외래에서흔히접하는 요통환자의진단과치료 울산의대서울아산병원가정의학과 R3 전승엽

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1 외래에서흔히접하는 요통환자의진단과치료 울산의대서울아산병원가정의학과 R3 전승엽

2 Index Introduction Etiology & Type Assessment History taking & Physical examination Red flag sign Imaging Common disorder Management

3 Reference

4 Introduction Pain between low rib margin and post. Thigh Acute: ~6 weeks Subacute: 6 weeks ~3 months Chronic: 3 months ~ Most common for visit family physician Prevalence: 5.6% of US Adult each day 60~70% of US Adult Life time 80% of Korean Adult Life time also * 대한가정의학회지 2001 vol22 no11 pp

5 Introduction Multiple anatomic sources discs, bone & joints, muscle & ligaments, nerve roots No standard methods for categorizing, diagnosing, or treating pain syndromes Treatment protocols varied

6 Type Acute vs Chronic According to pain generator Discogenic pain: herniated & degenerative Facet joint syndrome Lumbar spinal stenosis Lumbar strain Sacroiliac joint pain According to condition *F1000Res Jun 28;5.

7 Type according to condition Non specific: 85% Symptomatic HIVD: 4% Spinal stenosis: 3% Serious condition Compression fracture: 4% Neoplasm: 0.7% Infection: 0.01% Ankylosing spondylitis: 0.3 5% Cauda equina syndrome: 0.04% *AFP 2007 April 15 :75:1181-8

8 Assessment 요통의진단및치료진료지침 : 대한임상통증학회임상진료지침 * 요통의진단및치료진료지침 : 대한임상통증학회임상진료지침

9 History taking & physical examination Focused history and physical examination categorization Nonspecific LBP (85%) Back pain potentially ass/w radiculopathy or spinal stenosis Back pain potentially ass/w another specific spinal cause Serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation tumor, infection, or the cauda equina syndrome Other conditions may respond to specific treatments AS or vertebral compression fracture *Ann Intern Med. 2007;147:

10 Nonspecific LBP Pain occurring primarily in the back with no signs of a serious underlying condition such as cancer, infection, or cauda equina syndrome spinal stenosis or radiculopathy another specific spinal cause such as vertebral compression fracture or AS Degenerative changes on lumbar imaging usually considered nonspecific as they correlate poorly with symptoms No evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes

11 Physical exam

12 Straight leg test Positive: pain between degrees for HIVD Sensitivity: 91% Specificity: 26% Cf. (-) in SS Crossed SLR Sensitivity: 29% Specificity: 88%

13 Nerve root impingements

14 Red flags(i) Red flags that suggest cauda equina syndrome Saddle (perianal/perineal) anaesthesia or paraesthesia. Urination or bowel habit change Decreased anal tone Severe or progressive neurological deficit Red flags that suggest spinal fracture Sudden onset of severe central pain in the spine, which is relieved by lying down. Major trauma Fracture after minor trauma in people with osteoporosis. *Sciatica (lumbar radiculopathy), Prodigy, 2009

15 Red flags(ii) Red flags that suggest cancer or infection Onset > 50 years or < 20 years. History of cancer Constitutional symptoms, such as fever, chills, or unexplained weight loss. Recent bacterial infection (e.g. urinary tract infection). Intravenous drug abuse, Immune suppression. Night pain Thoracic pain (may suggest an aortic aneurysm). *Sciatica (lumbar radiculopathy), Prodigy, 2009

16 Psychosocial issues Important role in guiding the treatment of patients Respond to treatment - Reduced sense of life control - Disturbed mood - Negative self-efficacy - High anxiety levels - Mental health disorders - Engage in catastrophizing tend to not respond well to treatments Yellow flags - psychosocial risk factors for long-term disability

17 Common disorders of LBP Degenerative/Herniated disc (Radicular pain) Facet joint syndrome Spinal stenosis Lumbar strain Fibromyalgia, arthritis. Etc.

18 Discogenic pain Evoked by ectopic discharges emanating from an inflamed or lesioned dorsal root or its ganglion Radiates from the back and buttock into the leg in a dermatomal distribution Disc herniation is the most common cause inflammation > compression

19

20 Facet joint syndrome LBP with or without somatic referral to the legs terminating above the knee no radicular pattern No specific diagnostic test Hard to distinguish

21 Facet joint syndrome Back pain > leg pain Older age, normal gait hyperextension, rotation, lateral bending, walking uphill, waking up from bed, trying to stand after prolonged sitting Failure to aggravate pain with the Valsalva manuever Facet joint tenderness

22 Lumbar spinal stenosis Spinal canal diameter < 10mm Progressive narrowing of the central spinal canal & the lateral recesses Consequent compression of neurovascular structures By Disc herniation Thickening of the ligaments Hypertrophy of the articular processes Degenerative changes in the spine with aging

23 Lumbar spinal stenosis Improved with trunk flexion, sitting, stooping, or lying Aggravated with prolonged standing or lumbar extension, downhill ambulation Neurogenic claudication pain by venous congestion and hypertension around nerve roots m/c indication for spinal surgery > 65 years

24 Lumbar strain Muscular pain and weakness Local lumbar pain with lateral radiation Over utilized diagnosis and misdiagnosed Difficult to treat know anatomy

25 Management Pharmacological treatment AAP Non-steroidal anti-inflammatory drug Opioid Muscle relaxant Others Non pharmacological treatment Self care Exercise therapy Spinal manipulation Massage, yoga Acupuncture Injection

26 Management 요통의진단및치료진료지침 : 대한임상통증학회임상진료지침

27 Self care Non specific LBP Remain active severe symptoms requiring bed rest for Sx relieve encourage to return to normal activities Heat therapy Option for short term relief of acute LBP Medium firm mattress > firm mattress In chronic LBP Lumbar supports Insufficient evidence Acute radiculopathy or spinal stenosis Insufficient evidence Ann Intern Med. 2007;147:

28 Self care

29 Self care

30 Self care

31 Self care

32 Self care

33 Exercise 61 randomized, controlled trials (6390 participants) Exercise therapy seems to be slightly effective at decreasing pain and improving function in adults with chronic low back pain, particularly in health care populations

34 Exercise

35 Exercise

36 Manual therapy 3 most notable forms Manipulation rapid rotational, shear or distraction force into an articulation often associated with an audible popping sound Mobilization slower, more controlled process of articular and soft-tissue (myofascial) stretching intended to improve bio-mechanical elasticity Massage repetitive rubbing, stripping or kneading of myofascial tissue

37 Massage Non-specific LBP 여성 402 명을대상으로한 RCT 10 주뒤, uncomplicated chronic LBP 환자에게서 massage therapy 가 usual care 에비해좀더기능을향상시키고, 통증을감소

38 Massage Mechanisms of massage effect are unclear physiologic effects tissue local stimulation, generalized central nervous system response nonspecific effect 안락한환경에서시간보내기, therapist 로부터 care 를받는것, Self-care 에대한조언, 신체자각증진

39 Epidural steroid injections ESI is recommended as option for acute or subacute radicular pain syndromes lasting at least 3 weeks after treating with NSAIDs and without evidence of trending towards spontaneous resolution (ACOEM LOE Ib GOR A). ESI is recommended as 2nd-line treatment of acute spinal stenosis flare-ups (ACOEM LOE Ib GOR A). ESI for acute, subacute, or chronic low back pain in the absence of radicular signs and symptoms is not recommended (ACOEM LOE IV GOR C). * New York mid and low back injury medical treatment guidelines, 3 rd edition, Sep. 15,2014

40 감사합니다 즐겁고알찬학회되세요

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