Transcript Document

Integrative Approach to
Low Back Pain
Wendy Kohatsu, MD
Director, Integrative Medicine Fellowship
Santa Rosa Family Medicine
Residency Program
Sept 2011
Goals of this talk:
• Review key history
elements
• Learn how to do
better hands-on back
exam
• Focus on practical &
effective lifestyle
therapies
• Not ‘overmedicalize”
LBP via diagnostic
tests, drug therapies,
surgical interventions.
• Later: myriad of mindbody therapies
• Talk about something
other than food for a
change….
Low back pain
• 70-84% of the population affected at some
point in their lives
• 14-50% of adults have LBP each year
• Cost of > $100 billion/ year
• Quality of life impact of acute LBP
– 60% unable to perform some daily activity
– 72% gave up exercising
– 46% gave up sex
Spine 12:264,1987
Amer Acad Ortho Surg, 2006
Ann Rheum Dis 57:13, 1998
Posture
Patient case #1:
52 yo female, cc: “sciatica” bilateral numbness
hip to knees, since 1999. h/o prior LBP.
•30 years ago fell down flight of stairs at
Fisherman’s wharf, landing on tailbone.
•Currently works part-time at family business.
•On 800 mg ibuprofen. Took friend’s percocet.
Flexeril does “nothing”.
Patient case #2
• 86 yo Vietnamese male, DM2, reluctant
to see MD.
• Ambulates with 4-prong cane
• c/o LBP, radiating to back of legs,
doesn’t like to take medicine, uses
analgesic balm
• ROS: urinary retention, feels more tired,
recent weight loss.
History-taking
History-taking
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Onset/first episode?
Occupational risk
Co-morbidities
Activity & exercise level
Psychosocial stress/ diagnoses
Other?
3 main questions for LBP:
1. Is systemic disease causing the pain?
2. Is there social or psychological
distress that may amplify or prolong
the pain?
3. Is there neurologic compromise that
may require surgical evaluation?
Deyo & Weinstein NEJM 344:363, 2001
“Red flags”
ACR Criteria - Low Back Pain, 2005
“Red flags”
• Hx of trauma
• Focal neurologic signs - incontinence,
weakness, numbness
• Hx of cancer
• Age of first onset after 50 years
• Hx of IVDA
• Osteoporosis
• Signs of systemic disease - fever, wt loss,
lymphadenopathy
ACR Criteria - Low Back Pain, 2005
Perspective
• Among all primary care patients with LBP,
< 5% will have serious systemic pathology.
• 97% will have LBP w/o radiculopathy
– 60% Simple back pain
– 37% Complex back pain w/o radiculopathy
• 3% will have LBP with radiculopathy
– Sx of radiculopathy
– 1% with acute neuro sx – loss of bladder fxn,
saddle anesthesia, motor weakness
N Engl J Med. 2001;344(5):363
Up To Date –June 2011
To image or not to image…
• MRI evaluation to provide
reassurance for chronic LBP
does NOT lead to better
prognosis.
• Psychosocial variables are
stronger predictors of longterm disability than anatomic
findings found on imaging
studies.
• Radicular sx > 4-6 weeks,
severe enough to consider
Ann Intern Med. 2007;147(7):478.
JAMA. 2010;303(13):1295.
surgery.
So, let’s examine our patients…
2 1/2 -minute focused neuro exam
Position
All
Standing
Sitting
Supine
Prone
Test/feature
Findings
Observe
Behavior
•Posture & gait
•Toe / heel walking
•Asymmetry
•Straight leg raise
•Neurologic testing
•Posture habits
•L5 or S1 deficiency*
•Scoliosis
•Leg length
•Straight leg raise
•Fabere’s sign
•Mech contribution
•Palpation
•Hip Extension 5-20
•Prone prop
•Muscle dysfxn
•L2-4 radiculopathy
•Facet jt dysfxn
•Radicular pain
•Sensory defect
•Radicular pain
•Hip involvement
Biewen PC Postgrad Med 106:102, 1999
EXAM! - Anatomy Review
(what med school never taught you…)*
• *Except Natasha, Trang, Sarah W & Hana C.
• OMT basic evaluation
• 3 layer muscle palpation
• Skeletal survey -- L-spine, pelvic girdle,
lower extremities (joint above/below)
• Common culprits: Erector spinae
spasm, Lumbar rotation, SI joint dysfxn,
psoas, piriformis spasm, muscle
imbalance, myofascial syndrome!
OMT Common Culprits:
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Erector spinae spasm
Lumbar rotation
SI joint dysfxn
Psoas
Piriformis spasm
Muscle imbalance
Myofascial syndrome!
Psoas located deep
in abdomen, but
major hip flexor.
Radiates to:
- Lumbar region
- Front of hip
The “Dirty Half-Dozen” of
Refractory LBP
OMT diagnosis
Trunk-thigh imbalance
Lumbar dysfxn
Pubic dysfxn
Short leg/pelvic tilt
Posterior sacral base
Innominate shear
Frequency
100%
88%
76%
65%
60%
24%
n = 183 ‘untreatable’ pts with refractory LBP
75% restored to normal activity after OMT*
Phys Med Rehab Clin NA 7:773, 1996
Patient #1 - Exam
• 52 yo woman with sciatica
• Exam: Wt 151, BMI 25.5, anxious
• Neuro: 4+/5 left hip flexion, knee extension.
Preserved gait and balance walking in
hallway.
• MSK: level iliac crest heights, ++ 4 cm left
posterior hip rotation, ++ right sacral torsion,
L > R SI join tenderness, LEFT glut max,min
+ piriformis spasm.
• Imaging: NONE.
Patient # 2 - Exam
86 yo Vietnamese male with LBP
•Very stoic, pleasant, NAD
•Wt 111 (down from 129 lbs 4 mos prior)
•Thin frame, + increased thoracic
kyphosis, tight lumbar paraspinal
muscles.
•Rectal: Enlarged prostate.
Posture
What next?
Principle Based Treatment
Pyramid
relationship
Principle Based Treatment
Pyramid
resources
environment
relationship
Treatment Options
• “Internal Environment”
• Lifestyle
• CAM therapies
• Drugs
Treatment Options
• “Internal Environment”
– Pain is a signal for change
– John Sarno, MD ~ (TMS)Tension Myositis
Syndrome
• Lifestyle
• CAM therapies
• Drugs
Treatment Options
• “Internal Environment”
• Lifestyle
• CAM therapies
• Drugs
– NSAIDs
– Analgesics
– Muscle relaxants
NSAIDs
• For acute LBP
– Ibuprofen 400-600 mg up to qid
– Naproxen 220 -500 mg bid
• Side effect and risks limit use
Cochrane Database NSAIDS for LBP, 2008
ACP and Amer Pain Soc Guidelines 2007
Analgesics
• Acetaminophen
– Up to 2.6 grams/d as first line therapy
– Side efx - hepatoxicity
• Opioids
– Surprisingly little data
• One meta-analysis = not significantly reduce chronic low
back pain
– Inadequate data re: functional improvement
correlating to pain relief
– Reports of opioid abuse ~ 30-45% in LBP
CMAJ 174:1589, 2006
Ann Intern Med 146:166, 2007
Cochrane Database Syst Rev -Opioids for Chronic LBP, 2008
FDA guidelines June 2009
Muscle relaxants
• “Insufficient evidence” for chronic use
• CNS side effects - sedation
• Carisoprodol metabolized --> meprobamate,
abuse and addiction potential
• Limit to short-term use only in
conjunction with analgesics
vanTulder et al. Spine 28:1978; 2003
Drug-Nutrient Interactions
• NSAIDS deplete…
•Folic Acid
-Synthesis of folic acid is competitively
inhibited by NSAIDs
-Rx: eat your leafy greens! (“foliage”)
Treatment Options
• “Internal Environment”
• Lifestyle
• CAM therapies
– Acupuncture
– Massage
– Chiropractic or osteopathic manipulation
• Drugs
Acupuncture for LBP
• Like massage, data show acupuncture
is moderately more effective than no
treatment
• Short-term outcomes > long-term
• More likely to benefit those who expect
more out of acupuncture.
Cochrane Database Syst Rev - Acu for LBP, 2005
Spine 26:1418, 2001
Massage
• Appears to be better for acute vs
chronic back pain
• Studies inconclusive due to varying
styles, practitioner skill, duration of
treatment
Manipulation
• “Moderately superior” to sham Rx, null
therapies
• But equal to analgesics, exercises, back
school
• Mixed bag of techniques studied --Most
studies on HVLA techniques used in
chiropratic Rx
Ann Intern Med (meta-analysis)138:871 2003
Ann Intern Med 138:989, 2003
Treatment Options
• “Internal Environment”
• Lifestyle
– Exercise
• Stretching, strengthening, yoga
– Stress management
• CAM therapies
• Drugs
Low Back Pain - Exercise Rx
• 2005 Systematic Review
– 43 trials of 72 exercise treatments
– Improvement seen esp. with
• High-dose exercise programs
• Interventions that included conventional care
• Stretching and strengthening demonstrated the
largest improvements. (vs passive treatments)
Ann Intern Med 142(9): 776-85, 2005
Low back pain - Exercise Rx
• BMJ study 1995 with “moderately disabled” pts.
– 81 chronic LBP patients, referred from ortho
• Control – home exercises + ref’d to back school
• Intervention – above + 8 exercise classes/4 wks
– Two hour sessions
• Warm up, stretching
• 15 systematic progressive exercises
• Lite aerobic activity and stretching
• Signif. improvements in pain reduction, self-efficacy,
and walking distance noted at 4 weeks, and 6 month
f/u
Frost, H, et al. 1995 BMJ 310(6973): 151-4.
Low back pain Exercise Rx
• Study by Carpenter & Nelson, 60 pts
considering neurosurgery
– 10 week back-strengthening program
• Progressive resistance exercise
• Isolated lumbar extensions (with pelvis neutral)
• One set of 8-15 reps to volitional fatigue
1x/week
– 57/60 pain-free, no longer needed surgery!
Med Sci Sports Exerc 1999 31(1): 18-24.
Best outcomes for exercise
therapy
Best outcomes
achieved when
these 4 elements
included:
• Individualized regimens
• Stretching
• Strengthening
• Supervision
Hayden, Van Tulder et al. Ann Int Med 142:776, 2005
Home exercise Rx
• Tennis ball* -- myofascial and erector
spinae column
• Abdominal strengthening
• Quad strengthening
• Spinal twist
• Piriformis stretching
• Hamstring stretching
Pelvic Clock Technique
• Created and researched
by Phil Greenman, DO
• No prior training required
• Dx and Rx at same time
• Patient can do at home
Take home points
• Ask the 3 questions - are systemic dx, neurol
red flags, or psychosocial fx present?
• DO THE EXAM!
– Focused neuro exam
– Musculoskel exam
– Be judicious when ordering imaging
• Rx: Improve function, not just blunt pain
• Teach exercise therapies, can tailor to
individual patient
Strength training
• Why?
– Muscle strength declines rapidly after 50 in
sedentary people.  REVERSIBLE!
– Increase bone density
– Improves strength & ability to perform aerobic
exercise.
– INCREASE BASAL METABOLIC RATE (BMR) by
increasing lean body mass.
Life, J. CAM Secrets (2002)
“Core Four” Weight Training Program – Hewitt 2002