Good morning, everybody. I'd like to go ahead and introduce Dr. Patel, he's a fellowship trained interventional and non-interventional pain specialist at the New Spine Institute. Dr. Patel has spent years helping patients resolve their acute and chronic spine and joint pain. He earned his bachelor's degree with honors in biomedical engineering from the George Washington University School of Engineering and Applied Science. After earning his degree, he attended George Washington University Medical School and earned his MD. During his medical school years, Dr. Patel worked with the Neuroendocrine Unit at the Massachusetts General Hospital and Harvard Medical School to publish multiple papers and conduct research on athletes in the Boston area. After medical school, he trained at the Albert Einstein Medical Center in Philadelphia for three years as an emergency medicine resident. Around this time, Dr. Patel found an opportunity to move to Tampa, Florida for an occupational medicine residency position at the University of South Florida. Within two years, Dr. Patel became the chief resident of the occupational medicine residency and graduated with a master of science in public health from USF. Dr. Patel has also completed a fellowship in interventional and non-interventional pain at the Duke Institute in Melbourne, Florida. At this position, Dr. Patel completed over 2,700 procedures, including hypoplasties, spinal cord stimulator placements, and other minimally invasive procedure. Through his education experience, he brings a unique and progressive approach to pain management and the management of occupational injuries. But so this is actually one of my passions, is the SI joint pain. I've given this talk at ACOM and you name it, I'll talk about it, mostly because it's one of the most underrated sources of low back pain. Usually, the evidence is all over the place, but 25% of patients that have pretty severe chronic back pain have some element of SI joint issues. I say that because I've seen patients who've had fusions of their low back, who have hip replacements, knee replacements, this, that, and you just inject a little lidocaine into their SI joint and the pain is gone. And so the number one way to determine that they have SI joint pain is to make sure that we're looking for it, and we'll go over the provocative test for it, but pretty simple. I do it in my office all the time, and it's just something to keep an eye on of what could save people from pretty massive back surgeries and things like that. Disclaimer, I'm still the same guy, so I don't have to read this, I guess. Our objective here is to evaluate and discriminate the low back etiology, describe conservative and interventional approaches to returning patients back to work. I do a lot of research-based stuff on this one, as opposed to the other ones, mostly because it's a little bit newer, and a lot of the new research contradicts some of the older kind of things, so we'll talk about that and then incorporate physical examination like I was talking about, and then how to treat low back pain. If we have time, I'll also go over the algorithm that they have for the OIG, which is how to move forward with low back pain in general, not just for SI joint. So, all right, so this is a very complicated way of looking at low back pain, but the key, like we were just discussing, of whatever, is the history and physical, right? I can tell you that this is a severely underestimated kind of way of determining what causes patients pain, because a lot of times we just jump into opioids, and we've seen how that problem runs into the cost of low back pain overall in the country is $100 billion. The lifetime prevalence is about 40 to 70%, and then it's the leading cause of disability in adults younger than the age of 45, and so those people who have currently low back pain, 30% of them will move on to having chronic pain at some point, so usually, you know, like I said, if we can kind of detect it early, we can change the trajectory of our patients, so that's the key. Now, when you look at low back pain, especially with the SI, there's a lot of things that can kind of go into it. There's a lot of muscles in this area, there's the disc and the vertebral bodies, there's the sacrum, there's the hip, there's the muscles like we talked about, so there's a lot of things in that area. Dr. Yusuf is one of our ultrasound guys from ACOM, and he talks about all these different muscles that can literally cause SI joint-related pain or low back pain, and, you know, as I was talking about, there's a lot of muscles in the area, you know, the piriformis can cause SI joint pain and things like that. The other thing, once again, as an educator, I try to tell students, make sure you rule out red flags before you continue. You like the little flower? I tell them to rule out the red flags as much as possible, because you don't want to be in a deposition where you're like, hey, doc, did you know this patient had unexpected weight loss? And you're like, no, and then you look silly because you missed the, you know, the cancer that they might have. So usually this is, the red flags, I call it tuna fish, so trauma, unexplained weight loss, neurological symptoms, age greater than 50, which is, you know, not that old, if you think about it, fever, IV drug use, steroid use, and history of cancer. Unfortunately, in my career here, I've picked up a lot of cancer, especially in younger patients, just because of trying to figure out using these, this little acronym here. And then I guess it's a self-plug, but this is what, how I determine low back pain. It's typically broken into axia and radicular symptoms. I include SI joint on a separate issue now, mostly because of, like I was talking about how under-diagnosed it is, but then we look at, in this round here, it's basically the provocative tests that I do, what the treatment or diagnosis is, our diagnostic injections that I do, and then kind of like what is their true problem, or underlying issue. And this is just the simplest way to focus on the SI joint. I do three, at least three provocative tests, and then I can do an SI diagnostic injection, and this is after, obviously, conservative therapy, which means, you know, you're really trying to get them into physical therapy as early as possible. You're trying to make sure that they remain working. You kind of want to do the most amount before you get into these treatment options, because by that time, and we'll talk about the algorithm that Worker's Comp uses, but by the time you get to the injection stage, you probably have exhausted all conservative treatment options. So this is an interesting thing when I was looking up SI joint issues. So in 1905, it was actually the most common cause of low back pain, and it wasn't until 1934 when they started to elicit a lot more low back pain coming from herniated discs, or facet arthropathy, and things like that, and then it slowly started to phase out of existence. So now, you know, you barely hear about SI joint discomfort. Slipman did a referral zone, so basically, it can go anywhere from your SI joint, which is this PSIS, all the way to the foot. They actually have, I think it was like 10%, there was a, yeah, I think they were saying like 10% of pain can refer all the way to the foot. So it's very hard to differentiate between a true radiculopathy and SI joint discomfort, which is why, like I mentioned before, a lot of patients will get these like massive fusion surgeries, and they still have that lingering pain. Most of the time, however, with a 60% positive prevalence value, the pain is located right here. Like we talked about, there's a lot of muscles there, there's a lot of issues there, and there's not one specific test you can do that's going to say, yep, there it is. So then, what can you do, right? Do a bunch of provocative testing. And so this is, the next few slides are about the tests that I do in the office. I'll be honest with you, this image and stuff is coming from a company called SI Bone. They are a company that specializes in SI fusions, but I'm not going to talk about that. I'm just going to talk about how to appropriately, to diagnose the treatment for, to diagnose SI joint tenderness. So this is a distraction test. I literally have a patient laying flat, and then you could kind of open, they call it, open the book. So you want the SI joint to kind of slide into this little groove here. And this is a bilateral test, so you can't really pinpoint one or the other. The other tests coming up are more unilateral, and then you could kind of pinpoint if it's left versus right. Are you symmetrically pushing, or are you rocking underneath? So you're actually like opening a book. So you're really pushing down and like rocking underneath. So it's called a distraction test. This is one of the ones that's a little bit easier to do, especially when the patient's laying down. The others we'll get into, I kind of transition from one to the other, and depending on their discomfort level, their body habitus and all this thing, it makes it really difficult sometimes to get all these done. The thigh thrust test, this is basically, you're trying to push the femur directly into the SI joint to create tension on the SI joint. The Faber test, which is always a med student specialty, if you will. They love doing this one, but it's like a figure four. And then you push down to kind of... Sorry, I keep doing that. And you basically try to create tension on this SI joint here. This, once again, I do a modified version of this sometimes in a seated position, depending on the patients. And you really, the goal of all of these is to elicit tension on the SI joint. Another way of doing this is a compression test. So this is a unilateral test. Even though most of the times I do this, force is force, and if you do it right enough, there's obviously a resistance here. So they're actually, you're getting a bilateral test here. So when patients, when you do this, it's not unique to one level or not. And then the last test is a gala seed test. And this really, really difficult to do, especially on your slightly obese patients, is you have to have their foot hanging off on the affected side. And then you bring the other side as close as possible. So you're really generating torque in the SI joint there. Once again, the other way to test for this is to just have the patient try to sit up. And I do this all the time. I'm just like, don't use your hands, try to stand up. And as they stand up, they rock their hip onto their sacrum. And that just general motion will cause irritation to the SI joint. The other thing is I've noticed that women of childbearing age always have a higher tendency of having SI joint discomfort. And that's usually linked to the hormone relaxin that's produced during childbearing age. And it relaxes the muscles in the area that causes tension on the SI joint. Similar to what I saw- When they're pregnant or in general? So when they're pregnant, they definitely have it. But in general as well, because as women age, the thing is, as it opens and as a pelvic increase and decreases in size during like childbirth or whatnot, it remembers it. So what will happen, that incident of the birth, and then maybe like 10 years later, they'll continue to have irritation of the SI joint. And so it's the initial birth that caused the problem, if you will. And then eventually it's like 10 or 15 years down the line. Actually, I fixed it. Why is that? Okay. What happens is during the birth. Yes. Okay, you're right. The relaxin is there and everything relaxed. In America, the classic situation is the person's in the stirrups. What ends up happening is after the birth, and birth, you know, the afterbirth, basically what happens is somebody comes in and they'll take the woman out of the stirrups. And instead of getting two people together to take them out equally, put them together and stretch them out, what they do is they take down one, they then take down the other, and that torques the pelvis. And that's how it sticks. And that's who I take into play. So what I tell my female patients is, I get the husband, and then the physician, and together they do that, they stretch it out, and I do zero incidence of continuing low back pain. That is genius. That's actually pretty interesting because like I was talking about, it's the literal torque of the SI joint. That's pretty smart. And I'll show you a couple of other tests to do that are much quicker than those. But 50% of all my patients that I treat come to me for low back pain, and they all come back to me for something else. Okay. Because after I do, I can fix their low back pain with their SI joint issue. Perfect. Yeah, we'll have to talk. You know, the other thing I always hear is that it's from the epidural. It's from the epidural. And it's never from the, let's just say never, but it's usually not from the epidural for that long. You know what I mean? And so ironically, my wife actually had SI joint pain prior to pregnancy, hated it during pregnancy. She like literally wanted to murder me. And then after shoot, delivery was gone. It was, you know, it's almost like the relaxing hormones, it does exist, right? Yeah. So anyways, so let's say we did all of this. We got a concerning history of physical, concerning exam findings. We've ruled out all the alternative causes. We've gotten everything. What do we do now? Right? Well, I always turn to ACOM for my guidance. And unfortunately, or unfortunately, you know, they have suggested that the use of CT and fluoroscopic guidance of diagnostic procedures is not really up to par. They have not found any quality studies and long-term improvement with these injections or diagnostic blocks. And I'm going to go over this because this kind of contradicts some of the newer findings. Obviously it's going to take time for us to kind of catch up to it. But, you know, I like to just kind of see what's on the horizon for us. And so here we go. So in 1996, this is the other problem with a lot of these studies. I'll be up front, is that the sample size is very small. They have not been able to get a huge study together for the multicenter. But at least in the ACOM world, in other like PMNR, neurosurgery and things like that, they have these massive studies, but they're not really all work-related. Oh, question? And this is what I'm trying to work with at USF to kind of come up with a huge study that would even get, even if we get 50 or 60 patients, there'll be five or six times more than what we have available to us right now. This is out of France actually, and they injected saline versus corticosteroids. And I'll be honest with you, even in the setting of saline, it's not a placebo. You're still flushing out the joint at some point. So that's one of the biggest problems I have when people use saline as a placebo, because it's truly not. And so these patients actually showed significant improvement at both one month, three month, and six months. And overall, 86% of the time, they said that they had good or very good response to the injection. Like I said, the problem sample size and the fact that they weren't using the true placebo effect. This is a recent actual, January of 2021, this is our friends out of Loma Linda in California, did 64 patients and this is a true work-related injury. They found that steroid injections provided near-immediate relief and facilitated an earlier return to work. They did note that there are certain limitations there, just basically on the criteria of patients that they used, the different providers injecting and things like that, but they found that especially in patients with work-related SI joint that they had a pretty fast return to work. Another study which identified 12 articles, seven of them were from our neurosurgery colleagues and a few of them were from PM&R, showed that 40% improvement in the VAS scores and overall they had 20% improvement in functionality. The study that I'm referring here to is from the Spine Journal in 2012 and here's some pictures from it. This is just looking at the different types of treatment options and this is the improvement from baseline of their score, so nobody got it above 70, but even if you look at the steroid injections, it's not great. Obviously, the distribution is all over the place, the sample size is still pretty small, and you look at fusion, even a true fusion, you're looking at 40% relief. That's not, you know, something to kind of brag about. Botox surprisingly did a lot better, but once again, sample sizes are so small and it's the same author in all three, so I always wonder about what's going on with that. Right, exactly, so what's going on in that setting, you know? Which of all, if you also look at that same author also did pretty bad, pretty poorly in a steroid injection, which makes me wonder like how did your steroid injection fail, but your Botox injection didn't, you know? It's just, okay, all right, well, so I think this was, I want to say this was just placebo, basically, they just basically, yeah, so this is like the, we're just, I'll be honest with you, I've done some of these injections and I look, I'm like there's no way this person's getting relief and they get 100% relief and you're like how did this happen, you know, and so I think there is a component of placebo, because I, you know, it's well documented and well researched, but people do. Here's my criticism about that, there should be a whole other range of articles about osteopathic injections. Yes, yes. You should have a whole other category with another 30 or 40 journal articles talking about, you know, right, so I teach at WECOM, but I'm an MD trained, so every time a student comes to our clinic, I'm always like, hey, go try it, you know what I mean, because I'll be honest, there's some times where some of my staff, like not even like our patients, some of our staff actually request some of our students to go in and do some manipulations just because it helps, and I truly believe that if we can get away from the fluoroscopic techniques and, you know, these pseudo injections that work for six months and whatnot and get into like the true cause of it, we could probably make, you know, a little bit more, give repeat patients, because they know that you're not just in it to get them six months, you're in it to get the prolonged treatment option, and if you look, fusion's what, 23% effective in here? That's like, that's worse than a flip of a coin, you know, so you're not really looking at much significant relief there, and even here, you know, I honestly, I do not know what they're doing with their Botox, but this is the ODI, and they're getting substantial relief there. All right, so I like to do this just because to show how easy it is to do it in the clinic, our ACOM, one of our advisors, or one of the main people in ACOM, he does a course, Dr. Yusuf, of doing ultrasound at the national convention every year, and so he teaches providers how to do an SI joint injection with just an ultrasound, and he could do these within like two minutes. It's pretty phenomenal. I still am old-fashioned and use a fluoroscope, but, you know, it's possible, but as you can see here, this is the sacrum, the iliac crest, and then you could, this is a very, I guess, a light suit, but there's usually just one little gap right here. You're going right into the slot. You can't miss it. The good thing about x-ray guidance, it's real-time, or sorry, ultrasound is that it's real-time. You could actually move the needle as you need to. I typically use a fluoroscope, which is good and bad because you can obviously see this nice little flow on most of our patients for the x-rays, but every time you move, you're taking a picture, so you're exposing yourself to radiation, and so I don't love the idea of it, but it really does allow us to kind of make sure that the spread is completely through the SI joint, as opposed to the ultrasound, where it's just in that one little area. Sometimes what I'll find is that patients will have severe arthritis in some of these areas, and you'll have a backflow of some of the dye, and so you can't even get the main medications all the way up the SI joint. That becomes a problem, too. These are SI joint injections that kind of really going through the articles that we talked about before, just like point by point. This one was only 27 patients, and they provided the patient with Kenalog, and they found that at four weeks, eight weeks, and six weeks, that the patient saw great improvements of function and improvement in range of motion as well, and the VAS score was significantly decreased, too. Now we get into the controversial stuff. This is SI joint radiofrequency ablations. This is covered by some of the commercial insurances, but not usually workers comp, and not usually it's covered by Medicare, but not any of the big providers for the most part, but what this is doing is basically you're implying that the branches of the S2 and the S1 nerve root basically supplies the SI joint here. If you could burn it, this is the S2, if you could burn most of the nerves here, you knock off 80% of the supplying the nerves to the SI joint. Problem, however, is everyone's a little different, and the anatomy of this is going to be very difficult, so even in a complete burn, you might get 70% if you're lucky, but it's a good way to kind of provide patients with non-surgical options. This is just basically needle placement. You don't have to get too involved in it, but as you can see, there's a lot as you get closer to the the exiting foramen here, you get into this what they call the hot zone, and you can get some numbness and some pretty bad neuritis after the ablation, so sometimes patients get worse before they get better, so it was something to talk to them about, and this is one of the newest studies. They took into 30 some studies related to RFAs of the SI joint, and they found that patients who had an RFA were four times more likely to achieve greater than 50% reduction at three months compared with a sham procedure. However, it doesn't talk about non-interventions, so the question is always, well, how do you know that if they did absolutely nothing, that their pain wasn't going to get better, or if they had just continued conservative therapy, the pain was going to get better, so, and then this is a study with only 78 patients, and this is not through workers comp, but mostly just through low back pain, and they found that patients who underwent RF at 90%, it's a huge percentage, had greater than 50% relief, so once again, these are, you got to figure out which patients will do well with these, and you also got to warn them that, hey, there is the potential for post-RFA neuritis, so like I said, it sometimes can get worse before it gets better. All right, we've got some time, questions, concerns? Yeah. Yeah, so the question was about PRP and also about piriformis injections while we're determining if it's an SI joint etiology as well. That's a great question, because it's like the chicken or the egg that I always get into, like which one's causing which, and I usually, if I'm confused, well, most of the time, it's difficult, it's mostly difficult to determine that, right, if there was a magic x-ray or a picture that we could take that would tell us, then I would, you know, we could make a ton of money together, but usually I do diagnostic blocks first, so before I play steroids or RFA or any of that, I would just put a little bit of lidocaine just in the SI joint or just in the piriformis. Surprisingly, the younger patients, usually it's a little bit more the piriformis, and depending on the source of injury or whatnot, it's usually the piriformis, and as people start to age or start to get into these weird, like, incidents, like car accidents or work trauma or something, it could be a little bit more, the pendulum swings more towards the SI, but I usually, you know, I talk to the patients about it, like, look, if it doesn't help, then there's nothing wrong with it, you just let me know, and I send them home with a little, I call it homework, but it's a worksheet to see how much relief they get throughout the day, especially right after we injected them, yep. Oh my god, yeah. From the needle, yeah, so I, personal, this is obviously a sample size one, but I started recently doing acupuncture because, you know, I'm getting older and trying to pick up kids and stuff, I'll be honest with you, depending on which acupuncturist you go to, there's some phenomenal, you know, relief that you can obtain. They have, you know, electroacupuncture now, they have all these, like, conservative, and when I'm hinting at this, I'm saying you got to try all that stuff first, you know, you're not, you're not coming to me, I'm sticking a needle in that day, you know, but usually all these, you know, the CDC just released a bunch of guidelines about opioid management, and they kind of really hit the point home that before you start anybody on these pretty invasive or pretty involved drugs and injections and all that stuff, you got to try the basics, yoga, you know, acupuncture, physical therapy, like, things that we, as medical providers, were never taught in medical school, that you really got to focus on. You're saying that, yeah, you know, you're coming at it from, well, let me put it this way, you know, what our joke about MDs is in DR school? MD stands for Manipulation Deficient. So, you know, basically, you know, our approach is, okay, how do you put this in, you put it together? Part of the problem, I think, you know, and I used to be an associate dean, so I know what we do. Part of our problem, in my opinion, is that we stovepipe OMM as an add-on to a traditional medical curriculum. Now, a lot of us didn't do that when we went through school, and I went to school later than a lot of the folks in this room, but the thing is, is that when you put your OMM together as a diagnostic skill, then you can also apply it as a treatment modality where you determine it's appropriate. The only reason to perform OMT, osteopathic manipulative treatment, is on, you know, a finding of some sort of somatic dysfunction, all right, and nothing, you know, nothing else. I mean, so, but it's not that hard to find in many people with the appropriate pathology of, you know, or pathophysiological abnormalities, and you restore them back to where they should be, and a lot of the stuff goes away. Part of our problem also is that in the, in the literature, they take things out and they show things at 12 weeks, three months. Well, 90 percent of all people, if you did nothing, are going to get better at three months. Correct. Actually, I used to have that in my slide. Therefore, the differences between manipulation of some sort, drug therapy, are all going to be statistically insignificant, because if you did nothing, you're going to get to that point too. The question, can I do something in the first couple of weeks and get them back to work real quick? Correct, and for most of us who've been in the military, that was absolutely essential. Correct, and that's the biggest thing, is to return to work, or return to play, or return to just daily function, right, and I mean no disrespect, but I think that, you know, when I teach these students at LECOM, I learn more from their physical exam findings than I feel like I'm able to teach them, because, you know, like you talked about, even MD, or residents, or whatever it is, they don't focus on that anymore, and I think that we talked about this, the history and physical, so important, that if you can diagnose it without imaging, or injections, or whatever it is, you're doing the patient service of catching that problem early, without any kind of exposure risk to radiation, or in steroids, or this or that. I agree with you, I think, you know, and that's why I love doing these talks, because I feel like all these people, like I gain the insight of like, yeah, I do this in my clinic, you know what I mean, so should these guys doing the research, you know, so I agree with you. Unfortunately, I think the problem is that everybody in America wants a quick, get quick fix today, you know what I mean, and the more time we spend, the prolonged acupuncture, it takes months, you know, PT takes months, and all these things take a while, and people don't want to wait, they want to know, what's the problem, why don't you know, oh, you can't tell me, I'm going to go down the street and find somebody else, and so. So the captive audience, you know what they're doing, so the rules for that thing, they're running physical therapy on them, they're running to the primary care man, getting the physical therapy, applying it to their plaque, so those folks have to, they're not allowed to jump ship, they're not allowed to jump ship, and then it just comes back, and physical therapy releases them, immediately, no work done, it's done, and it catches the ones that need the work, that primary care starts that, right, or unless they make the appointment, and it's not picked up what it's for, so it's exactly the pipeline, yeah, it keeps it in the right path, right, huge majority, little three lines, yeah, they do better with nothing. into physical therapy and work at the end. I don't want someone not to be proud because they're wearing 45 pounds of lubricant on them. Right. And then plus another, depending on who the job was, might see that. Correct. Right. And in that setting, you don't need an aggressive RFA, you know what I mean, what you need is some good PT and some good posturing and stuff like that and you'll be fine. You know, and that's what I'm trying to hint at here is that the key is to have that good relationship with the physical therapist that, hey, is this piriformis, is this SI, can we both do this provocative test, can we do this on the physical exam table, you know what I mean. And I'll be honest, most of our referrals come in from our physical therapist, they don't, they stop coming in from the KMNR guys and stuff because, let's be honest, if you're, like we talked about, I think it's like 80 or 90% now, I used to have it on my other side, if you did absolutely nothing, I'm like 90% of cases, patients got better. So it's not to, you know, personally, I don't like to speed it up, I like to just, because the more you train your body in the beginning, the better you're going to do in 13 weeks or 15 weeks, you know what I mean. If I inject you day one, odds are that by 12 weeks, either the medication's wearing off or we've completely missed the piriformis syndrome and now it's going to flare back up on you after the steroids run out. And so that's a disservice to the patient. I agree with that. Anyways, yep. You may be hearing some of this, but let's say I send a patient to somebody like you. Yeah. So I have a rule that if I inject you two days after you got to start physical therapy again, and that's my rule. The key is if you stay in motion, you remain in motion, right? So if you slow somebody down and you put them out of work or you do something else, they're going to stop. And those, and I call this the seeding experiment, where if I am putting steroids in there and you start to move, you're actually going to seed the whole SI joint with steroids. Where if you're just sitting around and I'm doing anything, it's just going to pull right, right where it is. That's it. And so, um, you know, people are usually pretty good. Uh, especially they want to get back to normal. And you had a question about PRP as well. I don't want to, uh, uh, to overjump that, but now, especially with the risk of steroids and, you know, depending on the patient population, if it's a young person, I do not inject them more than once or twice for steroids a year. Uh, some guys will do up to six injections of steroids. I don't do that anymore. It's well, I've never done that, but by the time you get into six and 12 or six rounds of steroid injections, you're basically just messing up their adrenal. You're messing up there. You're, you're causing, uh, the potential for osteoporosis, uh, potential for fractures. So we talk about PRP in STEM, can't say STEM, bone marrow aspirates. My thought personally is I think PRP is a good, uh, kind of adjunct to what we do. It allows the body's own, uh, anti-inflammatory response to kind of take effect, but so does saline, right? Like if you can just flush out the area, um, the problem with PRP is not covered by insurance and it could be very expensive. So for a lot of our patients, that's like a hurdle that they have to be willing to jump. But I try to do the most conservative things first. And so I I've done probably about 7,000 or 8,000 injections. I've probably only have done five PRP or STEM or bone marrow because I just don't think it's, I don't think it's, it's, uh, it's, it's helpful in the athletes. It's helpful in the young patients. It's helpful in the, probably the, uh, the military or the army personnel. But in my, in my group, it's, you know, I see mostly 70 and above. It's not going to be great. Yeah. So the question was whether or not steroids were causing problems with the ligaments or the muscles. Yeah. Yeah. So, uh, yeah, multiple injections, even after one, actually, you can see a little bit of, uh, you could see a muscle deterioration because you can see like an indentation sometimes. Um, I forget which article it was, but it mentioned that, uh, they do not advise injections into the ligaments or the muscles. So I remember back in the ER days, they would say, here's a toroidal shot. Here's a steroid. Here's a dexamethasone, see your primary care in a week. And we stopped doing that because it was literally leading to muscle atrophy, muscle atrophy in the region, not to include, not to also say discoloration of the skin in that region. Uh, you know, depending on where you're injecting, especially in sunny Florida, you get these sun rashes. It's just miserable. So, um, you know, I stopped doing a lot of trigger points and steroids because of that reason too. There's no indication for it for the most part. Right. So if we got a little bit of time, I just want to go over, do you guys, uh, well, this is a comms guideline of how to work up, uh, uh, uh, just touch the screen. So this is just the initial, uh, visit here. Um, what, what they want you to do, like we talked about rule out red flags here. Um, and then if not, they should continue, uh, heat, ice, topical medications, exercises, walking program, things like that. Reassure, you know, like we talked about really conservative off the bat, unless of course you hit any of these red flags. So red flags, including spinal fractures, cancer, the, the, the tuna fish that we talked about. Right. So if you have any of those, then yeah, sure. Start working them up depending on what you need. You know, if you're worried about a fracture, get the MRI, if you're worried or get the x-ray, then potential MRI. If you're worried about cancer, obviously blood tests and follow up with their oncologist, um, things like that. And now, so let's say you, sorry about that. So let's say in the follow-up visit, like we were just discussing most of the time, they're going to get better, right? Most of the time they're either improving or they probably have complete resolution and, you know, MMI them and see you later. Now, if they don't get better or there's change in symptoms, you've got to go back and kind of go back to the initial reevaluation. If there, if there's no change in symptoms, but they're just feeling the same, look, this is the, this is what ACOM is saying. Now you got to provide assurance that recovery is expected. Like we talked about, most of these guys will get better. You want to, uh, start to increase the exercise, the conditioning. You want to make sure that they start any type of organized or what do they call it? Supervised, uh, mobility kind of, uh, as soon as possible. And you want to get it done as close to one to two weeks. And then you kind of reassure and see them back in about four to eight weeks to make sure that they either been compliant with it, or if they have not, why what's going on? Because this is the biggest hurdle I feel is the first few weeks is that you can get them to buy into your treatment plan. You can get those patients back to work as soon as possible. Now let's say they don't get any better. There's two ways. Remember I was talking about the axial versus radicular. This is saying that there's no improvement, but just axial pain. So then you look for specific conditions. You want to make sure that they, if you are concerned about any kind of, you want to get imaging at this point, you want to see if they have any kind of other issues that could be causing their low back pain. If there's any positive tests, you know, obviously you go down that revenue. If there's, if their x-rays come back normal, everything looks pretty good. We'll go to the next step, what to do. But if it's neurological, this is where they refer, they, they ask you to, to go and say, okay, fine. Do they require an EMG study or an MRI? And usually if they are having continued radiculopathy or a new onset, worst thing, then you're looking at getting an MRI about four to eight weeks. So you've tried all the conservative things. And at that point you move on to getting a MRI. And this is surgical consideration. Let's say one of the tests come back with low abnormal, the MRI looks a little bit shoddy. Then you can get a neurosurgical evaluation. The key is, this is my favorite line. Does patient desire surgery to speed up short-term recovery? You know, that is a good point to have a conversation with the patient to also discuss. This is ACOM's guideline, not mine, but short-term recovery is a big, big kind of hurdle here. Like how long do patients really want surgery can, you know, to get fully back to normal after surgery, you're looking at anywhere from six weeks to six months, you know, and that's to say, like we looked at the slides before 23% of percent, 23% of people get better, 75% either stay the same or get worse. So you have to have that honest conversation with patients about the true expectations of surgery. So now most of the times let's say they don't want to do that, but they're having worsening pain. What do you do? You know, and this is the circle that we kind of run into as, as we get these patients for several months, what are we really looking? There are, there is at this moment after four to six weeks of slow progression or no improvement, patient does not want surgery, you're looking at the desire for epidural injections or steroid injections. So only after, you know, it's a pretty lengthy process, then you could consider a second or third injection. Like, like we talked about after three injections, are you really, are you really improving the quality of life or are you just injecting? And so if there's no, if there's no improvement, then you're going to go back to the surgical evaluation. And look, if they don't want surgery, you're back at square one. And this is the kind of, we'll talk about the loop that people run into. This is the easiest way to think about it in the acute setting. You want to kind of remind the patient that it's going to take a long time. In a subacute, it could take a little bit longer. And then by the time they get into the chronic pain, you're looking at patients that have been dealing with it for 12 weeks or more. So yeah. And then that's the concern. I'm going to speed things up here, but this is all available to you on the ACOM website or the OIG, but this is super complicated about how to return people back to work. But the question is what happens to patients when they don't get that, right? And this is where we run into, is the patient convinced he or she will be able to tolerate intended work activity and is progressive? So it's subjective. By the end of the algorithm, we're looking at what does the patient really think is going to happen? And if they believe that they're going to get better, then yeah, continue to do all of these, you know, modifications of their work and try to get them back to at least where they can get. But if they don't believe it, this is the roadblock that we run into. It's like, okay, well, we will try this. We will repeat the supervised strengthening exercises, work rehabilitation, PT, all that stuff. But then it's like, all right, well, what if they're not getting any better? And you kind of go in this like circle for a very long time for patients. And so the key here, this is the end of the algorithm, if you will. So the end, all the way through, it's like, there's nothing helping, resolution of symptoms, no. So this is the end point here, right? So that end point, I just like to kind of amplify is consider multidisciplinary pain program, acupuncture, ergonomics, behavior modifications, biofeedback, psychological testing, all that stuff. So kind of like what we talked about in the beginning, you know, if you tell patients in the beginning, this is what you're trying to do, you prevent them from getting all the way through, you know, months and months and months of discussion in this and testing and all that to get to this end point. And then they're like, well, you didn't do anything. You know, how many times do I hear that a day? Like you, you didn't help me at all. And you're like, well, look, there's a long road ahead of you. You know what I mean? You got to, we got to work at this together. But there's a lot of things on this way that I start earlier than after 12 weeks, like we're talking about acupuncture and things like that. And usually there's a few red flags in the beginning that I kind of hint at how satisfied are they at their job right now? How much do they really want to get back to work? What are the benefits of not getting back to work? And so when you have that honest discussion in the beginning, usually, not always, it helps kind of guide you in your plans. And that's it. That's all I got for you. Questions, concerns? You're probably sticking here. All right. Eight minutes to spare. Yeah. For our virtual audience, are there any questions that you have or would like for us to repeat? We do have one here from Dr. Higginbotham. Have you any experience with evaluating or treating Tinder? I'll let you read this because I'm not a science major, and I was educated in our public schools. Well, I think the question is, Tinder, epi, sacroiliac, lipomas, otherwise layman's term as backbites? No, I've never had to deal with that, but that's an interesting kind of notion. I'll get back to you guys about that. It's lipomas of the sacroiliac, otherwise known as back mice. Have you heard of that? Yeah, you've got fatty deposits there, and basically, you can either treat it as a lipoma, and some people, you might send them for a blood test, or you might send them for a blood test, and they'll tell you that it's a backbite, and you can't treat it as a backbite. And basically, you can either treat it as a lipoma, and some people, you might send them for an excision of the lipoma, but you know, like an IED, and that's helped in a number of places, but that's a rare finding. It only hurts when I'm sitting in a hardback kitchen chair. If there's a rail that hits that spot, I have to kind of move it a little bit. It's just a little fatty lipoma. It doesn't hurt unless you press it, so stop pressing on it. The consensus was stop pushing on it, but also, you can get an IED. My uncle said it's a Bible bump. Let me show you how to fix it. It came out a little bit crooked. That's what they used to do. Thank you, Dr. Patel.

SI joint pain

low back pain

diagnosis

treatment

non-surgical interventions

physical therapy

multidisciplinary approach

acupuncture

chronic back pain