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**************************