Download - Integrative Approach to Low Back Pain
-
Integrative Approach to Low Back PainWendy Kohatsu, MDDirector, Integrative Medicine FellowshipSanta Rosa Family Medicine Residency Program Sept 2011
-
Goals of this talk:Review key history elementsLearn how to do better hands-on back examFocus on practical & effective lifestyle therapiesNot overmedicalize LBP via diagnostic tests, drug therapies, surgical interventions. Later: myriad of mind-body therapiesTalk about something other than food for a change.
-
Low back pain70-84% of the population affected at some point in their lives14-50% of adults have LBP each yearCost of > $100 billion/ yearQuality of life impact of acute LBP60% unable to perform some daily activity 72% gave up exercising46% 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 Fishermans wharf, landing on tailbone. Currently works part-time at family business.On 800 mg ibuprofen. Took friends percocet. Flexeril does nothing.
-
Patient case #286 yo Vietnamese male, DM2, reluctant to see MD. Ambulates with 4-prong cane c/o LBP, radiating to back of legs, doesnt like to take medicine, uses analgesic balm ROS: urinary retention, feels more tired, recent weight loss.
-
History-taking
-
History-takingOnset/first episode?Occupational riskCo-morbiditiesActivity & exercise levelPsychosocial stress/ diagnosesOther?
-
3 main questions for LBP:Is systemic disease causing the pain?Is there social or psychological distress that may amplify or prolong the pain? 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 traumaFocal neurologic signs - incontinence, weakness, numbnessHx of cancerAge of first onset after 50 yearsHx of IVDAOsteoporosisSigns of systemic disease - fever, wt loss, lymphadenopathyACR Criteria - Low Back Pain, 2005
-
PerspectiveAmong all primary care patients with LBP, < 5% will have serious systemic pathology.97% will have LBP w/o radiculopathy60% Simple back pain37% Complex back pain w/o radiculopathy3% will have LBP with radiculopathySx of radiculopathy1% 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 imageMRI 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, lets examine our patients
-
2 1/2 -minute focused neuro exam Biewen PC Postgrad Med 106:102, 1999
PositionTest/featureFindingsAllObserveBehaviorStandingPosture & gaitToe / heel walkingAsymmetryPosture habitsL5 or S1 deficiency*ScoliosisSittingStraight leg raiseNeurologic testingRadicular painSensory defectSupineLeg lengthStraight leg raiseFaberes signMech contributionRadicular painHip involvementPronePalpationHip Extension 5-20Prone propMuscle dysfxnL2-4 radiculopathyFacet jt dysfxn
-
EXAM! - Anatomy Review(what med school never taught you)**Except Natasha, Trang, Sarah W & Hana C.OMT basic evaluation3 layer muscle palpationSkeletal 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 spasmLumbar rotationSI joint dysfxnPsoasPiriformis spasmMuscle imbalanceMyofascial syndrome!
-
Psoas located deep in abdomen, but major hip flexor.
Radiates to: Lumbar regionFront of hip
-
The Dirty Half-Dozen of Refractory LBP n = 183 untreatable pts with refractory LBP75% restored to normal activity after OMT*
Phys Med Rehab Clin NA 7:773, 1996
OMT diagnosisFrequencyTrunk-thigh imbalance100%Lumbar dysfxn88%Pubic dysfxn76%Short leg/pelvic tilt65%Posterior sacral base60%Innominate shear24%
-
Patient #1 - Exam52 yo woman with sciatica Exam: Wt 151, BMI 25.5, anxiousNeuro: 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 - Exam86 yo Vietnamese male with LBPVery stoic, pleasant, NADWt 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 Pyramidenvironmentrelationshipresources
-
Principle Based Treatment Pyramidresourcesenvironmentrelationship
-
Treatment OptionsInternal Environment
Lifestyle
CAM therapies
Drugs
-
Treatment OptionsInternal EnvironmentPain is a signal for changeJohn Sarno, MD ~ (TMS)Tension Myositis SyndromeLifestyle
CAM therapies
Drugs
-
Treatment OptionsInternal Environment
Lifestyle
CAM therapies
DrugsNSAIDsAnalgesicsMuscle relaxants
-
NSAIDsFor acute LBP Ibuprofen 400-600 mg up to qidNaproxen 220 -500 mg bid
Side effect and risks limit useCochrane Database NSAIDS for LBP, 2008ACP and Amer Pain Soc Guidelines 2007
-
AnalgesicsAcetaminophenUp to 2.6 grams/d as first line therapySide efx - hepatoxicityOpioidsSurprisingly little data One meta-analysis = not significantly reduce chronic low back painInadequate data re: functional improvement correlating to pain reliefReports of opioid abuse ~ 30-45% in LBPCMAJ 174:1589, 2006 Ann Intern Med 146:166, 2007Cochrane Database Syst Rev -Opioids for Chronic LBP, 2008FDA guidelines June 2009
-
Muscle relaxantsInsufficient evidence for chronic useCNS side effects - sedationCarisoprodol metabolized --> meprobamate, abuse and addiction potentialLimit to short-term use only in conjunction with analgesics
vanTulder et al. Spine 28:1978; 2003
-
Drug-Nutrient InteractionsNSAIDS deplete Folic Acid Synthesis of folic acid is competitively inhibited by NSAIDs
Rx: eat your leafy greens! (foliage)
-
Treatment OptionsInternal Environment
Lifestyle
CAM therapiesAcupunctureMassageChiropractic or osteopathic manipulation
Drugs
-
Acupuncture for LBPLike massage, data show acupuncture is moderately more effective than no treatmentShort-term outcomes > long-termMore likely to benefit those who expect more out of acupuncture. Cochrane Database Syst Rev - Acu for LBP, 2005Spine 26:1418, 2001
-
MassageAppears to be better for acute vs chronic back pain Studies inconclusive due to varying styles, practitioner skill, duration of treatment
-
ManipulationModerately superior to sham Rx, null therapiesBut equal to analgesics, exercises, back schoolMixed bag of techniques studied --Most studies on HVLA techniques used in chiropratic RxAnn Intern Med (meta-analysis)138:871 2003Ann Intern Med 138:989, 2003
-
Treatment OptionsInternal Environment
Lifestyle ExerciseStretching, strengthening, yogaStress management
CAM therapies
Drugs
-
Low Back Pain - Exercise Rx2005 Systematic Review43 trials of 72 exercise treatmentsImprovement seen esp. withHigh-dose exercise programsInterventions that included conventional careStretching and strengthening demonstrated the largest improvements. (vs passive treatments) Ann Intern Med 142(9): 776-85, 2005
-
Low back pain - Exercise RxBMJ study 1995 with moderately disabled pts.81 chronic LBP patients, referred from orthoControl home exercises + refd to back schoolIntervention above + 8 exercise classes/4 wksTwo hour sessionsWarm up, stretching15 systematic progressive exercisesLite aerobic activity and stretchingSignif. improvements in pain reduction, self-efficacy, and walking distance noted at 4 weeks, and 6 month f/uFrost, H, et al. 1995 BMJ 310(6973): 151-4.
-
Low back pain - Exercise RxStudy by Carpenter & Nelson, 60 pts considering neurosurgery10 week back-strengthening program Progressive resistance exerciseIsolated 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 therapyBest outcomes achieved when these 4 elements included:Individualized regimensStretchingStrengtheningSupervisionHayden, Van Tulder et al. Ann Int Med 142:776, 2005
-
Home exercise RxTennis ball* -- myofascial and erector spinae columnAbdominal strengtheningQuad strengtheningSpinal twistPiriformis stretchingHamstring stretching
-
Pelvic Clock TechniqueCreated and researched by Phil Greenman, DONo prior training requiredDx and Rx at same timePatient can do at home
-
Take home pointsAsk the 3 questions - are systemic dx, neurol red flags, or psychosocial fx present?DO THE EXAM!Focused neuro examMusculoskel examBe judicious when ordering imagingRx: Improve function, not just blunt painTeach exercise therapies, can tailor to individual patient
-
Strength trainingWhy?Muscle strength declines rapidly after 50 in sedentary people. REVERSIBLE! Increase bone densityImproves 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
-
**************** Focus on L5 and S1 nerve root signs b/c 98% of clinically signficant disc herniations occur here********Acute or ChronicStep or Stratefied**************************