Monday, October 6, 2008

BACK PAIN MANAGEMENT UPDATE: 2008


Dr. Ajimshaw. M.S, MPT (Neuro), PhD


The Difference is Simple Ergonomics….!!!


Epidemiology of Back Pain
Who gets it?

60-90% lifetime prevalence.
80-90% have recurrent episode.
What is the Natural history?
80-90% resolves in 1 month.
20-30% remains "chronic"
5-10% "disabling
100% Acute LBP
90% Resolved in 12 weeks
70% Resolved in 3 weeks
Work related musculoskeletal disorders (RSI) and Back Pain
With rapidly increasing industrialization in India, especially in the sectors of Information Technology and IT enabled services, work related musculoskeletal disorders (also called Repetitive Strain Injury [RSI] or Cumulative Trauma Disorder [CTD]) are spiraling upwards. Preliminary reports of one of the leading work related injury research center’s (Recoup.org, Bangalore) ongoing study of over 35000 Indian IT professionals (2001-2008) found that 75% reported musculoskeletal symptoms related to work and 55% got injured within a year of starting their first job, reducing the productivity or work efficiency to a significantly low level.
Making the Diagnosis

"Up to 85% of pts cannot be given a definitive diagnosis because of weak associations among symptoms, pathological changes, and imaging results."
Deyo R, et al. JAMA 1992; 268;760-765
Mechanical Low Back Pain "Many, including myself, believe the character of the vast majority (possibly as many as 97%) of low back disorders to be mechanical."
Donelson R. J Musculoskel Med 1991;8:14-29
Bed Rest vs Exercises
"…. continuing ordinary activities within the limits permitted by the pain leads to more
rapid recovery than either bed rest."
Malmivaara A. Hakiinen U, Aro T, et al. "The Treatment of Low Back Pain" N Engl J Med 1995;332:351-355
Williams Flexion Exercises
" Knee to chest and partial sit-up exercises may actually slow recovery"
Bigos S "Acute Care to Prevent Back Disability" Clin Ortho and Related Res 1987;221 (August):121-130
Muscle Layers
There are many more joints in the back than discs.
There are many more muscles than joints.
The most common cause of low back pain is when one or more muscles "forget" to relax. We call this a somatic dysfunction
Deep
Multifidus, Quadratus lumborum
Iliocostalis, longissimus, (Erector s.)
Superficial
Thoracolumbar fascia
Lattisimus dorsi
Lumbar ligaments
ALL, PLL
Ligamentum flavum
Facet capsules
Interspinous ligaments
Supraspinous ligaments
Pain Generators
Annulus Fibrosis (outer 1/3 only?)
Periosteum
Neural Membranes (Anterior Dura)
Ligaments/ Z-joint capsules
Muscles.
Imaging or Not?
Low yield without RED FLAGS present.
"Abnormal" findings in Asymptomatic.
Jarvik- LAIDback study.
Psychological.
Anxiety, fear-avoidance- possibly help?
Depression- "there must be something wrong"
Guidelines for Imaging
NO RED FLAGS!
Acute pain- symptomatic treatment for 4 weeks, re-evaluate. Image if pain continues.
AHCPR Guidelines for Acute LBP.
Sub acute pain- Pain for >4wks.
Failed symptomatic treatment. Image.
Chronic pain- none, unless changes in sx’s
Chronic intermittent- TX as acute patients
Who needs Surgery? Or who only needs Surgery
Unstable Spine
Acute fractures with Neurologic deficit.
Severe Stenosis
After failure of aggressive non-operative tx.
Tumor?
Progressive Neurologic deficit
Recently several large studies of surgical approaches such as diskectomy, fusion, and IDET have not demonstrated efficacy – even for patients with established radiculopathy and HNP
1997 1st RCT to find that Lumbar Stabilization Exercises could treat and prevent future episodes of Low Back Pain and Disability in Patients with Spondylolithesis:
O’Sullivan et al: Spine 1997
Active System - Muscles
Many layered and overlapping muscles both anterior and posterior
Core Muscles:
n Transversus Abdominis (TrAb) anteriorly
n Multifidus posteriorly
The "deep subsystem"
n External Oblique
n Internal Oblique
n Rectus Abdominis
The "superficial subsystem"
Transversus Abdominis
Flexes, forms a rigid cylinder, assists in respiration, and decreases shear and torque forces
Note the fiber alignment, which allows you to see "Nature’s Back Belt"
Multifidus
Trunk extensor
Postural control (segmental control)
In same fascial plane as TrAbd
Why is it important???


Interesting Back Fact: Active System
Initial onset of LBP or subsequent acute episodes create a one-sided, one level atrophy of the multifidus muscle, which does NOT spontaneously recover when pain goes away.
Currently being investigated as a possible reason for the high recurrence rate of LBP
No chronic back pain treatment should be without motor control / coordination exercise
Neural Control System
Earlier studies focused on retraining "mechanical stability" of the spine through muscular training – mixed results
Recent research focuses more on the neural control aspect
Bottom line- it’s about endurance and control not strength, and "spinal stability" is a nervous system construct, not a muscular construct
In those with LBP, the contraction of the TrAb is delayed, demonstrating poor motor control.
We need to retrain this feed-forward, or anticipatory, contraction to help patients control their LBP and maintain stability
Why Not Surgery?
Re-operation Rates over 4 years:
Decompression 17-18%
Spinal Fusion 21-28%
N=24,882!
This isn’t the percentage who failed to be helped – it’s the percentage that failed to be helped AND needed another procedure.
ICD codes indicating fusion failure, hardware failure, or pseudoarthrosis
Make the DIAGNOSIS!
Remember finding is not a diagnosis..!
Spinal degenerative changes can be noted in normal individuals too
A positive MRI shouldn’t be the diagnosis! It’s just a finding……
Asymptomatic Adults- MRI Abnormalities
Disc degeneration 46- 72%
Bulging Disc 24- 81%
Disc Herniation 22- 40%
Annular tear 14- 56%
Stenosis 1- 21%
Several studies have shown that there is no correlation between MRI findings and patients’ low back symptoms.
1. Wittenberg et al., 1998
2. Smith et al., 1998
3. Savage et al., 1997
All types of Back pain is having Muscular-myofascial components Caused / Continued by cumulative traumas
The usual Mechanical Components for Chronic - Recurring Back Pain are chronic muscular spasms, which may be 1º & 2ndary (strains-sprains). 1º (muscle - motor unit - fatigue), 2ndary (nerve entrapment)
Ongoing Back Pain Symptoms are 95% Musculo – Myofascial (is it called idiopathic?).
In origin symptoms are not equal to cause…!
Make the Diagnosis, determine the specific anatomical muscular-myofascial dysfunction(s) then identify the causes for the anatomical musculo-myofascial dysfunction(s) which can be classified as Primary & Secondary, or in another way as Precipitant Cause (s) and/or All Contributing Cause (s)s
Back Pain: Etiology
Highest estimate: <10% Spinal canal: Intervertebral path: Disc ruptures, Radicular,
< (<1%) operable disc
Highest estimate: <5% Structural: stenosis, fracture, unstable. < ( <½ %) operable
Lowest estimate: >85% Idiopathic: (musculo,ligamentous, myofascial, facet, etc.)
Chronic Musculo-skeletal Strain-sprains Brought-on &/or Maintained by Cumulative Traumas developed during Daily Living – Work - - Recreation
Back pain symptoms May be relieved by:
a. Increasing central tolerance;
b. Central blocking of thalamic reception;
c. Interference with spinal neural receptors;
d. Severance of neural pathways;
e. Silencing the site or origin; or
f. Removal of the causes.
Back pain symptoms may be removed by Elimination of the causes
If back pain is an elephant our present understanding method is like
"The Blind Men and the Elephant"

Back Pain- Causation
The precipitant: may be a specific event.
Cause of pain is rarely singular usually multiple
All Back Pains are Cumulative-Trauma Phenomenon
Twelve considerations in the diagnosis and management of low back pain (Acute or Chronic – Recurring Back Pain)
We can divide it into 5-- Specific Diagnoses & 7– Contributors

• Structural injuries –disruptions, sudden or gradual: (2) -- <5%

Two Structure pathologies
1. Specific nerve-cord pressure
2. Structural instability/damage

Specific strain injuries (Jolting) – episodic, may be chronic, recurring: (3) -- 45%

Three Jolt , jarring – episodic
3. Ilio-psoas muscle strain
4. Costo-vertebral dysfunction
5. SI joint strain/ dysfunction
Axial support- muscle strain-sprains --- specific grouping (Default) --45%

Postural contributors– chronic disruptions Behavioral or Anatomical: (7) --Effect 90%
Four Behaviors / mechanics
1. Sleep position
2. Loss of arch height
3. Wallet in the back pocket
4. Stick-shift vehicle
Three Anatomical shapes
5. Short upper-arm length
6. Leg length difference
7. Short hemi-pelvis
Postural muscle strains
90% Prevalence: 45% Primary
LOW BACK
Quatrus lumborum
Ilio-costalis
Piriformis
(Ilio-psoas)
Gluteus-min, mid, max
Multifidus
HIP, LEG, GROIN
Piriformis
Tensor fascia lata
Gluteus min, mid, max
(Ilio-psoas)
All these muscle involvements are rarely alone – usually in multiples

Postural muscle strains
Symptoms:
A 1) Symptoms
Back-hip pain, +/- tingling // Diffuse back =+/- one-side // TTPs, specific

B1) Onset ; 2) Worsen ; 3) Activity
With episode or chronic // AM , sleep, drive, stand sit; // Torso move

C1) Behavior ; 2) Posture ; 3) Environment
Sleep, wallet, arch, drive // Leg-l, Hemi-p, S-A // normal-activity

D1) Physical Tests ; 2) Radiographic/ electrodiag
Cross-chest stretch, Balance, TTPs,; Pressure I-I Lgt // N/A

E1) Behavior ; 2) Posture ; 3) P.M. ; 4) Equipment
Sleep, Car, Wallet, Arch // Balance L-L, H-P, S-A support elbows // HEP, Mobility – all //
Activity

Postural muscle strains -
May have sudden trauma onset often caused by & always aggravated and maintained by
7 – factors ie 4 – behaviors & 3 –postures

Key Postural Muscles involved in CHRONIC MUSCULAR BACK SPASM are:
LOW BACK
Multifidi
Quatrus lumborum
Ilio-costalis
Piriformis
Ilio-psoas
Gluts-min-mid-max
HIP, LEG, GROIN
Piriformis
Tensor fascia lata
Gluteus minimus
Gluteus-medius
Gluteus maximus
Ilio-psoas
UP-BACK
Trapezius
Levator scapulae
Serratus anterior
Rhomboids
Serratus posterior
Latissimus dorsi
Multifidi
NECK
Trapezius
Levator scapulae
Scalenes
Occipital
Para-cervicals
FACET induced
(Thoracic)
(Lumbar)
(Cervical)
FACTORS -7

Behavior 1 mechanics (4)
1. Sleep position
2. Loss of arch height
3. Wallet in the back pocket
4. Stick-shift vehicle

Anatomical shape – posture (3)
1. Short upper-arm length
2. Leg length difference
3. Short hemi-pelvis

Structure pathology
Play a role in < 15%
1. S-1 Specific nerve-cord pressure
2. S-2 Structural instability/damage

Jolting - episodic
Play a role in 35% +
J-1 Ilio-psoas muscle strain
J-2 Facet dysfunction (Lumbar-thoracic)
J-3 SI joint strain/ dysfunction

20 +% of acute back injuries First onset is Jolting Trauma
Eg:- Jerking catch
Auto collision
Fall
Bike
Digging
Can turn chronic – 35+% chronic disabling "idiopathic" back problems
Eg:- Groin pains
Totally numb leg
Facet Dysfunction (Lumbar- Thoracic)- "Thoracic strain"
Often recurring / chronic 5+ % chronic disabling "idiopathic" mid-back problems
Low back, mid back, shoulder, neck, arm…
"Costochondritis"
"Non-cardiac chest pain"
"Idiopathic" neuropathy of the upper extremity

Causes
Cervico Thoracic
Twist & reach
Fall
Jerk arm
Sleep wrong
Fall, hit chest
Overhead pull
Lumbar
Twist & reach
Simple bend
Several weeks to resolve
Sudden onset
Recurs at 1 – 2 year intervals
J-3. SI Joint dysfunction
Fall on hip
Blow to pelvis
Slide over bump
Behaviors / costume / mechanics
Play a role in 85%+
Start Behavior
B-1 – Sleep position
B-2 - Loss of arch height
B-3 - Wallet in the back pocket
B-4 - Stick-shift vehicle

B-1. Dysfunctional sleep position:
Pain … neck, shoulders, arms, hands, upper back, low back…
Plays a role in 80%+
Dysfunctional Sleep Positions
Stomach sleeping
Flat, flat on back
Twisted to side
Arm(s) overhead
Commonly affecting parts
Back, also mid-back,
Shoulders, neck, arms and jaw
B-2. Uncorrected loss of arch height
Prevalence ( > 85 %)
Back pain, ache with prolonged standing/ walking
Plays a role in > 70 % LBP
B-3. Wallet in the back pocket
Plays a role in > 70 % of males
"Radicular pain" from butt to the back of knee
B-4. Stick-shift vehicle
Play a role in > 85%
Chronic – Recurring
Low Back Pain
Anatomical shape
Plays a role in 70% +
Leg length difference
A 2 Short hemi-pelvis
A 3 Short upper-arm length

Functional scoliosis: The brain commands the eyes to be level and the nose to be midline
Short hemi-pelvis Back Pain + Leg-length difference: Potential for Multiple myofascial strains
A-3. Short upper-arm syndrome
"long-waisted"
"long-necked"
"can’t sit still"
"shirt sleeves too-long"
>50% can’t reach chair arms.
Slender body is worse
If elbows are >8 ½" above the chair seat, chair arms fit only with slouching
A Quick Review
12 Considerations in Management of Back Pain
5-- Specific Diagnoses & 7– Postural Contributors
• Structural injuries –disruptions, sudden or gradual:
2 Structure pathology
• Specific nerve-cord pressure
• Structural instability/damage
• Specific strain injuries (Jolting) – episodic, may be chronic, recurring:
3 Jolt , jarring – episodic
• Ilio-psoas muscle strain
• Costo-vertebral dysfunction
• S-I joint strain / dysfunction
• Postural muscle disruptions – Axial
• Contributors to postural & structural dysfunction
4 Behaviors / mechanics
• Sleep position
• Loss of arch height
• Wallet in the back pocket
• Stick-shift vehicle
3 Anatomical shape
• Short upper-arm length
• Leg length difference
• Short hemi-pelvis
Managements
How will you manage a case of back pain?
From where you will start?
Single technique or a comprehensive approach?
Who will be the apt person for a back pain management?
How can you provide complete cure without relapses?
How will you manage a case of back pain?
Forgot the older concepts of individual approaches. Just think about the patient as a whole…………
From where you will start?
All back events are Osteomyofascial, you have to start from the reverse. That means to start from the fascia then muscle and then the Osteal part, but remember that the integration should consider the patient as a whole.


Single technique or a comprehensive approach?
Of course the approach should be always comprehensive, incorporating the above three….
Who will be the apt person for a back pain management?
The answer is a Physical Therapist…., of course he should have very deep knowledge in Back pain, mechanics, complete evaluation ( do you know one thing, a normal back pain evaluation will take a minimum of 30 minutes!), through hands on experience which is up-to-date. A Physical therapist is the only person who can implement the holistic approach. Before staring the treatment a case discussion with your Orthopaedician / Neurologist / PMR will be healthy and it will produce a positive feedback to them too.
How can you provide complete cure without relapses?
It needs an intelligent evaluation, planning & implementation. In SCeB CAPT® we are using AJIMSHAW’s Approach® for managing various Osteomyofascial dysfunctions including Back Pain.
AJIMSHAW’s approach is a unique program designed by Dr. Ajimshaw. M.S, MPT (Neuro), MTS. a specialist in Osteo Myofascial Manipulation, Neuro Physical Therapy & RSI ergonomics, which is a rare blend of recent advances in musculoskeletal disorder managements with "Hands- On" Techniques, proving to be one of the most effective method in the prevention and management of Osteomyofascial dysfunctions as per the various ongoing researches at MFTRF®, India.
AJIMSHAW’s Approach
Advanced Management for
Joint and musculofascial
Immobility, Pain and dysfunctions by
Mobilizations
Soft Tissue Manipulations through
Hands- On physical therapy coupled with
Active exercise programs and
Work site modifications
What do you mean by Advanced Management?
Management based on resent advances and Evidence Based Practices blended in a unique way…..
What do you mean by Joint and musculofascial ?
Treating the Osteomyofascial pathologies in a comprehensive way
What do you mean by Immobility, Pain and dysfunctions?
Immobility, Pain and dysfunctions induced due to MSD, rest etc….
What do you mean by Mobilizations ?
Realignment of the Osteal system.
What do you mean by Soft Tissue Manipulations ?
Realignment of the Myofascial System
What do you mean by Hands- On physical therapy?
Using of most modern Hands-On techniques.
What do you mean by Active exercise programs?
Aerobics, basic and advanced core stabilization programs etc.
What do you mean by Work site modifications?
The Difference is Simple Ergonomics….!!!
How AJIMSHAW’s Approach can cure Back Pain?
Hhhh…..thats a secret, Visit SCeB CAPT® for details….
How much percentage of cure do you offer for your patient, what do they say after the session?
We have only one answer… SCeB CAPT® care……100% cure….


REFERENCES
Spine: 2000; 25: 1373-81
Spine: 1997; 22: 427-34
N England J Med: 1994; 331: 69-73
Spine: 1995; 20: 2613-25
J Bone Joint Surg Am: 1990; 72: 403-8
JAMA: 2003; 279,21:2810-18 (value plain X-ray to MRI @ 6 wk.)
Martin et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 22(3). 2007.
Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ. 2005 May 28;330(7502):1233
Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005 May 28;330(7502):1239
Lumbar stabilization: core concepts and current literature, Part 1. Am J Phys Med Rehabil. 2005 Jun;84(6):473-80
Increasing days at work using function-centered rehabilitation in nonacute nonspecific low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2007May;86(5):857-64
Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005 May 3;142(9):776-85
United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ. 2004 Dec 11;329(7479):1377
United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ. 2006Dec 11;329(7479):1381
A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002 Dec 15;27(24):2835-43.
A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8.
Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract. 2005 Jul 14;6(1):29.
Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2007Dec 1;29(23):2593-602
Sacroiliac joint dysfunction: evidence-based diagnosis. Orthopedic Division Review May/Jun 2004. www.orthodiv.org
Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62
Martin et al. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 22(3). 2007
Caragee E et al. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005 Jan-Feb;5(1):24-35
Kleinstuck F et al. Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?. Spine 31(19) 2006.
Caragee E et al. Are first-time episodes of serious LBP associated with new MRI findings? . Spine J. 2006; 6 p624-635.
Borenstein et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2007Sep;83-A(9):1306-11.
Savage R et al. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6(2):106-14.
Jarvik J et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4;289(21):2810-8.

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