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M A T T H E W G R I E R S O N , M D

D E P A R T M E N T O F R E H A B I L I T A T I O NM E D I C I N E

U N I V E R S I T Y O F W A S H I N G T O N

S E P T E M B E R 1 0 , 2 0 1 2

Physiatric Approach to Treating

Chronic Low Back Pain

Epidemiology of Spine Care

LBP affects up to 80% of population at some point

1-2% of US population is disabled by LBP Estimated total cost for spine care: 2006: $85 billion

Annual incidence 5-10% in the US No consistent ways to predict the success of any

given treatment of LBP

Natural History: 1/3 resolve completely within 1 year

3/5 on-going relapsing pattern

1/10 never resolve

Deyo, 2001; Anderson 1997; Kent 2005

% of US Population with LBP

National Center for Health Statistics

Increases in Injections for Medicare Patients

Friendly, Deyo 2007

4-fold increase

Differential Diagnosis LBP Demographic Considerations

Pediatric Slipped capital femoral epiphysis orother hip disorders

Adolescent Spondylolysis College Disc injury resulting in radiculopathy or

annular tear; spondylolysis; nonspecific muscle painAdult Nonspecific lumbar pain, disc injury, some

facet pain, lumbar stenosis, degenerative disease

Senior Compression fractures, degenerativedisease with stenosis (causing radicular pain), facetarthropathy (causing axial pain)

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Pain generators: Lumbar disc (Annular Tear, Discitis)

Nerve Root (Lumbar Radiculopathy,

Lumbar Stenosis) Facet Z-joint (Facet arthropathy,

spondylosis)

Vertebral Body (Compression Fracture)

Muscles/Ligaments (Lumbar Strain)

Spinal Cord (Cauda Equina vs. ConusMedullaris)

Referred from SI Joint / Hips

Intervertebral Disc 5-39% Zygapophysial Joint 15-40% Sacroiliac Joint 6-13%

Lumbar Vertebrae 3 parts Vertebral Body

Weight bearing functionSome longitudinal forces transmittedNot Solid

Pedicles

Connect posterior element and bodyTransmit tensionCylinder with thick walls

Posterior Elements

Laminae, articular processes, spinousprocesses, transverse processes

Site of muscle attachmentsResist forward sliding, twisting

Functional Anatomy: HNP - Axial

Lateral Recess Central Disc

Functional Anatomy: L-Spine HNP

Herniated Disc at L5/S1? Paracentral?

Lateral Recess?

Which nerve roots wouldbe involved?

Where would thesymptoms be?

History

Time Course, Chronicity Location, Quality, DurationAggravating, Alleviating Factors Treatment Sought to Date Social History Red FlagsYellow Flags

Red Flags? (for serious medical illness)

Age > 70 Unexplained weight loss History of malignancy Nocturnal Pain

Fever IV Drug abuse Prolonged steroid use Bowel/Bladder Dysfunction Focal / Progressive Neurologic Changes Trauma

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Yellow Flags? (for risk of disability)

Depression / Mood issues

Psychiatric Illness Social issues / Poor support network Poor coping skillsWork-related issues Sleep disturbance Fear of movement (kinesiophobia) Deconditioning Family history of disability / chronic pain

Physical Exam

Inspection (shirt off or in gown): Body habitus

Posture (head position, shoulders) plumb line from ear lobe,to shoulder tip, to peak of iliac crest.

Look for scoliosis

Look for iliac crest symmetry

Lumbar shift away or toward nerve injury

Hyperlordosis

Physical Exam

Palpation STANDING

Iliac crests for symmetrySpinous processes (looking for step off)

PRONE

Spinous processesParaspinalsGreater trochanterIschial tuberositySegmental Motion

Physical Exam

ROM: Flexion, extension, lateral bending, rotation, coupled motions

(e.g. rotation and extension)

Note side-to-side differences

More of a gestalt

Normal: Flexion: 60, Extension: 20, Lateral Flexion: 30, Rotation:30

Schober Test:

Mark Dimples of Venus (S1), 5cm below, 10cm aboveShould increase 4-5 cm with flexionSpecific, but not sensitive

Melanga 2006

Physical Exam

Neurologic: MMT:

HF, HE, HAb, HAdKF, KEADF, APF Functional testing includes 10 toe raises, heel walks!GTE, Inv, Ev

Reflexes:

L4L5S1

Sensation: What are the dermatomes? Peripheral nerves?

How does exam narrow your DDx?

Facet Loading: Extension with rotation and axial compression

Radiculopathy with HNP Central herniation, often worse with flexion

Lateral recess herniation, often worse with extension

> 90% occur at L4-5 or L5-S1

Sclerotomal Pearls: PSIS Pain: Think L5/S1 (or SI joint) as source

Greater Trochanter: Think L5

Ischial Tuberosity: Think S1

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Physical Exam

Provocative Maneuvers SLR

Positive if 30-70 degrees, with pain below the kneeCan test seated (e.g., Slump) or supineMore sensitive than specificProvocation with head flexion, or ankle dorsiflexion

Femoral stretch test

Prone, place your hand in popliteal fossa, exert some pressure withthat hand while flexing the knee, and can also extend a little at thehip. Pain should be reproduced in anterior thigh or back.

Tests a high lumbar disc herniation

Femoral Stretch Test Adding Hip Extension

Upper Lumbar Radiculopathy

Slump Test Dural Tension Sign

and relief of pain with neck extension+ if provokes radicular pain

SI-Joint / Hip

Hip: FABER / FADIR

SI Joint (tests are not specific): Rare for pain above buttocks

Compression / Distraction Test

Gaenslens Test let leg drop off table while you stabilize thepelvis (supine)

Stork

Knee: Genu valgus, varusAnkle: Pes cavus, planus

Gaenslens Test

Lie patient supine.

Stabilize pelvis withdownward pressure oncontralateral ASIS.

Let ipsilateral leg dropoff side of examinationtable.

Apply downward force at

ipsilateral thigh andcontralateral ASIS

Positive with pain in theSI joint region (buttock,low back)

None of the SI

provocative maneuversare particularly specific.

Waddell Signs

Consider contribution from Non-Organic Causes: Distraction: Findings are only present on formal exam

Over-Reaction: disproportionate verbalization, facialexpressions, muscle tension/tremor, collapsing, sweating

Regional disturbance: Non-dermatomal, non-myotomal

Simulation tests: Pain with perception of testing

Tenderness: Not localized to anatomic structure

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How do you find the source of the pain?

Most physical examination and imaging findings lacksensitivity and specificity.

Degenerative changes on XR / MRI do not reliablypredict pain or disability.

Interventionalists can use dual blocks at presumedpain generator, but that offers little to the PCP

Jensen 1994

Imaging?

When to order an imaging study? Will it change management?

Will it alleviate anxiety in the patient (and thus help themcomply with treatment?

ACR Appropriateness Criteria: Natural course ofuncomplicated acute LBP and/or radiculopathy is abenign, self-limited condition that does not warrantany imaging studies.

Imaging is considered if no improvement within 6weeks, and for those with red flags.

Interventions

Physical Therapy Medication Functional restorationAcupuncture Chiropractor Epidural Steroid Injections Facet Injections Dorsal Rhizotomy Spinal Stimulator Surgery

Treatment Approaches

Acute (< 6 weeks) Subacute (6 weeks to 3 months) Chronic (> 3 months) Interventional Movement-Based Interdisciplinary

CONSERVATIVE1. Relative rest /

Activity Mod2. Meds3. PTMid-Range

1. ESIAggressive1. Surgery

Medications

Anti-inflammatories Includes course of oral corticosteroids

NSAIDs

Opioids analgesics

Neuromodulaing Agents Anticonvulsants Gabapentin

Antidepressants TCA, SNRI

Antispasmodics (relax the patient and the provider) Cyclobenzaprine

Tizanidine

Physical Therapy

Goal of centralization of radicular pain Segmental mobilization (vertebrae, SI joint) Lumbar stabilization Core strength Pelvic floor stabilization Other considerations Posture Assessment, ErgonomicsAre there biomechanical deficits to be addressed? Pelvic girdle weakness Joint contractures (HF, HAb) that place undo stress at painful joints Corrective Orthotics (AFO, FO)

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Interventional Approaches - ESI

Epidural Steroid Injection (ESI) Most effective at treating radicular symptoms.

Dramatic increase in use in Medicare population between 1994and 2001. (Less than half were performed for radicularsymptoms.)

Caudal, Transforaminal (most specific, delivery atthe site of pathology), Interlaminar

Must consider risks/benefits as any other procedure,including comprehensive history (risk for diabeticcomplications, Cushings)

Interventional Approaches Facet

Steroid (max 2-3 / year)

Anesthetic blocks (immediate, can be diagnostic) Dual blocks: short relief with a short-acting

anesthetic, and long relief with a long-actinganesthetic

Using this method, facet-mediated pain approachesprevalence of 30% in older patients (Bogduk 2008)

Scant medical literature to support steroid injections

Interventional Approaches Facet

Facets are innervated by the medial branches of thedorsal rami of the lumbar nerve roots.

Can consider radiofrequency ablation (neurotomy) ofthose nerve roots, sometimes called dorsalrhizotomy (not to be confused with the very differentprocedure performed in pediatrics)

8-12 months of relief Before you kill the nerves, important to have good

response (>90% relief of pain) from the selective nerveblocks.

Long term consequences of denervation are unknown (?segmental spine stabilization)

Chronic LBP

Traditional biomedical approach has beeninadequate.

Adoption of biopsychosocial model recognizing theinfluences of cognitive, emotional, behavioral, andsocial/environmental factors, as well as biomedicalones.

Research on chronic LBP has suggested thatpsychosocial factors are as least as important asbiomedical ones in predicting pain course.

Carragee 2005,Boos 2000

Fear-Avoidance

Individuals who believe that physical or workactivities should be avoided when in pain (or thatsuch activity is dangerous), have greater likelihood ofdeveloping LBP.

Avoidance leads to disuse, deconditioning, and pain-related disability.

Goal: appearance of pain is met with cognitiveappraisal of meaning and significance. Work to

appraise as a benign experience (such as frommuscle soreness or minor strain)

Linton 1999, Disord 2009

Pain Catastrophizing

exaggerated and dysfunctional negative appraisal ofpain as a threat

Leads to fear-avoidance, hypervigilance (which canresult in increased brain activity in pain sensitive

regions).Avoidance behaviors: limping, guarding, bracing,

reliance on passive techniques and modalities

Overtime these types of behaviors can become highlyresistant, and are reinforced by family, work,medical community, financial compensation

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How Do Physicians Reinforce Pain?

Ordering unnecessary tests

Referring for another opinion Reinforces the belief that something may have been missed

Being uncertain while reassuring a patient I dont think it is necessary to get a surgical opinion; it is very

unlikely that you have anything wrong that would requiresurgery

Telling patients to take it easy or listen to yourbody might reinforce thoughts that it is dangerousto be physically active or that pain is a sign of injury.

Depression

cLBP brings about a number of lifestyle changes thatcan worsen depression: occupational disability,financial stress, sleep disruption, negative healthconsequences, relationship distress, sexualdysfunction, family role changes, limitations insocial, recreational or household activities

Initial diagnosis can be missed Treatment may be inadequate Taking medications may lead the patient to not

accept responsibility for resolving their depression(such as through CBT).

Psychosocial Treatment

CBT identify and challenge dysfunctional painresponses

Exposure therapy confronting fears Education encourage as many normal activities as

the patient can tolerate

Interdisciplinary Pain Rehab

5 days a week each week for 4 weeks, with outpatientf/up visits

MD, RN, PT, OT, Voc Rehab, Pain Psychologist Treatment designed to reduce avoidance patterns,

improve strength and body biomechanics

Some reviews suggest that for non-radicular backpain, interdisciplinary pain rehabilitation probably

has better or at least equal outcomes to moreinvasive interventions (surgery or procedures)

Turk 2002, 2005

Work-place

Predictors of future LBP Low job satisfaction

Perceived lack of social support from co-workers or asupervisor

Limited control at work

Excessive workload

Papageorgiou 1997, Eriksen 2004

Case

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Case: Non-Cancer Pain - Opioids

55 y/o M axial LBP.

Denies radiation into legs. No bowel/bladder sx. Pain all the time Self-employed truck driver, light loading/unloading Divorced father, 2 adult childrenAble to work with minimal discomfort when taking

OxyContin 80mg BID

PE: Diffuse P/S tenderness, gluteal muscles Negative hip, SI joint signs

511, 230 lbs

Case: Non-Cancer Pain - Opioids

MRI mild DJD, no nerve root compression

Attempted PT, NSAIDs, muscle relaxants No sustained relief.

H/o bilateral facet injections (L4/5 L5/S1) No improvement

What to do?

Rehab Approach

Fully investigate attempts at prior therapy ? Modalities, vs. therapeutic exercise, stretching, functional

retraining, ergonomics

What other non-pharm approaches Yoga, massage, acupuncture, CBT, spinal manipulation

Other meds: Anti-depressants?

Other NSAIDs, Tylenol, other muscle relaxants, AED, TCA

Risk of diversion. Have risks/benefits of chronicopioid use been discussed?

Rehab Approach

Chronic Opioids for Non-Cancer Pain Moderate to severe pain

Pain causes an adverse functional impact or QOL

Benefits outweigh the harms

Ongoing monitoring, reassessment with appropriate labsIf h/o red flags, may need to seek support from addiction

treatment specialists.

S/E: Sedation, dizziness, N/V, constipation, physical dependence,tolerance, respiratory depression, sex hormone deficiencies

Follow-up

Is pain improved (documented)?How is function measured on follow-up?

Other Rehab Approach?

At age 55, patient will require 30 more years ofOxyContin, with titration as appropriate

Difficulty finding providers to prescribeAdverse Effects: cognitive difficulties, apathy,

depression, fatigue, worse with age.

Issue of diversion.What about a more comprehensive approach

(including weight loss, PT, CBT, etc.)?

Multidisciplinary programs not always covered byinsurance.

Other Rehab Approach?

Generally, better to involve Physiatrist BEFORE thepoint of OxyContin 80mg PO BID.

Could consider contract with downward titrationwith clear expectations for monitoring.

What do you do when the benefits vs. harm areunpredictable and you have a busy practice,especially when someone is still working (which isunusual in a situation like this)