Although back pain is a common problem, treatment options will vary depending on how long you had the pain and the severity of it. Dr. Rohit Oza explains the different types of injections you can use to help treat back pain.
PREFACE The AAPM&R PM&R Approach to Low Back Pain slide presentation (physician version) is provided as an educational service to assist physiatrists, particularly members of the American Academy of Physical Medicine and Rehabilitation, in marketing their services to primary care physicians. This presentation is one of the many products developed as part of the PM&R Awareness Initiative - a multi-year marketing and communications program addressing key audiences including: AAPM&R members, primary care physicians, employers, managed care organizations and insurers, allied health professionals, and the public. A key component of this plan is the creation of tools and resources that AAPM&R members can use to supplement marketing activities conducted at the national level. The PM&R Approach to Low Back Pain slide presentation is one of the tools developed specifically to help physiatrists demonstrate their role in providing total patient care. In addition to a general overview of the history and causes of low back pain, the presentation illustrates the PM&R approach to care and treatment. It includes a case study that can be easily adapted to reflect your own practice. The Academy welcomes your feedback on the utility of this product as well as suggestions or ideas for future updates to this presentation or additional products and services that would be useful to practicing PM&R physicians. Please direct comments and suggestions to the national office. The Academy acknowledges Drs. Stanley A. Herring, Jeff Young, and Joel Press for developing content for this presentation, and the AAPM&R Marketing Committee for their assistance in reviewing it. Members of the Marketing Committee include: Kristjan T. Ragnarsson, MD, ChairRoss D. Zafonte, DO (ex-officio) D. Nathan Cope, MDRobert D. Rondinelli, MD, PhD Steven L. Hendler, MDDavid L. Bagnall, MD, PASSOR Representative Kurtis M. Hoppe, MDNadine Maurer, MD, RPC Representative Austin I. Nobunaga, MDClaire V. Wolfe, MD, BOG Liaison Thanks are also due to members of the Academy national office staff and Tucker-Knapp Integrated Marketing Communications for overall management of the project and design, editing, and production of this slide presentation. (c) 1999 American Academy of Physical Medicine and Rehabilitation. All rights reserved. The PM&R Approach to Low Back Pain slide presentation (physician version) is owned and copyrighted by the American Academy of Physical Medicine and Rehabilitation. The PM&R Approach to Low Back Pain slide presentation cannot be licensed, sold, or distributed to another purchaser without the express written permission of the American Academy of Physical Medicine and Rehabilitation. Information in this presentation does not represent official policy of the American Academy of Physical Medicine and Rehabilitation unless specifically stated. The purpose of this presentation is to provide information for education and communication purposes only. The information contained herein is meant to be a helpful resource for AAPM&R members, referring physicians, healthcare professionals, and the public; AAPM&R does not guarantee and thus accepts no liability relative to the content, accuracy, or use of the content of this presentation. The information in this presentation should not be considered complete, nor should it be relied on to suggest a course of treatment for a particular individual. It should not be used as a substitute for a visit, call, consultation or the advice of a physician or other qualified health care provider. The information contained in this presentation was compiled from a variety of sources, and while every effort has been made to ensure its accuracy, it is intended only as a guide and is not a substitute for specific medical opinion.
I'm sure it comes as no surprise to any physician that low back pain is one of the most common medical problems in this country. 60-90% of all adults will experience low back pain during their lifetimes. Fifty-five percent will suffer annual recurrence. In fact, low back pain is the second most common reason patients visit their primary care physicians.
For example, it has been stated that 40-50% of patients with low back pain will improve within one week. That's true - as far as it goes in terms of immediate improvement.
However, over 40% of all patients with low back pain will have persistent complaints of pain at one- and two-year follow-ups. Even studies that report a favorable natural history for low back pain in terms of short-term follow-up commonly demonstrate frequent relapses of low back pain or persistent low back pain for longer time frames. Sixty-two percent of patients are likely to have one or more relapses during a one-year follow-up. And persistent pain can mean more physician visits, more diagnostic tests, and more frustration for patient and physician.
Improve, yes, but to what extent? Low back pain is the number one cause of disability in patients under the age of 45, and the number three disability in patients over 45. And consider the long-term consequences: If an injured worker has been off work for six months, there is only a 50% chance of that employee ever successfully returning to the same job. By the time an injured worker has been off work for two years or more, statistically there is little to no chance of that person ever returning to their previous job.
Finally, it has been reported that 90% of patients with low back pain improve without any medical care.
However, the truth is that continued problems with low back pain are even more likely in patients who wait six to 10 weeks from the first onset of pain before seeking medical care. These subacute back pain patients demonstrate an almost 80% incidence of back pain at six-month and one-year follow-ups. Indeed, in this patient group, there is a 26% increase in not only pain, but also marked disability at the six-month follow-up, and a 12% incidence of marked disability at the one year follow-up.
3.)Reducing the risk of recurring back pain requires thorough patient education and an individualized program which the patient can largely self-manage.
The complex interaction of physical, psychological, and lifestyle variables contributing to low back pain complicates the picture even more. And while attempts have been made to develop guidelines that can assist practitioners in diagnosis, their application hasn't been universally accepted. Clinical guidelines for low back pain published by the Agency for Health Care Policy and Research represent one of the most recent attempts to standardize this complex issue. The guidelines are valuable in that they emphasize conservative management, but they lack adequate data and research to support a practical guideline. Unfortunately, the science of low back pain therapy hasn't received the attention and funding necessary to adequately research and develop universally-accepted practice guidelines. The influence of managed care can also cause problems in treating low back pain. In an attempt to reduce costs, a health plan's definition of adequate outcome may differ significantly from that of the patient and treating physician.
April 2004 issue of Newsweek The issue wrote about massage, acupuncture, chiropractic. The issue notes the lack of proven efficacy for many of these treatments. “ Like a temperamental sports car, the human spine is beautifully designed but maddeningly unreliable.” As long as we continue to lead overweight, sedentary, and stressful lives, these numbers are unlikely to go anywhere but up. The article talked about managing pain with multiple disciplines: Acupuncture, massage, and chiropractic practitioners are increasing in numbers. The number of Chiropracters increased 50% from 1990 to 2004.
Interdisciplinary Approach to Pain Management Chronic spinal disorders are a complex phenomenon and is best managed by a interdisciplinary team. Primary coordination of treatment may depend on the individual patient’s needs and may change over time. For example, at one point the pain specialist’s input may be most urgent; subsequently, the physiatrist’s efforts may be most important, while at another point psychological therapy may be what the patient needs most. Chronic Spinal Disorders management challenges specialties to work together, often for long periods of time.
Injection Treatment for Back Injury
Injection Treatments for Back Injury
Rohit Oza, MD
Summit Medical Group
The Low Back Pain Story
60-90% of adults will have low
2nd most common reason to see
primary care physician
40-50% of patients with low back pain will
improve within one week
The Full Story
62% of patients likely to have one or more
relapses during a one-year follow-up
The Full Story
Low back pain is the #1 disability in
patients under 45
90% of patients with low back pain
improve without any medical care
The Full Story
Longer pain for patients who wait 6-10 weeks
80% have pain at six months and one year
12% disability at one year
Difficulties in Treating LBP
1. Difficult to diagnose source
2. Requires “whole care” approach
3. Preventive program needed to
Other Complicating Factors
Lack of research
Managed care restrictions
Leading cause of disability
70-90% of adults will
In their lifetime
medical expense anually
In medical bills, disabilty,
and loss of productivity
Approach at SMG
• Pain specialists
– Vertebral body
– Facet joints
Injection Treatments: Muscle/Ligaments
Trigger Point Injection
A trigger point is a knot or tight, rope-like band of
muscle that forms when a muscle fails to relax
Lidocaine is an injectable medication that can be used
to numb a joint or treat muscle pain. Research shows
that injections used to inactivate trigger points can
provide prompt relief of painful symptoms related to
joint and muscle ailments.
Injection Treatments: Muscle/Ligaments
Trigger Point Injection
Injection Treatments: Nerve
“Sciatica” Sciatica is a relatively common form of low back and leg pain, but the true meaning
of the term is often misunderstood.
Sciatica is a set of symptoms rather than a diagnosis
Symptoms include lower back pain, buttock pain, and pain, numbness or
weakness in various parts of the leg and foot. Other symptoms include a "
pins and needles" sensation, or tingling and difficulty moving or controlling the leg
Been around for 40
The epidural space is
accessed through the
Disc Herniation Location
Determines Affected Nerve
Low risk for thecal puncture. Dura ends at S2.
Unreliable above the L4-5 levels.
Requires higher volumes of medication
1. Cartilage degeneration with or
2. Osteophyte formation
3. Biomechanical transfer of
weight in disc degeneration
4. Trauma to the joint
Lumbar facet joints
recognized as a source
of pain since 1911
with or without
Pain after rotary
Low back pain with
radiation to thighs
imaging or exam
Intra-articular Joint Injections
Therapeutic (Local and steroid)
Paravertebral Facet Joint Nerve
Blocks(Medial Branch Blocks)
Diagnostic (Local only)
Therapeutic only with Neurolysis
Radiofrequency ablation produces
indescriminate destruction of all
nervous tissue including motor and
Lesion Shape Produced by RF:
Typical Energy Delivered 2-7 watts
* Thermal lesion is least at tip and greatest
along active shaft of RF needle
* Typical tissue temp 70-90 degrees C
* Optimum angle is parallel to nerve
Accepted source of low
back and buttock pain
Prevalence of SI pain:
13 to 30% of cases of
low back pain
Moderate evidence for
efficacy of SI joint
Discs well innervated
and can be source of
Presence of radial
fissures that reach the
outer third of the
Severe Degenerative Disc Disease
Load to the
Internal architecture of the disc is disrupted
External surface remains normal, no bulge or herniation
Characterized by degradation of the matrix of the nucleus pulposus and presence of
radial fissures that reach the outer third of the annulus
Stem Cells for Disc Degeneration
Dr. Alon Terry(newest SMG Physiatrist) trained at HSS where he
worked on regenerative strategies for the disc
In a recent study by Dr. Terry and Dr. Lutz, cells from a patient’s blood were
taken out and injected into the disc to see if can stimulate a repair response.
They also worked on a study injecting growth factor into the disc to try to
turn on the disc’s inherent ability to heal itself.
These are some of the first studies that have
been done in the world in this area.
Lumbar spine injections can be a valuable tool in
the management of LBP
Some injections can be diagnostic and/or
Injections represent one strategy in the
management of LBP
Multimodal treatment strategies have shown to
be most helpful in the long-term management of