(21F) Rehab patient with Low Back Pain and Neck Pains

Dr. Judah Leo G. Capistrano, MD, DPBRM, FPARM| May 12, 2017
FINALS QUIZ 2
THE PATH OF PAIN o Release of chemicals that inhibit pain transmission
11 POINTS (SCI), 4 OR 6 (STROKE), 3 OR 4 (NECK PAIN AND LOW BACK PAIN)
OUTLINE PAIN FIBERS
PAIN PATHWAY Fibers
Pain is perceived through afferent o Primary afferent
nerves A non-noxious
o Primary afferent nerve (Site of A-delta noxious, rapid, sharp, localized; mechanical, thermal
injury/skin area/ organ tissue C fibers noxious, slow, dull, non-localized; mechanical, thermal
Nucleus at dorsal root ganglia) and chemical
Synapses with secondary neuron o Secondary afferent
ascends to the spinal cord then Spinothalamic tract
to the brain Spinoreticular tract
o Tertiary afferent nerve (Thalamus o Third order neurons
Cortex) Somatosensory cortex (S1, S2)
Perception of pain Pre-frontal cortex
o Fast myelinated D fibers (More Periaqueductal gray matter
myelinated Faster and more localized pain) Pain medications act on certain target areas
Dorsal root ganglion o Site of inflammation (Release of pain substances like kinins and leukins that
o Preganglionic (Affects the primary afferent neuron) Sensory signals are trigger pain) Medications counteract the effects of these substances
not intact o Decreased sensitivity of nerves
o Postganglionc (At the SC or brain) Signals can still reach the DRG but no o Blocks transmission to the SC
signal goes up to the brain o Acts on the brain (Ex. Opiods)
GBS (areflexia) vs SCI (hyperreflexia)
PAIN CLASSIFICATION
PAIN PROCESS Nociceptive vs. Non-nociceptive
Transduction Acute (<2 months) vs. Chronic (>2 months)
Conduction o Hyperacute (within few hours or few days)
Transmission Somatic vs. Visceral
Perception Neuropathic (arising from the nerve itself; due to compression of the nerve or
Modulation demyelination)
o Facilitation vs. Inhibition o Burning, numbness or shooting type of pain
Pain= unpleasant stimuli that is a potential source of actual damage to tissues Central Sensitization
Mechanical/ Chemical / Thermal Injury (Transduction) Converted to electrical o Synaptic membrane adaptations
stimulus Conducted to afferent nerve fibers SC (transmission of synapse) o Increased membrane excitability, synaptic facilitation and disinhibition
Cerebrum (Sensory centers where it is perceived as pain) Modulation o Brain adpats to a certain pain Heightened response to prolonged pain
(Response from the brain which either facilitates ot inhibits stimulus) Hyperalgesia or Allodynia (Nonpainful stimulus triggers pain
Gate control theory
o Signal of pain can be competed by adding a non noxious stimuli that blocks PAIN MEDICATIONS
the signal of a noxious stimuli Steroids (at the site of trauma, SC)
o Effect (Numbness/ Decreased pain perception) NSAIDs, Paracetamol, COX inhibitors
Descending Inhibitory Pathway Opioids (SC and brain)
 Antidepressants (TCA, SNRIs, SSRIs)
Anticonvulsants (GABA Analogs, Benzodiazepines, Barbiturates) (SC and brain) Mild pain (Visual acuity = 1-3)
Anesthetics (peripheral nerves) Moderate pain (Visual acuity = 4-6)
Sometimes it is necessary to combine medications for chronic pain Severe pain (Visual acuity = 7-10)
Start with NSAIDs or Coxibs
Adjuvants (Not necessarily pain relievers but helps relieve the pain) Muscle
relaxants, Vitamin B

PARACETAMOL
Acetaminophen / APAP
N-acetyl-p-aminophenol
Antipyretic
Weak (aniline) analgesic
Weak anti-inflammatory (COX inhibitor)
Recommended maximum daily dose: 4g

TRAMADOL
Centrally-acting atypical opioid analgesic
WHO RECOMMENDATIONS
Serotonin-norepinephrine reuptake inhibitor

21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
Weak mu-opioid receptor agonist
5-HT2C receptor antagonist
Drug interactions:
Serotonergics, certain analgesics, and anxiolytics
Long-term use of high doses of tramadol may be associated with physical
dependence and a withdrawal syndrome

TRAMADOL + PARACETAMOL

MILD PAIN: MODERATE PAIN: SEVERE PAIN:

Non opioid Weak opioid Strong opioid +/-
+/- adjuvant +/- non opioid non opioid +/-
+/- adjuvant adjuvant

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 TRAMADAOL + PARACETAMOL

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21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
 Side Effects o Herpes zoster
o 4.2% - 57.6% (24% in most studies) o Infective endocarditis
o Dizziness, nausea, constipation, vertigo, headache, vomiting, somnolence o Granulomatous process
o Seizure, bradycardia, hepatitis o Epidural, intradural and subdural abscess
Safety and Tolerability o Retropharyngeal abscess
o In some studies, up to 8 tablets a day for 3 months o AIDS
o Not recommended for children (<18 y.o.) and pregnant/breastfeeding ENDOCRINOLOGIC and METABOLIC
women. o Osteoporosis
o Generally safe for patients with cardiovascular risks; patients with o Osteomalacia
moderate renal impairment o Parathyroid disease
o Safe for geriatric patients o Paget disease
o Pituitary disease
CONCLUSION TUMORS
Understanding the pain pathway is helpful in deciding treatment options for o Benign Tumors
our patients Osteochondroma
The WHO step-ladder for pain recommends the use of opioids +/- non-opioid Osteoid osteoma
analgesics, adjuvants for moderate to severe pain Osteoblastoma
Tramadol + Paracetamol is an effective add-on treatment for osteoarthritis Giant cell tumor
Aneurysmal bone cyst

21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
NECK PAIN REHABILITATION Hemangioma
DISORDERS AFFECTING THE NECK Eosinophilic granuloma
MECHANICAL Gaucher disease
o Cervical sprain (Tear in ligaments which is seen in Xray as calcified nuchal o Malignant Tumors
ligament Very prominent anterior ligament due to chronic overstreching Multiple myeloma
Repair Deposition of calcium) Solitary plasmacytoma
o Cervical strain (Musculotendinous overload injury) Chondrosarcoma
o Herniated nucleus pulposus Lymphoma
o Cervical radiculopathy Metastasis
o Osteoarthritis o Extradural Tumors
o Cervical spondylosis Hemangioma
o Cervical stenosis Lipoma
RHEUMATOLOGIC Meningioma
o Ankylosing spondylitis Neurofibroma
o Reiter syndrome Lymphoma
o Psoriatic arthritis o Intradural Tumors
o Enteropathic arthritis Extramedullary, intradural
o Rheumatoid arthritis Neurofibroma
o Diffuse idiopathic skeletal hyperostosis Meningioma
o Polymyalgia rheumatica Ependymoma
o Fibrositis (fibromyalgia) Sarcoma
INFECTIOUS Intramedullary
o Vertebral osteomyelitis Ependymoma
o Diskitis Astrocytoma

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 OTHERS Normal: Rectangular bone without sharp edges
o Arteriovenous malformations Spondylosis: With sharp edges (Osteophytes or spurs), Narrowing of spaces
o Syringomyelia between bones due to thinning of disk
Disk dessication: Drying up of the disk
COMMON NECK DISORDERS
DEGENERATIVE DISC DISEASE
CERVICAL STRAINS, SPRAINS and WHIPLASH
Cervical STRAIN: a musculotendinous injury produced by an overload injury
from excessive forces imposed on the cervical spine
Cervical SPRAIN: overstretching or tearing injuries of spine ligaments
o 40-50% of cervical axial rotation occurs at C1-C2 atlanto-axial joint Annulus fibrosis (Concentric rings) If this dries up the nucleus pulposus leaks
o Greatest amount of flexion occurs at C4-C5, C5-C6 Can be a source of pain because the outer layer of theAF is richly innervated
o Lateral bending occurs primarily at C3-C4, C4-C5
CERVICAL SPINAL STENOSIS
CERVICAL WHIPLASH INJURY More prominent UE affectation
Acceleration-deceleration injuries / Whiplash injury
o S-shaped curvature approximately 100 ms after a rear-end impact
Tear of the annulus fibrosus of the intervertebral disc
Tear of the anterior longitudinal ligament

21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
Articular pillar fracture VERTIBRO-BASILAR INSUFFICIENCY
Fracture involving the the articular surface Symptoms: Dizziness (VB system
End plate avulsion/fracture supplies the cerbellum) and
Contusion of the intra articular meniscus of the zygapohyseal joint Headache
Fracture of the subchondral plate
Vertebral body fracture
Rupture or tear of the zygapophyseal joint capsule DIAGNOSTICS
Hemarthrosis of the zygapophyseal joint CERVICAL X-RAY

75 ms to 100 ms = S shaped curvature of cervical spine

CERVICAL RADICULOPATHY and RADICULAR PAIN

CERVICAL JOINT PAIN, ARTHRITIS, SPONDYLOSIS

Normal: Cervical spine curvature
Straightening Due to muscle spasms
Oblique view to view the vertebral foramen

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CT SCAN Spondylolisthesis
Posterior column fractures
Anterior column fractures
Anterior and middle column fractures
Anterior and posterior column fractures
Osteoporotic compression fractures
Cancer
Spinal infections
MRI Spondyloarthropathies
o Ankylosing spondylitis
o Reactive arthritis / Reiter syndrome
o Psoriatic arthritis
Gouty arthritis
Lumbosacral radiculopathy
Lumbar spinal stenosis
Soft tissue disorders
1st image: Disk dessication Vascular disorders
2nd image: Spinal stenosis Peripheral nerve disorders

21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
3rd image: Syringomyelia Piriformis syndrome
4th image: Splitting ofthe SC Lumbosacral instability
Sacroiliitis
LUMBAR PAIN REHABILITATION Coccydynia
POTENTIAL PAIN GENERATORS OF THE BACK
INNERVATED STRUCTURES LUMBAR REGION
o Bone: Vertebrae
o Joints: Zygapophyseal
o Disc: Only the external annulus and potentially diseased disc
o Ligaments: Anterior longitudinal ligament, posterior longitudinal ligament,
interspinous
o Muscle and fascia
o Nerve root
NON-INNERVATED STRUCTURES
o Ligamentum flavum
o Disc: Internal annulus, nucleus pulposus

DIFFERENTIAL DIAGNOSIS
Nonspecific low back pain
Lumbar spondylosis
Lumbar disc disease
Internal disc disruption
Disc herniation
Spondylolysis

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 DIAGNOSTICS o Liniments
X-RAY o Bisphosphonates
o Neuroleptics

PHYSICAL MEDICINE
Physical Therapy
o Modalities
Heat
Cold
CT SCAN Electricity
Ultrasound
Shockwave
Microwave
Radiofrequency therapy
Stretching
Trigger point, myofascial release
Massage therapy
MRI Manual therapy
Strengthening exercises

21F MEDICINE 2: Rehab Patient with Low Back Pain and Neck Pains
Splinting
Taping
Bracing

INVASIVE INTERVENTIONS and SURGERY

Localized steroid injection
THERAPEUTICS
Ablation therapy
PAIN MEDICATIONS
o Paracetamol Prolotherapy
o Aspirin Accupuncture
o NSAIDs Dry needling
o COX 2 inhibitors Laminectomy
o Semi opioids Anterior decompression
o Opioids Discectomy
o Anticonvulsants Fixation
SUPPLEMENTS
o Vitamin B Alonzo I Mallari
o Vitamin D
o Calcium
o Collagen
o Glucosamine
o Hyaluronic acid
ADJUVANTS
o Muscle relaxants
o Anxiolytics
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