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Nontraumatic Low Back Pain

Nontraumatic Low Back Pain. Sarah McPherson Oct. 3, 2002. Why is it important?. High disease prevalence most expensive cause of work-related disability wide variations in medical care. Sickness days appear to be increasing. Waddell, G. Ann Rheum Dis . 1993;52:317-19.

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Nontraumatic Low Back Pain

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  1. Nontraumatic Low Back Pain Sarah McPherson Oct. 3, 2002

  2. Why is it important? • High disease prevalence • most expensive cause of work-related disability • wide variations in medical care

  3. Sickness days appear to be increasing Waddell, G. Ann Rheum Dis. 1993;52:317-19

  4. Practice patterns in the USA • US National survey of 114 ER physicians • answered questionnaire of case vignettes • results reflect that practice pattern does not follow recommended guidelines or the medical literature Elam KC, J Emerg Med.1995;13(2):143-50

  5. What causes low back pain? • May originate from many spinal structures: • ligaments • facets • periosteum • muscles • fascia • blood vessels • nerve roots • anulus fibrosus • ~ 85% no pathoanatomical diagnosis

  6. Important questions to ask • Is there a systemic disease that is the source for the pain? • Is there any indication that surgical evaluation is required? • How can I provide the best symptomatic relief? • Can I help to prevent chronicity or recurrence?

  7. What are the indications for further imaging? AHCPR guidelines for the ordering of radiographs: Possible Fracture: Possible tumor or infection: major trauma > 50yrs minor trauma age >50 < 20 yrs chronic steroid use history of cancer osteoporosis constitutional symptoms recent bacterial infection iv drug use immunosuppression supine pain nocturnal pain

  8. Problems with the AHCPR guidelines • There has been no prospective validation therefore we do not know the sensitivity or specificity • following the guidelines would increase utilization by ~ 200% Suarez-Almazor.JAMA .1997 277(22). 1782-86 • plain radiographs are not sensitive for the diseases that require specific therapy • 23% epidural abscess, 25% disc space infection, 68% bone tumor, 90% vertebral osteomyelitis Liang, M. Arch Intern Med. 1982, 142: 1108-12 • radiation dose of lumbar radiographs 40X > than CXR Whalen, JP.Dis Mon. 1982;28:73

  9. What about MRI? • Advantages: • highly sensitive for the detection of infection, tumors, nerve root compression, spinal stenosis • Disadvantages: • imaging may not correlate with clinical disease • 25% of asymptotic patients have disc herniation • 50% healthy young adults will have bulging or degenerative discs on MRI Jarvik, J.Radiology.1997;204(2):447-54 • cost effectiveness

  10. So when should you order an MRI? • No validated clinical guidelines • Recommendations: • clinical suggestion of underlying infection • clinical suggestion of underlying cancer • persistent neurologic deficit • evidence of cauda equina syndrome

  11. When is surgical evaluation required? • Cauda equina syndrome (surgical emergency) • bladder or bowel dysfunction (usually urinary retention) • numbness to perineum and medial thighs (saddle distribution) • bilateral leg pain, weakness and numbness • progressive or severe neurologic deficits • persistent neuromotor deficit after 4-6 weeks • persistent sciatica for 4-6 weeks (not low back pain alone) Deyo, RA. NEJM. 2001; 344(5): 363-70

  12. Pharmaceutical treatment of LBP AHCPR Guidelines: • Recommended medications: • Acetominophen • NSAIDs • “Optional” medications: • muscle relaxants • opioids for < 2 weeks • Recommended against: • opioids > 2 weeks • phenylbutazone • oral steroids • colchicine • antidepressants

  13. Evidence for NSAIDs • NSAID vs Placebo • 9 RCT (5 high quality, 4 low) • heterogeneity between studies with respect to dosing, mode of administration and type of NSAID RESULTS: • NSAIDs provide better pain control than placebo • improved global improvement in patients treated with NSAIDs • decreased need for additional analgesia in NSAID groups van Tulder, MW. Spine 2000;25:2501-13

  14. Evidence for NSAIDs • NSAID vs Acetominophen • 5 RCT (1 high quality, 4 low) RESULTS: • 2 low quality studies showed no difference • 1 low quality and 1 high quality showed superiority of NSAID for pain control Bottom line: Conflicting evidence but NSAIDs appear more effective than acetominophen van Tulder, MW. Spine 2000;25:2501-13

  15. Evidence for NSAIDs • NSAID + muscle relaxant • 3 RCT (1 high quality, 2 low quality) Results: • all 3 studies showed combined therapy to be better than NSAID alone but results not statistically significant van Tulder, MW. Spine.2000;25:2501-13

  16. Evidence for NSAIDs • Comparisons of different NSAID types • 24 trials • looked at ibuprofen, indomethacin, diclofenac, ketorolac, tenoxicam, piroxicam, naproxen RESULTS: • equal efficacy

  17. Evidence for NSAIDs • NSAID vs COX-2 • RCT • N = 104 • nimesulide vs ibuprofen Results: • no difference in pain or stiffness scores • no difference in side effects Pohjolainen, T. Spine 2000; 25(12):1579-85

  18. What about muscle relaxants • 14 RCT (8 high quality, 6 low quality) • 8 high quality: • 5 showed improvement in pain intensity, 3 no difference • many different muscle relaxants studied (cylcobenzaprine, tizanidine, diazepam, baclofen, butabarital) • all appear to have equal efficacy however good studies with head to head comparisons are lacking van Tulder, MW. Spine. 1997;22(18): 2128-56

  19. Cyclobenzaprine (Flexeril) • 14 RCT’s reviewed in meta-analysis • all studies but 2 treated for > 14 days • dosing was 10mg tid • Outcomes measured: • local pain • muscle spasm • tenderness to palpation • range of motion • activities of daily living

  20. Cyclobenzaprine - outcomes • Moderate improvement for all outcome measures • NNT = 3 Browning, R. Arch Intern Med. 2001; 161:1613-20

  21. Cyclobenzaprine - Side effects • 53% of patients experience at least one side effect compared with 28% in the placebo group

  22. What if your patient prefers “natural” remedies? • The efficacy of willow bark extract • RCT: high (240mg) and low dose(120 mg) willow bark vs placebo • N = 210 • outcomes measures VAS at 4 weeks, need of break-through analgesia • Results: high dose > low dose > placebo Chrubasik, S. Am J Med.2000;109:9-14

  23. Medical Management - What should you choose? • Regular dosing of NSAID of your choice for 1-2 weeks • addition of muscle relaxant (warn of side effects), acetominophen or a narcotic may be of benefit • the optimal combo of meds and duration is not known

  24. To rest or not to rest? • current guidelines advocate bed rest for a maximum of 2 days for LBP and up to 2 weeks for sciatica QUESTIONS: • Is there any evidence to suggest that bed rest may improve recovery? • Is there any evidence that bed rest may be harmful?

  25. Bed rest has not been shown to be effective treatment for LBP Systematic review: • 10 trial identified evaluating therapeutics of bed rest • length of bed rest varied from 2-7 days • 8 trials showed no difference in pain scores or activities of daily living • despite differences in length of rest, no trials showed a difference or efficacy of bed rest Waddell, G. Br J Gen Prac. 1997;47:647-52

  26. Could bed rest actually have negative effects? Bed rest vs Exercises vs ordinary activity? • RCT to 3 groups (N= 67,52,67) • outcome measures of duration & intensity of pain, absence from work, ability to work, & Oswestry back disability index • groups evaluated at 3 and 12 weeks • control group had less absenteeism, decrease pain intensity scores and similar satisfaction to bed rest group Malmivaara, A. NEJM.1995;332(6):351-55

  27. 3 week outcomes

  28. Outcomes at 12 weeks

  29. Bed rest for Sciatica • RCT 2 weeks bed rest vs normal activity • N = 92 & 91 • outcome measures: global assessment of function, pain scores, absenteeism, surgical requirements • evaluated at 3 and 12 weeks Vrooman, PCAJ. NEJM.1999;340(6):418-23

  30. Bed rest for sciatica Results: • 10 % lost to follow-up • mean # days in bed 22hr vs 10 hrs • no difference in outcome measures at 3 or 12 weeks • Bed rest is definitely not more effective in treating sciatica • Is it harmful? - this study does not answer that & no other studies were found in my review

  31. Physiotherapy and exercise programs Systematic Review – 1991 • 16 studies identified • Only 4 high quality studies • Different types of therapy studied • Chronic and acute LBP • 10 studies reported no difference between treatment and nontreatment groups • 6 studies reported positive results in the PT group Koes, BW. BMJ. 1991;302:1572-6

  32. What is the role of physiotherapy? • Since 1991 5 more studies looking at PT for acute LBP Positive Studies • 1 study identified • Retrospective review of randomly selected patients with acute LBP • Looked at 3 groups (immediate PT, start at 2-7 days or Pt started at 8-179days) • Delayed therapy group had increased absenteeism and more physician visits

  33. What is the role of physiotherapy? • 4 negative studies Cherkin et al , NEJM. 1998; 339(15) 1021-9: • prospective RCT McKenzie PT vs chiro vs educational booklet • N = 323, LBP < 7 days • PT and chiro group had less “bothersome” symptoms at 4 weeks but not at 12 weeks • no difference in Roland disability scores, absenteeism or recurrences at 1 or 2 years • PT and chiro costs similar, both +++ more expensive than educational booklet

  34. What is the role of physiotherapy? Faas, A et al. Spine 1995;20(8):941-7: • prospective RCT • no treatment vs PT vs sham PT • N= 473, LBP < 3 weeks • Outcomes: • higher absenteeism in PT group • no difference in releif from symptoms • no decreased duration of pain episodes • follow-up at 1,2,4 and 12 months

  35. What is the role of physiotherapy? Dettori, JR et al. Spine. 1995;20(21):2303-12: • prospective RCT • flexion vs extension exercises vs no exercises • N = 152, LBP < 7 days • Outcomes: • no difference in pain scores • no difference in disability scores • no difference time to return to work • ~60% recurrence rate at 6-12 months in all categories • follow-up at 1,2& 4 weeks, and at 6-12 months

  36. What is the role of Physiotherapy? • Does not appear to decrease acute symptoms • does not appear to decrease recurrence of back pain • despite the literature, physiotherapists are convinced from experience that it works

  37. What about spinal manipulation? • Meta-analysis of 7 studies • LBP 2-4 weeks • improvement in pain at 2-3 week post onset of treatment (50% vs 67%) • difference gone within weeks to months • studies did not look at disability scores or work absenteeism Shekelle, PG.Ann Intern Med. 1992;117(7): 590-8

  38. Is there a role for Acupuncture? • Number of studies have been done looking at the role in chronic LBP (> 3 months) • no studies looking at acupuncture acutely • appears to be beneficial in reduction of pain, improved activity, and decreased analgesic requirements Ernst, E. Arch Intern Med. 1998;158:2235-41 Christer, C. Clin J pain. 2001;17(4): 296-305 Ghoname, E. JAMA. 1999;281(7): 818-23

  39. Overview of non pharmaceutical interventions • Bed rest is not helpful and is probably harmful • Physiotherapy does not appear to reduce symptomatology or prevent recurrence • spinal manipulation may reduce short term symptoms but loses its effect in the long term • accupuncture appears to be helpful in chronic LBP

  40. Factors predicting chronicity • ~ 10% of all LBP becomes chronic • Risk factors include: • psychosocial issues primarily • fear avoidance model • depression • poor coping skills • chronic daily stress • poor job satisfaction • clinical • large disc protrusion Williams, R. Arch Phys Rehab Med. 1998;79:366-73 Burton, K. Spine. 1995;20(6): 722-8 Hasenbring, M. Spine. 1994: 19(24): 2759-65 Klenerman, L. Spine. 1995: 20(4): 478-84

  41. Can we influence the path to chronicity? • Prospective study of high risk patients • treatment of risk factor based cognitive behavioral intervention vs electromyographic biofeedback (relaxation techniques) vs no intervention • improved pain reduction, decreased immobility in daily life, decreased depression immediately post intervention and at 6 months • high risk patients with intervention had results similar to low risk patients Hasenbring, M. Spine. 1999;24(23):2525-35

  42. Can we influence Chronicity • Prospective RCT educational booklet vs advice consistent with current guidelines

  43. Can we influence chronicity • Effects of the booklet • improvement in beliefs at 1 year • decreased fear avoidance beliefs • improved Roland disability scores • no difference in pain scores Burton, K. Spine. 1999; 24(23): 2484-91

  44. Can we influence patients returning to normal work? • The sooner the recommendation to return to work is made, the more likely the patient will comply • the probability of return to work decreases as length of time off work increases • subjective pain ratings does not correlate with a person’s ability to accomplish physical activities Hall, H. Spine. 1994; 19(18): 2033-37

  45. Influencing return to work • Prospective study looking at unrestricted return to work recommendations vs return to work with restricted duties • enrolled patients through their PT rehabilitation program • part way thorough they enforced that all patients be given unrestricted return to work instructions regardless of pain ratings • OUTCOMES: • increased return to work in unrestricted group (84% vs 47%) Hall, H. Spine . 1994;19(18): 2033-37

  46. Overall recommendations • Regular NSAID +/- muscle relaxant/Tylenol • Spinal manipulation likely shortens course of symptoms • PT may be helpful • education emphasizing benign course of disease and encouragement to decrease fear avoidance behaviors

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