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Low Back Pain

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  • 1. Back Pain
    • 2 nd most common cause for office visit
    • 60-80% of population will have lower back pain at some time in their lives
    • Each year, 15-20% will have back pain
    • Most common cause of disability for persons < 45 years
    • 1% of US population is disabled
    • Costs to society: $20-50 billion/year
  • 2. Oh My Aching Back Treatment Options for Back Pain Steven Stoltz, M.D. Assistant Clinical Professor of Medicine UCSF-Fresno
  • 3. Outline
    • Part 1:
      • Introduction
      • Review of anatomy
    • Part 2:
      • Acute low back pain
    • Part 3:
      • Chronic low back pain
      • Prevention
    • Questions ??
  • 4. Low Back Pain
    • “ One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”
          • Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.
  • 5. - Anatomy Lesson #1
  • 6. - Anatomy Lesson #2
  • 7. Introduction to Ed
    • Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he did over the weekend. He missed work today, Monday.
    • He wants to know what can be done for his back pain?
  • 8. What should Ed expect from his health care professional?
    • Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain.
    • Provide information, advice, and a plan of action.
  • 9. % of Back Pain due to Herniated Disk?
    • 4%
    • 14%
    • 40%
    • None of the above
  • 10. Causes of Low Back Pain
    • Lumbar “strain” or “sprain” – 70%
    • Degenerative changes – 10%
    • Herniated disk – 4%
    • Osteoporosis compression fractures – 4%
    • Spinal stenosis – 3%
    • Spondylolisthesis – 2%
  • 11. Causes of Low Back Pain…
    • Spondylolysis, diskogenic low back pain or other instability – 2%
    • Traumatic fracture - <1%
    • Congenital disease - <1%
    • Cancer – 0.7%
    • Inflammatory arthritis – 0.3%
    • Infections – 0.01%
  • 12. Red Flags
    • History of cancer
    • Unexplained weight loss
    • Intravenous drug use
    • Prolonged use of corticosteroids
    • Older age
    • Major Trauma
    • Osteoporosis
    • Fever
    • Back pain at rest or at night
    • Bowel or bladder dysfunction
  • 13. Medications
    • Anti-inflammatory medications (NSAID’s):
      • Beneficial; no differences; watch side-effects
    • Tylenol:
    • Narcotic Pain Relievers:
      • No more effective than NSAID’s
      • Many side effects
    • Muscle Relaxants (ie. Flexeril ® ):
      • Can decrease pain and improve mobility
      • 70% with drowsiness/dizziness
  • 14. Chiropractic/Osteopathic
    • Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek)
    • Spinal manipulation
    • Conflicting evidence on the effects of spinal manipulation
      • ~75-90% improvement anyway within 4 weeks
    • Greater patient satisfaction
  • 15. Exercise & Bed Rest
    • Advice to stay active:
      • ‘ There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’
      • Hurt does not equal harm
    • One or two days of bed rest if necessary
    • Light activity, avoiding heavy lifting, bending or twisting (ie. walking)
    • No data on any particular exercises
  • 16. Massage & Physical Therapy
    • Might be beneficial
    • More quality research is needed
    • Different types of massage
  • 17. Acupuncture
    • Very little quality research and data
    • Seems to indicate that acupuncture is not effective for the treatment of back pain
  • 18. Other Modalities
    • Back Brace/Corset/Lumbar Support:
    • Traction:
    • Injections: Inconclusive evidence
    • TENS:
    • Hot/ Cold :
    • Ultrasound:
  • 19. Ed, again…
    • Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event.
    • What types of therapies might be beneficial for Ed now?
  • 20. Role of X-rays (Radiology)
    • Usually unnecessary and not helpful
    • Plain X-ray:
      • Age>50 years
      • No improvement after 6 weeks
      • Other worrisome findings
    • MRI:
      • After 6 weeks if have sciatica
  • 21. New England Journal of Medicine (February 2001)
  • 22. Medications
    • Similar to acute pain….
    • Antidepressant medications can improve pain relief
  • 23. Exercises
    • Improves pain and function
    • Many programs available, but difficult to make any scientific recommendations for one type versus another
  • 24. Injections
    • Epidural injections:
      • Insufficient and conflicting evidence
    • Facet joint injections:
      • No improvement
    • Local/Trigger point injections:
      • Possibly some benefit
  • 25. Surgery
    • Diskectomy improves pain in short term but not long term (ie. 10 years)
    • Microdiskectomy similar to standard diskectomy
    • Automated percutaneous diskectomy and laser diskectomy both less effective
    • ? Arthroscopic diskectomy
  • 26. Other Modalities
    • Back Schools: - possibly effective
    • Multidisciplinary Therapy: - probably yes
    • TENS: - no
    • Spinal manipulation: - conflicting data
    • Massage: - probably yes
    • IDET:
  • 27. Intradiscal Electrothermal Therapy
  • 28. IDET
    • No convincing evidence that shows the short or long-term clinical efficacy of this procedure.
    • Safe with few adverse effects
    • ? Long-term effects
    • Wall Street Journal (Feb. 11, 2003)
  • 29. Prevention
    • Exercise:
      • Aerobic, back/leg strengthening
    • Back braces and education about proper lifting techniques are ineffective
    • ? weight loss and smoking cessation
  • 30. Web Resources
    • www.mayo.edu
    • www.cochraneconsumer.com (“Helping people make well-informed decisions about health care.”)
    • www.library.ucsf. edu