1. Treating Pain Before It Becomes Chronic Mandeep Othee, M.D. Board Certified, Physical Medicine and Rehabilitation and Board Certified, Pain Medicine

2. What is Acute pain? Associated with specific cause such as fracture, disc bulge/herniation, recent surgery/medical procedure Some degrees of pain are normal, like discomfort during the healing process just after surgery or a healing bone fracture Usually acute pain resolves in days and up to several weeks

3. What is chronic pain? Does not heal May be present for months and even years Increases burden on society with longer hospital stays, lost worker productivity, lost income, loss of health insurance coverage

4. Chronic pain statistics Over 100 million Americans suffer with chronic pain which is more than the number of Americans with diabetes, coronary arterial disease, stroke and cancer combined! Pain costs America at least $560-$635 billion annually which is equal to $2000 for everyone living in America, which includes $297-$336 billion due to lost worker productivity.

5. Chronic pain statistics Back pain is the leading cause of disability in Americans under age 45. More than 26 million Americans between ages of 20 and 64 experience frequent low back pain 80% of adults experience low back pain at some point in their lifetimes.

6. Focus on Low back pain Second most common reason to see primary care physician after flu/”common cold” Second most common pain condition prompting lost worker production time after headaches Workers lost 5.2 hours/week of productive time

7. Low back pain Common Thinking 40-50% of patients with low back pain will improve within one week The Full Story 62% of patients likely to have one or more relapses during a one-year follow- up

8. Low back pain Common Thinking 85-90% of injured workers with low back pain will improve in 6 to 12 weeks The Full Story Low back pain is the #1 disability in patients under 45 After two years, there is little to no chance of returning to previous job

9. Low back pain Common Thinking 90% of patients with low back pain improve without any medical care The Full Story Longer pain for patients who wait 6-10 weeks 80% have pain at six months and one year 12% disability at one year

10. Low back pain The Financial Bottom Line LBP accounts for $25 billion in medical costs annually LBP contributes to another $50 billion in non-medical costs each year

11. Low back pain LBP Negatively Impacts: Worker’s Quality of life Increased Employer costs Increased US healthcare system costs

12. Low back Pain Difficulties in Treating LBP Difficult to diagnose source Requires “whole care” approach Preventive program needed to minimize recurrence

13. The Physical Medicine and Rehab Specialist Works to restore or maximize function by limiting use of opiate narcotic pain medications and avoiding surgery Integrates elements of: orthopedic/musculoskeletal care ( branch of medicine emphasizing the prevention, diagnosis, and treatment of disorders – particularly related to the nerves, muscles, and bones – that may produce temporary or permanent impairment) neurologic care rheumatologic care

14. Treating the LBP Patient Appropriate evaluation and diagnosis starts with history and physical examination physical exam: neurologic and functional psychosocial profile including functional work profile analysis

15. Diagnostic tests Initial X-ray Lumbar spine rule out fracture MRI Lumbar spine if no pain relief after 6 weeks of conservative care 40-90% of patients will have complete relief of pain using these measures

16. Conservative care for LBP Anti-inflammatory medications and ice as needed No more than 1-2 days of bed rest Physical therapy/chiropractic treatments Proper lifting techniques: avoid excessive bending forward with twisting motion

17. Conservative care for LBP Maintaining good posture Ergonomic support with office based tasks Weight and diet management Exercise 30 minutes a day and quit smoking if applicable

18. Avoiding Opiate Narcotic pain medications 80% of world’s narcotic pain medications are written in US 44 people die each day of from narcotic prescription drug overdoses

19. Interventional treatments for LBP Lumbar epidural injections Lumbar nerve blocks followed by nerve ablation SI joint injections Avoid surgery if possible which has mixed results and which may lead to degenerative disk disease at levels above and below surgery

20. LBP Outcomes Natural distinction between pain and function Function may be restored even though some pain may remain

21. What to tell patients/injured workers They are likely to improve and likely to return to work quickly, even if pain persists Back pain is usually recurrent May become chronic Most patients with chronic LBP continue to work

22. Goals of Treatment Return to normal functional activity Prevention of further injury Optimal core abdominal strength, endurance and conditioning. Staying active is KEY!

23. Effects of Immobilization Atrophy Deconditioning Impaired function

24. Important Reminders Symptom resolution is only an initial step Goal is prevention of recurrent injuries

25. PM&R Specialist can: Reduce pain Increase function Lessen risk of recurrence Maximize quality of life and KEY is early intervention to prevent pain from becoming chronic and to have the patient/worker return to work with full duty as soon as possible.

26. References Institute of Medicine from the Committee on Advancing Pain Research: Relieving Pain In America: A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011 www.CDC.gov National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. Results from the American Productivity Audit. www.ncbi.nlm.nih.gov/pubmed/14665809 www.ncbi.nlm.nih.gov/pubmed/14665809

27. References 2006 Voices of Chronic Pain Survey from the American Pain Foundation www.aapmr.org