Johnson et al, 2007 Spine (in press)

Back PainBack Pain2nd most common cause for office

visit60-80% of population will have

lower back pain at some time in their lives

Each year, 15-20% will have back pain

Most common cause of disability for persons < 45 years

Oh My Aching BackOh My Aching BackTreatment Options for Back Treatment Options for Back

PainPain

SciaticaSciatica

OutlineOutlinePart 1:

– Introduction– Review of anatomy

Part 2:– Acute low back pain

Part 3:– Chronic low back pain– Prevention

Questions ??

Low Back PainLow Back Pain

“One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.

- AnatomyLesson #1

- AnatomyLesson #2

Introduction to Madam “X”Introduction to Madam “X”

Madam “X” has had lower back pain for the past 24 hours that she feels is related to household work that she did over the weekend. She missed work today, Monday.

She wants to know what can be done for his back pain?

What should Madam “X” What should Madam “X” expect from her health care expect from her health care

professional?professional?

1. Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain.

2. Provide information, advice, and a plan of action.

% of Back Pain due to % of Back Pain due to Herniated Disk?Herniated Disk?

1. 4%

2. 14%

3. 40%

4. None of the above

Causes of Low Back PainCauses of Low Back Pain

Lumbar “strain” or “sprain” – 70%Degenerative changes – 10%Herniated disk – 4%Osteoporosis compression fractures

– 4%Spinal stenosis – 3%Spondylolisthesis – 2%

Causes of Low Back Pain…Causes of Low Back Pain…

Spondylolysis, discogenic low back pain or other instability – 2%

Traumatic fracture - <1%Congenital disease - <1%Cancer – 0.7%Inflammatory arthritis – 0.3%Infections – 0.01%

Risk factors Prognostic factors

Physical Age 35-55

Previous history of LBP

Possibly genetic factors?

Older age

Initial high intensity pain

Referred pain to LEX

Restriction in two + segments

Delay in treatment

Occupational Frequent bending

Frequent lifting

Unusual sitting posture?

Increase work tempo

Increase quantity of work

Work relations

Unavailability of light duties

Frequent lifting

Psychological Low job satisfaction

Low social support

Cognition

Fear avoidance

Depression

Anxiety

Distress

Sexual & physical abuse

Physical distress

Somatisation

Catastrophising

Etiology of back Etiology of back painpain

Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53

Sitting condition Risk factor CS implications

Normal prolong sitting

no Non

Core tensing irrelevant

Unusual sitting posture

Yes Advice on posture.

Core tensing irrelevant

Sitting + whole body vibration

Yes Advice on occupation

Core tensing irrelevant

CLBP + sitting May exacerbate existing LBP

Avoid prolong sitting

Encourage a dynamic working patterns

Core tensing irrelevant

CS in relationship to biomechanical factors: sittingCS in relationship to biomechanical factors: sitting

Red FlagsRed Flags

History of cancerUnexplained weight

lossIntravenous drug

useProlonged use of

corticosteroidsOlder age

Major TraumaOsteoporosisFeverBack pain at rest

or at nightBowel or bladder

dysfunction

MedicationsMedicationsAnti-inflammatory medications (NSAID’s):

– Beneficial; no differences; watch side-effects

Tylenol:Narcotic Pain Relievers:

– No more effective than NSAID’s– Many side effects

Muscle Relaxants (ie. Flexeril®):– Can decrease pain and improve mobility– 70% with drowsiness/dizziness

Chiropractic/OsteopathicChiropractic/Osteopathic

Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek)

Spinal manipulationConflicting evidence on the effects of spinal

manipulation– ~75-90% improvement anyway within 4 weeks

Greater patient satisfaction

Exercise & Bed RestExercise & Bed RestAdvice to stay active:

– ‘There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’

– Hurt does not equal harmOne or two days of bed rest if necessaryLight activity, avoiding heavy lifting,

bending or twisting (i.e. walking)No data on any particular exercises

Massage & Physical TherapyMassage & Physical Therapy

Might be beneficialMore quality research is neededDifferent types of massage

AcupunctureAcupuncture

Very little quality research and dataSeems to indicate that acupuncture is not

effective for the treatment of back pain

Other ModalitiesOther Modalities

Back Brace/Corset/Lumbar Support:Traction:Injections: Inconclusive evidenceHot/Cold:Ultrasound:

Madam “X”, again…Madam “X”, again…

Now, Madam “X” has not had improvement in her lower back pain and 6 weeks have gone by since the initial painful event.

What types of therapies might be beneficial for Madam “X” now?

Role of X-rays (Radiology)Role of X-rays (Radiology)

Usually unnecessary and not helpfulPlain X-ray:

– Age>50 years– No improvement after 6 weeks– Other worrisome findings

MRI:– After 6 weeks if have sciatica

New England Journal of Medicine (February 2001)

MedicationsMedications

Similar to acute pain….Antidepressant medications can

improve pain relief

ExercisesExercises

Improves pain and functionMany programs available, but difficult to

make any scientific recommendations for one type versus another

SciaticaSciatica

SciaticaSciatica• Sleep in semi-fetal position

with a pillow between the knees

InjectionsInjections

Epidural injections:– Insufficient and conflicting evidence

Facet joint injections:– No improvement

Local/Trigger point injections:– Possibly some benefit

SurgerySurgery

Discectomy improves pain in short term but not long term (i.e. 10 years)

Microdiskectomy similar to standard diskectomy

Automated percutaneous diskectomy and laser discectomy both less effective

? Arthroscopic discectomy

Other ModalitiesOther Modalities

Back Schools: - possibly effectiveMultidisciplinary Therapy: - probably

yesSpinal manipulation: - conflicting dataMassage: - probably yesIDET:

Intradiscal Electrothermal TherapyIntradiscal Electrothermal Therapy

IDETIDET

No convincing evidence that shows the short or long-term clinical efficacy of this procedure.

Safe with few adverse effects? Long-term effectsWall Street Journal (Feb. 11, 2003)

PreventionPrevention

Exercise:–Aerobic, back/leg strengthening

Back braces and education about proper lifting techniques are ineffective

? weight loss and smoking cessation

Web ResourcesWeb Resources

www.mayo.eduwww.cochraneconsumer.com (“Helping

people make well-informed decisions about health care.”)

www.library.ucsf.edu