Axial LBP

[lobelsteve]

From NASS forums:


Dr C:
56-year-old female patient with chronic back pain (5 years); Has received multiple treatments, NSAIDs, opioids, facet infiltrations, without any improvement.Recently the laboratory HLA-B27 was positive, already sent to rheumatology. Patient persists with back pain, without radiculopathy.

Dear Dr. C:
IMO your patient has a significantly elevated lumbo-sacral angle,aggravated by her exogenous obesity and probable markedly diminished core strength,as well as absent paraspinous and abdominal muscle tone. Her MRI identifies fatty infiltration of the multifidus muscles in conjunction with thick subcutaneous fat in the posterior lumbar region and abdominal walls. I am not surprised her sxs have not resolved with all the treatment you listed. She needs to lose weight and exercise. Have her evaluated by a McKenzie trained PT or Diplomat,initially performing the MDT evaluation. If you review her parasagittal MRI images you can see that the exiting lumbar nerve roots are accompanied by normal perineural fat and vessels without any evidence of extrinsic pressure from disk material, as they enter and traverse the neural foramina. The problem is not her disks or facets. The problem is that she is simply stressing the lumbosacral region of her skeleton with her deconditioned state & obesity complicated by her elevated LS angle. I see this type of patient 4-5 times per year and stress that there is no operation that is going to resolve her problem. She must diet and exercise. Be prepared for push-back comments such as "Dr.,l can't exercise, because it hurts my back." "I can't use the treadmill or elliptical trainer." "I can't ride a stationary bicycle." My response is then do mat exercises and swim.
If she responds ,"I am not a good swimmer.",suggest the use of a water skier's vest and buoyancy belt to support the LS region. This type of patient may not return because she is looking for a "quick fix",more injections or opiates. Stand your ground . Do not be dismissive, but in a professional and concerned manner establish that unless she is willing to get invested in her spinal health, you have nothing else to offer. Suggesting she lose weight will not be new recommendations to her. This type of patient tends to "doctor shop" here in the U.S. and will be attracted to chiropractors and alternative medicine practioners, rather than following your advice.

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[pmrmd]

It would be nice if the proud author of that reasonse was known.

 

[DrCommonSense]

From NASS forums:


Dr C:
56-year-old female patient with chronic back pain (5 years); Has received multiple treatments, NSAIDs, opioids, facet infiltrations, without any improvement.Recently the laboratory HLA-B27 was positive, already sent to rheumatology. Patient persists with back pain, without radiculopathy.

Dear Dr. C:
IMO your patient has a significantly elevated lumbo-sacral angle,aggravated by her exogenous obesity and probable markedly diminished core strength,as well as absent paraspinous and abdominal muscle tone. Her MRI identifies fatty infiltration of the multifidus muscles in conjunction with thick subcutaneous fat in the posterior lumbar region and abdominal walls. I am not surprised her sxs have not resolved with all the treatment you listed. She needs to lose weight and exercise. Have her evaluated by a McKenzie trained PT or Diplomat,initially performing the MDT evaluation. If you review her parasagittal MRI images you can see that the exiting lumbar nerve roots are accompanied by normal perineural fat and vessels without any evidence of extrinsic pressure from disk material, as they enter and traverse the neural foramina. The problem is not her disks or facets. The problem is that she is simply stressing the lumbosacral region of her skeleton with her deconditioned state & obesity complicated by her elevated LS angle. I see this type of patient 4-5 times per year and stress that there is no operation that is going to resolve her problem. She must diet and exercise. Be prepared for push-back comments such as "Dr.,l can't exercise, because it hurts my back." "I can't use the treadmill or elliptical trainer." "I can't ride a stationary bicycle." My response is then do mat exercises and swim.
If she responds ,"I am not a good swimmer.",suggest the use of a water skier's vest and buoyancy belt to support the LS region. This type of patient may not return because she is looking for a "quick fix",more injections or opiates. Stand your ground . Do not be dismissive, but in a professional and concerned manner establish that unless she is willing to get invested in her spinal health, you have nothing else to offer. Suggesting she lose weight will not be new recommendations to her. This type of patient tends to "doctor shop" here in the U.S. and will be attracted to chiropractors and alternative medicine practioners, rather than following your advice.

I always find it amusing that clowns like Roger Chou et al. are now "recommending" as "high quality" treatments such as Acupuncture, Chiropractic or some other nonsense for these types of patients with lower yield being "injections or surgery".

Do you honestly ever see these people improve with any of this crap or CBT? I have literally NEVER seen it but maybe im biased. I get a CONSTANT stream of such patients who have failed all the above before they come to me and PT.

Also, I am almost never successful in getting them into weight loss programs or CBT programs that emphasize weight loss.

 

[IN2B8R]

Two words: gastric bypass.


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[DrCommonSense]

Two words: gastric bypass.


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Yeah I see these patients all the time but the problem that occurs is:

1) Multiple comorbidities develop after the surgery including dumping syndrome, adhesions requiring reoperations, poor digestion (especially after part of small intestine is removed) whereby they are nutrient deficient and abdominal pain.

2) These patients will often be in the 350-400 range before surgery and will drop to around 300 or so. They remain morbidly obese but less so immediately after surgery. After about 3-5 years, they are usually back up to about 350-400 because they figure out ways to get around the bypass including smaller sugary meals, pop tart diets, etc. The underlying psychological problem isn't solved.

I rarely see long term successful patients that are NOT morbidly obese 3-5 years later plus have zero other problems as a result of the surgery.

 

[Aether2000]

She will die in pain because of her intransigence regarding her health. Sometimes you just have to write them off

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[DrCommonSense]

Yeah I see these patients all the time but the problem that occurs is:

1) Multiple comorbidities develop after the surgery including dumping syndrome, adhesions requiring reoperations, poor digestion (especially after part of small intestine is removed) whereby they are nutrient deficient and abdominal pain.

2) These patients will often be in the 350-400 range before surgery and will drop to around 300 or so. They remain morbidly obese but less so immediately after surgery. After about 3-5 years, they are usually back up to about 350-400 because they figure out ways to get around the bypass including smaller sugary meals, pop tart diets, etc. The underlying psychological problem isn't solved.

I rarely see long term successful patients that are NOT morbidly obese 3-5 years later plus have zero other problems as a result of the surgery.

Also, not to beat a "dead horse" but I will often get many "pain patients with abdominal pain" after the bypass surgery as well.

Recently, I had a woman who had lost 100lbs after the bypass surgery but literally couldn't eat. She was in constant pain and wanted to get on opioids due to this pain.

The problem with the surgery is:

1) Never solve the underlying psychological/willpower issue that caused the patient to become obese.

2) Create environment of very poor digestive health by cutting out ESSENTIAL portions of the digestive tract (stomach +/- part of small intestine) that are CRUCIAL in digestive because the patient has a lack of willpower/psychological health to control eating. Essentially, you are creating an environment where the person is probably nutrient depleted for life with poor digestive health to get them to "lose weight".

3) Cost of surgery is 50K without complications (100s of K if/when complications arise). Maybe the benefit is they get off some diabetics meds or BP meds for a short period of time but not much else (usually cheap drugs). I don't see them consistently losing >10% of body weight 3-5 years out from the surgery. Initially for first 2 years or so after surgery they usually have DRAMATIC weight loss due to inability to eat at all but have many other problems during that period of time with digestion. Then they normalize their weight and usually gain a decent amount back with remaining poor digestive health.

If there was ever a surgery due to a mental disorder/will power disorder it would be gastric bypass surgery. You are literally cutting out someone's HEALTHY digestive system because they can't control their eating patterns.

I have seen studies that say they "lose weight over 3-5 years" with "better BP and blood glucose readings" but they all seem to be marginal in benefit without discussing the digestive health costs of losing part of small intestine and stomach.

No mortality studies have been done where bypass patients have been shown to live longer. The slight weight benefit/BP/BS is likely more than offset by nutrient depletion and other sequalae that develop from poor digestive health.

 

[IN2B8R]

I'd rather see them go through the gastric bypass while they are young and motivated to change their lives; otherwise, if they have already given up, they will surely regain their weight. Goes back to a simple thing called "patient selection."


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