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Physiatric Approach to Treating Chronic Low Back Pain

MATTHEW GRIERSON, MD DEPARTMENT OF REHABILITATION MEDICINE UNIVERSITY OF WASHINGTON SEPTEMBER 10, 2012

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

Increases in Injections for Medicare Patients

4-fold increase

National Center for Health Statistics

Friendly, Deyo 2007

Differential Diagnosis LBP

Demographic Considerations
Pediatric Slipped capital femoral epiphysis or

other hip disorders

Adolescent Spondylolysis College Disc injury resulting in radiculopathy or

annular tear; spondylolysis; nonspecific muscle pain

Adult Nonspecific lumbar pain, disc injury, some

facet pain, lumbar stenosis, degenerative disease

Senior Compression fractures, degenerative

disease with stenosis (causing radicular pain), facet arthropathy (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. Conus Medullaris) Referred from SI Joint / Hips Intervertebral Disc 5-39% Zygapophysial Joint 15-40% Sacroiliac Joint 6-13%

Lumbar Vertebrae 3 parts Vertebral Body

Weight Some

bearing function longitudinal forces transmitted Not Solid

Pedicles
Connect

posterior element and body tension Cylinder with thick walls

Transmit

Posterior Elements
Laminae, Site

articular processes, spinous processes, transverse processes of muscle attachments Resist forward sliding, twisting

Functional Anatomy: HNP - Axial

Functional Anatomy: L-Spine HNP

Herniated Disc at L5/S1? Paracentral?

Lateral Recess?

Which nerve roots would

be involved?
Where would the

symptoms be?

Lateral Recess

Central Disc

History
Time Course, Chronicity Location, Quality, Duration Aggravating, Alleviating Factors Treatment Sought to Date Social History Red Flags Yellow 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 skills Work-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 Spinous

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:

crests for symmetry processes (looking for step off) processes

PRONE
Spinous Greater Ischial Paraspinals

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

30

trochanter tuberosity Segmental Motion

Schober Test:
Mark

Dimples of Venus (S1), 5cm below, 10cm above increase 4-5 cm with flexion Specific, but not sensitive
Should

Melanga 2006

Physical Exam
Neurologic: MMT:
HF, KF,

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

HE, HAb, HAd KE ADF, APF Functional testing includes 10 toe raises, heel walks! GTE, Inv, Ev

Reflexes:
L4 L5 S1

Sensation: What are the dermatomes? Peripheral nerves?

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Physical Exam
Provocative Maneuvers SLR
Positive Can

Upper Lumbar Radiculopathy

Femoral Stretch Test Adding Hip Extension

if 30-70 degrees, with pain below the knee test seated (e.g., Slump) or supine More sensitive than specific Provocation with head flexion, or ankle dorsiflexion

Femoral stretch test

Prone,

place your hand in popliteal fossa, exert some pressure with that hand while flexing the knee, and can also extend a little at the hip. Pain should be reproduced in anterior thigh or back. Tests a high lumbar disc herniation

Slump Test Dural Tension Sign

Hip: FABER / FADIR

SI-Joint / Hip

SI Joint (tests are not specific): Rare for pain above buttocks Compression / Distraction Test Gaenslens Test let leg drop off table while you stabilize the pelvis (supine) Stork Knee: Genu valgus, varus Ankle: Pes cavus, planus
+ if provokes radicular pain and relief of pain with neck extension

Waddell Signs
Lie patient supine. Stabilize pelvis with downward pressure on contralateral ASIS. Let ipsilateral leg drop off side of examination table. Apply downward force at ipsilateral thigh and contralateral ASIS Positive with pain in the SI joint region (buttock, low back) None of the SI provocative maneuvers are particularly specific.

Consider contribution from Non-Organic Causes: Distraction: Findings are only present on formal exam Over-Reaction: disproportionate verbalization, facial expressions, muscle tension/tremor, collapsing, sweating Regional disturbance: Non-dermatomal, non-myotomal Simulation tests: Pain with perception of testing Tenderness: Not localized to anatomic structure

Gaenslens Test

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How do you find the source of the pain?

Most physical examination and imaging findings lack

Imaging?
When to order an imaging study? Will it change management? Will it alleviate anxiety in the patient (and thus help them comply with treatment? ACR Appropriateness Criteria: Natural course of

sensitivity and specificity. Degenerative changes on XR / MRI do not reliably predict pain or disability. Interventionalists can use dual blocks at presumed pain generator, but that offers little to the PCP

uncomplicated acute LBP and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered if no improvement within 6 weeks, and for those with red flags.

Jensen 1994

Interventions
Physical Therapy Medication Functional restoration Acupuncture 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
CONSERVATIVE 1. Relative rest / Activity Mod 2. Meds 3. PT Mid-Range 1. ESI Aggressive 1. 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
Posture Assessment, Ergonomics Are there biomechanical deficits to be addressed? Pelvic girdle weakness Joint contractures (HF, HAb) that place undo stress at painful joints Corrective Orthotics (AFO, FO)

Other considerations

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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 1994 and 2001. (Less than half were performed for radicular symptoms.) Caudal, Transforaminal (most specific, delivery at

Interventional Approaches Facet

Steroid (max 2-3 / year) Anesthetic blocks (immediate, can be diagnostic) Dual blocks: short relief with a short-acting

the site of pathology), Interlaminar

Must consider risks/benefits as any other procedure,

including comprehensive history (risk for diabetic complications, Cushings)

anesthetic, and long relief with a long-acting anesthetic Using this method, facet-mediated pain approaches prevalence 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 the

Chronic LBP
Traditional biomedical approach has been

dorsal rami of the lumbar nerve roots. Can consider radiofrequency ablation (neurotomy) of those nerve roots, sometimes called dorsal rhizotomy (not to be confused with the very different procedure 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 nerve blocks. Long term consequences of denervation are unknown (? segmental spine stabilization)

inadequate.
Adoption of biopsychosocial model recognizing the

influences of cognitive, emotional, behavioral, and social/environmental factors, as well as biomedical ones. Research on chronic LBP has suggested that psychosocial factors are as least as important as biomedical ones in predicting pain course.
Carragee 2005, Boos 2000

Fear-Avoidance
Individuals who believe that physical or work

Pain Catastrophizing
exaggerated and dysfunctional negative appraisal of

activities should be avoided when in pain (or that such activity is dangerous), have greater likelihood of developing LBP. Avoidance leads to disuse, deconditioning, and painrelated disability. Goal: appearance of pain is met with cognitive appraisal of meaning and significance. Work to appraise as a benign experience (such as from muscle soreness or minor strain)
Linton 1999, Disord 2009

pain as a threat
Leads to fear-avoidance, hypervigilance (which can

result 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 highly resistant, 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 require surgery Telling patients to take it easy or listen to your

Depression
cLBP brings about a number of lifestyle changes that

body might reinforce thoughts that it is dangerous to be physically active or that pain is a sign of injury.

can worsen depression: occupational disability, financial stress, sleep disruption, negative health consequences, relationship distress, sexual dysfunction, family role changes, limitations in social, 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 pain

Interdisciplinary Pain Rehab

5 days a week each week for 4 weeks, with outpatient

responses Exposure therapy confronting fears Education encourage as many normal activities as the patient can tolerate

f/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 back

pain, interdisciplinary pain rehabilitation probably has better or at least equal outcomes to more invasive 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 a supervisor Limited control at work Excessive workload

Case

Papageorgiou 1997, Eriksen 2004

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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 children Able to work with minimal discomfort when taking

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?

OxyContin 80mg BID

PE: Diffuse P/S tenderness, gluteal muscles Negative hip, SI joint signs 511, 230 lbs

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 chronic

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 If

monitoring, reassessment with appropriate labs 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 How

opioid use been discussed?

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

Other Rehab Approach?

At age 55, patient will require 30 more years of

Other Rehab Approach?

Generally, better to involve Physiatrist BEFORE the

OxyContin, with titration as appropriate Difficulty finding providers to prescribe Adverse 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 by insurance.

point of OxyContin 80mg PO BID.

Could consider contract with downward titration

with clear expectations for monitoring.

What do you do when the benefits vs. harm are

unpredictable and you have a busy practice, especially when someone is still working (which is unusual in a situation like this)