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CC July 2017 LBP

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echoecho's version from 2017-09-05 16:53

Section

Question Answer
____ of 10 people will have LBP in their life time?9
In 2006, the cost for LBP was?$100 billion per year
2/3 of the $100 billion was attributed to what 2 things?1) lost wages 2) reduced productivity
List the 3 categories of LBP with definition?1) acute back pain (lasts < 4 weeks) 2) subacute pain (lasts 4-12 weeks) 3) chronic pain (>12 weeks)
What % of the population with acute back pain will progress to chronic back pain?10%
To dx and treat BLP, what 2 things are needed?1) careful hx 2) PE
List the LBP red flags?1) pain worse at rest or night 2) hx of trauma 3) hx of chronic infection 4) glucocorticoid use 5) age > 70, 6) fever 7) chills 8) weight loss 9) hx of CA 10) symptoms of cauda equina syndrome
List the symptomsof cauda equina syndrome?1) saddle numbness 2) urinary retention 3) fecal incontinence
What should be looked for on physical exam?1) back appearance 2) strength 3) reflexes 4) sensations 5) ROM 6) straight-leg-raising sign
***Is imaging necessary and does it improve clinical outcomes if red flags are absent and the exam is consistent with an acute condition such as muscle strain?no
Imaging may be necessary if what are elicited in hx and exam and may include what imaging modalities?1) red flags 2) x-rays, CT, MRI, bone scan
The choice of imaging modality is dictated by what?clinical findings and hx
Interpretation of abnormal findings on imaging tests is often difficult because of?similar abnormalities are often found in asymptomatic individuals
What x-ray may be helpful as an initial imaging study, especially in patients with osteoporosis?lumbar spine x-ray
CT scanning is useful to detect what?fractures when there is hx of significant trauma
MRI is used to identify?soft tissue lesions and disc herniation
Lab studies are indicated only if what? What are the lab tests?1) risk fxs are present 2) CBC-D, ESR, urinalysis
According to the American College of Radiology, which imaging tests with ACR ratings concerning acute, subacute or chronic umcomplicated low back pain. No red flags. No prior managements?rating = 2 for MRI LS w/o contrast and LS X-ray and CT lumbar spine
According to the American College of Radiology, which imaging tests with ACR ratings concerning pain with radiculopathy, low-velocity trauma, age > 70, osteoporosis or chronic steroid use?rating = 7 for MRI w/ and w/o contrast and LS x-ray and CT without contrast if contraindications to MRI
According to the American College of Radiology, which imaging tests with ACR ratings concerning for cancer, infection or immunosuppressive?rating = 8 for MRI w/ and w/o contrast; rating = 6 for CT w/o contrast if contraindication to MRI
According to the American College of Radiology, which imaging tests with ACR ratings concerning low back pain with radiculopathy > 6 weeks after conservative management?rating = 8 for MRI without contrast; rating = 5 for CT without contrast if contraindication to MRI
According to the American College of Radiology, which imaging tests with ACR ratings concerning low back pain with prior surgery, new or progressing symptoms?rating = 8 for MRI w/ and w/o contrast; rating = 6 for CT with contrast if contraindication to MRI
According to the American College of Radiology, which imaging tests with ACR ratings concerning suspected cauda equina syndrome or rapidly progressive neurological deficit?rating = 9 for MRI w/o contrast; rating = 8 for MRI w/ and w/o contrast; rating = 6 for x-ray myelography and post-myelography CT lumbar spine
Explain the ACR ratings scale?1,2,3 = not usually appropriate; 4,5,6 = may be appropriate; 7,8,9 = usually appropriate
***In April 2017, the American College of Physicians (ACP) released their guidelines for treatment of acute, subacute low back pain, list these?1) given that most acute or subacute LBP improves over time regardless of treatment, the following is recommended. 2) superficial heat (moderate-quality evidence), massage, acupuncture or spinal manipulation (low-quality evidence) 3) NSAIDs or skeletal muscle relaxants (moderate-quality evidence)
In comparison wto the 2007 guideline, why is acetaminophen no longer recommended for acute back pain?because there is some low-quality evidence that it is no more effective than placebo
NSAIDS have long been the mainstay of Rx for back pain, but what does recent data show?only moderate evidence that they are more effective than placebo.
Compare NSAIDS and COX-2 selective drugs?there was a small increase in function noted and no difference in effect between the two
For skeletal muscle relaxants, they improve pain and function in short-term and there is moderate-quality evidence to support this. True or false?true
Comment on the benefit of injectable forms of corticosteroids over a 5 day oral course?no clear benefit
Was there sufficient evidence to guide the use of antidepressants, antiseizure medications, benzodiazepines or opioids?no sufficient evidence
*** In April 2017, the American College of Physicians (ACP) released their guidelines for treatment of chronic low back pain, list these?1)for chronic LBP, select nonpharmacologic treatment as follows 2) exercise 3) multidisciplinary rehabilitation 4) acupuncture 5) mindfulness-based stress reduction (moderate-quality evidence). 6) tai chi 7) yoga 8) motor control exercise 9) progressive relaxation 10)electromyography biofeedback 11) low-level laser therapy (low-power lasers or light-emitting diodes applied to the surface of the skin) 12) operant therapy 13) cognitive behavioral therapy 14) spinal manipulation
List the nonpharmacologic modalities and treatments of chronic back pain with their modality, evidence for pain relief, pain decrease in arrows, evidence for improvement in function, function improvement in arrows. Some show at least a moderate reduction in pain (at least a 10-20 point reduction on Visual Analog Pain Scale)? 1) motor control exercise = low; 2 down arrows (pain decrease); low; 1 up arrow (function) 2) tai chi = low; 2 down arrows; low; 1 up arrow 3) yoga = low; 2 down arrows; low; no change in function 4)progressive muscle relaxation = low; 2 down arrows; low; 2 up arrows 5)biofeedback = low; 2 down arrows; low; 2 up arrows 6)biofeedback = low, 2 down arrows,;low; no change in function 7)cognitive behavioral therapy = low; 2 arrows down; low; no change 8)mindfulness-based stress reduction = moderate; 2 arrows down; moderate; 1 arrow function increase 9)multidisciplinary rehab: moderate, 2 arrows down, moderate, 1 arrow up 10) acupuncture = moderate, 2 arrows down, moderate 2 arrows up 11) massage therapy = low, 2 arrows down, low, no change 12) spinal manipulation = low, 2 arrows down, low, 2 arrows up
***Summarize as to the best non-pharmacologic modalities per your opinion 1) MODERATE evidence = a) mindfulness-based stress reduction (mod/2 arrows down for pain /mod/ 1 arrow up for function) b) NEXT BEST = multidisciplinary rehab (mod/ 2 arrows down for pain / mod / 1 arrow up for function) c) BEST = acupuncture (mod / 2 arrows down for pain / mod / function 2 arrows up 2) BEST is acupuncture, followed by multidisciplinary rehab and mindfulness-based stress reduction
Define motor control exercises?are those focused on strengthening and improving control of the set of muscles that support the back
Define progressive muscle relaxation?practice during which the patient learns to relax each muscle group in sequence
Define mindfulness-based stress reduction?8 week program in which participants learn and practice different meditation and mindfulness techniques
*** In April 2017, the American College of Physicians (ACP) released their guidelines for chronic low back pain unresponsive to nonpharmacologic therapy, list these?1) puts w/ chronic LBP who have had an inadequate response to nonpharmacologic therapy should consider NSAIDS as first-line therapy; tramadol (Ultram) or fluoxetine (Cymbalta) as second-line therapy 2) should only consider opioids as an option in patients who have failed the aforementioned teatments and only if the potential benefits outweigh the risks for individual patients and after a discuss of known risks and realistic benefits with patients
Did head to head trials with different NSAID preparations show any significant differences in pain or function? Comment on side effects comparison?1) no significant differences in pain or function
*** List medications and treatments of chronic low back pain?1) NSAIDs = moderate evidence / 1 to 2 arrows pain decrease / low evidence / one arrow up function. 2) opioids = moderate / one arrow decrease / moderate / one arrow up increase. 3) tramadol = moderate / 2 arrows decrease / moderate / one arrow increase. 4) skeletal muscle relaxants = low / no change / no evidence 5) benzodiazepines = low / 2 arrows decrease / no evidence 6) TCAs = moderate / no change/ low / no change
*** Summarize as to the medications and treatment of chronic low back pain with moderate evidence?1) BEST = Tramadol (mod/2 arrow decrease / mod/ 1 arrow increase) 2) NEXT BEST = NSAIDS (mod / 1-2 arrows decrease / low / 1 arrow increase
*** Summarize as to medications and treatments for chronic low back pain1) best med is Tramadol followed by NSAIDs. However NSAIDs is first line followed by Tramadol and Duloxetine as second line therapy 2) best modality is acupuncture followed by multidisciplinary rehab and mindfulness-based stress reduction
Is the use of TCAs and SSRIs recommended for treatment of chronic back pain, if not, why?no; newer, moderate-quality data show no change in pain levels or function
What medication was shown to result in slight improvement in both function and pain over placebo?Duloxetine
Low quality evidence showed no difference in pain levels between what two types of medications in treatment of chronic low back pain?1) skeletal muscle relaxants 2) benzodiazepines
Although opioids have long been the treatment of choice for chonic back pain, what does moderate-quality evidence show?that strong opioids (tapentaold (Nucynta), morphine, hydromorphone, and oxymorphone) were associated with about a 1-point improvement on a pain scale of 0-10 and no improved function compared with placebo
Was there a difference between short and long-acting formulations?no
What type of pain relief and what function improvement was there with Tramadol compared to placebo?1) moderate short-term pain relief 2) small improvement in function
Why shoulder we prompt a discussion with patients regarding the approach to low back pain?1) excellent safety profile associated with non-harm pharmacological approach to acute and subacute low back pain 2) most cases resolve without treatment
For chronic low back pain, what is the recommendation?a multidisciplinary treatment plan should focus on the lowest risk and lowest cost, because there is very little difference in outcomes regardless of chosen treatment
*** SUMMARY = True or false? Acute low back pain is common and usually self-limited?true
*** SUMMARY = Imaging is not necessary in the absence of ____ _____ signs and symptoms?red flag
*** SUMMARY = What treatments are recommended initial treatment for all forms of low back pain?nonpharmacologic treatments
*** SUMMARY = What medication is recommended first line if nonpharmacologic approaches are ineffective?NSAIDs
*** SUMMARY = Why should a multidisciplinary approach to chronic low back pain focus on the lowest risk and lowest cost treatments?because there is very little difference in outcomes regardless of chosen treatment modality.
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