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Low Back Pain: Update Jesus Sanchez, Jr. D.O.
OPSC Spring Conference
San Diego
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• Published 10/2/07 • 2007 Clinical Guidelines for
Diagnosis and Treatment of Low Back Pain
• 7 Recommendations for Evaluation and Treatment of Low Back Pain
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Main Points
• 85% of patients present with back pain that cannot be attributed to specific disease or spinal abnormality
• Do a focused history and physical determine the likelihood of specific underlying conditions and measure the presence of neurologic involvement
• Recommended Classification 1. Non-specific Back Pain
2. Back Pain with Radiculopathy
3. Back Pain with other specific cause
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• Published 2/14/17 • Partial update to the 2007 Clinical
Guidelines for Diagnosis and Treatment of Low Back Pain
• 3 Recommendations for Noninvasive Treatment of Acute, Subacute and Chronic Low Back Pain
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Recommendation 1 (Acute or Subacute LBP)
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Recommendation 2 (Chronic LBP)
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Recommendation 3 (Chronic LBP with inadequate response)
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ACP Updated Guidelines: Low Back Pain
• Symptom Duration
• Potential Cause
• +/- Radicular Symptoms
• Anatomic Abnormalities
• Radiologic Abnormalities
• Acute < 4 weeks
• Subacute 4-12 weeks
• Chronic 12 weeks
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Interventions (Acute)
• Acetametaphen (LQ, ND)
• NSAIDS (MQ, SE)
• SMR (MQ, ND)
• Systemic Steroids (LQ, ND)
• Exercise (LQ,ND)
• Accupuncture (LQ, SE)
• Massage (MQ, SE)
• Spinal Manipulation (LQ, SE)
• Superficial Heat (MQ, ME)
• Low Level Laser Therapy (LQ, +NSAID MQ)
• Lumbar Support (LQ, ND)
• TENS, Superficial Cold, Tai Chi, Yoga, Pilates (insufficient data)
OMM/OMT ???
Quality of Evidence (High, Moderate, Low)
Magnitude of Effect (Small, Moderate, Large)
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• AOA Funded Research • AOA Bureau of Osteopathic Clinical Education and Research • Published in 2010 on the National Guideline Clearinghouse • Essentially the AOA’s “White Paper” on Low Back Pain • Systematic Review and Meta-analysis (Evidence Level 1a) • Guideline for osteopathic physicians to utilize OMT for patients
with non-specific acute or chronic low back pain
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Franke H, Franke J-D, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskeletal Disorders 2014, 15:286 doi:10.1186/1471-2474-15-286. (Published: 30 August 2014)
• Identified 307 studies
• 31 evaluated 15 included (6 Germany, 5 US, 2 UK, 2 Italy)
• 1502 participants (both qualitative and quantitative)
• Moderate quality evidence suggested that OMT had a significant effect on pain relief and functional status.
• Analysis included pregnant and post-partum women
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• Update to the AOA guidelines for Osteopathic Physicians to utilize OMT for patients with non-specific acute or chronic low back pain
• Published in JAOA August 2016 • Updated every 5 years • Evidence (Level 1a) supports the
recommendation • AOA making an effort to inform its
members and the public about the appropriate utilization of OMT
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Nonspecific Low Back Pain
“… which can be defined as tension, soreness, or stiffness in the lower back region with an unidentified cause.”
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Somatic dysfunction is defined as: “Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.
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Osteopathic Structural Exam
Gait Analysis
Standing Flexion Test
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OSE continued
Seated Flexion Test
Segmental Exam
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OMT is defined in the Glossary of Osteopathic Terminology as: “The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.
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Osteopathic Manipulative Treatment (OMT)
Soft Tissue
Strain Counter Strain
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OMT continued
HVLA MET
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Take Home Point
“Once a patient with low back pain is diagnosed with somatic dysfunction as the cause, or contributing factor, of the low back pain, OMT should be utilized by the osteopathic physician.”
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Thank you!
Low Back Pain Workshop
Tomorrow 7-9 am
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References
• Noninvasive Treatment of Acute, Subacute and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017; doi:10.7326/M16-2367
• Snow, RJ, et. al. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients with Low Back Pain. JAOA. 2016; 116:536-549
• Chou, R, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491