Magnitude of the Problem - Baptist Health South Florida presentation… · Diffuse aching with...

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My My Aching Back! Aching Back! Diagnosing andDiagnosing and

Treating Low Back PainTreating Low Back Pain

Ronald B. Tolchin, D.O., FAAPM&RRonald B. Tolchin, D.O., FAAPM&R

Director, Center for Spine CareDirector, Center for Spine CareBaptist Baptist Health South FloridaHealth South Florida

Voluntary Assistant Professor of Clinical Rehabilitation Medicine, University of Voluntary Assistant Professor of Clinical Rehabilitation Medicine, University of Miami Miller School of MedicineMiami Miller School of Medicine

Voluntary Clinical Assistant ProfessorVoluntary Clinical Assistant ProfessorFIUFIU--HWCOMHWCOM

Voluntary Associate Professor of Clinical Rehabilitation Medicine, Nova Voluntary Associate Professor of Clinical Rehabilitation Medicine, Nova Southeastern University, College of Osteopathic MedicineSoutheastern University, College of Osteopathic Medicine

Ronald B. Tolchin, D.O. has indicated he has no relevant financial relationships to disclose.Ronald B. Tolchin, D.O. has indicated he has no relevant financial relationships to disclose.

Baptist Hospital

Low Back PainLow Back Pain

�� ““One would have thought by now that the One would have thought by now that the problem of diagnosis and treatment would problem of diagnosis and treatment would have been solved, but the issue remains have been solved, but the issue remains mysterious and clouded with uncertainty.mysterious and clouded with uncertainty.””

�� Rosomoff HL, Rosomoff RS, Low back pain: Evaluation and management in Rosomoff HL, Rosomoff RS, Low back pain: Evaluation and management in

the primary care setting. Med Clin North Am 1999;83:643the primary care setting. Med Clin North Am 1999;83:643--6262..

Magnitude of the ProblemMagnitude of the Problem�� 5% ann. Incidence5% ann. Incidence

•• FrymoyerFrymoyer

� In 2005 Americans spent $85.9 billion looking for relief from back and neck pain through surgery, doctor's visits, X-rays, MRI scans and medications, up from $52.1 billion in 1997

�� Number one cause of Number one cause of disability Age 24disability Age 24--3939

•• (Burton 1991)(Burton 1991)

Magnitude of the ProblemMagnitude of the Problem�� Professional golfers 10Professional golfers 10--

30%/yr (McCarroll)30%/yr (McCarroll)�� 11% of gymnasts with 11% of gymnasts with

spondylolysis (Jackson)spondylolysis (Jackson)�� 5% of runners develop LBP 5% of runners develop LBP

per yr (Brody)per yr (Brody)�� 15% of tennis players 15% of tennis players

(Chard)(Chard)�� 30% of football players (Saal)30% of football players (Saal)�� 35% of sedentary workers35% of sedentary workers�� 47% of physical laborers 47% of physical laborers

(Svensson)(Svensson)

Common thinkingCommon thinking

�� 90% of back pain 90% of back pain resolves on its own resolves on its own in 1in 1--2 weeks2 weeks

�� Lumbar disc Lumbar disc herniation is a herniation is a surgical diseasesurgical disease

�� ““Get back to workGet back to work””

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The Data!The Data!

�� 3030--60% recover in one week60% recover in one week�� 6060--90% recover in six weeks90% recover in six weeks�� 95% recover in 12 weeks95% recover in 12 weeks�� Specific causes of LBP account for 20% of Specific causes of LBP account for 20% of

the casesthe cases

Lumbar SpineLumbar Spine

Low Back Pain

� Not all low back pain is bulge or herniation

Differential Differential DiagnosesDiagnoses

�� Aortic AneurysmAortic Aneurysm�� Tumors/cancerTumors/cancer�� Bony metastasisBony metastasis�� Vertebral Osteomyelitis Vertebral Osteomyelitis �� Epidural abscessEpidural abscess�� NeurofibromatosisNeurofibromatosis�� Pelvic pathologyPelvic pathology�� Abdominal pathology Abdominal pathology �� Herniated discHerniated disc

�� Compression fracture Compression fracture �� Rheumatoid arthritisRheumatoid arthritis�� Degenerative joint Degenerative joint

Disease Disease �� OsteoarthritisOsteoarthritis�� Ankylosing spondylitisAnkylosing spondylitis�� Cauda equina syndromeCauda equina syndrome�� UTI UTI �� Strain/ sprainStrain/ sprain

Symptoms of Symptoms of Benign LBPBenign LBP

�� Dull and achy qualityDull and achy quality

�� Diffuse aching with Diffuse aching with associated muscle associated muscle tendernesstenderness

�� Exacerbated with Exacerbated with movementmovement

�� Relieved with rest in Relieved with rest in recumbent positionrecumbent position

�� No radiation, No radiation, paresthesias paresthesias

�� No dermatomal No dermatomal patternpattern

�� Pt. is able to find a Pt. is able to find a position of comfortposition of comfort

�� DTR are within DTR are within normal limitsnormal limits

Risk Factors for Risk Factors for Back ProblemsBack Problems

�� NonNon--modifiable:modifiable:�� Family history (osteoporosis/joint problems)Family history (osteoporosis/joint problems)�� AgeAge

�� Modifiable:Modifiable:�� PosturalPostural :: Poor postural habitsPoor postural habits�� Physical:Physical: Poor fitness in low back area Poor fitness in low back area �� Behavioral:Behavioral: Lifestyle behaviorsLifestyle behaviors

•• Dangerous exercises or movements Dangerous exercises or movements •• Frequent or improper liftingFrequent or improper lifting•• Extended standing or extended sitting Extended standing or extended sitting

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Are there risk factors for LBP?Are there risk factors for LBP?�� ObesityObesity�� SmokingSmoking�� Poor educationPoor education�� PregnancyPregnancy�� Socioeconomic statusSocioeconomic status�� Flexibility, Strength & Flexibility, Strength &

EnduranceEndurance�� Age Age –– Males = Females to Males = Females to

age 60, then Femalesage 60, then Females�� Size & Shape of CanalSize & Shape of Canal�� Psychosocial factorsPsychosocial factors�� Occupation Occupation

�� -- LiftingLifting�� -- VibrationVibration

DefinitionsDefinitions

�� Acute LBP: Back pain <6 weeks durationAcute LBP: Back pain <6 weeks duration�� Subacute LBP: back pain >6 weeks but <3 Subacute LBP: back pain >6 weeks but <3

months durationmonths duration�� Chronic LBP: Back pain disabling the patient Chronic LBP: Back pain disabling the patient

from some life activity >3 monthsfrom some life activity >3 months�� Recurrent LBP: Acute LBP in a patient who has Recurrent LBP: Acute LBP in a patient who has

had previous episodes of LBP from a similar had previous episodes of LBP from a similar location, with asymptomatic intervening intervalslocation, with asymptomatic intervening intervals

AnatomyAnatomy

�� Vertebral bodyVertebral body�� DiscDisc�� Intervertebral foramenIntervertebral foramen�� Anterior longitudinal ligamentAnterior longitudinal ligament

�� Posterior longitudinal ligamentPosterior longitudinal ligament�� Ligamentum flavumLigamentum flavum�� Facet jointsFacet joints

Anatomy Continued:Anatomy Continued:

Intervertebral DiscIntervertebral Disc

�� Posterior disc Posterior disc receives innervation receives innervation from the sinovertebral from the sinovertebral nervesnerves

�� Lateral disc receives Lateral disc receives innervation from the innervation from the gray rami gray rami communicantes.communicantes.

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LigamentsLigaments�� Anterior longitudinal ligamentAnterior longitudinal ligament

�� Posterior longitudinal ligamentPosterior longitudinal ligament

�� LigamentumLigamentum flavumflavum

�� InterspinousInterspinous ligamentligament

�� SupraspinousSupraspinous ligamentligament

Anterior longitudinal ligament

Ligamentous

•L4•L5•S1

Diagnoses & Diagnoses & Red FlagsRed Flags�� CancerCancer

�� Age > 50Age > 50�� History of CancerHistory of Cancer�� Weight lossWeight loss�� Unrelenting night Unrelenting night

painpain�� Failure to improveFailure to improve

�� InfectionInfection�� IVDUIVDU�� Steroid useSteroid use�� FeverFever�� Unrelenting night painUnrelenting night pain�� Failure to improveFailure to improve

�� FractureFracture�� Age >50Age >50�� Trauma Trauma �� Steroid useSteroid use�� OsteoporosisOsteoporosis

�� CaudaCauda EquinaEquina SyndromeSyndrome�� Saddle anesthesiaSaddle anesthesia�� Bowel/bladder Bowel/bladder

dysfunctiondysfunction�� Loss of sphincter controlLoss of sphincter control�� Major motor weaknessMajor motor weakness

Overview of Guidelines: Overview of Guidelines: ACP/APS 2007ACP/APS 2007

�� Diagnosis and Treatment of Low Back Diagnosis and Treatment of Low Back Pain: A Joint CPG from the American Pain: A Joint CPG from the American College of Physicians and the American College of Physicians and the American Pain SocietyPain Society

�� Two Supplemental PublicationsTwo Supplemental Publications�� Medications Medications

�� Nonpharmacologic TherapiesNonpharmacologic Therapies

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Overview of Guidelines: Overview of Guidelines: ACP/APS 2007ACP/APS 2007

�� Multidisciplinary panel of expertsMultidisciplinary panel of experts

�� Extensive literature review of RCTs onlyExtensive literature review of RCTs only

�� Systematic evidence reviewSystematic evidence review

�� InterventionIntervention�� Level of EvidenceLevel of Evidence�� Net Net BenefitBenefit�� GradeGrade

�� Formulated 7 key recommendationsFormulated 7 key recommendations

Overview of Guidelines: Overview of Guidelines: ICSI 2010 14ICSI 2010 14thth Ed.Ed.

�� Institute for Clinical Systems Improvement Institute for Clinical Systems Improvement Health Care Guideline: Adult LBPHealth Care Guideline: Adult LBP

�� ““ICSI is a nonICSI is a non--profit organization that brings profit organization that brings together diverse groups to transform the health together diverse groups to transform the health care system so that it delivers patientcare system so that it delivers patient--centered centered and valueand value--driven care.driven care.””


�� ““Consistent & defined processConsistent & defined process”” for guideline for guideline development using development using ‘‘Conclusion GradingConclusion Grading’’

�� Primary care and practice orientedPrimary care and practice oriented�� Phone TriagePhone Triage

�� Assessment ToolsAssessment Tools

�� PPerformance Measureserformance Measures


�� ““Consistent & defined processConsistent & defined process”” for guideline for guideline development using development using ‘‘Conclusion GradingConclusion Grading’’

�� Primary care and practice orientedPrimary care and practice oriented�� Phone TriagePhone Triage

�� Assessment ToolsAssessment Tools

�� PPerformance Measureserformance Measures

Evaluation of Low Back PainEvaluation of Low Back Pain��ACP/APS Key Recommendation ACP/APS Key Recommendation

#1:#1:�� Focused physical and history should place LBP Focused physical and history should place LBP

patients in 1 of 3 broad categories:patients in 1 of 3 broad categories:

1.1. NSLBPNSLBP

2.2. LBP potentially assoc. with LBP potentially assoc. with radiculopathy/stenosisradiculopathy/stenosis

3.3. Back pain potentially assoc. with another specific Back pain potentially assoc. with another specific spinal causespinal cause

* Strong rec, moderate* Strong rec, moderate--quality evidencequality evidence

Causes of Causes of ““ NonNon--specific specific LBPLBP””

�� Spondylosis Spondylosis (Osteoarthritis of (Osteoarthritis of facet/disk)facet/disk)

�� Spondylolysis/Spondylolysis/--listhesislisthesis

�� Kyphosis/scoliosisKyphosis/scoliosis

�� Acute lumbar strainAcute lumbar strain

�� Facet painFacet pain

�� Discogenic painDiscogenic pain

�� Ligamentous painLigamentous pain

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Pain HistoryPain History

�� Localization:Localization:�� Where does it hurt? central, unilateral, bilateralWhere does it hurt? central, unilateral, bilateral�� Does the pain go anywhere? upper lumbar, lower Does the pain go anywhere? upper lumbar, lower

lumbar, gluteal, perineal, legslumbar, gluteal, perineal, legs

�� Onset:Onset:�� When did the pain start? days, weeks, months, yearsWhen did the pain start? days, weeks, months, years�� How did the pain start? suddenly, graduallyHow did the pain start? suddenly, gradually

�� Severity:Severity:�� 00--10 Scale: Current? Average? Worst?10 Scale: Current? Average? Worst?

Pain HistoryPain History

�� Evolution: Evolution: �� How has the pain changed over time?How has the pain changed over time?

�� Relationship to activity:Relationship to activity:�� What postures or movements worsen the What postures or movements worsen the

pain?pain?

�� Does it hurt to cough or sneeze?Does it hurt to cough or sneeze?

�� Does the pain wake you at night?Does the pain wake you at night?

�� What makes the pain better?What makes the pain better?

Focused HistoryFocused History

�� Clarify Current Condition:Clarify Current Condition:1.1. Pain assessmentPain assessment

2.2. Neurologic involvementNeurologic involvement

3.3. Previous history of LBPPrevious history of LBP

�� Exclude Exclude RED FLAGSRED FLAGS::1.1. CancerCancer

2.2. Cauda EquinaCauda Equina

3.3. InfectionInfection

BAD low back pain BAD low back pain (examples)(examples)


�� CANCER (0.7%)CANCER (0.7%)1. Age > 50 years1. Age > 50 years

2. History of Cancer2. History of Cancer

3. Unexplained Weight Loss3. Unexplained Weight Loss

4. Failure to improve in 44. Failure to improve in 4--6 weeks6 weeks

�� + History of Cancer Raises Probability to 9%+ History of Cancer Raises Probability to 9%

�� If all 4 absent, cancer ruled out w/100% If all 4 absent, cancer ruled out w/100% sensitivity.sensitivity.


�� CAUDA EQUINA (0.04%)CAUDA EQUINA (0.04%)1.1. Urinary retention (if absent, likelihood is less Urinary retention (if absent, likelihood is less

than 1 in 10,000)than 1 in 10,000)

2.2. Urinary IncontinenceUrinary Incontinence

3.3. Saddle AnesthesiaSaddle Anesthesia

4.4. Fecal IncontinenceFecal Incontinence

5.5. Radicular Symptoms (less reliable)Radicular Symptoms (less reliable)

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�� SPINAL INFECTION (0.01%)SPINAL INFECTION (0.01%)1.1. Fever, recent infectionFever, recent infection

2.2. IV Drug useIV Drug use

3.3. ImmunosuppressionImmunosuppression

4.4. History of TB (inactive or active)History of TB (inactive or active)

Focused HistoryFocused HistorySpecific Spinal CausesSpecific Spinal Causes

��Red Flag ConditionsRed Flag Conditions

��FX: FX: Compress/TraumaticCompress/Traumatic

��SpondylolysisSpondylolysis, , --ListhesisListhesis

��Congenital Congenital Abnormalities (i.e. Abnormalities (i.e. scoliosis)scoliosis)

��PagetPaget’’s Diseases Disease

��Inflammatory Arthritis Inflammatory Arthritis ((AnkylosingAnkylosing Spondylitis)Spondylitis)

NonNon--Spinal CausesSpinal Causes�� Ruptured Ruptured AAAAAA

�� Retroperitoneal Retroperitoneal HematomaHematoma

�� NephrolithiasisNephrolithiasis

�� PyelonephritisPyelonephritis

�� EndometriosisEndometriosis

�� PancreatitisPancreatitis

�� Duodenal Duodenal UlcerUlcer

Focused History:Focused History:Assessment of Psychosocial Risk FactorsAssessment of Psychosocial Risk Factors

Psychosocial risk factors are Psychosocial risk factors are stronger predictors of outcome stronger predictors of outcome

than exam findings and severity of than exam findings and severity of pain!!pain!!


�� Belief that pain and activity are harmfulBelief that pain and activity are harmful

�� Depressed moodDepressed mood

�� Passive copingPassive coping

�� Disputed compensation claimsDisputed compensation claims

�� Low job satisfactionLow job satisfaction

�� NonNon--compliancecompliance

�� Life stressorsLife stressors

�� Lack of supportLack of support


�� 6 Specific Screening Questions (ICSI):6 Specific Screening Questions (ICSI):1.1. Have you had time off work in the past with back Have you had time off work in the past with back

pain?pain?

2.2. What do you understand is the cause of your back What do you understand is the cause of your back pain?pain?

3.3. What are you expecting will help you?What are you expecting will help you?

4.4. How is your employer responding to your back pain? How is your employer responding to your back pain? Your Family?Your Family?

5.5. What are you doing to cope with back pain?What are you doing to cope with back pain?

6.6. Do you think youDo you think you’’ll return to work? When?ll return to work? When?

Focused ExamFocused Exam

�� Inspection of back, posture, +/Inspection of back, posture, +/-- ROMROM

�� Palpation of paraspinal m. and spinePalpation of paraspinal m. and spine

�� Straight leg raisingStraight leg raising

�� Neurologic assessment of L4, L5, and S1 Neurologic assessment of L4, L5, and S1 rootsroots

�� NonNon--Organic (WaddellOrganic (Waddell’’s) signs for s) signs for malingeringmalingering

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Clinical EvaluationClinical Evaluation

Nerve Root Nerve Root LevelLevel

Motor TestingMotor Testing

L1L1 Hip flexionHip flexion

L2L2 Hip flexionHip flexion

L3L3 Knee extensionKnee extension

L4L4 Knee extension, DorsiflexionKnee extension, Dorsiflexion

L5L5 Great toe extensionGreat toe extension

S1S1 PlantarflexionPlantarflexion

S2S2 NANA

Lower Quarter Neurological ScreenLower Quarter Neurological Screen

Evaluation of Lumbar Spine DiseaseEvaluation of Lumbar Spine Disease

� Reflexes:� L3 - iliopsoas reflex

(meaningful?)� L4 - knee jerk� L5 - extensor hallicus reflex

(meaningful?), Medial Hamstrings

� S1 - ankle jerk� Babinski - in adults, UMN

lesion from motor strip to lower spinal cord


� Range of Motion:� Straight leg raise - most

sensitive for sciatic pain syndromes

� Pain in contralateral leg with straight leg raise is most specific for sciatic pain syndromes

� Lumbar flexion/extension (lumbar stenosis worse with extension, better with flexion)


� ROM to rule out other causes of back/leg pain: internal and external hip rotation

� Palpation over spine, SI joint, pelvis and hip

Diagnostic Testing:Diagnostic Testing:When to ImageWhen to Image

1.1. IMMEDIATEIMMEDIATE::

-- Previous history of cancer (plain film + ESR)Previous history of cancer (plain film + ESR)

-- Infection, cauda equina, SEVERE neurologic deficits Infection, cauda equina, SEVERE neurologic deficits (MRI)(MRI)

2. 2. DEFERREDDEFERRED imaging until trial of therapy complete:imaging until trial of therapy complete:

-- Weak RF for cancer, AS, CompFx (plain film +/Weak RF for cancer, AS, CompFx (plain film +/--ESR)ESR)

-- Radiculopathy, spinal stenosis (MRI)Radiculopathy, spinal stenosis (MRI)

3. 3. NO imagingNO imaging::

-- Does not meet criteria aboveDoes not meet criteria above

-- Pain improved or resolved in 4Pain improved or resolved in 4--6 weeks6 weeks

-- Previous spinal imaging w/ no change in clinical statusPrevious spinal imaging w/ no change in clinical status

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DIAGNOSTIC TESTINGDIAGNOSTIC TESTING

Diagnostic StudiesDiagnostic Studies

�� XraysXrays

�� MRIMRI

�� CT scanCT scan

�� MyelogramMyelogram

�� EMG/NCSEMG/NCS

�� DiscogramsDiscograms

�� Radionucleotide Bone ScanningRadionucleotide Bone Scanning

�� Selective blocksSelective blocks

Diagnostic TestingDiagnostic Testing

��ACP/APS Key Recommendation ACP/APS Key Recommendation #2:#2:

““Clinicians should not routinely obtain imaging Clinicians should not routinely obtain imaging or other diagnostic tests in patients with or other diagnostic tests in patients with NSLBP.NSLBP.””




““Imaging/testing for patients w/ low back pain Imaging/testing for patients w/ low back pain when severe or progressive neurologic deficits when severe or progressive neurologic deficits are present or when serious underlying are present or when serious underlying conditions are suspected on the basis of history conditions are suspected on the basis of history and physical exam.and physical exam.””


Diagnostic TestingDiagnostic Testing��ACP/APS Key Recommendation ACP/APS Key Recommendation

#4#4::““Clinicians should evaluate patients with Clinicians should evaluate patients with

persistent LBP and signs or symptoms of persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with MRI radiculopathy or spinal stenosis with MRI (preferred) or CT ONLY if they are (preferred) or CT ONLY if they are potential candidates for surgery or epidural potential candidates for surgery or epidural steroid injection.steroid injection.””



�� Imaging Strategies for Low Back Pain: Imaging Strategies for Low Back Pain: Systematic Review and MetaSystematic Review and Meta--Analysis. Analysis. Lancet 2009.Lancet 2009.�� 6 RCTs of 1804 patients with acute or 6 RCTs of 1804 patients with acute or subacutesubacute

nonnon--specific low back painspecific low back pain

�� NO difference in outcomes with routine NO difference in outcomes with routine imaging vs. usual care for pain, function, imaging vs. usual care for pain, function, quality of life, anxiety, or patientquality of life, anxiety, or patient--rated rated improvementimprovement

*Routine imaging = More cost w/o clinical *Routine imaging = More cost w/o clinical benefit*benefit*

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�� Relationship of Early MRI for WorkRelationship of Early MRI for Work--Related Related Acute LBP with Disability and Medical Acute LBP with Disability and Medical Utilizations Outcomes. JOEM 2010.Utilizations Outcomes. JOEM 2010.

* 8* 8--fold increase in surgery *fold increase in surgery *

* 5* 5--fold increase in total cost *fold increase in total cost *


�� Why is routine imaging not beneficial?Why is routine imaging not beneficial?1.1.Abnormalities VERY commonAbnormalities VERY common

2.2.Acute LBP has a favorable historyAcute LBP has a favorable history

3.3. Imaging rarely affects treatment plansImaging rarely affects treatment plans

4.4.Potential benefits offset by harmsPotential benefits offset by harms

5.5.Unintended harms related to Unintended harms related to ‘‘labelinglabeling’’6.6.May lead to unnecessary proceduresMay lead to unnecessary procedures

Diagnostic Imaging for LBP: Advice for High Value Health Care from the ACP. Ann Int Diagnostic Imaging for LBP: Advice for High Value Health Care from the ACP. Ann Int Med 2011.Med 2011.

Plain FilmsPlain Films

�� Disc space narrowingDisc space narrowing�� Marginal sclerosisMarginal sclerosis�� Vacuum phenomenonVacuum phenomenon�� Disc calcificationDisc calcification

SpondylolisthesisSpondylolisthesis

�� Localized pain from Localized pain from the free nerve the free nerve endings at the endings at the fracture sitefracture site

�� Compression of the Compression of the L5 nerve root as it L5 nerve root as it exits the foramenexits the foramen

�� Traction the S1 nerve Traction the S1 nerve root over the posterior root over the posterior aspect of the sacrumaspect of the sacrum

Diagnostic StudiesDiagnostic Studies��MRI indicationsMRI indications

�� Possible cancer, infection, Possible cancer, infection, cauda equina syndcauda equina synd

�� >6>6--12 weeks of pain12 weeks of pain�� PrePre--surgery or invasive surgery or invasive

therapy therapy �� DisadvantagesDisadvantages

�� FalseFalse--positives; may not be positives; may not be causing paincausing pain

�� More costly, increased time More costly, increased time to scan, problem with to scan, problem with claustrophobic patientsclaustrophobic patients

MRIMRI

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Myelogram with CTMyelogram with CT

�� To confirm clinical diagnosisTo confirm clinical diagnosis�� Determines lesions at other levelsDetermines lesions at other levels�� Inflammatory complications of surgeryInflammatory complications of surgery�� Identifies disc fragmentsIdentifies disc fragments

Radionucleotide Bone ScanningRadionucleotide Bone Scanning

�� Assess metabolic activity of boneAssess metabolic activity of bone�� Infiltrating tumorInfiltrating tumor�� Infectious processes and blood flowInfectious processes and blood flow�� Inflammatory Inflammatory arthropathiesarthropathies

�� Adolescent LBP (r/o Adolescent LBP (r/o spondyspondy))

•• SPECT scanSPECT scan

DiscogramsDiscograms

�� Reproduce patients symptomsReproduce patients symptoms�� Assess characteristics of disc anatomyAssess characteristics of disc anatomy�� Most useful at L5Most useful at L5--S1 levelS1 level

Electrodiagnostic StudiesElectrodiagnostic Studies

�� BenefitsBenefitsphysiologic integrity of nerve rootphysiologic integrity of nerve rootchanges in uncooperative patientchanges in uncooperative patientnoncompressive radiculopathynoncompressive radiculopathy

Diagnostic StudiesDiagnostic Studies

�� EMG/NCVEMG/NCV�� r/o peripheral neuropathyr/o peripheral neuropathy

�� localize nerve injurylocalize nerve injury

�� correlate with radiographic correlate with radiographic changeschanges

�� order after 6order after 6--12 weeks of 12 weeks of symptomssymptoms

�� PrePre--surgical or invasive surgical or invasive therapytherapy

Selective BlocksSelective Blocks

�� Nerve rootNerve root�� Facet blocksFacet blocks

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Lab StudiesLab Studies

�� IndicationsIndications

�� Chronic LBPChronic LBP

�� Suspected systemic diseaseSuspected systemic disease

�� CBC, CRP, ESR, +/CBC, CRP, ESR, +/-- UA, SPEP, UA, SPEP, UPEPUPEP

�� Avoid RF, ANA or others unless Avoid RF, ANA or others unless indicatedindicated

Additional InvestigationsAdditional Investigations

�� Routine blood work Routine blood work –– ESR, CRP, CBC for those ESR, CRP, CBC for those who may have an infection or malignancy and who may have an infection or malignancy and have not improved. Urinalysis for unexplained have not improved. Urinalysis for unexplained LBP.LBP.

�� May add SPEP, Serum immunoelectrophoresisMay add SPEP, Serum immunoelectrophoresis

�� HLAHLA--B27 if xray suggests sacroiliac involvement.B27 if xray suggests sacroiliac involvement.

�� Psychological testingPsychological testing�� MMPIMMPI

What to do aboutWhat to do about

Possible BAD Low Back PainPossible BAD Low Back Pain

�� Cauda Equina: Cauda Equina: �� MRI STAT MRI STAT ��Neurosurgery consultNeurosurgery consult

�� Fracture: xFracture: x--raysrays�� MRI/CT if still suspectMRI/CT if still suspect

�� Cancer: xCancer: x--rays + CRP, ESR, CBC (+/rays + CRP, ESR, CBC (+/-- PSA)PSA)�� MRI if still suspectMRI if still suspect

�� Infection: xInfection: x--rays; CRP, ESR, CBC, +/rays; CRP, ESR, CBC, +/-- UAUA

CLINICAL CASESCLINICAL CASES

Clinical EvaluationClinical Evaluation

�� Sciatica:Sciatica:�� General term for any General term for any

inflammation involving sciatic inflammation involving sciatic nervenerve

�� Causes:Causes:•• Lumbar disc herniationLumbar disc herniation•• SI joint dysfunctionSI joint dysfunction•• Scar tissue around nerve rootScar tissue around nerve root•• Nerve root inflammationNerve root inflammation•• Spinal stenosisSpinal stenosis•• Synovial cystsSynovial cysts•• Cancerous or noncancerous Cancerous or noncancerous

tumorstumors

Disc HerniationDisc Herniation

�� Intervertebral Disc Intervertebral Disc Herniation:Herniation:�� Extrusion of nucleus Extrusion of nucleus

pulposus through annulus pulposus through annulus fibrosusfibrosus

•• Impingement/pressure on Impingement/pressure on nerve root below affected nerve root below affected discdisc

�� Sequestrated Sequestrated –– nuclear nuclear material breaks away from material breaks away from rest of discrest of disc

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MRI lumbar image:

L5/S1 disc has suffered a 9mm disc extrusion (red arrow) that is not contained by the PLL

L4/5 disc has suffered a smaller 4mm disc protrusion (green arrow) that is contained by the PLL

L3/4 (blue arrow) is completely normal and has no disc material projecting posteriorly into the epidural space

Note: L3/4 disc is white in color, which indicates it is non-degenerated (i.e., full of water and healthy proteoglycan)

Herniated discs (L4/5 & L5/S1) are "black" which indicates disc desiccation (lack of water and proteoglycan)

Clinical EvaluationClinical Evaluation�� Lumbar Disc Degeneration:Lumbar Disc Degeneration:

�� Inspection:Inspection:•• Slow GAITSlow GAIT•• Flattened lumbar spineFlattened lumbar spine•• Changes in body position Changes in body position –– guarded and painfulguarded and painful

�� Sitting → standing / sitting → lyingSitting → standing / sitting → lying•• Changes in disc pressureChanges in disc pressure

•• Standing position:Standing position:�� Lateral shift away from side of leg painLateral shift away from side of leg pain

�� Palpation:Palpation:•• Musculature spasmMusculature spasm

Facet Joint Disease

�� History:History:•• Onset Onset –– insidiousinsidious•• Pain characteristics Pain characteristics ––

localizedlocalized•• MOI MOI –– extension, rotation, extension, rotation,

lateral bending of vertebraelateral bending of vertebrae•• Predisposing conditions Predisposing conditions ––

repeated motions of spinal repeated motions of spinal extension, rotation, lateral extension, rotation, lateral bendingbending

SpondylolysisSpondylolysis//ListhesisListhesis

�� Spondylolysis:Spondylolysis:�� Defect in pars interarticularis (area Defect in pars interarticularis (area

between inferior and superior articular between inferior and superior articular facets)facets)

�� MOI MOI –– repetitive stressrepetitive stress•• Unilateral or bilateral defectsUnilateral or bilateral defects•• Listhesis:Listhesis:

�� Posterior portion of the vertebrae, Posterior portion of the vertebrae, laminae, inferior articular surfaces, laminae, inferior articular surfaces, spinous process separates from spinous process separates from vertebral bodyvertebral body

�� ““Collared Scotty dogCollared Scotty dog”” deformitydeformity�� Symptoms:Symptoms:

•• Localized low back pain ( ↑ Localized low back pain ( ↑ during/after activity)during/after activity)

•• Pain with extensionPain with extension

Lateral view of the lumbar spine: Bilateral break in the pars interarticularis (spondylolysis - black arrow) L5 vertebral body (red arrow) has slipped forward on the S1 vertebral body (blue arrow –spondylolisthesis)

Normal pars interarticularis -white arrow.Degree of forward slippage is equal to about 1/4 to 1/2 of the AP diameter of S1 (Grade1-Grade 2 spondylolisthesis)

Sacroiliac JointSacroiliac Joint

�� Sacroiliac Dysfunction:Sacroiliac Dysfunction:�� History:History:

•• Onset:Onset:�� Acute or insidiousAcute or insidious

•• Pain characteristics:Pain characteristics:�� One or both SI joints; One or both SI joints;

possibly radiating pain in possibly radiating pain in buttocks, groin, thighbuttocks, groin, thigh

•• Mechanism:Mechanism:�� Prolonged stressProlonged stress

•• Predisposing conditions:Predisposing conditions:�� Postpartum women Postpartum women

((relaxinrelaxin levels)levels)�� Hormonal levels during Hormonal levels during

menstruationmenstruation

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Sacroiliac PainSacroiliac Pain�� Usually buttock, hip, groin locationUsually buttock, hip, groin location�� As high as 15% of all acute LBPAs high as 15% of all acute LBP

�� Fortin, J, Spine 1994 Fortin, J, Spine 1994 –– 10 volunteers had 10 volunteers had ““mappingmapping””

�� Fortin, Tolchin, 2005 (Pain Physician)Fortin, Tolchin, 2005 (Pain Physician)�� Joint injection may help Joint injection may help –– Pilot Pilot

studystudy�� 31 patients 31 patients –– retrospective retrospective

analysisanalysis�� Total pain scores and disability Total pain scores and disability

scores were lowerscores were lower�� Slipman CW, et al, Am J PMR 2001Slipman CW, et al, Am J PMR 2001

Spinal StenosisSpinal Stenosis

�� Narrowing canal due to hypertrophy, HNPNarrowing canal due to hypertrophy, HNP�� Neurogenic claudication. From metabolic deprivation, Neurogenic claudication. From metabolic deprivation,

venous engorgement, blocked CSF impairs nutrient venous engorgement, blocked CSF impairs nutrient supply to N. rootssupply to N. roots

�� Relief with spinal flexionRelief with spinal flexion�� Vague pain in buttocks, LEVague pain in buttocks, LE’’ss�� Cart use in supermarketCart use in supermarket

Spinal stenosisSpinal stenosis

�� NOT a cause of back painNOT a cause of back pain

�� The clinical presentation is neurogenic The clinical presentation is neurogenic claudicationclaudication�� Classical presentation:Classical presentation:

•• Bilateral thigh and or lower extremity pain for canal Bilateral thigh and or lower extremity pain for canal stenosisstenosis

•• Unilateral dermatomal radicular pain for foraminal Unilateral dermatomal radicular pain for foraminal stenosisstenosis

�� Variant presentation:Variant presentation:•• Buttock pain only with standing and walkingButtock pain only with standing and walking

Why is pain in the legs present with standing and walking?

Axial loadedSupine, standard technique

Spinal stenosisSpinal stenosis

�� Epidural steroid injections may be effective for Epidural steroid injections may be effective for reducing symptoms reducing symptoms for for months at a timemonths at a time

�� In most cases, physical therapy is not helpful, In most cases, physical therapy is not helpful, but but occassionallyoccassionally……

�� Tolerance for standing and walking will Tolerance for standing and walking will decrease slowly with time in most casesdecrease slowly with time in most cases

�� Surgical decompression results are excellent Surgical decompression results are excellent and this should be considered earlier in the and this should be considered earlier in the course of the disease then it often is.course of the disease then it often is.

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Radiculopathy, Spinal Radiculopathy, Spinal StenosisStenosis

�� Sciatica (pain below Sciatica (pain below knee)knee)

�� May have abnl neuro May have abnl neuro examexam

�� Radiates to legRadiates to leg

�� Pain worse walking, Pain worse walking, better sitting (pseudobetter sitting (pseudo--claudication)claudication)

Compression FractureCompression Fracture

�� Sudden, severe back pain. Sudden, severe back pain. �� Worsening of pain when standing or walking. Worsening of pain when standing or walking. �� Some pain relief when lying down. Some pain relief when lying down. �� Difficulty and pain when bending or twisting. Difficulty and pain when bending or twisting. �� Loss of height. Loss of height. �� Deformity of the spine Deformity of the spine -- the curved, the curved,

"hunchback" shape. "hunchback" shape. �� Bracing and spine center referralBracing and spine center referral

Issues specific to Issues specific to CHRONICCHRONICLBPLBP

(>6 weeks and/or non(>6 weeks and/or non--responsive)responsive)�� EvaluationEvaluation

�� XX--rays, labsrays, labs

�� Evaluate for Evaluate for ““YELLOW FLAGSYELLOW FLAGS””

�� ManagementManagement�� Medication selectionMedication selection

�� InterventionsInterventions

YELLOW FLAGS YELLOW FLAGS in in ChronicChronicLBPLBP

�� Affect:Affect: anxiety, depression; feeling useless; anxiety, depression; feeling useless; irritabilityirritability

�� Behavior:Behavior:adverse coping, impaired sleep, adverse coping, impaired sleep, treatment passivity, activity withdrawaltreatment passivity, activity withdrawal

�� Social:Social:h/o abuse, lack of support, older ageh/o abuse, lack of support, older age

�� Work:Work: believe pain will be worse at work; believe pain will be worse at work; pending litigation; workers comp problems; pending litigation; workers comp problems; poor job satisfaction; unsupportive work envpoor job satisfaction; unsupportive work env’’tt

ConsiderationConsideration

�� Up to 85% of patients cannot be given a Up to 85% of patients cannot be given a definitive diagnosis because of weak definitive diagnosis because of weak association among symptoms, association among symptoms, pathological changes, and imaging resultspathological changes, and imaging results

�� Nachemson A, Spine, 1972Nachemson A, Spine, 1972

�� NonNon--specific diagnosis leads to Nonspecific diagnosis leads to Non--specific treatmentsspecific treatments-- leads to nonleads to non--specific outcomesspecific outcomes

�� Herring S, 1998Herring S, 1998

Red Flags for Serious Low Back Red Flags for Serious Low Back PainPain

�� Recent significant trauma, or milder trauma age >50Recent significant trauma, or milder trauma age >50�� Unexplained weight lossUnexplained weight loss�� Unexplained feverUnexplained fever�� ImmunosuppressionImmunosuppression�� History of cancerHistory of cancer�� Intravenous (IV) drug useIntravenous (IV) drug use�� Osteoporosis, prolonged use of corticosteroids Osteoporosis, prolonged use of corticosteroids �� Age >70Age >70�� Focal neurologic deficit progressive or disabling Focal neurologic deficit progressive or disabling

symptomssymptoms�� Duration greater than 6 weeksDuration greater than 6 weeks�� Night painNight pain

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TREATMENT OPTIONSTREATMENT OPTIONS

Treatment OptionsTreatment Options

��ACP/APS Key Recommendation ACP/APS Key Recommendation #5#5::

““Provide patients w/ evidenceProvide patients w/ evidence--based based information on LBP w/ regards to expected information on LBP w/ regards to expected course, advise patients to remain active, and course, advise patients to remain active, and provide information about effective selfprovide information about effective self--care options.care options.””




““Consider use of medications w/ proven Consider use of medications w/ proven benefits in conjunction w/selfbenefits in conjunction w/self--care. Assess care. Assess baseline severity of pain and functional baseline severity of pain and functional deficits, potential benefits/risks, and relative deficits, potential benefits/risks, and relative lack of longlack of long--term efficacy and safety before term efficacy and safety before initiating meds.initiating meds.””



““For pts who do not improve w/ selfFor pts who do not improve w/ self--care, care, consider the addition of nonpharmacologic consider the addition of nonpharmacologic therapy with PROVEN benefits.therapy with PROVEN benefits.””

* Weak rec, moderate* Weak rec, moderate--quality evidencequality evidence

Treatment Options:Treatment Options:Medications (ACUTE)Medications (ACUTE)

�� Acetaminophen: Acetaminophen: GoodGood ModerateModerate BB

�� NSAIDs: NSAIDs: GoodGood ModerateModerate BB

�� Skeletal Muscle Relaxants: GoodSkeletal Muscle Relaxants: Good ModerateModerate BB

----------------------------------------------------------------------------------------------------------------------------------------------

�� Benzodiazepines: Benzodiazepines: FairFair ModerateModerate BB

�� Opioids: Opioids: FairFair ModerateModerate BB

�� Systemic Steroids: Systemic Steroids: FairFair NoneNone DD

�� Aspirin: Aspirin: PoorPoor UnableUnable II

�� Tramadol, Antidepressants, Antiepileptic: No Tramadol, Antidepressants, Antiepileptic: No EvidenceEvidence

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Treatment Options:Treatment Options:Medications (Discussion)Medications (Discussion)

�� Pain relief does not equal functional Pain relief does not equal functional improvementimprovement

�� Short term use is recommendedShort term use is recommended

�� More headMore head--head data is neededhead data is needed

�� Better evidence regarding long term useBetter evidence regarding long term use

�� Better understanding of risk/benefit profiles Better understanding of risk/benefit profiles

Treatment Options:Treatment Options:MedicationsMedications

�� BottomBottom--line…line…ADAPTADAPT approach to each specific approach to each specific casecase

�� CONSIDERCONSIDER::

�� Risk factors for complicationsRisk factors for complications

�� Potential for interactionsPotential for interactions

�� Duration and severity of painDuration and severity of pain

�� CostCost

�� ALWAYSALWAYS discuss risks/benefits with the patient discuss risks/benefits with the patient and documentand document

Treatment Options:Treatment Options:Nonpharmacologic (ACUTE)Nonpharmacologic (ACUTE)

�� Superficial Heat: Superficial Heat: GoodGood ModModBB

�� Advice Remain Active:Advice Remain Active: GoodGood Small*Small*BB

�� SelfSelf--Care Information: Care Information: FairFair Small*Small*BB

�� Spinal Manipulation: Spinal Manipulation: FairFair SmSm--Md Md BCBC

------------------------------------------------------------------------------------------------------------------------------

Treatment Options:Treatment Options:Nonpharmacologic (ACUTE)Nonpharmacologic (ACUTE)

�� Poor Evidence / Unable to Estimate / IPoor Evidence / Unable to Estimate / I-- AcupunctureAcupuncture

-- Back SchoolsBack Schools

-- UltrasoundUltrasound

-- Lumbar SupportsLumbar Supports

-- MassageMassage

-- Modified WorkModified Work

-- TENSTENS

-- Superficial ColdSuperficial Cold

Treatment Options:Treatment Options:Nonpharmacologic (Subacute or Chronic)Nonpharmacologic (Subacute or Chronic)

�� CBT: CBT: GoodGood ModMod BB

�� Exercise Therapy: Exercise Therapy: GoodGood ModMod BB

�� Interdisc. Rehab: Interdisc. Rehab: GoodGood ModMod BB

�� Spinal Manipulation:Spinal Manipulation: Good Good ModMod BB

�� Acupuncture: Acupuncture: FairFair ModMod BB

�� Massage: Massage: FairFair ModMod BB

�� Yoga (Viniyoga): Yoga (Viniyoga): FairFair ModMod BB

�� Firm Mattresses: Firm Mattresses: FairFair NoneNone DD

�� Traction: Traction: FairFair NoneNone DD

Treatment Options:Treatment Options:Counseling (ICSI)Counseling (ICSI)

�� Most improve in 4 weeksMost improve in 4 weeks

�� Bed rest NOT recommendedBed rest NOT recommended

�� Recurrence expectedRecurrence expected

�� Adopt lifestyle changesAdopt lifestyle changes

�� Remain activeRemain active

�� Discuss red flag symptomsDiscuss red flag symptoms

�� ReRe--evaluate in 2evaluate in 2--4 weeks if NO improvement4 weeks if NO improvement

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Treatment Options:Treatment Options:SelfSelf--Care Brochures (ICSI)Care Brochures (ICSI)

�� Focus less on anatomy, ergonomics, & Focus less on anatomy, ergonomics, & exercisesexercises

�� Focus on benign course of LBP, reduction Focus on benign course of LBP, reduction of fear, and promotion of active selfof fear, and promotion of active self--managementmanagement

�� Emphasize lack of serious disease when red Emphasize lack of serious disease when red flags are absentflags are absent

�� Hurt is NOT equal to harmHurt is NOT equal to harm

�� Progressive resumption of work activities Progressive resumption of work activities

�� BETTER OUTCOMESBETTER OUTCOMES

Key PointsKey Points

�� Classify the patientClassify the patient’’s back pain.s back pain.

�� Assess and treat prognostic indicators.Assess and treat prognostic indicators.

�� Avoid unnecessary imaging.Avoid unnecessary imaging.

�� Utilize proven therapies.Utilize proven therapies.

�� Take the time to educate.Take the time to educate.

Approach to LBPApproach to LBP

�� History & physical examHistory & physical exam�� Classify into 1 of 4:Classify into 1 of 4:

�� BAD: LBP from other serious causesBAD: LBP from other serious causes�� Cancer, infection, Cancer, infection, caudacauda equinaequina, fracture, fracture

�� LBP from radiculopathy or spinal stenosisLBP from radiculopathy or spinal stenosis

�� NonNon--specific LBPspecific LBP

�� NonNon--back LBPback LBP

�� Workup or treatmentWorkup or treatment

Management of an acute low back muscle strain should consist of all

the following EXCEPT:

1.1. XX--rays to rule out a rays to rule out a fracturefracture

2.2. Educate the patient Educate the patient on generally good on generally good prognosisprognosis

3.3. NonNon--opiate opiate analgesicsanalgesics

4.4. Remain activeRemain active


NonNon--specific Low Back Painspecific Low Back Pain�� Educate patient about expected good prognosisEducate patient about expected good prognosis

�� Advise to remain active as toleratedAdvise to remain active as tolerated

�� Provide analgesics and selfProvide analgesics and self--care directionscare directions

�� FU in 2FU in 2--4 weeks; adjust tx as needed4 weeks; adjust tx as needed

�� DonDon’’t do xt do x--rays unless it becomes chronicrays unless it becomes chronic

�� WU if no improvementWU if no improvement

Integration of Therapy

� Physical therapy� Pilates for Core strengthening� Chiropractic� Home Education

� Wellness program including Tai Chi and other enhancement

� Pain Management

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NonNon--operative treatment of operative treatment of lumbar disc herniationlumbar disc herniation

�� Saal JA and Saal JS (1989)Saal JA and Saal JS (1989)�� 64 patients with CT and EMG 64 patients with CT and EMG

confirmed HNPconfirmed HNP�� Aggressive rehabAggressive rehab�� 90% good outcome and return to 90% good outcome and return to

workwork�� 6 patients 4/6 w/stenosis req. surgery6 patients 4/6 w/stenosis req. surgery

�� Saal JA et al (1995)Saal JA et al (1995)�� 52 patients w/degenerative stenosis 52 patients w/degenerative stenosis

treated w/rehab & ESItreated w/rehab & ESI�� 63% improved pain and ADL scores63% improved pain and ADL scores�� 4 required surgery4 required surgery

Physical therapyPhysical therapy�� Provide additional evaluationProvide additional evaluation�� Provide initial treatment modalitiesProvide initial treatment modalities

�� Deep heat/ultrasoundDeep heat/ultrasound�� Different types of massageDifferent types of massage�� TENS/EstimTENS/Estim

�� Provide exercise treatmentsProvide exercise treatments�� Address areas of tightness, weakness, Address areas of tightness, weakness,

instabilityinstability�� Communicate findings to MDCommunicate findings to MD�� Communicate progress in therapyCommunicate progress in therapy

Role of the physical therapist Role of the physical therapist (stretching is not evidence based medicine)(stretching is not evidence based medicine) Why therapy?Why therapy?

““ While pain relief may be While pain relief may be achieved, the functional achieved, the functional deficits persist and deficits persist and maladaptive patterns maladaptive patterns emerge…emerge… ””

-- Stan Herring, MDStan Herring, MD

�� Combat effects of bedrestCombat effects of bedrest�� Certain muscles are prone Certain muscles are prone

to tightness, others prone to tightness, others prone to weakness to weakness

•• Vladimir Janda 1993 JOSPTVladimir Janda 1993 JOSPT

What therapy?What therapy?�� Williams flexion Williams flexion

exercisesexercises�� But did not work in But did not work in

everybodyeverybody�� Flexion caused Flexion caused

increased increased intradiscal pressureintradiscal pressure

•• Nachemson AL 1981Nachemson AL 1981

�� Used now for Used now for stenosis patientsstenosis patients

Mc Kenzie extensionsMc Kenzie extensions

�� Goal is centralization of leg Goal is centralization of leg painpain

�� Decrease intradiscal Decrease intradiscal tensiontension

�� Decrease nerve root tensionDecrease nerve root tension�� 76/87 patients achieved 76/87 patients achieved

centralization and centralization and outcomes goodoutcomes good--exc in 83%exc in 83%�� Donnalson R 1997 SpineDonnalson R 1997 Spine

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Lumbar stabilizationLumbar stabilization�� Basics: Finding Basics: Finding

““neutral spineneutral spine”” where where there is the least painthere is the least pain

�� Performing the Performing the stretching and stretching and strengthening in this strengthening in this positionposition

�� Individualized rehabIndividualized rehab�� ““PainlessPainless”” RehabRehab

�� Saal JS et al 1992Saal JS et al 1992

What is “the Core”

� It is the lumbo-pelvic-hip complex� Center of Gravity is

located there� Where all movement

begins

� It consists of 29 different muscles

The Core Muscles

Lumbar spine muscles

Abdominal muscles

Hip muscles

Transversospinalis Group

Transversospinalis group

Rectus Abdominus

Gluteus Maximus

Rotatores

Erector Spinae External Oblique

Gluteus Medius

Interspinales

Quadratus Lumborum

Internal Oblique

Psoas Intertransversarii

Latissimus dorsi Transverse Abdominus

Semispinalis

Multifidus

Rationale for Core Training

� Will improve• Posture• Muscle balance• Stabilization

� Help prevent low back pain� Help prevent the development of muscle

imbalances and inefficient neuromuscular control

� All movement starts here

Strength Training Exercises

� Planks� Trunk Bridge� Front plank with lower extremity on

Theraball� Theraball curls� Supermans

� Trunk bridge with leg extension

Planks

� Lie on your stomach� Forearms flat on floor with

hands together� Feet together with toes on

ground� Lift stomach off ground and

hold� Keep body in straight line from

shoulders to toes� Keep stomach tight

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Trunk Bridge

� Lay with back on Theraball� Feet flat on floor, and knees

bent to 90 degrees� Move forward until just

shoulders are on Theraball� Keep body in a straight line

from head to knees� Keep stomach tight

Front Plank with lower extremity on Theraball

� Lay with stomach on Theraball

� Walk hands out until lower leg is on Theraball

� Keep arms extended.� Stay in straight line head

to toes and hold� Keep stomach tight

Theraball Curls

� Lay on ground with heels on Theraball

� Arms out to side for stability

� Lift hips off ground until just the shoulder blade is in contact with the ground

� Curl legs in towards the body and hold

� Return to start position and repeat

� Keep stomach tight

Supermans

� Lay with stomach on ground� Extend legs and arms� Lift left arm and right leg and

hold� Lower slowly and then lift

opposite arm and leg

� Keep hips neutral (do not roll with movement)

� Keep stomach tight

Trunk Bridge with Leg Extension

� Lay with back on ground� Put feet flat on floor with knees bent at 90 degrees� Lift hips off of ground and hold� Lift one foot off of ground and extend lower leg� Return to starting position and then lift other leg� Keep body in straight line between head and knees� Keep stomach tight

Trunk Bridge with Leg Extension (continued)

Before After

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Exercise Progression

� As training program progresses it may be necessary to increase the difficulty of the

exercises, or change the program

Dynamic Stabilization/PilatesDynamic Stabilization/Pilates


Suspected Radiculopathy or Suspected Radiculopathy or Spinal StenosisSpinal Stenosis

�� Refer to Physical TherapyRefer to Physical Therapy

�� Follow in 2Follow in 2--4 weeks for progress4 weeks for progress

�� If no improvement by 6If no improvement by 6--12 weeks12 weeks�� Plain films, MRI, +/Plain films, MRI, +/-- EMG/NCVEMG/NCV

�� Refer for interventionsRefer for interventions•• Epidural steroid injections for radiculopathyEpidural steroid injections for radiculopathy

Modalities

� TENS� Ultrasound� Electrical stimulation� Ice and Heat� Biofeedback� Acupuncture� Laser� Others

Bracing

� Restrict ROM� Reflexive muscle relaxation� Reduce soft-tissue swelling and edema� Generates heat, pressure, massage like

effect� Increase trunk support and improve

posture

Bracing Types

� Corsets� Lumbar belts� SIJ belt and corset� Rigid orthoses – chairback

� Cruciform anterior spinal hyperextension (CASH)

� Custom molded

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Medications in Chronic LBPMedications in Chronic LBP

�� FIRST: AcetaminophenFIRST: Acetaminophen

�� Second: NSAIDsSecond: NSAIDs�� If one fails, change classesIf one fails, change classes

•• Meloxicam Meloxicam �� naproxen naproxen �� COX2COX2’’ss

�� Third: tramadolThird: tramadol

�� Fourth: triFourth: tri--cyclic antidepressantscyclic antidepressants�� Radiculopathy: gabapentinRadiculopathy: gabapentin

�� LOATHE: narcoticsLOATHE: narcotics

NonNon--pharmacologic treatmentspharmacologic treatments

EFFECTIVEEFFECTIVE�� AcupunctureAcupuncture

�� Exercise therapyExercise therapy

�� Behavior therapyBehavior therapy

�� MassageMassage

�� TENSTENS

�� Spinal manipulationSpinal manipulation

�� Multidisciplinary rehab Multidisciplinary rehab programprogram

NOT EFFECTIVE/NOT EFFECTIVE/CONFLICTING EVIDENCECONFLICTING EVIDENCE

�� BACK SCHOOLSBACK SCHOOLS�� LOWLOW--LEVEL LASERLEVEL LASER�� LUMBAR SUPPORTSLUMBAR SUPPORTS�� PROLOTHERAPYPROLOTHERAPY�� SHORT WAVE SHORT WAVE

DIATHERMYDIATHERMY�� TRACTIONTRACTION�� ULTRASOUNDULTRASOUND

Epidural Steroid InjectionsEpidural Steroid Injections

�� Indicated for radiculopathy not Indicated for radiculopathy not responding to conservative mgmtresponding to conservative mgmt�� Conflicting evidenceConflicting evidence

�� Small improvement up to 3 monthsSmall improvement up to 3 months

�� Less effective in spinal stenosisLess effective in spinal stenosis

Trigger Point Injection� Beneficial in patients with tender points in the lumbar paraspinals or

iliolumbar ligaments associated with myofascial pain syndrome.� Limited benefit observed in heterogeneous, low quality studies. � Several studies found the injections superior to control intervention

but not statistically significant.

Surgery for Chronic LBPSurgery for Chronic LBP

�� Most do NOT benefit from surgeryMost do NOT benefit from surgery

�� Should have ANATOMIC LESION C/W Should have ANATOMIC LESION C/W PAIN DISTRIBUTIONPAIN DISTRIBUTION

�� Significant functional disability, unrelenting Significant functional disability, unrelenting painpain�� Several months despite conservative txSeveral months despite conservative tx

�� Procedures: spinal fusion, spinal Procedures: spinal fusion, spinal decompression, nerve root decompression, disc decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapyarthroplasty, intradiscal electrothermal therapy

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Myofascial Pain

� Generalized non-descriptive pain� Diffuse but more spinal� Overall deconditioning� Poor sleep associated

Underlying Effects of Manual Medicine

� Improved pain and increased movement

� Less deconditioning

� Interruption the pain/spasm cycle

� Restoration of function

� Muscle rebalancing

� Use of Chiropractic Manipulation in Lumbar Rehabilitation; John J. Triano, MA, DC; Marion McGregor, DC, MSc; Dennis R. Skogsbergh, DC Journal of Rehabilitation Research and Development Vol. 34 No. 4, October 1997; Pages 394-404

High Velocity Low Amplitude Thrust (HVLA)

Post Isometric RelaxationPost Isometric Relaxation NeurotoxinNeurotoxin

�� Injection of Neurotoxin into the paraspinal Injection of Neurotoxin into the paraspinal muscles to cause graded neuromuscular muscles to cause graded neuromuscular blockadeblockade

�� Foster, 2001: Small randomized trial of Foster, 2001: Small randomized trial of patients with chronic LBP. Superior to patients with chronic LBP. Superior to placebo and improved function at 8 weeks placebo and improved function at 8 weeks 60% vs. 16%. 60% vs. 16%.

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AcupunctureAcupuncture

�� Useful adjunct in pain managementUseful adjunct in pain management�� Wide variety of conditions: postWide variety of conditions: post--operative operative

pain, fibromyalgia, headache, low back pain, fibromyalgia, headache, low back and neck pain, myofascial pain, and neck pain, myofascial pain, osteoarthritis, enthesopathy, osteoarthritis, enthesopathy, rheumatologic conditionsrheumatologic conditions

�� National Center for Complementary and National Center for Complementary and Alternative Medicine (NCAM) funded Alternative Medicine (NCAM) funded studiesstudies

Tai Chi Maintenance exerciseMaintenance exercise

��Yoga Yoga

��PilatesPilates

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Rehabilitation must connect to Rehabilitation must connect to the workplacethe workplace

““We conclude that there is moderate We conclude that there is moderate evidence of positive effectiveness of evidence of positive effectiveness of multidisciplinary rehabilitation for subacute multidisciplinary rehabilitation for subacute low back pain low back pain and that a workplace visit and that a workplace visit increases the effectivenessincreases the effectiveness..””

Cochrane Database Systematic Review 2000;(3):CD002193

SummarySummary

�� Classify the patientClassify the patient’’s back pain.s back pain.

�� Assess and treat prognostic indicators.Assess and treat prognostic indicators.

�� Avoid unnecessary imaging.Avoid unnecessary imaging.

�� Utilize proven therapies.Utilize proven therapies.

�� Take the time to educate.Take the time to educate.

SummarySummary

�� Spine pain Spine pain –– many facetsmany facets

�� Commonly found, frequently misunderstoodCommonly found, frequently misunderstood

�� Keep in mind less common causes of LBPKeep in mind less common causes of LBP

�� Many treatment optionsMany treatment options

�� A coordinated and comprehensive program is A coordinated and comprehensive program is the best approachthe best approach

�� Keep an open mind and know as many options Keep an open mind and know as many options as possible working in team oriented approachas possible working in team oriented approach

ReferencesReferences

�� Primary Care; Clinics in Office PracticePrimary Care; Clinics in Office PracticeVolume 31 • Number 4 • December 2004Volume 31 • Number 4 • December 2004Copyright © 2004 W. B. Saunders Company, PhiladelphiaCopyright © 2004 W. B. Saunders Company, Philadelphia

�� Orthopedic Physical Assessment, Magee DJ, 1992, W.B. Saunders Orthopedic Physical Assessment, Magee DJ, 1992, W.B. Saunders Company. PhiladelphiaCompany. Philadelphia

�� Physical Examination of the Spine and Extremities, Hoppenfeld S, Physical Examination of the Spine and Extremities, Hoppenfeld S, 1976, Appleton1976, Appleton--CenturyCentury--Crofts. Norwalk, CTCrofts. Norwalk, CT

�� Sackett DL, Rennie D. The science of the art of the clinical Sackett DL, Rennie D. The science of the art of the clinical examination. JAMA 1992; 267: 2650examination. JAMA 1992; 267: 2650--52.52.

ReferencesReferences�� Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition, Bickley LS. Bates' Guide to Physical Exam and History Taking. 7th edition,

Philadelphia; Lippincott 1999: 163Philadelphia; Lippincott 1999: 163--70, 18470, 184--95, 21195, 211--27. 27. �� Chapman MW. Chapman's Orthopaedic Surgery 3rd Ed., Philadelphia; Chapman MW. Chapman's Orthopaedic Surgery 3rd Ed., Philadelphia;

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Clinician. Cole AJ, Herring SA. 1997. Hanley and Belfus, Inc.. PhiladelphiaClinician. Cole AJ, Herring SA. 1997. Hanley and Belfus, Inc.. Philadelphia�� Essentials of Physical Medicine and Rehabilitation. Frontera WR, Silver JK. Essentials of Physical Medicine and Rehabilitation. Frontera WR, Silver JK.

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�� Bogduk, N. Lumbar Radiofrequency Neurotomy. Clin J Pain 2006; 22:409. Bogduk, N. Lumbar Radiofrequency Neurotomy. Clin J Pain 2006; 22:409. �� Gofeld, M. Radiofrequency facet denervation: a randomized control placebo Gofeld, M. Radiofrequency facet denervation: a randomized control placebo

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�� Staiger, TO, Gaster, B, Sullivan, MD, Deyo, RA. Systematic review of Staiger, TO, Gaster, B, Sullivan, MD, Deyo, RA. Systematic review of antidepressants in the treatment of chronic low back pain. Spine 2003; antidepressants in the treatment of chronic low back pain. Spine 2003; 28:2540.28:2540.

�� Yaksi, A, Ozgonenel, L, Ozgonenel, B. The efficiency of gabapentin therapy Yaksi, A, Ozgonenel, L, Ozgonenel, B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine 2007; 32:939.in patients with lumbar spinal stenosis. Spine 2007; 32:939.

�� Machado, LA, de Souza, MS, Ferreira, PH, Ferreira, ML. Machado, LA, de Souza, MS, Ferreira, PH, Ferreira, ML. The McKenzie The McKenzie method for low back pain: a systematic review of the literature with a metamethod for low back pain: a systematic review of the literature with a meta--analysis approach. Spine 2006; 31:E254.analysis approach. Spine 2006; 31:E254.

ReferencesReferences�� Hayden, JA, van Tulder, MW, Tomlinson, G. Systematic review: strategies Hayden, JA, van Tulder, MW, Tomlinson, G. Systematic review: strategies

for using exercise therapy to improve outcomes in chronic low back pain. for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med 2005; 142:776.Ann Intern Med 2005; 142:776.

�� Heymans, MW, van Tulder, MW, Esmail, R, et al. Back schools for Heymans, MW, van Tulder, MW, Esmail, R, et al. Back schools for nonspecific low back pain: a systematic review within the framework of the nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2005; 30:2153.Cochrane Collaboration Back Review Group. Spine 2005; 30:2153.

�� Atlas SJ, Keller TB, Wu YA, et al. Atlas SJ, Keller TB, Wu YA, et al. Long term outcomes of surgical and Long term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. Spine 2005; 30:927.10 year results from the Maine Lumbar Spine Study. Spine 2005; 30:927.

�� Hagen, KB, Hilde, G, Jamtvedt, G, Winnem, M. Bed rest for acute lowHagen, KB, Hilde, G, Jamtvedt, G, Winnem, M. Bed rest for acute low--back back pain and sciatica. Cochrane Database Syst Rev 2004; :CD001254.pain and sciatica. Cochrane Database Syst Rev 2004; :CD001254.

�� Deyo, RA, Mirza, SK, Martin, BI. Back pain prevalence and visit rates: Deyo, RA, Mirza, SK, Martin, BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 2006; 31:2724.estimates from U.S. national surveys, 2002. Spine 2006; 31:2724.

�� Katz, JN. Lumbar disc disorders and lowKatz, JN. Lumbar disc disorders and low--back pain: socioeconomic factors back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006; 88 Suppl 2:21.and consequences. J Bone Joint Surg Am 2006; 88 Suppl 2:21.


�� Fairbank, J, Frost, H, WilsonFairbank, J, Frost, H, Wilson--MacDonald, J, et al. Randomised MacDonald, J, et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005; low back pain: the MRC spine stabilisation trial. BMJ 2005; 330:1233.330:1233.

�� Gibson, JN, Waddell, G. Surgery for degenerative lumbar Gibson, JN, Waddell, G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine 2005; 30:2312.spondylosis: updated Cochrane Review. Spine 2005; 30:2312.

�� Gibson, JNA, Waddell, G. Surgical interventions for lumbar disc Gibson, JNA, Waddell, G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev 2007; CD001350prolapse. Cochrane Database Syst Rev 2007; CD001350

�� Pauza, KJ, Howell, S, Dreyfuss, P, et al. A randomized, placeboPauza, KJ, Howell, S, Dreyfuss, P, et al. A randomized, placebo--controlled trial of intradiscal electrothermal therapy for the treatment controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 2004; 4:27. of discogenic low back pain. Spine J 2004; 4:27.

�� Peul, WC, van Houwelingen, HC, van den, Hout WB, et al. Surgery Peul, WC, van Houwelingen, HC, van den, Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356:2245.2007; 356:2245.

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�� Mirza, SK, Deyo, RA. Systematic review of randomized trials Mirza, SK, Deyo, RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 2007; 32:816.of chronic back pain. Spine 2007; 32:816.

�� Riew, KD, Park, JB, Cho, YS, et al. Nerve root blocks in the Riew, KD, Park, JB, Cho, YS, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum fivetreatment of lumbar radicular pain. A minimum five--year followyear follow--up. J up. J Bone Joint Surg Am 2006; 88:1722. Bone Joint Surg Am 2006; 88:1722.

�� Riew, KD, Yin, Y, Gilula, L, et al. The effect of nerveRiew, KD, Yin, Y, Gilula, L, et al. The effect of nerve--root injections root injections on the need for operative treatment of lumbar radicular pain. A on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, doubleprospective, randomized, controlled, double--blind study. J Bone blind study. J Bone Joint Surg Am 2000; 82Joint Surg Am 2000; 82--A:1589. A:1589.

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for disorders of the lumbar spine. Mayo Clin Proc 2003; 78:1249.for disorders of the lumbar spine. Mayo Clin Proc 2003; 78:1249.�� Weinstein, JN, Lurie, JD, Tosteson, TD, et al. Surgical vs Weinstein, JN, Lurie, JD, Tosteson, TD, et al. Surgical vs

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�� Jewell, DV, Riddle, DL. Interventions that increase or decrease the Jewell, DV, Riddle, DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther 2005; 85:1139. with sciatica. Phys Ther 2005; 85:1139.

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�� Maher, CG. Effective physical treatment for chronic low Maher, CG. Effective physical treatment for chronic low back pain. Orthop Clin North Am 2004; 35:57. back pain. Orthop Clin North Am 2004; 35:57.

�� Assendelft, WJ, Morton, SC, Yu, EI, et al. Spinal Assendelft, WJ, Morton, SC, Yu, EI, et al. Spinal manipulative therapy for low back pain. Cochrane manipulative therapy for low back pain. Cochrane Database Syst Rev 2004; :CD000447. Database Syst Rev 2004; :CD000447.

�� Bronfort, G, Haas, M, Evans, RL, Bouter, LM. Efficacy of Bronfort, G, Haas, M, Evans, RL, Bouter, LM. Efficacy of spinal manipulation and mobilization for low back pain spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence and neck pain: a systematic review and best evidence synthesis. Spine J 2004; 4:335. synthesis. Spine J 2004; 4:335.

�� Fritzell, P, Hagg, O, Wessberg, P, Nordwall, A. 2001 Fritzell, P, Hagg, O, Wessberg, P, Nordwall, A. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001; 26:2521. Lumbar Spine Study Group. Spine 2001; 26:2521.

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interventional treatment, Chou R, September 2007 interventional treatment, Chou R, September 2007 �� Up To Date, Approach to the diagnosis and evaluation of low back Up To Date, Approach to the diagnosis and evaluation of low back

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�� Up To Date, Rehabilitation program for the low back, Sheon RP, Up To Date, Rehabilitation program for the low back, Sheon RP, Duncombe AM, July, 2007 Duncombe AM, July, 2007

�� Up To Date, Subacute and chronic low back pain: Surgical Up To Date, Subacute and chronic low back pain: Surgical treatment, Chou R, Sept. 2007 treatment, Chou R, Sept. 2007

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