Upload
others
View
5
Download
0
Embed Size (px)
Citation preview
12/20/2018
1
ECHO BOOT CAMP
Low Back Pain &
Lumbar Spinal Stenosis
Practical Evaluation &
Management Tips
Carlo Ammendolia DC, PhD
Assistant Professor, IHPME, University of Toronto
Associate Scientist/Chiropractor, Mount Sinai Hospital, Toronto
CCRF Professorship in Spine, Dept of Surgery, University of Toronto
Disclosures
No Relationships with Commercial Interests
Funding: Canadian Chiropractic Research
Foundation (CCRF)
and The Arthritis Society
Founder spinemobility Research & Resource
Centre- Not-for-Profit Organization
Objectives
Understand the epidemiology of low back pain and
lumbar spinal stenosis
Perform a systematic assessment of patients with
back pain and related leg symptoms
Make a diagnosis and differential diagnosis in patients
with back and leg pain
Learn about effective non pharma treatment options
Mysteries of
Low Back Pain
Mystery #1
Prevalence Back Pain
Mystery #1- Prevalence- Back Pain
Point prevalence
10% to 20%
Yearly
25% to 45%
Lifetime
70% to 80%
Female gender
Age
40-80 yrs
Carey et al. Spine. 2000; Andersson. Lancet. 1999, Hoy et al Arth Rheum 2012
12/20/2018
2
Evolution of Man Prevalence- Back Pain
Role of Primary Prevention?
Mystery #2-
Mystery #2
Cause of low back pain
Classification LBP
90% non specific LBP
10% specific LBP
- herniated discs 2-4%
- lumbar spinal stenosis 3%
- compression fracture 4%
- spondylolisthesis 2%
- cancer, infection, inflammatory 1%
Deyo et al. N Engl J Med. 2001;344:363-370 (C).
What causes LBP?
12/20/2018
3
Back Pain Disability
Mystery #3
Back Pain Disability
Lancet 2012:380:2163-96
Lancet 2012:380:2163-9620122012
12/20/2018
4
Loisel et al 2005
Back Pain Disability
Back Pain Management
Case No. 1
12/20/2018
5
Case No. 1
20 yo female
Picked up child
Lower back ache x 24 hours
Decreased ROM
No numbness/tingling
No B/B problems
Healthy, no medications
26
Acute or Sub Acute LBP
1st line Treatment
Advice to stay active
Avoid bed rest
Superficial heat
Massage
Acupuncture
Spinal manipulation
2nd Line Treatment
NSIADS
Muscle relaxants
ACP Guidelines Feb 2017
Case No. 2
Case No. 2 45 yo construction worker
Multiple work related back injuries most recent 5 months ago
Since then persistent LBP
Pain all the time across the LB
Worse with physical activity
Off work for 5 months
Physical exam unremarkable
30
12/20/2018
6
Yellow FlagsPsychosocial
Fear of re-injury/ activity avoidance
Catastrophizing
Depressed mood
Negative expectation
Passive coping
Pain focused
Lack of social networkRamond 2011, Nicholas 2011, Steenstra 2005
Blue Flags
Workplace
Work satisfaction
High physical load
Low job control
Low supervisor/co-workers support
Lack of communication with workplace/supervisor
Unsafe work/ergonomic design/equipment
High stress/pace/demandNicholas 2011, Guzman 2007,
Chronic Non Specific LBP
Management
No investigations
Reassurance/Advice to stay active
Psychosocial/workplace factors
Focus on RTW not pain
Return-to-work coordination
Chou et al 2007, Dagenais et al , Spine J 2012,
Costa-Black et al Best Pract Rhuem 2010
Back Group reviews, The Cochrane Library 2012, issue 2.
Case No.3
Case No. 3
35 yo medical researcher
Has had vague back pain for a month while writing grant
While bending forward to tie shoes
Excruciating, lancinating pain down right leg to foot– toothache
Worsens with sitting, and coughing
Needs to lie down to relieve pain
Case No. 3
Ambulatory, antalgic
Lumbar spasm
Decreased ROM
Positive neural tension
Numbness L5
Great toe dorsiflexion decreased
12/20/2018
7
Neural Tension - SLR Neural Tension - Slump
Lumbar Radiculopathy
Management
No initial imaging /investigations (6w)
Monitor for progressive weakness -referral
Bladder/bowel control- ER
Qaseem et al ACP 2017
Chou et al 2009, Dagenais et al , Spine J 2012
Back Group reviews, The Cochrane Library 2012, issue 2.
van Tulder et al. Eur Spine J 2006; 15 Suppl 1:S64-S81.
Lumbar Radiculopathy
NSAIDS?
Gabapentin +/?
Symptom guided
exercises
Epidural injections
Stabilization exercise
or SMT
Opioids?
Surgery
Traction/VAD-not likely
Management- pain control
Qaseem etal 2017, Dagenais etal 2010, Jacobs et al 2011, Luijsterburg etal 2007, Chou etal 2009
Lumbar Radiculopathy
Avoid sitting
Keep active
Extension exercises
Self management
Neuro-mobilization
.
Advice for Patients
12/20/2018
8
Directional
Preference
Flexion
Aggravated
Directional
Preference
Extension
Aggravated
Non-Directional
Preference
Recovery
Positions
Daily
Positions
Standing
Walking
Reduced sitting
Lumbar Roll
Sitting
Limited walking
Flex one leg
Frequent changes
No sustained
postures
Starter
Exercises
Repeated passive
extension in lying
progressing to
standing
Sitting trunk
flexion
Knees-to-chest
stretch
Neutral Positions
Small
progressions
43Hall, Rampersaud, Alleyne Provincial LBP Strategy 2013
Case No.4
Case No. 4
70 yo retired female
Bilateral buttock pain and radiating right
leg pain when standing and walking
Limited walking to 2 blocks
Relieved by sitting and forward bending
Worsens with lumbar extension
SLR negative
Most useful
Age > 70
Age < 60
Bilateral buttock or leg pain
No pain when seated
Symptoms worse standing/walking/extension
Symptoms improve when bending forward
Positive Rhomberg / wide stance gait
Urinary disturbancesSuri 2010, Genevay 2017, Tomkins-lane 2017
Diagnosis
Peripheral vascular disease-vascular claudication
Hip OA
Hip-Spine Syndrome
Greater Trochanteric Syndrome
Lumbar Disc Herniation
Cervical stenosis (myelopathy)
Metabolic syndromes – diabetes and hypothyroidism
Nutritional – Vit B12, B1 and folic acid
Ammendolia 2014
Differential DiagnosisNeurogenic Claudication
Management
No initial imaging /investigations unless
surgical candidate
Monitor for progressive weakness –referral
Monitor balance-high risk for falls
Chou et al 2009, Dagenais et al , Spine J 2012
Back Group reviews, The Cochrane Library 2012, issue 2.
van Tulder et al. Eur Spine J 2006; 15 Suppl 1:S64-S81.
12/20/2018
9
Neurogenic Claudication
Gabapentin ?
Vit B12?
prostaglandins?
NSAIDS/opioids?
Physical
therapy/exercise/
manual therapy
Surgery
Epidural injections-not
likely
Management
Ammendolia et al Spine 2012
Dagenais etal 2010, Jacobs et al 2011, Luijsterburg et al 2007, Chou et al 2009
Neurogenic Claudication
Aerobic exercise –
stationary bike
Self management
strategies/education
Avoid extension
Standing/walking
pelvic tilt
Assisted devices-
walkers, canes
Balance Exercise
.
Advice for Patients
ImagingNon Specific LBP- no imaging
Specific LBP
-Radiculopathy-Herniated Disc *–not routine- MRI
-Neurogenic claudication- Spinal Stenosis*- not routine- MRI
-Spinal fracture- Plain radiography
-Cancer/infection/cauda equina- MRI
-AS- plain radiography/MRI
* No response 4- 6w and decrease QOL and need to refer
Chou et al , Ann Intern Med 2007
Summary
Prevalence LBP not decreasing
90% LBP non specific
LBP disability on the rise
Acute LBP –less is more, normal activity
Chronic LBP- address psychosocial and workplace
factors
Radiculopathy- pain control, avoid sitting and
positional therapy
Neurogenic claudication- conditioning, flexion
exercises, avoid extension, gabapentin
Contact info:[email protected]
Carlo Ammendolia
Funded by the Canadian Chiropractic Research Foundation and
The Arthritis Society
.com.. .com