Acute Back Pain
Evidence Based Approach
Scott Hardy, MD, MPH, FACOEM
Occupational Medicine
UCI, December, 2015
Objectives
• Present & discuss clinical cases demonstrating
evidence based guidelines for low back pain
management-encountered in the clinics, wards
and boards.
• Review differential diagnosis of this common
but multifactorial complaint.
• Recognize Red flags-immediate work up.
• Yellow flags for delayed recovery that
accompany the complaint of low back pain.
Objectives
• Know historical and physical exam findings that suggest
additional imaging tests, laboratory evaluation and/or
immediate specialty referral.
• Primary care physicians can play and essential role in
managing symptoms & return to work and function.
• Evidenced based guidelines will enhance
recovery & avoid iatrogenic expense.
• Multidisciplinary approach.
BACK PAIN
INITIAL EVALUATION
PRIMARY CARE--50%
ORTHOPEDIST--33%
DC, PAIN
MGMT/OTHER-17%
OEM Mission
Occupational and environmental medicine is
the medical specialty devoted to prevention and
management of occupational and environmental
injury, illness, and disability; and promotion
of health and productivity of workers, their
families, and communities.
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Epidemiology-Natural History
• Lifetime incidence of Acute Low Back Pain is 60-90%
of the population annual incidence 5% of
population.
• 2nd to 5th chief complaint seeing primary care
specialists.
• Natural history of acute low back pain favorable90% resolve within in 6-12 weeks.
• Vs. Chronic low back pain-13 million physician visits
annually for-prevalence, disability & expense
remain high.
• Back pain is the number one cause of disability in
U.S. for people under 45 years.
Epidemiology
• Epidemic of back pain in industrialized countries.
• One of the most expensive medical conditions,
especially when work disability is considered.
• 2005 expenditures to treat ~86 billion annually.
• An ‘illness in search of a disease’…
• Multiple synonyms-lumbar sprain/strain, lumbago,
regional back pain, musculoligamentous strain,
sprain.
JAMA: 2008
Natural History
• LBP/musculoskeletal complaints are the second
to fifth most common reason for outpatient
primary care physician visits.
• Most resolve with conservative measures.
• However, only 14% have LBP as long as 2 wks.
• 1.5% present with sciatica.
• 98% of clinically important disc herniations
occur at L4-5 (the L5 root) or L5-S1 (the S1
root).
Top 10 most common reasons for
seeing the doctor were (14K patients).
• 1. Skin disorders, including cysts, acne and dermatitis.
2. Joint disorders, including osteoarthritis.
3. Back problems.
4. Cholesterol problems.
5. Upper respiratory conditions.
6. Anxiety, bipolar disorder and depression.
7. Chronic neurologic disorders.
8. High blood pressure.
9. Headaches and migraines.
10. Diabetes.
• St. Sauver, JL. J. Mayo Clinic Proceedings. 2013. Vol 88, No
1, pp. 56-7.
Guidelines
• American College of Physicians and the
American Pain Society formed the Clinical
Annals of Internal Medicine (2007). Two
primary principles.
• Most low back pain improves without
intervention, and although the history and
physical are the cornerstones of management
• Costly radiologic evaluation of patients with
low back pain was still popular in 2007.
Multiple Guidelines-Literature Ratings
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1. Systemic Review-Meta Analysis
2. Controlled Trial-RCT.
3. Cohort Study-Prospective/Retro.
4. Case Control Series.
5. Unstructured Review.
6. Nationally Recognized Guidelines (Guidelines.gov).
7. State Treatment Guidelines.
8. Other Treatment Guidelines.
9. Textbook.
10. Conference Proceedings.
ACOEM, ACP/APS, ODG, MTUS, Washington State, Cochrane…..
ACOEM
American College of Occupational & Environmental Medicine
• The Personal Physician’s Role in Helping
Patient with Medical Conditions Stay at Work
or Return to Work
http://www.acoem.org/Guidelines.aspx
Primary Differential
Detailed history & physical examination to determine:
1. The presence of red flags for urgent conditionsmusculoskeletal vs. other etiologies.
2. Non-specific regional back pain-pain is typically axial in
location that predicts favorable course.
3. Radiculopathy/other neuro related spine condition.
Case-Mr. J.M.
• 58 year old landscaper presents with stiffness and
soreness in the low back one day after repetitive
bending installing a company sprinkler system.
• Sharp pain, 8/10 with bilateral leg weakness.
Complains of numbness in the groin region. No
constitutional symptoms. N/V/F/C.
• PMH: BPH. Med-Tamsulosin, NKA.
• PSH: Negative.
• ROS: No hx of LBP, No recent fever, infection,
weight loss, cancer, fever, abdominal complaints.
• Social: Ex smoker 5 pack-yrs., no EtOH, no other
drugs. Hobbies, soccer, motorcycle riding.
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Case-Mr. J.M.
• Exam: 5’9”, 195, 112/82, P-88, RR-14.
• W/D fit appearing muscular male ambulates with
difficulty, slow guarded gait, prefers to stand.
• HEENT, Heart, Lungs, WNL.
• Abdomen-Soft flat, non-tender, without rebound
or bruit, no CVAT or hernia genitalia WNL.
• Lumbar spine-flat lordosis, spasm, with L/S
junction TTP, and ROM limited to few degrees.
• Neuro-Reduced touch, and sharp dull, bilaterally
L4-S1, global weakness, 4/5 multiple myotomes.
Case-Mr. J.M.
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Other exam findings?
Tests?
Radiographs?
Imaging?
Diagnosis?
Referral?
Large Central L5-S1 disc herniation.
Cauda Equina Syndrome
For a diagnosis of CES, one or more of the following
must be present:
(1) bladder and/or bowel dysfunction.
(2) reduced sensation in the saddle area.
(3) sexual dysfunction, with possible neurologic
deficit in the lower limb (motor/sensory loss,
reflex change).
Cauda equina syndrome: a literature review of its
definition and clinical presentation
Fraser, S, et. al. Arch Phys Med Rehabilitation. 2009
Nov;90(11):1964-8.
Red Flags
• A focused medical history, work history and physical
exam.
• Evaluation of underlying conditions, including
sources of referred symptoms in other parts of the
body.
• Frequency, intensity and duration of complaints.
• Aggravating an relieving factors.
• History and Physical findings that raise suspicion for
serious underlying disorders= Red Flags
Anterior compression fractures may present with
stiffness but no pain or tenderness of the spinous
processes.
Red Flags-for back pain
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Age over 50.
Unexplained weight loss, history of cancer.
Persistent fever; recent bacterial infection.
History of intravenous drug use.
Immunocompromized.
Urinary or stool incontinence/urinary retention.
Trauma.
Neurologic deficit, weakness.
Red Flags
• Rule out “red flag” diagnoses, including diagnostic
studies, for specialist referral:
• o Cauda Equina Syndrome (Schedule emergency
procedure)
• o Fracture, Compression fracture, Dislocation,
Wound
• o Cancer, Infection
• o Dissecting/Ruptured Aortic Aneurysm
• o Others (prostate problems,
endometriosis/gynecological disorders, urinary
tract infections, & renal pathology)
Cancers metastatic to bone. mnemonic
Lead Kettle: PB KTL
• Prostate-blastic sclerotic
• Breast-mixed
• Kidney-lytic
• Thyroid-lytic
• Lung-lytic
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• Women: 80% from lung and breast
• Men: 80% from lung and prostate.
• 20% in both sexes, kidney, thyroid, GI and others
Case Ms. T.W.
• 48 year old female financial services secretary presents with
a three week history of bilateral low frequent back pain 6/10
without radiation. The cause of the pain is unknown but is
worsened by prolonged sitting. She feels unable to do her
walking program-requests MRI to “find out what is wrong”.
• PMH: Depression, r/o fibromyalgia per family physicianrheumatic work up negative.
• PSH: TAH-BSO 1 year ago. Bilateral CTS releases.
• ROS: Negative for F/C, constitutional symptoms, head or
neck pain, -IBS, -chronic fatigue, +weight gain
• Social Hx:
Divorced, college grad, resides with two
teenagers, Ex. ½ ppd smoker x 8 yrs, 3 glasses of wine/week.
Case-Ms. T.W.
• Exam: 5’4”, 212 lbs., 142/92, P-90, RR-16
• Anxious woman, ambulatory without
encumbrance.
• Lumbar exam: ROM with voluntary guarding on
flexion >30 degrees, extension, lateral bending
WFL. TTP, diffusely over the thoracolumbar spine,
SLR negative bilaterally.
• DTR’s 2+ throughout, sensation and motor testing
WNL.
What are yellow flags?
What are yellow flags?
• Risk factors for delayed functional recovery.
• Multiple prior injuries, prolonged or multiple
absences, victim of abuse in the past, Smoking, EtOH
abuse, FH of disability, depression, chemical
dependency, stress, job dissatisfaction, adversarial
relationship, severity of symptoms, delayed
presentation, chronic pain symptoms, multiple
diagnoses, prior CTS, multiple personal or
occupational/personal injury back/neck claims,
excessive physical medicine treatment, economic,
legal factors, subjective> objective findings.
Pain
• IASP “Unpleasant sensory and emotional experience
associated with actual or potential tissue damage”.
• Need to address emotional component of pain
fist…then understand the actual or potential tissue
damage.
• Pain is subjective…interacting with the limbic
system with modulation of pain…many potential
sources of potential pain in the low back…muscles,
facets, discs, nerve impingement.
Biopsychosocial Model
Biological
Psychological
Social
Clinical Management-Functional Recovery
• Detailed history-good investment of time initially.
• Understand ADLs and workplace functions
• Hands on physical examination. observation,
manual motor testing, detailed neuro exam,
understand mechanism of injury.
• Written prescription for activity, rest.
• Patient participation.
• Patient alliance-request team approach.
• Address concerns, discuss expectations.
• Work status-compliance.
Yellow Flags-management
• Multidisciplinary approach.
• Consider cognitive behavioral therapy.
• Avoid disability-explore barriers to work, written work
status, based on tolerated ADLs.
• Physical/Occupational Therapy-to teach home
program.
• Ergonomic assessment/adjustment of work station.
• Exercise prescription-walking, swimming, etc.
• Consider TCA and/or SNRI, sleep hygiene.
• Nurse case manager.
• Employee assistance program.
• Early follow up, limit detailed work up.
Common Back Pain
Misconceptions
• I injured my disc lifting something heavy at work.
That’s why my disc is bulging.
• My “degenerated” disc is causing my pain.
• Because I have back pain, I should stay away from
work.
• Back pain often leads to permanent impairment or
disability.
• Because I have back pain, I will need permanently
modified work.
Common Back Pain
Misconceptions
• I should rest until my back pain goes away.
• My back pain means I have really
significant biological damage or disease.
• X-rays, CT, and MRI can always identify
the cause of pain.
• Back pain will usually be cured by medical
treatment.
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MRI Imaging
• Although MRI is very sensitive, providing excellent
view of soft tissues and vertebrae.
• Limitation is lack of specificity—false positives.
• NEJM study of 98 asymptomatic individuals between
20 and 80 years (average 42.3).
• 52% had a bulge at least one level.
• 27% had a protrusion.
• 1% had an extrusion.
• Jensen MC, et. Al, MRI of the Lumbar Spine in People without
Back Pain, NEJM, 1994, Jul 14, 331(2): 69-73.
Back Pain & MRI
Several studies have shown that
there is a poor correlation between
MRI findings and patients’ low back
symptoms.
1. Wittenberg et al., 1998
2. Savage et al., 1997
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Active Resumption of ADLs
• Patients understandably have concerns and fears
about re-injury and will underestimate their
abilities.
• Based on history and findings, prescribe a graded
exercise program-with P.T. input.
• When ongoing subjective complaints exceed
objective findings, a focus should move away from
a focus on pain and instead focus on function.
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Daily Exercise Plan
PRESCRIBE
EXERCISE !!
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Medication Management
• APAP and non-selective NSAIDS Recommended
for acute low back pain as a first line to allow
activity and functional restoration.
• Associated with NNT of 2-3 for a 50%
reduction in pain.
• Muscle relaxants are an alternative.
• Use opioids uncommonly in severe cases
presentations for short period-up to 2 weeksin the acute phase only, with caveats.
• Chronic: TCA’s-yes; SSRIs-no SNRIs-unstudied.
Acupuncture
• Acupuncture not recommended for acute low back pain.
• Acupuncture has been found to be more effective than no
treatment for short-term pain relief in chronic low back
pain, but the evidence for acute back pain does not
support its use.
• Acupuncture is an accepted treatment in the California
Worker’s Compensation system-many other states are
adding this modality. (NY-starting pilot, Ilinois-No, OR-if
referred by PTP, NV-yes, AZ-yes, PA-if deemed “medically
necessary”).
• If successful treatment in past—trial indicated.
• MediCare does not cover acupuncture.
• Cochrane Review Database, 2000.
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Work Strong-UC Employees
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Work Strong
• Flexible 12 week program following work
related injury, staffed by kinesiologists.
• Stretching and Mobility
• Fitness Training
• Stress Reduction through Massage Therapy.
• Cooking Classes, Yoga in some cases.
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Case-Mr. R.R.
• 51 year old man, a plumber for a local
municipality.
• MOI: Bending with a tool and twisting with a
sudden onset of acute right lower back pain, with
weakness and dysesthesias his right leg radiation
to his right great toe, and to a lessor degree toes
2, and 3.
• Complains of severe back pain 8/10 with difficulty
walking due to pain. 50% of symptoms are in the
low back, 50% in right leg.
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Mr. R.R.
• PMH: Hypertension and hypothyroidism, otherwise
negative.
• Prior Occ Hx: 1 back injury, ditch partial cave-in, 10
years ago. Treated by personal physician, ibuprofen
and physical therapy < one week TTD.
• PSH: negative.
• Meds: levothyroxine, benazepril.
• NKA
• Social: Divorced, 2 adult daughters, never smoker,
Ethanol-occasional < 1drink/day, no other drugs.
Hobbies/activities: Racquetball, 1 hour, 3 x week,
daily walking.
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Case-Mr. R.R.
• 5’10”, 244 lbs. muscular male, overweight.
• Afebrile, 132/84, pules-78/min, RR-14.
• Slow, guarded gait, flat lordosis, pelvis shifted,
+muscle spasm, bridging with arms.
• Lumbar range limited to a few degrees in each planeflexion most difficult.
• DTR’s 2 and symmetric at patellar & Achilles.
• Light touch reduced on dorsum of foot/1st web with
10 gram monofilament-otherwise intact; 4/5 EHL on
Right.SLR—marked pain bilaterally at 30 degrees.
• Thoughts?
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Dermatomes and Myotomes
MUSCLE GRADATION
DESCRIPTION
5-Normal
5-complete range of motion against gravity with full
resistance
4-Good
4-complete range of motion against gravity with
some resistance
3-Fair
3-complete range of motion against gravity
2-Poor
2-complete range of motion with gravity eliminated
1-Trace
1-reads evidence of slight contractility, no joint
motion
0 (Zero)
0-no evidence of contractility
Mr. R.R. Follow up
• Mr. RR received ketorolac (Toradol) 60 mg IM acutely, treated
with ice and heat and was off work for two days, with ice and
heat, returning to modified work
• MRI revealed a 6 mm right sidedL4-5 HNP with L5 root
contact.
• Referred for and active physical therapy program-initially for
pain control and then mobility exercises-24 visits.
• Epidural injection considered, not needed.
• Had lifestyle change-particularly with diet-achieved a 38
pound weigh loss.
• Does regular core exercises, NSAID 1-2 times weekly.
• AMA Guides to the Evaluation of Permanent Impairment-6%
whole person. Able to continue work as a plumbing
supervisor with a 50 pound lifting limit x past 10 years.
• One flare since 2005 injury, minor right leg discomfort, with
no lost time from work.
Case-Ms. W.J.
• 44 year old nurse
Transferring patient on
Neurosurgery ward-L.A.
hospital.
Severe initial axial LBP,
unable to walk, with RLE
severe dysesthesias.
Neuro-reduced sensation
lateral foot and absent
Achilles reflex.
• Diagnosis?
Spondylolisthesis
Case-Ms. W.J.
• Grade 1-2 isthmic spondylolisthesis with severe
impingement of right S1 nerve root.
• Went on to discectomy and anterior/posterior
fusion due to instability, back and radicular
pain.
• Vigorous active post op therapy, has returned
to walking 7,500 steps daily.
• RTW 8 months following injury, now doing
medical case management to avoid clinical
nursing and heavy patient transfers.
Ms. W.J.
Grade 1-2 Isthmic Spondylolisthesis
s/p discectomy and fusion
Conclusions
• Internists and other primary care physicians will need
expertise in the E & M of acute back pain.
• Providers may have a positive impact on improving
outcomes, reducing symptoms, and improving functional
recovery.
• Excessive over-medicalization, and disability are not
supported by the evidence in the majority of cases.
These outcomes can be prevented with close attention to
patient’s history, detailed exam, and multidisciplinary
approach to management.
Conclusions
• Less common red flag conditions will be
encountered by all of us-on boards & wards.
• A high index of suspicion in red flag clinical
scenarios that are unusual is indicated, so as to
proceed with prompt evaluation, selective
diagnostic testing and referral in these cases.
• We can expect the unexpected and keep our
eyes and ears open!
The End.