Management of Low Back Pain - Prince of Songkla...

Management of Low Management of Low Back PainBack Pain

May 8May 8thth, 2008, 2008

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Patient assessmentPatient assessmentTreatment toolsTreatment tools–– PharmacologicalPharmacological–– NonNon--pharmacologicalpharmacological

Patient assessmentPatient assessment

MusculogenicMusculogenicSpondylogenicSpondylogenicNeurogenicNeurogenicViscerogenicViscerogenicPsychogenic Psychogenic IdiopathicIdiopathic

Patient assessmentPatient assessment

Types : Types : –– Duration of painDuration of pain–– Severity of painSeverity of pain

Previous treatmentPrevious treatment

Investigation Investigation

Acute VS Chronic LBPAcute VS Chronic LBP

Duration : 3 monthsDuration : 3 months

80% of acute LBP resolve within 6 80% of acute LBP resolve within 6 weeksweeks

Precaution : Precaution : red flagsred flags !!!!!!

Red flagsRed flags

DisorderDisorder Medical Medical HistoryHistory

Physical ExamPhysical Exam

FractureFracture Major trauma, such Major trauma, such as vehicular as vehicular accident or fall form accident or fall form height.height.Minor trauma or Minor trauma or strenuous lifting in strenuous lifting in older or older or osteoporoticosteoporoticpatients.patients.

Percussion Percussion tenderness over tenderness over specific specific spinousspinousprocesses.processes.Decrease ROM due Decrease ROM due to protective muscle to protective muscle spasmspasm

Red flagsRed flags

DisorderDisorder Medical Medical HistoryHistory

Physical ExamPhysical Exam

TumorTumor Severe localized Severe localized pain pain History of cancerHistory of cancerAge > 50 yearsAge > 50 yearsUnexplained wt lossUnexplained wt lossPain at night or at Pain at night or at restrest

Percussion Percussion tenderness over tenderness over specific specific spinousspinousprocesses.processes.Decrease ROM due Decrease ROM due to protective muscle to protective muscle spasmspasm

Red flagsRed flags

DisorderDisorder Medical HistoryMedical History Physical ExamPhysical Exam

InfectionInfection Risk factorsRisk factors: recent bacterial : recent bacterial infection (e.g. UTI) infection (e.g. UTI) : : immunocompromisedimmunocompromised(HIV, steroid, transplant) (HIV, steroid, transplant) : fever, chills, : fever, chills, unexplained wt lossunexplained wt loss

Percussion Percussion tenderness over tenderness over specific specific spinousspinousprocesses.processes.Decrease ROMDecrease ROMTachycardia, Tachycardia, tachypneatachypnea, , hypotension, feverhypotension, fever

Red flagsRed flags

CaudaCaudaequinaequinasyndromesyndrome

Direct blow or fall, with Direct blow or fall, with axial loadingaxial loadingPerianalPerianal sensory losssensory lossBowel & bladder Bowel & bladder dysfunctiondysfunctionSevere or progressive Severe or progressive neurological deficit in neurological deficit in lower extremities lower extremities

Laxity of anal Laxity of anal sphinctersphincterMajor motor Major motor weakness (ankle , weakness (ankle , knee)knee)Increased or Increased or decreased reflexesdecreased reflexes

Red flagsRed flags

Dissecting Dissecting abdominal abdominal aortic aortic aneurysmaneurysm

Excruciating low back Excruciating low back painpainHistory of History of atherosclerotic diseaseatherosclerotic diseaseHistory of History of hypertensionhypertension

PulsatilePulsatile midline midline abdominal mass abdominal mass

Red flagsRed flags

Renal colicRenal colic Excruciating pain from Excruciating pain from costovertebralcostovertebral angle to angle to testis or labiatestis or labiaHistory of History of urolithiasisurolithiasis

Possible tenderness Possible tenderness at at costovertebralcostovertebralangleangle

Red flagsRed flags

RetrocecalRetrocecalappendixappendix

ConstipationConstipationSubacuteSubacute onset without onset without inciting eventinciting event

Low grade feverLow grade feverRight lower Right lower quadrant quadrant painpain

Red flagsRed flags

No No ““red flagsred flags”” imaging or other tests imaging or other tests not helpful in first 4not helpful in first 4--6 weeks6 weeks

Investigation Investigation

Identify physiologyIdentify physiology–– Lab chemistryLab chemistry–– Bone scanBone scan–– ElectrodiagnosisElectrodiagnosis

(EMG/NCV/SEP)(EMG/NCV/SEP)

Define anatomicalDefine anatomical–– XX--rayray–– CTCT–– CTCT--myelographymyelography–– MRIMRI

30% False positive of people without symptom at age 30 (incidental finding)

OverinvestigationOverinvestigation

Objective of investigationObjective of investigation

Confirm the Confirm the DxDxCan change the treatment and Can change the treatment and resultresultThe strategy of psychological The strategy of psychological supportsupportReevaluate in nonReevaluate in non--response to response to treatmenttreatment

Common DisorderCommon Disorder

Acute Back StrainAcute Back StrainLumbar Disc Lumbar Disc HerniationHerniationLumbar Spinal Lumbar Spinal StenosisStenosisLumbar Disc DegenerationLumbar Disc DegenerationLumbar Lumbar spondylolisthesisspondylolisthesisChronic nonspecific LBPChronic nonspecific LBP

Treatment toolsTreatment tools

MedicationMedicationPhysical modalityPhysical modalityExercise Exercise Assistive devicesAssistive devicesCognitive & Behavioral ModificationCognitive & Behavioral Modification

Medication Medication

SpecificSpecificSymptomaticSymptomatic

Must think about drug Must think about drug interactioninteraction

SpecificSpecificAs pathologic processAs pathologic processNeurogenicNeurogenic inflammation ?inflammation ?Muscle spasm ?Muscle spasm ?Depression and pain ?Depression and pain ?

Symptomatic : painSymptomatic : painAcetaminofenAcetaminofenNSAIDsNSAIDsMuscle relaxantMuscle relaxantOpioidOpioidTCAsTCAs / SSRI / SNRI/ SSRI / SNRI

AcetaminophenAcetaminophen

Widely and long usageWidely and long usageMultiple mechanism : Interfere Multiple mechanism : Interfere with prostaglandin synthesis in with prostaglandin synthesis in the CNSthe CNSLiver and kidney damage in Liver and kidney damage in prolonged userprolonged userCombination therapy with Combination therapy with tramadoltramadol HClHCl

TramadolTramadol

For moderate to severe painFor moderate to severe painActs via the CNS, binding to the Acts via the CNS, binding to the opioidopioidreceptorreceptorSide effect : nausea, vomiting, Side effect : nausea, vomiting, dizziness, vertigo, itching and dizziness, vertigo, itching and constipationconstipationShould start with lower dosage and Should start with lower dosage and increase slowly until reaching full increase slowly until reaching full dose.dose.

TramadolTramadol

Combination therapy (multimodal Combination therapy (multimodal analgesia)analgesia)–– AcetaminofenAcetaminofen + + TramadolTramadol HClHCl–– Fast actingFast acting + + Prolong effectProlong effect–– Low dose Low dose less less side effectsside effects

NSAIDNSAID

Classical / Conventional NSAIDClassical / Conventional NSAID

Cox2 inhibitorsCox2 inhibitors

NSAIDNSAID

COXIBSCOXIBS

EndotheliumKidneyPlatelet

Platelet Smooth m. vv.Macrophage

Kidney

Mast cellBrain

Airway

GIBrain

KidneySmooth m vv.

UterusAirway

Smooth m.vv.Eye

Prostacyclin Thromboxane A2 Prostaglandin D2 Prostaglandin E2 Prostaglandin F2αProstanoids

Tissue specific isomerasesCOX-1 COX-2

Diverse physical, chemical,Diverse physical, chemical,Inflammatory & Inflammatory & mitogenicmitogenic stimulistimuli

Prophylaxis of NSAIDProphylaxis of NSAID--induced induced GastropathyGastropathyRecommendationRecommendationGI RiskGI Risk Low CV RiskLow CV Risk High CV RiskHigh CV RiskLowLow--riskrisk

No risk factorNo risk factor Classical NSAID, Classical NSAID, lowest effective lowest effective dosedose

NSAID + PPI/NSAID + PPI/CoxibCoxib

CoxibCoxib + PPI/+ PPI/

*NSAID + PPI*NSAID + PPI

CoxibCoxib + PPI+ PPI

NSAID + PPI/NSAID + PPI/Low dose Low dose coxibcoxib

ModerateModerate--riskrisk11--2 risk factors2 risk factors NSAID + PPI/NSAID + PPI/

Low dose Low dose coxibcoxibHighHigh--riskrisk≥≥ 3 risk factors3 risk factorson anticoagulanton anticoagulanton ASA*on ASA*

Avoid NSAIDAvoid NSAID

*NSAID + PPI*NSAID + PPIVery highVery high--riskrisk

Prior PU complicationPrior PU complication Avoid NSAIDAvoid NSAID

Is an NSAID needed ? Inflammation ?

Use non-pharmacologic or other pharmacologic Rx

Is there a contraindication to NSAID ?- Renal insufficiency ( CrCl < 30 )- Allergic reaction- Concurrent GI injury

No Yes

Is there a reason that a classical NSAID cannot be used ?- GI risk+ & Bleeding risk

Use classical NSAID Use COX-2 inhibitor ( or classical NSAID + PPI+)

Is patient at increased risk for CV events ?

Select NSAID on the basis of GI risk Avoid NSAID esp. COX-2 inhibitor

No Yes

Physical modalityPhysical modality

Therapeutic heat and coldTherapeutic heat and cold

MassageMassage

Electrotherapy Electrotherapy

Therapeutic heat and coldTherapeutic heat and cold

HeatHeat•• AnalgesiaAnalgesia•• Muscle Muscle ““spasmspasm””

relaxationrelaxation•• HyperemiaHyperemia•• Increased collagen Increased collagen

extensibilityextensibility

ColdCold1.1. AnalgesiaAnalgesia2.2. Muscle Muscle ““spasmspasm””

relaxationrelaxation3.3. Decreased Decreased

swellingswelling

Gate control Gate control theorytheory

Heat modalityHeat modality

Contraindication of heatContraindication of heat

Acute hemorrhage, inflammation, Acute hemorrhage, inflammation, or traumaor traumaIschemiaIschemiaInsensitivityInsensitivityMalignancyMalignancyInability to respond to painInability to respond to painAtrophic or scarred skinAtrophic or scarred skinBleeding Bleeding dyscrasiasdyscrasias

Cold modalityCold modality

Contraindication of coldContraindication of coldIIschemiaschemiaRaynaudRaynaud’’ss syndromesyndromeCold insensitivityCold insensitivityInability to respond to painInability to respond to painCold allergyCold allergycryoglobulinemiacryoglobulinemia

Massage Massage

Electrotherapy Electrotherapy

Exercise Exercise

General (aerobic exercise) General (aerobic exercise)

Specific (back exercise)Specific (back exercise)

Back exerciseBack exercise

Flexibility exerciseFlexibility exercise

Strengthening exerciseStrengthening exercise

Flexion or Extension groupFlexion or Extension group

HNP patientsHNP patients

Encourage back extension Encourage back extension exerciseexercise–– Stretching hip flexor, abdominalStretching hip flexor, abdominal–– Strengthening Strengthening paraspinalparaspinal musclemuscle

HNP patientsHNP patients

Spinal Spinal stenosisstenosis patientspatients

Encourage back flexion exerciseEncourage back flexion exercise–– Stretching the muscles of the back Stretching the muscles of the back

that hold the spine in extension that hold the spine in extension (backwards bending)(backwards bending)

–– Strengthening the muscles that Strengthening the muscles that bring the spine into flexion (forward bring the spine into flexion (forward bending)bending)

Spinal Spinal stenosisstenosis patientspatients

Alternative versionAlternative version

Assistive devicesAssistive devices

LS supportLS supportLumbar corsetLumbar corset

Assistive devicesAssistive devices

Ergonomics Ergonomics

Good postureGood posture

Right mannerRight manner

Proper environmentProper environment

LyingLying

SittingSitting

Standing Standing

Lying : acute painLying : acute pain

LyingLying

Sitting Sitting

Standing Standing

Good PostureGood Posture

Standing Standing

Lifting TechniqueLifting Technique

Instruction for sitting and Instruction for sitting and liftinglifting

Symptoms severitySymptoms severityNone None MildMild ModerateModerate SevereSevere

Sitting (min)Sitting (min) 5050 2020

Lifting (men, lbs)Lifting (men, lbs) 8080 6060 2020 2020

Lifting (women, lbs)Lifting (women, lbs) 4040 3535 2020 2020

Cognitive and behavioral Cognitive and behavioral modificationmodification

Cognitive errorsCognitive errors

Wrong and illness behaviorWrong and illness behavior

Cognitive errorsCognitive errors

How to treat How to treat degenerative degenerative process ?process ?

Wrong and illness behaviorWrong and illness behavior

Spiritual partSpiritual part

Algorithm Algorithm

From : From : UU..SS.. AgencyAgency forfor HealthHealth CareCarePolicyPolicy andand ResearchResearch

Management of Low Back Pain - Prince of Songkla...

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