Acute Back PainEvidence Based Approach

Scott Hardy, MD, MPH, FACOEMOccupational Medicine

UCI, December, 2015

Objectives• Present & discuss clinical cases demonstrating

evidence based guidelines for low back pain management-encountered in the clinics, wards and boards.

• Review differential diagnosis of this common but multifactorial complaint.

• Recognize Red flags-immediate work up.• Yellow flags for delayed recovery that

accompany the complaint of low back pain.

Objectives• Know historical and physical exam findings that suggest

additional imaging tests, laboratory evaluation and/or immediate specialty referral.

• Primary care physicians can play and essential role in managing symptoms & return to work and function.

• Evidenced based guidelines will enhance recovery & avoid iatrogenic expense.• Multidisciplinary approach.

BACK PAININITIAL EVALUATION

PRIMARY CARE--50%

ORTHOPEDIST--33%

DC, PAIN MGMT/OTHER-17%

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OEM Mission

Occupational and environmental medicine is the medical specialty devoted to prevention and management of occupational and environmental

injury, illness, and disability; and promotion of health and productivity of workers, their

families, and communities.

Epidemiology-Natural History• Lifetime incidence of Acute Low Back Pain is 60-90%

of the population annual incidence 5% of population.• 2nd to 5th chief complaint seeing primary care

specialists.• Natural history of acute low back pain favorable-90%

resolve within in 6-12 weeks.• Vs. Chronic low back pain-13 million physician visits

annually for-prevalence, disability & expense remain high.

• Back pain is the number one cause of disability in U.S. for people under 45 years.

Epidemiology• Epidemic of back pain in industrialized countries.• One of the most expensive medical conditions,

especially when work disability is considered. • 2005 expenditures to treat ~86 billion annually.• An ‘illness in search of a disease’…• Multiple synonyms-lumbar sprain/strain, lumbago,

regional back pain, musculoligamentous strain, sprain.

JAMA: 2008

Natural History

• LBP/musculoskeletal complaints are the second to fifth most common reason for outpatient primary care physician visits.

• Most resolve with conservative measures.• However, only 14% have LBP as long as 2 wks.• 1.5% present with sciatica.• 98% of clinically important disc herniations

occur at L4-5 (the L5 root) or L5-S1 (the S1 root).

Top 10 most common reasons for seeing the doctor were (14K patients).

• 1. Skin disorders, including cysts, acne and dermatitis.2. Joint disorders, including osteoarthritis.3. Back problems.4. Cholesterol problems.5. Upper respiratory conditions.6. Anxiety, bipolar disorder and depression.7. Chronic neurologic disorders.8. High blood pressure.9. Headaches and migraines.10. Diabetes.

• St. Sauver, JL. J. Mayo Clinic Proceedings. 2013. Vol 88, No 1, pp. 56-7.

Guidelines

• American College of Physicians and the American Pain Society formed the Clinical Annals of Internal Medicine (2007). Two primary principles.

• Most low back pain improves without intervention, and although the history and physical are the cornerstones of management

• Costly radiologic evaluation of patients with low back pain was still popular in 2007.

Multiple Guidelines-Literature Ratings• 1. Systemic Review-Meta Analysis• 2. Controlled Trial-RCT.• 3. Cohort Study-Prospective/Retro.• 4. Case Control Series.• 5. Unstructured Review.• 6. Nationally Recognized Guidelines (Guidelines.gov).• 7. State Treatment Guidelines.• 8. Other Treatment Guidelines.• 9. Textbook.• 10. Conference Proceedings.

ACOEM, ACP/APS, ODG, MTUS, Washington State, Cochrane…..

ACOEMAmerican College of Occupational & Environmental Medicine

• The Personal Physician’s Role in Helping Patient with Medical Conditions Stay at Work or Return to Work

http://www.acoem.org/Guidelines.aspx

Primary Differential

Detailed history & physical examination to determine:

1. The presence of red flags for urgent conditions-musculoskeletal vs. other etiologies.

2. Non-specific regional back pain-pain is typically axial in location that predicts favorable course.

3. Radiculopathy/other neuro related spine condition.

Case-Mr. J.M.• 58 year old landscaper presents with stiffness and

soreness in the low back one day after repetitive bending installing a company sprinkler system.

• Sharp pain, 8/10 with bilateral leg weakness. Complains of numbness in the groin region. No constitutional symptoms. N/V/F/C.

• PMH: BPH. Med-Tamsulosin, NKA.• PSH: Negative.• ROS: No hx of LBP, No recent fever, infection, weight

loss, cancer, fever, abdominal complaints.• Social: Ex smoker 5 pack-yrs., no EtOH, no other drugs.

Hobbies, soccer, motorcycle riding.15

Case-Mr. J.M.

• Exam: 5’9”, 195, 112/82, P-88, RR-14.• W/D fit appearing muscular male ambulates with

difficulty, slow guarded gait, prefers to stand.• HEENT, Heart, Lungs, WNL.• Abdomen-Soft flat, non-tender, without rebound

or bruit, no CVAT or hernia genitalia WNL.• Lumbar spine-flat lordosis, spasm, with L/S

junction TTP, and ROM limited to few degrees.• Neuro-Reduced touch, and sharp dull, bilaterally

L4-S1, global weakness, 4/5 multiple myotomes.

Case-Mr. J.M.

• Other exam findings?• Tests? • Radiographs?• Imaging?• Diagnosis?• Referral?

Large Central L5-S1 disc herniation.

Fraser, S, et. al. Arch Phys Med Rehabilitation. 2009 Nov;90(11):1964-8.

Cauda equina syndrome: a literature review of its definition and clinical presentation

Cauda Equina SyndromeFor a diagnosis of CES, one or more of the following must be present: (1) bladder and/or bowel dysfunction. (2) reduced sensation in the saddle area.(3) sexual dysfunction, with possible neurologic deficit

in the lower limb (motor/sensory loss, reflex change).

Red Flags• A focused medical history, work history and physical

exam.• Evaluation of underlying conditions, including

sources of referred symptoms in other parts of the body.

• Frequency, intensity and duration of complaints.• Aggravating an relieving factors.• History and Physical findings that raise suspicion for

serious underlying disorders= Red Flags

Anterior compression fractures may present with stiffness but no pain or tenderness of the spinous processes.

Red Flags-for back pain

• Age over 50.• Unexplained weight loss, history of cancer.• Persistent fever; recent bacterial infection.• History of intravenous drug use.• Immunocompromized.• Urinary or stool incontinence/urinary retention.• Trauma.• Neurologic deficit, weakness.

Red Flags

• Rule out “red flag” diagnoses, including diagnostic studies, for specialist referral:• o        Cauda Equina Syndrome (Schedule emergency

procedure)• o        Fracture, Compression fracture, Dislocation,

Wound• o        Cancer, Infection• o        Dissecting/Ruptured Aortic Aneurysm• o        Others (prostate problems,

endometriosis/gynecological disorders, urinary tract infections, & renal pathology)

Cancers metastatic to bone. mnemonic Lead Kettle: PB KTL

• Prostate-blastic sclerotic• Breast-mixed

• Kidney-lytic• Thyroid-lytic• Lung-lytic----------

• Women: 80% from lung and breast• Men: 80% from lung and prostate.• 20% in both sexes, kidney, thyroid, GI and others

Case Ms. T.W.• 48 year old female financial services secretary presents with

a three week history of bilateral low frequent back pain 6/10 without radiation. The cause of the pain is unknown but is worsened by prolonged sitting. She feels unable to do her walking program-requests MRI to “find out what is wrong”.

• PMH: Depression, r/o fibromyalgia per family physician-rheumatic work up negative.

• PSH: TAH-BSO 1 year ago. Bilateral CTS releases.• ROS: Negative for F/C, constitutional symptoms, head or

neck pain, -IBS, -chronic fatigue, +weight gain• Social Hx: Divorced, college grad, resides with two

teenagers, Ex. ½ ppd smoker x 8 yrs, 3 glasses of wine/week.

Case-Ms. T.W.• Exam: 5’4”, 212 lbs., 142/92, P-90, RR-16• Anxious woman, ambulatory without

encumbrance.• Lumbar exam: ROM with voluntary guarding on

flexion >30 degrees, extension, lateral bending WFL. TTP, diffusely over the thoracolumbar spine, SLR negative bilaterally.

• DTR’s 2+ throughout, sensation and motor testing WNL.

What are yellow flags?

What are yellow flags?• Risk factors for delayed functional recovery.• Multiple prior injuries, prolonged or multiple

absences, victim of abuse in the past, Smoking, EtOH abuse, FH of disability, depression, chemical dependency, stress, job dissatisfaction, adversarial relationship, severity of symptoms, delayed presentation, chronic pain symptoms, multiple diagnoses, prior CTS, multiple personal or occupational/personal injury back/neck claims, excessive physical medicine treatment, economic, legal factors, subjective> objective findings.

Pain• IASP “Unpleasant sensory and emotional experience

associated with actual or potential tissue damage”.• Need to address emotional component of pain fist…

then understand the actual or potential tissue damage.

• Pain is subjective…interacting with the limbic system with modulation of pain…many potential sources of potential pain in the low back…muscles, facets, discs, nerve impingement.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwic6rLw3-TJAhUS0mMKHckvAtcQjRwIBw&url=http://cn.cutcaster.com/photo/800943715-Doctor-thinking/&psig=AFQjCNESnaHuTAUrttnAM2vRV4C0yhOlaQ&ust=1450505357892755

Biopsychosocial Model

Biological

SocialPsychological

Clinical Management-Functional Recovery

• Detailed history-good investment of time initially.• Understand ADLs and workplace functions• Hands on physical examination. observation,

manual motor testing, detailed neuro exam, understand mechanism of injury.

• Written prescription for activity, rest. • Patient participation.• Patient alliance-request team approach.• Address concerns, discuss expectations.• Work status-compliance.

Yellow Flags-management• Multidisciplinary approach.• Consider cognitive behavioral therapy.• Avoid disability-explore barriers to work, written work

status, based on tolerated ADLs.• Physical/Occupational Therapy-to teach home program.• Ergonomic assessment/adjustment of work station.• Exercise prescription-walking, swimming, etc.• Consider TCA and/or SNRI, sleep hygiene.• Nurse case manager.• Employee assistance program.• Early follow up, limit detailed work up.

Common Back Pain Misconceptions

• I injured my disc lifting something heavy at work. That’s why my disc is bulging.

• My “degenerated” disc is causing my pain.• Because I have back pain, I should stay away from

work.• Back pain often leads to permanent impairment or

disability.• Because I have back pain, I will need permanently

modified work.

Common Back Pain Misconceptions

• I should rest until my back pain goes away.• My back pain means I have really

significant biological damage or disease.• X-rays, CT, and MRI can always identify

the cause of pain.• Back pain will usually be cured by medical

treatment.

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MRI Imaging• Although MRI is very sensitive, providing excellent view of soft

tissues and vertebrae.• Limitation is lack of specificity—false positives.• NEJM study of 98 asymptomatic individuals between 20 and 80

years (average 42.3).• 52% had a bulge at least one level.• 27% had a protrusion.• 1% had an extrusion.

• Jensen MC, et. Al, MRI of the Lumbar Spine in People without Back Pain, NEJM, 1994, Jul 14, 331(2): 69-73.

Back Pain & MRI

Several studies have shown that there is a poor correlation between MRI findings and patients’ low back symptoms.

1. Wittenberg et al., 19982. Savage et al., 1997

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Active Resumption of ADLs• Patients understandably have concerns and fears

about re-injury and will underestimate their abilities.

• Based on history and findings, prescribe a graded exercise program-with P.T. input.

• When ongoing subjective complaints exceed objective findings, a focus should move away from a focus on pain and instead focus on function.

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Daily Exercise Plan

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PRESCRIBE EXERCISE !!

Medication Management• APAP and non-selective NSAIDS Recommended

for acute low back pain as a first line to allow activity and functional restoration.

• Associated with NNT of 2-3 for a 50% reduction in pain.

• Muscle relaxants are an alternative.• Use opioids uncommonly in severe cases

presentations for short period-up to 2 weeks-in the acute phase only, with caveats.

• Chronic: TCA’s-yes; SSRIs-no SNRIs-unstudied.

Acupuncture• Acupuncture not recommended for acute low back pain.• Acupuncture has been found to be more effective than no

treatment for short-term pain relief in chronic low back pain, but the evidence for acute back pain does not support its use.

• Acupuncture is an accepted treatment in the California Worker’s Compensation system-many other states are adding this modality. (NY-starting pilot, Ilinois-No, OR-if referred by PTP, NV-yes, AZ-yes, PA-if deemed “medically necessary”).

• If successful treatment in past—trial indicated.• MediCare does not cover acupuncture.• Cochrane Review Database, 2000.

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Work Strong-UC Employees

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Work Strong• Flexible 12 week program following work

related injury, staffed by kinesiologists.• Stretching and Mobility• Fitness Training• Stress Reduction through Massage Therapy.• Cooking Classes, Yoga in some cases.

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Case-Mr. R.R.• 51 year old man, a plumber for a local

municipality.• MOI: Bending with a tool and twisting with a

sudden onset of acute right lower back pain, with weakness and dysesthesias his right leg radiation to his right great toe, and to a lessor degree toes 2, and 3.

• Complains of severe back pain 8/10 with difficulty walking due to pain. 50% of symptoms are in the low back, 50% in right leg.

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Mr. R.R.• PMH: Hypertension and hypothyroidism, otherwise

negative.• Prior Occ Hx: 1 back injury, ditch partial cave-in, 10 years

ago. Treated by personal physician, ibuprofen and physical therapy < one week TTD.

• PSH: negative.• Meds: levothyroxine, benazepril.• NKA• Social: Divorced, 2 adult daughters, never smoker, Ethanol-

occasional < 1drink/day, no other drugs. Hobbies/activities: Racquetball, 1 hour, 3 x week, daily walking.

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Case-Mr. R.R.• 5’10”, 244 lbs. muscular male, overweight.• Afebrile, 132/84, pules-78/min, RR-14.• Slow, guarded gait, flat lordosis, pelvis shifted,

+muscle spasm, bridging with arms.• Lumbar range limited to a few degrees in each plane-

flexion most difficult.• DTR’s 2 and symmetric at patellar & Achilles.• Light touch reduced on dorsum of foot/1st web with

10 gram monofilament-otherwise intact; 4/5 EHL on Right.SLR—marked pain bilaterally at 30 degrees.

• Thoughts? 59

Dermatomes and Myotomes

MUSCLE GRADATION DESCRIPTION

5-Normal 5-complete range of motion against gravity with full resistance

4-Good 4-complete range of motion against gravity with some resistance

3-Fair 3-complete range of motion against gravity

2-Poor 2-complete range of motion with gravity eliminated

1-Trace 1-reads evidence of slight contractility, no joint motion

0 (Zero) 0-no evidence of contractility

Mr. R.R. Follow up• Mr. RR received ketorolac (Toradol) 60 mg IM acutely, treated

with ice and heat and was off work for two days, with ice and heat, returning to modified work

• MRI revealed a 6 mm right sidedL4-5 HNP with L5 root contact.

• Referred for and active physical therapy program-initially for pain control and then mobility exercises-24 visits.

• Epidural injection considered, not needed.• Had lifestyle change-particularly with diet-achieved a 38

pound weigh loss.• Does regular core exercises, NSAID 1-2 times weekly.• AMA Guides to the Evaluation of Permanent Impairment-6%

whole person. Able to continue work as a plumbing supervisor with a 50 pound lifting limit x past 10 years.

• One flare since 2005 injury, minor right leg discomfort, with no lost time from work.

Case-Ms. W.J.

• 44 year old nurse Transferring patient on Neurosurgery ward-L.A. hospital. Severe initial axial LBP, unable to walk, with RLE severe dysesthesias.Neuro-reduced sensation lateral foot and absent Achilles reflex.

• Diagnosis?

Spondylolisthesis

Case-Ms. W.J.

• Grade 1-2 isthmic spondylolisthesis with severe impingement of right S1 nerve root.

• Went on to discectomy and anterior/posterior fusion due to instability, back and radicular pain.

• Vigorous active post op therapy, has returned to walking 7,500 steps daily.

• RTW 8 months following injury, now doing medical case management to avoid clinical nursing and heavy patient transfers.

Ms. W.J.Grade 1-2 Isthmic Spondylolisthesis

s/p discectomy and fusion

Conclusions• Internists and other primary care physicians will need

expertise in the E & M of acute back pain.

• Providers may have a positive impact on improving outcomes, reducing symptoms, and improving functional recovery.

• Excessive over-medicalization, and disability are not supported by the evidence in the majority of cases. These outcomes can be prevented with close attention to patient’s history, detailed exam, and multidisciplinary approach to management.

Conclusions• Less common red flag conditions will be

encountered by all of us-on boards & wards.• A high index of suspicion in red flag clinical

scenarios that are unusual is indicated, so as to proceed with prompt evaluation, selective diagnostic testing and referral in these cases.

• We can expect the unexpected and keep our eyes and ears open!

The End.