An approach to Low Back Pain and Neuropathic Pain

1. An approach to Low Back Pain and Neuropathic Pain Russ O’Connor FRCPC (PMR), CASM, EMG

2. Objectives-By the end of the session the participant will be able to: • Outline common causes of low back pain in the Paralympic athlete • Discuss things not to miss in Paralympic athletes with low back pain- the so called RED FLAGS • Discuss treatment suggestions for athletes with low back pain • Discuss how to manage neuropathic pain in the athlete with a disability

3. Why is LBP worth talking about? • Common • 81% of AK and 62% BK amputees1 • ** of SCI • Prevalence in athletes ranges from 10 to 35% • Affects QOL/ sleep/ PERFORMANCE • Physical findings different? • Previous surgery 1Kulkarni et al Clin Rehab. 2005; 19:81-6.room

4. Mr. A.S. • 30 yo paraplegic sit skier- L2 burst # fused with Harrington rods and right femur # • Long standing pain right thigh and shin. • Increased training since torino • Pain increased • Spasms increased • New feeling in post thigh and new muscle bulk right glut

5. Mr. AS • Pain • Burning and electric shoot pain down thigh medial shin and foot • Increased with workouts and ski days esp at night • Settled with rest and gabapentin

6. Mr. AS • Bowel and bladder- no recent fu • Right post thigh pain and swelling with stretch • Meds – • Gabapentin 900-600-900 • Baclofen 5 bid • Sedated

7. Mr. AS- Exam • LNSL L1 right and left but has some feeling to L3 • Some flickers of abduction on right

8. What do you want to know? • What makes you worried?

9. RED FLAGS for LBP in athlete with a disability • Progressive pain • Weight loss • Fevers or ssx of infection Increased None None

10. RED FLAGS for LBP in athlete with a disability • CHANGE in: • Motor or sensory function • Muscle bulk or new atrophy • fasciculation's • Bowel or bladder function • Spasticity New post thigh sensation and bulk None Increased

11. Mr. AS • Careful History - physical • Increased pain • improved in motor sensory function • No new atrophy or fasciculation's • No change in bowel or bladder function • But no recent follow-up • Increased in spasticity or tone

12. What do you think is wrong with Mr. AS? • MSK • Spinal • Hardware issue or instability • Fracture – • Facet degeneration • Spondylolysis or Spondylolisthesis • Deg disc disease – discogenic pain • Mechanical LB muscle Strain – overuse • Peripheral • Buttock / hip • SI • Femur – rod, muscle

13. What do you think is wrong with Mr. AS? • Neuro • Spinal cord • Syrinx • SC compression from disc or central stenosis or infection • Central segmental neuropathic pain • Nerve root • Disc or osteophyte • Peripheral nerve • Pelvis, buttock

14. Mr. AS • Imaging – What would you order • XR spine – no loosening • Bone scan – • CT – best for bone trauma, fast, cheaper • MRI – best for disc or cord • Urology follow up 1 3 2

17. MRI • best for disc or cord but hardware really interferes with quality • L2 central stenosis and at L4/5 as well • Significant artifact making comments on the rest of the structures difficult

18. Treatment - Mr. AS • Goals to allow RTP with less pain and spasms- depends on diagnosis • Conservative – Stretching/ strengthening / PT etc • Medications oral – • Medications injections • Trigger • Epidural • Botox • Surgery?

19. Mr. AS • Oral medications • Spasms – Baclofen 5 bid • Pain - Gabapentin 900/600/900 • Seemed to be enough for awhile but returned with more pain after training • Increased gabapentin and baclofen at night

20. Mr. AS • Discussed with team • Saw – Neurosurgery

21. Mr. AS Returns • Increased pain – having to take more time off • Central stenosis at L2 with preserved L5 function clinically and L4/5 pain pattern.

22. Mr. AS • Other options • Decrease training – competition • Increase or change medications • Trial of injections • Trigger point • Nerve root • Epidural

23. Mr. AS • After L2 epidural steroid • Neuropathic shooting and burning pain down legs much better • Still has activity related axial back pain • Spasms persist Prohibited list

24. L1

25. L2

27. Mr. AS • CT scan shows • fused Tspine to L4 • Severe stenosis at L2 • Widening of disc space and moderate L4/5 canal stenosis • Severe foraminal stenosis at L4.5 and mod at L5-S1

28. Mr. AS- Update • Going for second injection • Still on Gabapentin and Baclofen • Has seen neurosurgery for opinion • Will consider L4/5 injection

29. Neuropathic pain • Why is it worth talking about? • Common- • 2-3 % general population • SCI 54% at 6 months and 75% @5y 1 • Amputee 79.9%2 1MM Backonja and Jordi Serra. Pain Medicine 2004; 5: S1 PS48-S59. 2Ephraim et al. Arch of Phys Med and Rehab 2005; 86:10, P 1910-19.

30. Neuropathic pain • Disabling- QOL, sleep, exercise, work, ADLs3 • Constant in up to 40% of people with SCI • 10% report severity of pain not paralysis prevents employment • 83% people with SCI who are employed state pain interferes with work • Performance!! 3Widerstrom-Nog et al. Arch Phys Med Rehab 2001;82:1271-7.

31. Neuropathic pain • What is it? • IASP = "pains resulting from disease or damage of the peripheral or central nervous systems, and from dysfunction of the nervous system”

32. Neuropathic Pain • Central • Brain • SCI • Peripheral • Root • Plexus • Nerve

33. Classification - Spinal cord injury – Neuropathic pain • Above Level • Compressive neuropathy arms • At Level • Radiculopathy • SCord- syrinx, segmental injury • Below Level

34. Mr. AS • What kind of pain does Mr. AS have? • Below the level of injury - • Neuropathic pain • Axial Low back pain – • Nociceptive – musculoskeletal

35. Ms. BK • 24 yo woman traumatic amputation right below knee in a bicycle accident 3 y ago • Medically well • Pain right leg over distal residual limb, focal severe tenderness, with pressure or touch – severe shooting and stabbing pain • Pain over right foot- feels like foot is being crushed and occasionally like it is burned

36. What type of pain does Ms. BK have?

37. Classification – Amputee Neuropathic Pain • Phantom limb pain • Residual limb pain – stump • Neuroma Other MSK causes for limb pain- Not neuropathic in origin Skin, muscle, bone, joint, ligament

39. Presentation • Description • Burning, shooting, lancinating, electric, itching • Stimulus evoke pain – • hyperalgesia – hurts more than it should • Allodynia – ALL - everything hurts

40. Pathophysiology • Peripheral • Nerve injury and regeneration – neuroma • Neuronal sprouts – aberrant depolarization and increased expression of Na channels and voltage gated Ca ch • Release of Sub P and glutamate • Central • Central Spinal sensitization – NMDA receptor • Periaquaductal gray matter can modulate and suppress or accentuate pain- opioid receptors • Altered connectivity – inapprop connections

41. CMAJ • August 1, 2006 • 175(3) | 269

42. Investigations • Look for treatable causes • Peripheral nerve, plexus, root, SCI or brain causes • Systemic conditions • Diabetes, B12, thyroid, renal and liver disease • Infectious processes- shingles, • Toxic, nutritional defic • Focal conditions • Peripheral compression – carpal tunnel, ulnar, radiculopathy, SCI • Nerve or SCI abnormality – tumor syrinx etc

43. Treatment Look for underlying cause!

44. Treatment • Nonpharmacologic- desensitization, contrast baths, TENS, CBT, meditation, acupuncture • Pharmacologic – • First-line- tricyclic antidepressant or gabapentin • Second line – consider switching or adding adjuvant agent • Third line – opioids* banned

47. Neuropathic pain in SCI • TCA’s less effective There is level 1 evidence (based on two RCTs) that tricyclic antidepressants do not reduce post-SCI pain. GO WITH NEURONTIN OR LYRICA IN SCI

48. Objectives-By the end of the session the participant will be able to: • Outline common causes of low back pain in the Paralympic athlete • Discuss things not to miss in Paralympic athletes with low back pain- the so called RED FLAGS • Discuss treatment suggestions for athletes with low back pain • Discuss how to manage neuropathic pain in the athlete with a disability

49. RED FLAGS for LBP in athlete with a disability • Progressive pain • Weight loss • Fevers or ssx of infection

50. RED FLAGS for LBP in athlete with a disability • CHANGE in: • Motor or sensory function • Muscle bulk or new atrophy • fasciculation's • Bowel or bladder function • Spasticity