1. Lower Back Pain Management

2. Diagnoses  Low back pain  DDD  Facet joint syndrome  Sciatica  Piriformis syndrome  Disc herniation  Sprain / Strain  Muscle spasm

3. Low Back Pain

6. Arthritis/Degenerative Changes  Maintain mobility (ROM)  Strengthen +++  Address muscle imbalances  Typical radiological finding  Symptomatic / Non-symptomatic  Anterolisthesis / Posterolisthesis

7. Sciatica   Lumbar nerve roots   Piriformis   Sacro-iliac joint

8. Nerve Root Compression Foraminal vs Central Stenosis

9. Sciatica

10. Sacro-Iliac Joints

11. Neurological vs Mechanical Origins  Neurological - Pain into the leg - Pins and needles, burning, numbness in the leg - Dermatomes/myotomes - Diminished reflexes - Lateral shifting, its causes and its relevance - SLR test

12. Neurological vs Mechanical Origins  Mechanical - Primary area of pain is in the lumbar area - There may be pain in the buttock or down the leg, almost always above the knee - Neurological tests are negative

13. Sciatica  Maintain / Improve mobility (ROM)  Strengthen +++  Address imbalances / stabilize  Monitor pain, weakness

14. Disc Herniations

16.  Avoid constant and repetitive flexion movements - Crunches - Bike - Reading / TV in bed, counter top use  Favor extension - Strengthen in this position

17. Sprains

18. Sprains  Rest / remain active  Ice

19. Muscle Spasms

20.  Massage  Ice / Heat  Light stretching  Use of muscle relaxants – When and Why?

21. Early Referral to Physiotherapy  Ehrmann-Feldman et al 1996 - with early referral, increase chance of return to work in less than 60 days  Wand et al 2004 - increase function, mood, quality of life, general health - assess/advise/treat model of care is more beneficial than a assess/advise/wait model for acute lower back pain

22. Treatment Protocol   pain - treat the cause, not the symptoms - differentiate the cause of pain   ROM  Strengthen / stabilize  Educate the patient on dos and don’ts, ergonomics, lifestyles, sports

23. Long Term  Stabilization and Reconditioning exercises  “Core stability”  Lifestyle adaptation (work/sports/leisure)  Prevention +++

24. Our Clientele  85% Private patients  15% - CSST - SAAQ - insurance companies

25. Multi-disciplinary Approach  Physiotherapy  Physiotherapy / Occupational Therapy  Rehabilitation - PT - OT - AT - Osteopathy - Psychology (as needed)

26. Occupational Therapy  Case managers  Functional Capacity Evaluations (FCE)  Rehabilitation Programs  Driving Evaluations  PT – OT  Splinting  Communication +++

27. Communication  Progress note  Avis Motivé

28. Questions?

29. Thank you