Multidisciplinary Management of Low Back Pain USAFP April 2009 Orlando, Florida

1. Multidisciplinary Management of Low Back PainUSAFP April 2009 Orlando, Florida Robert Martin MD CDR, MC, USN FP/Sports Medicine

2. Objectives Discuss a differential diagnosis with practice tips. Discuss the tools and team members that can assist in management. Discuss the evidence and expectations from the tools and team members. Trying to get away from pooling all LBP patients together. Many EBM studies do not isolate out the causes of LBP. I hope to change the way you approach back pain and Trying to get away from pooling all LBP patients together. Many EBM studies do not isolate out the causes of LBP. I hope to change the way you approach back pain and

3. Low Back Pain Leading cause of disability among chronic ailments. 70-90% of adults will experience LBP in their lifetime. Number 2 reason for physician visits after respiratory conditions. $100 billion in medical expenses annually in medical bills, disability and lost productivity. April 2004 issue of Newsweek The issue wrote about massage, acupuncture, chiropractic. The issue notes the lack of proven efficacy for many of these treatments. “ Like a temperamental sports car, the human spine is beautifully designed but maddeningly unreliable.” As long as we continue to lead overweight, sedentary, and stressful lives, these numbers are unlikely to go anywhere but up. The article talked about managing pain with multiple disciplines: Acupuncture, massage, and chiropractic practitioners are increasing in numbers. The number of Chiropracters increased 50% from 1990 to 2004. April 2004 issue of Newsweek The issue wrote about massage, acupuncture, chiropractic. The issue notes the lack of proven efficacy for many of these treatments. “ Like a temperamental sports car, the human spine is beautifully designed but maddeningly unreliable.” As long as we continue to lead overweight, sedentary, and stressful lives, these numbers are unlikely to go anywhere but up. The article talked about managing pain with multiple disciplines: Acupuncture, massage, and chiropractic practitioners are increasing in numbers. The number of Chiropracters increased 50% from 1990 to 2004.

4. Making a Diagnosis Muscular or Ligamentous Mechanical Herniated Disk Spinal Stenosis Infection Vitamin D Facet Syndrome Spondylolysis Sacroiliac Joint Pain Ankylosing Spondylitis Coccygeal Injuries Scheuermann Disease Tumors Secondary Gain LBP may also be from other medical Dz: pneumonia, Pyelonephritis, fibromyalgia, ruptured AAA, etc but this talk will only address conditions from within the anatomy of the Lower Back. We will cover those listed. The yellow highlighted conditions I call posterior element conditions. They are exacerbated by hyper-extension. Once I see that I can reproduce the pain with hyperextension maneuvers, then I narrow this differential. Many conditions on Sports Medicine we like to divide into “Traumatic or non-traumatic” but I can’t do this for the back. LBP may also be from other medical Dz: pneumonia, Pyelonephritis, fibromyalgia, ruptured AAA, etc but this talk will only address conditions from within the anatomy of the Lower Back. We will cover those listed. The yellow highlighted conditions I call posterior element conditions. They are exacerbated by hyper-extension. Once I see that I can reproduce the pain with hyperextension maneuvers, then I narrow this differential. Many conditions on Sports Medicine we like to divide into “Traumatic or non-traumatic” but I can’t do this for the back.

5. Sacroiliac Joint Pain Insidious onset or from a Twist on the pelvis. Highly innervated joint. Muscle insertions: Piriformis, Hamstring, Quad Lumborum, Psoas. Pain with extension, sitting, transitioning. Tender at SI joint. Mimics and may be radicular pain. Rx with OMT Most common condition I see among chronic LBP patients. Si joint immobility. Most are not traumatic. Gillet test or one legged stork test. Don’t exclude HNP. All herniated discs have an SI joint component to the pain. Not all SI joint is from a herniated discs. The more attention we give to the SI joint, the more success we have with all LBP patients. Most common condition I see among chronic LBP patients. Si joint immobility. Most are not traumatic. Gillet test or one legged stork test. Don’t exclude HNP. All herniated discs have an SI joint component to the pain. Not all SI joint is from a herniated discs. The more attention we give to the SI joint, the more success we have with all LBP patients.

6. Musculoligamentous Injuries Acute Soft Tissue Injuries. No Fracture or Neuro deficits. Muscle Pain and Spasm RX: NSAIDs, stretch and strengthen (like a hamstring injury). Like any other joint, it can be overloaded. Like a groin strain, hamstring pull, ankle sprain, or sudden shoulder strain. Tobacco smokers have weaker back muscle strength of Lumbar Spine Isometric Extension strength. Like any other joint, it can be overloaded. Like a groin strain, hamstring pull, ankle sprain, or sudden shoulder strain. Tobacco smokers have weaker back muscle strength of Lumbar Spine Isometric Extension strength.

7. Chronic Mechanical LBP Similar to Patello-Femoral Pain Syndrome of the Knee. Tight hamstrings and hip flexors. Weak Abs. Rx: Stretch, Strengthen and Mobilize Any short muscle that attaches to the pelvis will cause a problem with the back: Piriformis, psoas, hamstrings, quadratus lumborum. The same goes for any other joint in the body like the knee. Chronic sacral dysfunction like water dripping on a stone can produce severe problems.Any short muscle that attaches to the pelvis will cause a problem with the back: Piriformis, psoas, hamstrings, quadratus lumborum. The same goes for any other joint in the body like the knee. Chronic sacral dysfunction like water dripping on a stone can produce severe problems.

8. Minimize Risk factors Job related Manual handling tasks Lifting Twisting Bending Falling Reaching Excessive Weights Prolonged Sitting Vibration Related to Individual Prior Episode Job Dissatisfaction Smoking Obesity Genetic factors Related to Job    Manual handling tasks (almost two thirds of compensated cases)    Lifting (about one half of claims; most often from floor)    Twisting (about one fifth of cases)    Bending (one tenth of cases)    Falling (one tenth of cases)    Reaching    Excessive weights    Prolonged sitting    Vibration---------Helo Pilots Related to Individual    Prior episode (threefold risk if occurred within 3 years) Job dissatisfaction (very important; based on longitudinal questionnaire data)    Smoking (accelerates disk degeneration)    Obesity and genetic factors Dr John Sarno , author of “Healing Back Pain”, works at NYU’s Rusk Institute for Rehabilitation Medicine believes almost all back pain is rooted in bottled up anger.

9. Herniated Disk Radicular Pain with flexion or sitting. Varying degrees of back pain to leg pain. Rx: Pain control, activity modification, regular follow up, PT, ESI, Surgery rarely needed. Anterior Elements: Discs and Vertebrae Varying range of Back and Leg pain. Some people primarily c/o of leg pain with little back pain. Severity of pain at presentation does not predict outcome or need for surgery. Physical therapy can help correct the faulty biomechanics leading to the disc degeneration. They can also provide modalities to decrease pain and relax the muscles. Anterior Elements: Discs and Vertebrae Varying range of Back and Leg pain. Some people primarily c/o of leg pain with little back pain. Severity of pain at presentation does not predict outcome or need for surgery. Physical therapy can help correct the faulty biomechanics leading to the disc degeneration. They can also provide modalities to decrease pain and relax the muscles.

10. Spinal Stenosis Radicular Pain worsened by walking or running and improved by sitting. Degeneration of facets Posterior Longitudinal ligament or ligamentum flavum can also get thickened and cause spinal stenosis Disc degeneration Spondylolisthesis Post surgical. Traction works here temporarily. Traction works here temporarily.

11. Cauda Equina Syndrome Saddle Anesthesia Bladder Retention Start Dexamethasone Emergent MRI Operative decompression in < 24 hours.

12. Infections Discitis Young Children <10 yrs old Stiff Back or Abdominal pain and often refuse to walk. Spine tenderness and loss of motion. Elevated ESR, CRP. CBC often normal. X-rays may take 2 weeks for abnormalities. Bone scan or MRI if suspicious. Osteomyelitis Follow blunt trauma 1/3 of the time. Fever in 58%. Neurologic complications Elevated ESR 73%, WBC elevated 35%. X-rays may take 4 -8 weeks for erosive changes. Bone scan or MRI when suspicious.

13. Holick MF at Boston University school of medicine states that decreased Vitamin D is linked to increased risk of TB, DM type 1, HTN, CHF, and cancers of the Breast, Colon, Prostate, and Ovaries. Gloth FM III from JHU has linked Vit D deficiency with Bone pain and Myopathy. Case reports with bone pain and myopathy. March 2006 article mentions exam findings of tenderness with pressing thumb and forefinger into sternum or tibia as an exam finding for osteomalacia. Mentions muscle weakness, aches and pains. Measure 25-hydroxy Vitamin D Holick MF at Boston University school of medicine states that decreased Vitamin D is linked to increased risk of TB, DM type 1, HTN, CHF, and cancers of the Breast, Colon, Prostate, and Ovaries. Gloth FM III from JHU has linked Vit D deficiency with Bone pain and Myopathy. Case reports with bone pain and myopathy. March 2006 article mentions exam findings of tenderness with pressing thumb and forefinger into sternum or tibia as an exam finding for osteomalacia. Mentions muscle weakness, aches and pains. Measure 25-hydroxy Vitamin D

15. Facet Joint Syndrome Age 30s-40s Pain with hyperextension or running Frequent radicular pain. X-ray: Facet hypertrophy or DJD Facet injections diagnostic Spinal Fusion definitive Rx for spinal stenosis symptoms Frequent with facet asymmetry or sacralization of transverse process. Typically intermittent. Treat like mechanical LBP and avoid hyperextension. Frequent with facet asymmetry or sacralization of transverse process. Typically intermittent. Treat like mechanical LBP and avoid hyperextension.

16. Spondylolysis/ Spondylolisthesis Pain with hyperextension. More frequent in top competitors. Single Leg hyperextension test. X-ray, Spect Scan. Avoid hyperextension, fusion is rarely needed. Univ of Indiana College Football players had pars defects in 13% of players and increased 2.4% over 4 years. White population is 5.8%, Black population and general female population rate is 2 %. Pre-elite Gymnasts had a 9% incidence but 63% of Olympic gymnasts had pars defects. Is the vertebrae slipping forward ? Prone pt flex leg into table firing ileopsoas pulling vertebrae into the table or rotating. Univ of Indiana College Football players had pars defects in 13% of players and increased 2.4% over 4 years. White population is 5.8%, Black population and general female population rate is 2 %. Pre-elite Gymnasts had a 9% incidence but 63% of Olympic gymnasts had pars defects. Is the vertebrae slipping forward ? Prone pt flex leg into table firing ileopsoas pulling vertebrae into the table or rotating.

17. Ankylosing Spondylitis 10 Male : 1 Female Age 15-35 Slowly progressive SI joint pain with morning stiffness. Look for loss in motion particularly extension. Elevated ESR. Normal ANA and RF. HLA B27 positive in 90% Treatment is postural training to avoid flexion contracture. Sleep supine on firm mattress. NSAIDS and new research with Tumor necrosis factor antagonists. Treatment is postural training to avoid flexion contracture. Sleep supine on firm mattress. NSAIDS and new research with Tumor necrosis factor antagonists.

18. Coccygeal Injuries Fall on buttocks Pain with sitting Localized tenderness Manual Reduction shown

19. Scheuermann Disease Juvenile Kyphosis Pain late in the day after activity. Thoracic T7-9 or Thoracolumbar T11-12 apex on flexion. X-rays: anterior wedging of 5 degrees of consecutive vertebrea and Schmorl’s nodes. Second most common cause of back pain in children and adolescents. Radiographically evident on 20-30% of the population. Genetic predisposition. Usual presentation is back pain 50% or painless thoracic kyphosis. Rx: Mild symptoms can be treated with postural exercises and mild pain relievers. F/U 3-4 months. Milwaukee Brace for angles over 55 degrees of thoracic kyphosis. Normal is 25-40 degrees of kyphosis Bracing is for 12-18 months so use a pediatric spine surgeon. Second most common cause of back pain in children and adolescents. Radiographically evident on 20-30% of the population. Genetic predisposition. Usual presentation is back pain 50% or painless thoracic kyphosis. Rx: Mild symptoms can be treated with postural exercises and mild pain relievers. F/U 3-4 months. Milwaukee Brace for angles over 55 degrees of thoracic kyphosis. Normal is 25-40 degrees of kyphosis Bracing is for 12-18 months so use a pediatric spine surgeon.

20. Spinal Tumors Osteoid Osteoma or Osteoblastoma Night Pain relieved by NSAIDs. Get a fine cut CT scan.

21. Secondary Gain Waddell Signs Non-organic superficial tenderness. Axial loading or En Bloc Rotation. Distraction test: Tripod negative with positive SLR. Non-anatomic weakness or sensory loss. Over reactive verbally or exaggerated response.

22. Back Pain Management Tools You and your tools. You and your tools.

23. Interdisciplinary Team Approach to Chronic Spinal Disorders Spine Surgeons Neurosurgeons Pain specialists Psychiatrists/ Psychologists Physiatrists Radiologists Interdisciplinary Approach to Pain Management Chronic spinal disorders are a complex phenomenon and is best managed by a interdisciplinary team. Primary coordination of treatment may depend on the individual patient’s needs and may change over time. For example, at one point the pain specialist’s input may be most urgent; subsequently, the physiatrist’s efforts may be most important, while at another point psychological therapy may be what the patient needs most. Chronic Spinal Disorders management challenges specialties to work together, often for long periods of time. Interdisciplinary Approach to Pain Management Chronic spinal disorders are a complex phenomenon and is best managed by a interdisciplinary team. Primary coordination of treatment may depend on the individual patient’s needs and may change over time. For example, at one point the pain specialist’s input may be most urgent; subsequently, the physiatrist’s efforts may be most important, while at another point psychological therapy may be what the patient needs most. Chronic Spinal Disorders management challenges specialties to work together, often for long periods of time.

24. The Role Of The Manager Make a diagnosis using a differential diagnosis. Educate the patient about the plan. Prescribe appropriate medications. Make appropriate referrals at appropriate times.

26. Back Pain Management Tools

27. EFNS guidelines on pharmacological treatment of neuropathic pain. The Task Force recommends TCA or GBP/pregabalin as first choice for painful polyneuropathy.(Level A) EBM-CME GBP 300mg qhs f3, bid f3 then tid http://www.guideline.gov/summary/summary.aspx?doc_id=10472&nbr=005495&string=neuropathic%2bAND%2bpain European Federation of Neurological Societies (EFNS)

28. NSAIDS EBM-CME A randomized controlled trial (RCT) comparing etoricoxib 60mg and 90mg with placebo for people with chronic back pain found both doses of etoricoxib resulted in significant improvements in pain scores and function vs placebo after 12 weeks. Level A [1] Koes B, van Tulder M. Low back pain (acute) (search date November 2004). In: Clinical Evidence; London: BMJ Publishing Group, 2007. Clinical Evidence [2] Ruoff GE, Rosenthal N, Jordan D, et al; Protocol CAPSS-112 Study Group. Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study. Clin Ther 2003;25:1123-41Abstract PubMed [3] Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability: a randomized, placebo-controlled, 3-month trial. J Pain. 2003;4:307-15Full text PubMed [4] Pallay RM, Seger W, Adler JL, et al. Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 2004;33:257-6Abstract PubMed CrossRef [5] Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol 2000;27:772-8Abstract PubMed Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability: a randomized, placebo-controlled, 3-month trial. J Pain. 2003;4:307-15Full text PubMed [4] Pallay RM, Seger W, Adler JL, et al. Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 2004;33:257-6 [1] Koes B, van Tulder M. Low back pain (acute) (search date November 2004). In: Clinical Evidence; London: BMJ Publishing Group, 2007. Clinical Evidence [2] Ruoff GE, Rosenthal N, Jordan D, et al; Protocol CAPSS-112 Study Group. Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study. Clin Ther 2003;25:1123-41Abstract PubMed [3] Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability: a randomized, placebo-controlled, 3-month trial. J Pain. 2003;4:307-15Full text PubMed [4] Pallay RM, Seger W, Adler JL, et al. Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 2004;33:257-6Abstract PubMed CrossRef [5] Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol 2000;27:772-8Abstract PubMed Birbara CA, Puopolo AD, Munoz DR, et al. Treatment of chronic low back pain with etoricoxib, a new cyclo-oxygenase-2 selective inhibitor: improvement in pain and disability: a randomized, placebo-controlled, 3-month trial. J Pain. 2003;4:307-15Full text PubMed [4] Pallay RM, Seger W, Adler JL, et al. Etoricoxib reduced pain and disability and improved quality of life in patients with chronic low back pain: a 3 month, randomized, controlled trial. Scand J Rheumatol 2004;33:257-6

29. Muscle Relaxants EBM-CME Meta-analysis of the randomized controlled trials (RCTs), that included sufficient data, in a review studying non-benzodiazepine muscle relaxants found an significant improvement in pain and global assessment after 2-4 days vs placebo. Level A Three RCTs included in the systematic review compared muscle relaxants with each other and found no significant differences between them. Level A More effective than placebo in achieving short-term symptomatic relief in people with non-specific acute low back pain. Level A van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database of Systematic Reviews 2003, Issue 4 Cochrane Reviewvan Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database of Systematic Reviews 2003, Issue 4 Cochrane Review

30. Back Pain Management Tools

31. OMT/ Mobilization Spinal manipulation for acute back pain slightly reduced pain at 6 weeks compared with sham treatment, but there was no significant difference in functional outcomes. There was no significant difference between spinal manipulation , physical therapy, exercises or back school . Level A The same systematic review found that spinal manipulation therapy for chronic back pain reduced pain in the short and long term compared with sham manipulation, but found no significant difference in function after 6 weeks. There was no significant difference in pain or function between spinal manipulative therapy and general practitioner care, physical therapy, exercises or back school [17]Level A A randomized controlled trial (RCT) was unable to find a statistically significant difference in pain or function between manipulative therapy and stabilizing exercises at 3 months or 12 months [18]Level A Another RCT compared spinal manipulative therapy with exercise therapy over 2 months in patients with chronic low back pain, and found spinal manipulation significantly decreased pain and increased functioning and return to work at 12 months [19]Level A A second subsequent RCT compared osteopathic manipulation, sham manipulation and no treatment over 5 months in patients with chronic low back pain, and found that both spinal manipulation and sham manipulation significantly reduced pain at 6 months compared with no treatment, but no significant differences in function [20]Level A [17] Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003;138:871-81Abstract PubMed [18] Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Man Ther 2003;8:233-41Abstract PubMed [19] Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Spine 2003;28:525-32Abstract PubMed CrossRef [20] Liccardione JC, Stoll ST, Fulda KG, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine 2003;28:1355-62Abstract PubMed CrossRef The same systematic review found that spinal manipulation therapy for chronic back pain reduced pain in the short and long term compared with sham manipulation, but found no significant difference in function after 6 weeks. There was no significant difference in pain or function between spinal manipulative therapy and general practitioner care, physical therapy, exercises or back school [17]Level A A randomized controlled trial (RCT) was unable to find a statistically significant difference in pain or function between manipulative therapy and stabilizing exercises at 3 months or 12 months [18]Level A Another RCT compared spinal manipulative therapy with exercise therapy over 2 months in patients with chronic low back pain, and found spinal manipulation significantly decreased pain and increased functioning and return to work at 12 months [19]Level A A second subsequent RCT compared osteopathic manipulation, sham manipulation and no treatment over 5 months in patients with chronic low back pain, and found that both spinal manipulation and sham manipulation significantly reduced pain at 6 months compared with no treatment, but no significant differences in function [20]Level A [17] Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003;138:871-81Abstract PubMed [18] Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Man Ther 2003;8:233-41Abstract PubMed [19] Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Spine 2003;28:525-32Abstract PubMed CrossRef [20] Liccardione JC, Stoll ST, Fulda KG, et al. Osteopathic manipulative treatment for chronic low back pain: a randomized controlled trial. Spine 2003;28:1355-62Abstract PubMed CrossRef

32. Back Pain Management Tools

33. “Ladder” Approach to Pain Management* Traditional “Ladder” Approach to Pain Management* In the traditional approach to chronic pain management, patients are carefully taken step by step through the treatment ladder you see here. The first step is a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). The danger here, of course, is that chronic use may cause renal and hepatic damage. Physical therapy and similar treatments, as well as muscular relaxants, are recommended when NSAIDs fail to control a patient’s pain. If pain is still not under control, the physician moves up the ladder through successive treatments: Nerve blocks Behavioral therapy Corrective surgery Long-term oral opioids Implantable therapies – either neurostimulation or intrathecal pain therapy Finally, the patient arrives, often after many years of therapy, at the option of last resort, neuroablation * Treatment “Ladder” based on E. Krames “Intraspinal Opioid Therapy for Chronic Nonmalignant Pain: Current Practice and Clinical Guidelines,” JPSM 11(6):333-352, Jun 1996.Traditional “Ladder” Approach to Pain Management* In the traditional approach to chronic pain management, patients are carefully taken step by step through the treatment ladder you see here. The first step is a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). The danger here, of course, is that chronic use may cause renal and hepatic damage. Physical therapy and similar treatments, as well as muscular relaxants, are recommended when NSAIDs fail to control a patient’s pain. If pain is still not under control, the physician moves up the ladder through successive treatments: Nerve blocks Behavioral therapy Corrective surgery Long-term oral opioids Implantable therapies – either neurostimulation or intrathecal pain therapy Finally, the patient arrives, often after many years of therapy, at the option of last resort, neuroablation * Treatment “Ladder” based on E. Krames “Intraspinal Opioid Therapy for Chronic Nonmalignant Pain: Current Practice and Clinical Guidelines,” JPSM 11(6):333-352, Jun 1996.

34. Pain Management:A More Flexible Approach* Different time frames Multiple therapies at one time Different starting points Pain Management: A More Flexible Approach The traditional ladder approach suggests an equal trial at every step of the treatment continuum. However, every chronic pain patient is different, and his or her physician’s clinical experience is different. For those reasons, a physician may decide a shorter trial of one type of therapy is sufficient or that multiple therapies can be explored at the same time. Or a physician’s clinical experience and the patient’s condition may suggest a different starting point on the continuum. Implantable therapies should be considered after failure of more conservative measures. Graphic developed by Medtronic Pain Therapies (Medtronic U.S. Pain Business), 2000. Published in Prager J and Jacobs M. Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clin J Pain. 2001 Sep;17(3):206-14. Pain Management: A More Flexible Approach The traditional ladder approach suggests an equal trial at every step of the treatment continuum. However, every chronic pain patient is different, and his or her physician’s clinical experience is different. For those reasons, a physician may decide a shorter trial of one type of therapy is sufficient or that multiple therapies can be explored at the same time. Or a physician’s clinical experience and the patient’s condition may suggest a different starting point on the continuum. Implantable therapies should be considered after failure of more conservative measures. Graphic developed by Medtronic Pain Therapies (Medtronic U.S. Pain Business), 2000. Published in Prager J and Jacobs M. Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clin J Pain. 2001 Sep;17(3):206-14.

35. Epidural Steroid InjectionsEBM-CME The American Academy of Neurology has produced recommendations concerning the treatment of radicular lumbosacral pain with epidural steroid injection. Epidural steroid injection may be associated with short-term improvement in radicular lumbosacral pain it does not, in general, result in any change in the need for surgery at a later date and does not improve pain beyond 3 months. Level C [14] Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;68:723-9Full text PubMed CrossRef [14] Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;68:723-9Full text PubMed CrossRef

36. EPIDURAL STEROID INJECTION The main goal of the epidural injection is to decrease any inflammation response that may be caused from the pressing on a spinal nerve.

37. Diagnostic Facet Injections The rationale for using facet joint blocks for diagnosis is based on the fact that facet joints are capable of causing pain and they have a nerve supply. Blocks of a facet joint can be performed in order to test the hypothesis that the target joint is the source of the patient’s pain Summary of evidence: Based on these evaluations, the validity, specificity and sensitivity of facet joint nerve blocks are considered strong in the diagnosis of facet joint pain. Facet Median Branch blocks can also be done to confirm that the facet is the source of pain. Long term pain reduction may be achieved by Radiofrequency ablation. Facet Median Branch blocks can also be done to confirm that the facet is the source of pain. Long term pain reduction may be achieved by Radiofrequency ablation.

38. Back Pain Management Tools

39. Physical Activity EB-CME A brief period of bed rest may help initially to overcome the severe pain of the acute phase. Clinical trials have shown that there is no benefit from extending the period of bed rest beyond 48h. Studies have shown that an exercise regimen commencing after 6 weeks will yield a superior clinical outcome compared to other forms of treatment.

40. [9] Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract 1997;47:647-52Abstract PubMed [10] Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3 Exercise therapy may improve return to normal daily activities and work in patients with chronic low back pain. Level A Patients who remained active had reduced pain, disability, and time away from work. Level A [9] Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract 1997;47:647-52Abstract PubMed [10] Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3 Exercise therapy may improve return to normal daily activities and work in patients with chronic low back pain. Level A Patients who remained active had reduced pain, disability, and time away from work. Level A

41. Lumbar Traction EBM-CME A systematic review was unable to find any significant benefit for traction in people with acute, sub-acute, or chronic low back pain with or without sciatica. Level A [23] Clarke JA, van Tulder MW, Blomberg SEI, et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2007, Issue 2(Cochrane Review)[23] Clarke JA, van Tulder MW, Blomberg SEI, et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2007, Issue 2(Cochrane Review)

42. Acupuncture EBM-CME Acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Level A [15] Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1 Cochrane Review http://www.cochrane.org/reviews/en/ab001351.html[15] Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1 Cochrane Review http://www.cochrane.org/reviews/en/ab001351.html

43. Back Pain Management Tools

44. Lumbar Microdiscectomy EBM-CME A randomized controlled trial compared early surgery with conservative therapy followed by surgery if the symptoms persisted in people with sciatica lasting longer than 6-12 weeks. It found that at 1 year follow-up, the level of perceived recovery in both groups was similar at 95% . However the group treated by early lumbar disk surgery had a faster recovery from pain and a quicker perceived recovery than the group initially managed conservatively . Level B 11] Peul WC, van Houwelingen HC, van den Hout WB, et al; Leiden-The Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56Abstract PubMed CrossRef [12] Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257-70 Abstract PubMed CrossRef [13] Malmivaara A, Slatis P, Heliovaara M, et al; Finnish Lumbar Spinal Research Group. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 2007;32:1-8PubMed [14] Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;68:723-9Full text PubMed CrossRef http://essentialevidenceplus.com/myaccount/login.cfm?showlogin=true11] Peul WC, van Houwelingen HC, van den Hout WB, et al; Leiden-The Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56Abstract PubMed CrossRef [12] Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007;356:2257-70 Abstract PubMed CrossRef [13] Malmivaara A, Slatis P, Heliovaara M, et al; Finnish Lumbar Spinal Research Group. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine 2007;32:1-8PubMed [14] Armon C, Argoff CE, Samuels J, Backonja MM; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007;68:723-9Full text PubMed CrossRef http://essentialevidenceplus.com/myaccount/login.cfm?showlogin=true

45. Disc Replacement Charite Artificial Disc received FDA approval in October 2004. Allows Motion Preserves disc height. Several different types now: Flexicor shown, Prestige, VertePlex.

46. Patient Education Tell patients your plan and your expectations. Set reasonable expectations. Severity of Acute Pain does not correlate with outcome or duration. Follow up regularly to check response to treatment. Reassess for further diagnostic of therapeutic options.

47. Example Management for HNP Percocett, Gabapentin, PT consult, f/u 2 wks MRI for motor weakness or lost reflexes. Consider EMG. f/u after MRI (3 weeks) After confirmatory MRI, consult Pain for ESI for Pain, consult Surgery for weakness. f/u monthly or after surgery. Duty Status Changes according to plan: Limited Duty, Temporary Profile, etc.

48. Recommended References Lilligard WA. Handbook of Sports Medicine (2nd edition), Butterworth-Heinemann 1999 Magee DJ. Orthopedic Physical Assessment (3rd edition), Saunders 1997 Ferri FF. Ferri's Clinical Adviso, Mosby 2009 Aside from the references shown on the slides.Aside from the references shown on the slides.