CoMorbidities in Spinal Care The Complicated Spine Patient

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Co-Morbidities in Spinal Care The Complicated
Spine Patient

• Tara Jo Manal DPT,OCS, SCS

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Fibromyalgia

• Fibromyalgia Syndrome
• 1990 American College of Rheumatology
• Pain in muscles and fibrous connective-tissue,
  muscular rheumatism
• Primary(no other musculoskeletal/organic
  disorder)
• Secondary (trauma, repetitive motion, rheumatic
  diseases, non-rheumatic conditions and viruses)

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Fibromyalgia Symptoms

• Musculoskeletal pain
• Stiffness
• Easy Fatigability
• Daily varying symptoms
• Remissions/Exacerbations
• Mood Disturbances- anxiety, panic, anger,
  depression, irritability, agitation, frustration

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Fibromyalgia Symptoms

• Aggravate
• Cold
• Humid
• Overactivity
• Stress/Anxiety
• Inactivity
• Fatigue
• Poor Nutrition
• Poor Sleep

• Relieve
• Warm
• Controlled Activity
• Decreased Stress

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Fibromyalgia Incidence/Prevalence

• Female/Male Ratio 201
• Age- Begins in childbearing years 25-40
• Diagnosis- often 40-60 years old
• Genetic Predisposition- Familial
• Remission in 20 of cases

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Fibromyalgia Diagnosis

• Lab Work-up
• CBC Blood Count
• Sed rate
• Muscle Enzymes
• TSH (Thyroid)
• Rh Factor RA, Lupus
• Lymes Titer
• X-ray
• EMG Dx of exclusion

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Physical Exam

• Tender Points Jump sign of at least 11 of 18
  tender points
• Moderate tension and snap band for visible
  shortening
• gt5 years of chronic pain
• Sleep disorder (Stage 4-deep interrupted)
• Irritable Bowel Syndrome
• Chronic Headaches
• TMJ Dysfunction
• Fatigue- brain fatigue

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Fibromyalgia Treatment

• Education/Support Group Stress Management
• Medications
• Tricyclic anti-depressants decrease anxiety, may
  increase sleep, decrease fatigue and pain,
  increase serotonin (Elavil, Pamelor, Sinequan,
  Nopramin
• Analgesics
• NSAIDS (Ibuprofin, Aleve)

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Fibromyalgia Treatment

• Medications
• Muscle Relaxers (Flexeril, Valium) usually not
  effective
• Seratonin Re-Uptake Inhibitiors blocks
  destruction of serotonin. Prozac, Zoloft, Paxil,
  Effexor
• Estrogen Replacement Therapy
• Combination Therapies of Listed meds

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Fibromyalgia Treatment

• Injections Lidocaine or procaine with
  corticosteriod at tender points (saline)
• Psychological testing For anxiety and depression

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Trigger Points

• Prolonged muscle contraction causes local
  ischemia
• Ischemia pain (angina and arm pain, vascular
  and intermittant claudication)
• Pain related to accumulation of metabolites (esp.
  lactic acid and bradykinins and protolytic
  enzymes)
• Pain receptors are poor adaptors (Sub P)
• Mechanical sensitivity to contraction
• Sympathetic component

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Trigger Point vs Tender Point

• Hyperirritable muscle
• Tender points flat, swollen regions, local pain
• Trigger points have referred pain following a
  specific innervation
• Possible result of tissue damage (maybe
  Sarcplasmic reticulum- Ca2 exposure)

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Trigger Point vs Tender Point

• Can induce referral pattern in normals with
  saline injection
• May go into latency and be painful only with
  palpation and not activity
• Tender points are critical to dx of Fibromyalgia

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Trigger Points

• Teres Minor
• Deltoid bursitis or C8 radiculopathy
• Trigger of Quadratus Lumborum and Piriformis
• SIJ pain
• Iliopsoas
• Failed LBP

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Trigger Point Treatment

• Injection
• Needling (mechanical breakup)
• Analgesic/Anti-inflammatory
• Spray and Stretch
• Stretch for relaxation feedback loop
• Ischemic Compression
• Mechanical stretch to muscle
• Heat/TENS
• Counterirritation
• E-stim- Acupuncture like stim

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Trigger Point Treatment

• Consider in rehabilitation, the muscle has been
  working in a shortened position
• Restore eccentric function

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RSD

• Complex Regional Pain Syndrome
• Shoulder Hand Complex
• Causalgia

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RSD

• Incidence
• 1 to 2 of various fractures
• 2 to 5 of peripheral nerve injuries
• 7 to 35 of prospective studies of Colles
  fracture
• The diagnosis is often not made early and some of
  the very mild cases may resolve with no treatment
  and others may progress through the stages and
  become chronic, and often debilitating

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RSD

• Reflex sympathetic dystrophy (RSD) is a complex,
  poorly understood disorder that is characterized
  by chronic, severe pain and progressive changes
  in skin, muscle, and bone.
• Although the precise causes of RSD are unknown,
  it often occurs following an injury, often minor
  in nature.
• Some experts believe that RSD represents an
  exaggerated response of the sympathetic nervous
  system to some form of injury or insult (eg.
  surgery) to the area resulting in chronic,
  severe, sometimes debilitating pain

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RSD

• Although the signs and symptoms of RSD vary
  depending upon the clinical stage of the
  disorder, the one common feature shared by all 3
  clinical stages (early, established, or late RSD)
  is pain
• The common pathway contributing to symptoms is
  the sympathetic nervous system where a reflex arc
  develops between an area of injury, one of the
  extremities to the spinal cord, with the
  sensation of pain being mediated along the
  peripheral sympathetic nerve

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RSD Symptoms

• Severe hyperesthesia of the skin overlying the
  extremity
• Cool or cold fingers or toes
• Hyperhidrosis(sweat) of the extremity
• Severe edema can develop as well

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RSD Treatment

• Upper thoracic ganglion blocks
• Dorsal column stimulator
• Oral medications
• narcotics, which provide temporary relief, but
  do not actually cure or play much of a role in
  the improvement of symptoms
• Neuro-modulating medications including Neurontin
  can be used.
• Sympathectomy of the upper thoracic chain has
  been described to be effective in improving or
  lessening symptoms in between 40 - 60 of
  patients
• typically of the T2 to T3, and sometimesT4

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RSD

• Goals of treatment include
• Controlling and minimizing pain to the greatest
  extent possible
• Restoring function to the RSD-affected limb
• Preventing progression of the disease process to
  the late stage
• Improving the patient's quality of life and
  psycholocial functioning

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RSD

• Mobilization of the affected limb is a very
  important part of treatment
• The goal is to keep the limb moving as much as
  possible and enable the patient to perform normal
  activities
• Aquatic therapy at a comfortable water
  temperature can often facilitate mobilization of
  extremities, especially if RSD/CRPS is in the
  lower extremity

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Smoking and Spine Care

• Increased Incidence
• Cardiovascular disease
• Depression
• Cancer
• Pulmonary disease
• Osteoporosis and related fracture
• DDD

• Increased Risk
• Postop Infection
• Delayed Wound Healing
• Non union of fusion
• Independent Risk Factor for back pain