Johnson et al, 2007 Spine (in press)

Back Pain 2 nd most common cause for office visit 60-80% of population will have lower back pain at some time in their lives Each year, 15-20% will have back pain Most common cause of disability for persons < 45 years

Oh My Aching Back Treatment Options for Back Pain

Sciatica

Outline Part 1: – Introduction – Review of anatomy Part 2: – Acute low back pain Part 3: – Chronic low back pain – Prevention Questions ??

Low Back Pain “One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.” Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:

- Anatomy Lesson #1

- Anatomy Lesson #2

Introduction to Madam “X” Madam “X” has had lower back pain for the past 24 hours that she feels is related to household work that she did over the weekend. She missed work today, Monday. She wants to know what can be done for his back pain?

What should Madam “X” expect from her health care professional? 1. Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. 2. Provide information, advice, and a plan of action.

% of Back Pain due to Herniated Disk? 1. 4% 2. 14% 3. 40% 4. None of the above

Causes of Low Back Pain Lumbar “strain” or “sprain” – 70% Degenerative changes – 10% Herniated disk – 4% Osteoporosis compression fractures – 4% Spinal stenosis – 3% Spondylolisthesis – 2%

Causes of Low Back Pain… Spondylolysis, discogenic low back pain or other instability – 2% Traumatic fracture - <1% Congenital disease - <1% Cancer – 0.7% Inflammatory arthritis – 0.3% Infections – 0.01%

Risk factorsPrognostic factors Physical Age Previous history of LBP Possibly genetic factors? Older age Initial high intensity pain Referred pain to LEX Restriction in two + segments Delay in treatment Occupational Frequent bending Frequent lifting Unusual sitting posture? Increase work tempo Increase quantity of work Work relations Unavailability of light duties Frequent lifting Psychological Low job satisfaction Low social support Cognition Fear avoidance Depression Anxiety Distress Sexual & physical abuse Physical distress Somatisation Catastrophising Etiology of back pain Nikolai Bogduk. Psychology and low back pain. IJOM 9 (2006) 49-53

Sitting conditionRisk factorCS implications Normal prolong sitting noNon Core tensing irrelevant Unusual sitting posture YesAdvice on posture. Core tensing irrelevant Sitting + whole body vibration YesAdvice on occupation Core tensing irrelevant CLBP + sittingMay exacerbate existing LBP Avoid prolong sitting Encourage a dynamic working patterns Core tensing irrelevant CS in relationship to biomechanical factors: sitting

Red Flags History of cancer Unexplained weight loss Intravenous drug use Prolonged use of corticosteroids Older age Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction

Medications Anti-inflammatory medications (NSAID’s): – Beneficial; no differences; watch side-effects Tylenol: Narcotic Pain Relievers: – No more effective than NSAID’s – Many side effects Muscle Relaxants (ie. Flexeril ® ): – Can decrease pain and improve mobility – 70% with drowsiness/dizziness

Chiropractic/Osteopathic Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek) Spinal manipulation Conflicting evidence on the effects of spinal manipulation – ~75-90% improvement anyway within 4 weeks Greater patient satisfaction

Exercise & Bed Rest Advice to stay active: – ‘There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’ – Hurt does not equal harm One or two days of bed rest if necessary Light activity, avoiding heavy lifting, bending or twisting (i.e. walking) No data on any particular exercises

Massage & Physical Therapy Might be beneficial More quality research is needed Different types of massage

Acupuncture Very little quality research and data Seems to indicate that acupuncture is not effective for the treatment of back pain

Other Modalities Back Brace/Corset/Lumbar Support: Traction: Injections: Inconclusive evidence Hot/Cold: Ultrasound:

Madam “X”, again… Now, Madam “X” has not had improvement in her lower back pain and 6 weeks have gone by since the initial painful event. What types of therapies might be beneficial for Madam “X” now?

Role of X-rays (Radiology) Usually unnecessary and not helpful Plain X-ray: – Age>50 years – No improvement after 6 weeks – Other worrisome findings MRI: – After 6 weeks if have sciatica

New England Journal of Medicine (February 2001)

Medications Similar to acute pain…. Antidepressant medications can improve pain relief

Exercises Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another

Sciatica

Sciatica Sleep in semi-fetal position with a pillow between the knees

Injections Epidural injections: – Insufficient and conflicting evidence Facet joint injections: – No improvement Local/Trigger point injections: – Possibly some benefit

Surgery Discectomy improves pain in short term but not long term (i.e. 10 years) Microdiskectomy similar to standard diskectomy Automated percutaneous diskectomy and laser discectomy both less effective ? Arthroscopic discectomy

Other Modalities Back Schools: - possibly effective Multidisciplinary Therapy: - probably yes Spinal manipulation: - conflicting data Massage: - probably yes IDET:

Intradiscal Electrothermal Therapy

IDET No convincing evidence that shows the short or long-term clinical efficacy of this procedure. Safe with few adverse effects ? Long-term effects Wall Street Journal (Feb. 11, 2003)

Prevention Exercise: – Aerobic, back/leg strengthening Back braces and education about proper lifting techniques are ineffective ? weight loss and smoking cessation

Web Resources (“Helping people make well-informed decisions about health care.”)