from acute to chronic lbp - mcgill university · from acute to chronic lbp mohan radhakrishna, md,...
TRANSCRIPT
![Page 1: From Acute to Chronic LBP - McGill University · From Acute to Chronic LBP Mohan Radhakrishna, MD, FRCPC Physical Medicine and ... • To be able to identify the different management](https://reader030.vdocuments.us/reader030/viewer/2022011808/5ca0f23388c993ca178e0c89/html5/thumbnails/1.jpg)
From Acute to Chronic LBP
Mohan Radhakrishna, MD, FRCPC
Physical Medicine and Rehabilitation
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No disclosures
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Objectives
• To be able to name risk factors for developing chronic low back pain.
• To be able to identify the different management strategies required to treat chronic low back pain.
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Case
• A 45 year old customer service agent presents to
your office with a 1 week history of low back
pain.
This began the day after raking leaves at
home.
He has tried acetaminophen but remains symptomatic.
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Case
• 2.5 months after the back pain began it is
– “As bad as before”– “I’m scared of paralyzing”
– “Do I need an MRI?”
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When Acute Becomes Chronic
• Many acute LBP sufferers have no pain at 1 year
• Recurrence is common
• 20% of CSST patients make up 80% of the costs
• About 10% of acute LBP will have ongoing work disability at 1 year
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• Biological• Psychosocial
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Biological
• Non‐
modifiable: Age, gender, race
• Modifiable: Specific, treatable condition; muscle weakness,
inflexibility
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Biological
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Multiple Populations
• Experimental volunteers
• Phantom pain
• Chronic lumbar radicular pain
• Chronic post‐operative radicular pain
• Post‐mastectomy pain
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Behaviours and beliefs that individually constitute proven or presumed risk factors for chronicity of LBP
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Cardinal Yellow Flags
• Work –related
• Beliefs• Behaviours• Affective
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Work
• All pain must be abolished before RTW
• Expectations of pain with RTW
• Fear of
pain
with RTW
• Belief that work is harmful
• Poor work history• Unsupportive work environment
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Beliefs
• Pain= harm• Catastrophizing• Pain is uncontrollable• Misinterpreting body signals
• Expectation of high‐tech fix
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Affective
• Depression• Lack of self‐worth• Irritability/Anxiety• Disinterest in social activity• Partner overly protective or
punitive
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Behaviours
• Passivity• Extended rest• Reduced activity/ADL• Impaired sleep
• Alcohol/drug abuse
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Chou and Shekelle, JAMA 2010
• Evaluated 20 studies and almost 11000 patients
• Likelihood ratios for findings obtained in the clinical
evaluation were calculated
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Individual Risk Factors
• Non‐organic signs• Smoking
• Maladaptive coping
• Demographics
• Baseline pain• Baseline functional
impairment
• Psychiatric co‐ morbidities
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Individual Risk Factors
• Non‐organic signs• Smoking
• Maladaptive coping
• Demographics
• Baseline pain• Baseline functional
impairment
• Psychiatric co‐ morbidities
• 3.0• 1.2• 2.5• 1• 1.3• 2.1
• 2.2
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Signs and Symptoms
Intensity of Pain 1.3
Intensity of Fear Avoidance
2.5
Leg pain 1.4
Non‐organic signs 3
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General Health
Health Status overall low 1.8
Psychiatric co‐morbidities 2.2
Prior episodes of back pain 1.1
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Work Issues
Compensation 1.4
Less job satisfaction 1.5
Higher physical demands 1.4
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Acute versus Chronic Low Back Pain:
How does treatment differ?
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Past experience,
beliefs, context
Mixed messages
Deconditioning
Referral
Chronic pain disability
The long and winding road to chronic pain disability
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Acute• Pain reduction• Reassurance• Discussion of natural
history
Chronic• Pain management
• Focus on function: the barometer
• Self‐management
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Case
• Active therapy• Sleep• Stress• Consistent message
• Challenge assumptions!
• One pair of hands on the steering wheel!
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Summary
• People who develop chronic disabling pain are not the same as those who don’t.
• There are risk factors which have been identified
• Usually the patient will mention many of these risk factors spontaneously.
• Recognize, Reassure and Redirect