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Integrative Approach to Low Back Pain Wendy Kohatsu, MD Director, Integrative Medicine Fellowship Santa Rosa Family Medicine Residency Program Sept 2011 Goals of this talk: • Review key history elements • Learn how to do better hands-on back exam • Focus on practical & effective lifestyle therapies • Not ‘overmedicalize” LBP via diagnostic tests, drug therapies, surgical interventions. • Later: myriad of mindbody therapies • Talk about something other than food for a change…. Low back pain • 70-84% of the population affected at some point in their lives • 14-50% of adults have LBP each year • Cost of > $100 billion/ year • Quality of life impact of acute LBP – 60% unable to perform some daily activity – 72% gave up exercising – 46% gave up sex Spine 12:264,1987 Amer Acad Ortho Surg, 2006 Ann Rheum Dis 57:13, 1998 Posture Patient case #1: 52 yo female, cc: “sciatica” bilateral numbness hip to knees, since 1999. h/o prior LBP. •30 years ago fell down flight of stairs at Fisherman’s wharf, landing on tailbone. •Currently works part-time at family business. •On 800 mg ibuprofen. Took friend’s percocet. Flexeril does “nothing”. Patient case #2 • 86 yo Vietnamese male, DM2, reluctant to see MD. • Ambulates with 4-prong cane • c/o LBP, radiating to back of legs, doesn’t like to take medicine, uses analgesic balm • ROS: urinary retention, feels more tired, recent weight loss. History-taking History-taking • • • • • • Onset/first episode? Occupational risk Co-morbidities Activity & exercise level Psychosocial stress/ diagnoses Other? 3 main questions for LBP: 1. Is systemic disease causing the pain? 2. Is there social or psychological distress that may amplify or prolong the pain? 3. Is there neurologic compromise that may require surgical evaluation? Deyo & Weinstein NEJM 344:363, 2001 “Red flags” ACR Criteria - Low Back Pain, 2005 “Red flags” • Hx of trauma • Focal neurologic signs - incontinence, weakness, numbness • Hx of cancer • Age of first onset after 50 years • Hx of IVDA • Osteoporosis • Signs of systemic disease - fever, wt loss, lymphadenopathy ACR Criteria - Low Back Pain, 2005 Perspective • Among all primary care patients with LBP, < 5% will have serious systemic pathology. • 97% will have LBP w/o radiculopathy – 60% Simple back pain – 37% Complex back pain w/o radiculopathy • 3% will have LBP with radiculopathy – Sx of radiculopathy – 1% with acute neuro sx – loss of bladder fxn, saddle anesthesia, motor weakness N Engl J Med. 2001;344(5):363 Up To Date –June 2011 To image or not to image… • MRI evaluation to provide reassurance for chronic LBP does NOT lead to better prognosis. • Psychosocial variables are stronger predictors of longterm disability than anatomic findings found on imaging studies. • Radicular sx > 4-6 weeks, severe enough to consider Ann Intern Med. 2007;147(7):478. JAMA. 2010;303(13):1295. surgery. So, let’s examine our patients… 2 1/2 -minute focused neuro exam Position All Standing Sitting Supine Prone Test/feature Findings Observe Behavior •Posture & gait •Toe / heel walking •Asymmetry •Straight leg raise •Neurologic testing •Posture habits •L5 or S1 deficiency* •Scoliosis •Leg length •Straight leg raise •Fabere’s sign •Mech contribution •Palpation •Hip Extension 5-20 •Prone prop •Muscle dysfxn •L2-4 radiculopathy •Facet jt dysfxn •Radicular pain •Sensory defect •Radicular pain •Hip involvement Biewen PC Postgrad Med 106:102, 1999 EXAM! - Anatomy Review (what med school never taught you…)* • *Except Natasha, Trang, Sarah W & Hana C. • OMT basic evaluation • 3 layer muscle palpation • Skeletal survey -- L-spine, pelvic girdle, lower extremities (joint above/below) • Common culprits: Erector spinae spasm, Lumbar rotation, SI joint dysfxn, psoas, piriformis spasm, muscle imbalance, myofascial syndrome! OMT Common Culprits: • • • • • • • Erector spinae spasm Lumbar rotation SI joint dysfxn Psoas Piriformis spasm Muscle imbalance Myofascial syndrome! Psoas located deep in abdomen, but major hip flexor. Radiates to: - Lumbar region - Front of hip The “Dirty Half-Dozen” of Refractory LBP OMT diagnosis Trunk-thigh imbalance Lumbar dysfxn Pubic dysfxn Short leg/pelvic tilt Posterior sacral base Innominate shear Frequency 100% 88% 76% 65% 60% 24% n = 183 ‘untreatable’ pts with refractory LBP 75% restored to normal activity after OMT* Phys Med Rehab Clin NA 7:773, 1996 Patient #1 - Exam • 52 yo woman with sciatica • Exam: Wt 151, BMI 25.5, anxious • Neuro: 4+/5 left hip flexion, knee extension. Preserved gait and balance walking in hallway. • MSK: level iliac crest heights, ++ 4 cm left posterior hip rotation, ++ right sacral torsion, L > R SI join tenderness, LEFT glut max,min + piriformis spasm. • Imaging: NONE. Patient # 2 - Exam 86 yo Vietnamese male with LBP •Very stoic, pleasant, NAD •Wt 111 (down from 129 lbs 4 mos prior) •Thin frame, + increased thoracic kyphosis, tight lumbar paraspinal muscles. •Rectal: Enlarged prostate. Posture What next? Principle Based Treatment Pyramid relationship Principle Based Treatment Pyramid resources environment relationship Treatment Options • “Internal Environment” • Lifestyle • CAM therapies • Drugs Treatment Options • “Internal Environment” – Pain is a signal for change – John Sarno, MD ~ (TMS)Tension Myositis Syndrome • Lifestyle • CAM therapies • Drugs Treatment Options • “Internal Environment” • Lifestyle • CAM therapies • Drugs – NSAIDs – Analgesics – Muscle relaxants NSAIDs • For acute LBP – Ibuprofen 400-600 mg up to qid – Naproxen 220 -500 mg bid • Side effect and risks limit use Cochrane Database NSAIDS for LBP, 2008 ACP and Amer Pain Soc Guidelines 2007 Analgesics • Acetaminophen – Up to 2.6 grams/d as first line therapy – Side efx - hepatoxicity • Opioids – Surprisingly little data • One meta-analysis = not significantly reduce chronic low back pain – Inadequate data re: functional improvement correlating to pain relief – Reports of opioid abuse ~ 30-45% in LBP CMAJ 174:1589, 2006 Ann Intern Med 146:166, 2007 Cochrane Database Syst Rev -Opioids for Chronic LBP, 2008 FDA guidelines June 2009 Muscle relaxants • “Insufficient evidence” for chronic use • CNS side effects - sedation • Carisoprodol metabolized --> meprobamate, abuse and addiction potential • Limit to short-term use only in conjunction with analgesics vanTulder et al. Spine 28:1978; 2003 Drug-Nutrient Interactions • NSAIDS deplete… •Folic Acid -Synthesis of folic acid is competitively inhibited by NSAIDs -Rx: eat your leafy greens! (“foliage”) Treatment Options • “Internal Environment” • Lifestyle • CAM therapies – Acupuncture – Massage – Chiropractic or osteopathic manipulation • Drugs Acupuncture for LBP • Like massage, data show acupuncture is moderately more effective than no treatment • Short-term outcomes > long-term • More likely to benefit those who expect more out of acupuncture. Cochrane Database Syst Rev - Acu for LBP, 2005 Spine 26:1418, 2001 Massage • Appears to be better for acute vs chronic back pain • Studies inconclusive due to varying styles, practitioner skill, duration of treatment Manipulation • “Moderately superior” to sham Rx, null therapies • But equal to analgesics, exercises, back school • Mixed bag of techniques studied --Most studies on HVLA techniques used in chiropratic Rx Ann Intern Med (meta-analysis)138:871 2003 Ann Intern Med 138:989, 2003 Treatment Options • “Internal Environment” • Lifestyle – Exercise • Stretching, strengthening, yoga – Stress management • CAM therapies • Drugs Low Back Pain - Exercise Rx • 2005 Systematic Review – 43 trials of 72 exercise treatments – Improvement seen esp. with • High-dose exercise programs • Interventions that included conventional care • Stretching and strengthening demonstrated the largest improvements. (vs passive treatments) Ann Intern Med 142(9): 776-85, 2005 Low back pain - Exercise Rx • BMJ study 1995 with “moderately disabled” pts. – 81 chronic LBP patients, referred from ortho • Control – home exercises + ref’d to back school • Intervention – above + 8 exercise classes/4 wks – Two hour sessions • Warm up, stretching • 15 systematic progressive exercises • Lite aerobic activity and stretching • Signif. improvements in pain reduction, self-efficacy, and walking distance noted at 4 weeks, and 6 month f/u Frost, H, et al. 1995 BMJ 310(6973): 151-4. Low back pain Exercise Rx • Study by Carpenter & Nelson, 60 pts considering neurosurgery – 10 week back-strengthening program • Progressive resistance exercise • Isolated lumbar extensions (with pelvis neutral) • One set of 8-15 reps to volitional fatigue 1x/week – 57/60 pain-free, no longer needed surgery! Med Sci Sports Exerc 1999 31(1): 18-24. Best outcomes for exercise therapy Best outcomes achieved when these 4 elements included: • Individualized regimens • Stretching • Strengthening • Supervision Hayden, Van Tulder et al. Ann Int Med 142:776, 2005 Home exercise Rx • Tennis ball* -- myofascial and erector spinae column • Abdominal strengthening • Quad strengthening • Spinal twist • Piriformis stretching • Hamstring stretching Pelvic Clock Technique • Created and researched by Phil Greenman, DO • No prior training required • Dx and Rx at same time • Patient can do at home Take home points • Ask the 3 questions - are systemic dx, neurol red flags, or psychosocial fx present? • DO THE EXAM! – Focused neuro exam – Musculoskel exam – Be judicious when ordering imaging • Rx: Improve function, not just blunt pain • Teach exercise therapies, can tailor to individual patient Strength training • Why? – Muscle strength declines rapidly after 50 in sedentary people. REVERSIBLE! – Increase bone density – Improves strength & ability to perform aerobic exercise. – INCREASE BASAL METABOLIC RATE (BMR) by increasing lean body mass. Life, J. CAM Secrets (2002) “Core Four” Weight Training Program – Hewitt 2002