Professional Documents
Culture Documents
ORTHOPEDIST--33%
DC, PAIN
MGMT/OTHER-17%
OEM Mission
5
Epidemiology-Natural History
• Lifetime incidence of Acute Low Back Pain is 60-90%
of the population annual incidence 5% of
population.
• 2nd to 5th chief complaint seeing primary care
specialists.
• Natural history of acute low back pain favorable-
90% resolve within in 6-12 weeks.
• Vs. Chronic low back pain-13 million physician visits
annually for-prevalence, disability & expense
remain high.
• Back pain is the number one cause of disability in
U.S. for people under 45 years.
Epidemiology
• Epidemic of back pain in industrialized countries.
• One of the most expensive medical conditions,
especially when work disability is considered.
• 2005 expenditures to treat ~86 billion annually.
• An ‘illness in search of a disease’…
• Multiple synonyms-lumbar sprain/strain, lumbago,
regional back pain, musculoligamentous strain,
sprain.
JAMA: 2008
Natural History
• LBP/musculoskeletal complaints are the second
to fifth most common reason for outpatient
primary care physician visits.
• Most resolve with conservative measures.
• However, only 14% have LBP as long as 2 wks.
• 1.5% present with sciatica.
• 98% of clinically important disc herniations
occur at L4-5 (the L5 root) or L5-S1 (the S1
root).
Top 10 most common reasons for
seeing the doctor were (14K patients).
• 1. Skin disorders, including cysts, acne and dermatitis.
2. Joint disorders, including osteoarthritis.
3. Back problems.
4. Cholesterol problems.
5. Upper respiratory conditions.
6. Anxiety, bipolar disorder and depression.
7. Chronic neurologic disorders.
8. High blood pressure.
9. Headaches and migraines.
10. Diabetes.
• St. Sauver, JL. J. Mayo Clinic Proceedings. 2013. Vol 88, No
1, pp. 56-7.
Guidelines
• American College of Physicians and the
American Pain Society formed the Clinical
Annals of Internal Medicine (2007). Two
primary principles.
• Most low back pain improves without
intervention, and although the history and
physical are the cornerstones of management
• Costly radiologic evaluation of patients with
low back pain was still popular in 2007.
Multiple Guidelines-Literature Ratings
• 1. Systemic Review-Meta Analysis
• 2. Controlled Trial-RCT.
• 3. Cohort Study-Prospective/Retro.
• 4. Case Control Series.
• 5. Unstructured Review.
• 6. Nationally Recognized Guidelines (Guidelines.gov).
• 7. State Treatment Guidelines.
• 8. Other Treatment Guidelines.
• 9. Textbook.
• 10. Conference Proceedings.
http://www.acoem.org/Guidelines.aspx
Primary Differential
• Kidney-lytic
• Thyroid-lytic
• Lung-lytic
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Psychological Social
Clinical Management-Functional Recovery
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MRI Imaging
• Although MRI is very sensitive, providing excellent
view of soft tissues and vertebrae.
• Limitation is lack of specificity—false positives.
• NEJM study of 98 asymptomatic individuals between
20 and 80 years (average 42.3).
• 52% had a bulge at least one level.
• 27% had a protrusion.
• 1% had an extrusion.
• Jensen MC, et. Al, MRI of the Lumbar Spine in People without
Back Pain, NEJM, 1994, Jul 14, 331(2): 69-73.
Back Pain & MRI
50
Medication Management
• APAP and non-selective NSAIDS Recommended
for acute low back pain as a first line to allow
activity and functional restoration.
• Associated with NNT of 2-3 for a 50%
reduction in pain.
• Muscle relaxants are an alternative.
• Use opioids uncommonly in severe cases
presentations for short period-up to 2 weeks-
in the acute phase only, with caveats.
• Chronic: TCA’s-yes; SSRIs-no SNRIs-unstudied.
Acupuncture
• Acupuncture not recommended for acute low back pain.
• Acupuncture has been found to be more effective than no
treatment for short-term pain relief in chronic low back
pain, but the evidence for acute back pain does not
support its use.
• Acupuncture is an accepted treatment in the California
Worker’s Compensation system-many other states are
adding this modality. (NY-starting pilot, Ilinois-No, OR-if
referred by PTP, NV-yes, AZ-yes, PA-if deemed “medically
necessary”).
• If successful treatment in past—trial indicated.
• MediCare does not cover acupuncture.
• Cochrane Review Database, 2000.
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Work Strong-UC Employees
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Work Strong
• Flexible 12 week program following work
related injury, staffed by kinesiologists.
• Stretching and Mobility
• Fitness Training
• Stress Reduction through Massage Therapy.
• Cooking Classes, Yoga in some cases.
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Case-Mr. R.R.
• 51 year old man, a plumber for a local
municipality.
• MOI: Bending with a tool and twisting with a
sudden onset of acute right lower back pain, with
weakness and dysesthesias his right leg radiation
to his right great toe, and to a lessor degree toes
2, and 3.
• Complains of severe back pain 8/10 with difficulty
walking due to pain. 50% of symptoms are in the
low back, 50% in right leg.
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Mr. R.R.
• PMH: Hypertension and hypothyroidism, otherwise
negative.
• Prior Occ Hx: 1 back injury, ditch partial cave-in, 10
years ago. Treated by personal physician, ibuprofen
and physical therapy < one week TTD.
• PSH: negative.
• Meds: levothyroxine, benazepril.
• NKA
• Social: Divorced, 2 adult daughters, never smoker,
Ethanol-occasional < 1drink/day, no other drugs.
Hobbies/activities: Racquetball, 1 hour, 3 x week,
daily walking.
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Case-Mr. R.R.
• 5’10”, 244 lbs. muscular male, overweight.
• Afebrile, 132/84, pules-78/min, RR-14.
• Slow, guarded gait, flat lordosis, pelvis shifted,
+muscle spasm, bridging with arms.
• Lumbar range limited to a few degrees in each plane-
flexion most difficult.
• DTR’s 2 and symmetric at patellar & Achilles.
• Light touch reduced on dorsum of foot/1st web with
10 gram monofilament-otherwise intact; 4/5 EHL on
Right.SLR—marked pain bilaterally at 30 degrees.
• Thoughts?
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Dermatomes and Myotomes
MUSCLE GRADATION DESCRIPTION