Integrative Approach to Low Back Pain

Wendy Kohatsu, MDDirector, Integrative Medicine Fellowship

Santa Rosa Family Medicine

Residency Program

Sept 2011

Goals of this talk:

• Review key history elements

• Learn how to do better hands-on back exam

• Focus on practical & effective lifestyle therapies

• Not ‘overmedicalize” LBP via diagnostic tests, drug therapies, surgical interventions.

• Later: myriad of mind-body therapies

• Talk about something other than food for a change….

Low back pain

• 70-84% of the population affected at some point in their lives

• 14-50% of adults have LBP each year• Cost of > $100 billion/ year• Quality of life impact of acute LBP

– 60% unable to perform some daily activity – 72% gave up exercising– 46% gave up sex

Spine 12:264,1987Amer Acad Ortho Surg, 2006Ann Rheum Dis 57:13, 1998

Posture

Patient case #1:

52 yo female, cc: “sciatica” bilateral numbness hip to knees, since 1999. h/o prior LBP.

•30 years ago fell down flight of stairs at Fisherman’s wharf, landing on tailbone. •Currently works part-time at family business.•On 800 mg ibuprofen. Took friend’s percocet. Flexeril does “nothing”.

Patient case #2

• 86 yo Vietnamese male, DM2, reluctant to see MD.

• Ambulates with 4-prong cane • c/o LBP, radiating to back of legs,

doesn’t like to take medicine, uses analgesic balm

• ROS: urinary retention, feels more tired, recent weight loss.

History-taking

History-taking

• Onset/first episode?

• Occupational risk

• Co-morbidities

• Activity & exercise level

• Psychosocial stress/ diagnoses

• Other?

3 main questions for LBP:

1. Is systemic disease causing the pain?2. Is there social or psychological

distress that may amplify or prolong the pain?

3. Is there neurologic compromise that may require surgical evaluation?

Deyo & Weinstein NEJM 344:363, 2001

“Red flags”

ACR Criteria - Low Back Pain, 2005

“Red flags” • Hx of trauma• Focal neurologic signs - incontinence,

weakness, numbness• Hx of cancer• Age of first onset after 50 years• Hx of IVDA• Osteoporosis• Signs of systemic disease - fever, wt loss,

lymphadenopathy

ACR Criteria - Low Back Pain, 2005

Perspective

• Among all primary care patients with LBP,

< 5% will have serious systemic pathology.• 97% will have LBP w/o radiculopathy

– 60% Simple back pain– 37% Complex back pain w/o radiculopathy

• 3% will have LBP with radiculopathy– Sx of radiculopathy– 1% with acute neuro sx – loss of bladder fxn,

saddle anesthesia, motor weakness

N Engl J Med. 2001;344(5):363Up To Date –June 2011

To image or not to image…• MRI evaluation to provide

reassurance for chronic LBP does NOT lead to better prognosis.

• Psychosocial variables are stronger predictors of long-term disability than anatomic findings found on imaging

studies.• Radicular sx > 4-6 weeks,

severe enough to consider

surgery.Ann Intern Med. 2007;147(7):478.JAMA. 2010;303(13):1295.

So, let’s examine our patients…

2 1/2 -minute focused neuro exam Position Test/feature Findings

All Observe Behavior

Standing •Posture & gait•Toe / heel walking•Asymmetry

•Posture habits•L5 or S1 deficiency*•Scoliosis

Sitting •Straight leg raise•Neurologic testing

•Radicular pain•Sensory defect

Supine •Leg length•Straight leg raise•Fabere’s sign

•Mech contribution

•Radicular pain•Hip involvement

Prone •Palpation•Hip Extension 5-20•Prone prop

•Muscle dysfxn•L2-4 radiculopathy•Facet jt dysfxn

Biewen PC Postgrad Med 106:102, 1999

EXAM! - Anatomy Review(what med school never taught you…)*

• *Except Natasha, Trang, Sarah W & Hana C.

• OMT basic evaluation• 3 layer muscle palpation• Skeletal survey -- L-spine, pelvic girdle,

lower extremities (joint above/below)• Common culprits: Erector spinae

spasm, Lumbar rotation, SI joint dysfxn, psoas, piriformis spasm, muscle imbalance, myofascial syndrome!

OMT Common Culprits:

• Erector spinae spasm

• Lumbar rotation

• SI joint dysfxn

• Psoas

• Piriformis spasm

• Muscle imbalance

• Myofascial syndrome!

Psoas located deep in abdomen, but major hip flexor.

Radiates to: -Lumbar region-Front of hip

The “Dirty Half-Dozen” of Refractory LBP

OMT diagnosis FrequencyTrunk-thigh imbalance 100%Lumbar dysfxn 88%Pubic dysfxn 76%Short leg/pelvic tilt 65%Posterior sacral base 60%Innominate shear 24%

n = 183 ‘untreatable’ pts with refractory LBP75% restored to normal activity after OMT*

Phys Med Rehab Clin NA 7:773, 1996

Patient #1 - Exam• 52 yo woman with sciatica • Exam: Wt 151, BMI 25.5, anxious• Neuro: 4+/5 left hip flexion, knee extension.

Preserved gait and balance walking in hallway.

• MSK: level iliac crest heights, ++ 4 cm left posterior hip rotation, ++ right sacral torsion, L > R SI join tenderness, LEFT glut max,min + piriformis spasm.

• Imaging: NONE.

Patient # 2 - Exam

86 yo Vietnamese male with LBP

•Very stoic, pleasant, NAD

•Wt 111 (down from 129 lbs 4 mos prior)

•Thin frame, + increased thoracic kyphosis, tight lumbar paraspinal muscles.

•Rectal: Enlarged prostate.

Posture

What next?

Principle Based Treatment Pyramid

environment

relationship

resources

Principle Based Treatment Pyramid

resourcesenvironment

relationship

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies

• Drugs

Treatment Options

• “Internal Environment”– Pain is a signal for change

– John Sarno, MD ~ (TMS)Tension Myositis Syndrome

• Lifestyle

• CAM therapies

• Drugs

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies

• Drugs– NSAIDs– Analgesics– Muscle relaxants

NSAIDs

• For acute LBP – Ibuprofen 400-600 mg up to qid– Naproxen 220 -500 mg bid

• Side effect and risks limit use

Cochrane Database NSAIDS for LBP, 2008ACP and Amer Pain Soc Guidelines 2007

Analgesics• Acetaminophen

– Up to 2.6 grams/d as first line therapy– Side efx - hepatoxicity

• Opioids– Surprisingly little data

• One meta-analysis = not significantly reduce chronic low back pain

– Inadequate data re: functional improvement correlating to pain relief

– Reports of opioid abuse ~ 30-45% in LBP

CMAJ 174:1589, 2006 Ann Intern Med 146:166, 2007Cochrane Database Syst Rev -Opioids for Chronic LBP, 2008FDA guidelines June 2009

Muscle relaxants

• “Insufficient evidence” for chronic use• CNS side effects - sedation• Carisoprodol metabolized --> meprobamate,

abuse and addiction potential

• Limit to short-term use only in conjunction with analgesics

vanTulder et al. Spine 28:1978; 2003

Drug-Nutrient Interactions

• NSAIDS deplete…

•Folic Acid -Synthesis of folic acid is competitively inhibited by NSAIDs

-Rx: eat your leafy greens! (“foliage”)

Treatment Options

• “Internal Environment”

• Lifestyle

• CAM therapies– Acupuncture– Massage– Chiropractic or osteopathic manipulation

• Drugs

Acupuncture for LBP

• Like massage, data show acupuncture is moderately more effective than no treatment

• Short-term outcomes > long-term

• More likely to benefit those who expect more out of acupuncture.

Cochrane Database Syst Rev - Acu for LBP, 2005Spine 26:1418, 2001

Massage

• Appears to be better for acute vs chronic back pain

• Studies inconclusive due to varying styles, practitioner skill, duration of treatment

Manipulation

• “Moderately superior” to sham Rx, null therapies

• But equal to analgesics, exercises, back school

• Mixed bag of techniques studied --Most studies on HVLA techniques used in chiropratic Rx

Ann Intern Med (meta-analysis)138:871 2003Ann Intern Med 138:989, 2003

Treatment Options

• “Internal Environment”

• Lifestyle – Exercise

• Stretching, strengthening, yoga

– Stress management

• CAM therapies

• Drugs

Low Back Pain - Exercise Rx

• 2005 Systematic Review– 43 trials of 72 exercise treatments– Improvement seen esp. with

• High-dose exercise programs• Interventions that included conventional care• Stretching and strengthening demonstrated the

largest improvements. (vs passive treatments)

Ann Intern Med 142(9): 776-85, 2005

Low back pain - Exercise Rx

• BMJ study 1995 with “moderately disabled” pts.– 81 chronic LBP patients, referred from ortho

• Control – home exercises + ref’d to back school

• Intervention – above + 8 exercise classes/4 wks– Two hour sessions

• Warm up, stretching• 15 systematic progressive exercises

• Lite aerobic activity and stretching

• Signif. improvements in pain reduction, self-efficacy, and walking distance noted at 4 weeks, and 6 month f/u

Frost, H, et al. 1995 BMJ 310(6973): 151-4.

Low back pain - Exercise Rx

• Study by Carpenter & Nelson, 60 pts considering neurosurgery– 10 week back-strengthening program

• Progressive resistance exercise• Isolated lumbar extensions (with pelvis neutral)• One set of 8-15 reps to volitional fatigue

1x/week

– 57/60 pain-free, no longer needed surgery!

Med Sci Sports Exerc 1999 31(1): 18-24.

Best outcomes for exercise therapy

Best outcomes achieved when these 4 elements included:

• Individualized regimens

• Stretching

• Strengthening

• Supervision

Hayden, Van Tulder et al. Ann Int Med 142:776, 2005

Home exercise Rx

• Tennis ball* -- myofascial and erector spinae column

• Abdominal strengthening

• Quad strengthening

• Spinal twist

• Piriformis stretching

• Hamstring stretching

Pelvic Clock Technique

• Created and researched by Phil Greenman, DO

• No prior training required• Dx and Rx at same time• Patient can do at home

Take home points

• Ask the 3 questions - are systemic dx, neurol red flags, or psychosocial fx present?

• DO THE EXAM!– Focused neuro exam– Musculoskel exam– Be judicious when ordering imaging

• Rx: Improve function, not just blunt pain• Teach exercise therapies, can tailor to

individual patient

Strength training

• Why?– Muscle strength declines rapidly after 50 in

sedentary people. REVERSIBLE! – Increase bone density– Improves strength & ability to perform aerobic

exercise.– INCREASE BASAL METABOLIC RATE (BMR) by

increasing lean body mass.

Life, J. CAM Secrets (2002)

“Core Four” Weight Training Program – Hewitt 2002