Management of Low Back Pain - Prince of Songkla...
Transcript of Management of Low Back Pain - Prince of Songkla...
Management of Low Management of Low Back PainBack Pain
May 8May 8thth, 2008, 2008
Heading Heading
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
DisorderDisorder Medical HistoryMedical History Physical ExamPhysical Exam
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
DisorderDisorder Medical HistoryMedical History Physical ExamPhysical Exam
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
DisorderDisorder Medical HistoryMedical History Physical ExamPhysical Exam
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
DisorderDisorder Medical HistoryMedical History Physical ExamPhysical Exam
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
Medication Medication
SpecificSpecificAs pathologic processAs pathologic processNeurogenicNeurogenic inflammation ?inflammation ?Muscle spasm ?Muscle spasm ?Depression and pain ?Depression and pain ?
Medication Medication
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
brain
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
Yes
No
Is there a reason that a classical NSAID cannot be used ?- GI risk+ & Bleeding risk
YesNo
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
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
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
HNP patientsHNP patients
Encourage back extension Encourage back extension exerciseexercise–– Stretching hip flexor, abdominalStretching hip flexor, abdominal–– Strengthening Strengthening paraspinalparaspinal musclemuscle
HNP patientsHNP patients
HNP patientsHNP patients
HNP patientsHNP patients
Spinal Spinal stenosisstenosis patientspatients
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
Spinal Spinal stenosisstenosis patientspatients
Spinal Spinal stenosisstenosis patientspatients
Alternative versionAlternative version
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
Good postureGood posture
LyingLying
SittingSitting
Standing Standing
Good postureGood posture
Lying : acute painLying : acute pain
Good postureGood posture
LyingLying
Good postureGood posture
LyingLying
Good postureGood posture
Sitting Sitting
Good postureGood posture
Sitting Sitting
Good postureGood posture
Sitting Sitting
Good postureGood posture
Good postureGood posture
Sitting Sitting
Good postureGood posture
Standing Standing
Good PostureGood Posture
Good postureGood posture
Standing Standing
Lifting TechniqueLifting Technique
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
Cognitive errorsCognitive errors
How to treat How to treat degenerative degenerative process ?process ?
Wrong and illness behaviorWrong and illness behavior
Wrong and illness behaviorWrong and illness behavior
Spiritual partSpiritual part
Spiritual partSpiritual part
Algorithm Algorithm
From : From : UU..SS.. AgencyAgency forfor HealthHealth CareCarePolicyPolicy andand ResearchResearch