1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID:

2. AR-IMPACT Team Members
Michael Cucciare, PhD
Johnathan Goree, MD
Corey Hayes, PharmD
Teresa Hudson, PharmD, PhD
Shona Ray-Griffith, MD
Leah Tobey, PT, DPT
Graduate Student: Andrea Melgar-Castillo

3. Flow of the Case Conferences
General Information: 5 minutes
Topic Presentation: 20 minutes
Case Conference: 25 minutes
Feedback and Thoughts on Future Sessions: 5 minutes

4. AR-IMPACT website: arimpact.uams.edu
AR-IMPACT address:
Joining the Conference:
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5. Faculty Disclosure of Financial Relationships:
The planners of this RSS, Corey Hayes, Michael Cucciare, Johnathan Goree, Leah Tobey, Teresa Hudson, Marti Morrison and Cathy Buzbee have no financial relationships with commercial interests to disclose. A planner of this RSS, Shona Ray-Griffith, MD, has a financial relationship with a commercial interest to disclose: Neuronetics, Inc. – Contracted Research. The speaker of this RSS has no financial relationships with commercial interests to disclose. The accreditation compliance reviewers of this RSS, Karen Fleming and Courtney Bryant, have no financial relationships with commercial interests to disclose.

6. Continuing Education
Accreditation: In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Credit Designation: The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 ANCC contact hour. Nurses must attend the entire session in order to receive credit.
This knowledge-based activity will provide pharmacists up to 1.0 contact hours or 0.1 CEU. ACPE# JA L01-P
AAFP Credit: Submit your AMA credit
Pharmacists: Please us your NABP number and month and day of birth

7. Other General Information
CISCO IPhone App
CISCO Meeting Information
Please mute your microphone in CISCO
Able to ask questions through CISCO Chat

8. Tips: Chronic Back Pain.
Johnathan Goree, MD
Director of Interventional Pain Management Services
Assistant Professor
Department of Anesthesiology
University of Arkansas for Medical Sciences

9. Outline Anatomy of Chronic Back Pain?
2 minute lumbar spine examination

10. Why Back Pain?
8 out of 10 people experience some type of back pain during their lifetime.
One quarter of adults have reported having low back pain lasting at least one whole day in the past three months.
Total direct costs of chronic low-back pain-related health care utilization are estimated to be $90 billion a year.

11. Categories of Chronic Back Pain
Axial
Pain along the axis of the spine
Usually Isolated in Low back
Sometimes has referral patterns to buttocks, posterior (and even anterior) thighs
Never pain below the knees.
Radicular
Pain extending to one of more extremity
Characterized by pain in legs.
Usually burning or electric in character
Usually in a dermatomal pattern or in a specific nerve distribution.

12. Axial Pain Generating Structures
Muscle/Skin
Facet Joints
Intervertebral Discs
Vertebral fractures
Sacroiliac Joints

13. Axial Pain Generating Structures
Muscle/Skin
Facet Joints
Intervertebral Discs
Vertebral fractures
Sacroiliac Joints

14. Facet Joints

15. Facet Joint

16. Facet Mediated Pain/Facet Arthropathy
Diagnosis
Clinical
Based on History of Physical
Can be confirmed with diagnostic facet and medial branch procedures
Typical History
Axial low back pain
Worse when standing or walking
Have to lean on counter when washing dishes or brushing teeth
Osteoarthritis in geriatric population
Car accidents/ Whiplash
Morning stiffness

17. Facet Referral Patterns

18. Intervertebral Discs

19. Discogenic Pain Diagnosis Typical History Clinical
Based on History of Physical
Can be confirmed with Imaging
Typical History
Axial low back pain
Worse when bending or sitting
Intermittent radicular component
Often after acute event
Often associated with spasm

20. Discogenic Pain

21. Vertebral compression fractures
Osteoporosis prevalence
44 million or 55% of people over 50 years of age
Increasing prevalence with aging population
Prevalence expected to double by 2040

22. Vertebral Compression Fracture
Diagnosis
Initially Clinical
Confirmed with X-ray
MRI will determine age of fracture and what treatment can be offered
Typical History
Sudden axial Low back pain
Often after fall or trauma
Often in geriatric population
High risk for Osteoporosis
Patients with history of fractures at higher risk

23. Basic Lumbar Spine Examination
Ambulation (can begin in the waiting room)
Could gait be causing pain or be a result of pain?
Inspection
Look for signs of imbalance, skin disease, or trauma
r/o scoliosis, shingles, spasm
Flexion and Extension
Look for worsening/improvement of pain by position
r/o facet disease or disc disease

24. Basic Lumbar Spine Examination II
Palpation
Midline palpation (r/o compression fractures)
1 cm from midline (r/o facet disease)
Quadratus lumborum (r/o myofascial disease)
Heel and Toe walk
Screening test for lower leg strength
FABER and Log Roll
r/o causes of hip pain and SI joint pain.

25. FABER

26. Summary The vast majority of lumbar spine pain is myofascial in nature
Ruling out other causes of lumbar spine pain can allow for more expedient treatment if conservative management fails
There are multiple structures that can cause acute or chronic lumbar spine pain
A quick examination of the lumbar spine can be done in less than 2 minutes.

27. Questions about the Topic
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28. Case Conference and Feedback
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