Robin R. Dyer, D.O. Associate Dean for Academic Affairs Professor/Chair OMM Department Tulsa, Oklahoma. LBP Prevalence

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1 Robin R. Dyer, D.O. Associate Dean for Academic Affairs Professor/Chair OMM Department Tulsa, Oklahoma LBP Prevalence Approx. 80% adults sometime in their lifetime 2 nd most common pain complaint (headache #1) The cost of evaluating and treating acute LBP runs into billions of dollars annually, not including time lost from work 1

2 Causes of LBP LBP Healthy young male S- 23 y/o male comes to your office with the complaint of low back pain for 2-3 weeks. He is physically very active: he usually runs 3-5 miles 3/week; lifts weights 2 days/week and has started biking recently. He states he bought a new road bike about a month ago and is training to ride in the MS 150 next month, so he has been riding more and running less recently. He states the pain is on the right side of his low back and radiates into his right buttocks. Sometimes the pain goes down the back of his thigh, but not always. The pain is worse when he sits. 2

3 LBP Cont. Medication: OTC NSAID s (prn), Zyrtec (prn) A- Acute Low Back Pain (847.2) P- 1) Mobic 7.5 mg i BID #30, 1 RF 2) Flexeril 10 mg i TID prn #45, 1 RF 3) X-ray Lumbar Spine 4) RTC in 2 weeks Was this appropriate treatment? CONSIDER THE FOLLOWING: Any potential benefits of routine imaging may also be offset by potential harms. Lumbar radiography and CT contribute to cumulative low-level radiation exposure, which could promote carcinogenesis. On the basis of the 2.2 million lumbar CT scans performed in the United States in 2007, 1 study projected 1200 additional future cases of cancer. Average radiation exposure from lumbar radiography is 75 x higher than for chest radiography. Particular concern in young women because of the proximity to the gonads, which are difficult to effectively shield. Amount of female gonadal irradiation from lumbar radiography has been estimated as equivalent to having chest radiography daily for several years. 3

4 ACR appropriateness criteria An American College of Radiology Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). May be accessed on the ACR website at Ratings are a scale between 1 and 9, which is further divided into three categories: 1, 2, or 3 is defined as "usually not appropriate" 4, 5, or 6 is defined as "may be appropriate" 7, 8, or 9 is defined as "usually appropriate 4

5 Tx for at least 70% LBP! 5

6 LBP revisited. O- Mild moderate tenderness over the right lumbar region with palpation. Bilateral Hamstrings tight R>L; L 4 FSR R ; L/LST; Piriformis Tp; T 7 FSR L A- 1) Acute Low Back Pain (847.2) 2) Somatic Dysfunction Thoracic, Lumbar, Pelvis, Sacrum, Lower Extremity (98927) LBP revisited. P 1) OMM Soft tissue, Muscle Energy, Counterstrain 2) Mobic 7.5 mg i BID #30, 1 RF 3) Flexeril 10 mg i TID prn #45, 1 RF 4) RTC 1 week After 6 weeks of OMM, NSAIDs and Muscle Relaxers your patient states he only gets minimal short term relief from the OMM and the NSAIDs are becoming less effective. NOW WHAT??? 6

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8 Low Back Pain Following a Fall 8

9 LBP Fall (cont.) S- 72 y/o female comes to your office complaining of intense LBP since she fell 4 days ago. She states she was leaving her house and she slipped on the ice and missed the last step of her front porch. She doesn t think she hit anything in the fall, but she landed hard on her buttocks. She can point to an area around T where she says is the most tender. The pain does not radiate to either leg. She describes the pain as sharp and stabbing. She rates it an 8/10. The pain is bad standing or sitting but some better if she lies flat on her back. LBP Fall (cont) Medication: Extra Strength Tylenol(prn), Lisinopril 40mg, Crestor 40 mg, Fosamax 70mg/week, Allergies: NKDA PMHx: HTN, Hypercholesteremia, Osteoporosis PSHx: Hysterectomy 20 years ago. Social: Retired teacher; recently widowed, lives alone. Denies tobacco or illicit drugs, but states she has a glass of scotch each evening. 9

10 LBP Fall (cont) O- HR: 72 RR:18 BP: 144/88 Wt:116 lbs. Ht: 5 2 DTR s +2/4 bilaterally. (-) SLRT. Very tender to palpation over thoracolumbar area. No bruising noted over the region (but she states her bottom is bruised). A- Acute back Pain P- 1) Norco 5/325 #50 1 q 4-6 hours for pain 2) Diagnostic Testing?? Indications of a more complicated status/ red flags include back pain/radiculopathy in the following settings: 1. Trauma, cumulative trauma. 2. Unexplained weight loss, insidious onset. 3. Age >50 years, especially women, and males with osteoporosis or compression fracture. 4. Unexplained fever, history of urinary or other infection. 5. Immunosuppression, diabetes mellitus. 6. History of cancer. 7. Intravenous drug use. 8. Prolonged use of corticosteroids, osteoporosis. 9. Age >70 years. 10. Focal neurologic deficit(s) with progressive or disabling symptoms, cauda equina syndrome. 11. Duration longer than 6 weeks. 12. Prior surgery. 10

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13 Treatment After Kyphoplasty Soft tissue techniques to the area affected AND the regions above and below. 13

14 Epidemiology of neck & upper back pain Most common reason for patients to seek medical care (if connected with HA) Mechanical neck disorder (somatic dysfunction) is the most common cause of neck & back pain Incidence peaks between in general population Females > Males Somatic Dysfunction in the Cervical Spine Somatic dysfunction of the OA and AA cause head pain; C2-C7 cause neck pain Cervical facet pain is typically a dull, unilateral achiness (C2-3) C2-3 zygapophyseal joint (or below) is the pain generator in 60% of patients 14

15 Chronic Neck Pain S- A 53 y/o female returns to your office with continued complaint of right-sided neck pain. About every 4-6 weeks the past 2 years she has come in with this and other somatic complaints. You have treated her conservatively with OMM, NSAIDs and muscle relaxers. To date, no imaging has been ordered. She is a very active lady: she works as an office manager for a large surgical group, she gardens, walks 3 miles daily and is compliant with her stretches. 15

16 Neck Pain Cont. S At today s visit she states that her neck pain has just gotten more persistent. She has not been able to ride her bike because her right arm tingles and goes to sleep within 10 minutes of riding. This is getting worse and now happens after any activity of looking up. She has been going to sleep with an ice pack on her neck and that seems to give her some relief. She is here today for OMM and any additional suggestions to help her with her pain. Today her pain is a 7 out of 10. Neck Pain Cont. Medication: Aleve BID; Parafon Forte DSC TID; Tramadol 2 q am; Lisinopril 20mg q am; vitamins O- BP 126/78, HR 80, Ht. 5 6 Wt 155lb Tight musculature OA through mid thoracics; O/A FS R R L ; C 3 FSR L ; C 5 FSR L ; C 3 Posterior Tp; T 2 ESR R ;T 7 FSR L A- 1) HTN controlled 2) Chronic Neck Pain 3) Somatic Dysfunction H,C,T 16

17 Neck Pain Cont. P- 1) OMM (soft tissue, Muscle Energy, Counterstrain, You want to order diagnostic testing to see if there is something you are missing. What should you order? 17

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20 Spaces within the neck LO3,7 Spaces within the neck Retropharyngeal space A potential space between prevertebral fascia and buccopharyngeal fascia (the posterior region of the pretracheal fascia) LO3,7 20

21 retropharyngeal space Spaces within the neck Buccopharyngeal fascia Prevertebral fascia LO3,7 From cranial base to superior mediastinum at approx. T2 level Spaces within the neck Anterior to trachea, from thyroid cartilage to superior mediastinum LO3,7 21

22 Retropharyngeal space CT Scan infection???? Pretracheal and retropharyngeal spaces are routes for spread of infection in neck and upper mediastinum LO3,7 LO3,7 Retropharyngeal space???? CT Scans 22

23 Retropharyngeal space? Air in the retropharyngeal space of a 10-year-old girl. Often the result of an injury puncturing the pharynx. LO3,7 Thank you for your attention!! 23