Transcript PERIPHERAL NERVE INJURIES IN THE ATHLETE

Physiatric Approaches to the Management of Low Back Pain:
Applying CPG to our Clinical Practice
Joseph Feinberg, M.D.
Evidence Based Medicine vs Judgment Based Medicine
 How do guidelines affect our decisions?
 Where is the science?
 How do we weigh our judgment that at times is as much intuitive as it is
scientific?
 Does relying on pure science undermine practicing medicine as an art?
 Do the guidelines address the outline questions?
Applying CPG to Our Clinical Practice
Ordering imaging studies
a. Plain X rays – how often do they affect our decision?
b. MRI
i. In the absence of concerns for a malignancy or infection and before
considering an injection does it play a role in conservative care?
ii. In the absence of neurological findings does it add value (press ganey)?
Applying CPG to Our Clinical Practice
Ordering Electrodiagnostics
a. In the absence of neurological sxs do they play a role?
b. In the absence of neurological exam findings do they play a role?
c. When do they contribute to the clinical plan?
Applying CPG to Our Clinical Practice
Prescribing PT
a. Do different approaches give different outcomes?
b. How many sessions do patients really need?
c. When does the argument “I need someone to help make sure I do my
exercises” justify ordering PT (press ganey scores)
Prescribing chiropractor care
a. Does CP care offer something different?
Prescribing acupuncture
a. What criteria determine who is a candidate for
acupuncture?
b. Is it disease specific or personality
(psychological) dependent?
Prescribing oral medications
a. Should NSAIDS be taken in sustained way to decr inflammation or prn for
pain?
b. What is the role for narcotics & do they lower pain threshold (press
ganey)?
c. What’s the threshold for oral steroids & how often can they be repeated?
Prescribing spine interventional procedures
a. Can epidural impact neurological deficits?
b. Is there truly an amount that is unsafe?
Referring to a spine surgeon
a. In the absence of an obvious surgical l emergency (i.e. cauda equina
syndrome) when should a spine surgeon be engaged in the patient’s care?
Patient expectations
a. How much do patient expectations affect our decisions and determine what
pathway of care is most appropriate and most effective?
Grading the Studies
Level 1 studies – high quality randomized controlled trial or systematic review
of level I RCT
Level 2 studies – lesser quality RCT or prospective comparative study or
systematic review of level II or level I
Level 3 studies – case control
Level 4 studies – case series
Level 5 – expert consensus
Grading Recommendations
Level A - Recommended - Good Evidence
Two or more consistent Level I studies
Level B - Suggested – Fair Evidence
One Level I study with additional supporting Level II or Level III
Two or more consistent Level II or III studies
Level C - May be considered and is an option – Poor Quality Evidence
One Level I, II or III study with additional supporting Level IV studies
Two or more consistent Level IV studies
I (Insufficient or conflicting evidence) – Insufficient evidence to make recommendations for or against
A Level I, II, III or IV study without other supporting evidence
More than one study with inconsistent findings
Degenerative Spinal Stenosis CPG Guidelines 2011
Kreiner et al. Spine J, 2013 Jul 13 (7) 734-43 (most current publication)
Endorsed by AAPM&R (on AAPM&R and NASS website)
a. Defined as diminished space secondary to degenerative changes in spinal
canal that can cause gluteal or lower limb pain
b. Natural history is favorable in 33-50% of patients with mild to moderate
stenosis (Consensus statement)
c.
PE findings are inconclusive for making dx (Insufficient evidence)
Imaging
i. Radiographs not routinely needed
ii.MRI, CT (when MRI contraindicated)
a. probably unnecessary in early management
b. useful for making diagnosis in patients with positive clinical
history and exam for stenosis
c. correlation of clinical symptoms with anatomic narrowing
(Insufficient evidence)
EDX
i. EMG (paraspinal mapping) to confirm dx in mild to moderate sxs
and when there is radiographic evidence (Level B)
ii. EMG of limbs and NCS – to dx spinal stenosis but may be helpful to
identify other comorbidities (Inconclusive)
Oral Medications – inconclusive for all meds
i. NSAIDs if no contra-indications (or acetaminophen)
ii. Narcotics
iii. gabapentin for short term use for break through
iv. Oral steroids depending on severity of symptoms
Rehabilitation
i. inconclusive but work group’s opinion is that active PT is an option
ii. inconclusive for traction, TENS, E stim
Interventional Spine Procedures
i. Contrast fluoroscopy is recommended for epidurals (Level A)
ii.Interlaminar epidural for short term relief (2 wks to 6 mos) and
conflicting evidence for long term (Level B)
iii.Multiple injections for long term relief (3 to 36 months) for
radicular or neurogenic claudication sxs (average was 3.6
injections per patient) (Level C)
Medical/Interventional
i. can provide long term relief (2-10 years) in a large percentage of
patients (Level C)
ii.recommended for patients with mild (Consensus) and with
moderate (Level C) stenosis
Alternative Care
i. Acupuncture - inconclusive
ii.Manipulation – inconclusive
Bracing LS corset -
can reduce pain and increase walking distance
(Level B)
Surgery
i. Decompression surgery recommended in moderate to severe
stenosis (Level B)
ii.Decompression alone if there is no instability (Level B)
Lumbar Disc Herniation with Radiculopathy (2012)
Kreiner et al. Spine J, 2014 Jan 14 (1), 180-91 (most curent publication)
Radiculopathy
defined as pain, numbness or weakness along a
dermatomal or myotomal distribution
Natural history – the majority of patients will improve independent
(not without) of treatment. This in part is probably do to shrinkage of
HNP (Work group consensus statement)
Imaging
i. Plain radiographs – no recommendations but probably not needed
in uncomplicated cases (no red flags)
ii. MRI (or CT scan) – In patients with history and PE findings c/w
HNP & radiculopathy, MRI (CT or CT myelo when MRI contraindicated) is recommended to confirm HNP (Level A
recommendation)
Physical Exam
i. MMT, sensory testing, supine SLR, Laseque’s sign and crossed
Laseque’s sign are recommended to help dx (Level A
recommendation)
ii. Supine SLR is suggested over seated SLR for dx (Level B
recommendation)
iii. Insufficient evidence to recommend for or against cough impulse
test, Bell test, femoral nerve stretch test, slump test, lumbar ROM or
absence of reflexes to dx HNP with radiculopathy
EDX
i. Recommended to confirm presence of comorbid conditions (Work
group consensus)
ii. No statement on role when motor deficits are present
iii. EMG, NCS & F waves have limited utility in dx of HNP with
radiculopathy (Level B)
Oral Medications (insufficient info on all meds)
i. NSAIDs, acetaminophen
ii. Narcotics
iii. gabapentin (insufficient evidence), amitriptyline (insufficient
evidence)
iv. Oral steroids
Rehabilitation
i. Insufficient evidence to recommend for or against PT as
stand alone txs
ii. Limited course of structured exercise is an option for
patient’s with mild to moderate sxs (Work group consensus)
Interventional Spine Procedures
i. Contrast fluoroscopy recommended for epidural injections (Level A)
ii. Transforaminal
a. Recommended for short term (2-4 wks) relief (Level A)
b. Improve functional outcome in majority (Level B)
iii. Interlaminar epidural may be considered (Level C)
iv. Insufficient evidence for 12 month efficacy
v. No optimal frequency or quantity of injections (Lack of info)
vi. Insufficient evidence for one approach (transforaminal, interlaminar,
caudal)
vii. Higher degree of nerve root compression negatively affects outcomes
with transforaminal epidurals
Medical/Interventional
• Suggested to improve functional outcomes in the majority of
patients (Level B)
• Interlaminar considered (Level C)
• Medical/Interventional are suggested to improve functional
outcomes (Level B)
• Insufficient evidence on the influence of age
• Cost-effective for contained herniations but not extrusions
Manipulation
• An option for symptomatic relief (Level C)
• insufficient for or against to improve functional outcome
Traction – insufficient evidence
Surgery
i. Insufficient evidence for surgery for patients with motor deficits
ii. Surgical intervention recommended before 6 months in patients
who symptoms are severe enough (Level B)
Degenerative Lumbar Spondylolisthesis (2008)
Endorsed by AAPM&R (on AAPM&R and NASS websites)
Definition
i. Acquired vertebral displacement associated with degenerative changes
Natural History
i. Majority of patients without neurologic deficits do well with conservative care
ii. Patients with neurological changes are more likely to develop functional without
surgery
iii. Progression of clinical sxs does not correlate with progression of slip
Clinical Dx
i. Patients complain primarily of radiculopathy or neurogenic claudication (usually
secondary to associated stenosis) with or without LBP
ii. No clinical sxs specific and many patients will be asymptomatic
Imaging
i. Lateral radiograph is most appropriate test (Level B)
ii. MRI (or CT scan) – most appropriate to assess associated spinal
stenosis (Consensus)
Physical Exam
i. Obtaining an accurate history and PE is essential for dx and plan
(Consensus)
EDX
i. No comments on EDX
Oral Medications – no comments
i. NSAIDs, acetaminophen
ii. Narcotics
iii. Anticonvulsants, antidepressants
Rehabilitation
i. No conclusive recommendations on PT (paucity of literature)
Interventional Spine Injections
i. No recommendations on facet inections or RF
Medical/Interventional
i. No studies to compare tx to natural history
ii. Tx should be similar to Spinal Stenosis when radicular sxs of
stenosis predominate (Consensus)
Alternative Care (no commentary)
i. Acupuncture
ii. Manipulation
Surgery
i. Indicated for low grade deg spondylolisthesis with stenosis in
patients recalcitrant to medical/interventional tx (Level B)
ii. Decompression with fusion is better than decompression alone
for symptomatic stenosis with degenerative spondylolisthesis
(Level B)
Summary Remarks
How do these guidelines affect our Clinical Practice?
How useful are they and what’s missing?
Some Key Points
1) There is no evidence for or against PT.
2) No comment on role of EDX when neuro deficits exist.
3) Limited comment on facet injections which are extremely
relevant for spinal stenosis and spondylolisthesis.