Low Back Pain: Update Jesus Sanchez, Jr. D.O.

OPSC Spring Conference

San Diego

• Published 10/2/07 • 2007 Clinical Guidelines for

Diagnosis and Treatment of Low Back Pain

• 7 Recommendations for Evaluation and Treatment of Low Back Pain

Main Points

• 85% of patients present with back pain that cannot be attributed to specific disease or spinal abnormality

• Do a focused history and physical determine the likelihood of specific underlying conditions and measure the presence of neurologic involvement

• Recommended Classification 1. Non-specific Back Pain

2. Back Pain with Radiculopathy

3. Back Pain with other specific cause

• Published 2/14/17 • Partial update to the 2007 Clinical

Guidelines for Diagnosis and Treatment of Low Back Pain

• 3 Recommendations for Noninvasive Treatment of Acute, Subacute and Chronic Low Back Pain

Recommendation 1 (Acute or Subacute LBP)

Recommendation 2 (Chronic LBP)

Recommendation 3 (Chronic LBP with inadequate response)

ACP Updated Guidelines: Low Back Pain

• Symptom Duration

• Potential Cause

• +/- Radicular Symptoms

• Anatomic Abnormalities

• Radiologic Abnormalities

• Acute < 4 weeks

• Subacute 4-12 weeks

• Chronic 12 weeks

Interventions (Acute)

• Acetametaphen (LQ, ND)

• NSAIDS (MQ, SE)

• SMR (MQ, ND)

• Systemic Steroids (LQ, ND)

• Exercise (LQ,ND)

• Accupuncture (LQ, SE)

• Massage (MQ, SE)

• Spinal Manipulation (LQ, SE)

• Superficial Heat (MQ, ME)

• Low Level Laser Therapy (LQ, +NSAID MQ)

• Lumbar Support (LQ, ND)

• TENS, Superficial Cold, Tai Chi, Yoga, Pilates (insufficient data)

OMM/OMT ???

Quality of Evidence (High, Moderate, Low)

Magnitude of Effect (Small, Moderate, Large)

• AOA Funded Research • AOA Bureau of Osteopathic Clinical Education and Research • Published in 2010 on the National Guideline Clearinghouse • Essentially the AOA’s “White Paper” on Low Back Pain • Systematic Review and Meta-analysis (Evidence Level 1a) • Guideline for osteopathic physicians to utilize OMT for patients

with non-specific acute or chronic low back pain

Franke H, Franke J-D, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskeletal Disorders 2014, 15:286 doi:10.1186/1471-2474-15-286. (Published: 30 August 2014)

• Identified 307 studies

• 31 evaluated 15 included (6 Germany, 5 US, 2 UK, 2 Italy)

• 1502 participants (both qualitative and quantitative)

• Moderate quality evidence suggested that OMT had a significant effect on pain relief and functional status.

• Analysis included pregnant and post-partum women

• Update to the AOA guidelines for Osteopathic Physicians to utilize OMT for patients with non-specific acute or chronic low back pain

• Published in JAOA August 2016 • Updated every 5 years • Evidence (Level 1a) supports the

recommendation • AOA making an effort to inform its

members and the public about the appropriate utilization of OMT

Nonspecific Low Back Pain

“… which can be defined as tension, soreness, or stiffness in the lower back region with an unidentified cause.”

Somatic dysfunction is defined as: “Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements.

Osteopathic Structural Exam

Gait Analysis

Standing Flexion Test

OSE continued

Seated Flexion Test

Segmental Exam

OMT is defined in the Glossary of Osteopathic Terminology as: “The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.

Osteopathic Manipulative Treatment (OMT)

Soft Tissue

Strain Counter Strain

OMT continued

HVLA MET

Take Home Point

“Once a patient with low back pain is diagnosed with somatic dysfunction as the cause, or contributing factor, of the low back pain, OMT should be utilized by the osteopathic physician.”

Thank you!

Low Back Pain Workshop

Tomorrow 7-9 am

References

• Noninvasive Treatment of Acute, Subacute and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017; doi:10.7326/M16-2367

• Snow, RJ, et. al. American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients with Low Back Pain. JAOA. 2016; 116:536-549

• Chou, R, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491