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LOW BACK PAIN IN HUMAN

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Slide 1 - 3/4/03 Steven Stoltz, M.D. Back Pain 2nd most common cause for office visit 60-80% of population will have lower back pain at some time in their lives Each year, 15-20% will have back pain Most common cause of disability for persons < 45 years 1% of US population is disabled Costs to society: $20-50 billion/year
Slide 2 - Oh My Aching BackTreatment Options for Back Pain Steven Stoltz, M.D. Assistant Clinical Professor of Medicine UCSF-Fresno
Slide 3 - 3/4/03 Steven Stoltz, M.D. Outline Part 1: Introduction Review of anatomy Part 2: Acute low back pain Part 3: Chronic low back pain Prevention Questions ??
Slide 4 - 3/4/03 Steven Stoltz, M.D. Low Back Pain “One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.” Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.
Slide 5 - 3/4/03 Steven Stoltz, M.D. - Anatomy Lesson #1
Slide 6 - 3/4/03 Steven Stoltz, M.D. - Anatomy Lesson #2
Slide 7 - 3/4/03 Steven Stoltz, M.D. Introduction to Ed Ed has had lower back pain for the past 24 hours that he feels is related to yard work that he did over the weekend. He missed work today, Monday. He wants to know what can be done for his back pain?
Slide 8 - 3/4/03 Steven Stoltz, M.D. What should Ed expect from his health care professional? Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. Provide information, advice, and a plan of action.
Slide 9 - 3/4/03 Steven Stoltz, M.D. % of Back Pain due to Herniated Disk? 4% 14% 40% None of the above
Slide 10 - 3/4/03 Steven Stoltz, M.D. Causes of Low Back Pain Lumbar “strain” or “sprain” – 70% Degenerative changes – 10% Herniated disk – 4% Osteoporosis compression fractures – 4% Spinal stenosis – 3% Spondylolisthesis – 2%
Slide 11 - 3/4/03 Steven Stoltz, M.D. Causes of Low Back Pain… Spondylolysis, diskogenic low back pain or other instability – 2% Traumatic fracture - <1% Congenital disease - <1% Cancer – 0.7% Inflammatory arthritis – 0.3% Infections – 0.01%
Slide 12 - 3/4/03 Steven Stoltz, M.D. Red Flags History of cancer Unexplained weight loss Intravenous drug use Prolonged use of corticosteroids Older age Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction
Slide 13 - 3/4/03 Steven Stoltz, M.D. Medications Anti-inflammatory medications (NSAID’s): Beneficial; no differences; watch side-effects Tylenol: Narcotic Pain Relievers: No more effective than NSAID’s Many side effects Muscle Relaxants (ie. Flexeril®): Can decrease pain and improve mobility 70% with drowsiness/dizziness
Slide 14 - 3/4/03 Steven Stoltz, M.D. Chiropractic/Osteopathic Davenport, Iowa in 1895 by David Palmer; ‘done by hand’ (Greek) Spinal manipulation Conflicting evidence on the effects of spinal manipulation ~75-90% improvement anyway within 4 weeks Greater patient satisfaction
Slide 15 - 3/4/03 Steven Stoltz, M.D. Exercise & Bed Rest Advice to stay active: ‘There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica.’ Hurt does not equal harm One or two days of bed rest if necessary Light activity, avoiding heavy lifting, bending or twisting (ie. walking) No data on any particular exercises
Slide 16 - 3/4/03 Steven Stoltz, M.D. Massage & Physical Therapy Might be beneficial More quality research is needed Different types of massage
Slide 17 - 3/4/03 Steven Stoltz, M.D. Acupuncture Very little quality research and data Seems to indicate that acupuncture is not effective for the treatment of back pain
Slide 18 - 3/4/03 Steven Stoltz, M.D. Other Modalities Back Brace/Corset/Lumbar Support: Traction: Injections: Inconclusive evidence TENS: Hot/Cold: Ultrasound:
Slide 19 - 3/4/03 Steven Stoltz, M.D. Ed, again… Now, Ed has not had improvement in his lower back pain and 6 weeks have gone by since the initial painful event. What types of therapies might be beneficial for Ed now?
Slide 20 - 3/4/03 Steven Stoltz, M.D. Role of X-rays (Radiology) Usually unnecessary and not helpful Plain X-ray: Age>50 years No improvement after 6 weeks Other worrisome findings MRI: After 6 weeks if have sciatica
Slide 21 - 3/4/03 Steven Stoltz, M.D. New England Journal of Medicine (February 2001)
Slide 22 - 3/4/03 Steven Stoltz, M.D. Medications Similar to acute pain…. Antidepressant medications can improve pain relief
Slide 23 - 3/4/03 Steven Stoltz, M.D. Exercises Improves pain and function Many programs available, but difficult to make any scientific recommendations for one type versus another
Slide 24 - 3/4/03 Steven Stoltz, M.D. Injections Epidural injections: Insufficient and conflicting evidence Facet joint injections: No improvement Local/Trigger point injections: Possibly some benefit
Slide 25 - 3/4/03 Steven Stoltz, M.D. Surgery Diskectomy improves pain in short term but not long term (ie. 10 years) Microdiskectomy similar to standard diskectomy Automated percutaneous diskectomy and laser diskectomy both less effective ? Arthroscopic diskectomy
Slide 26 - 3/4/03 Steven Stoltz, M.D. Other Modalities Back Schools: - possibly effective Multidisciplinary Therapy: - probably yes TENS: - no Spinal manipulation: - conflicting data Massage: - probably yes IDET:
Slide 27 - 3/4/03 Steven Stoltz, M.D. Intradiscal Electrothermal Therapy
Slide 28 - 3/4/03 Steven Stoltz, M.D. IDET No convincing evidence that shows the short or long-term clinical efficacy of this procedure. Safe with few adverse effects ? Long-term effects Wall Street Journal (Feb. 11, 2003)
Slide 29 - 3/4/03 Steven Stoltz, M.D. Prevention Exercise: Aerobic, back/leg strengthening Back braces and education about proper lifting techniques are ineffective ? weight loss and smoking cessation
Slide 30 - 3/4/03 Steven Stoltz, M.D. Web Resources www.mayo.edu www.cochraneconsumer.com (“Helping people make well-informed decisions about health care.”) www.library.ucsf.edu