Chronic Low Back Pain: Beyond Narcotics

1. Chronic Low Back Pain: Beyond Narcotics May S. Jennings, MD February 5, 2008 GIM Conference

2. Learning Objective To develop a reasonable approach to the patient with chronic, non-specific low back pain Chronic is defined as > 4 monthsChronic is defined as > 4 months

3. Russell Clinic Patient 36yo WF here to establish primary care with a chief complaint of persistent low back pain 6 months duration, no radiation, no weakness, no incontinence, no fever, no recent trauma One prior episode 15 years ago when she lifted a canoe, completely resolved Husband�s Lortab helped some

4. Russell Clinic Patient PMHx sig for hypothyroidism and depression Only medication is Synthroid Used to work part-time in retail, now works at home with her 2 preschool children Accompanied by her mother and her husband Neurologic exam is normal Family is concerned because she just �lays on the couch all day� and is unable to care for her childrenFamily is concerned because she just �lays on the couch all day� and is unable to care for her children

5. Sources of Data �Persistent Low Back Pain� in NEJM, May 5, 2005 by Eugene Carragee 3 clinical guidelines on low back pain diagnosis and treatment in The Annals of Internal Medicine, October 2, 2007 by Roger Chou, et al Up to Date articles by Roger Chou

6. Quality of Evidence Expert opinion based on meta-analyses Predominantly 2B recommendations Weak recommendation Best evidence of the benefits and risks comes from randomized, controlled trials with important limitations or very strong evidence of another form

7. Outline Definitions and Epidemiology Risk factors for persistent disability Evaluation Psychosocial assessment Diagnostic studies Treatment Patient Education Pharmacologic Non-pharmacologic Interventional An approach to diagnosis and therapy

8. Classification of Low Back Pain Low back pain without obvious etiology (non-specific) Low back pain associated with radiculopathy or spinal stenosis Low back pain associated with other specific causes Chronic = > 4 months duration

9. Epidemiology Among healthy, active adults the prevalence of low back pain may be as high as 15% annually Acute back pain usually resolves within a month Very small percentage of patients continue to have significant persistent back pain

10. Risk factors for the development of persistent disability from back pain Pre-existing psychological distress Depression Passive coping strategies Disputed compensation issues Other types of chronic pain Job dissatisfaction High level of �fear avoidance� Only 6% of these patients were out of work more than a week per year due to back painOnly 6% of these patients were out of work more than a week per year due to back pain

11. Evaluation:Psychosocial Assessment Psychosocial factors are an even greater predictor of low back pain outcomes than either physical exam findings or severity and duration of pain No good tool to use here

12. Evaluation:Diagnostic Testing Plain films Cancer Vertebral compression fracture Ankylosing spondylitis MRI Cancer in pt with known cancer Vertebral infection Cauda equina syndrome Severe, progressive neurologic deficits Symptoms > 1 month?

13. Evaluation:Diagnostic Testing 85% of patients with chronic low back pain have nonspecific patterns on MRI Patients should be warned that the purpose of the MRI is to rule out certain emergency diagnoses and that �degenerative changes� are expected �Degenerative changes� are very common in the asymptomatic adult as well

14. Treatment:Patient Education Treatment goals should be directed at restoring function and adaptive strategies rather than a cure Self care education booklets are helpful Self care education booklets are even more helpful in acute low back pain.Self care education booklets are even more helpful in acute low back pain.

15. Treatment:Patient Education Patients should remain active Patients may benefit from adaptations in the workplace Medium-firm mattresses No lumbar supports

16. Treatment: Pharmacologic Recommended Acetaminophen NSAIDs Tricyclic antidepressants Tramadol Opiates Herbal therapies (?) Devil�s claw Willow bark Capsicum NOT Recommended Muscle Relaxants Benzodiazepines SSRIs Trazodone Gabapentin Other antiepileptics Systemic corticosteroids Acetaminophen is cheaper and safer. NSAIDS slightly more potent. Tricyclic antidepressants have been shown to relieve pain in the absence of depression, but have many side effects. Acetaminophen is cheaper and safer. NSAIDS slightly more potent. Tricyclic antidepressants have been shown to relieve pain in the absence of depression, but have many side effects.

17. Tramadol and Opiate Use For severe, disabling pain that is not controlled by other means Should not be used in patients that appear vulnerable to addiction An initial time course and list of goals should be established for re-evaluation

18. Treatment: Non-pharmacologic Important components of physical therapy Individual tailoring of exercises Supervision Stretching Strengthening

19. Treatment: Non-pharmacologic Recommended Intensive interdisciplinary rehabilitation Exercise therapy Acupuncture Massage therapy Spinal manipulation Yoga Cognitive-behavioral therapy Progressive Relaxation NOT Recommended Traction Trancutaneous electrical nerve stimulation (TENS) Acupressure Neuroreflexotherapy Percutaneous electrical nerve stimulation Interferential therapy Low-level laser therapy Shortwave diathermy Ultrasonography Back schools Patient expectatations of benefit influences outcomes. Traction and TENS units have been studied and are not effective. The rest under the �NOT recommended� category are not well studied or not widely available in the United States.Patient expectatations of benefit influences outcomes. Traction and TENS units have been studied and are not effective. The rest under the �NOT recommended� category are not well studied or not widely available in the United States.

20. Treatment:Interventional Injections NOT Recommended Surgery NOT Recommended Not effective. Spinal fusion most commonly done surgery. Some benefit short term (1-2 years) but not at five years as compared to physical therapy alone in large trial.Not effective. Spinal fusion most commonly done surgery. Some benefit short term (1-2 years) but not at five years as compared to physical therapy alone in large trial.

21. An Approach to the Patient with Non-specific Chronic Low Back Pain

22. Russell Clinic Patient 36yo WF here to establish primary care with a chief complaint of persistent low back pain 6 months duration, no radiation, no weakness, no incontinence, no fever, no recent trauma One prior episode 15 years ago when she lifted a canoe, completely resolved Husband�s Lortab helped some

23. Russell Clinic Patient PMHx sig for hypothyroidism and depression Only medication is Synthroid Used to work part-time in retail, now works at home with her 2 preschool children Accompanied by her mother and her husband Neurologic exam is normal

24. Recommendations for Our Patient 1. Patient Education 2. Psychosocial screening 3. Re-check thyroid studies 4. Acetaminophen or NSAIDs 5. Physical Therapy 6. Close follow-up for several months to assess progress