2Overview Important statistics History and Physical back pain patient “ Red Flags” for further work-up and imaging
3Overview Diagnostic workup- Electromyography and nerve conduction velocity studies(EMG/NCV)When to order what?
4Overview Treatment recommendations Physical therapy When to Order InjectionsPutting It Together For the Patient
5Why do we care?Back pain accounts for 2-3% of all physician visits in the United States (Cielo, 1994)Two National Surveys- 26.4% reported an entire day of low back pain in the last 3 months13.8 of the 26.4% also had and entire day of neck pain in the last 3 months(Cielo, 1994)
7The History It’s as easy as ABC Or Rather P-Q-R-S-T Start With The BasicsIt’s as easy as ABCOr RatherP-Q-R-S-T
8Don’t Ask Don’t Tell Yes, it has been overturned ! This was about Low Back Pain . Right?Do Ask the right questions and they will Tell you the AnswerNow Back to our alphabetP-Q-R-S-TAlso- Hint- I Spy A Red Flag- look for these throughout the History, PMHX, ROS, and PE
9Do Ask the right questions and they will Tell you the Answer Now Back to our alphabetP-Q-R-S-TAlso- Hint- I Spy A Red Flag- look for these throughout the History, PMHX, ROS, and PE
10The History P- Pain Q-Quality R-Radiation S-Severity or Situation T-Timing
11History-Pain- Where is the pain? How did the pain occur? Insidiously, *injury, acutely -did it start like a thunderbolt- Point with one fingerSignificant trauma-red flagWhat makes it better? What makes it worse?What would you rather do for 15 min?Sit , stand in place, lie down, walkSoft Rule- sitting makes disc pain worse
13Soft Rules From the Quality History Sitting is worse bending is worse, driving , shaving brushing my teeth, first thing in the morning-think discStanding in one place, getting in and out of the car, lying down, rolling over in bed, twisting- think facetNeurogenic vs. Vascular Claudication
14Quality Quality- Description words- throbbing, sharp, burning,constant, intermittent, pins and needles,It moves around or changes“You are going to think I am crazy”It is usually nerve!
15History-Q for Quality Throbbing- often a word to describe swelling, Burning, pins and needles, or it is difficult to pin point or explain,or it changes with the situation, like a toothache – nerve painWhen the patient says –”you are going to think I am crazy” my experience- it is nerve pain until proven otherwiseAssociated weakness *progressive (red flag)
16From Here to Eternity? Radiation-does the pain travel, From Where to Where?Cervical travels to the neck, arms , chest, upper back –scapulae-think C6Thoracic around the chest and flankLumbar to the back, buttocks, legsThe cervical can cause leg weakness but not the other way around
17How Bad Is It Really?Severity- very few things bring patients to their knees like nerve painPositive Valsalva?Is it worse with bearing down to have a bowel movement or cough?Yes- think disc herniation
18Review of Systems reveals Red Flags Constitutional-*Fever and Chills, Unexplained weight lossthink contrast MRI,GI-*fecal incontinenceGU- *urinary retention, overflow incontinence, saddle anesthesia
19Use the scale 0 to 10 , 0 is no pain and 10 is worst pain of your life It helps let you know if you are getting anywhere later in your treatmentAre they happy as a clam sitting there but reporting a 10. Clarify before assuming
20SeverityUse the scale 0 to 10 , 0 is no pain and 10 is worst pain of your lifeIt helps let you know if you are getting anywhere later in your treatmentAre they happy as a clam sitting there but reporting a 10. Clarify before assuming
21TimingIf the person is describing right sided neck pain that last only 20 to 30 minutes and only with activity-that is not neck painWhen does the pain occur- on first awakeningas the day progresses, intermittent , constant
22When do we worry?When something becomes so common, and frankly not so fun, for doctor or patient-We can become complacentWe can order too many tests, the wrong testsWrite too many prescriptionsFail to follow upFail to think it is something to worry aboutPain- Where is the pain? How did the pain occur? Insidiously, *injury, acutely -did it start like a thunderbolt- Point with one fingerSignificant trauma-red flag- imaging work-upWhat makes it better? What makes it worse?What would you rather do for 15 min?Sit , stand in place, lie down, walkSoft Rule- sitting makes disc pain worse
23Review -Red Flag for Work-UP and Imaging AGE- under 20 or over 50Less common in under age 20More common in over age 50 but so is malignancy ( timing hx-night pain)Unexplained Weight Loss- people will say they have had pain and didn’t feel like eatingWeight loss is always a Worry
24Red Flags for Further Work Up The Obvious is Always ObviousInformation isn’t always offeredRemote history of cancer-Common metastatic disease to the spine includes-Lymphoma, Lung, Breast, and Prostate( my personal one- smokers with poor medical follow up)
25More Things to Work Up Progressive Weakness of the lower extremities History of significant TraumaCT – (think bones) for fracturesMRI – (think soft tissue) with contrast when thinking infection or metastatic disease, herniationWhen do we think vascular workup? Go back to your history- what relieves the pain
26Fun Physical General- are they sitting, standing, pacing Posture- Do they have a shift, flattened lordosis,cervical-head tilt and rotationMeasure from tragus of the ear to anterior border of upper trapIliac crests – is a knee bent- may need to measure leg lengthsScapulae high or low- kyphosis, scoliosis-true?
27Musculoskeletal- palpation Palpation- where does it hurt to pressUpper trapezius, levator scapulae, rhomboidsSpinous processes, facets, quadratus, SI, sacrum, gluteus medius, greater trochanter,Sacrotuberous ligamnets, ischial bursaeCoccyxSternum, tibia- pain (think vitamin D deficiency)
28Physical-Musculoskeletal Cervical and Lumbar Range of MotionFlexion-hurts with herniated discsExtention with rotation hurts the opposite lumbar facets, cervical tilt hurts the same sideAtrophy of muscles notes-look at the EDB, First DI of the hand, Abductor and Opponins
29Neurologic Exam Alert and Oriented Cranial Nerves Remember CN XII- TrapeziusStraight Leg Raise vs Tight HamstringsMuscle Stretch Reflexes- upper and lowerSpurlings for CervicalSensation- remember the DRG is distal to the nerve root– back problems do not give you neuropathy-intact with nerve root lesion
30More Work Up Options- Don’t forget Your EMG/NCV Electromyography and Nerve Conduction Velocity StudiesProvides information on the function of the anatomy at the level of the nerve and motor unitMRI’s and CT’s give you information on anatomy only
31When to do The EMG/NCV Sometimes the body doesn’t read the book MRI shows a right HNP and the left is symptomatic, Normal radiographs, or level not consistent with exam normalSensory findingspinpoint acuity, location,i.e.multilievel disease, severityRule out Double Crush -
32Nerves Conduction Velocity NCV- this gives you information on all nerves those that may be affected by the pathology and those that shouldn’t be affected by that pathologyEg. Peripheral Neuropathy-only way to diagnose other than biopsy of the nerveRadiculopathy- shows up as drop in amplitude but must be followed up by a complete EMG
33NCVSensory involvement is not consistent with spinal stenosis or radiculopathyPeripheral neuropathy is not caused by stenosisSensory finding are reflect problems distal to the dorsal root ganglionBeware of the double crush injury
34Electromyography Tells the story of the nerve root Tells the severity of nerve pathology noted on nerve conduction studyCannot assess severity without an EMGRadiculopathy or radiculitis can only be assessed by EMG- also can assess timingAcute vs. subacute vs, chronicEMG- looks easy to do but hard to interpret
35Musculoskeletal -Strength Atrophy of muscles notes-look at the EDB, First DI of the hand, Abductor and OpponensDo They Make The Grade? Things that make you go Hmm2/5-fullROM without gravity3/5 full ROM against gravityToe walk and heel walk the best way to test L5 and S1 muscles
36Red Flag Review Prolonged Steroid Use Immunosuppressed patients or those with known infectionIV Drug AbuseBack Pain not improved with rest- I think this one is vagueAcute urinary symptoms and/or fecal incontinence, Saddle anesthesia
37Treatment Aside from the red flags- lots of studies In the first four weeks – conservative tx.Stay activeSome evidence for spinal manipulation in the first four weeks ( Chou 2007)Belief that 80-90% will get better regardless of the treatment
38Protocols of treatment This can get very detailed and the majority is for pain that is not intractable and for pain lasting for greater than four weeksMultimodal approachPhysical therapy is a key factorAntiinflammatoriesChanging the simple things- workplace
39Physical Therapy Is Your Prescription Evaluate and Treat? Always give some parametersDon’t order Williams Flexion Exercises fordisc problem- think MCKenzieQualifications of the therapistDay one –are they being put on a treadmill for 45 minutes?
40Physical Therapy Beware of Modalities USG is contraindicated in an acute disc herniationKnow your therapistAre they placing the patient in traction and walking away? Traction is to reduce a disc but it can also cause a herniation, very scary without experience
41Physical TherapyAre they getting heat and ice for 60 minutes and nothing else?Do they know what to do at home? This should be discussed from day one.Exercises- however simple should be given on day oneThe patient should have a complete program to do at home by completion
42GoalsThe Doctor and Therapist and patient need to have a plan and this plan needs to be understood by the patientTherapy doesn’t end when the insurance runs out. It ends when goals are met.Therapist should give recommendations and so should the doctor after follow-up.
43Treatment When to do injections? Sometimes although rarely –the injection is the entire answer.When the patient is seen, a plan is mapped out and injections can be part of the plan?Let us look at an example to clarify .
44Sample Case34 yo female has new onset LBP that began insidiously and has been getting progressively worse over the past two months. She was taking OTC motrin and aleve which helped but did not resolve the pain. Without the medication the pain would be 6/10. No weakness, no valsalvaWorse with sitting and lifting her child
45Plan Physical therapy – was then prescribed and a once a day NSAID After 3 weeks in PT she calls office and says she cannot continue to deal with this pain.PT helps for that day but doesn’t lastShe went to her chiropracter as well as after a daily manipulation she is still not better
46What do you do?A. Tell the nurse to tell the patient you are on a cruise and not reachable by cell.B. Make your Partner call the patientC. Quickly realize you do not have a partner and therefore cannot do B.D. Hide under your desk and turn out the light hoping your staff thinks you have left for the day even though they are standing in front of you.E. See the patient and then order a Lumbar MRI
47The planLumbar MRI is ordered and shows disc protrusion at L4-5 and degenerative disc disease at L5-S1. Now what? Because you and your patient discussed Your plan at the time she was evaluated You know that you will refer the patient for A multipmodal approach
48Injections This is a talk for another. There are more than just epidurals andThe story doesn’t end because the patient “failed the epidurals”
49To Review The treatment Plan You tell the patient.Sally you have been having pain for two months and it isn’t getting better.We have a couple of options.If you are able to care for your child and work, we can try:
50More on SallyOur other option is to refer you to a physician who works more closely with low back pain patients. This doctor may offer you injections to treat your pain, as part of her treatment plan.Sally responds that she will try PT and the NSAID and the rest is history.She is ready and expecting the referral when she does not get better.
51More on SallyDirected physical therapy for four weeks. If you begin to plateau in four weeks, let me know and we can go forward with a Lumbar MRI. ( explanation of MRI given)We can also add some moderate pain med like tramadol or use a stronger longer lasting antiinflammatory like meloxicam .
52TreatmentThis 90 % theory is being questioned because most patients will go on to experience multiple episodes of back –Stanton most conservative study –found reoccurrence of ranging 24-33% ( still higher than 10%)Multimodal approach is RecommendedCombination of medication, physical therapywhen necessary spinal injections
53summary Important statistics History and Physical back pain patient “ Red Flags”Diagnostic workup-When to order what?Electromyography
54Summary Treatment recommendations Physical therapy When to Order InjectionsPutting It All Together