2016 1a/2a: “back 2 basics” treating chronic low … jail health conference 1a/2a: “back 2...
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2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Reported to affect 8 out of 10 people at some point in their lives
People with CLBP are also more likely to report widespread pain
Cost the US $96 billion dollars as of 2012
Total incremental cost of health care due to all chronic pain ranged from $560 to $635 billion
More than heart disease ($309 billion), cancer($243 billion), and diabetes ($188 billion) and nearly 30 percent higher than the combined cost of cancer and diabetes
Overutilization of imaging, medication, injections, and surgery
629% increase in Medicare expenditures for ESI’s
423% increase in opioids for back pain
307% increase in lumbar MRI among Medicare beneficiaries
220% increase in spinal surgery rates
Imaging is NOT predictive of pain or future injury
Immediate imaging IS indicated if ACUTE back pain AND the following signs / symptoms
Cancer
Infection
History of major trauma
Rapidly worsening neurological function
Need to try physical therapy for 6 weeks
If no improvement then imaging is appropriate
Don’t kid yourself: The longer the patient has been in pain, the harder it is to find where the exact problematic tissue is
There are NO STUDIES that show that an extra mattress will ease LBP. NONE!!
ACUTE
No imaging UNLESS there are red flags
Advise to keep moving and stay active
Avoid prolonged rest and time off work
Pain education OTC medications: NSAID’s and Tylenol over opioids
Early physical therapy: manual therapy (manipulation / mobilization) and exercise
CHRONIC
No imaging unless there are red flags (likelihood of red flags diminish with chronicity)
Develop ACTIVE coping strategies (don’t reinforce passive techniques)
Aerobic exercise
Advice on relaxation techniques and activity pacing
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Features
Previous history malignancy (however long ago)
Age <16 or >50 with NEW onset pain
Weight loss (unexplained)
Previous longstandingsteroid use
Recent serious illness
Recent significant infection
Signs
Saddle anesthesia
Reduced anal tone
Hip or knee weakness
Generalized neurological deficit
Urinary retention
Progressive spinal deformity
Symptoms
Non‐mechanical pain(worse at rest)
Thoracic pain
Fevers/ rigors
General malaise
Urinary retention
RULING IN / OUT RED FLAGS
Neoplasm Spinal Fractures Cauda Equina Spinal Infection Ankylosing Spondylitis‐Age > 50yrs* ‐Major Trauma ‐ Saddle anesthesia ‐Recent fever and chills ‐Morning Stiffness ‐Previous hx ‐Stress Fx ‐Recent onset ‐Recent bacterial ‐Awakening the 2nd half of thecancer * Athletes bowel/bladder infection night‐Unexplained Younger dysfunction ‐Immunosuppression ‐Relief with exercise and weight loss ‐Compression Fx ‐Rapidly ‐Hx IV drug abuse activity‐Night Pain ‐Minor trauma to older worsening LE ‐Age of onset<35ys ‐No relief with adult neurologic deficit ‐Malebest rest ‐Distracting painful injury ‐No relief lying down
‐Hx of corticosteroid use
SEE FULL PAGE – END OF HANDOUTRecognize Signs and Symptoms
Disease / Pathology Identified
Treat the impairments /dysfunction to correct the pathology
Signs and symptoms disappear
This model assumes the following:
Signs and symptoms are directly proportional tothe underlying disease / pathology
Identifying the underlying pathology is critical forguiding the treatment
Signs and symptoms SHOULD disappear whenthe pathology is corrected
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Chronic LBP is:
Frequently mismanaged in the acute stage thusbecoming chronic
Surgery is often avoidable
Where you live is a high predictor of whether ornot you get low back surgery
Strongest predictor of chronic pain and disability:
▪ Psychosocial factors
Do we all need more stabilization?
Preliminary research indicates stabilization ex inpatient with CLBP can lead to
▪ Increased co‐contraction (stability) of trunk muscles and guarded spinal movement
▪ An inability of the back muscles to relax
Trouble with the term “instability”
▪ Should be reserved for unstable spinal fractures orunstable spondylolisthesis
▪ Perpetuates unhealthy belief
Takes into account how the patients thoughts, beliefs, social environment, and illness behaviors contribute to their physical dysfunction
Increased Pain
Fear/Anxiety/Worry
Poor Coping
Sleeping problems
Social issues
Cognitive / Psychosocial Issues
Stress, fear, catastrophizing behavior, anxiety, hypervigilance, care seeking, depression
Social Factors
Work, socioeconomics, culture, family, educationlevel
Lifestyle Issues
Activity level, sleep, diet, smoking
Recognize yellow flags through
History
Screening tools
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Orebro MSK Pain Questionnaire‐short form Measure along several psychosocial domains Predicts long‐term disability and failure to return to work
Pain Catastrophizing Scale > 20= at risk
Start Back Tool Great for Triage and used most in primary care or direct access
setting
Fear Avoidance and Belief Questionnaire (FABQ) Most commonly used Keep in mind only measure one psychosocial domain: Fear Dived into Work and Physical Activity subscale
Tampa Scale of Kinesiophobia Measure fear of movement risk
Beck Depression Index Depressive symptoms
Oswestry ( Modified) Disability Index: MCID = 12
0‐20% minimal disability
21‐40% moderate disability
41‐60% severe disability
61‐80% crippled
81‐100% bed bound or symptom exaggeration
Patient Specific Functional Scale: MCID = 2
Global Rating of Change: MCID = 2
+7 to –7: How much better, worse, or the same do you feel
Patient belief greatly impact disability and must be addressed with the CLBP patient to make meaningful change
Common Beliefs/Fear
Fear of not returning to work
Belief that their pain with never improve
Belief that their back is unstable and vulnerable
Belief that they won’t be able to do the things they love
Beliefs regarding: Physicians Medications System Work Activity Life experiences Severity and chronicity of symptoms Mental illness Abuse Family dynamics▪ EVEN WITH AWARENESS OF PSYCHOSOCIAL ISSUES PATIENTS MAY NOT DISPLAY OVERT PAIN BEHAVIORS▪ IT TAKES TIME▪ IT OFTEN TAKES A TEAM
An amplification of neural signaling within the central nervous system (CNS) that elicits pain hypersensitivity
This process can begin early and doesn’t necessarily take years
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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SUBJECTIVE (MOST VALUABLE)
Disproportionate Pain
Multiple sites of pain
Pain “spreading”
Pain persisting past expected healing times
Cold or Heat Sensitivity
Sensitivity to sounds, light
Emotional trauma
Depression, anxiety, poor sleep, difficulty concentrating
Family history persistent pain
CLINICAL EXAM / OBJECTIVE
Decreased pain pressure thresholds
Positive identification of various psychosocial factors (e.g. catastrophization, fear‐avoidance behavior
Allodynia: sensitivity to light touch or non painful stimuli
Hyperalgesia: increased sensitivity to a painful stimuli in local and remote sites
Disproportionate, inconsistent, non‐mechanical / non‐anatomical pattern of pain provocation in response to movement / mechanical testing
Though Neuroscience Education has an anatomic component (anatomy of the nervous system)….It deemphasizes tissue pathology / injury (i.e.: disk or joint)
Teaches patient that their nervous system is sensitized vs back damage
▪ The nervous system has the ability to increase or decrease sensitivity, which is neuroplasticity, to help the cope with persistent pain
RA
Irritable Bowel Syndrome
Temporomandibular Dysfunction
Osteoarthritis
Fibromylagia
Headache
Neuropathic Pain
When patients with CLBP are compared with controls using fMRI we see changes in neurochemical profile of the:
Thalamus
Actual brain structure and alterations in greymatter
Changes in cortical activity and responsiveness
There is no evidence to suggest that neurochemical changes cause CLBP
Some findings suggest CLBP may cause neurochemical changes
How are these brain changes relevant to what PT’s do?
Cortical changes contribute to:
▪ Enhanced / increased response to noxious stimuli
▪ Psychological and cognitive effects
▪ Altered body perception / impaired body schema
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Not just one pain center in the brain, there are many
The brain makes a judgment on the inputs and responds with a quiet signal or an excitatory “ danger” signal
How does the brain decide whether to sound the alarm or send a quiet message?
Context
External Stimulus or Internal Stimulus (in bones, joint, fascia, muscles)
Spinal Cord
Peripheral Nerve
Dorsal Root Ganglion
Release of excitatory synapses sent to brain
The synapse or “message” is processed by the brain and then the brain decides if its should sound the alarm or send a quiet message
If chronic pain is precipitated by nervous system oversensitivity and impaired pain signals, should we always let pain be our guide with regard to our movements?
No
In chronic stages “Hurt does not always equal harm”
Do we really need to explain this to patients and use big words like synapses and dorsal root ganglion?
Yes, evidence suggests that the patient can comprehend it and learning about pain physiology reduces the “threat” of pain
Biggest barrier is clinicians’ comfort level explain pain science to the patient
Peripheral Nocioceptive / Mechanical Stimulus ‐ Response Symptoms after prolonged/unusual postures ( ischemic pain)
Peripheral Inflammatory Cardinal signs of acute inflammation Associated with acute pain
Peripheral Neurogenic Burning, radiating, paresthesia Neurodynamic tests Nocturnal pain Often what people describe as radiculopathy
Central Amplified Widespread Central Sensitization
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Are there any red flags?
What are the impairments?
Why hasn’t the problem gone away?
What are the perpetuating factors?
Motivational Interviewing
Helps the patient come to their own understanding, and calls forth their level of motivation
Collaborative and patient centered, the clinician asks open ended questions that help patient self realize
Collaboration(vs. “Confrontation”)
Evocation (“Drawing Out”, Rather Than “Imposing” Ideas)
Autonomy (vs. “Authority”)
Empathetic listening: OARS
Open ended questions▪ “How are you dealing with your back pain?”
▪ “What do you think is wrong with your back”
▪ “Do you think it will ever get better”
Affirmations▪ “You’re very active even with your back pain”
▪ “You show great resolve to keep working despite your back pain!”
Reflections▪ “You sound upset because everyone thinks you are faking it”
▪ “You seem frustrated that you struggle to do the things you once loved”
Summaries
▪ “ Before we move on, let me make sure I have this correct…You said…..”
“What do you take away from today”
“Do you think you can do it?
“I see lots of people with similar problems”
“What do you think?”
“Is the pain on your mind a lot”
“Does your mood effect your pain?”
“Does it get you down?”
“What do you think is the cause of your problem?”
“Do you hold your breath while doing that?”
“What do you think your body wants to do?”
“Do you try to protect your back?”
“Are you fearful of your back?”
“Let me reflect back on what you told me.”
ENDURANCE COPING
Presses on despite pain.
High activity level
Fear of losing independence, job, or self‐identity
Does not want to let self and others down
AVOIDANCE COPING
Avoids activities perceived as harmful and painful
High fear
Low activity level
Deconditioned
Sedentary
Both styles maladaptive and increase risk of chronic pain
What we say will effect the patients perception of their condition
Negative beliefs about back pain are predictive of pain intensity, work absenteeism, disability, and chronicity
Don’t reinforce negative behavior by using harmful language
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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“You have the back of an 80 year old”
“Pinched nerve”
“Disc bulge or slipped disc”
“Wear and tear”
“Avoid bending/lifting”
“You’ll have this the rest of your life”
“Instability”
“Out of alignment”
“Your S‐I joint is out”
“Muscle imbalance”
“Stop if you feel any pain”
‘Back pain does not mean your back is damaged –it means it is sensitized’
‘The brain acts as an amplifier –the more you worry and think about your pain the worse it gets’
‘Back sprain similar to ankle sprain’
‘Relaxed movement will help your back pain settle’
‘Your back gets stronger with movement’
‘Motion is lotion’ ‘Movements will be painful at
first – like an ankle sprain –but they will get better as you get active’
‘Let’s work out a plan to help you help yourself’
‘Getting back to work as you’re able, even part time at first, will help you recover’
‘Protecting your back and avoiding movement can make you worse’
‘Your imaging changes are normal, like grey hair’
‘The pain does not mean you are doing damage –your back is sensitive’
‘Let’s work out a plan to help you help yourself’
Deemphasize pathology and imaging findings
Explain biopsychosocial pain mechanisms
Explain how stress, anxiety, beliefs, hyper‐vigilance, fear, and protective behaviors effects pain and movement
Discuss pacing of activities
Discuss stress reduction strategies and active coping
Reassure patients regarding the benign nature of LBP…. But don’t minimize their feelings or tell them it’s in their head
STRESS MANAGEMENT AND RELAXATION TECHNIQUES
Mindful Based Stress Reduction
Sleep Hygiene
Diaphragmatic Breathing
NEURODYNAMICS
“Slider” vs “Tensioner”
▪ Sliders often more gentle and thought to glide the nerve by through repeated tension and slack
▪ Tensioners attempt to restore the neural tissues ability to tolerate movement that lengthen the nerve
Typically done Supine or Slump position
Mixed efficacy in the literature
▪ Needs more research
EDUCATION
Evidence Based Chronic Pain Truths
▪ Pain does not equal tissue damage
▪ The longer you’ve been in pain, the harder it is to find where the exact problematic tissue is
▪ Pain is modulated by many factors from across somatic, psychological and social domains
▪ Pain does not provide a measure of the state of the tissues
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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EDUCATION
Discourage pain behaviors
▪ Limping
▪ Grimacing
▪ Groaning
▪ Bracing back with hands
▪ Holding breath
▪ Holding painful area
▪ Rigid postures
▪ Back Braces and devices
OLDER ADULTS Lumbar Spine Stenosis▪ Most common cause of L/S surgery in older adults
▪ Most indicative factors:▪ No pain with sitting
▪ Improved symptoms with sitting
▪ Age >65▪ LE pain▪ Able to walk better when bending forward ie: walking with shoppingcart
▪ Pain below the knees or buttocks
Hip impairment and CLBP▪ Burns et al 2011 found short term improvement in disabilityin patients with CLBP
▪ Pos. FABER, Decreased Hip AROM
EXERCISE
Aerobic exercise goal: 20 to 30 minutes each day
Advise patients to increase activity gradually (e.g. 10% per week)
Time based activity vs pain based
MOVEMENT RETRAINING Motor Re‐education▪ Retrain Lumbopelvic position sense in various positions (supine, forward bending, quadruped)
▪ Do unloaded first then progress to loaded If excessive guarding▪ Relaxation Techniques▪ Diagphragmatic breathing
▪ Teach to decrease guarding during functionalmovement
If fear with movement ‐ change the CONTEXT▪ Very important!
Not likely the main stay of treatment
Use to Decrease the “Threat”
Avoid Aggressive Manual
1‐2x/wk in the beginning
Wean to 1x/wk
Often time dependent vs visit dependent
Discourage care seeking behavior
Active vs passive treatment
Encourage patient autonomy and self efficacy
2016 Jail Health Conference1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
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Putting the pieces together Any Red flags / need for referral?
Patients thoughts, beliefs?
Patients coping style?
Driving pain mechanism?
What are the impairments?
What’s perpetuating the issue and why hasn’t theirdysfunction gone away?
What tests / measures will I perform to guide my day 1 treatment
If there is fear of movement, change the context of the activity
Day 1
Bike (or treadmill) warm‐up, PPT, LTR, DK ‐> Cstretches
Electric stim with heat after all exercises
Day 2
Above plus: PPU, SLR, SL hip ABD
Day 3
Above plus: Ab crunches, HS stretches
Day 4
Above plus: Bird‐dogs, 90 / 90 ab crunches
(continued)
Day 5
Above plus: Bridging (first both legs thenunilateral); Glute stretches
Day 6
Above plus: planks, side planks
The above program is continued as a home program with the addition of aerobic exercise 20 – 30 minutes a day
OWESTRY Patients MCID = 8% – 10% Average of the patients below = 14.6% ; Mean = 15.7%; Removethe worsening = 20.3%
▪ Initial = 52%; DC 42% (6 visits) 6% improvement ▪ Initial = 86%; DC = 76% (6 visits) 10% improvement▪ Initial = 52%; DC = 48 % (6 visits) 4% improvement▪ Initial = 40%; DC = 46% (6 visits) 6% worsening ****▪ Initial = 46%; DC = 8% (6 visits) 38% improvement ▪ Initial = 72%; DC = 32% (6 visits) 40% improvement▪ Initial = 70%; DC = 26% (6 visits) 44% improvement▪ Initial = 32%; DC 30% (4 visits) 2% improvement▪ ..........
Understanding Pain: What to do about it in less than 5 minutes( video)
http://www.youtube.com/watch?v=4b8oB757DKc#t=25
Pain education Blog for Patients (Peter O’Sullivan
http://www.pain‐ed.com/public/health‐information/
Booklet(Free)‐A Self Help Guide to Managing your own Back Pain
http://www.pain‐ed.com/wp‐content/uploads/2013/11/THO‐S‐ManagingYourBackPain_booklet_offset‐printed‐professional‐April‐2013‐Final.pdf
Great patient resource for coping, pain management, understanding pain (PainHealth.com)
http://painhealth.csse.uwa.edu.au/pain‐management‐making‐sense‐of‐pain.html
RULIN
G IN / OUT RED FLAGS
Neoplasm
Spinal F
ractures
Cauda Equina
Spinal Infection
Ankylosing Spondylitis
‐Age > 50yrs*
‐Major T
rauma ‐Sad
dle anesthesia ‐Rece
nt feve
r an
d chills‐M
orning Stiffness
‐Previous hx
‐Stress Fx
‐Rece
nt onset
‐Rece
nt bac
terial ‐Awak
ening the 2
ndhalf of the
cance
r *
Athletes
bowel/bladder
infection
night
‐Unex
plained
Younger
dysfunction
‐Immunosuppression ‐Relie
f with exe
rcise and
weight loss
‐Compression Fx
‐Rap
idly
‐HxIV drug abuse
activity
‐Night Pain
‐Minor trau
ma to older worsen
ing LE
‐Age of onset<35
ys
‐No relief with ad
ult
neu
rologic deficit
‐Male
best rest
‐Distrac
ting painful injury
‐No relief lying down
‐Hxof co
rticosteroid use
2016 Jail Health Conference 1A/2A: “BACK 2 BASICS” ‐ Treating Chronic Low Back Pain in a Correctional Setting
REFERENCES Purdue. In the Face of Pain Fact Sheet.
2012http://www.inthefaceofpain.com/content/uploads/2012/05/factsheet_Back.pdf
Weinstein. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22;296(20):2451‐9
Jensen, M. Psychosocial Factors and Adjustment to Chronic Pain in Persons With Physical Disabilities: A Systematic Review. Arch Phys Med Rehabil. Jan 2011; 92(1): 146–160.
Delitto, T. Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther. 2012;42(4):A1‐A57.
Boos N et al,” 1995 Volvo Award in clinical science:: The diagnostic accuracy of MRI, work perception and psychosocial factors in identifying symptomatic disc herniations.” Spine‐1995; 20:2613‐2625
Moseley, L. Reconceptualising pain according to modern pain science. Physical therapy reviews 2007; 12: 169–178
Egan, B. LBP overview and guidelines. Temple University DPT. 2013
Fritz, J. Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. J Orthop Sports PhysTher2007;37(6):290‐302
O’Sullivan, P. It’s time for change with the management of non‐specific chronic low back pain. Br J Sports Med. 2011
Smart, K. Mechanisms‐based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitization in patients with low back (leg) pain. Manual Therapy 17 (2012) 336‐344
Woolf, C. Central sensitization: Implications for the diagnosis and treatment of pain. 2011 March; 152(3 Suppl): S2–15.
Wand, B. Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. Manual Therapy 16 (2011) 15‐20
Moseley L, Butler D. Explain Pain. 2013
Hunter Integrated Pain Service. 2011. Understanding Pain: What to do about it in less than five minutes? http://www.youtube.com/watch?v=4b8oB757DKc#t=25
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf. 2011
Egan, Bill LBP psychologically Informed management. Temple University DPT. 2013
Smart, K. Mechanisms‐based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitization in patients with low back (leg) pain. Manual Therapy 17 (2012) 336‐344
Woolf, C. Central sensitization: Implications for the diagnosis and treatment of pain. 2011 March; 152(3 Suppl): S2–15.
Wand, B. Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. Manual Therapy 16 (2011) 15‐20
Moseley L, Butler D. Explain Pain. 2013
Hunter Integrated Pain Service. 2011. Understanding Pain: What to do about it in less than five minutes? http://www.youtube.com/watch?v=4b8oB757DKc#t=25
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf. 2011
Egan, Bill. LBP psychologically Informed management. Temple University DPT. 2013
Hasenbring, M. Fear‐avoidance and Endurance‐related Responses to Pain: New Models of Behavior and Their Consequences for Clinical Practice. Clin J Pain 2010;26:747–753
Katz, J. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995 Sep;38(9):1236‐41
O’Sullivan P, Lin I. Acute Low Back Pain Therapies. PAIN MANAGEMENT TODAY 2014; 1(1): 8‐13
Ted Xtalks. Lorimer Moseley. 2011 http://www.youtube.com/watch?v=gwd‐wLdIHjs