1 Caring for patients with low back painSadia A. Ali,MD

2 OBJECTIVES Understanding patient’s concerns and assessing disabilityAnatomy of low back Conduct a focused, evidence-based medical history and physical examination. Tailoring low back pain management plan on individual case basis for acute and sub-acute back pain.

3 OUTLINE Background and Anatomy Classification, Etiology, HistoryPhysical exam Practice session Management scenarios

4 STATS 2nd most common cause for office visit60-80% of population will have lower back pain at some time in their lives Most common cause of disability for persons < 45 years Costs to society: $20-50 billion/year

5 UNDERSTANDING PTS Mr. Joe has had lower back pain for the past 24 hours that he feels is related to carrying heavy boxes at work 2 days ago.  He missed work today, Thursday. He wants to know what can be done for his back pain?

6 ACTION PLAN Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. Provide information, advice, and a management plan.

7 ANATOMY

8 ANATOMY

9 CLASSIFICATION ACUTE---- < 6wks SUB-ACUTE------ 6-12wksCHRONIC >12wks

10 CAUSES Lumbar “strain” or “sprain” – 70% Degenerative changes – 10%Herniated disk – 4% Osteoporosis compression fractures – 4% Spinal stenosis – 3% Spondylolisthesis – 2% Spondylolysis, diskogenic low back pain or other instability – 2% Traumatic fracture - <1% Congenital disease - <1% Cancer – 0.7% Inflammatory arthritis – 0.3% Infections

11 HISTORY DEMOGRAPHICS: Age, gender, co-morbidities , social and occupational history. PAIN: Onset, location, duration, intensity and frequency of pain, any past episodes of LBP, activities inc.pain, bladder or bowel dysfunction. FUNCTIONAL STATUS:

12 HISTORY cont GOAL: Nonspecific LBPNo specific patho-anatomical diagnosis Back pain with radicular symptoms Radicular Radiculopathy Spinal stenosis (neurogenic claudication) Another specific spinal cause Cancer, infection or cauda equina syndrome.

13 RED FLAGS Hx of CA Age > than 50 with other s/s or risk factorsFever, IVD, recent infection Urinary retention, multiple level motor deficits Osteoporosis, steroid use Abd pulsating mass Significant weakness, progressive weakness

14 YELLOW FLAGS Reflect chronicity, poor pt. outcome and psycho-social distress BELIEF SYSTEM COMORBIDITIES AFFECTIVE FACTORS WADDLLE’S SIGNS

15 PHYSICAL Inspection---Asymmetry, rash Palpation----Fx, spasmROM----Flexion, extension, lat bending Motor/Sensory/Reflexes Provocative tests---SLR, FABER test Waddell Signs Gait Abd/rectal

16 PRACTICE SESSION Divide in 3 groups and practice back exam(refer to handout 1)

17 CASE 2 Sam, a 30-year-old man who works at the local home and garden center, strained his back three days ago while loading some plants. He tells his physician that he has been using a local heat wrap and ibuprofen (Motrin, Advil) 800 mg four times a day without relief. Sam denies any history of LBP, bowel or bladder dysfunction, radicular pain or weakness. A careful physical examination reveals limited flexibility and range of motion. Sam is locally tender over the right (R) paraspinal muscles. The lower extremity neurologic examination is otherwise within normal limits and shows a negative SLR test. Sam asks his physician whether he should initiate disability paperwork at this time.

18 ACTION PLAN! Goal: PAIN CONTROL & DISABILITY LIMITATION----ACUTE BACK PAIN Hx & Physical Red/yellow flags Imaging???? BED REST Pharmacologic rx--- Non pharmacologic modalities

19 PHARMACOLOGIC MODALITIESNSAIDS VS Acetaminophen Muscle relaxants (first 2 wks in NS LBP) Opioids (mod to severe, d/c if not impr) Benzodiazepines ( muscle spasm-not FDA approved) Systemic steroids (case reports-radicular symptoms) TCA and Gabapentin (radicular pain)

20 NON-PHARMACOLOGIC MODALITIESHeat (level II)/Cold packs PT (2-6 sessions in Sub-acute) Exercise (individualize plan) Chiropractic/Spinal manipulation(level II) Acupuncture(inconclusive) Brace, support(not effective)

21 FOLLOW UP Improves out-comes Questions chronicityReturn to work and disability issues Communication with family and employer

22 Sam again! 6 wk f/u Sam is back at you office with no improvement---SUB ACUTE BACK PAIN Re-evaluate pt Imaging: Plain X-ray: Age>50 years No improvement after 6 weeks Other worrisome findings MRI: After 6 weeks if have sciatica Pharmacologic

23 INTERVENTION RX Epidural injections: Facet joint injections:Insufficient and conflicting evidence Helpful in sub-acute LBP and radicular pain Should be part of comprehensive plan Facet joint injections: No improvement Local/Trigger point injections: Possibly some benefit

24 RECAP Beware of red and yellow flags, assess disabilityNon-specific/ nerve distribution/Sp. Cause NSAIDs and Acetaminophen mainstay Acute LBP- spinal manipulation Imaging and bed rest not necessary in most cases Closer f/u Pt education

25 REFERENCES CORE CONTENT AAFP(http://www.aafp.org/online/en/home/cme/selfstudy/cmebulletin/acutelbp/article/read.html) ESSENTIALS OF MUSCULOSKELETAL CARE NEJM 2001