Download Physical Therapy Steven Severyn, MD, MBA, MSS – Anesthesia

Fran Pulver, MD - PM&R
Laurie Bell, PT - Physical Therapy
Steven Severyn, MD, MBA, MSS – Anesthesia
Gregg Weidner, MD - Anesthesia
Case Presentation-Lumbar Sprain/Strain
 Patient is 42 years old
 Had sudden low back pain with lifting boxes
 Pain is sharp and localized to the back. It is
made worse with movement and not different
with sitting or standing.
 There is only sharp stabbing, back pain, 5/10. No
numbness or tingling or weakness
 Exam-normal except for tenderness in low back
and some pain with movement
Lumbar sprain/strain
 Most common cause of acute low back pain
 Sprains and strains imply stretching or tearing of
the tissue involved, either muscles (strain) or
ligaments (sprain).
 Result from overuse or an acute injury
 Present with focal back pain with restricted
motion.
PULVER
Lumbar sprain/strain
 The pain of less severe lumbar sprains and strains
typically lasts about 5 to 10 days.
 90% of lumbar sprain/strains resolve regardless of kind
of treatment in 6-12 weeks.
 If symptoms do not improve within this period of time,
consider other diagnosis
 ICD-9 847.2 lumbar sprain, 846 lumbosacral sprain
PULVER
Low Back Pain: Physical Therapy Perspective – Laurie Bell, PT
 Patient education
 Exercise/Modalities
 Length of treatment
BELL
Lumbar Sprain: patient education
 Provide assurance to patients and advise them
to remain active
 Avoid bed rest as a means of pain control
 Activity modification as needed
 Teach safe body mechanics
 Continue working if possible
BELL
Lumbar Sprain: therapeutic
exercise/modalities
 Ice if acute x 1-3 days
 Then heat if preferred: superficial heat,deep
heat, ultra sound
 Electric stimulation to lessen pain and/or
decrease muscle spasm
BELL
Lumbar Sprain: length of treatment
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Assess for directional preference
Stretching to improve ROM and muscle flexibility
Core strengthening to improve spinal stability
Functional exercise to return patient to all normal
activities
 Length of treatment: average 6-10 visits
BELL
Medications for Treatment of
Lumbosacral Strain
Steven A. Severyn, MD, MBA, MSS
Low Back Pain:
Acute, Sub-acute, Chronic
 Pain, muscle tension, or stiffness with or without leg pain
 Acute:
< 6 weeks
 Sub-acute:
6 weeks to 3 months
 Chronic:
> 3 months
 Chronic condition occurs in 5-10% of patients with low back pain but
is associated with majority of health care expense and
socioeconomic costs
SEVERYN
Lumbar Strain
 Muscles
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Rotatores lumborum longus/brevis muscles (segmental)
Interspinalis lumborum muscles (segmental)
Intertransversarius muscles (segmental)
Multifidus
Erector spinae
Quadratus lumbotum
 Fascia

Thoracolumbar (anterior, middle, and posterior layers)
 Ligaments

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Zygoapophyseal (facet) joint capsules (segmental)
Interspinous (segmental)
Supraspinous
Iliolumbar
Sacroiliac (partially segmental)
Sarotuberous
Sacrococcygeal (lateral and posterior)
SEVERYN
SEVERYN
SEVERYN
Medications
 Acetaminophen
 NSAID
 Muscle relaxant

Methocarbamol (Robaxin)

Cyclobenzaprine (Flexeril)

Tizanidine (Zanaflex)

Metaxalone (Skelaxin)

Carisoprodol (Soma)
 Tramadol (Ultram)
 Tricyclic antidepressant

Nortriptyline (Pamelor)

Amitriptyline (Elavil)
SEVERYN
Medications
 Neuromodulators
 Gabapentin (Neurontin)
 Pregabalin (Lyrica)
 Corticosteroid (5 day course of oral medication)
 Narcotic analgesics (7-10 day course)
 Hydrocodone/APAP (Vicodin, Lortab, Norco)
 Oxycodone/APAP (Percocet)
 Local anesthetic injection
 Local steroid injection
SEVERYN
Multi-modal Treatment
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Physical therapy (active, passive)
Behaviorial therapy
Massage
Spinal manipulation
Traction
Accupuncture
Prevention (conditioning)
SEVERYN
Sprains and Strains
 Medical Management
NSAIDS
Muscle relaxants
Anti-Convulsants
Analgesics
Topical Agents
TENS
Modalities
WEIDNER
Sprains and Strains
 Interventional Techniques

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Ethyl Chloride or VapoCoolant Sprays
Lidoderm Patches
Trigger Point injections
Acupuncture/ Dry Needling
Joint Injections
WEIDNER
Discussion and Questions