Back Pain <ul><li>2 nd  most common cause for office visit </li></ul><ul><li>60-80% of population will have lower back pai...
Oh My Aching Back Treatment Options for Back Pain Steven Stoltz, M.D. Assistant Clinical Professor of Medicine UCSF-Fresno
Outline <ul><li>Part 1: </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>Review of anatomy </li></ul></ul><ul...
Low Back Pain <ul><li>“ One would have thought by now that the problem of diagnosis and treatment would have been solved, ...
- Anatomy Lesson #1
- Anatomy Lesson #2
Introduction to Ed <ul><li>Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he ...
What should Ed expect from his health care professional? <ul><li>Be able to recognize the difference between routine lower...
% of Back Pain due to Herniated Disk? <ul><li>4% </li></ul><ul><li>14% </li></ul><ul><li>40% </li></ul><ul><li>None of the...
Causes of Low Back Pain <ul><li>Lumbar “strain” or “sprain” – 70% </li></ul><ul><li>Degenerative changes – 10% </li></ul><...
Causes of Low Back Pain… <ul><li>Spondylolysis, diskogenic low back pain or other instability – 2% </li></ul><ul><li>Traum...
Red Flags <ul><li>History of cancer </li></ul><ul><li>Unexplained weight loss </li></ul><ul><li>Intravenous drug use </li>...
Medications <ul><li>Anti-inflammatory medications (NSAID’s): </li></ul><ul><ul><li>Beneficial; no differences; watch side-...
Chiropractic/Osteopathic <ul><li>Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek) </li></ul><ul><li>Spinal ...
Exercise & Bed Rest <ul><li>Advice to stay active: </li></ul><ul><ul><li>‘ There is no evidence that advice to stay active...
Massage & Physical Therapy <ul><li>Might be beneficial </li></ul><ul><li>More quality research is needed </li></ul><ul><li...
Acupuncture <ul><li>Very little quality research and data </li></ul><ul><li>Seems to indicate that acupuncture is not effe...
Other Modalities <ul><li>Back Brace/Corset/Lumbar Support: </li></ul><ul><li>Traction: </li></ul><ul><li>Injections: Incon...
Ed, again… <ul><li>Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painf...
Role of X-rays (Radiology) <ul><li>Usually unnecessary and not helpful </li></ul><ul><li>Plain X-ray: </li></ul><ul><ul><l...
New England Journal of Medicine (February 2001)
Medications <ul><li>Similar to acute pain…. </li></ul><ul><li>Antidepressant medications can improve pain relief </li></ul>
Exercises <ul><li>Improves pain and function </li></ul><ul><li>Many programs available, but difficult to make any scientif...
Injections <ul><li>Epidural injections: </li></ul><ul><ul><li>Insufficient and conflicting evidence </li></ul></ul><ul><li...
Surgery <ul><li>Diskectomy improves pain in short term but not long term (ie. 10 years) </li></ul><ul><li>Microdiskectomy ...
Other Modalities <ul><li>Back Schools: - possibly effective </li></ul><ul><li>Multidisciplinary Therapy: - probably yes </...
Intradiscal Electrothermal Therapy
IDET <ul><li>No convincing evidence that shows the short or long-term clinical efficacy of this procedure. </li></ul><ul><...
Prevention <ul><li>Exercise: </li></ul><ul><ul><li>Aerobic, back/leg strengthening </li></ul></ul><ul><li>Back braces and ...
Web Resources <ul><li>www.mayo.edu </li></ul><ul><li>www.cochraneconsumer.com  (“Helping people make well-informed decisio...
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Low Back Pain

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Low Back Pain

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

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