integrative approach to low back pain wendy kohatsu, md director, integrative medicine fellowship...

Integrative Approach to Low Back Pain

Wendy Kohatsu, MDDirector, Integrative Medicine Fellowship

Santa Rosa Family Medicine

Residency Program

Sept 2011

Goals of this talk:

• Review key history elements

• Learn how to do better hands-on back exam

• Focus on practical & effective lifestyle therapies

• Not ‘overmedicalize” LBP via diagnostic tests, drug therapies, surgical interventions.

• Later: myriad of mind-body therapies

• Talk about something other than food for a change….

Low back pain

• 70-84% of the population affected at some point in their lives

• 14-50% of adults have LBP each year• Cost of > $100 billion/ year• Quality of life impact of acute LBP

– 60% unable to perform some daily activity – 72% gave up exercising– 46% gave up sex

Spine 12:264,1987Amer Acad Ortho Surg, 2006Ann Rheum Dis 57:13, 1998

Posture

Patient case #1:

52 yo female, cc: “sciatica” bilateral numbness hip to knees, since 1999. h/o prior LBP.

•30 years ago fell down flight of stairs at Fisherman’s wharf, landing on tailbone. •Currently works part-time at family business.•On 800 mg ibuprofen. Took friend’s percocet. Flexeril does “nothing”.

Patient case #2

• 86 yo Vietnamese male, DM2, reluctant to see MD.

• Ambulates with 4-prong cane • c/o LBP, radiating to back of legs,

doesn’t like to take medicine, uses analgesic balm

• ROS: urinary retention, feels more tired, recent weight loss.

History-taking

History-taking

• Onset/first episode?

• Occupational risk

• Co-morbidities

• Activity & exercise level

• Psychosocial stress/ diagnoses

• Other?

3 main questions for LBP:

1. Is systemic disease causing the pain?2. Is there social or psychological

distress that may amplify or prolong the pain?

3. Is there neurologic compromise that may require surgical evaluation?

Deyo & Weinstein NEJM 344:363, 2001

“Red flags”

ACR Criteria - Low Back Pain, 2005

“Red flags” • Hx of trauma• Focal neurologic signs - incontinence,

weakness, numbness• Hx of cancer• Age of first onset after 50 years• Hx of IVDA• Osteoporosis• Signs of systemic disease - fever, wt loss,

lymphadenopathy

ACR Criteria - Low Back Pain, 2005

Perspective

• Among all primary care patients with LBP,

< 5% will have serious systemic pathology.• 97% will have LBP w/o radiculopathy

– 60% Simple back pain– 37% Complex back pain w/o radiculopathy

• 3% will have LBP with radiculopathy– Sx of radiculopathy– 1% with acute neuro sx – loss of bladder fxn,

saddle anesthesia, motor weakness

N Engl J Med. 2001;344(5):363Up To Date –June 2011

To image or not to image…• MRI evaluation to provide

reassurance for chronic LBP does NOT lead to better prognosis.

• Psychosocial variables are stronger predictors of long-term disability than anatomic findings found on imaging

studies.• Radicular sx > 4-6 weeks,

severe enough to consider

surgery.Ann Intern Med. 2007;147(7):478.JAMA. 2010;303(13):1295.

So, let’s examine our patients…

2 1/2 -minute focused neuro exam Position Test/feature Findings

All Observe Behavior

Standing •Posture & gait•Toe / heel walking•Asymmetry

•Posture habits•L5 or S1 deficiency*•Scoliosis

Sitting •Straight leg raise•Neurologic testing

•Radicular pain•Sensory defect

Supine •Leg length•Straight leg raise•Fabere’s sign

•Mech contribution

•Radicular pain•Hip involvement

Prone •Palpation•Hip Extension 5-20•Prone prop

•Muscle dysfxn•L2-4 radiculopathy•Facet jt dysfxn

Biewen PC Postgrad Med 106:102, 1999

EXAM! - Anatomy Review(what med school never taught you…)*

• *Except Natasha, Trang, Sarah W & Hana C.

• OMT basic evaluation• 3 layer muscle palpation• Skeletal survey -- L-spine, pelvic girdle,

lower extremities (joint above/below)• Common culprits: Erector spinae

spasm, Lumbar rotation, SI joint dysfxn, psoas, piriformis spasm, muscle imbalance, myofascial syndrome!

OMT Common Culprits:

• Erector spinae spasm

• Lumbar rotation

• SI joint dysfxn

• Psoas

• Piriformis spasm

• Muscle imbalance

• Myofascial syndrome!

Psoas located deep in abdomen, but major hip flexor.

Radiates to: -Lumbar region-Front of hip

The “Dirty Half-Dozen” of Refractory LBP

OMT diagnosis FrequencyTrunk-thigh imbalance 100%Lumbar dysfxn 88%Pubic dysfxn 76%Short leg/pelvic tilt 65%Posterior sacral base 60%Innominate shear 24%

n = 183 ‘untreatable’ pts with refractory LBP75% restored to normal activity after OMT*

Phys Med Rehab Clin NA 7:773, 1996

Patient #1 - Exam• 52 yo woman with sciatica • Exam: Wt 151, BMI 25.5, anxious• Neuro: 4+/5 left hip flexion, knee extension.

Preserved gait and balance walking in hallway.

• MSK: level iliac crest heights, ++ 4 cm left posterior hip rotation, ++ right sacral torsion, L > R SI join tenderness, LEFT glut max,min + piriformis spasm.

• Imaging: NONE.

Patient # 2 - Exam

86 yo Vietnamese male with LBP

•Very stoic, pleasant, NAD

•Wt 111 (down from 129 lbs 4 mos prior)

•Thin frame, + increased thoracic kyphosis, tight lumbar paraspinal muscles.

•Rectal: Enlarged prostate.

Posture

What next?

Principle Based Treatment Pyramid

environment

relationship

resources

Principle Based Treatment Pyramid

resourcesenvironment

relationship

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies

• Drugs

Treatment Options

• “Internal Environment”– Pain is a signal for change

– John Sarno, MD ~ (TMS)Tension Myositis Syndrome

• Lifestyle

• CAM therapies

• Drugs

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies

• Drugs– NSAIDs– Analgesics– Muscle relaxants

NSAIDs

• For acute LBP – Ibuprofen 400-600 mg up to qid– Naproxen 220 -500 mg bid

• Side effect and risks limit use

Cochrane Database NSAIDS for LBP, 2008ACP and Amer Pain Soc Guidelines 2007

Analgesics• Acetaminophen

– Up to 2.6 grams/d as first line therapy– Side efx - hepatoxicity

• Opioids– Surprisingly little data

• One meta-analysis = not significantly reduce chronic low back pain

– Inadequate data re: functional improvement correlating to pain relief

– Reports of opioid abuse ~ 30-45% in LBP

CMAJ 174:1589, 2006 Ann Intern Med 146:166, 2007Cochrane Database Syst Rev -Opioids for Chronic LBP, 2008FDA guidelines June 2009

Muscle relaxants

• “Insufficient evidence” for chronic use• CNS side effects - sedation• Carisoprodol metabolized --> meprobamate,

abuse and addiction potential

• Limit to short-term use only in conjunction with analgesics

vanTulder et al. Spine 28:1978; 2003

Drug-Nutrient Interactions

• NSAIDS deplete…

•Folic Acid -Synthesis of folic acid is competitively inhibited by NSAIDs

-Rx: eat your leafy greens! (“foliage”)

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies– Acupuncture– Massage– Chiropractic or osteopathic manipulation

• Drugs

Acupuncture for LBP

• Like massage, data show acupuncture is moderately more effective than no treatment

• Short-term outcomes > long-term

• More likely to benefit those who expect more out of acupuncture.

Cochrane Database Syst Rev - Acu for LBP, 2005Spine 26:1418, 2001

Massage

• Appears to be better for acute vs chronic back pain

• Studies inconclusive due to varying styles, practitioner skill, duration of treatment

Manipulation

• “Moderately superior” to sham Rx, null therapies

• But equal to analgesics, exercises, back school

• Mixed bag of techniques studied --Most studies on HVLA techniques used in chiropratic Rx

Ann Intern Med (meta-analysis)138:871 2003Ann Intern Med 138:989, 2003

Treatment Options

• “Internal Environment”

• Lifestyle – Exercise

• Stretching, strengthening, yoga

– Stress management

• CAM therapies

• Drugs

Low Back Pain - Exercise Rx

• 2005 Systematic Review– 43 trials of 72 exercise treatments– Improvement seen esp. with

• High-dose exercise programs• Interventions that included conventional care• Stretching and strengthening demonstrated the

largest improvements. (vs passive treatments)

Ann Intern Med 142(9): 776-85, 2005

Low back pain - Exercise Rx

• BMJ study 1995 with “moderately disabled” pts.– 81 chronic LBP patients, referred from ortho

• Control – home exercises + ref’d to back school

• Intervention – above + 8 exercise classes/4 wks– Two hour sessions

• Warm up, stretching• 15 systematic progressive exercises

• Lite aerobic activity and stretching

• Signif. improvements in pain reduction, self-efficacy, and walking distance noted at 4 weeks, and 6 month f/u

Frost, H, et al. 1995 BMJ 310(6973): 151-4.

Low back pain - Exercise Rx

• Study by Carpenter & Nelson, 60 pts considering neurosurgery– 10 week back-strengthening program

• Progressive resistance exercise• Isolated lumbar extensions (with pelvis neutral)• One set of 8-15 reps to volitional fatigue

1x/week

– 57/60 pain-free, no longer needed surgery!

Med Sci Sports Exerc 1999 31(1): 18-24.

Best outcomes for exercise therapy

Best outcomes achieved when these 4 elements included:

• Individualized regimens

• Stretching

• Strengthening

• Supervision

Hayden, Van Tulder et al. Ann Int Med 142:776, 2005

Home exercise Rx

• Tennis ball* -- myofascial and erector spinae column

• Abdominal strengthening

• Quad strengthening

• Spinal twist

• Piriformis stretching

• Hamstring stretching

Pelvic Clock Technique

• Created and researched by Phil Greenman, DO

• No prior training required• Dx and Rx at same time• Patient can do at home

Take home points

• Ask the 3 questions - are systemic dx, neurol red flags, or psychosocial fx present?

• DO THE EXAM!– Focused neuro exam– Musculoskel exam– Be judicious when ordering imaging

• Rx: Improve function, not just blunt pain• Teach exercise therapies, can tailor to

individual patient

Strength training

• Why?– Muscle strength declines rapidly after 50 in

sedentary people. REVERSIBLE! – Increase bone density– Improves strength & ability to perform aerobic

exercise.– INCREASE BASAL METABOLIC RATE (BMR) by

increasing lean body mass.

Life, J. CAM Secrets (2002)

“Core Four” Weight Training Program – Hewitt 2002