low back pain
TRANSCRIPT
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Low Back Pain Syndrome and Associated Conditions
Developed for OUCOM CORE by Craig Warren, D.O.
Edited by Mindy Ford, D.O. and the
CORE Osteopathic Principles and Practices Committee
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Low Back Pain
• Annual US prevalence is 15-20%• 2nd most common symptomatic reason for visits
to primary care physicians.• 90% of all episodes will resolve within 6 weeks
regardless of treatment• 90% of all persons disabled for more than 1 year
will never work again without intense intervention
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Low Back Pain
• Most common cause of disability in people younger than 45.
• 1% of U.S. population is chronically disabled due to back problems.
• 1% of U.S. population is temporarily disabled due to back problems.
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Definitions
• Acute LBP: Back pain <6 weeks duration• Subacute LBP: back pain >6 weeks but <3
months duration• Chronic LBP: Back pain disabling the patient
from some life activity >3 months• Recurrent LBP: Acute LBP in a patient who has
had previous episodes of LBP from a similar location, with asymptomatic intervening intervals
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Origins of Low Back Pain
• Referred pain from visceral disease
• Non-activity related:– Inflammation
• Infectious/rheumatic
– Osseous– Acquired defects– Intra-spinal lesions– Metabolic disorders
• Activity related spinal disorders:– Disco dural or disco
radicular – Capsuloligamentous – Stenotic
• Non-organic causes
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Initial Assessment
• Focused HxCC, PMHx, FMHx, PE• Be aware of Red Flags
– Findings that suggest a serious underlying pathology
– Refer to chart on next slide• In absence of Red Flags, imaging studies and
further testing not helpful in first 4 weeks.
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Cauda Equina
Fracture Cancer Infection
Progressive neuro deficit X
Recent bowel or bladder dysfunction
X
Traumatic Injury X
Steroid use history X X
Women age > 50 X
Men age >50 X
Male with osteoporosis X X
Cancer history X
Diabetes Mellitus X
Insidious onset X X
No relief at bedtime or worsens when supine
X X
Constitutional Symptoms X X
Hx UTI/other infection X
IV Drug Use X
HIV X
Immune suppression X
Previous surgery X
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Differential Diagnoses
• Aortic Aneurysm• Tumors/cancer• Bony metastasis• Vertebral Osteomyelitis • Epidural abscess• Neurofibromatosis• Pelvic pathology• Abdominal pathology • Herniated disc
• Compression fracture • Rheumatoid arthritis• Degenerative joint
Disease • Osteoarthritis• Ankylosing spondylitis• Cauda equina syndrome• UTI • Strain/ sprain
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Viscerosomatic Considerations
• 10% Medical Cause– UTI/Cystitis/
Nephrolithiasis– Prostatitis– Endometriosis– Dysmenorrhea– Primary cancer
metastatic to bone– Aneurysm
• 90% Musculoskeletal Cause– Somatic
Dysfunction– Postural
Decompensation
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Symptoms of Benign LBP
• Dull and achy quality• Diffuse aching with
associated muscle tenderness
• Exacerbated with movement
• Relieved with rest in recumbent position
• No radiation, paresthesias
• No dermatomal pattern
• Pt. is able to find a position of comfort
• DTR are within normal limits
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
General Considerations
• The history is of vital importance.
• Go slowly, be patient. Listen to the patient.
• Goal is to ascertain the cause for low back pain.
• Somatic dysfunction is not a cause for low back pain.
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Important aspects of the history
• Age of patient• Daily activities• Symptoms:
– Pain, paresthesia, radiation, weakness– Influence of posture/activity– Bowel/bladder incontinence– Saddle anesthesia– ROS, including constitutional, possibly
gastrointestinal, gynecologic
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Pain History
• Localization:– Where does it hurt? central, unilateral, bilateral– Does the pain go anywhere? upper lumbar, lower
lumbar, gluteal, perineal, legs
• Onset:– When did the pain start? days, weeks, months, years– How did the pain start? suddenly, gradually
• Severity:– 0-10 Scale: Current? Average? Worst?
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Pain History
• Evolution: – How has the pain changed over time?
• Relationship to activity:– What postures or movements worsen the
pain?– Does it hurt to cough or sneeze?– Does the pain wake you at night?– What makes the pain better?
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Osteopathic Exam
• General Impression
• Is there a problem?– What
regions exhibit a problem?
• Diagnostic Characteristics
• What―What are the
specific characteristics of the identified segment(s)?
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Screening
• Appropriate screening includes the following the regions– Thoracic– Lumbar– Sacral– Pelvic– Lower extremities
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Physical Exam
• Standing:– Inspection– Range of motion
• Flexion• Extension• Sidebending
– Toe raise– One legged Extension
• Inspection: for deviation, scoliosis, muscle wasting. Skin/hair changes
• ROM: range, pain, deviation, painful arc.
• Toe raise: neurological testing, motor, S1/2
• One leg extension: loading of pars interarticularis
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Physical Exam
• Supine– Muscle strength– Sensory testing– Plantar reflex– Sacroiliac joint
• distraction– Hip joint
• ROM– Dural tension signs
• SLR– Sacroiliac screening– Hip screening– Dural tension signs L4-S2
• Seated– Neurological
• Patellar Reflex• Achilles reflex• Muscle strength
– Neurological testing• DTR L4• Motor L2-S2• Sensory L2-S2• Babinski
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Physical Exam
• Prone– Dural tension signs
• Femoral stretch
– Palpation
• Spinous processes
• Interspinous ligaments
• Iliolumbar ligaments
• Sacroiliac ligaments
• Neurological testing– DTR S1/2– Motor L2/3, S1/2
• Dural tension signs L3 nerve root
• Palpation: of osseous and ligamentous structures.
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
LBP – Osteopathic Considerations
• What will be your highest yield regions?– How does previous trauma influence these regions?
• Which 1 or 2 of the aspects below has the greatest influence on the patient complaint?– Pain– Hyper-sympathetic influence– Parasympathetic influence– Fluid Congestion
• Devise a focused examination based on the patient’s complaint– What are your expected findings?– Your expected palpatory findings (TART/STAR) ?– What are the acute or chronic aspects?
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
LBP – Osteopathic Considerations
• Propose an appropriate differential diagnosis
• Devise an appropriate treatment plan based on musculoskeletal components involved in the patient complaint– What are the dose and frequency considerations?– What are the OP – IP – ER considerations?
• Devise an appropriate manipulative approach or technique w/indications and contraindications– How are you going to talk to your patient about their complaint?– How will you communicate your findings, diagnosis, and
treatment to your preceptor?
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Treatment Sequence
• Leg restrictors
• Pubes
• Superior innominate Upslip (shear)
• Lumbar Spine
• Sacrum
• Innominate
• Iliopsoas
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Sequence Rationale
• Leg restrictor muscle problems will affect the bony attachments of the innominate, sacrum, and pelvis
• Treatment of the innominate, sacrum or pelvis will not be as effective without treating leg muscles first
• Articular dysfunction will return more rapidly if muscular problem not resolved during treatment
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Treatment Techniques
• Techniques that could be used include:– Direct techniques:
• HVLA• Muscle Energy• Articulatory
– Indirect techniques:• Strain Counterstrain• Functional Methods
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Muscle Energy Techniques
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
MET – Lumbar – FRLSL
Seated Technique
• Patient seated:– left hand holding right shoulder– Pt’s right arm dropped at the side
• Operator:– straddles pt’s left knee & left hand grasping
the pt’s right shoulder– Control the pt’s left shoulder with the left axilla– Right middle finger monitors the L4-5
interspinous space– Right index finger monitors the left transverse
process of L4
• Localization: Trunk Translation Anterior to Posterior to introduce L4-5 Flexion
Greenman, English 2nd ed., p.282
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
MET – Lumbar – FRLSL
Seated Technique
• Pt cooperation: Ask the pt to reach for the floor to help introduce right sidebending & rotation
Greenman, English 2nd ed., p.282-3
• Pt side bends left against operator resistance• Isometric contraction, relax, reposition, repeat until sidebending & rotation resolution
• Forward bend the pt (to fully open zygapophysial joints) while maintaining right rotation• Pt attempts extension
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
MET – Lumbar – FRLSL
Lateral Recumbant Technique
Fine tune extension by moving shoulders posterior to feather edge of L4 movement
Fine tune extension from below via the lower extremities
Maintain shoulders perpendicular to table for right sidebending
Fine tune extension by moving shoulders posterior to feather edge of L4 movement
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
MET – Lumbar – FRLSL
Lateral Recumbant Technique
• Pt reaches behind under guidance to grasp side of table; this enhances right rotation & sidebending
• LE abduction enhances R SB from below & sets pt up for ME effort – adduction• Repeat
• Left hand cephalad translation to barrier; (for right sidebending)• Right elbow resists pt attempt to turn left• Repeat
Greenman, English 2nd ed.,p.292
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Neutral Technique Slide
Notice the physician’s right arm under the pt’s right axilla – allows easy sidebending left.
Neutral SRRL
Physician’s Left Thumb palpates the posterior transverse process.
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
• Side bend pt. left using easy control via the right axilla
• Rotate right by gently carrying the right shoulder backward
• Isometric force 3-5 seconds, reposition, repeat
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
Let’s discuss and practice other
techniques
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CORE OMM Curriculum
for Students, Interns, & Residents ©2006
References
• Ward, R.C., Foundations for Osteopathic Medicine, 1997, Williams and Wilkins, Baltimore, MD: 337-345, 591-592, 583.
• Acute Low Back Pain, MCARE Guidelines, 2005, http://mcare.org/media/pdf_autogen/cpg_lowbackpain_mcare05.pdf