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    Evaluation and Treatment of Low Back Pain in the Primary Care ... Evaluation and Treatment of Low Back Pain in the Primary Care ... Presentation Transcript

    • 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 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
    • Is This Really A Problem?
      • 80 % 0f adults in industrial countries have at least one episode of disabling back pain .
      Bonica 1980
    • Is This Really A Problem ?
      • 80 % 0f adults in industrial countries have at least one episode of disabling back pain.
      • By the 3 rd decade 50% of people have experienced an episode of LBP that required alteration in activity .
      Leboeuf-Yde 1998
    • Is This Really A Problem?
      • 80 % 0f adults in industrial countries have at least one episode of disabling back pain.
      • By the 3 rd 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
      • 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 .
      Is Back Pain a Problem? Medical Data International 1998
      • 8 million are totally disabled from back pain
    • Is Back Pain a Problem?
      • Pai found in 2004 1 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 . 2004;35:1-5.
    • Is Back Pain a Problem, At Work?
          • Back pain is the most common reason for filing workers’ compensation claims 1
        • 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 combined 2
      1. Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. AM J Public Health . 1999;89:1029-1035. 2. Pai S, Sundaram LJ. Low back pain: an economic assessment in the united states. Orthop Clin N Am . 2004;35:1-5.
    • In 1999, back pain accounted for 40 percent of absences from work, second only to the common cold. Absences from Work Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. AM J Public Health . 1999;89:1029-1035. Is Back Pain a Problem at Work?
    • General Aspects Regarding Back Pain
      • Low back pain is recurrent in 33-70% of patients 1,2
      • 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.
      Three facts that should help frame our approach from here forward (evidence follows): 1. Von Korf, Spine 1996 21(24):2833-37; 2. Haestbaek L European Spine Journal 2003 Apr;12(2):149-65
    • 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.
    • 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 > 2 relapses
      • 33% had relapses of work absence
    • 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.
    • Evidence base for these statements: The patient’s 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.
    • Evidence base for these statements: The patient’s 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”
    • 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
    • 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 pain 1
        • 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 pain 2
        • Equal improvement, no difference in outcome at 1 year.
      1 Linton SJ Spine 2000 Nov 1;25(21):2825-31 2 Brox JI Spine 2003 Sep 1;28(17):1913-21
    • 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.
    • 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.
    • New Topic: Duration of symptoms
      • Less than eight weeks duration
      • Eight weeks-six months duration
      • Greater than six months duration
      It is generally useful to break back pain into three categories according to duration of symptoms:
    • General management, according to duration of symptoms 0-8 wks 8 wks-6 mo >6 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 weeks 1
      • Patients remaining symptomatic after six months have a poor prognosis for significant improvement 2
      1 Phase III Guidelines for Multidisciplinary Spine Specialists , North American Spine Society, 2000 2 Mayer TG, pg 3-9 in Contemporary Conservative Care for Spine Disorders
    • 0-8 weeks 8 weeks – 6 months
    • 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
      • Physician’s role: palliate symptoms to support spontaneous recovery
      • Patient education is key
    • Diagnoses we don’t 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
    • 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
    • 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
    • Historical aspects that increased suspicion for infection
      • Recent IV drug abuse
      • Immunosuppression
      • Diabetes
    • 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
    • Things we don’t want to miss physical exam 2
      • The patient can’t 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
    • 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 patient’s needs
    • 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
    • PATHOANATOMIC LESION PAIN DISABILITY SOCIAL FACTORS CULTURAL FACTORS PSYCHOLOGICAL FACTORS COGNITIVE FACTORS
    • PATHOANATOMIC LESION PAIN DISABILITY SOCIAL FACTORS CULTURAL FACTORS PSYCHOLOGICAL FACTORS COGNITIVE FACTORS
      • Measure disability
      • Evaluate the cause of disability
      • Treat the cause of the disability
      Concept:
    • 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
    • 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
    • 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?
    • Functional impairment: Disability consequent to pain
      • Impairment of work life
      • Impairment of recreational activity
      • Impairment of social activity
      • Impairment of sleep
      • Impairment of sex life
      • Patient specific disability
      The 6 major areas of function worth quantifying:
    • Decision Making: The Patient’s basis
      • Function at work
      • Function at home
      • Social function
      • Recreational function
            • “ I can’t lift my grandchild”
            • “ I can’t make it through a day at work”
            • “ I have to sleep in a recliner, can’t join my spouse in bed”
            • “ I can’t sit through a game of cards ”
    • Decision Making: The Physician’s basis
      • Symptom driven
      • Limited to Pathoanatomy
      • “Bio-reductionist model”
      • “Bio-medical model”
      • “ This is a patient with:
      • Chronic back pain
      • Due to degenerative disc disease”
      For Example:
    • 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.
    • How does this compare to the patient’s perspective?
      • 74% of patients indicated that they had significant interference with work, 42% rated this as > 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”
    • 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 patient’s needs
      • 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
      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
      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
      Patients rated the following as either “very important” or “extremely important”:
    • 0-8 weeks Identify early predictors of chronicity
        • Identify unrealistic expectations, such as complete cure.
          • 51% of patients expect this
        • Identify the patient’s motivation for self-care
        • Identify and treat depression and anxiety
        • Look for a pattern of multiple somatic complaints
    • 0-8 weeks Symptom palliation
      • 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
      1/2
    • 0-8 weeks Symptom palliation
      • To support progress toward resumption of activity
        • Acupuncture
        • Trigger point injections
        • Epidural steroid injection for radiculopathy and for the “acute disc”with mostly back pain.
      2/2
    • 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
    • 0-8 weeks Symptom palliation
      • When leg symptoms predominate
      • Oral steroids or
      • Early referral for epidural steroid injection 1
      • Imaging and early referral if neurological red flags are present on history or exam
      1 Phase III Clinical Guidelines For Multidisciplinary Spine Care Specialists , North American Spine Society, 2000
    • When leg symptoms predominate
      • Physical therapy should include a trial traction
    • 0-8 weeks: Patient’s 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 wouldn’t have this much pain of the work something dangerously wrong”
      • 31% “I might injure myself if I exercise”
    • 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
    • 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
    • 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
      TIMESAVER!
    • 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 >600 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.
    • 0-8 weeks
      • 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
      What can the physical therapist do besides teach exercises and apply modalities? Cognitive therapy! TIMESAVER! TIMESAVER!
    • 0-8 weeks
      • Educate the patient on how to prevent recurrence of pain
      • Help you grade the patient’s progress toward functional goals
      • If your patient is missing work, design a return to work program and follow it along with the physical therapist
      What can the physical therapist do besides teach exercises and apply modalities? TIMESAVER! TIMESAVER!
    • 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
    • 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
    • Role of the physical therapist (stretching is not evidence based medicine)
    • 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.
    • Maintenance exercise
      • Yoga
      • Pilates
      • If the patient is not improving and psychosocial factors appear prominent, refer to behavioral health for evaluation and treatment recommendations early.
    • Eight weeks - six months
      • Re- evaluation
      • Treatment
    • 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?
    • Eight weeks-six months Re-evaluation The “missed medical diagnosis”
    • Common “benign” diagnoses in chronic back and leg pain
      • 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
    • Less common “benign” causes of chronic back and leg pain
      • Sacroiliac joint pain
      • Coccydynia
      • Polymyalgia rheumatica
      • Stiff man syndrome
      • Multiple sclerosis
      • Parkinson’s disease
      • Sciatic nerve entrapment
      • Post viral and other autoimmune radiculitis/plexitis
    • Nonexistent causes of chronic back and leg pain
      • Chronic low back strain
      • Chronic myofascial pain
    • First question:
      • Which is worse, back pain or leg pain?
    • First question:
      • Which is worse, back pain or leg pain?
      • BACK PAIN
    •  
    •  
    •  
    • NOT
    • Why might pain radiating down the legs to the feet occasionally, especially with heavy loads and activity?
    • 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
    • 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%).
    • 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
    • Is MRI useful in diagnosing painful degenerative disc disease?
      • L ongitudinal A ssessment of I maging and D isability of the Back
      LAID Back
    • 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
    • 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
    •  
    • Low back pain from intravertebral disc and facet joint The two most common causes of pain in the 8 week – 6 month period
    • Low back pain from intravertebral disc (the disc is painful)
      • What shall we call it?
      • Painful degenerative disc disease
      • Discogenic pain
      • Internal disk disruption
    • 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
    • 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
    • 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
    • Patho-mechanical: compression Adapted from: Adams M, et al. Mechanical initiation of disc degeneration. Spine. 2000;25:1625-36 posterior anterior Distance across L1-2 disc Distance across L1-2 disc posterior anterior Normal disc Damaged endplate
      • Discogenic pain was found to be associated with anomalous loading of the posterolateral anulus (P < 0.001) and nucleus (P < 0.01).
      Patho-mechanical: compression Mcnally DS, Shackleford M, Goodship AE, Mulholland RC. In-Vivo Stress Measurement Can Predict Pain on Discography. Spine. 1996;21:2580-7
      • Painful discs were found to have a 38% wider posterolateral anulus (P < 0.023) than painless discs and to have a 63% lower mean nuclear stress (P < 0.017)
    •  
    •  
    •  
    • Annular tear
    • 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.
      • 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
    • Disc and facet pain: Degenerative Cascade Stage 2 (Instability)
      • Facet
        • Capsular tear (major) with laxity
        • Increasing rotational and sagittal movement
        • Increasing cartilagenous damage
        • Increasing inflammation
      • 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 .
    • 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
    • Disc and facet pain:Degenerative 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
    • Disc and facet pain:Degenerative 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
    • Eight weeks-six months Re-evaluation
      • Are psychosocial factors contributing significantly to disability?
    • 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
    • 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.
    • When Psychosocial factors predominate: How can one recognize them efficiently?
    • 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
    • Eight weeks - six months
      • Re- evaluation
      • Treatment
    • 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
    • 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
    • Pharmacotherapy: NSAIDs
      • Review of 50 RCTs:
      • Available evidence supports their use in acute and chronic back pain
    • Pharmacotherapy: Muscle relaxants
      • Review of 50 RCTs:
      • NO QUALITY EVIDENCE supports their use in chronic back pain
      • Special caution: Carisoprodol
    • 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
    • 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
      • 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
    • 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.&quot;
    • 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
    • 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
    • Maintenance exercise
      • Yoga
      • Pilates
    • 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
    • Disease specific intervention Discogenic pain
    • Procedural possibilities
      • Chronic opioid therapy
      • Intra-discal electrothermal annuloplasty
        • “ IDETT”
      • Disc replacement
      • Fusion
    • Procedural possibilities Selection criteria:
      • When pain prevents rehabilitation
    • Intradiscal electrothermal annuloplasty (Indications)
      • Pain that limits ADL’s
      • 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.
    • IDETT ORIGINAL CONDUCTIVE TECHNIQUE 1 MODIFIED RF TECHNIQUE
    • IDETT ORIGINAL CONDUCTIVE TECHNIQUE MODIFIED RF TECHNIQUE
    • 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?)
    • ≥ 50% pain relief = 86% ≥ 70% pain relief = 55% 100% pain relief = 9% n = 22
    • ≥ 50% pain relief = 72% ≥ 70% pain relief = 64% 100% pain relief = 18% n = 11
    • ≥ 50% pain relief = 51% ≥ 70% pain relief = 28% 100% pain relief = 10% n = 29
    • Outcomes of IDEA 27% 14% 41% No pain relief 64% 55% 28% >70 % pain relief 73% 86% 51% >50% pain relief New technique 6 mo New technique 3 mo Old technique 3 mo
    • Outcomes of RF IDEA: athletes 4 yes no GYMNAST 3 yes yes SWIMMING 1 yes yes BASKETBALL Latest follow up (years post procedure) Better in routine activities Back to 100% in competition 3 Div 1 Collegiate athletes
    • Outcomes of IDEA
      • 1 year, 25 patients
      • 3.5 average reduction of VAS
      • 68% of patients >50% functional improvement on Roland scale
      • 74% very satisfied with results
      • 17% went on to successful (in terms of patient satisfaction) fusion
    • 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.”
    • 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
    • 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
    • Painful lumbar facet joints
    • 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
    • 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 > 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
    • 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)
    •  
    • 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
    • Other causes of back > leg pain
    • Lumbar instability
      • Definition: unequivocal anterior-posterior translation of one vertebral segment on another > 6 mm on lateral standing flexion extension radiograph, or side to side motion of one vertebral body on another with sidebend.
    • 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
    •  
    • 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
    • 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
    • Lumbar instability
      • Action to take when instability is identified:
      • Early surgical referral when it presents with neurologic symptoms or signs, even if intermittent
    • 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
    • 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
    • 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
    • Sacroiliac joint painful instability “sacroiliac joint dysfunction”
      • Over diagnosed, but real (estimates of prevalence range between <1% 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
    • 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!
    • 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
    • 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
    •  
    •  
    • First question:
      • Which is worse, back pain or leg pain?
    • First question:
      • Which is worse, back pain or leg pain?
      • LEG PAIN
    • When leg pain is greater than back pain
      • Herniated nucleus pulposus
      • Spinal stenosis
    • Disc herniation
    •  
    • 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
    • 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
    • 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)
    • Pain on internal rotation Pain on hyperflexion/IR
    • 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
    • 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
    • Regarding imaging studies
      • &quot;Imaging studies do not test for pain. Rather, they identify structural abnormalities which may or may not correlate with production of pain&quot;    
      Phase III Clinical Guidelines For Multidisciplinary Spine Care Specialists , North American Spine Society, 2000
    • Regarding imaging studies
      • &quot;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&quot;
      Phase III Clinical Guidelines For Multidisciplinary Spine Care Specialists , North American Spine Society, 2000
    • Regarding imaging studies
      •   &quot;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&quot;
    • Treatment algorithm for radiculopathy Leg pain > back pain, no significant neurological compromise Oral steroids Physical therapy modalities Analgesics/TCA/Gabapentin Epidural steroid 1 Imaging no better Percutaneous disc decompression Diskectomy debilitating 1
    • 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
    • Spinal stenosis
      • However, claudication often coexists with back pain because they derive from the same process: degenerative disease of the spine
    • Why is pain in the legs present with standing and walking? Axial loaded Supine, standard technique
    • 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.
    •  
    • 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”
    • The end