Transcript my-aching-back-revised1

Oh-My Aching Back
A panel discussion of spinal paindiagnosis & treatment
Michael Kassels, D.O.
Diablo Valley Specialist in Internal &
Sports Medicine
Introduction
• Musculoskeletal Conditions:
OA, LBP,
Fibromyalgia a diverse group disorders linked in their
common symptoms; pain, decreased well-being, physical
and psych impact.
• Pain :
Based on Duration. 1) ACUTE- less than 3
months duration 2) CHRONIC- beyond the healing period
and disruption of sleep and normal activity. Lack of
pathology to explain the presence or extent of pain.
Impact of Chronic Pain
• 25% of all adults in the past 3 months had
LBP
• One of the most common reasons for PCP
visits- 26 million age 20-64 yrs and 6 million age 65 and
older.
• Most common reason for work related
disability in patients less then age 45 - 2% US
work force annually at direct cost of $90 billion and
indirect(lost wages, absences) cost of $100 billion/ year.
Pain Control Studies
• American Pain Society • Michigan Chronic
only 55% non cancer pain
Pain Study: 70% adults
patients felt adequate pain
control.
receiving txmt reported
inadequate control.
Pathopysiology of Neck & LBP
• Mechanical or
chemical irritants to
sensory neurons
innervating ligaments,
neural or muscular
tissues. Compressive vs Auto
immune theory of lumbar disc ds.
• Natural aging of the
spine. ie. Spondylosis,
spondylolisthesis
• Majority all cases is
mechanical.
• Differential of Non
mechanical etio. <2% of
all cases i.e.. CA, infection,
inflammatory disease, and
visceral ds. (PID,
endometriosis, nephrolithiasis)
• Strain/Sprain 57% of LBP
cases. DJD 12.5% , Disc Hern.
11%, Stenosis 4%, Instability
2%, Failed Back <1%
Osteopathic Physicians’
Approach to Diagnosis
• Osteopathic Medicine- adjunctive diagnosis and txmt
approaches to common muscular skeletal injuries that involve
traditional allopathic (MD) and Osteopathic (DO) structural
examination skills employing a holistic approach via the use of (OMT)
Osteopathic Manipulative Treatment.
• Anatomical Dysfunction- is evaluated via palpatory
and muscular skeletal testing maneuvers that illicit “lesions” in the
spine that can be corrected via various forms of structural medicine
techniques.
Diagnosis of Neck & LBP
• Diagnostic testinginitially not required.
• Simplistic and time
consuming exam - 1)
patient interview. 2) physical and
neuro exam. 3) Diagnostic test and
pain measures. 4) clinical
knowledge and recognition of
“RED FLAGS”
Patient Interview
• Pain Description- how long in pain, quality,
intensity, location, impact on quality of life.
• Current and Past txmts-how long have you been on
medications.
• Psychological Status- support, family and caregiver
relationships.
• Prior Diagnostic Studies- often multiple and need not be
repeated.
Physical Examination
• Determine Overall Musculoskeletal Health
Status- vitals, (signs of withdrawal), physical function, site of the
pain.
• General Inspection: Spinal asymmetry, Posture
• ROM (flexibility) and Gait.-Anterior flexion (Loading the Discs),
Extension, Lateral Rotation and Side Bending.
• Palpation: for swelling, tenderness, and laxity
Neurological Examination
• Measure Pain
Intensity• Strength & SymmetryTest for Sciatica-SLR Testing,
active vs. passive testing w
reproducible radicular pain at 70%
flexion, significance of contralateral testing & Sciatic notch
compression. False + if Hamstring
tightness- seated and standing
flexion testing or bow string exam.
• Sensory /Motor Exam
Diagnostic Testing
• Labs-r/o RED FLAGS
infection, cancer, etc. CBC,
calcium, esr, LFT, Alk Phos.
• Electro diagnosticsEGD and NC for
myopathies/neuropathies.
• Diagnostic Blocks
Epidural Nerve blocks- diagnostic
and therapeutic. Local anestheticsFacet Syndrome and Sacroiliitis.
• Radiographics-MRI, Plain
Films, CT and Myelograms
RED FLAGS
• ID ETIO: anxiety, depression, • Other: hs of malign,
substance abuse, work stress,
PTSD.
• Non Mechanical: <2%
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age -exclude spinal stenosis pt >50
yrs.
Wt loss/fever- CA or infection.
Trauma- Recent or remote MVA,
Sports ?spondylolisthesis/lysis- Fx
neck of the Scotty dog.
Recent skin infection or UTIbacteremia or osteomyelitis.
immunosuppression, corticosteroid
use, substance abuse, pain or
weakness in BOTH legs, increase
pain when supine. Ankylosis
• When to refer to
surgeon- cauda equina
symptoms, foot drop, unremitting
pain, spinal infection or neurologic
compromise, Arachnoiditis, spinal
abscess or tumor. When ever it is
Out of your scope of practice.
Before the lawyer does.
Osteopathic Treatment
• Stand Alone: established utility in ACUTE pain syndromes with
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statistically significant pain reduction of 50% or greater. Annals of Internal
Medicine-UCLA RAND STUDY 1993
The same study failed to show the value of long term treatment in CHRONIC
pain conditions. These findings have been refuted in both the DO and DC
literature.
• Adjunct to Medication and Other Treatment: length
of injury time decreased in acute and chronic injury with the addition of
manipulative medicine treatments improving overall deconditioning, pain
scores and recovery times in acute LBP.
Other Non Drug Treatments
• MULTI DISCIPLINE
APPROACH
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PATIENT EDUCATION
PSYCHOSOCIAL- biofeedback,
relaxation, cognitive behavioral
therapy.
EXERCISE - increases quality of
life.
MASSAGE, PHYSICAL, and
ACCUPRESSURE Therapies
WORK HARDENING
• Heat and Ice Packs -only
heat stimulates release of
endogenous opioids. Ice rebounds
pain.
• Assistance Devices cane or walker.
• Homeopathy
• Acupuncture
Pharmacologic Therapy
Acetaminophen
Topical Analgesics
Muscle Relaxants
NSAIDs
COX -2 Inhibitors
Tramadol
Opioids
Interventional Options
• Intra-articular Steroids-Epidural and Selective
Nerve Root Blocks.
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Botulinum and Sclerotherpy Injections
Spinal Cord Stimulator and Pumps-steroid delivery to CSF
IDET
Joint and Disc Replacement
Disectomy, Laminectomy w or w/o
Instrumentation (rods, cages) etc.
• Future: Endoscopic Disectomy
Osteopathic Treatment
• Stand Alone: established utility in ACUTE pain syndromes with
•
statistically significant pain reduction of 50% or greater. Annals of Internal
Medicine-UCLA RAND STUDY 1993
The same study failed to show the value of long term treatment in CHRONIC
pain conditions. These findings have been refuted in both the DO and DC
literature.
• Adjunct to Medication and Other Treatment: length
of injury time decreased in acute and chronic injury with the addition of
manipulative medicine treatments improving overall deconditioning, pain
scores and recovery times in acute LBP.