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Many patients with acute and chronic low back and neck pain are treated by spine surgeons or other spine specialists. In most instances, patients are treated with rehabilitation, spinal injections, and/or medications. Only a small proportion will eventually require surgery, and even these patients will benefit from early and well executed rehabilitation medical care. Therefore it is apparent that the modern spine specialist, whether surgeon, physiatrist, pain specialist, or other practioners must be familiar with the current state of the art of rehabilitation, interventions, and medical spine care (RIMS). For some, RIMS was not an integral part of their training. Others may not have had the time to keep up with the current evidence for RIMS care.

This course will bring all practitioners up to date with current recommendations. We present the preferred RIMS options for the treatment of patients with acute and chronic low back and neck pain. Our faculty explores the options, rationale, and evidence for RIMS at each stage of spine illness. We review the natural history of back and neck pain. We show that most patients with recent onset spine pain can be treated without a specific diagnosis by using the history and physical examination. For patients who are not improving, we provide the evidence regarding the most efficient use of imaging and diagnostic injections. We describe the best way to write a physical therapy prescription based on either patient’s structural pathology or directional preference. We show how to evaluate the patient at follow-up visits to ensure proper therapy was administered. We explain the appropriate use of spinal injections and medications for pain as an adjunct to assist the patient through rehabilitation. We describe the roles of fear and fear-avoidance behavior and other psychological factors that may contribute to pain and especially to impairment and disability. Finally we discuss the rehabilitation process before and after spine surgery to maximize the opportunity for the best outcome.

This course includes videotaped podium presentations in conjunction with audio and slide lectures.  A post-course evaluation and assessment questions will be given to help reinforce your knowledge.

Course Chairman:
Jerome Schofferman, MD

Faculty:
Michael DePalma, MD, Ron Donelson, MD, Michael Geraci, MD, PT, Carol Hartigan, MD, Heidi Prather, DO, Joel Press, MD

Agenda:

Introduction – J. Schofferman
Acute Low Back Pain: Debate

• Directional Preference Is Important – R. Donelson
• Exercise and Acute Low Back Pain – J. Press
• Basic Directional Preference Exam – R. Donelson

Acute LBP: Medications – J. Schofferman

• NSAIDs
• Muscle Relaxants
• Opioids

Subacute Low Back Pain: What Do We Do Now? – J. Press
Monitoring Physical Therapy Progress – M. Geraci
Subacute Low Back Pain: Injections to Facilitate Rehabilitation – M. DePalma

• Epidural Injections
• SIJ
• Facets: Intra-articular

Psychology for Spine Doctors – J. Schofferman
Functional Restoration for Chronic Low Back Pain – C. Hartigan
Poorly Responsive Low Back Pain: Rehabilitation – H. Prather

• SI Joint
• Hip and GTPS
• Pregnancy and Post-partum

Chronic Low Back Pain: Therapeutic Injections – M. DePalma

• Epidural
• SIJ:  IA vs. RFN
• Facet joints: RFN

Pharmacological Management of Chronic Low Back Pain – J. Schofferman

• Opioids
• Anti-convulsants
• Anti-depressants

Specific Rehabilitation: Spinal Stenosis – J. Press
Specific Rehabilitation: Disc Herniation – R. Donelson

This course was originally presented to a live audience at the NASS 24th Annual Meeting in San Francisco, CA, on November 10, 2009, and has been adapted for online presentation. 

Continuing Medical Education (CME) Information
This activity has been planned and implemented in accordance with the Essential Areas and Standards of the Accreditation Council for Continuing Medical Education (ACCME). The North American Spine Society is accredited by the ACCME to provide continuing medical education for physicians and takes responsibility for the content, quality and scientific integrity of this CME activity.

The North American Spine Society designates this enduring material for a maximum of 3.75 AMA PRA Category 1 Credit(s)^TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The American Medical Association has determined that physicians not licensed in the US to participate in this CME activity are eligible for AMA PRA Category 1 Credits™.

This course was released on 7/1/2010, and is available for purchase through 6/30/2013.

Appropriate Audience
Orthopedic surgeons, neurosurgeons, radiologists, physiatrists, pain management specialists, anesthesiologists, psychologists, chiropractors, physician assistants, nurse practitioners, nurses, physical therapists, researchers, administrators and all other health care professionals with an abiding interest in spine care.

Learning Objectives
Upon completion of this course, participants should be able to:  

• Appraise the value of evidence-based RIMS care to achieve best patient outcomes.
• Assess the value of evidence-based RIMS care as a means to build a more successful surgical or rehabilitation practice.
• Prescribe and then monitor rehabilitation for best outcomes.
• Describe the latest evidence and controversies regarding the best medication management to supplement rehabilitation.
• Determine when, which and why therapeutic injections might be most appropriate at each stage of spine pain.

Conflict of Interest Disclosure
All faculty provided estimated dollar amounts per the NASS Disclosure Policy through the NASS online disclosure module. NASS staff then translated that information into dollar ranges for purposes of this index, as well as for presentation at the live course.

These ranges are as follows:

• None: Existing relationship but no remuneration in prior calendar year
• Level A: $100 to $1000
• Level B: $1,001 to $10,000
• Level C: $10,001 to $25,000
• Level D: $25,001 to $50,000
• Level E: $50,001 to $100,000
• Level F: $100,001 to $500,000
• Level G: $500,001 to $1M
• Level H: $1,000,001 to $2.5M
• Level I: Greater than $2.5M

DePalma, Michael J.: Stock Ownership: AOI Medical (4000 shares/<5%); Consulting: AOI Medical (None), Kyphon/Medtronic (B), Stryker Interventional Spine (B); Speaking and/or teaching arrangements: Lilly (None), St. Jude Medical/ANS (None); Trips/Travel: International Spine Intervention Society (A); Scientific Advisory Board: Kyphon/Medtronic (B); Research Support (Staff/Materials): Stryker Biotech (B); Grants: Genzyme Biosurgery (B); Fellowship Support: St. Jude Medical/ANS (C); Other: Demos Publishing (None).

Donelson, Ron: Nothing to Disclose.

Geraci, Michael C.: Nothing to Disclose.

Hartigan, Carol: Nothing to Disclose.

Prather, Heidi: Nothing to Disclose.

Press, Joel M.: Consulting: Spine Advisory Board (A, paid to institution); Scientific Advisory
Board: United Health Care (Consulting disclosed).

Schofferman, Jerome: Board of Directors: American Academy of Pain Medicine (None); Fellowship Support: Nuvasive (D, paid to institution), Medtronic (E, paid to institution, relationship dissolved 12/31/09).

Disclosures are current as of April 27, 2010.

Technical Requirements
The following hardware/software specifications must be met or exceeded to complete this course:

• Web browser and internet connection
• Computer equipped with audio output (speakers or headphones)
• Printer (to print PDF handout)
• Internet Explorer 7 or higher
• Adobe reader 7 or higher
• Microsoft Silverlight (if you do not have the program on your computer, you will be prompted to install it)
• Disable pop-ups

Disclaimer
The material presented is made available by the North American Spine Society for educational purposes only. The material is not intended to represent the only, nor necessarily the best, method or procedure appropriate for the medical situations discussed; rather, it is intended to present an approach, view, statement or opinion of the faculty, which may be helpful to others who face similar situations. NASS disclaims any and all liability for injury or other damages to any individual attending the meeting and for all claims which may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by physicians or any other person.