management of low back pain webinar - woema...management of low back pain / dallin demordaunt, md...

Management of Low Back Pain / Dallin DeMordaunt, MD

August 26, 2015 / WOEMA 2015 Webinar Series

Early Management of Occupational Low Back Pain

Cure-back-pain.org

PLEASE STAND BY – WEBINAR WILL BEGIN AT 12:00 PM PST

FOR AUDIO: CALL 866-740-1260 / ACCESS CODE: 764-4915#

Conflict of Interest Disclosure

My partner/spouse and I have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content I am planning, developing, presenting, or evaluating.

I, Dallin DeMordaunt, hereby declare that the content for this activity, including any presentation of therapeutic options, is well balanced, unbiased, and to the extent possible, evidence-based.

Learning Objectives

1. Recognize the prevalence and expense of occupational low back injuries.

2. Learn the steps for performing a history and examination for low back pain.

3. Recognize the “red flags” of low back pain that require further diagnostic work up.

4. Understand when and what imaging/tests are indicated early on in low back pain.

5. Understand what treatments are usually indicated for most acute and subacute low back injuries.

6. Understand what occupational activity modifications are usually indicated for acute and subacute low back injuries.

Statistics

u  60-80% of general population will have LBP during their lifetime.

u  Low back disorders that may be work related are the most frequent problems presenting to occupational health providers and PCP.

u  It is the most common cause of reported occupational complaints resulting in days absent from work

u  Comprise 15-25% of all occupational injuries. 1

Back Pain is Expensive

u  Low back disorders disproportionately expensive, accounting for 10-33% of all workers’ compensation costs.

u  Estimated nationally that occupationally related back pain has a DIRECT cost of $10.8 billion annually. 1

u  Indirect costs to employers to rehire, retrain, loss of productivity, administrative costs, losses to patient and patient’s family much more(estimates of 30-50 billion). In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville,

u  The Journal of the American Medical Association reports that spine care costs reached $85.9 billion in 2005.Martin, B., Deyo, RA, et. al. Original Contribution Expenditures and Health Status Among Adults With Back and Neck Problems JAMA. 2008;299(6):656-664.doi:10.1001/jama.299.6.656 http://jama.ama-assn.org/content/299/6/656.full

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Anatomy of Lumbar Spine

u  Typically 5 lumbar vertebrae

u  Connects the Thoracic spine to the Sacrum

Snowstrength.com



Anatomy cont-

u  Vertebral Body- weight bearing

u  Pedicles— Connection between vertebral body and posterior elements

u  Posterior elements-Laminae, the articular processes, spinous processes, transverse processes.

u  Laminae-transmits forces between spinous processes and articular processes.

u  Articular processes-form synovial joints to provide a locking mechanism to resist forward sliding and twisting of vertebral bodies.

u  Transverse processes, spinous processes and other processes provide for areas for muscle attachments. 2

Ittcs.wordpress.com

Initial History and Evaluation

u  History and Physical Exam to look for signs or symptoms of red flags or urgent injury or other pathology that requires immediate imaging and further work up.

u  Many non-spine related problems can present as low back pain.

u  In the absence of these red flags, further special studies or specialty referral is usually not indicated

u  Determine work relatedness of the injury

Documentation

u  With an occupational injury, documentation of any event or events and the mechanism of injury as stated by the patient is extremely important in determining the work relatedness of any injury

u  Also discussion with patient about the day-to-day physical requirements/demands of their job. (weights, sizes and frequency of specific activities; light, medium, heavy work demands).

u  Outside recreation/activities.

u  Any previous low back injuries or treatment (chiropractic treatment often not stated by patient.)

Questions ?????????????????

u  What do you think caused this problem?

u  How is it work related?

u  When did the pain start?

u  Was there any trauma (fall, trip)?

u  Have your symptoms changed?

u  Have you had previous similar episodes?

u  Any previous treatment or testing for your back?

u  How does your injury limit you?1

Questions continued- ??????????

u  What are your job duties?

u  How long have you been at this job?

u  What previous jobs did you have?

u  What recreational activities/ hobbies do you do?

u  Do you exercise?

u  What is your relationship with your co-workers and supervisor and how do they treat you?

u  Do you like your job?

u  What are you concerned may have been injured?1

Other Risk Factors for low back pain

u  smoking

u  obesity

u  Age

u  female gender

u  physically strenuous work, sedentary work

u  psychologically strenuous work

u  low educational attainment

u  Workers' Compensation insurance

u  job dissatisfaction

u  psychologic factors such as somatization disorder, anxiety, and depression 3



Activities associated with Back Pain

u  Heavy physical work

u  Heavy awkward lifting

u  Prolonged or repetitive bending

u  Frequent reaching

u  Forceful pushing or pulling

u  Prolonged sitting

u  Whole body vibration

u  Unaccustomed work 1 Betweenthebind.blogspot.com

Psychological Factors

u  Both Occupational and Non-Occupational should be explored

u  Task enjoyment

u  Monotony

u  Job Satisfaction

u  Supervisor and co-worker support. Employee/ employer conflict

u  Anxiety, depression, Somatization.

u  ****Strongest risk factor—prior history of LBP 1

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Red Flags for Serious Disorders

Meredithwalters.com

Spinal Red Flags

u  Fracture

u  Tumor/ Neoplasia

u  Infection

u  Cauda Equina

u  Progressive Neurologic Deficit

Fractures

u  Fracture- 4% of cases- suspect in any significant trauma (Fall, MVA) 3

u  Minor trauma in older/osteoporotic individual.

u  PE: Percussion tenderness over spinous processes. Abnormal Neurologic exam. 1

Orthopedicsindia.com

Tumor/ Neoplasia; Spinal Infection; Cauda Equina Less than 1% have systemic cause. 3



Tumor/ Neoplasia u  The bone is one of the most common sites of metastasis. A history

of cancer (excluding nonmelanoma skin cancers) is the strongest risk factor for back pain from bone metastasis. Among solid cancers, metastatic disease from breast, prostate, lung, thyroid, and kidney cancers account for 80 percent of skeletal metastases. Approximately 60 percent of patients with multiple myeloma have skeletal lytic lesions present at diagnosis. 3

u  Pain over spinal processes. History of cancer. Age> 50. Constitutional symptoms, such as recent weight loss, fatigue. Pain worse when supine or at night or at rest. Sciatica, paresthesias.

u  PE: Pallor, low blood pressure, diffuse weakness, tender over spinous process and percussion tenderness; decreased Range of motion due to muscle spasm 1

Blog.safemedtrip.com

Spinal Infection -Epidural Abscess, Vertebral osteomyelitis, discitis

u  Recent bacterial infection (UTI); recent spinal injection or catheter or procedure. IV drug abuse; diabetes or immune suppression (steroids, HIV). Fever, chills, night sweats, unexplained weight loss.

u 

u  PE: Tender over spinous process, decreased range of motion, Vital signs with tachycardia, tachypnea, hypotension, elevated temperature, pelvic or abdominal tenderness 1

Cauda Equina Syndrome

u  Most common due to metastatic tumor, epidural abscess or hematoma. 3 Direct blow or fall with axial loading

u  Perianal/ perineal sensory loss “saddle anesthesia”

u  Recent onset of bladder dysfunction (urinary retention, increased frequency, or overflow incontinence)

u  Bowel dysfunction or incontinence

u  Severe or progressive neurologic deficit in lower extremities (multiple myotomes and dermatomes) 1

T2tphysiotherapy.com

Progressive Neurologic Deficit

u  Severe Low Back Pain

u  Progressive weakness and/or numbness

u  PE: Myotomal motor weakness

u  Significant and increased loss of sensation in anatomical distribution.

u  Loss of reflex

u  Radicular signs 1

Extraspinal Red Flags

u  Dissecting Abdominal Aortic Aneurysm

u  Renal Colic

u  Retrocecal Appendicitis

u  Pelvic Inflammatory Disease

u  Urinary Tract Infection

u  Others: Pancreatitis, Herpes Zoster

Meredithwalters.com

Dissecting Abdominal Aortic Aneurysm

Excruciating Low back pain; history of atherosclerotic disease/ CAD; Hypertension

u  PE: Pulsatile abdominal mass

u  Absent/variable pulses

u  Asymmetric BP/ bruits 1

Aorticdissection.co.uk



Renal Colic

u  Excruciating pain from costovertebral angle to groin, testis, or labia

u  History of kidney stones

u  Hematuria

u  PE: Tender at costovertebral angle 1

Retrocecal Appendicitis

u  Right lower quadrant abdominal pain/ Right Low back pain

u  Constipation

u  Subacute onset without typical event

u  Nausea/vomiting variable

u  PE: Low-grade fever

u  Tender Right lower quadrant

u  Pain on rectal exam in RLQ 1

Pelvic Inflammatory Disease

u  Vaginal Discharge

u  Pelvic Pain

u  Prior Episode

u  Uterine tenderness

u  Tender over Right or Left Lower Quadrants

u  Cervical Discharge 1

Urinary Tract Infection

u  Dysuria

u  History of UTI

u  Fever

u  Suprapubic tenderness

u  Smelly or cloudy urine 1

Medical History- Open ended questions

u  What are the patient’s symptoms? u  Onset, Location, duration, character of pain, alleviating and

aggravating factors, radiation, Temporal pattern of when the pain is there, Severity

u  Ex. Numbness, tingling, stiffness, swelling, pain in the back verses leg, pain in the morning verse end of work day or at night, worse pain with sitting vs. standing, bending forward vs. bending backward, walking, going upstairs/uphill vs. downstairs/downhill, lifting, coughing and sneezing, constant vs, intermittent pain, start suddenly or gradually, getting worse or better.

u  Fever, chills, night-sweats, change in bowel or bladder function, weakness

u  Visual Analog Scales and Pain Diagram also very helpful!! 1

Physical Exam

u  Goal: To determine the etiology of the pain (spine vs. nonspine in origin), severity of injury, and consistency with the patient’s medical history.



Physical Exam Components

u  Observation

u  Regional Exam of Low Back

u  Neurologic Exam

u  Lumbosacral Nerve Root testing

u  Exam of associated Musculoskeletal areas and Organ Systems

u  Monitoring for Pain Behaviors

Observation

u  Physical exam starts with initial introduction to patient.

u  General observation of patient’s:

u  Gait

u  Positions

u  Stance

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Gait

u  One of the most helpful aspects of physical exam

u  Observe walking in hallway and room

u  Is back in a flexed posture, erect or stiff?

u  Gait fluidity; how patient turns around.

u  Back pain decreases mobility of lumbar spine and restriction of normal spine movement

u  Low back pain patients walk with stiff, guarded fashion.

u  Depend on hip movement and lateral spine flexion to walk

u  Helps guage severity of patients problem

u  Gauge subsequent progress 1

Eagleonline.com

Regional Exam

u  Palpation-During standing, bending, laying down, sitting

u  Check bilateral paraspinous muscles simultaneously to compare differences in firmness, tenderness, spasm. Muscles become more prominent as they contract with spasm.

u  Identify trigger or tender points

u  Palpate bony structures

u  Spinous process- Tender if infection, tumor, fracture or sign of amplification. 1

Inspection

u  Standing viewed from anterior and posterior. Evaluation for any deviation of the spine due to scoliosis or spasm.

u  Symmetry of pelvic brim/ knees/ shoulders/ gluteal folds 1

Range of Motion

u  Flexion/ extension/ lateral bending, rotation u  Evaluation for any listing to one side due to spasm. u  Evaluation of the rhythm and symmetry of motion u  Flexion 40-60 degrees, extension 20-35, lateral bending 15-20, rotation

3-18. Evaluating for pain. Smooth reversal of normal lumbar lordosis as flex forward (lumbosacral rhythm)

u  Compensatory scoliosis due to spasm; spasm is nonspecific finding u  Abnormal flexion-keeps lumbar lordosis and bends from hips with flexion u  Most movement occurs at L5-S1 and L4-5 levels (8-10 degrees)

u  Compared tested movement to distracted movement u  Measurement from floor to fingertips- not exact but can use to measure

progress 1

Topendsports.com



Flexion

u  Return to neutral-during the last 45 degrees, the low back regains lordosis.

u  Back pain-regain erect posture keeping a fixed lordosis without any spine movement; pelvis hips and knees do all the motion.

u  Lateral Flexion (side bending)- check for pain with movement

u  Non-specific; May indicate joint, disc protrusion, muscle injury 1

Extension

u  Causes increased lordosis; forces the facet joints together, narrows the foramen where nerves exit and compresses the posterior aspect of the disc.

u  Rotation- must stabilize the pelvis to prevent hip motion. More accurately tested when sitting 1

Neurologic Exam

u  Must test each nerve root (L2-S2)

u  Strength, Sensation, Reflex, Muscle atrophy

u  Nerve Roots most commonly injured are L5/S1/L4

Wisegeekhealth.com

Strength

u  Loss of strength is most reliable indicator of nerve injury. Sensation more subjective.

u  Examine for atrophy of muscles. Measure circumference of muscle. Up to 2cm difference normal.

u  Manual Muscle Testing

u  L1-Hip flexion- iliopsoas

u  L2- Hip flexion and adduction; slight contribution to knee extension

u  L3-Hip flexion and adduction; knee extension

u  L4-Hip adduction; knee extension; ankle dorsiflexion

u  L5-Great toe extension; ankle dorsiflexion; hip abduction

u  S1-Knee flexion; plantar flexion. 1

Nerve Myotome Table

Operativemonitoring.com

Functional Tests

u  Squat- tests general muscle strength and general function of joints from hip to feet.

u  Repetitive toe raises both simultaneously and unilaterally. May uncover subtle weakness.

u  Walk on heels to test foot dorsiflexors.



Sensation

u  Sensory testing is more subjective

u  Light Touch and Pinprick (light pinprick should not cause pain- if so suggest non-organic cause of pain). 1

u  Looking for a dermatome pattern

Medical-dictionary.thefreedictionary

Reflexes

u  S1- ankle reflex

u  L5- Medial hamstring reflex

u  L4- Patella reflex

u  Reflexes can be decreased or loss due to prior nerve injury. Also reflexes decrease with time. Usually age related decrease is bilateral. Looking for asymmetry in reflexes.

Wisegeek.com

Upper Motor Neuron changes

u  Lesion is above the anterior horn cell in spinal cord

u  Spasticty

u  Hyperreflexia

u  Muscle weakness (flexor muscles weaker than extensors in legs)

u  Increased muscle tone (evaluate resistance to passive limb stretch)

u  Positive Babinski (up going plantar response)-extension of the large toe and spreading of other toes with stroking of the sole of the foot.

u  Ankle clonus 1

Provocative Maneuvers

u  Stretches the dura

u  Straight leg raise (Lasegue test)-pain past knee at 30-70 degrees

u  Seated straight leg raise

u  Bragard’s Test

u  Cross straight leg raise

u  Femoral nerve stretch test-upper lumbar nerve stretch

u  Check SI joint and Hip joints 1

Nonorganic Findings

u  Findings that do not have a specific anatomical explaination.

u  Examples: Patient may give resistance to pressure briefly and then suddenly give way OR stepwise release of muscle- “cogwheel”

u  Unilateral and Bilateral manual muscle strength testing is done to check for consistency 1

Waddell signs

u  Non organic/ nonphysiogic responses

u  Tenderness- widespread, superficial, nonanatomic pain >2cm lateral to spine

u  Simulation-Two tests- 1. Axial loading 2. rotation simulation

u  Distraction-Seated straight leg raise vs. straight leg raise

u  Regional-evaluate for non-physiologic weakness and numbness. 1



Psychosocial Barriers

u  Early identification may help prevent prolonged treatment and management

u  May suggest the need for early referral to specialist

u  Prior history of disability, excessive focus on permanent impairment, family with work related disability, history of substance abuse, mental illness, non-organic findings on exam,

u  Medication dependence, fear of returning to any activity or to transitional work, poor compliance 1

Functionalfitnessllc.org

Diagnostic Testing

u  WHEN???

u  Two questions:

u  What question are you trying to answer?

u  What will be done with the results? 1

u  Radiographic

u  MRI/ CT

u  EMG

u  LABS godissues.org

Radiographs

u  Usually not indicated in first month for acute low back pain unless red flags

u  Is Recommended if there are red flags for fracture, systemic illness, or subacute pain that isn’t improving.

u  AP/LAT/ Coned view L5/S1.

u  Oblique if strong suspicion of fracture not seen on AP/LAT.

u  Flexion/Extension to evaluate for spinal instability in spondylisthesis and fractures. 1

MRI/CT

u  MRI- Gold standard for defining anatomy.

u  CT-Good for bony abnormalities. Lots of radiation

u  Rarely indicated in acute setting except (typically with red flags):

u  Progressive neurologic deficit

u  cauda equina

u  significant trauma with atypical symptoms that isn’t improving

u  History of cancer

u  Symptoms suggesting multiple nerve root injury 1

MRI cont-

u  Consider MRI at 3-4 weeks in low back radicular pain prior to epidural steroid injection if patient willing to undergo injection

u  Consider ordering before 6 weeks (ACUTE) if severe radicular pain and not improving and patient willing to consider surgery if indicated by MRI

u  Consider MRI in SUBACUTE pain with radicular pain lasting AT LEAST 4-6 weeks if not gradually improving and patient and surgeon are considering prompt surgical treatment if nerve root compression confirmed by MRI. 1

MRI cont-

u  Health care provider should inform patient to anticipate many incidental findings. Most MRI’s have abnormal findings even in asymptomatic individuals.

u  Goal is to determine if there is an objective anatomical abnormality on MRI that would explain the patients clinical symptoms and exam findings.

u  Avoid diagnosing the patient by the “MRI findings”. We are treating the patient—not the MRI. 1



ELECTROMYOGRAPY (EMG)

u  Involves assessment of the motor unit (ant. horn cell, its axon, the neuromuscular junctions, muscle fibers it supplies).

u  Typically includes nerve conduction testing and “needle EMG”

u  Nerve conduction studies evaluate for other causes of lower limb pain (peripheral neuropathy, entrapment neuropathy).

u  Needle EMG typically used to diagnose radiculopathy 1

EMG cont-

u  Indicated:

u  When radicular pain does not resolve or plateaus after 4-6 weeks.

u  When there is equivocal imaging findings for radiculopathy

u  When there is suspicion that symptoms are from a different neurologic condition (ex. neuropathy) or a combination of multiple neurologic problems.

u  Not until 3-4 weeks post injury. Needle EMG in a radiculopathy will NOT be abnormal until approximately 4 weeks after the injury. (Exception-some MD may order before 3-4 weeks to determine pre-existing neurologic pathology). 1

LABS

u  Most patients do not require laboratory testing.

u  Mainly in patients to rule out suspected infection or malignancy.

u  CBC, Sed Rate and C-reactive protein in patients with suspected infection or malignancy. 3

u  Maybe CMP, Urinalysis, HLA B27, SPEP/UPEP depending on clinical scenario.

Acute Treatment (nonspecific low back pain)

u  Medications

u  Therapy/ Exercise

u  Manipulation and Mobilization

u  Massage

u  Fear Avoidance Belief Training

u  Activity modifications/ accommodations (work restrictions)

u  Sleep modifications

u  Heat/ Cold

u  Lumbar Discectomy

Exercise

u  Goals of symptom reduction, functional improvement, patient education with transition to independent exercise program.

u  Acute LBP-Stretching and aerobic exercise recommended. 1-3x/ wk x 4 weeks.

u  Acute Radicular LBP-Same except focus on reducing radicular symptoms. If symptoms worsening, then may need to d/c and do further work up.

u  Subacute LBP-Stretching/ aerobic/ strengthening. Watch for psychosocial factors affecting compliance with exercise. 2-5x/wk x 4 weeks.

u  Subacute Radicular LBP-Same except monitor for progression of radicular symptoms/ worsening—D/C; further work up.

u  ***Always assess for objective functional improvement, compliance, symptom reduction before requesting additional treatment. 1

Ldphysicaltherapy.com

Therapy/ Massage

u  May be done for acute/ subacute LBP.

u  Typically 8-12 visits over 6-8 weeks with functional improvement documented.

u  Mild-moderate pain may require less visits.

u  Research inconclusive due to multiple treatment variables within studies and lack of controls.

u  MASSAGE- shown to be beneficial (in combo with exercise/conditioning. 6-10 sessions (1-2x/ week for 4-10 weeks.) 1



Medications- acute/ subacute LBP

u  Providing comfort for patient is often paramount initially

u  NSAIDS- are recommended for acute/ subacute LBP. Generic ibuprofen, naproxen with scheduled dosage ok initially.

u  GI-protective meds for those at risk for GI bleeding/ gastritis. (misoprostol, PPI’s, etc).

u  Acetominophen-2nd line for acute LBP. 1st line if NSAID contraindicated.

u  Caution COX-2 and in general NSAIDS for pt’s with recent MI/ CAD.

u  Muscle Relaxants as 2nd or 3rd line agents. Bedtime preferred.

u  Capsaicin cream- short term use 1

Medications- acute/ subacute LBP Medications- acute/ subacute LBP

Ipharmd.net

Medications- cont

u  Opioids- only if fails initial meds and treatment.

u  Should note improvement in pain AND function.

u  Should have opioid contract between patient and provider especially if chronic prescribing.

u  Screen patient for increased addiction risk (CAGE or screening tools).

u  Bedtime/ not at work preferred. Start low dose. Taper as improves.

u  Urine Drug Screening if chronic use or MD concern for abuse/ diversion 1

Ipharmd.net

Manipulation/ Mobilization

u  Typically with a chiropractor but may be with other health care providers (physical therapist/ DO/MD).

u  Typically 5-12 visits over 6-8 weeks. u  Not recommended for treatment of radicular pain with neurologic

deficits

u  Is recommended for acute/ subacute low back pain. Especially if meets “Clinical Prediction Rule” u  Clinical Prediction Rule- meet 4/5 criteria to be positive

u  Low back pain <16 days

u  No symptoms below the knees

u  At least one hypomobile segment in LS spine

u  At least one hip with >35 degrees of internal range of motion

u  Fear-avoidance Belief Questionnaire work subscale score with < 19 points 1

Cold/ Heat

u  Cold/ Heat both recommended for acute/ subacute low back pain

u  15-20 min. 3-5x/ day

u  Infrared Therapy- health care provider treatment with infrared may help in conjunction with exercise for acute LBP (typically 4 or less treatments).

u  Ultrasound may be tried with exercise. Equivocal evidence.

u  Interferential may be tried for acute low back pain w/wo radicular.

u  Trigger point injections for subacute pain and 2nd/3rd line treatment. 1

Fear-Avoidance Belief Training

u  Goal: Help patients overcome fears that make patients avoid activity

u  Effective with all stages of low back pain (acute to chronic)

u  Is a “de-emphasis” on anatomical abnormalities

u  Typically done in physical or occupational therapy but all health care providers may be able to assist along the treatment pathway.

u  Fear-Avoidance Belief Questionnaire (FABQ)- 2 components; fear about work and physical activity. 1

Sleep Posture

u  The most important sleeping posture is one that helps the patient sleep the best! (I know-Earth Shattering!)

u  Encourage patient to change from painful position to non-painful.

u  No specific bed, pillow shown to be superior.

u  Many find sleeping on their side with pillow between legs or on back with pillow under knees helpful. But if not helping—try another position. 1

u  My advice when patients ask for what type of bed to get: one with a 60 day money back warrantee. J

Rhynecats.com



Activity Modification/ Restrictions

u  Increased Pain does not always mean increased damage.

u  Discuss what aspects of patient’s job he/she has control over.

u  Consider the physical requirements of job, severity of injury, patient’s insight into the injury.

u  Initially for most severe acute LBP- no lift>10 pounds, no repetitive bending, alternate sit/stand as needed.

u  Reassess weekly in acute injuries

u  Write restrictions whether the employer has modified activity or not so patient knows also what applies at home. 1

Lumbar Discectomy

u  Is an “option” to speed recovery with patients with radiculopathy from persistent nerve root compression with significant pain and loss of function after4-6 weeks and use of initial conservative treatment.

u  Patient should have:

u  Radicular pain/ numbness in nerve root distribution and /or myotomal weakness.

u  Imaging confirming nerve root compression from “herniated disc”

u  Persistent pain/ loss of function after initial conservative treatment for 4-6 wks 1

Low back pain with Radicular pain (Sciatica)

u  NSAIDS (w/ wo GI protection), Acetaminophen. u  TCA (amitriptyline, nortriptyline etc) u  Muscle Relaxants as 2nd or 3rd line agents. Bedtime preferred. u  Capsaicin cream-short term use u  Gluco-corticosteroids in acute severe radicular pain for short term.

u  Opioids- only if fails initial meds and treatment. u  Should note improvement in pain AND function.

u  Should have opioid contract between patient and provider especially if chronic prescribing.

u  Screen patient for increased addiction risk (CAGE or screening tools).

u  Bedtime/ not at work preferred. Start low dose. Taper as improves.

u  Urine Drug Screening if chronic use or MD concern for abuse/ diversion 1

Low back pain with Radicular cont-

u  Acute Radicular LBP-Aerobic exercises/ stretching with focus on reducing radicular symptoms. If symptoms worsening, then may need to d/c and do further work up.

u  Subacute Radicular LBP-Aerobic exercises/ stretching/strengthening with focus on reducing radicular symptoms. Monitor for progression of radicular symptoms/ worsening—D/C; do further work up.

u  Lumbar Epidural-to provide pain relief while awaiting improvement.

u  Lumbar Discectomy-no improvement in-spite of treatment >4-6 weeks. 1

Spinal Stenosis

u  Narrowing of the spinal canal with potential impingement of the spinal cord and nerves.

u  Usually from degenerative changes of the spine but can be acute from disc herniation or trauma with spondylolisthesis; also aggravation of underlying degenerative changes.

u  Present with low back pain and leg pain. Walking/ standing typically make it worse. Sitting/ bending forward alleviate. (shopping cart sign).

u  Epidural may help temporarily

u  Lumbar surgery (typically laminectomy) if not improving 1

Sacroiliac

u  Debated source of pain except in non-rheumatologic /non-inflammatory arthritis

u  Current guidelines do not recommend injections for this condition except in rheumatologic/inflammatory conditions due to insufficient evidence.

u  Some research suggest it to be a cause of chronic low back pain in 20-30% cases. 1



Spinal Fractures

u  Transverse fractures- same management as low back pain except avoid heavy activity longer

u  Vertebral body fracture- if not due to an obvious reason, need MRI to rule out pathologic fracture.

u  Stable with <50% loss of height without progression of collapse on follow up x-rays usually heal in 6-12 weeks.

u  Maybe Kyphoplasty in patients with fractures despite bisphosphonate therapy

u  Burst Fractures- Would refer to Spine specialist especially if any neurologic symptoms. Likely significant bracing or surgery. Remember the Denis Classification Three Column for vertebral fractures. 1

Spineuniverse.com

Prevention

u  Decrease risk by :

u  Not smoking

u  Obesity-losing weight

u  Aerobic exercise & strengthening exercises (stabilization exercises)

u  Lumbar supports-NOT helpful 1

Peopleint.wordpress.com

Questions?

Cure-back-pain.org

References:

u  1. Hegmann, Kurt, T. ACOEM’s Occupational Medicine Practice Guidelines 3rd Edition; Volume 2, Spinal Disorders. 2011.

u  2. Nikolai Bogduk. Clinical Anatomy of the Lumbar Spine and Sacrum. 3rd Edition. 1997.

u  3. Evaluation of low back pain in adults. UPTODATE website. www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults Literature review current through: Jul 2015. Last Updated: Aug 04, 2015.

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