Thank you Mona, I really appreciate that. Hello everybody and thank you so much for your time in a busy Monday. My name is Dr. Zainab Ullawadi. I'm a physical medicine and rehab specialist, brain injury subspecialist, fellowship trained and board certified. I'm also PM&R certified in Canada and the States. So I'm a fellow of the Royal College of Physicians and Surgeons of Canada and I'm a fellow of the AAPM&R. This is an approach or a case based approach to low back pain or back pain or pain in general. I'm a very interactive approach kind of physiatrist so I'm gonna ask you for more engagement to make you awake and to make sure that we all get out of this session with a maximum benefit. So I want to share my screen and I'm sorry I'm not a good techno girl, I might need some help here. Happy to help Dr. Ullawadi, anything you need. Thank you, I really appreciate it. Is the screen available for everybody? And I can't see the chat so just anybody can yell and scream and say yes, it's obvious. Yes, we do see. Thank you. So what I'm going to do basically, we're going to talk about a case based approach to pain management. I'm going to use one case as an example, but to make sure I'm going to incorporate different experiences and I've seen one of the audience questions either whether we can have a non interventional certified pain specialist. I don't think there's a fellowship per se that is dedicated and there is a board certification for that. But I can tell you just being a physiatrist board certified and a PM&R trained, it's by default, this is your bread and butter. So there is an expectation that you would know how to manage pain from a non interventional perspective, just being a physiatrist. Nothing to disclose, just a disclosure, some slides were adopted from my previous mentors and conferences I personally attended throughout my career, whether it was a board, like for my board certification, or through the North American Spine Society. So you might see some familiar slides, hopefully not because I kind of worked it to make it more like original, my kind of handmade slides. So objectives, develop a strategy to help your patients cope with pain. We're going to discuss what is the multimodal approach to pain management. We will describe the non-pharmacological and pharmacological approaches to pain management, and when is the right time to implement aggressive measures. Throughout my career in early, I'm a fresh graduate, I finished in 2020, but low back pain has been quite close to my heart because I would have seen it a lot in my outpatient clinic. And by the time you develop that skill set to manage, you kind of know when to follow the guidelines, when to use the right words, especially if it's a worker's compensation or IME, and when you would say to the patient that I'm so sorry. Okay, here we go. So we will start with a case, we have a 50 years old gentleman, hypertensive, otherwise healthy. He came to your clinic complaining of acute pain in the lower back and right anterior groin. He also has mild lateral leg pain that extends to the knee. He also has difficulty distinguishing if the pain extends past the knee or not, and I know as far as we all know, there is a great significance of knowing if the pain goes beyond the knee or not, in terms of neurological versus musculoskeletal causes. Symptoms worsen with sitting and tying his shoelace. It gets better with changing position, and there is a history of hip impingement. Now you can see the layout of this case, this is not uncommon. You see this patient almost all the time. Out of your 10 low back pain patients, there will be at least five, if not more, would go with the same pattern. Non-specific findings, prolonged sitting or standing, that gets it worse, better with changing position. And there are other factors within the history that you go through that would add value to your differential diagnosis, and we will talk about that. So what will be your differential diagnosis listening to this story? How about if I hear one or two thoughts through the chat, or you can chime in, say it out loud, I would like to hear your thoughts. What would you think is going on? Hip osteoarthritis. Okay, that's a good start, bang on. I see radiculopathy, beautiful. I like that, but give me an idea who my audience is and how I would proceed. Love it. Okay. So as you folks said, the differential diagnosis vary from hip impingement. And as you know, there are two types. You have the CAM and the pincer. We don't know which type our patient has. You have dyskogenic. You have facet-related pathology. You have SI joint pain. And you have other. You might have a patient who has abdominal pathology, and this is a revert pain. Or you could have any sort of like non-low back-related muscle joint and tendon issue. Could have, I would say, trigger point, sorry, myofascial pain, and that would need trigger point injections. So the etiology varies based on the history on physical exam. I would say in low back pain, 70% of your diagnosis relies on the history. So the more information you gather, the better. Not to say that most of the patient's history are vague, non-specific, and sometimes that's why you need your physical exam, your MRIs, your EMGs, and we'll go from there. So what does the pain diagram tell you? So initially when I started my kind of like being on my own as an adult, I was very much on the pain diagram. This is very important. This is for my initial level. This is for the follow-up. And this is what I got all the time. Good luck with that, girl. You have it all in your pain diagram. It's scratched everywhere. There is blue. There is red. Sometimes there was yellow at times. So it tells you some information. It doesn't help you much to narrow your differential diagnosis because, again, your patient comes with a full meal deal. It's not just the low back pain. It's the overuse injury to the shoulders. It's one leg over the other with leg length discrepancy, whether it's a true or apparent leg length discrepancy. So it kind of gives you a guide that's not really a guide. At the same time, when you use it consistently in the follow-up, it tells you the management that you're applying works or not and whether it is you need to tweak that, increase it, or change it to another whole new pain management program. And how do we determine improvement? There are certain scales that we use to determine improvements. So, for example, in the neck scale, in the neck pain, we use the neck disability index. In the low back, we use the Roland Morris Disability Questionnaire and the Ostrich Disability Index. I can tell you for sure that at least when I deal with the low back pain in your typical patient, I don't use those. But in workers' compensation or IME, independent medical evaluation, these are more objectified manifestations of the pain that you are dealing with. So it gives you a lot of an objective flavor. It's not going to change your management. It's basically if you do it on a persistent basis in follow-ups, it will give you an idea how the pain management is going. So what are the common disorders of the lumbar spine? If somebody can shout, you said one of them, OA, radiculopathy. I'm going to say a couple. The commonly used ones or the commonly used disorders of the lumbar spine, you have the spondylosis or what we call in layman language, aging of the spine, which could be evident by either disc narrowing or arthritic changes at the facet joints or both. You have your spondylolisthesis. That's your, again, I will use a lot of for your exam preparation not to scare you, but it's my style of saying this is important for exam and it's not. And whether you're board certified or preparing for it, it's kind of giving you these buzzwords. So in spondylolisthesis, your typical exam case, you're a teenage girl playing gymnastics, presenting with low back pain, and that's when you think of spondylolisthesis. Again, it's not uncommon to see it as well in geriatrics population, keeping in mind that there should be a history of trauma before they present with low back pain. Grade 1, 2, and controversial grade 3, non-surgically. Grade 3 and some 4 and 5, you might definitely need surgical intervention. Otherwise, their spinal cord would be affected. Spondylolisthesis, you have the fracture in the pars interarticularis. Again, you might see it congenitally. Depends on the institution you work. Some neurosurgeons would like to correct it early on. Some would not. Pick your battles. Spinal stenosis, this is where you're finding your typical central spinal canal narrowing with red flags manifestations. Like your bowel and bladder incontinence, your saddle anesthesia, or either your osteomyelitis-related manifestations or spine tumor-related spinal stenosis symptoms and signs. That's where you're like, no, I need my neurosurgeon here as soon as possible to make changes and to do surgical intervention. Other common use terms, radiculopathy. It's important to mention that we need to know the difference between radiculopathy and radicular pain because I am sure that we as physiatrists know the difference, but it's not all the time. So when you get a referral from a family doctor with radiculopathy and you go through the history, you can see that there is no element of nerve root compression or irritation. In fact, it's more of a peripheral nerve disorder or pathology. So you got to make sure that you question the history back without relying on everybody's diagnosis. Because again, when it comes to low back pain, we are the first line in terms of proper management, not to discredit the family doctors. But again, they have a lot on their plate. And to diagnose that properly, we have been well-trained to do that. You would see a lot with sciatica diagnosis or lumbago. It kind of drives me crazy. I'm not going to lie, because it tells you that there is a particular issue with the sciatic nerve distribution. And it's not always the case. You might see that once in a while. You might see that as a part of another syndromes, like the piriformis syndrome, where there is a compression of the sciatic nerve. But it's not a diagnosis per se. Again, cauda equina incanaus medullaris. These are common spinal cord urgencies slash emergencies that needs to be taken care of. The new era in geriatrics rehab, that there is a lot of kyphosis and lordosis happening as the patient ages or as the population ages. And in that case, you kind of question what exactly we need to do in terms of managing them. From managing them with pain management versus surgical intervention versus therapeutic or physical therapy exercises. Scoliosis, you will see that a lot with idiopathic scoliosis in the teenagers. Again, it's a new era coming in the geriatrics rehabilitation world. That curvature of the spine needs to be taken care of. And sometimes your patients have enough of their morbidity issues that they are not good surgical candidates. And that's where you come in and advise on proper non-surgical treatment plans. How common is low back pain? In your practice, just hearing from the audience, how common you see that? Do you see it every day? Are you like, I'm more specialized in spinal cord or brain injury. I don't deal with that. What are your thoughts? Very common. Thank you. I like this participation. It's very common. Now, this study is like almost a decade ago, which shows that there is like a 15% one-year incidence of first lower back pain. But then it goes high up to one-third within like multiple episodes and flare-ups within the one year. Again, there is a lot of money lost in terms of low back pain, whether it's related to work absence, workers' compensation, days absent due to low back pain and the patient or the workers being sick, the hospital care, the therapies, and the list goes on. So it is a burden on the healthcare financially. It's a burden on the patient's function and quality of life. And that's what we physiatry care about is the function and quality of life. What's the natural history of low back pain? So this is an article from 2019 that says there are two main categories of low back pain. You have your axial low back pain that would usually persist and stay for at least one year after the initial consultation. And you have your radicular lumbosacral pain with almost a similar story, but then they recover within at least six months to a year and then come up with flares. So it's important to mention to your patients that with low back pain, you might have a one kind of flare that keeps going or you can have episodes of flares that comes in and goes. And you have to make sure that whether it's a low back pain flare or a pseudo flare, which means that there are other factors going on from psychosocial circumstances that could play or feed into the low back pain. It's important to mention that when you see your low back pain patient, and again, this is from a personal experience, I would say some of them would have their MRI ready to show you that their back pain is from their significant herniated lumbar disc. And they would be like, OK, do I need to do surgery right now or do I need to do interventions? It's the history, it's the symptoms, it's the functional history of the patient that would tell you how much you want to intervene, because more than half of these patients would have their herniated disc resorbed within one year, which means if you repeat the MRI in a year, you would see the herniated disc went back to its place and you'd be like, what happened? I just saw that disc kind of herniated out of its place and now it's back. Yeah, it got resorbed. So it's really a question and a collaboration between you and the neurosurgeon, how much this has affected the patient's function and when would you intervene surgically to correct that? So what are the risk factors for low back pain? This is where your history comes in. This is where the art of taking more information comes in. We all know that the older we get, the worse it's going to be in terms of low back pain. It sounds like according to this study women are more prone to have low back pain than men. Of course we know the health issues and concerns when it comes to obesity and smoking and I can tell you no good surgeon is going to operate on a patient that is actively smoking. So having that counseling education with your patient before even considering surgical intervention would be ideal because they might not need surgery but at least you prep them for a better healthy lifestyle and if they need surgery no one is going to operate on them if they're actively smoking. Of course depression and anxiety and somatization disorder plays into factor. We all know that when you take the low back pain history it's important for you as a physiatrist to mention red and yellow flags of low back pain. We are all familiar with the red flags of low back pain including but not limited to fever, night sweats, weight loss, prolonged steroid use more than 10 milligrams for three months, bowel bladder symptoms, anesthesia and the list goes on and on. With yellow flags of low back pain you might need to go into the biopsychosocial model of care which means you're going to ask about their psychological factors, occupational factors, and social factors. You want to know how much stress they have in their life and I literally ask my patient do you find that your stress feeds into your low back i.e. does your low back pain gets worse when you have a stress in your life and I would say 90 the answer is yes and it kind of tells you that these patients are more prone to be to have flares. They are more prone to have a more multi-modal approach to back pain and they would benefit a lot from intervention behaviorally, therapeutically and interventionally. I don't hesitate to send them to the psychology or psychiatry and the way I put it on the table is like listen this is part of your care you have a lot on your plate we need to make sure that your recovery is smooth and for that I can't be the one man army I need the resources around me and one of them is psychology psychiatry care so you would have that room to say what you got to say when it comes to your stressful life events. Not all the patients agree from the get-go again we have the mental health stigma that is still running around but then by the second or the third appointment they go with it. What's the etiology of low back pain and when I say what is the etiology it's an unfavorable question because what are the etiologies of low back pain? It's multifactorial, it's when we as physiatry think of low back pain we think about neurological, muscular, skeletal, bone, tendon, ligament, joint, muscle, referred you name it all. So the the main three categories that I would highlight is the non-specific or mechanical low back pain and you have other like etiology of back pain with lower extremity symptoms and then you have systemic or visceral diseases. You have non-specific or mechanical low back pain that's more of a musculoskeletal strain or sprain that is 70 percent. You have the disc or facet degeneration that's 10 percent. These are the common ones I'll come to the less common later on. You have back pain with lower extremity symptoms when there is a disc herniation or spinal stenosis coming into picture and that's why it's important to know whether the back pain radiation goes above or below the knee because if it's below the knee that can consolidate the neurological component that predominates the manifestation. Not to exclude the disc and not to exclude the muscle or the facet joint but at least it gives you guidance on how to start. Systemic causes. You have neoplasia. This is the new kind of era in the geriatrics rehabilitation world when you have multiple myeloma and you find that clear MRI bone marrow edema manifestations. You have metastatic cancer. Sometimes you have a patient who was treated for breast cancer 10 or 20 years ago has been in remission and now presents with low back pain. One of the things that you would put and I'll talk later on on a protocol is in this population you're going to have a low threshold for MRI-ing him. Yes, you might start with x-ray but you wouldn't settle until you have an MRI that excluded metastasis. Of course, infection. There is a certain population that comes into play especially with IV drug use but it's not uncommon to have osteomyelitis and discitis in an uncontrolled diabetes or an immune compromise and that's where you're like also having a low index of suspicion. Less common mechanical low back pain causes. You have osteoporotic compression fractures, spondylolisthesis, your spine curve deviations, scoliosis, kyphosis, or traumatic fracture. When you have systemic diseases, don't forget you have your inflammatory diseases, ankylosing spondylitis, psoriasis, or in other words seronegative arthropathies. Don't forget again your other referred causes like endometriosis, nephrolithiasis, pylos, or perinephric abscesses, aortic aneurysm, or ulcers, and don't forget your bone-related pathologies such as osteochondrosis and Paget's disease. What are the referral pain patterns for low back pain? This is important to mention because as much as it's non-specific and it doesn't give you like a nailed answer on what exactly the etiology is, it kind of gives you a guidance when you would proceed. What I mean by that, if you have a root pain and when you do your dermatomal and myotomal examination, you kind of know that this type of pain distribution goes with L4, L5, or L5-S1, especially when you do dermatomal and motor weakness. You're not doing the reflexes all the time, especially the cremasteric for your typical low back pain, but it's also to mention it's important to do your achilles and patellar tendon reflexes. I do the hamstring reflexes where I'll put my hand on the insertion of the adductors and tap on my hands. If they have increased reflexes, their legs would jump, but it's not uncommon to do that. It's not very common to do that. Again, this is kind of repeating myself. You need to know the difference between radicular pain and radiculopathy. This is more or less, if you're doing an EJ exam, this is going to be a bread and butter, but you've got to keep that at the back of your mind when you do an exam on back pain patients. Some core muscle referred patterns. I use this a lot when you have your mechanical low back pain and the patient is a good candidate for trigger point injection of the lower back, especially the quadratus lumborum. Because again, when you consider low back pain management, and I'm going to get to the details of the multimodal approach, you're going to consider therapy, medications, interventions, whether trigger point versus the set joint versus epidural steroid versus the new upcoming spine stem. One of the things you might consider as a, I would say, a temporary relief or a band-aid is trigger point injections and quadratus lumborum is very important to mention with that regards. You have the SI joint referred pain. It's important to note that SI joint pain should be excluded in any rheumatological, especially in ankylosing spondylitis related causes, and sometimes patients would have these early degenerative changes, especially women after pregnancy. When and what do I order for imaging? So I'm going to pause here and I want to hear the audience because I'm pretty sure they would be asleep by now. When would you order imaging and what would you order as a start? You can type, you can scream, whatever works for you. After three, four weeks of physical therapy, no improvement. Okay, that's good. And would you order normal imaging or would you go ahead to MRI? X-rays. Okay, I like that stepwise approach. Perfect. So this is, again, I'm a Canadian trained, this is Choosing Wisely Canada for imaging in a non-urgent versus urgent manner. I totally agree with my awesome colleague that you would start first with the basics, the x-ray. The non-urgent ones, when you start a six-week course of therapy, including two weeks of NSAIDs, and they're still having unremitting pain, radiculopathy, or candidates for surgery or intervention, you suspect spinal stenosis, but there are no red flags as of yet. When would you kind of pick up the phone and call the radiology department and you're sending the patient as soon as possible? When there is cauda equina, when there is unexplained fever, weight loss, when there's clear focal neurological deficits. Now some patients would have some giveaway pain or general neurological deficits or proximal weakness. It doesn't follow any dermatome or myotome distribution, so be aware of that. In that case, it's your judgment how much urgent you need these images. You have immune suppressed, history of cancer, IV drug use, osteoporosis, or prolonged steroid use, and you suspect a compression fracture. In that case, yeah, you really need to act quicker in an urgent manner and ask for imaging. Again, in cases of progressive neurological findings, there is a malignancy or infectious risk, or there is sort of a radiculopathy. You might want to consider MRI as a modality. With that said, you might, with the rest of the non-urgent, you might consider plain radiographs. And generally speaking, most of the radiology departments would not allow you to do MRI until you do plain x-ray, so you might want to go with that ahead. But in terms of urgent, as long as you justify your rationale, nobody can fault you for that. Whenever I review the image findings with a patient, I keep telling them I treat patients, I don't treat images. If I would image all of us in the room, I would say 90% of us would have herniated discs. I hope not, but I wouldn't be surprised that would be the case. And as long as we're functional, we're walking around, we're not having low back pain, I'm not going to treat that. I'm going to treat it when it's like affecting their function and quality of life. And when there is something, I would say a red flag, they'll be like, okay, we need to do something about it. But generally speaking, when a patient walks in having their MRI CD, telling me, Doc, look at my MRI, there is a huge herniated disc. I'm like, let's pause on looking at your CD. Let's focus on you as a person, as a human. What are your symptoms and manifestations? Let me know your function and your quality of life. And then we can talk about imaging. So back to the case, I think we have a clear idea where we're heading with our 50 years old gentleman with non-specific low back pain, not clear whether it goes beyond the knee or not. And there is a history of hip impingement. What would be your diagnosis? I'm sorry, I'm going to give, I'm kind of giving you some hints here. What will be your diagnosis here? You can type it, you can scream. I just want to hear your voices. I still think it is hip. You still think it's hip? I like the stuff you are. Okay. Well, here's the thing. It's a degenerative disc disease. So you're kind of correct because his hip would be degenerated as well. But basically, and again, I kind of agree with you because if he had a history of CAM, a hip impingement, there would be definitely some degeneration going along. So I'm going to make it broad and big and say degenerative disc disease, but I'm going to focus more on the back at this time. So when you explain the degenerative disc disease to a patient, you would say the process in which the discs of the spine kind of shorten in their length, losing their flexibility and shock absorbing characteristics. And that's why you would have, in a layman language, I would say it's, I would say aging process, being careful that not everybody would like to hear the word aging. This is important to mention that just for your knowledge, you have the nucleus pulposus and the annulus fibrosus, the amount of water in the nucleus pulposus is kind of shrunken as we age and that's why you have shrunken spine and that's why they compress on each other and that's why the discs get bulged and we get herniations. What are the common diagnostic image findings? It's important, I have a full faith on my radiology colleagues, but I also look at the images on my own and make sure that I see the osteophytes, the irregular facet joints and the narrow disc space because looking at that on my own, correlating my clinical findings with the imaging would help my management plan. This is another MRI finding showing the bulge in narrow discs and the osteophytes and some irregularities around the discs. How do I manage low back pain? This is, this is what I show my patients all the time and I start with education. It's not going to be, and I tell them, it's not going to be a fix. I'm sorry. Okay, I would assume that was a kind of external noise. Okay, so I'm not going to tell them it's going to be a fix in a dime. You will have some time, you will have ups and downs, you will have good days and bad days and it's important to have that education to your patients because guess what, once they hear you in the history, they might give you a call in two or three days time saying, oh, my back pain didn't improve. Like we said, we're going to have some good days and bad days. Let's wait for a couple of days. Let's wait for implementations. We as humans want a quick fix, but in low back pain, there is no quick fix to that. It's going to take a while to break that cycle. You will do your biomechanical assessment, you will do your rehab, referring to therapy, in physical therapy. It depends on the therapist you have. Some of them are good at McKenzie exercise protocol and core strengthening, some are not. So you really need to have that rapport with your therapist to know what they know and what they don't and advise on what they need to be aware of in the world of low back pain. Medications, we'll talk about the evidence-based one as well as interventional procedures and surgery. Unfortunately, sometimes when you see patients as a physiatrist, they have skipped all the stages of this cycle and they ended up in having surgery. And they come to you with, I don't want to label them with failed back surgery syndrome. It's now the new terminology called persistent spine pain syndrome or PSPS, which it's two sides of the same coin. But then at the same time, you're not starting from scratch with proper education. You're starting from a surgery that was unnecessarily done or done but incompleted, but we could have had better outcomes if we started with the non-interventional approaches. So unfortunately, that's the reality of the world we're living in, of the low back pain. And having that rapport with your therapist, with your community, and with your surgeons, whether they are neurosurgeon or ortho, is very important to make sure that you're getting the referrals at the right time and it's not too late. This is the planned approach of low back pain. I'm happy to share this kind of approach in a different PDF if that's not clear. Or generally speaking, most of the time, if we start from this far left in the slide, you will deal with 60% of simple low back pain, whether your patient is age 50 or under with no red or yellow flags, you will propose therapy, and if it's not improved, you will definitely do plain films. I would add to add ESR and CRP, and then if they don't improve, consider MRI. Now, I started implementing this approach early on in my career, and I had one patient who was low, her age was less than 50. She had no red flags, she had no yellow flags. She was a marathon runner, and she had this low back pain, and she had her X-ray and her ESR. Her X-ray was normal, but our ESR was high to the sky, and with MRI, it showed discitis. Now, she had no risk factor, so it's not common that you see it, but you have to keep a low threshold, and doing X-ray and ESR kind of protects you not to miss any discitis. She ended up having antibiotics for a while, but the fact that we detected that early on was very helpful. One third of your patients would present with complicated back pain, where they are all, they have systemic issues, some red flags. You're gonna make sure that the cancer is ruled out of the table, and then you have to, if that is ruled out of the table, then you might consider, again, plain films and X-rays and ESR, CRP, and you start first with non-interventional approaches, but you're gonna keep a close eye on them. My low back pain patients are similar to my concussion patients. Frequent follow-ups, small, short, brief visits, what happened, what things have been done good, what can we do better, and go from there. There is a certain component of them, whether with radiculopathy, that you would need more, as well, close monitoring. You might need to add MRI and EMG early on. Some neurosurgeons would not operate until you do EMG, which is, I kind of support that, but it really depends on your resources and what is available at your place. Some of them definitely are urgent, and you really need to knock the neurosurgeon's door in cauda equina situations. What are medications options? So just to keep you in the loop, I wanna hear some medications. So can some of you throw some medications here and there? What medications you folks are using? You can type it, you can shout it out, And gang, I need to hear your voices. And sex. Okay, perfect, perfect. I hear nephricine, cyclobenzaprine. And muscle relaxants. You got it, you got it. Okay, what else? Let's go with the second step of the ladder. What are like your high yields or the ones you'll be like, I might prescribe, but I'm very reluctant. I think we all know what I'm talking about, but I'll move forward. Opioids, you nailed it. Okay, perfect. I like that. Somebody like knows what I'm thinking about. Okay, let's go first with the non-pharmacological approaches. Now, most of them are a level two B evidence. So there is some moderate benefits behind that. And again, in our world where we use the multimodal approach of pain management, we use it most of the time. Like this is your number one to go to. Because again, it's not one intervention that will be the full and final word. You have to keep in mind that the more you feed into the low back pain interventions, the better. Not excessively, you have to have that balance, but acupuncture, physical therapy, massage, cognitive behavioral and spine manipulation, as well as yoga. I might step aside when it comes to spinal manipulations. I have some hesitancy around that. Again, not everybody would agree with me, especially the DOs. It depends on whom they are following for spinal manipulation and what exactly the manipulation is. Because sometimes in low back pain, they go through some aggressive manipulation and they end up having fractures. So this is according to the American College of Physicians and the American Pain Society. I know it's not a new study, it's a bit old. I'll get to the newer studies in the next two slides, but it hasn't got any different to be honest. They're all saying the same verbose when it comes to the same medications. You start first with NSAID and acetaminophen. There is a good moderate evidence that NSAIDs are good. However, when you consult the patient, make sure that you evaluate their GI, their renal and their cardiovascular risk factors. There is some benefit on opioids, but I can tell you the truth. At the time when I get to the opioids as the potential management plan, I get to a pain specialist because at that time, I think as a physiatrist, it's a lot on my plate to evaluate for the risk of addiction, do their opioid evaluation, check through the DEA, their consumption, do the urine test, the spectrometry test. There is a lot and I think at that time, I can't be the one man army. I need somebody with me to protect the patient, to protect me and to protect my organization. I know some would disagree, especially the pain specialist would definitely do it on their own. But again, it's the level of your comfort zone that you're dealing with opioids. It's very individualized. This is my personal approach. Antidepressants, there is a mild evidence for amitriptyline and SNRI for radicular pain. Be aware of Cymbalta, sometimes it can get nasty. Sometimes it works well and people swear by it. And sometimes it works very nasty and you have to have that sort of a discussion with the patient on the side effects and how to proceed. There is a recent Cochrane review that was published a week ago. And again, they went through the acute low back pain and the chronic low back pain. It's not any different to be honest than the study that was done in 2007. You know Cochrane, it's hard to get something different than what is available in the market. So in acute low back pain, you have moderate certainty that NSAIDs and muscle relaxant will provide small effect on pain, but there is no difference between paracetamol and placebo. And in chronic low back pain, opioids might provide a small effect on pain, but you have to weigh your risks. And again, you know that by approaching 50 morphine millicovalent, that's where you're like, no, I need to be cautious about that. There is also a new study that was published in 2020 with collaboration between the American College of Physicians and the American Academy of Family Physicians. They had three recommendations, simple and easy. You have to use NSAIDs with or without menthol gel, and there is no difference between paracetamol and placebo. Oral NSAIDs can be used to reduce or relieve symptoms and acupressure to reduce pain can provide some relief. The last recommendation goes against the use of opioids, including tramadol. That's something I want to highlight because most of our patients, when they go to the ER, they're given tramadol. And you can say that tramadol is a partial opioid agonist, and it does have opioid at the end of the day. So they might be at risk of being or getting used to it. And they might come to your clinic saying, hey, I got better with tramadol, can you re-prescribe or refill it? In that case, it depends on your comfort zone, whether you want to continue that cycle and having the risk of that patient being addicted to opioids or not. In my situation or personally speaking, I had to deal with a lot of tramadol refills from the ER. And my answer would be, no, I'm not doing it. I need a full evaluation of your low back pain. I need to start from the non-opioid. If I need to go to opioids, then I need to send you to a pain specialist because that's not going to be just tramadol. We're going to perk it up to oxycodone and something else. And I don't want to be alone in that situation. What are the procedures I can use for low back pain? Again, the common ones, the PASET joint injections, whether it's cervical, thoracic, or lumbar, radiofrequency ablation. If they had good benefit from medial branch block, you have epidural steroid injection, whether it's intralaminal, intralaminar, caudal, or transforaminal. You have disc-related procedures, diagnostic through the IDET, kyphoplasty, or injection of the SI joints or the symphysis pubis, yeah. We use the arm fluoroscopy and ultrasound, or ultrasound, I should say. Again, there are many rationales behind using a device or a tool. I'm going to go through proper diagnostic and therapeutic procedure, increases accuracy. There is a direct delivery of therapeutic kind of approach. It's a joy for you as a physiatrist when you see the needle hitting the right spot. It's something that's, I would say, priceless. And it gives you that sort of a satisfaction on how good you are. At the same time, it kind of protects you between you and me under the table that, hey, I used the right approaches. This is the evidence I have that I used, that I hit the right landmark. And it's minimally invasive. You're not doing surgery. It's CR fluoroscopy versus ultrasound. You got to be careful though, because ultrasound is not always having that depth that you want for low back. So either or, pick your battles on what you can use. The goals of interventional pain is a similar goal for any low back pain management plan. It's improved pain function and quality of life. You have to ask the patient about their function and their follow-up. You have to make sure that it helps. Some of the patients would say, oh, they might come to you already had that interventional pain and how they have not got the benefit from. And in that case, you have to divert your approach, whether you want to be more of a non-interventional versus if the surgery is indicated where we are with that. This is very individualized. And that's why you start by taking the history from scratch. Any questions so far? Should I carry on? Okay, I am going to carry on. So what are the potential complications of interventional pain management? This is important to mention in any consent when you do with your patient. I do it even when I do a simple procedure like trigger point injection. So there is a risk of bleeding, infection, nerve injury. Again, in epidural steroid injection, the risk of uterine puncture, the adverse reaction to the anesthetic or steroid agent. There is the risk of cardiovascular compromise. Again, it really depends on the procedure you're doing and how invasive, but you have to mention that. It's also important. This is a slide that is important for your oral boards if you're doing it, because it's not uncommon to ask about these potential complications. Not that I'm a board examiner. It's the way that kind of you expect the oral boards would go. Now, minor complications, pain, vasovagal reaction. Not uncommon in my setting that the patient would have vasovagal reaction. Not to panic, not to do anything. Just ask, calm the patient down, check their vitals, have them rest. Make sure that your crash cart is close by. Not that you're gonna use it. It just kind of gives you that, okay, I have everything beside me. Post-injection flare. You tell your patient, take it easy for this day. Wait for three days. But if you notice anything out of the norm, call us or go to the ER. And again, you have side effects from the steroids. In your patients with diabetes or hypertension, you tell them that because you have injected steroids, they might see an increase in their blood sugar or blood pressure for the first three days. So they should keep an eye on that. What are the contraindications of interventional pain management? Again, if they have active infection, they have a bleeding disorder with poor anticoagulation. Now, anticoagulation itself is not an absolute contraindication, but if they have an uncontrolled warfare and sub-therapeutic, supra-therapeutic, then you get away your battles. Allergy to the medication you're being injected. In pregnancy, again, it depends on the injection. You're not gonna contraindicate it in a simple ones. Relative contraindication, uncontrolled hyperglycemia, adrenal suppression, immune compromise, active congestive heart failure, and again, sometimes in pregnancy. Radiofrequency ablation, because here's the case. You do the medial bundle branch block. I'm not gonna go through the details of how you would approach the medial bundle branch block or radiofrequency ablation. That's a whole fellowship training program that are designed for it. But I would say that if they benefit from a medial bundle branch block, you would go for radiofrequency ablation. Again, getting back to the cycle, you go through this all back and forth. And again, it's a stepwise approach. They might benefit from therapy from the get-go, but they come up with a flare. You need to start them on a medication, they get better, and then they need intervention. So it's a very fluid or dynamic approach to manage these patients. It's not that one intervention would help or keeping that intervention every single time same would help them. You might need to tweak your approach based on the way they respond. One of the emergent technologies that is gaining popularity is spinal cord stimulator. There is a lot going on in terms of the mechanistic theories. The simple layman language that you tell your patient is like the main resource or the main source of your pain is the spinothalamic tract. So the stimulator will block it and will predominate the brain inhibitory function. So the brain tries to calm you down. And that's why you have that proper pain management. Of course, you can add to that the neurotransmitters or neurohormones that would calm the pain down, especially the serotonin. This is a big slide. You don't have to worry about it. Generally speaking, spinal cord stimulator has been very approachable, has been used in a lot of pain-related syndromes. The low back pain is the most common one, but it's not uncommon to see it in brachial neuritis or in phantom pain. Honestly, I never used it in phantom pain because most of the time they have neuroma and you kind of do a nerve block and you go with it, but it's not uncommon that you have a low back pain that would benefit from spinal cord stimulator. There is a certain population that cannot be fitted to the spinal cord stimulation, especially if they have active sepsis, bleeding disorder that is uncontrolled or infection that is uncontrolled, and certain myelomeningocele or spina bifida where you know that there is a defect in their spine that you cannot risk by implanting a stimulator. That's pretty much of my presentation. I hope you got the maximum benefit out of it, and I am happy to answer any questions. Any questions through the audience? I can, let's see. Yeah, of course. Thank you for attending. Is there any way you can share the slides? So I'll be very honest with you because some of these slides were from my mentors. I emailed them asking and some of them said no. So I might ask the AAPMNR organizers to share some slides but after deducting the mentors who said no, I do apologize. Sometimes it's out of my control but I can definitely share what I can. And just to remind everybody that recording for this session will also be available on our learning portal. So you can always access that. Thank you. And please don't forget to fill out the evaluation after you'll get CME credit from attending the session once you do. Alrighty, so if there are no questions, I think we are ahead of the time. Is that correct, Mona? Yes, yeah, we're ending early, seven o'clock. Perfect, I really can't complain. Unless somebody wanna share one of their life experiences with back pain and we can learn from each other, I'm happy to stick around. Alrighty, sounds like everyone wanna run for five. So I'll leave you be. Thank you so much for attending. And yeah, we'll see you in the future AAPMNR assembly. Take care, everyone. Thank you.

Dr. Zainab Ullawadi

physical medicine and rehab specialist

low back pain

case-based approach

interactive approach

differential diagnosis

non-pharmacological approaches

pharmacological approaches