Escolar Documentos
Profissional Documentos
Cultura Documentos
Natural History: 1/3 resolve completely within 1 year 3/5 on-going relapsing pattern 1/10 never resolve
Deyo, 2001; Anderson 1997; Kent 2005
4-fold increase
Demographic Considerations
Pediatric Slipped capital femoral epiphysis or
disease with stenosis (causing radicular pain), facet arthropathy (causing axial pain)
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Pain generators: Lumbar disc (Annular Tear, Discitis) Nerve Root (Lumbar Radiculopathy, Lumbar Stenosis) Facet Z-joint (Facet arthropathy, spondylosis) Vertebral Body (Compression Fracture) Muscles/Ligaments (Lumbar Strain) Spinal Cord (Cauda Equina vs. Conus Medullaris) Referred from SI Joint / Hips Intervertebral Disc 5-39% Zygapophysial Joint 15-40% Sacroiliac Joint 6-13%
Pedicles
Connect
Posterior Elements
Laminae, Site
articular processes, spinous processes, transverse processes of muscle attachments Resist forward sliding, twisting
Lateral Recess?
be involved?
Where would the
symptoms be?
Lateral Recess
Central Disc
History
Time Course, Chronicity Location, Quality, Duration Aggravating, Alleviating Factors Treatment Sought to Date Social History Red Flags Yellow Flags
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Physical Exam
Inspection (shirt off or in gown): Body habitus Posture (head position, shoulders) plumb line from ear lobe, to shoulder tip, to peak of iliac crest. Look for scoliosis Look for iliac crest symmetry Lumbar shift away or toward nerve injury Hyperlordosis
Physical Exam
Palpation STANDING
Iliac Spinous
Physical Exam
ROM: Flexion, extension, lateral bending, rotation, coupled motions (e.g. rotation and extension) Note side-to-side differences More of a gestalt
Normal:
PRONE
Spinous Greater Ischial Paraspinals
30
Schober Test:
Mark
Dimples of Venus (S1), 5cm below, 10cm above increase 4-5 cm with flexion Specific, but not sensitive
Should
Melanga 2006
Physical Exam
Neurologic: MMT:
HF, KF,
HE, HAb, HAd KE ADF, APF Functional testing includes 10 toe raises, heel walks! GTE, Inv, Ev
Reflexes:
L4 L5 S1
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Physical Exam
Provocative Maneuvers SLR
Positive Can
if 30-70 degrees, with pain below the knee test seated (e.g., Slump) or supine More sensitive than specific Provocation with head flexion, or ankle dorsiflexion
place your hand in popliteal fossa, exert some pressure with that hand while flexing the knee, and can also extend a little at the hip. Pain should be reproduced in anterior thigh or back. Tests a high lumbar disc herniation
SI-Joint / Hip
SI Joint (tests are not specific): Rare for pain above buttocks Compression / Distraction Test Gaenslens Test let leg drop off table while you stabilize the pelvis (supine) Stork Knee: Genu valgus, varus Ankle: Pes cavus, planus
+ if provokes radicular pain and relief of pain with neck extension
Waddell Signs
Lie patient supine. Stabilize pelvis with downward pressure on contralateral ASIS. Let ipsilateral leg drop off side of examination table. Apply downward force at ipsilateral thigh and contralateral ASIS Positive with pain in the SI joint region (buttock, low back) None of the SI provocative maneuvers are particularly specific.
Consider contribution from Non-Organic Causes: Distraction: Findings are only present on formal exam Over-Reaction: disproportionate verbalization, facial expressions, muscle tension/tremor, collapsing, sweating Regional disturbance: Non-dermatomal, non-myotomal Simulation tests: Pain with perception of testing Tenderness: Not localized to anatomic structure
Gaenslens Test
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Imaging?
When to order an imaging study? Will it change management? Will it alleviate anxiety in the patient (and thus help them comply with treatment? ACR Appropriateness Criteria: Natural course of
sensitivity and specificity. Degenerative changes on XR / MRI do not reliably predict pain or disability. Interventionalists can use dual blocks at presumed pain generator, but that offers little to the PCP
uncomplicated acute LBP and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered if no improvement within 6 weeks, and for those with red flags.
Jensen 1994
Interventions
Physical Therapy Medication Functional restoration Acupuncture Chiropractor Epidural Steroid Injections Facet Injections Dorsal Rhizotomy Spinal Stimulator Surgery
Treatment Approaches
Acute (< 6 weeks) Subacute (6 weeks to 3 months) Chronic (> 3 months) Interventional Movement-Based Interdisciplinary
CONSERVATIVE 1. Relative rest / Activity Mod 2. Meds 3. PT Mid-Range 1. ESI Aggressive 1. Surgery
Medications
Anti-inflammatories Includes course of oral corticosteroids NSAIDs Opioids analgesics Neuromodulaing Agents Anticonvulsants Gabapentin Antidepressants TCA, SNRI Antispasmodics (relax the patient and the provider) Cyclobenzaprine Tizanidine
Physical Therapy
Goal of centralization of radicular pain Segmental mobilization (vertebrae, SI joint) Lumbar stabilization Core strength Pelvic floor stabilization
Posture Assessment, Ergonomics Are there biomechanical deficits to be addressed? Pelvic girdle weakness Joint contractures (HF, HAb) that place undo stress at painful joints Corrective Orthotics (AFO, FO)
Other considerations
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anesthetic, and long relief with a long-acting anesthetic Using this method, facet-mediated pain approaches prevalence of 30% in older patients (Bogduk 2008) Scant medical literature to support steroid injections
Chronic LBP
Traditional biomedical approach has been
dorsal rami of the lumbar nerve roots. Can consider radiofrequency ablation (neurotomy) of those nerve roots, sometimes called dorsal rhizotomy (not to be confused with the very different procedure performed in pediatrics) 8-12 months of relief Before you kill the nerves, important to have good response (>90% relief of pain) from the selective nerve blocks. Long term consequences of denervation are unknown (? segmental spine stabilization)
inadequate.
Adoption of biopsychosocial model recognizing the
influences of cognitive, emotional, behavioral, and social/environmental factors, as well as biomedical ones. Research on chronic LBP has suggested that psychosocial factors are as least as important as biomedical ones in predicting pain course.
Carragee 2005, Boos 2000
Fear-Avoidance
Individuals who believe that physical or work
Pain Catastrophizing
exaggerated and dysfunctional negative appraisal of
activities should be avoided when in pain (or that such activity is dangerous), have greater likelihood of developing LBP. Avoidance leads to disuse, deconditioning, and painrelated disability. Goal: appearance of pain is met with cognitive appraisal of meaning and significance. Work to appraise as a benign experience (such as from muscle soreness or minor strain)
Linton 1999, Disord 2009
pain as a threat
Leads to fear-avoidance, hypervigilance (which can
result in increased brain activity in pain sensitive regions). Avoidance behaviors: limping, guarding, bracing, reliance on passive techniques and modalities Overtime these types of behaviors can become highly resistant, and are reinforced by family, work, medical community, financial compensation
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Depression
cLBP brings about a number of lifestyle changes that
body might reinforce thoughts that it is dangerous to be physically active or that pain is a sign of injury.
can worsen depression: occupational disability, financial stress, sleep disruption, negative health consequences, relationship distress, sexual dysfunction, family role changes, limitations in social, recreational or household activities Initial diagnosis can be missed Treatment may be inadequate Taking medications may lead the patient to not accept responsibility for resolving their depression (such as through CBT).
Psychosocial Treatment
CBT identify and challenge dysfunctional pain
responses Exposure therapy confronting fears Education encourage as many normal activities as the patient can tolerate
f/up visits
MD, RN, PT, OT, Voc Rehab, Pain Psychologist Treatment designed to reduce avoidance patterns,
pain, interdisciplinary pain rehabilitation probably has better or at least equal outcomes to more invasive interventions (surgery or procedures)
Turk 2002, 2005
Work-place
Predictors of future LBP Low job satisfaction Perceived lack of social support from co-workers or a supervisor Limited control at work Excessive workload
Case
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PE: Diffuse P/S tenderness, gluteal muscles Negative hip, SI joint signs 511, 230 lbs
Rehab Approach
Fully investigate attempts at prior therapy ? Modalities, vs. therapeutic exercise, stretching, functional retraining, ergonomics What other non-pharm approaches Yoga, massage, acupuncture, CBT, spinal manipulation Other meds: Anti-depressants? Other NSAIDs, Tylenol, other muscle relaxants, AED, TCA Risk of diversion. Have risks/benefits of chronic
Rehab Approach
Chronic Opioids for Non-Cancer Pain Moderate to severe pain Pain causes an adverse functional impact or QOL Benefits outweigh the harms
Ongoing If
monitoring, reassessment with appropriate labs h/o red flags, may need to seek support from addiction treatment specialists. S/E: Sedation, dizziness, N/V, constipation, physical dependence, tolerance, respiratory depression, sex hormone deficiencies
Follow-up
Is How
OxyContin, with titration as appropriate Difficulty finding providers to prescribe Adverse Effects: cognitive difficulties, apathy, depression, fatigue, worse with age. Issue of diversion. What about a more comprehensive approach (including weight loss, PT, CBT, etc.)? Multidisciplinary programs not always covered by insurance.
unpredictable and you have a busy practice, especially when someone is still working (which is unusual in a situation like this)