2016 1a/2a: “back 2 basics” treating chronic low … jail health conference 1a/2a: “back 2...

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


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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


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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


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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


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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


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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


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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


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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


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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


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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