Treatment of Lower back Pain. Andrew Dubin, MD, MS Associate Professor, PMR Albany Medical College

Size: px

Start display at page:

Download "Treatment of Lower back Pain. Andrew Dubin, MD, MS Associate Professor, PMR Albany Medical College"

Willa Wilkerson
7 years ago
Views:

1 Treatment of Lower back Pain Andrew Dubin, MD, MS Associate Professor, PMR Albany Medical College

2 Natural History and Acute LBP The art of medicine consists of amusing the patient while nature cures the disease. Voltaire

3 LBP- second only to the common cold for visits to primary care Benign natural history % resolve within 1 week. 90 % resolve within 6-12 weeks DixonAJ.Problems of progresson back pain research.rheumatol Rehab. 1973;12:

4 If this is the case what is the problem? Long term outcomes post acute pain are less favorable

5 Significant amounts of chronic LBP have been reported 1 and 2 years after an acute episode. Phillips and Grant showed that 62% of patients with acute episodes had one or more relapses during a 1-year follow-up, and 40% still had pain at 6 months. PhilipsHC, Grant L.The evolution of chronic back pain problems: A longitudinal study. Behaviour research and therapy. 1991;29(5): Carey and colleagues found that 95% of such patients had a functional recovery at 6 months, but 31% were not completely better.carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project. N. Engl. J. Med. 1995;333(14):

6 How do we evaluate low back pain? Remember: First figure out the problem, then treat!!!!

7 How do you try and figure out what is the cause of a particular patients back pain complaints?

8 Rules to live by: Rule # 1: When all else fails take a history and perform a physical. Rule # 2: Failure to follow rule # 1 is the fast road to perdition. Rule # 3: Imaging studies can help or confuse. Must realize that changes on imaging studies may or may NOT mean anything

9 History: Where is the pain? Have you had it before? When did it start? What were you doing when it started? What makes it better/worse? Where is the pain? Back, leg, both? id

10 Good questions to ask! Does pain worsen or radiate with walking? Positive shopping cart sign - Think lumbar stenosis. Positive movie goers sign - Think lumbar DDD with reactive psoas spasm

11 Physical Exam : Things you must do. Check reflexes present/absent/ blunted / or hyper-reflexic? What is the significance. reflex -What nerve roots assessed? Achilles reflex - What nerve root assessed? Can we assess an L 5 reflex? YES

12 Motor exam Must see how strong leg muscles are

13 Provocative maneuvers SLR. Good for L 5 and S 1 nerve roots Reverse SLR - good for L3,4 radiculopathy. Check for pain with resisted hip flexion - psoas issue CHECK THE HIPS - check pain with hip ROM. Hips are the great masquerader.

14 Assess spine ROM and pain response. Pain with forward flexion /extension Pain with extension and rotation Pain with return to extension from flexed posture.

15 Sensory exam : Check - nice when it works, but typically the least reproducible part of the exam.

16 Once you are done with the history and physical the diagnosis becomes easy.

17 Imaging studies. Maybe yes / Maybe no! Start with plain films. Looks at overall alignment, osseous structures. MRI - Not so fast. Very sensitive but not very specific ( helpful ) when done blindly.

22 What is the significance of what the previous imaging studies showed? Answer - Who knows? Images in isolation are of very limited utility, may be useless and may also be red herrings.

23 Treatment low low back pain? Question - Does PT. help? Answer Yes / No Question - Does Exercise help? Answer Yes.

24 What is the best type of exercise? Flexion? Extension? Strength Training - Core Strengthening? Aerobics?

25 Multiple studies fail to show efficacy of core stabilizing exercises over conventional exercises - global conditioning and aerobics Standaert et al, Spine J. 2008; 8 ( 1)

26 In a meta-analysis, Bigos and colleagues found strong and reproducible evidence that exercise has a significant impact on preventing symptoms and reducing back-pain related work loss. Positive results in seven out of eight trials evaluating exercise; three revealed significant differences in work absence for subsequent LBP episodes.most people in the United States avoid exercise they either don t like it or don t want to do it. Fifty-nine percent of residents engage in moderate sports or recreational activities; 32% regularly participate in vigorous exercise; and only 15% report regular weight lifting. All too often, the high cost of inactivity becomes apparent after LBP is present. A simple question must be asked, whether the addition of exercise into our daily schedules is worth the effort to offset morbidity?

27 The controversy continues: McGill et al at the spine biomechanics lab in Waterloo Ontario raise some interesting questions and food for thought.

28 As mentioned earlier need to find out what makes things worse. Flexion? Extension? Hamstring stretch? Weak Gluteals?

29 Examples of provocative and possible therapeutic interventions Flexion intolerance. Patient is seated in chair. Sit upright and grasp the edges of the chair and pull down. Repeat with flexed/ kyphus posture. More pain with the second maneuver is consistent with a flexion intolerant patient.

30 Standing posture correction Retract the shoulders- patients with pain will shrug shoulders To correct, have the patient place arms at side with thumbs in hitchhikers position. Then steer thumbs outward to bring shoulders into external rotation. Chin tuck will further relax spinal erectors and reduce cramping pain in the back muscles

31 Chronic back pain compensations. Chronic back pain patients tend to use hamstrings as hip extensors. Therefore gluteals get weak and cause altered biomechanics. Bridging exercises : Supine, knees flexed, tuck buttocks and raise buttocks off the table strengthen gluteals and relax hamstrings.

32 What to avoid. Avoid flexion first thing in the morning. McGill et all have conclusively shown that the compressive forces on lumbar discs are greatest with flexion first thing in the morning owing to optimal disc height and hydration upon awakening. Nice take home point

33 In summary exercise does have a role in the treatment of low back pain. It has also been shown to decrease the incidence of low back pain. It is the ONLY intervention that has the potential to help long term AND is low risk

Exercises for Low Back Injury Prevention

DIVISION OF AGRICULTURE RESEARCH & EXTENSION University of Arkansas System Family and Consumer Sciences Increasing Physical Activity as We Age Exercises for Low Back Injury Prevention FSFCS38 Lisa Washburn,