Getting at the CORE of Low-back pain Treatment Dr. John Flannery Dr. Carlo Ammendolia

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1 Disclosure & Acknowledgment Getting at the CORE of Low-back pain Treatment Dr. John Flannery Dr. Carlo Ammendolia Disclosures - None Acknowledgements Dr. Andrea Furlan Dr. Julia Alleyne Dr. Hamilton Hall Dr. Raja Rampersaud At the end of the session the participants should be able to: Recognize Yellow and Red Flags in Acute and Chronic Low Back Pain (A/CLBP) Intervene appropriately to prevent evolution into Chronic Low- Back Pain (CLBP) Manage: chronic non-specific low-back pain spinal stenosis radicular syndromes using guideline-based treatments Context and Impact of LBP LBP is the 5 th most common reason for all physician visits in the US 2 nd most common cause for work absenteeism (1 st is common cold) Yearly, 2% of the workforce have back injuries requiring compensation Return-to-work: 95% return to work within 3 months Otherwise Poor prognostic factor 2% return to work after 2 years of disability Chou et al, Ann Int Med, 2007; Andersson et al Lancet. 1999; Hart et al Spine. 1995;20: Epidemiology of LBP Point prevalence(lbp) 10%-30% Yearly Lifetime CLBP 50%-80% 25%-45% 5%-8% Conservative estimates Carey et al. NEJM Pain history/diagram/vas 2. Red flags 3. Physical exam 4. Psychosocial assessment/ Yellow Flags 5. Functional assessment 6. Investigations - Imaging 7. Diagnosis 8. Treatment Today s Road Map Resources: Carey et al

2 Pain History: The 5 Key Questions Pain Tools VAS = Quantity of Pain Back Dominant Intermittent Extension: facet OA, Spondylosis, Spondylolisthesis Flexion: discogenic Constant NIFTI or Chronic Pain Disorder Pain Tools Diagrams = Pain Location Leg dominant Constant: radiculopathy (herniated disc) Intermittent: spinal stenosis Location: lumbar, unilateral, regional, whole body Pain Details Intensity: use scale, pain right now, worst in 24hs., intensity in the back, intensity in the leg Quality: aching, dull, burning, tingling, electrical shocks Onset: Acute/Subacute/Chronic. Fall, accident, or fracture Radiation: buttock, thigh, leg, foot, to the other side Frequency: constant, intermittent Associated symptoms: fever, chills, joint pain, numbness, motor weakness, bowel and bladder incontinence Alleviating factors: sitting, lying down, heat/cold, manual therapy, acupuncture, medications, relaxation, distraction Aggravating factors: exercise, posture walking, going up stairs, cold, psychological stress Pain Patterns Central Sensitization Clifford Woolf, Anesthesiology, 2007 NIFTI Red Flag Screening on the Hx Radiation of: Pain Parathesias 2

3 Screening Yellow Flags on Hx 3 Domains Yellow Flags Tools Psychological Assessments Brief Pain Inventory (BPI) 9 Domains General activity Mood Walking Work Relationships Sleep Enjoyment of life Ability to concentrate Appetite The Physical Exam: The test in green are the suggested minimum Pain behaviours, affect, anxiety, mood. Gait Observation BMI, abdominal circumference A/PROM Neurological: motor, sensory, DTR Physical Exam Leg Length Discrepancy Aerobic fitness testing Core Strength testing Flexibility testing Palpation: bone, ligaments, myofascial trigger points, fibromyalgia. Special tests Acute or Sub acute LBP 1st line Treatment Advice to stay active Avoid bed rest Superficial heat Massage Acupuncture Spinal manipulation 2 nd Line Treatment NSIADS Muscle relaxants Chronic LBP 1 st line Treatment Exercise Self-management Multidisciplinary rehab, goal setting Acupuncture Mindfulness stress reduction Tai chi, yoga, motor control exercise, progressive relaxation EMG biofeedback, CBT, Low Level laser Spinal manipulation 2 nd line Treatment 1) NSAIDS 2) Tramadol or duloxetine 3) Opioids ACP Guidelines Feb 2017 ACP Guidelines Feb

4 skills fear avoidance knowledge self-confidence attitudes & beliefs expectations Comprehensive Cognitive problem solving Exercise pacing Approach SMART goals Behavourial imagery relaxation Positive Health ability to adapt and to self-manage in the face of social, physical and emotional challenges Huber et al BMJ 201 Contextual Factors Living well with chronic pain Positive expectations harm vs. hurt positive reinforcement mindfulness Makris et al. JAMA 2014 Buchbinder et al Lancet 2018 Lumbar Radiculopathy 1 st line Treatment Symptom guided exercises? Stabilization exercises? Traction - Gabapentin +/? NSAIDS? Pregabalin? 2 nd line Treatment Opioids? Epidural injection? Surgery ACP Guidelines Feb 2017, Chou et al 2009 Lumbar Spinal Stenosis Stationary bike program Home based flexibility and strength program Manual therapy Cognitive behavioural approach Self-management strategies Self-monitoring Instruction of body alignment techniques NASS guidelines 2010, Ammendolia et al

5 Key Messages for the Health Care Providers Regarding Treatment Non pharmacologcial treatment should be tried first Acute - LBP less is more Chronic - LBP multimodal with focus on psychosocial aspects Radiculopathy - favourable natural history Lumbar Spinal stenosis multi-modal with focus on exercise and cognitive behavioural approach At the end of the session the participants should be able to: Recognize Yellow and Red Flags in acute Low Back Pain (LBP) Intervene appropriately to prevent evolution into Chronic Low-Back Pain (CLBP) Manage: chronic non-specific low-back pain spinal stenosis radicular syndromes using guideline-based treatments Key References Andersson GB. Epidemiological features of chronic low-back pain. Lancet Aug 14;354(9178): Cohen S, Argoff CE, Carragee EJ. of Low-back pain. BMJ 2008:337 Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep 2001;5: Chou 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: van Tulder et al. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J Mar;15 Suppl 2:S Airaksinen et al. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J Mar;15 Suppl 2:S Opioid Pain guidelines at the McMaster CMAJ June 15, 2010 Qaseem et al. Noninvasive treatments for acute, sub acute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017 February. 5