an approach to low back pain and neuropathic pain n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
An approach to Low Back Pain and Neuropathic Pain PowerPoint Presentation
Download Presentation
An approach to Low Back Pain and Neuropathic Pain

Loading in 2 Seconds...

play fullscreen
1 / 53

An approach to Low Back Pain and Neuropathic Pain - PowerPoint PPT Presentation


  • 237 Views
  • Uploaded on

An approach to Low Back Pain and Neuropathic Pain. Russ O’Connor FRCPC (PMR), CASM, EMG. Objectives- By the end of the session the participant will be able to:. Outline common causes of low back pain in the Paralympic athlete

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

An approach to Low Back Pain and Neuropathic Pain


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
    Presentation Transcript
    1. An approach to Low Back Pain and Neuropathic Pain Russ O’Connor FRCPC (PMR), CASM, EMG

    2. Objectives-By the end of the session the participant will be able to: • Outline common causes of low back pain in the Paralympic athlete • Discuss things not to miss in Paralympic athletes with low back pain- the so called RED FLAGS • Discuss treatment suggestions for athletes with low back pain • Discuss how to manage neuropathic pain in the athlete with a disability

    3. Why is LBP worth talking about? • Common • 81% of AK and 62% BK amputees1 • ** of SCI • Prevalence in athletes ranges from 10 to 35% • Affects QOL/ sleep/ PERFORMANCE • Physical findings different? • Previous surgery 1Kulkarni et al Clin Rehab. 2005; 19:81-6.room

    4. Mr. A.S. • 30 yo paraplegic sit skier- L2 burst # fused with Harrington rods and right femur # • Long standing pain right thigh and shin. • Increased training since torino • Pain increased • Spasms increased • New feeling in post thigh and new muscle bulk right glut

    5. Mr. AS • Pain • Burning and electric shoot pain down thigh medial shin and foot • Increased with workouts and ski days esp at night • Settled with rest and gabapentin

    6. Mr. AS • Bowel and bladder- no recent fu • Right post thigh pain and swelling with stretch • Meds – • Gabapentin 900-600-900 • Baclofen 5 bid • Sedated

    7. Mr. AS- Exam • LNSL L1 right and left but has some feeling to L3 • Some flickers of abduction on right

    8. What do you want to know? • What makes you worried?

    9. RED FLAGS for LBP in athlete with a disability • Progressive pain • Weight loss • Fevers or ssx of infection Increased None None

    10. RED FLAGS for LBP in athlete with a disability • CHANGE in: • Motor or sensory function • Muscle bulk or new atrophy • fasciculation's • Bowel or bladder function • Spasticity New post thigh sensation and bulk None Increased

    11. Mr. AS • Careful History - physical • Increased pain • improved in motor sensory function • No new atrophy or fasciculation's • No change in bowel or bladder function • But no recent follow-up • Increased in spasticity or tone

    12. What do you think is wrong with Mr. AS? • MSK • Spinal • Hardware issue or instability • Fracture – • Facet degeneration • Spondylolysis or Spondylolisthesis • Deg disc disease – discogenic pain • Mechanical LB muscle Strain – overuse • Peripheral • Buttock / hip • SI • Femur – rod, muscle

    13. What do you think is wrong with Mr. AS? • Neuro • Spinal cord • Syrinx • SC compression from disc or central stenosis or infection • Central segmental neuropathic pain • Nerve root • Disc or osteophyte • Peripheral nerve • Pelvis, buttock

    14. Mr. AS • Imaging – What would you order • XR spine – no loosening • Bone scan – • CT – best for bone trauma, fast, cheaper • MRI – best for disc or cord • Urology follow up 1 3 2

    15. MRI • best for disc or cord but hardware really interferes with quality • L2 central stenosis and at L4/5 as well • Significant artifact making comments on the rest of the structures difficult

    16. Treatment - Mr. AS • Goals to allow RTP with less pain and spasms- depends on diagnosis • Conservative – Stretching/ strengthening / PT etc • Medications oral – • Medications injections • Trigger • Epidural • Botox • Surgery?

    17. Mr. AS • Oral medications • Spasms – Baclofen 5 bid • Pain - Gabapentin 900/600/900 • Seemed to be enough for awhile but returned with more pain after training • Increased gabapentin and baclofen at night

    18. Mr. AS • Discussed with team • Saw – Neurosurgery

    19. Mr. AS Returns • Increased pain – having to take more time off • Central stenosis at L2 with preserved L5 function clinically and L4/5 pain pattern.

    20. Mr. AS • Other options • Decrease training – competition • Increase or change medications • Trial of injections • Trigger point • Nerve root • Epidural

    21. Mr. AS • After L2 epidural steroid • Neuropathic shooting and burning pain down legs much better • Still has activity related axial back pain • Spasms persist Prohibited list

    22. L1

    23. L2

    24. Mr. AS • CT scan shows • fused Tspine to L4 • Severe stenosis at L2 • Widening of disc space and moderate L4/5 canal stenosis • Severe foraminal stenosis at L4.5 and mod at L5-S1

    25. Mr. AS- Update • Going for second injection • Still on Gabapentin and Baclofen • Has seen neurosurgery for opinion • Will consider L4/5 injection

    26. Neuropathic pain • Why is it worth talking about? • Common- • 2-3 % general population • SCI 54% at 6 months and 75% @5y 1 • Amputee 79.9%2 1MM Backonja and Jordi Serra. Pain Medicine 2004; 5: S1 PS48-S59. 2Ephraim et al. Arch of Phys Med and Rehab 2005; 86:10, P 1910-19.

    27. Neuropathic pain • Disabling- QOL, sleep, exercise, work, ADLs3 • Constant in up to 40% of people with SCI • 10% report severity of pain not paralysis prevents employment • 83% people with SCI who are employed state pain interferes with work • Performance!! 3Widerstrom-Nog et al. Arch Phys Med Rehab 2001;82:1271-7.

    28. Neuropathic pain • What is it? • IASP = "pains resulting from disease or damage of the peripheral or central nervous systems, and from dysfunction of the nervous system”

    29. Neuropathic Pain • Central • Brain • SCI • Peripheral • Root • Plexus • Nerve

    30. Classification - Spinal cord injury – Neuropathic pain • Above Level • Compressive neuropathy arms • At Level • Radiculopathy • SCord- syrinx, segmental injury • Below Level

    31. Mr. AS • What kind of pain does Mr. AS have? • Below the level of injury - • Neuropathic pain • Axial Low back pain – • Nociceptive – musculoskeletal

    32. Ms. BK • 24 yo woman traumatic amputation right below knee in a bicycle accident 3 y ago • Medically well • Pain right leg over distal residual limb, focal severe tenderness, with pressure or touch – severe shooting and stabbing pain • Pain over right foot- feels like foot is being crushed and occasionally like it is burned

    33. What type of pain does Ms. BK have?

    34. Classification – Amputee Neuropathic Pain • Phantom limb pain • Residual limb pain – stump • Neuroma Other MSK causes for limb pain- Not neuropathic in origin Skin, muscle, bone, joint, ligament

    35. Presentation • Description • Burning, shooting, lancinating, electric, itching • Stimulus evoke pain – • hyperalgesia – hurts more than it should • Allodynia – ALL - everything hurts

    36. Pathophysiology • Peripheral • Nerve injury and regeneration – neuroma • Neuronal sprouts – aberrant depolarization and increased expression of Na channels and voltage gated Ca ch • Release of Sub P and glutamate • Central • Central Spinal sensitization – NMDA receptor • Periaquaductal gray matter can modulate and suppress or accentuate pain- opioid receptors • Altered connectivity – inapprop connections

    37. CMAJ • August 1, 2006 • 175(3) | 269

    38. Investigations • Look for treatable causes • Peripheral nerve, plexus, root, SCI or brain causes • Systemic conditions • Diabetes, B12, thyroid, renal and liver disease • Infectious processes- shingles, • Toxic, nutritional defic • Focal conditions • Peripheral compression – carpal tunnel, ulnar, radiculopathy, SCI • Nerve or SCI abnormality – tumor syrinx etc

    39. Treatment Look for underlying cause!

    40. Treatment • Nonpharmacologic- desensitization, contrast baths, TENS, CBT, meditation, acupuncture • Pharmacologic – • First-line- tricyclic antidepressant or gabapentin • Second line – consider switching or adding adjuvant agent • Third line – opioids* banned

    41. Neuropathic pain in SCI • TCA’s less effective There is level 1 evidence (based on two RCTs) that tricyclic antidepressants do not reduce post-SCI pain. GO WITH NEURONTIN OR LYRICA IN SCI

    42. Objectives-By the end of the session the participant will be able to: • Outline common causes of low back pain in the Paralympic athlete • Discuss things not to miss in Paralympic athletes with low back pain- the so called RED FLAGS • Discuss treatment suggestions for athletes with low back pain • Discuss how to manage neuropathic pain in the athlete with a disability

    43. RED FLAGS for LBP in athlete with a disability • Progressive pain • Weight loss • Fevers or ssx of infection

    44. RED FLAGS for LBP in athlete with a disability • CHANGE in: • Motor or sensory function • Muscle bulk or new atrophy • fasciculation's • Bowel or bladder function • Spasticity