PM

1
PMR APPROACH TO LOWER BACK PAIN

• In Kwang Yoon, M.D
• SKYL Physiatrist Associates, PC
• Medical Director of PMR
• Department of Oakwood
• Healthcare System

2
THE LOW BACK PAIN STORY

• 60-90 of adults will have LBP
• 2nd most common reason to see PCP
• 55 will suffer annual recurrence

3
COMMON THINKING

• 40-50 of patients with LBP will improve within 1
  week

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THE FULL STORY

• 62 of patients likely to have one or more
  relapses during a 1 year follow-up

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COMMON THINKING

• 85-90 of injured workers with LBP will improve
  in 6 to 12 weeks

6
THE FULL STORY

• LBP is the 1 disability in patients under 45
• After 2 years, there is little to no chance of
  returning to previous job

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COMMON THINKING

• 90 of patients with LBP improve without any
  medical care

8
THE FINANCIAL BOTTOM LINE

• LBP accounts for 25 billion in medical costs
  annually
• LBP contributes to another 50 billion in
  non-medical costs each year

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DIFFICULTIES IN TREATING LBP

• Difficult to diagnose source
• Requires whole care approach
• Preventive program needed to minimize recurrence

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TREATING THE LBP PATIENT

• Appropriate evaluation and diagnosis starts with
  history and physical examination
• Physical exam neurologic, kinesiologic,
  functional
• Psychosocial profile
• Work profile

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LBP Outcomes

• Natural distinction between pain function
• Function may be restored even though some pain
  may remain

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WHAT TO TELL YOUR PATIENTS

• They are likely to improve
• Likely to return to work quickly, even if pain
  persists
• Back pain is usually recurrent
• May become chronic
• Most patients with chronic LBP continue working

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PATIENT SATISFACTION

• Most frequent complaint inadequate information
• Dissatisfied patients request more tests, new
  physicians
• Adequate explanations do not always take more time

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HISTORICAL QUESTIONS

• Alleviating vs. aggravating activities
• Flexion vs. extension
• Sitting vs. standing

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HIGHEST RISK OF INJURY

• Combined motions, flexion and rotation

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HISTORICAL QUESTIONS

• Bowel and bladder symptoms

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DRAWINGS PAIN QUESTIONNAIRES

• Supplement verbal descriptions
• May yield information about non-organic causes

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Low Back Pain Generators

• Nerves
• dorsal ganglia
• dura
• nerve root
• Muscles
• Ligaments
• ALL
• PLL
• supra
• interspinous
• Facet joints

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PMR Examination

• Neurologic
• Kinesiologic
• Functional

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PMR Examination

• Standing
• Scoliosis
• Shoulder tilt
• Protrusion of scapula
• Pelvic tilt
• Slouching
• Kyphosis
• Lordosis

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• Squating
• Heel Tip Toeing
• Bending side
• Flexion / extension

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SITTING

• SLR / EHL
• DTR
• DERMATOME

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SUPINE POSITION

• Leg Length
• SLR

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SIDE LYING

• Tenderness
• Trochanter
• Ischial Tuberosity

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PRONE POSITION

• TENDERNESS
• SI joint
• Spinal segment
• Post iliac crest
• Muscle spasm
• Skin rolling

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Functional Examination

• In and Out of chair
• On and off table
• Pain response

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3 Most Common LBP other than Radiculopathy

• Sacroiliac Disorder
• Trochanteric Bursitis
• Pyriformis Syndrome

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DDX

• Intra Abdominal
• Retro Peritoneal
• Genitourinary

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Lumbar Spine Imaging Studies

• 36 of CT scans abnormal in asymptomatic persons
• 24 of myelograms abnormal in asymptomatic
  persons
• 37 positive discograms in asymptomatic persons

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Other Diagnostic Tools

• Serologic tests
• Electrodiagnostic studies
• Injections

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The Rehabilitation of Low Back Pain

• Acute Phase
• Recovery Phase
• Maintenance Phase

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Goals of Rehabilitation

• Full pain-free ROM
• Return to normal functional activity
• Prevention of further injury
• Optimal strength, endurance, coordination

33
Effects of Immobilization

• Atrophy
• Increased problems with injury

34
Treatment Options Acute Phase

• Pain Relief
• Modalities
• Patient education

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Pain Medication

• Under Prescription
• Social Dilemma
• Pain Cocktail

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Modality

• Heat VS Cold
• Deep Heat U.S. VS Microwave Diathermy
• Electric Stimulation
• Traction
• Cranio Sacral Therapy

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• Neuro Mobilization
• Acupuncture
• Magnetics
• Modification of foot wear

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Treatment Options Recovery Phase

• Flexibility
• Strengthening
• Body mechanics
• Exercise

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Flexibility

• Lower extremity
• Hip flexors and extensors

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Strengthening

• Primary stabilizers
• Multi-segmental muscles
• Lower extremity musculature

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Body Mechanics

• Posture
• Bending and Lifting
• Pelvic Tilt

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EXERCISE

• Spine stabilization exercise
• Neutral spine exercises
• General exercises

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Treatment Options Maintenance Phase

• Proper cardiovascular conditioning
• Work-specific training
• Ergonomic issues

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Important Reminders

• Absence of symptoms does not mean normal function
• Neurologic as well as functional evaluation
  necessary
• Symptom resolution is only an initial step
• Goal is prevention of recurrent injuries