivation for self-care
  • Identify and treat depression and anxiety
  • Look for a pattern of multiple somatic complaints

49
0-8 weeks Symptom palliation
1/2
  • To support progress toward resumption of activity
  • Analgesics, paying particularly close attention
    to good analgesia 1. at night to help the patient
    sleep and 2. to help the patient stay at work.
  • Short-term muscle relaxants.
  • Physical therapy modalities TENS, ultrasound,
    hot packs, massage

50
0-8 weeks Symptom palliation
2/2
  • To support progress toward resumption of activity
  • Acupuncture
  • Trigger point injections
  • Epidural steroid injection for radiculopathy and
    for the acute discwith mostly back pain.

51
0-8 weeks Symptom palliation Epidural steroid
injection when back pain is greater than leg pain
"There may be a limited role for epidural steroid
injections in the documented presence of a
central disc herniation or annular tear, but
epidural steroid injection cannot be
recommended for non-specific unremitting low back
pain."
Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
52
0-8 weeks Symptom palliation
  • When leg symptoms predominate
  • Oral steroids or
  • Early referral for epidural steroid injection1
  • Imaging and early referral if neurological red
    flags are present on history or exam

1Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
53
When leg symptoms predominate
  • Physical therapy should include a trial traction

54
0-8 weeks Patients worries, Patient education
  • 64 the wrong movement could lead to a serious
    problem
  • 60 I might become disabled for a long time
  • 51 Avoiding movement is the safest way to
    prevent pain from worsening
  • 45 I wouldnt have this much pain of the work
    something dangerously wrong
  • 31 I might injure myself if I exercise

55
0-8 weeks Yet more information gathering
  • Identify and reinforce positive self-help
    strategies, help patient add new ones
  • Research has shown that only 10 of physicians do
    this.
  • Existence of 3 or more appropriate self help
    activities is one of the strongest predictors of
    rapid recovery from acute low back pain

56
0-8 weeks Education
  • Educate regarding diagnosis most have a limited
    episode of pain originating from lumbar
    intervertebral disc, but it may recur
  • Focus on typical worries and any specific
    worries
  • Educate some more!
  • develop a program with your local physical
    therapist

57
Role of the physical therapist
TIMESAVER!
  • Cognitive
  • Patient education
  • Assessment and reporting of progress towards
    functional goals
  • Identify barriers to recovery in communicate
    these to the physician

58
Is there evidence that early referral to a
physical therapy program for patient education
and monitoring of progress is effective?
  • 2004 primary care study of gt600 patients with
    acute LBP in a national health care setting
  • Early hand-off to physical therapy for
    evaluation, treatment, patient education, and
    monitoring progress with reporting to MD.
  • Treatment outcomes were as good as MD management,
    but lost work days were reduced, and PCP return
    visits and specialist referrals were drastically
    reduced.

59
0-8 weeks
TIMESAVER!
TIMESAVER!
What can the physical therapist do besides teach
exercises and apply modalities? Cognitive
therapy!
  • Review and modify the patients self-management
    strategies
  • Reinforced the diagnosis
  • Address patients worries
  • Review red flags and action to take should they
    occur, reassure that none are present
  • Address any unrealistic expectations

60
0-8 weeks
TIMESAVER!
TIMESAVER!
What can the physical therapist do besides teach
exercises and apply modalities?
  • Educate the patient on how to prevent recurrence
    of pain
  • Help you grade the patients progress toward
    functional goals
  • If your patient is missing work, design a return
    to work program and follow it along with the
    physical therapist

61
Role of the physical therapist
  • Cognitive
  • Patient education
  • Assessment and reporting of progress towards
    functional goals
  • Identify barriers to recovery in communicate
    these to the physician

62
Role of the physical therapist
  • Procedural
  • Apply analgesic modalities
  • Teach aerobic exercise appropriate to patient
  • Train in core stabilization exercise
  • Manual therapy
  • For radiculopathy
  • Extension biased exercise (McKenzie)
  • Flexion-based exercise (Williams)
  • Traction

63
Role of the physical therapist (stretching is not
evidence based medicine)
64
Role of the physical therapist
  • Procedural
  • A wide range of skills is needed, as is the
    time to employ them (time is unfortunately
    limited by low-ball insurance contracts these
    days) so that the right techniques can be found
    (empirically) and applied each patient is
    different. Routine exercise for all is not
    effective.

65
Maintenance exercise
  • Yoga
  • Pilates

66
  • If the patient is not improving and psychosocial
    factors appear prominent, refer to behavioral
    health for evaluation and treatment
    recommendations early.

67
Eight weeks - six months
  • Re- evaluation
  • Treatment

68
Eight weeks-six months Re-evaluation
  • A known diagnosis, not yet treated?
  • Managed-care, patient has not been triaged to
    appropriate care, geography
  • A known diagnosis, the nature of which is
    chronic?
  • A missed medical diagnosis? (includes the patient
    who shows up for first evaluation two months into
    the pain)
  • Are psychosocial factors contributing
    significantly to disability?

69
Eight weeks-six months Re-evaluation The
missed medical diagnosis
70
Common benign diagnoses in chronic back and leg
pain
71
  • Predominantly back pain
  • Discogenic pain (annular tear)
  • Painful osteoarthritis of the facet joints
  • Structural pathology
  • Congenital or degenerative kyphosis/scoliosis
  • Compression fracture
  • Spondylolysis/spondylolisthesis
  • Inflammatory spondylitis
  • Visceral pathology
  • Predominantly leg pain
  • Herniated nucleus pulposus
  • Spinal stenosis

72
Less common benign causes of chronic back and
leg pain
  • Sacroiliac joint pain
  • Coccydynia
  • Polymyalgia rheumatica
  • Stiff man syndrome
  • Multiple sclerosis
  • Parkinsons disease
  • Sciatic nerve entrapment
  • Post viral and other autoimmune
    radiculitis/plexitis

73
Nonexistent causes of chronic back and leg pain
  • Chronic low back strain
  • Chronic myofascial pain

74
First question
  • Which is worse, back pain or leg pain?

75
First question
  • Which is worse, back pain or leg pain?
  • BACK PAIN

76
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78
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79
NOT
80
Why might pain radiating down the legs to the
feet occasionally, especially with heavy loads
and activity?
81
Back pain without radiculopathy 8 weeks - 6
months Further evaluation
  • Plain x-ray and ESR, with flexion extension in
    elderly patients and patients with significant
    sharp sudden pain with movement.
  • Fracture, instability, infection, tumor,
  • inflammatory spondylitis

82
Back pain without radiculopathy 8 weeks - 6
months Further evaluation for the missing
diagnosis
  • Neuroimaging MRI recommended for initial
    screening of persistent back pain, over CT and
    Bone scan
  • Infection, tumor, stress fracture, or visceral
    pathology are suspected but not seen on plain
    x-ray (sensitivity of x-ray about 42).

83
What is the role of MRI in low back pain
diagnosis/treatment?
  • To rule out scary stuff when it might be the
    cause of back pain
  • To confirm suspected diagnosis, when confirmation
    is necessary
  • EX compression fracture when plain films are
    unremarkable
  • To plan treatment
  • EX to evaluate disc height
  • Special circumstances
  • EX to gauge the age of the compression fracture

84
Is MRI useful in diagnosing painful degenerative
disc disease?
LAID Back
  • Longitudinal Assessment of Imaging and Disability
    of the Back

85
Is MRI useful in screening for painful
degenerative disc disease ?
  • Evaluated lumbar disc hydration, height, annular
    tears, bulging, protrusion, and extrusion
  • No relationship between previous episodes of pain
    and bulges, annular tears, end plate changes,
    facet joint degeneration, and spondylolithesis on
    MRI.
  • Current MR imaging provides little to no
    correlate with pain

86
Is MRI useful in diagnosis of painful
degenerative disc disease in patients with
chronic back pain ?
  • Posterior annular high intensity zone most likely
    does have meaning when present in the clinical
    context of low back pain
  • The disc(s) with the HIZ are very likely to be
    have a painful annular tear on provocative
    discogram

87
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88
Low back pain from intravertebral disc and facet
joint The two most common causes of pain in the 8
week 6 month period
89
Low back pain from intravertebral disc (the disc
is painful)
  • What shall we call it?
  • Painful degenerative disc disease
  • Discogenic pain
  • Internal disk disruption

90
Trending the thinking on back pain
  • Dynasty of the Prolapse
  • 1934. Mixter WJ, Barr JS Rupture of the
    intervertebral disc with involvement of the
    spinal canal. New Engl J Med.
  • 1957. Morgan FP, King T. Primary vertebral
    instability as a cause of low back pain. J Bone
    Joint Surg.
  • 1972. Sprangfort EV. The lumbar disc herniation.
    Acta Orthop Scand
  • Dynasty of the facet joint
  • 1976. Mooney V, Robertson J. The facet syndrome.
    Clin Orthop.
  • 1992. Jackson RP. The Facet Syndrome. Myth or
    reality? Clin Orthop.
  • Dynasty of discogenic pain
  • 1948. Lindblom. Diagnostic puncture of the
    intervertebral disc. Acta Orthopedica Scand.
  • 1986. Crock. The presidential Address ISSLS.
    Internal disc disruption. A challenge to disc
    prolapse fifty years on. Spine

91
Low back pain from lumbar facet joint
  • What shall we call it?
  • Painful degenerative joint disease of the spine
  • Osteoarthritis of the spine
  • Facet pain
  • Zygoapophyseal joint pain

92
Disc and facet pain Degenerative Cascade Stage 1
(Dysfunction)
  • Facet
  • Inflammation (synovitis)
  • Capsular tear (minor)
  • Meniscal tear
  • Minor cartilagenous injury
  • Disc
  • Vertebral end plate injury
  • Annular strain
  • Annular tear

93
Patho-mechanical compression
Normal disc
Damaged endplate
posterior
anterior
posterior
anterior
Distance across L1-2 disc
Distance across L1-2 disc
Adapted from Adams M, et al. Mechanical
initiation of disc degeneration. Spine.
2000251625-36
94
Patho-mechanical compression
  • Discogenic pain was found to be associated with
    anomalous loading of the posterolateral anulus (P
    lt 0.001) and nucleus (P lt 0.01).
  • Painful discs were found to have a 38 wider
    posterolateral anulus (P lt 0.023) than painless
    discs and to have a 63 lower mean nuclear stress
    (P lt 0.017)

Mcnally DS, Shackleford M, Goodship AE,
Mulholland RC. In-Vivo Stress Measurement Can
Predict Pain on Discography. Spine. 1996212580-7
95
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98
Annular tear
99
Disc and facet pain Clinical correlation of the
Degenerative Cascade Stage 1 (Dysfunction)
  • History
  • Acute mechanical low back pain
  • First episode short-lived, self limited, and
    improves with minimal intervention
  • Facet Revel criteria
  • Disc/annulus sitting is the most painful
    position, traction relieves pain at least
    temporarily.

100
  • Exam
  • Facet Revel criteria
  • Disc observe reproduction of patients familiar
    pain while sitting in the chair, with bending in
    most directions while standing, and positive
    slump sit test
  • Watch for a sudden sharp pain (a catch) are
    refusal to allow the lumbar spine to flex during
    forward bend as signs of instability that require
    radiographic evaluation

101
Disc and facet pain Degenerative Cascade Stage 2
(Instability)
  • Disc/annulus
  • Increasing annular tears and delamination
  • Annular disruption with laxity
  • Increasing rotational and sagittal movement
  • Decreasing nuclear proteoglycans and decreasing
    hydration
  • Increased transfer of forces to annulus
  • Loss of disc height, annular buckling and tears.
  • Facet
  • Capsular tear (major) with laxity
  • Increasing rotational and sagittal movement
  • Increasing cartilagenous damage
  • Increasing inflammation

102
Disc and facet pain Degenerative Cascade Stage 2
(Instability)
  • Predominant LBP, more severe and not self limited
  • Repeated exacerbations
  • Probable progression of annular tears to disc
    rupture/herniation
  • Often associated with radicular symptoms from
    nerve root compression
  • Episodes of LBP increase in frequency, severity,
    disability
  • Degenerative scoliosis appears with attendant
    signs and symptoms of instability of the spine

103
Disc and facet painDegenerative Cascade Stage 3
(Stabilization)
  • Facet
  • Severe cartilagenous damage, eroded joint
    surfaces
  • Joint hypertrophy and bone spurs
  • Canal and foraminal spinal stenosis and nerve
    root compression
  • Disc/annulus
  • Increased annular tears and loss of elasticity
  • Increased nuclear degeneration and loss of
    proteoglycans
  • Disc resorption and loss of disc height
  • End plate irregularities
  • Annular buckling
  • Osteophytic ridging along annulus

104
Disc and facet painDegenerative Cascade Stage 3
(Stabilization)
  • Back pain with increasing prevalence of leg pain.
  • Hypertrophy and bone spurs of facets in
    conjunction with decreasing disc height and
    annular bone spurs lead to spinal stenosis,
    lateral recess and foraminal stenosis
  • Neurogenic claudication and radiculopathy is
    common, actually in people with congenitally
    small spinal canal

105
Eight weeks-six months Re-evaluation
  • Are psychosocial factors contributing
    significantly to disability?

106
Pertinent psychosocial factors in back pain
  • Motivation for self-care
  • Depression
  • Job satisfaction
  • Job stress
  • Support of significant other/marital stress
  • Secondary gain
  • Maladaptive thinking and coping styles
  • History of physical or sexual abuse

107
Pertinent psychosocial factors in back pain
  • The patients understanding of
  • The diagnosis
  • The prognosis
  • Appropriate self-help strategies, including
    activities that may be harmful and those that
    will not.
  • The range of medical options available to them.

108
When Psychosocial factors predominate How can
one recognize them efficiently?
109
Recognizing psychosocial factors
  • Pattern of multiple somatic complaints
  • Look for incongruence between observed and
    reported disability
  • Look for incongruence between pain report and
    observed behavior
  • Formally assess psychological distress
    depression       
  • Look for illness behaviors
  • Overt pain behaviors
  • Nonorganic symptoms
  • Nonorganic signs responses to examination
  • Downtime

110
Eight weeks - six months
  • Re- evaluation
  • Treatment

111
Treatment of persistent back pain
  • Brief Pharmacotherapy notes
  • What to do when psychosocial factors figure
    prominently
  • Disease specific interventions for selected
    diagnoses an integrated approach

112
Pharmacotherapy Opioids
  • Effective in some in reducing pain and
    disability, without significant side effects or
    addiction issues.
  • End point for titration must be related to
    FUNCTION.
  • Difficult to do in a health care system weak in
    evaluation and treatment of behavioral problems
    related to health care.
  • Documentation in primary care project underway in
    AZ

113
Pharmacotherapy NSAIDs
  • Review of 50 RCTs
  • Available evidence supports their use in acute
    and chronic back pain

114
Pharmacotherapy Muscle relaxants
  • Review of 50 RCTs
  • NO QUALITY EVIDENCE supports their use in chronic
    back pain
  • Special caution Carisoprodol

115
Pharmacotherapy Antidepressants
  • Tricyclic antidepressants
  • Effective analgesics when radicular symptoms are
    present (effective for neuropathic pain)
  • Effective for improving sleep in chronic back
    pain with or without radiculopathy
  • As effective for depression as SSRIs
  • SSRIs
  • No analgesic effect

116
Treatment of back pain eight weeks-six
months Address psychosocial barriers
  • Medical psychology evaluation to identify major
    psychosocial barriers, and hopefully, skilled
    therapy to address these
  • Cognitive-behavioral therapy
  • Recent study showed to be as effective as fusion
    1
  • Overcome maladaptive behaviors and thoughts,
    promote healthy behaviors in relation to back
    pain
  • Aggressive treatment of depression and anxiety

117
  • Refer to a comprehensive pain clinic if you have
    one that can help with all four issues
  • Triage to appropriate care,whether in-house or
    not.
  • Integrated with manual medicine, but not always
    used
  • Integrated with behavioral medicine, but not
    always used
  • Integrated with a team of specialists who are
    called upon on an as needed basis
  • Willing to manage with medications
  • Capable of making a diagnosis
  • Willing to initiate, coordinate, and follow-up on
    care when referral to procedures is necessary

118
Is there any evidence that multidisciplinary
approaches that combine treatment of psychosocial
and physical barriers to good outcome are
effective in subacute LBP?
We found only two relevant studies that
satisfied our criteria on subacute low back pain.
No more studies were found during the updates.
The clinical relevance of included studies was
sufficient. There was moderate scientific
evidence showing that multidisciplinary
rehabilitation, which includes a workplace visit
or more comprehensive occupational health care
intervention, helps patients to return to work
faster, results in fewer sick leaves and
alleviates subjective disability."
119
Treatment of back pain eight weeks-six months
Integrate medical and physical medicine efforts
designed to help your patient COPE effectively
with what may be a chronic problem
  • Provide good analgesia to support optimal rehab
  • Cardiovascular conditioning and specific exercise
  • Stabilization through strengthening core trunk
    muscles
  • Manual therapy (one small RCT)
  • Job site assessment and modification

120
Rehabilitation must connect to the workplace
  • We conclude that there is moderate evidence of
    positive effectiveness of multidisciplinary
    rehabilitation for subacute low back pain and
    that a workplace visit increases the
    effectiveness.

 Cochrane Database Systematic Review
2000(3)CD002193
121
Maintenance exercise
  • Yoga
  • Pilates

122
The question regarding pain clinics here
  • Pain clinics are places to send patients for
    injections when necessary
  • I refer to pain clinics for evaluative services
  • I do not refer to pain clinics

123
Disease specific intervention Discogenic pain
124
Procedural possibilities
  • Chronic opioid therapy
  • Intra-discal electrothermal annuloplasty
  • IDETT
  • Disc replacement
  • Fusion

125
Procedural possibilities Selection criteria
  • When pain prevents rehabilitation

126
Intradiscal electrothermal annuloplasty
(Indications)
  • Pain that limits ADLs
  • Efficacy limited to proven discogenic pain
    back pain with or without spread to buttocks,
    thighs, and/or groin, discogram positive
  • Failure of aggressive conservative care to
    relieve pain
  • Patient preference for a minimally invasive
    procedure over a major surgical intervention
  • Willingness to participate in an intense post-op
    rehabilitation program.

127
IDETT ORIGINAL CONDUCTIVE TECHNIQUE1
MODIFIED RF TECHNIQUE
128
IDETT ORIGINAL CONDUCTIVE TECHNIQUE
MODIFIED RF TECHNIQUE
129
Proposed Mechanisms of Action
  • Denaturation of collagen fibrils produce a new
    contracted state
  • Debulking of the disc decreases tissue volume
    of a disrupted disc with decreased intradiscal
    pressures.
  • Tightened annulus may enhance the structural
    integrity of a damaged disc and stabilize annular
    tears,
  • Thermal disruption of nociceptors in the outer
    annulus fibrosis (or maybe endplate?)

130
50 pain relief 86 70 pain relief
55 100 pain relief 9 n 22
131
50 pain relief 72 70 pain relief
64 100 pain relief 18 n 11
132
50 pain relief 51 70 pain relief
28 100 pain relief 10 n 29
133
Outcomes of IDEA
134
Outcomes of RF IDEA athletes
135
Outcomes of IDEA
  • 1 year, 25 patients
  • 3.5 average reduction of VAS
  • 68 of patients gt50 functional improvement on
    Roland scale
  • 74 very satisfied with results
  • 17 went on to successful (in terms of patient
    satisfaction) fusion

136
Outcomes of IDEA
  • Metanalysis of prospective cohort studies- the
    best information we have thus far
  • The studies published so far suggest that the
    pain resulting from lumbar disc disease may be
    diminished by intradiscal electrothermal
    annuloplasty. All these studies project a
    positive therapeutic effect.

137
Outcomes of IDEA
  • Pauza
  • Double-blind, randomized, sham treatment
    controlled study of 64 subjects, 6 mo. follow-up
  • Statistically significant improvement in pain in
    the treatment group only
  • Statistically significant improvement in physical
    functioning in the subgroup of patients who had
    pre-op limitation in Physical functioning

138
Disease specific intervention Other diagnoses
that may cause persistent back pain
  • Painful osteoarthritis of the facet joints
  • Structural pathology
  • Congenital or degenerative kyphosis/scoliosis
  • Compression fracture
  • Spondylolysis/spondylolisthesis
  • Inflammatory spondylitis
  • Visceral pathology

139
Painful lumbar facet joints
140
Facet Pain Incidence by placebo
controlled Median Branch Blocks
  • Lumbar
  • Incidence 15 in younger population s/p injury
    Schwartzer Spine 1994
  • Incidence 40 in patients over 50 without trauma
    Schwartzer Ann Rheum
    Disease 1995
  • Cervical (after whiplash)
  • Headache 27- 53 C2-3
    Lord 1994
  • Neck pain 54, most common C4-5
  • Barnsley Spine 1995

141
Facet Pain a note on history and exam
  • No one piece of information is useful
  • Revel Criteria 5 of the 7 predict relief with
    median branch blocks
  • Age gt 65
  • Better with lying down
  • No increase in pain with coughing
  • Not worse with forward bend
  • Not worse with extension
  • Not worse with rising from forward bend
  • Not worse with extension-rotation

Revel Spine 1998
142
Facet Pain Median Branch Blocks
  • Perform as advertised - Dreyfuss Spine 1997
  • Also anesthetize the lamina - spondylolysis may
    respond
  • Must be performed with a control to avoid
    unacceptable false positive - Schwartzer Pain
    1994
  • Predict sustained pain relief with median branch
    neurotomy (data presented later)

143
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144
Results of treatment Based on Median Branch
Blocks RF Neurotomy
  • Cervical 70 of patients pain free at 1 year
    Lord Neurosurgery 1999
  • Lumbar 70 average decrease in pain at 1 year
    Dreyfuss Spine 2000

145
Other causes of back gt leg pain
146
Lumbar instability
  • Definition unequivocal anterior-posterior
    translation of one vertebral segment on another gt
    6 mm on lateral standing flexion extension
    radiograph, or side to side motion of one
    vertebral body on another with sidebend.

147
Lumbar instability
  • Congenital or traumatic lytic Spondylolysis
  • Incidence of this condition with listhesis 5-9
  • Degenerative disease
  • Post-operative
  • When more than 50 of the facet joint is removed
  • Flexion-extension films may be normal,
    instability may be rotational

Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
148
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149
Lumbar instability
  • History
  • There may be a complaint of sudden sharp pain
  • rolling over in bed at night
  • transitions between sitting and standing
  • Pain worst with standing and walking
  • Exam
  • Guarding of lumbar spine during standing flexion
    patient maintains lordosis through the movement
  • Sudden catch (brief sharp pain) in the back
    part way through standing flexion or extension of
    the lumbar spine

150
Lumbar instability
  • L4-L5 is the most common level in degenerative
    instability, followed by L3-L4, and less common
    L5-S1
  • L5-S1 is the most common level affected in
    younger patients with spondylolysis

151
Lumbar instability
  • Action to take when instability is identified
  • Early surgical referral when it presents with
    neurologic symptoms or signs, even if intermittent

152
Lumbar instability
  • Action to take when instability is identified
    and no neurological signs or symptoms are
    present
  • External bracing is not effective for mid to
    lower lumbar spine instability.
  • Push trunk strengthening (core stabilization)
  • Consider referral for treatment of possible facet
    component
  • Monitor over time with repeat history, exam, and
    radiographs
  • Surgical stabilization

153
Spondylolysis
  • Possible cause of pain in athletic younger
    patients
  • Some sports present particular risk
  • Gymnastics
  • Weight lifting
  • Wrestling
  • Offensive linemen
  • Dancers
  • High jumpers
  • Pole vault

154
Spondylolysis
  • Pain at first with activity, later may be
    constant
  • Fracture may heal, may not
  • In those that do not heal, instability can
    develop over time and become symptomatic
  • Spondylolisthesis may develop and needs to be
    followed at intervals to assess for progression

155
Sacroiliac joint painful instability sacroiliac
joint dysfunction
  • Over diagnosed, but real (estimates of prevalence
    range between lt1 and 15)
  • Usually in parous women
  • History of
  • pain in the area of the sacroiliac joint
  • occasionally radiating to the groin and posterior
    thigh
  • possibly with suprapubic pain originating from
    pubic symphysis
  • worse with unipodal loading

156
Sacroiliac joint painful instability
  • Examination
  • Reproduction of familiar pain with
  • Flare test
  • Ostgaard test
  • Standing forward bend and extension are not
    painful (the pain is not discogenic)
  • Tenderness to palpation around the sacroiliac
    joint, over PSIS, is nonspecific, usually is
    present with other back pain syndromes, and
    should not be part of the exam.

BOGUS!
157
Painful sacroiliac joint instability treatment
  • There are specific stabilization exercises that
    patients must be taught
  • Try sacroiliac joint belts
  • Anesthetic and steroid injections may help in the
    diagnosis but are usually not therapeutic.
  • Prolotherapy to stabilize the jointis safe and
    may be effective
  • Fusion of the sacroiliac joint is a last resort

158
Compression fracture vertebroplasty/kyphoplasty
  • Appropriate for fractures with at least 30
    retention of the people height
  • Vertebroplasty is most effective in the first
    several months following fracture
  • Vertebroplasty is worth considering even in the
    first several weeks one patient is severely
    debilitated by pain

159
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160
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161
First question
  • Which is worse, back pain or leg pain?

162
First question
  • Which is worse, back pain or leg pain?
  • LEG PAIN

163
When leg pain is greater than back pain
  • Herniated nucleus pulposus
  • Spinal stenosis

164
Disc herniation
165
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166
All that radiates to the leg is not disease of
the nerve root
  • Occasional, usually bilateral radiation to the
    feet with disc pain
  • Hip joint osteoarthritis can be confused with L3
    and L4 radiculopathy
  • Trochanteric bursitis can be confused with L5
    radiculopathy
  • Sciatic nerve entrapment and S1 radiculopathy can
    look identical

167
Pain arising from the hip joint
  • Always a groin component
  • Often lower outer buttock pain as well
  • Radiates to anterior thigh and knee
  • Worse with many of the activities that aggravate
    radiculopathy

168
Pain arising from the hip joint
  • Distinguished easily from radiculopathy by
    reproduction with supine flexion/internal
    rotation
  • Negative slump sit test (leg pain is not better
    with plantar flexion of the ankle or extension of
    the neck)

169
Pain on internal rotation Pain on hyperflexion/IR
170
Sciatic nerve entrapment
  • Consider this when imaging is normal or not
    consistent with location of pain and patient is
    not improving. It is real given results of
    decompression of the nerve
  • Pain pattern will closely mimic S1 radiculopathy
  • Tension tests will be positive including slump
    sit and straight leg raise
  • Neurological exam will be nonfocal
  • Most spine surgeons and neurologists are unaware
    of the problem

171
Leg pain greater than back pain
  • MRI is the preferred imaging test
  • EMG/NCV is not useful except for
  • The rare case when peripheral nerve problem
    closely mimics radiculopathy
  • To confirm the presence of radiculopathy in
    ambiguous cases

Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
172
Regarding imaging studies
  • "Imaging studies do not test for pain. Rather,
    they identify structural abnormalities which may
    or may not correlate with production of pain"    

Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
173
Regarding imaging studies
  • "On the other hand, using an imaging study such
    as an MRI or CT scan to screen for pathology and
    using the results of the study alone to generate
    or to exclude diagnosis can only lead to many
    incorrect and costly conclusions"

Phase III Clinical Guidelines For
Multidisciplinary Spine Care Specialists, North
American Spine Society, 2000
174
Regarding imaging studies
  •   "It is necessary for the clinician to take a
    careful history and perform a thorough physical
    examination in order to arrive at a differential
    diagnosis before ordering an imaging study to
    confirm our exclude a specific diagnosis"

175
Treatment algorithm for radiculopathy
Leg pain gt back pain, no significant neurological
compromise
debilitating
Oral steroids Physical therapy modalities Analgesi
cs/TCA/Gabapentin
no better
Imaging
Epidural steroid1
Percutaneous disc decompression Diskectomy
1
176
Spinal stenosis
  • NOT a cause of back pain
  • The clinical presentation is neurogenic
    claudication
  • Classical presentation
  • Bilateral thigh and or lower extremity pain for
    canal stenosis
  • Unilateral dermatomal radicular pain for
    foraminal stenosis
  • Variant presentation
  • Buttock pain only with standing and walking

177
Spinal stenosis
  • However, claudication often coexists with back
    pain because they derive from the same process
    degenerative disease of the spine

178
Why is pain in the legs present with standing and
walking?
Axial loaded
Supine, standard technique
179
Spinal stenosis
  • Epidural steroid injections may be effective for
    reducing symptoms four months at a time
  • In most cases, physical therapy is not helpful,
    but occassionally
  • Tolerance for standing and walking will decrease
    slowly with time in most cases
  • Surgical decompression results are excellent and
    this should be considered earlier in the course
    of the disease then it often is.

180
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181
Prolotherapy injection for chronic back pain
  • In the presence of co-interventions,
    prolotherapy injections were more effective than
    control injections there is no evidence that
    prolotherapy injections are more effective than
    control injections alone

182
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