What about Muscle and Low Back pain? Christine Keating, MD The Baptist Back and Spine Clinic The Ochsner Healthy Back Clinic

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1 What about Muscle and Low Back pain? Christine Keating, MD The Baptist Back and Spine Clinic The Ochsner Healthy Back Clinic

2 Causes of Back Pain Trauma Specific Incident Non-Specific Why does someone injure their back on a given day doing something they have always done?

3 Large Spine muscles

4 Muscles Support the Spine

5 Low back Muscle stabilizers The Erector spinae muscles are designed to support us. They straighten out back and help with rotation There are three columns: the iliocostalis, longissimus, and spinalis

6 The Multifidi The Multifidi play an important part in stabilizing the spine They span three joint spaces and stabilize each

7 The Multifidi The stiffness and stability of the muscle makes the vertebra work more effectively reducing degenerative changes from friction caused by normal activities Dysfunction of the Multifidi is strongly associated with back pain and reoccurrence of back pain As a society we are not as active, we sit, and we do not sit correctly Aging: there is a normal loss of muscle

8 Sitting

9

10 SLOUCH- WHO ME??

11 ALL OF US!

12

13 POSTURE!!!

14 POOR STANDING POSTURES

15 Cell phones and neck pain gets-and-neck-pain/

16 AGING Aging and its effects Effects on muscle - sarcopenia Importance of resistance training in the aged

17 Old When age things is like are everything young they else. are To supple, make a success when they of it, are you ve old they got to become start young. stiff Lao Tzu (Laozi) Tao Te Ching Theodore Roosevelt - 26th President of United States

18 Aging Causes of death Acute % Chronic Pneumonia, Influenza & diarrhea Cancer & Heart Disease 1) Leading Causes of Death, ) 10 Leading Causes of Death, United States 2006, All Races, Both Sexes

19 Aging Point? People are living much longer!...and remaining more active

20 Effects of Aging Loss of strength Strength is directly related to cross section area of muscle strength in elderly is major cause of disability activities of daily living (e.g. climbing stairs, carrying packages, etc.) walking coordination, speed & balance falls (e.g. weak ankle strength) Evans W., Resistance Exercise, Aging, and Weight Control, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001

21 Effects of Aging Loss of muscle mass basal metabolism muscle strength activity levels (aerobic power) anaerobic threshold caloric intake/output Evans W., Resistance Exercise, Aging, and Weight Control, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001

22 Effects of Aging Decreased energy requirements abdominal obesity fat/muscle ratio may be linked to type 2 diabetes 35% + between ages of 30 & 80 years of age Evans W., Resistance Exercise, Aging, and Weight Control, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001

23 Effects of Aging 2 to as many as 5 Comorbidities of Chronic Back Pain Cardio Pulmonary Obesity Osteoarthritis Inflammatory arthritis Stroke Chronic Back and Neck Pain Parkinson s disease Osteoporosis Diabetes Psychological issues

24 Effects of Aging Chronic Deconditioning Syndrome Pain Decrease ability to withstand stress Guarding movements Pain affects Behavior Disuse of Muscles

25 What About Muscle? Muscle health not linked to specific chronic disease, but muscle mass is key determinant of function in chronic disease It is the mediator of function Physical Activity Guidelines for Americans: Department of Health and Human Services Preliminary Report 2006

26 What About Muscle? Sarcopenia Age-related loss of muscle mass, strength and function

27 Sarcopenia No particular marker for lean body mass Begins in fourth decade Accelerates after 75th year Mostly fast twitch fibers Somewhat reversible with exercise Inactivity greatest contributor

28 Second most common cause for physician visits Most common cause of activity limitation in people less than % of people will have back pain at some point in their life LBP is a common problem but many different causes, and many times a definite source can not be found LOW BACK PAIN

29 LOW BACK PAIN Less then 50% of patients are pain free in 1 month After 3 months 40% still have discomfort Lifetime recurrence rate of 85% Bed rest is no longer considered best treatment Early return to daily activities and exercise leads to less chronic disability

30 Low Back Pain Back pain is the #1 reason for missed work days Ranked #6 most costly medical condition Over $100 billion spent annually on the management of chronic back and neck pain At any given time, >80 million Americans experience some type of back or neck pain Back pain is the second leading cause of disability next to arthritis 90% of back pain is mechanical in nature

31 Management: Current State Often expense is related to determining an exact diagnosis through advanced imaging, testing, etc ~85% of the time a precise diagnosis for chronic low back pain cannot be determined, especially at the initial visit Different treatments and recommendations often lead to confusion, fear, and anxiety along with escalating costs

32 Who treats Back pain??? Over 10 different specialties Over 30 different treatment approaches Each with a slightly different vocabulary and point of view and diagnosis

33 Who Treats Back and Neck Pain: Neurosurgeons Orthopedic spine surgeons Physical Medicine and Rehabilitation Pain Management Physical Therapist Neurologist Chiropractors/Massage therapist Internal Medicine

34 Management: What We Know Fortunately, it is not necessary to know the exact cause to treat back and neck pain effectively Recognizing a distinctive pattern of signs and symptoms can lead to effective treatment Key: Well-informed patients taking an active role Focusing on return to function in addition to pain reduction will allow us to have the greatest impact

35 Why Exercise?

36 We need to get moving and get stronger

37 Exercise Muscles help support joints Our bodies want to move Chronic pain causes inactivity Inactivity breeds stiffness, stiffness breeds weakness and weakness breeds more pain

38 Physical Therapy Exercise therapy is one of the only conservative treatments that has evidence to support its use and success Patients responded better to exercises based on directional preference McKenzie was the first to describe directional preference and centralization

39 Exercise Cardiovascular Resistance Exercise

40 Resistance exercise

41 Healthy Back Program Is a functional strengthening program with isokinetic extension exercises. We load the spine through flexion and extension with progressive resistance. Isokinetic exercise is exercise in which variable resistance is applied while in motion. It blends the intense contraction achieved with isometric with ROM achieved with isotonic

42 Physical therapy: LET S GET PEOPLE MOVING Advise patients to stay active Promote empowerment for individuals to manage their pain Restore movement and function Restore spinal and core strength

43 We can except the effects of aging and muscle loss or we can exercise

44 References Andersson GB. Epidemiological features of Chronic Low Back Pain. Lancet 1999; 354: Bogduk N, McGuik B. "Medical Management of Acute & Chronic Low Back Pain." vol 13 Amsterdam; Elservier: 2002 Chou, Roger. Interventional therapies, surgery, and interdisciplinary rehabilitation for Low Back pain. Spine 2009; 10: Chou, roger. Diagnosis and treatment low back pain. Annals of internal medicine. October 2007 Volume 147:7: pages Cyron BM, Hutton WC. "Variations in the amount and Distribution of Cortical Bone Across the Pars Interarticulares of L5. A predisposing Factor in Spondylolysis?" Spine 1979; 4: Deyo RA, Weinstein JN. Low Back Pain. N Engl J Med 2001; 344: Dunn, IAN; Proctor, Mark; Day, arthur. Lumbar Spine injuries in athletes Neurosurg Focus. 2006; 21(4) Evans W., Resistance Exercise, Aging, and Weight Control, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001 Hall, Hamilton, MD. A consultation with the back Doctor Lively, Matthew W.,DO. Sports medicine Approach to Low Back Pain. South Med J. 2002; 95(6) Long, Audrey. Does It matter which exercise? Spine 2004; 23: Nachemson, AL. Disc Pressure Measurements. Spine Jan-Feb;6(1):93-7. Sackett DL, Rosenberg MM, Gary JA, Haynes RB, Richardson. Evidence Based Medicine: What it is and what it isn't. BMJ.312(7023): 71-72, 1996 Singh MF., Elderly Patients and Frailty, Graves JE, Franklin BA editors. Resistance Training for Health and Rehabilitation. Champaign: Human Kinetics, 2001 Theiss, Steven. Isthmic Spondylolithesis and spondylosis J of South orthop assoc 2001;10(3) Waddell G. The Back Pain Revolution. Kent, United Kingdom, Churchill-Livingstone, 1998, pp Wetzel, F. Todd. The Role of repeated end-range/pain response assessment in the management of symptomatic lumbar discs. The spine Journal 2003; 3:

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