1. Acute Back Pain Evidence Based Approach Scott Hardy, MD, MPH, FACOEM
Occupational Medicine
UCI, December, 2015
I am on the part-time UCI, I am an Occupational Physician & have a private practice in Santa Ana, and
Serve as OC employee health medical director. I have done utilization review for Calif. State Compensation Insurance Fund in prior to 2011.
No other disclosures.

2. Objectives
Present & discuss clinical cases demonstrating evidence based guidelines for low back pain management-encountered in the clinics, wards and boards.
Review differential diagnosis of this common but multifactorial complaint.
Recognize Red flags-immediate work up.
Yellow flags for delayed recovery that accompany the complaint of low back pain.
Substantial over treatment of back pain. Probably no
Other condition is over medicalized

3. Objectives
Know historical and physical exam findings that suggest additional imaging tests, laboratory evaluation and/or immediate specialty referral.
Primary care physicians can play and essential role in managing symptoms & return to work and function.
Evidenced based guidelines will enhance
recovery & avoid iatrogenic expense.
Multidisciplinary approach.
Unusual case presentations.
Spinal and extra spinal causes of spine pain.

4. Evidence shows that outcomes are similar between primary care providers, orthopedists, DC and pain management
specialists however primary care providers have the most cost-effective care. Still there is evidence that after years
Of EB Guidelines, there is significant amounts of medically unnecessary diagnostics.

5. OEM Mission
Occupational and environmental medicine is the medical specialty devoted to prevention and management of occupational and environmental injury, illness, and disability; and promotion of health and productivity of workers, their families, and communities.
Slide Title: OEM Mission
Primary Care Specialty.
Acute LBP—prevention & treatment common.

6. 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.
Frequency:
In the US: Lifetime incidence of LBP is reported to be 60-90% with annual incidence of 5%. Each year, 14.3% of new patient visits to primary care physicians are for LBP, and nearly 13 million physician visits are related to complaints of chronic LBP, according to the National Center for Health Statistics.
Mortality/Morbidity: The natural history has been reported to be favorable in some studies and is frequently quoted to patients. Reports indicate that 40-50% of patients are symptom-free within 1 week and up to 90% of symptoms resolve without medical attention in 6-12 weeks.
Deyo and Tsui-Wu reported that 33.2% of patients with LBP reported symptoms for less than 1 month, 33% reported pain for 1-5 months, and 32.7% reported pain for longer than 6 months (Deyo, 1987). More recently, 44% of patients reported chronic symptoms (defined as back pain for >90 d in the previous 6 mo) over 2-year follow-up. Most patients had low levels of back pain, with 20% rating their pain at 4 or greater on a scale of 0-10 (where 0 indicates no pain), 13% rated their pain as 5 or greater, and 8% reporting pain of 6 or greater.

8. 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

9. 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).
Second to URIs. Some surveys indicate 5th. Still ---high incidence.

10. 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 Vol 88, No 1, pp
If you've ever sat in the doctor's office and wondered what, exactly, everyone else was there for, a new Mayo Clinic study might quench your curiosity.
Surprisingly, researchers found that the most common condition people visit their health care providers for isn't heart disease or diabetes -- it's skin disorders, like acne or dermatitis, which accounted for 42.7 percent of the doctor visits. The study is published in the journal Mayo Clinic Proceedings.
The study included data from 14,000 people in Olmsted County, Minn., who were part of the Rochester Epidemiology Project and who visited a doctor or other health care provider sometime between Jan. 1, 2005 and Dec. 31, 2009.
January 2013Volume 88, Issue 1, Pages 56–67
Why Patients Visit Their Doctors: Assessing the Most Prevalent Conditions in a Defined American Population
Jennifer L. St. Sauver, PhD, MPH
, David O. Warner, MD
, Barbara P. Yawn, MD, MSc
, Debra J. Jacobson, MS
, Michaela E. McGree, BS
, Joshua J. Pankratz, BS
, L. Joseph Melton III, MD, MPH
, Véronique L. Roger, MD, MPH
, Jon O. Ebbert, MD
, Walter A. Rocca, MD, MPH

11. 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.

12. 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.
ACOEM, ACP/APS, ODG, MTUS, Washington State, Cochrane…..
High Quality
Medium Quality
Low Quality

13. ACOEM American College of Occupational & Environmental Medicine
The Personal Physician’s Role in Helping Patient with Medical Conditions Stay at Work or Return to Work
Currently in revision….[Preventing Needless Work Disability by Helping People Stay Employed]

14. Primary Differential
Detailed history & physical examination to determine:
The presence of red flags for urgent conditions-musculoskeletal vs. other etiologies.
Non-specific regional back pain-pain is typically axial in location that predicts favorable course.
3. Radiculopathy/other neuro related spine condition.
The differential for low back pain can be divided into 3 major subsets: (1) back pain that is
not related to a neurologic problem, (2) back pain related to a problem with the spinal
column, or (3) back pain related to another neurologic issue. In addition to separating
back pain into 1 of these 3 categories, pain can also be classified as acute versus chronic.
For patients with low back pain who are not currently on any type of therapy, the first-line
treatment is self-care and continued activity, because bed rest can worsen the prognosis
for acute low back pain.
Identify Radicular Signs
·         Determine presence or absence of radiculopathy:
o        Medical history
o        Sensation: Feeling pain radiating below the knee (calf or lower), not just referred pain (pain radiating to buttocks or thighs), & dermatological sensory loss
o        Straight leg raising test (sitting & supine), productive of leg pain
o        Motor strength and deep tendon reflexes
o        Document flexibility/ROM (fingertip test), muscle atrophy (calf measurement),
o        local areas of tenderness, visual pain analog, sensation alternation
o         NOTE: Radiculopathy is often over-diagnosed. For unequivocal evidence of radiculopathy, refer to the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, page (Andersson, 2000)

15. Case-Mr. J.M.
58 year old landscaper presents with stiffness and soreness in the low back one day after repetitive bending installing a company sprinkler system.
Sharp pain, 8/10 with bilateral leg weakness. Complains of numbness in the groin region. No constitutional symptoms. N/V/F/C.
PMH: BPH. Med-Tamsulosin, NKA.
PSH: Negative.
ROS: No hx of LBP, No recent fever, infection, weight loss, cancer, fever, abdominal complaints.
Social: Ex smoker 5 pack-yrs., no EtOH, no other drugs. Hobbies, soccer, motorcycle riding.
Tamsulosin (Flomax) 0.8 mg Q day PC dinner.

16. Case-Mr. J.M. Exam: 5’9”, 195, 112/82, P-88, RR-14.
W/D fit appearing muscular male ambulates with difficulty, slow guarded gait, prefers to stand.
HEENT, Heart, Lungs, WNL.
Abdomen-Soft flat, non-tender, without rebound or bruit, no CVAT or hernia genitalia WNL.
Lumbar spine-flat lordosis, spasm, with L/S junction TTP, and ROM limited to few degrees.
Neuro-Reduced touch, and sharp dull, bilaterally L4-S1, global weakness, 4/5 multiple myotomes.
Using cane. Accompanied by wife.
Rectal-reduced sensation and tone, BPH, guiac negative.
Decreased sensation on urination….urinary retention in men can be confounded by a history of BPH.
NOTE: This patient appears too healthy to have this injury.
Smoking and working in a manual occupation increase risk.
Obesity and increased height associated with back pain.

17. Case-Mr. J.M. Other exam findings? Tests? Radiographs? Imaging?
Diagnosis?
Referral?
Bilateral SLR + at 40 degrees.

18. Large Central L5-S1 disc herniation.
Early identification …discharged with foley…return of bladder function by 10 days post decompression.

21. Cauda Equina Syndrome
For a diagnosis of CES, one or more of the following must be present:
bladder and/or bowel dysfunction.
reduced sensation in the saddle area.
sexual dysfunction, with possible neurologic deficit in the lower limb (motor/sensory loss, reflex change).
(1) bladder and/or bowel dysfunction, (2) reduced sensation in the saddle area, and (3) sexual dysfunction, with possible neurologic deficit in the lower limb (motor/sensory loss, reflex change).
Recommended. After ruling out “red flags, there is considerable value in first determining whether or not there are radicular signs. This will allow branching based on generalized low back pain including spains and strains, versus potential disc problems. Determine radiculopathy via sensation (pain radiating below the knee) not just referred pain (pain radiating to buttocks or thighs), & dermatological sensory loss, plus straight leg raising test (sitting & supine), motor strength (deep tendon reflexes), flexibility (fingertip test), muscle atrophy (calf measurement), and local areas of tenderness. (Bigos, 1999) Among the "red flags" for serious abnormalities are inflammatory disease, fracture, referred pain (eg, from rupturing aortic aneurysm), infection, or cancer. In this study only 11 of 1172 (0.9%) patients were confirmed as having a serious spinal condition, including spinal fracture (n = 8), cauda equina syndrome (n = 1), or inflammatory disorder (n = 2). No patients were identified with cancer or infection as the cause of their pain. For spinal fractures, the diagnostic accuracy of the following red-flag questions was determined: (1) age > 70 years; (2) significant trauma; (3) prolonged corticosteroid use; & (4) altered sensory level (from the trunk down). The authors concluded that serious spinal abnormalities are rare in primary care settings, and the questions on the possibility of fracture may be useful. (Henschke, 2009)
Cauda equina syndrome: a literature review of its definition and clinical presentation
Fraser, S, et. al. Arch Phys Med Rehabilitation. 2009 Nov;90(11):

22. Red Flags A focused medical history, work history and physical exam.
Evaluation of underlying conditions, including sources of referred symptoms in other parts of the body.
Frequency, intensity and duration of complaints.
Aggravating an relieving factors.
History and Physical findings that raise suspicion for serious underlying disorders= Red Flags

23. For review—History & Physical …for Red Flags for serious conditions.

24. Anterior compression wedge fracture
How many of you have had patients CXR’s read as indicating “incidental healed old compression fractures” in the T-spine?
This happens with osteopenia and osteoporosis without much pain…even without demineralization, have seen patient in the 20’s
s/p fall and NO pain….stiffness only with reduced ROM and NO tenderness of the T-spine spinous processes…
but 3 mild compression fractures noted on films. Treated in bivalve type vest x 3 months…
Red Flag. Bottom line—if there is trauma-that is significant: radiographs or imaging to r/o fx.
Kyphoplasty/Vertebroplasty
Anterior compression fractures may present with stiffness but no pain or tenderness of the spinous processes.

25. Red Flags-for back pain
Age over 50.
Unexplained weight loss, history of cancer.
Persistent fever; recent bacterial infection.
History of intravenous drug use.
Immunocompromized.
Urinary or stool incontinence/urinary retention.
Trauma.
Neurologic deficit, weakness.

26. Red Flags
Rule out “red flag” diagnoses, including diagnostic studies, for specialist referral:
o        Cauda Equina Syndrome (Schedule emergency procedure)
o        Fracture, Compression fracture, Dislocation, Wound
o        Cancer, Infection
o        Dissecting/Ruptured Aortic Aneurysm
o        Others (prostate problems, endometriosis/gynecological disorders, urinary tract infections, & renal pathology)

27. Cancers metastatic to bone. mnemonic Lead Kettle: PB KTL
Prostate-blastic sclerotic
Breast-mixed
Kidney-lytic
Thyroid-lytic
Lung-lytic
Women: 80% from lung and breast
Men: 80% from lung and prostate.
20% in both sexes, kidney, thyroid, GI and others
Cancers that metastasize to bone may be remembered using the mnemonic "Lead Kettle" spelled PBKTL (lead is Pb on the Periodic Table).
PB-KTL
Mnemonic
P: prostate
B: breast
K: kidney
T: thyroid
L: lung
For females, breast and lung are the most common primary sites; nearly 80% of cancers that spread to the skeleton are from these locations. In males, prostate and lung cancers make up 80% of carcinomas metastasising to bone. The other 20% of primary disease sites in both sexes are: kidney, thyroid, GI and other locations.
Lytic vs blastic in the "lead kettle" PB-KTL mnemonic:
By knowing the typical behavior of the metastatic lesion - lytic or blastic - you can help sort between the types to make the mnemonic even more useful.
prostate = blastic/sclerotic (induces bone growth)
breast = mixed pattern
kidney, thyroid, lung = lytic (induces bone destruction)
The spreading pathways of metastasis from the starting site to the bones are only partially understood, and some authors propose some bone metastasis via the Batson venous plexus, a two-way, valveless venous pathway that allows cancer cells, infection and emboli to travel freely both to cranial and caudal direction without passing through the main "tumour-catching" places: liver, lung, peritoneum and others.
Carcinoma metastases are the most common malignant tumors in the skeleton, with maybe somewhat vague symptoms or an acute onset, often with pain or pathological fractures. In people with breast and prostate cancer, the bone is often the first distant site of cancer spread. More than 2 out of 3 breast and prostate cancers that spread to other parts of the body spread to the bones. Of lung, thyroid, and kidney cancers that spread to other parts of the body, about 1 out of 3 will spread to the bones. 
Basic knowledge of a simple mnemonic about the main types of bone metastases can be a handy tip in the medical routine: with a good history taking from the patient, clinical findings and sharp eyes on the images it's possible to nail a nice and elegant diagnostic hypothesis allowing a more specific investigation.

30. Case Ms. T.W.
48 year old female financial services secretary presents with a three week history of bilateral low frequent back pain 6/10 without radiation. The cause of the pain is unknown but is worsened by prolonged sitting. She feels unable to do her walking program-requests MRI to “find out what is wrong”.
PMH: Depression, r/o fibromyalgia per family physician-rheumatic work up negative.
PSH: TAH-BSO 1 year ago. Bilateral CTS releases.
ROS: Negative for F/C, constitutional symptoms, head or neck pain, -IBS, -chronic fatigue, +weight gain
Social Hx: Divorced, college grad, resides with two teenagers, Ex. ½ ppd smoker x 8 yrs, 3 glasses of wine/week.

31. Case-Ms. T.W. Exam: 5’4”, 212 lbs., 142/92, P-90, RR-16
Anxious woman, ambulatory without encumbrance.
Lumbar exam: ROM with voluntary guarding on flexion >30 degrees, extension, lateral bending WFL. TTP, diffusely over the thoracolumbar spine, SLR negative bilaterally.
DTR’s 2+ throughout, sensation and motor testing WNL.
Rx: Cognitive Behavioral Therapy, Ergonomic Adjustment Work Station.

32. What are yellow flags?
PMH of prior injuries, functional and social issues are important.

33. What are yellow flags? Risk factors for delayed functional recovery.
Multiple prior injuries, prolonged or multiple absences, victim of abuse in the past, Smoking, EtOH abuse, FH of disability, depression, chemical dependency, stress, job dissatisfaction, adversarial relationship, severity of symptoms, delayed presentation, chronic pain symptoms, multiple diagnoses, prior CTS, multiple personal or occupational/personal injury back/neck claims, excessive physical medicine treatment, economic, legal factors, subjective> objective findings.
ACOEM Guidelines

34. Pain
IASP “Unpleasant sensory and emotional experience associated with actual or potential tissue damage”.
Need to address emotional component of pain fist…then understand the actual or potential tissue damage.
Pain is subjective…interacting with the limbic system with modulation of pain…many potential sources of potential pain in the low back…muscles, facets, discs, nerve impingement.
According to the International Association for the Study of Pain (IASP),1
pain is an unpleasant sensory and emotional experience associated with actual or
potential tissue damage. Based on this description, a few things become apparent:
pain is by definition subjective; pain has an emotional component; and pain may or
may not be caused by any actual damage. How does this relate to the approach to
patients with low back pain? When physicians try to understand a patient’s subjective
experience of pain, they need to address the emotional component of pain first and
foremost, and only then try to understand what the actual or potential tissue damage
was that caused the pain.
Pain by definition is subjective. A variety of neural pathways are involved in the generation
and propagation of pain. Pain is emotional. Pain pathways interact with the
limbic system, and this interaction modulates pain. The experience of pain is related
to the experience of past pain. Many potential pain generators are present in the
low back. The most likely source of pain is the intervertebral disc. Treating pain
requires a multifactorial approach, because pain is very complex.

35. Very useful clinically for communication.

36. Here we need a multidisciplinary approach…PT, rheumatology, possibly cognitive behavioral therapy.
treatment, specifically cognitive behavioral therapy (CBT), may be an effective treatment for patients with chronic low back pain, but it is still unknown what type of patients benefit most from what type of behavioral treatment. Some studies provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. (Newton-John, 1995) (Hasenbring, 1999) (van Tulder-Cochrane, 2001) (Ostelo-Cochrane, 2005) (Airaksinen, 2006) (Linton, 2006) (Kaapa, 2006) (Jellema, 2006) Recent clinical trials concluded that patients with chronic low back pain who followed cognitive intervention and exercise programs improved significantly in muscle strength compared with patients who underwent lumbar fusion or placebo. (Keller, 2004) (Storheim, 2003) (Schonstein, 2003) Multidisciplinary biopsychosocial rehabilitation has been shown in controlled studies to improve pain and function in patients with chronic back pain. However, specialized back pain rehabilitation centers are rare and only a few patients can participate on this therapy. It is unclear how to select who will benefit, what combinations are effective in individual cases, and how long treatment is beneficial, and if used, treatment should not exceed 2 weeks without demonstrated efficacy (subjective and objective gains). (Lang, 2003) A recent RCT concluded that lumbar fusion failed to show any benefit over cognitive intervention and exercises, for patients with chronic low back pain after previous surgery for disc herniation. (Brox, 2006) Another trial concluded that active physical treatment, cognitive-behavioral treatment, and the two combined each resulted in equally significant improvement, much better compared to no treatment. (The cognitive treatment focused on encouraging increased physical activity.) (Smeets, 2006) For chronic LBP, cognitive intervention may be equivalent to lumbar fusion without the potentially high surgical complication rates. (Ivar Brox-Spine, 2003) (Fairbank-BMJ, 2005) Cognitive behavioral therapy (CBT) significantly improves subacute and chronic low back pain both in the short term and during 1 year compared with advice alone and is highly cost-effective, a new RCT suggests. Disability scores as measured by the Roland Morris questionnaire improved by 2.4 points at the end of 12 months in the CBT group compared with 1.1 points among control patients. Patients were treated with up to 6 sessions of group CBT, whereas controls received no additional treatment other than a 15-minute session of active management advice. According to self-rated benefit from treatment, results showed that 59% of patients assigned to CBT reported recovery at 12 months compared with 31% of controls. Fear avoidance, pain self-efficacy, and the Short Form Health Survey physical scores also improved substantially in the CBT group but not in the control group. The CBT taught people how to challenge their fear of making things worse and to test out ways of improving their physical activity. (Lamb, 2010) See also Multi-disciplinary pain programs in the Pain Chapter. See also Psychological treatment in the Mental Illness & Stress Chapter.
ODG cognitive behavioral therapy (CBT) guidelines for low back problems:
Screen for patients with risk factors for delayed recovery, including fear avoidance beliefs. See Fear-avoidance beliefs questionnaire (FABQ).
Initial therapy for these “at risk” patients should be physical therapy exercise instruction, using a cognitive motivational approach to PT.
Consider separate psychotherapy CBT referral after 4 weeks if lack of progress from PT alone:
- Initial trial of 3-4 psychotherapy visits over 2 weeks
- With evidence of objective functional improvement, total of up to 6-10 visits over 5-6 weeks (individual sessions)
- Psychotherapy visits are generally separate from physical therapy visits, and psychotherapy may be appropriate after physical therapy has been exhausted
ODG Psychotherapy Guidelines (if mental diagnosis):
- Up to visits over 7-20 weeks (individual sessions), if progress is being made.
(The provider should evaluate symptom improvement during the process, so treatment failures can be identified early and alternative treatment strategies can be pursued if appropriate.)
- In cases of severe Major Depression or PTSD, up to 50 sessions if progress is being made.
See the Mental Chapter.

37. What to do…. involve a multidisciplinary approach…follow closely
What to do…..involve a multidisciplinary approach…follow closely..see what else is going on…

38. Biopsychosocial Model
Biological
Social
Psychological
As with all medical diagnoses, there are contributions from all these areas.
An expanded social history is indicated. Evaluation and Management of
Back pain involves understanding all three-frequently.,,
How is work going? …….& more……
Cognitive Behavioral Therapy

39. Clinical Management-Functional Recovery
Detailed history-good investment of time initially.
Understand ADLs and workplace functions
Hands on physical examination. observation, manual motor testing, detailed neuro exam, understand mechanism of injury.
Written prescription for activity, rest.
Patient participation.
Patient alliance-request team approach.
Address concerns, discuss expectations.
Work status-compliance.

40. Yellow Flags-management
Multidisciplinary approach.
Consider cognitive behavioral therapy.
Avoid disability-explore barriers to work, written work status, based on tolerated ADLs.
Physical/Occupational Therapy-to teach home program.
Ergonomic assessment/adjustment of work station.
Exercise prescription-walking, swimming, etc.
Consider TCA and/or SNRI, sleep hygiene.
Nurse case manager.
Employee assistance program.
Early follow up, limit detailed work up.

41. Common Back Pain Misconceptions
I injured my disc lifting something heavy at work. That’s why my disc is bulging.
My “degenerated” disc is causing my pain.
Because I have back pain, I should stay away from work.
Back pain often leads to permanent impairment or disability.
Because I have back pain, I will need permanently modified work.
After evaluation…and understanding…..need to reassure…….and overcome some of these beliefs…

42. Common Back Pain Misconceptions
I should rest until my back pain goes away.
My back pain means I have really significant biological damage or disease.
X-rays, CT, and MRI can always identify the cause of pain.
Back pain will usually be cured by medical treatment.

43. 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):

44. Back Pain & MRI
Eur Spine J. 1997;6(2):
The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males.
Savage RA1, Whitehouse GH, Roberts N.
Author information
1Magnetic Resonance and Image Analysis Research Centre, University of Liverpool, UK.
Abstract
The purpose of this study was to undertake a critical review of the potential role of magnetic resonance imaging (MRI) in the evaluation of low back pain (LBP) and to determine if there were differences in the MRI appearances between various occupational groups. The study group, 149 working men (78 aged years and 71 aged years) from five different occupations (car production workers, ambulance men, office staff, hospital porters and brewery draymen), underwent MRI of the lumbar spine. Thirty-four percent of the subjects had never experienced LBP. Twelve months later, the examination was repeated on 89 men. Age-related differences were seen in the MRI appearances of the lumbar spine. Disc degeneration was most common at L5/S1 and was significantly more prevalent (P < 0.01) in the older age group (52%) than in the younger age group (27%). Although LBP was more prevalent in the older subjects there was no relationship between LBP and disc degeneration. No differences in the MRI appearance of the lumbar spine were observed between the five occupational groups. Overall, 45% had 'abnormal' lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression). There was not a clear relationship between the MRI appearance of the lumbar spine and LBP. Thirty-two percent of asymptomatic subjects had 'abnormal' lumbar spines and 47% of all the subjects who had experienced LBP had 'normal' lumbar spines. During the 12-month follow-up period, 13 subjects experienced LBP for the first time. However, there was no change in the MRI appearances of their lumbar spines that could account for the onset of LBP. Although MRI is an excellent technique for evaluating the lumbar spine, this study shows that it does not provide a suitable pre-employment screening technique capable of identifying those at risk of LBP.
Int Orthop. 1998;22(4):241-4.
The correlation between magnetic resonance imaging and the operative and clinical findings after lumbar microdiscectomy.
Wittenberg RH1, Lütke A, Longwitz D, Greskötter KH, Willburger RE, Schmidt K, Plafki C, Steffen R.
1St. Josef-Hospital Bochum, Ruhr University, Germany.
Fifty-four consecutive patients were studied prospectively with magnetic resonance imaging before microdiscectomy, and the findings correlated with clinical symptoms before and after operation. A sequestrated fragment was found in 59% of cases, a subligamentous disc sequestration in 25% and a disc protrusion in 16%. The levels operated on were L4/5-36%, L5/S1-62.5%, and one at L3/4; 71% were laterally placed, 10% lay intraforaminal and 10% medial. The diameter of the protrusion was 4 mm to 13 mm for the craniocaudal extension, and 5 mm to 18 mm for the anteroposterior extension. No correlation could be found between a neurological deficit and the size of the prolapse. A positive correlation was present between the increasing degree of canal obstruction and the degree of disc degeneration determined by imaging for extrusions, subligamentous disc sequestrations and free sequestrations. Nerve root inflammation and enlargement was seen in 36% of the images, corresponding to an operative finding of 32%. Magnetic resonance imaging is a helpful pre-operative diagnostic investigation which shows structural changes in the disc and the correct localisation and size of the disc sequestration, but there was no correlation between the imaging findings and the clinical symptoms.
Several studies have shown that there is a poor correlation between MRI findings and patients’ low back symptoms.
1. Wittenberg et al., 1998
2. Savage et al., 1997

45. Switch Gears……..Blue whale btwn Long Beach and Catalina………largest animal to have ever lived.
Welcome to the Blue Whale Project Workshop Homepage!‎ > ‎
Fun Facts About Blue Whales
Blue Whale-Bigness What’s the biggest animal that ever lived? Yes, blue whales are the largest animal that ever lived – larger than the largest dinosaur! Biggest blue whale ever recorded was ~110 feet (33m). Our whale is pretty big – she’s 85 feet long, which is about 25 m. That’s as long as two school buses parked end to end! - A blue whale’s tail is as wide as a soccer net (a professional soccer net, not a school one). That’s about 25 ft (8m). - A blue whale’s flipper (which is analagous to a human’s hand) is as long as you are tall. - Blowhole (which is like your nose, it’s just on top of their head so it’s easy for them to breathe in water), is large enough for a baby to crawl through. When they exhale, the blow can reach 30 feet tall (and smells terrible). - Arteries are big enough for a baby to crawl through, at about 9 inches in diameter (approx the same diameter as a dinner plate). - Heart is as big as a small car (VW beetle for example). - Blue whale mouths are huge, too – they can swallow a volume of water larger than themselves. Their throat stretches down to their navel. Tongue is the size of an elephant. You and 400 of your friends could fit in its mouth. - A baby blue whale is about the size of 2 minivans.

46. ADLs…………. American Medical Association. 1984
ADLs………….American Medical Association Instrumental Activities of Daily Living…
These are helpful in understanding FUNCTIONAL limitations…in relation to symptoms….
Evidence in multiple guidelines suggest this is more predictive than the VAS

47. Active Resumption of ADLs
Patients understandably have concerns and fears about re-injury and will underestimate their abilities.
Based on history and findings, prescribe a graded exercise program-with P.T. input.
When ongoing subjective complaints exceed objective findings, a focus should move away from a focus on pain and instead focus on function.
Williams Flexion Exercises indicated stenotic conditions.
Extension, McKenzie Ex’es for HNP.

48. Similar to rehab following cardiac events……
……....involve friends & family.
Aerobic exercise…ODG Guidelines:
Recommended. Aerobic exercise is beneficial as a conservative management technique, and exercise of as little as 20 minutes twice a week can be effective in managing low back pain. At a minimum, a graded walking program is generally desired. (Malmivaara-NEJM, 1995) (Sculco-Spine, 2001) (Mannion, 2001) (Liddle, 2004) (Kool, 2004) (Oleske, 2004) (Airaksinen, 2006) (Machado, 2007) (Chatzitheodorou, 2007) A recent study of the long term impact of aerobic exercise on musculoskeletal pain, in a prospective cohort of 866 healthy seniors followed for 14 years, found that exercise was associated with a substantial and significant reduction in pain even after adjusting for gender, baseline BMI and attrition, and despite the fact that fractures, a significant predictor of pain, were slightly more common among exercisers. (Bruce, 2005) A multicenter randomized controlled trial with 1-year follow-up of 129 predominantly male soldiers compared: (1) a 10-week device-supported isolated lumbar extension training, twice a week; or (2) regular PT, mainly consisting of exercise therapy and aerobic activities; found that both groups showed favorable development over time and short-term improvements (after 10 weeks of treatment) remained stable or even slightly increased throughout the 12-month follow-up, but there were no significant differences between the 2 groups for any of the outcome measures, at any time. (Helmhout, 2008) See also Exercise.

49. Daily Exercise Plan

50. PRESCRIBE EXERCISE !!
May begin with a walking program…and exercise prescription…..move into an active core exercise program.
McKenzie exercises are very effective and involve similar exercises—prop ups, pelvic tilt and planks…………..

51. 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.
Opioids
Not recommended except for short use for severe cases, not to exceed 2 weeks. See the Pain Chapter for more information and studies. When used only for a time-limited course, opioid analgesics are an option in the management of patients with acute low back problems. The decision to use opioids should be guided by consideration of their potential complications relative to other options. Patients should be warned about potential physical dependence and the danger associated with the use of opioids while operating heavy equipment or driving. The studies found that patients taking opioid analgesics did not return to full activity sooner than patients taking NSAIDs or acetaminophen. In addition, studies found no difference in pain relief between NSAIDs and opioids. Finally, side effects of opioid analgesics were found to be substantial, including the risk for physical dependence. These side effects are an important concern in conditions that can become chronic, such as low back problems. (Bigos, 1999) Recent studies document a 423% increase in expenditures for opioids for back pain, without demonstrated improvements in patient outcomes or disability rates. (Deyo, 2009) With opioid therapy for nonspecific low back pain compared with no opioids, the odds of chronic work loss were six times greater for claimants with schedule II ("strong") opioids; were times greater for claimants with opioid prescriptions of any type during a period of >or=90 days; and 3 years after injury, costs of claimants with schedule II opioids averaged $19,453 higher than costs of claimants in the no opioids group. (Volinn, 2009) This large study found that prescription of opioids was common among patients with back pain, and increasing duration of opioid use was strongly associated with an increasing prevalence of mental health conditions (depression, anxiety, post-traumatic stress disorder, or substance abuse); almost 50% of patients receiving long-term opioids had at least one of these diagnoses. Similarly, negative health habits (obesity, smoking) were associated with duration of opioid use. The wisdom of long-acting opioid use for chronic pain remains controversial. (Deyo, 2011) For more information, and Criteria for Use of Opioids, see the Pain Chapter.
Anti-inflammatory medications
Recommended for acute LBP. For detailed pharmaceutical recommendations, see the Pain Chapter. Anti-inflammatories are the traditional first line of treatment, to reduce pain so activity and functional restoration can resume. (vanTulder-Cochrane, 2000) (Airaksinen, 2006) A comprehensive review of clinical trials on the efficacy and safety of drugs for the treatment of low back pain concludes that available evidence supports the effectiveness of non-selective nonsteroidal anti-inflammatory drugs (NSAIDs) in acute and chronic LBP, of muscle relaxants in acute LBP, and of antidepressants in chronic LBP. (Schnitzer, 2004) Common oral medications such as acetaminophen and NSAIDs are associated with a number needed to treat of 2 to 3 for 50% pain improvement during 4 to 6 hours. (Kinkade, 2007) See Nonprescription Medications. See also the Pain Chapter: NSAIDs (non-steroidal anti-inflammatory drugs); NSAIDS, GI symptoms & cardiovascular risk; Anti-inflammatory medications; and Medications for acute pain (analgesics). Note: There is also a school of thought that anti-inflammatories may delay healing of sprains as they do in fractures. (Talmage, 2002) This has not been proven by quality studies, so anti-inflammatory medications are recommended if they help the patient return to normal functional activities by reducing

52. 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.
Tulder MW VA, Cherkin DC, Berman B, Lao L, Koes BW, Acupuncture for low back pain, Cochrane Database Syst Rev 2000;(2):CD Meta Analysis (1b). PMID:
Does Medicare Cover Acupuncture?
Medicare does not cover acupuncture.  Remember Medicare offers some coverage for physical, occupational, and speech therapy but no acupuncture as of yet.
Under Original Medicare, you will pay 100% of the costs for acupuncture treatment.
Updated with new information 6/17/2015
Does Medicare Cover Chiropractic Care?
Medicare does cover medically necessary chiropractic services. According to the CMS,  Medicare Part B now covers 80% of the cost for “manipulation of the spine if medically necessary to correct a subluxation.”  There is no cap on the number of medically necessary visits to a chiropractor.
Under Original Medicare, without any additional insurance, you would have to pay your part B deductible and 20% coinsurance for all medically necessary chiropractic appointments.
Does Medigap cover Chiropractic and Acupuncture?
Medigap plans do not cover acupuncture.
Medigap plans cover chiropractic care. Medigap plan “C” and plan “F” cover 100% of your Part B deductible and will also pay the 20% coinsurance. Combined with Medicare there will be no charge for any medically necessary chiropractic work.  Click here to get a Medigap quote.

54. University of California employees..all campuses...Work Strong.

55. Work Strong-UC Employees
Kinesiology

56. 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.

57. 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.

58. 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.

59. 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?
SLR, cross leg test, high sensitivity and specificity for herniated disc… SLR btwn for radiation distally to knee.

61. Dermatomes and Myotomes

63. MUSCLE GRADATION
DESCRIPTION
5-Normal
5-complete range of motion against gravity with full resistance
4-Good
4-complete range of motion against gravity with some resistance
3-Fair
3-complete range of motion against gravity
2-Poor
2-complete range of motion with gravity eliminated
1-Trace
1-reads evidence of slight contractility, no joint motion
0 (Zero)
0-no evidence of contractility

64. Mr. R.R. Follow up
Mr. RR received ketorolac (Toradol) 60 mg IM acutely, treated with ice and heat and was off work for two days, with ice and heat, returning to modified work
MRI revealed a 6 mm right sidedL4-5 HNP with L5 root contact.
Referred for and active physical therapy program-initially for pain control and then mobility exercises-24 visits.
Epidural injection considered, not needed.
Had lifestyle change-particularly with diet-achieved a 38 pound weigh loss.
Does regular core exercises, NSAID 1-2 times weekly.
AMA Guides to the Evaluation of Permanent Impairment-6% whole person. Able to continue work as a plumbing supervisor with a 50 pound lifting limit x past 10 years.
One flare since 2005 injury, minor right leg discomfort, with no lost time from work.

65. Switch Gears…..Kings Canyon, CA

66. Case-Ms. W.J. 44 year old nurse
Transferring patient on Neurosurgery ward-L.A. hospital.
Severe initial axial LBP, unable to walk, with RLE severe dysesthesias.
Neuro-reduced sensation lateral foot and absent Achilles reflex.
Diagnosis?
Scotty Dog on Oblique Views….assess for spondylolisthesis.

67. Spondylolisthesis

68. Case-Ms. W.J.
Grade 1-2 isthmic spondylolisthesis with severe impingement of right S1 nerve root.
Went on to discectomy and anterior/posterior fusion due to instability, back and radicular pain.
Vigorous active post op therapy, has returned to walking 7,500 steps daily.
RTW 8 months following injury, now doing medical case management to avoid clinical nursing and heavy patient transfers.
21% whole person impairment per AMA Guides. 33% apportionment to underlying isthmic spondylolisthesis.

69. Ms. W.J. Grade 1-2 Isthmic Spondylolisthesis s/p discectomy and fusion

70. Conclusions
Internists and other primary care physicians will need expertise in the E & M of acute back pain.
Providers may have a positive impact on improving outcomes, reducing symptoms, and improving functional recovery.
Excessive over-medicalization, and disability are not supported by the evidence in the majority of cases. These outcomes can be prevented with close attention to patient’s history, detailed exam, and multidisciplinary approach to management.

71. Conclusions
Less common red flag conditions will be encountered by all of us-on boards & wards.
A high index of suspicion in red flag clinical scenarios that are unusual is indicated, so as to proceed with prompt evaluation, selective diagnostic testing and referral in these cases.
We can expect the unexpected and keep our eyes and ears open!

72. Be alert to Red and Yellow Flags…keep our eyes & ears..and minds open.

73. Comments or Questions?
The End.