6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.

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1 High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty Certification in Pain Medicine Physiatry Consultant U.C. Berkeley Sports Medicine Low back pain is 5 th most common reason for all physician office visits in the U.S. Second most common symptomatic reason next to headache Only 25-20% of people who experience low back pain will seek medical care Americans spend at least $50 billion each year on low back pain. Low back pain is the most common cause of job-related disability and a leading contributor to missed work Represents up to 25% of lost work days The majority of people with low back pain improve without a physician interaction 30-60% of people recover within one week 60-90% of people recover in six weeks 95% of people recover in 12 weeks 1

2 Up to 75% of patients with an episode of low back pain will have a recurrence of low back pain during one year follow-up 5% of patients develop chronic disabling low back pain Increasing age Greatest incidence in year old individuals Heavy physical work Long periods of static postures Heavy lifting Twisting Vibration Psychosocial factors Work dissatisfaction Depression Obesity Smoking Severe scoliosis Drug abuse History of headaches Anthropometric status (height and body build) Posture Leg-length differences State of physical fitness 2

3 Determine etiology Formulate treatment plan Important to identify patients who require immediate surgical evaluation and those whose symptoms suggest a more serious underlying condition such as malignancy or infection. Mechanical low back pain (97%) Lumbar strain or sprain (> 70%) Degenerative disc or facet process (10%) Herniated disc (4%) Osteoporotic compression fracture (4%) Spinal stenosis (3%) Spondylolisthesis (2%) Nonmechanical spine conditions (1%) Neoplasia (0.7%) Inflammatory arthritis (0.3%) Infection (0.01%) Taken from Kincade 2007 Nonspinal/visceral disease (2%) Pelvic organs - prostatitis, endometriosis, & pelvic inflammatory disease Renal organs nephrolithiasis, pyelonephritis Aortic aneurysm Gastrointestinal system pancreatitis, cholecystitis, peptic ulcer Shingles History Physical Exam Treatment Related Factors Taken from Kincade

4 Onset Location Duration Severity Time of day Associated symptoms Triggers aggravating factors Motor symptoms. Sensory disturbances Bladder and Bowel disturbances Recent major injury or trauma Radiation of pain down a leg Pain that is constant Unexplained fever or weight loss Pain that increases at night Subjective pain rating score verbal rating scale (VRS) visual analogue scale (VAS), Assessment of prior treatment and response Employment status Evaluate for "red flags" Conditions requiring more prompt intervention Evaluate for yellow flags factors that may predict poor response and/or chronicity Stratification of acute low back pain patients into appropriate treatment groups nonspecific low back pain back pain related to lumbar radiculopathy and/or spinal stenosis; low back pain related to other causes Appropriateness for injections Appropriateness for cognitive behavioral therapy Appropriateness for surgery 4

5 Focused spine-related physical exam: spine range of motion, motor strength muscle stretch reflexes dural tension testing Motor and sensory exam sacroiliac joint maneuvers A directional preference which plane of movement improves or exacerbates symptoms Age > 50 Fever, chills, recent urinary tract or skin infection Significant trauma Unrelenting night pain or pain at rest Progressive motor or sensory deficit Unexplained weight loss History of cancer History of osteoporosis Chronic oral steroid use IV drug use Failure to improve after 6 weeks of conservative therapy. Age over 50 years old History of Cancer Unexplained weight loss No progress with conservative therapy Vague, general presentation of symptoms Constant pain not affected with position or activity Worse with weight bearing Worse at night Neurological signs in lower extremity Recent infection (i.e. urinary tract or skin infection) IV drug user Concurrent immunosuppressive disorder Deep constant pain that may increases with weight bearing and may radiate Fever, malaise, swelling Spine rigidity, hypomobile joints 5

6 History of trauma or falls May be relatively minor in older patients Osteoporosis Prolonged steroid use Over 70 years old Loss of function or mobility Point tenderness over site of fracture Increased pain with weight bearing Edema in local area History of peripheral vascular disease, coronary artery disease Age over 50 History of hypertension and/or diabetes Symptoms not related to movement Abnormal width of aortic or iliac arterial pulses Presence of a bruit in the central epigastric area upon auscultation Unilateral flank or low back pain Difficulty with initiating urination, painful urination, blood in the urine Recent UTI History of Kidney Stones Positive percussion test over kidney Patients with signs of cauda equina syndrome may require immediate surgical referral Progressive neurologic deficits Bowel or bladder dysfunction Bilateral sciatica Leg weakness Numbness in a saddle distribution 6

7 Maladaptive beliefs Expectations and pain behavior Reinforcement of pain Heightened emotional activity Job dissatisfaction Poor social support Taken from Cairns; Spine 2003 Assessment Focused history and physical examination Evaluate psychosocial risk factors which may indicate a risk for chronic, disabling low back pain Limited use of diagnostic imaging and testing Patient Stratification Non-specific low back pain Lumbar pain related to radiculopathy and/or spinal stenosis Low back pain related to other causes 7

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