LOW BACK PAIN

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LOW BACK PAIN

• STRATEGIES AND MANAGEMENT
• Dr. Richard EYB
• Dr. Andreas KRÖNER
• Dr. Georg GRABMEIER

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• persistent ? non mechanical
  ?
• acute ?
  young ?
• old ? chronic ?
• depression ? mechanical ?
• visceral ?
• working ability
  ?

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one year prevalence 73

• annual incidence (gt 4 VAS) 10 15
• most frequent cause for early retirement
• (second after upper respiratory problems)

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3 QUESTIONES

• Is a systemic disease causing the pain?
• Are there social or psychological disorders?
• Is there neurological compromise?

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Systemic diseases

• history of cancer
• unexplained weight loss
• chronic polyarthritis ( drug use ?)
• infection ( no relief when lying)

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psychological reasons

• depression
• family problems
• job dissatisfaction
• somatisation
• drug abuse
• etc.

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neurological compromise

• sciatica
• spinal claudication
• radicular symptoms
• bladder or bowel
• dysfunction

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DD for low back pain(adult patient app.40-60
yr., percentage of primary care)97 mechanical

• 70 unspecific LBP
• 10 deg. discs and facets
• 4 disc herniation
• 3 spinal stenosis
• 4 osteoporotic fracture
• (Hart 1995, Deyo

• 2 olisthesis
• lt 1 traumatic fracture
• lt 1 severe deformity
• spondylolysis
• instabilitiy
• 1992 , 2001 )

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DD for low back pain (cont)1 non mechanical

• 0,7 neoplasia mult. myeloma
• metastasis
• 
  retroperiton. tumours
• primary
  vertebral tumours
• 0,3 rheumatoid arthritis ankylosing
  spondylitis
• 
  psoriatic arthritis
• 
  Reiter syndrome
• 0,01 infection osteomyelitis
• discitis
• epidural abscess
• Scheuermann disease
• Paget disease
• 
  

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DD for low back pain(cont) 2 visceral disease

• Diseases of pelvic organs prostatitis
• 
  endometriosis
• Renal diseases
  nephrolithiasis
• 
  pyelonephritis
• Aortic aneurysma
• Gastic ulcer
• Pancreatitis
• Cholecystitis

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The (typical) patient

• A 53 years old female, history of depression,
• reports of previous episods of back pain,
• relief with analgetics, but now severe back
• pain for 1 month, since then out of work,
• massage and analgetics without improvement.
• HOW TO START ?

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• Do n o t start with X-ray or MRI imaging,
• because in asymptomatic patients
• 25 50 herniation of lumbar disc
• up to 18 extrusion of disc material
• 25 70 degeneration of lumbar disc (increasing
  with age)
• about 10 vertebral endplate changes
• 14 33 annular fissures
• These findings are often discribed as causing
  serious
• low back pain and are treated with spinal
  fusion.
• (Carragee 2005)

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• year follow up prospective cohort
• early disc degeneration in adolescents with LBP
  had
• enhanced disc degeneration in adulthood, but not
• associated with severe LBP or increased frequency
  of
• spinal surgery.
  
• 
  (Waris 2007)

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Physical examinationes I

• Muscle tenderness not reproducible
• not
  specific
• Spinal stiffness not specific
• may
  help in monitoring phys.
• therapy
  
• Chest expansion specificity , not
  sensitivity
• 
  ?ankylosing spondylitis
• Lasegue test negative spinal
  stenosis
• 
  sensitive for the irritation of the
• nerve
  root

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Physical examinations II

• Motor weakness ankle,
  great toe dorsiflexion (L5)
• 
  plantar flexion (S1)
• Dermatomal sensory loss app. 95 of
  lumbar disc herniations
• 
  medial resp. lateral of the lower leg
• 
  and foot
• Reflexes
  patellar tendon (L4)
• 
  achilles tendon (S1)
• Hip and sacroiliac joint to exclude
  L3 symptoms

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IMAGING

• Children MRI !! Most frequntly tumour
• Adolescents X ray in absence of trauma,
  MRI
• Adults only with red flags
• Adults over 50 X ray to detect compression
• fractures, spinal
  stenosis, cancer,
• aortic aneurysm
  

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X ray for adults

• should be limited to patients with
• Suggestion of systemic disease
• History of trauma
• Unexpected weight loss
• Fever
• History of cancer
• Age over 55
• Alcohol, drug abuse, HIV
• Neural deficit
• Pain duration gt 6 weeks

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Red Flags indicate serious underlying pathology

• onset age lt 20 and gt 55
• non mechanical pain
• history of carcinoma, steroids, HIV
• Thoracic pain
• Weight loss
• Neural symptoms
• Vegetative symptoms
• Structural deformity

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Natural history

• Acute LBP
• app. 30 recover within 1 week
• app. 60 recover within 7 weeks
• app. 90 stop consulting their doctor within 10
  weeks
• app. 40 recurrence (most of them not disabling)
• within 6 months
• 73 within one year
• return to work depends on clinical
• 
  social
• 
  economic situation.
• 5 become chronic

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Natural history

• persistent LBP
• definition absence of neurological symptoms
• lasting 4 to 8 weeks
• app. 30 chronicity
• ? treatment as early as possible

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Risk factors for occurrence and chronicity of LBP

• Risk factors occurrence
  chronicity
• individual age
  obesity
• physical fitness
  low educational
• 
  level
• weakness back
  high level of pain
• and abdom.
  and disability
• muscles
• smoking

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Risk factors for occurrence and chronicity of LBP

• Risk factors occurrence
  chronicity
• Psychosocial stress
  distress
• anxiety
  depressive mood
• negative mood
  somatisation
• poor cognitive
• functioning
• pain behaviour

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Risk factors for occurrence and chronicity of LBP

• Risk factors occurrence
  chronicity
• manual material job
  dissatisfaction
• Occupational handling
  inavailability of
• bending and
  twisting light duty on re-
• whole body
  vibration turn to work
• job
  dissatisfaction
• monotonous
  tasks heavy lifting
• poor work
  relationship work
• poor social
  support

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T H E R A P Y

• CONSERVATIVE
• INTERVENTIONAL
• SURGICAL

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THERAPY / CONSERVATIVE

• Drugs
• NSAIDs (1 RCT,1 SR) marginal
  improvement
• 
  (VAS 75 to 35, placebo 75 to 45)
• Muscle relaxants moderate
  improvement
• (2 RCT, 1 SR) no
  particular class proved
• 
  superior
• Antidepressant (1 SR) good
  evidence for small
• for chronic LBP but
  consistend benefit
• 
  20-40 pain reduction compared
• 
  to placebo, decreased use of
• 
  analgetics
• Weak opioids (1 SR) greater
  effect on pain and mood
• 
  than NSAIDs, lower activity
• 
  level

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THERAPY / CONSERVATIVE

• Physical
• Massage (1 SR) decrease
  pain, no improvement in
• for chronic LBP function
  compared to exercise
• 
  some improvement in function
• 
  compared to sham treatment
• Exercise (1 SR)
  conflicting evidence
• Strengthning, stretching possible
  improvement in work
• Endrange motion treatment tolerance and
  daily activities
• Manipulation (1 RCT, 1 SR) moderate
  improvement in pain
• 
  no clear superiority to medication
• 
  and physical therapy

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THERAPY / CONSERVATIVE

• Behavioural treatment
• 21 studies out of 244 publications)
• 1 SR chronical LBP
• Operant positive reinforcement of
  healthy behaviour
• consequent withdraw
  of attention towards
• pain
• Cognitive identify and modify
  cognitions regarding the
• patients pain and
  disability
• attention diversion
• modification of
  maladaptive thoughts
• Respondent modify the psychologic
  respons system
• reduction of
  muscular tension
• progressive
  relaxation

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THERAPY / CONSERVATIVE

• Combined programs
• Physical training and strong
  evidence decreased sick leave
• Cognitive behavioural approach
  improvement of function
• ( 1 RCT, 2 SR)
  pain reduction questionable
• chron. LBP
• Multidisciplinary programs strong
  evidence of improved
• medical , psychological
  function
• and rehabilitative components moderate
  pain reduction
• ( 2 SR)
  (with intensive programs)
• chron. LBP

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THERAPY / INTERVENTIONAL

• (
  Chou 5/2009)
• 105 RCT out of 1331 citations
• 1994 2001 rates of epidural injection
  
• 271
• 1994 2001 rates of facet joint injection
• 231

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THERAPY/INTERVENTIONAL

• Injection outside the spine
  superior to placebo 2 weeks
• ( 4 RCT, 2SR)
  LA vs. Cort. n.s.
• Pers. and chron.LBP
• Botulinum toxin injection
  superior to saline injection
• ( 1 RCT)
  ODI 67 vs.19 3 months
• 
  cave ! Allergic reaction
• Prolotherapy (sclerosant inject.)
  ineffective vs. saline inject.
• (5 RCT)
• Chron. LBP

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THERAPY/INTERVENTIONAL cont

• Epidural steroid injection inconsistent in
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• (40 RCT, 21 placebo contr.) high quality RCT
• 4
  lower quality RCT
• 
  benefit 3 months
• 
  3 headache
• Facet joint injection 1-3 months
  no difference
• (8 RCT, 4 SR)
  improvement after
• 
  6 months
• 
  low quality RCT moderate
• 
  short time evidence
• 
  no adverse events

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THERAPY /INTERVENTIONAL cont

• Intradiscal steroid injection no
  difference comp-
• ( 6 RCT, 3 placebo-controlled) ared to
  saline ( 4 high
• DDD
  quality RCT)
• 
  1 low quality RCT
• 
  intradisc.epi better
• 
  in inflammatory endplate
• 
  changes
  
  
• 
  
• Intradiscal electrothermal one RCT VAS
  1.1 vs.2.4
• Therapy (IDET) ODI
  11vs.4,SF36 no diff.
• (2RCT,5SR) one
  RCT no difference
• chron.LBP SR
  inconsistent data

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THERAPY /INTERVENTIONAL cont

• Radiofrequency denervation one high level
  RCT 1.5 VAS
• (9 RCT, 8 placebo contr., 5 SR) better 6
  months
• 
  three RCT conflicting results
• 
  two small samples
• 
  50 better 8 weeks
• 
  SR moderate evidence
• 
  short time
• Spinal cord stimulation radicular
  pain only
• (2 RCT, 3 SR) gt 50
  pain relief 6 months
• 
  no RCT for LBP
• 
  26 to 32 complications
• 
  

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THERAPY /INTERVENTIONAL cont

• Conclusion
• Good or fair evidence prolotherapy, facet joint
  injec-
• tion, intradiscal steroid injection
• for LBP not effective
• Poor evidence to reliably evaluate local
  injections,
• botulinum toxin injection, radiofrequency
  denervation
• and IDET
• Fair evidence spinal cord stimulation moderatly
• effective for LBP plus radiculopathy
• complicationes being common.

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THERAPY / SURGERY

• Chou 5/2009
• 1449 citations
• 14 surgery non
  surgery
• 84 RCT
• 2 fusion art.
  Disc
• 24 SR

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THERAPY / SURGERYcont

• Fusion
• 20 RCT surgery chron.LBP
• 4 RCT surgery vs. non surgery
• 2 RCT fusion vs. art. disc
• 12 SR included all trials

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THERAPY / SURGERYcont

• Fusion non surgery
• Swedish spine study 2 yr. 46 vs. 18 good
• VAS
  4 vs. 21
  
• 2 smaller studies no difference
• 
  (intensive conservat.
• 
  treatment)
• no
  significant
• 
  difference ODI

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THERAPY / SURGERYcont

• Fusion non surgery
• 2 high quality SR
• Pooled data no difference
  (heterogenicity)
• Insufficient evidence optimal fusion method
• Complication rate (pooled data) 16 (12-20)
• (swed. spine study 12 non instr. 22 instr.
• - 40 360 !!)
  

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THERAPY / SURGERYcont

• Fusion art. Disc
• ( 2 RCT for chron. LBP) no clear
  differences 2yr
• One Charite BAK ODI 48 vs.42
• 
  VAS 40 vs. 31
  
  
• One Prodisc 360 ODI 53 vs. 41
  (sign.)
• Unclear long term follow up, migration,
  adjacent disc.
• degeneration, device related,
  second ingression

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THERAPY / SURGERYcont

• Conclusion
• Chronical LBP fair evidence fusion no more
  effective than intensive rehab with cognitive
  behavioural emphasis
• Artificial disc fair evidence as effective as
  fusion.
• 
  
  
  

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RECOMMENDATIONS

• For acute LBP
• Re-assure patients
• Advise patients to stay active
• Prescribe medication (at fixed time intervals)
• - NSAIDs
• - Muscle relaxants or weak opioids
• - Paracetamol
• Discourage bed rest
• Consider spinal manipulations
• Do not advise back specific exercises

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RECOMMENDATIONS

• For chronic LBP
• Recommended cognitive behavioural treatment
• supervised exercise
  therapy
• educational
  interventions
• multidisciplinary
  (biopsychosocial)
• treatment
• short time use of
  NSAIDs and
• weak opioids

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RECOMMENDATIONS cont

• Consider short courses of manipulation and
• mobilisation
• Antidepressants
• Muscle relaxants
• Not recommended passive treatment
• gabapentin
• invasive
  treatment

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LATEST RCT

• Slater et al Arch. Phys. Med. Rehabil 2009 April
• 90 (4) 542 52
• Preventing progression to chronicity in subacute
• LBP
• Behavioural med. focused on function
• pain education, self management, activity in-
• creases, fear reduction and pain believe
  change

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LATEST RCT cont

• Result proportions recovered 52 vs. 31
• 6 months
• 79 vs. 68 12 months
• work status recovered 96 full duty
• 
  4 light duty
• chronic 61 full duty
• 18 light duty
• 21 med.
  discharge
• Conclusion early intervention may enhance
• recovery

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LATEST RCT cont

• Georg et al Eur. Spine 2009 May 6 (ahead of
  point)
• Psychological education improves low back pain
• beliefs results from a cluster rand. clin.
  trial
• Evidence based psychological educational
  program
• (PSEP) on 3792 soldiers
• Back belief questionair (BBQ) score
• PSEP group 25.6 to 26.9
• CG 26.1 to 25.6 ( p lt 0,001)

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FUTURE PERSPECTIVES

• Prevent chronicity
• Identify subgroups of patients, for
• whom specific treatment modalities
• are helpful

Created by JB
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T H A N K Y O U !