Transcript back pain - a comprehensive guide

Back pain – a comprehensive guide
Lawrence Pike
James Street Family Practice
Introduction


First, we will discuss the formal
medical model: definition,
incidence, aetiology, diagnosis,
and treatment.
Secondly we will look at the
recommendations of the RCGP on
Acute Back Pain
Introduction


Back pain is one of the most
common ailments of mankind. An
estimated 80 percent of people will
experience back pain at some
point in their lives, and slightly
more men suffer from it than
women
Potent cause of absence from
work
Causes








Musculoskeletal
Degenerative
Rheumatic
Neoplastic
Referred
Infection
Psychological
Metabolic
Musculoskeletal







Ligamentous
Muscular
Facet joint
Sacroiliac strain
Prolapsed disc
Fracture
Scoliosis
Degenerative


Osteoarthritis
Spondylosis
Rheumatic


Rheumatoid Arthritis
Ankylosing Spondylitis
Neoplastic


Primary
Secondary
 Prostate
 Lung
 Renal
 Breast
 Thyroid
Referred Pain



Gynaecological
Renal
Other abdominal
Infection



TB
Osteomyelitis
Herpes Zoster
Psychological


Depression
Malingering
Metabolic



Osteoporosis
Paget’s
Osteomalacia
History


Sometimes a clear cause but often
not
In a young, fit person then usually:
 muscle
or ligament strain
 facet joint problem
 prolapsed disc
Muscle or ligament
strain




Usually can give you the cause
Related to posture
Episodic
Pain worse on movement, helped
by rest
Facet Joint



Sudden backache with a simple
movement “I was just picking up a
coin off the floor”
Often flexion with rotation
May have heard a click
Prolapsed Disc




Shooting pain
Pain radiating down the leg below
the knee
Aggravated by coughing/sneezing
Usually sudden onset and often no
trauma
Red Flags in the History








Retention of urine or incontinence
Onset over age 55 or under 20
Symptoms of systemic illness weight loss, fever
Morning stiffness
Severe progressive pain
A prior history of cancer
Intravenous drug use
Prolonged steroid use
Examination








Observation
Palpation
Movements
Straight leg raising
Femoral stretch test
Power
Sensation
Reflexes
L4/5 Prolapse



Straight Leg Raising reduced
Ankle Jerk present
Weakness
 Big
Toe
 Foot Dorsiflexion

Sensory Loss
 Medial
foot
L5/S1 Prolapse



Straight leg raising reduced
Ankle jerk absent
Weakness
 Plantar
flexion
 Foot eversion

Sensory Loss
 Lateral
foot
Investigations


For simple backache, age 20-50
<4 weeks duration,no red flags no x-rays necessary. Patients
expect one.
X-ray:
 recent
significant trauma
 recent mild trauma over 50
 prolonged steroid use
 osteoporosis
 age over 70
Investigations


Plain x-ray with FBC and ESR to
rule out tumour, infection if red
flags suggest likely
If red flags present and plain x-ray
normal then bone scan, CT or MRI
may still be indicated
RCGP Guidelines
Acute Low Back Pain
Clinical Guidelines for
the Management of
Acute Low Back Pain



First published 1999
Updated yearly
Evidence based
Management




RCGP Guidelines recommends
triage into 3 groups
1/ simple backache / low back pain
2/ nerve root pain
3/ possible serious spinal
pathology
Simple Backache





Presents 20-55 years
Pain in lumbosacral area, buttocks
and thighs
“mechanical” pain
patient well
includes muscle or ligament strain
and facet joint problems
Nerve Root Pain





Unilateral leg pain worse than low
back pain
Radiates to foot or toes
Numbness and paraesthesia in
same distribution
SLR reproduces leg pain
Localised neurological signs reflexes and power
Possible Serious Spinal
Pathology






Symptoms of systemic illness weight loss, fever
Morning stiffness
Severe progressive pain
A prior history of cancer
Intravenous drug use
Prolonged steroid use
Cauda Equina Syndrome




Sphincter disturbance
Gait disturbance or widespread
motor weakness involving more
than on nerve root or progressive
motor weakness in the legs
Saddle anaesthesia of anus,
perineum or genitals
Needs emergency referral
Red Flags (again)








Retention of urine or incontinence
Onset over age 55 or under 20
Symptoms of systemic illness weight loss, fever
Morning stiffness
Severe progressive pain
A prior history of cancer
Intravenous drug use
Prolonged steroid use
Yellow Flags



RCGP refers to Psychosocial
problems “Yellow Flags” as they
may predict likelihood of Chronicity
May be more important than the
physical factors
Lets look at these in more detail
Psychological Risks



Attitudes and Beliefs
Distress and Depression
Excessive adoption of Sick Role
Social Factors


Family
Work
 Physical
demands of job
 Job satisfaction
 Poor health record at work
 Other factors leading to time off medico-legal proceedings, marital
strife and financial problems
Psychological
Management





Encouraging positive attitudes
towards recovery
Adequate pain relief and continue
work
Reassurance
Encourage to keep active, consider
manipulation
Back problems become less
common after 50-60
Drug Treatment





Prescribe analgesics at regular
intervals, not prn.
Start with paracetamol
If inadequate add NSAIDs
(Ibuprofen or Diclofenac)
Then try Co-proxamol or Codydramol
Finally consider muscle relaxant
Avoidance of Bed Rest



Bed rest has not been shown to be
effective in trials of simple
backache or nerve root pain
Strong evidence that bed rest
leads to debilitation, disability and
difficult rehabiliation
Evidence in favour of activity is
strong and unequivocal
What to tell the patient



Increase physical activity
progressively over a few days or
weeks
Stay as active as possible and
continue normal daily activities
Stay at work or return to work as
soon as possible as beneficial
Who to Refer




Nerve root pain not resolving after
4 weeks (Orthopaedics)
One or more red flags leads to
credible evidence of serious
pathology
Cauda equina syndrome
Can have manipulation as long as
no progressive neurology
Manipulation


Strong evidence that manipulation
provides better short-term
improvement in pain and activity
and higher patient satisfaction
Moderate evidence that risks are
very low in trained hands
Back Exercises


Strong evidence that back
exercises do not produce any
significant improvement in acute
back pain
Moderate evidence that exercise
programmes can improve pain and
function in chronic low back pain
Other Therapies

Inconclusive
 TENS
 Shoe
insoles or lifts
 Local injections
 Back schools

No evidence
 corsets
or supports
 acupuncture
Other Therapies

Evidence of no effect
 Traction
 Physical
agents (ultrasound, heat,
ice, diathermy, massage)

Evidence against
 Narcotics
or Benzodiazepines
beyond 2 weeks
 Plaster jackets
 Steroids
Summary





Common problem
Carry out diagnostic triage
Adequate pain relief and early
mobility - resolving < 4 weeks
Give positive messages to patient
Remember yellow and red flags
Patients perspective






What has happened
Why has it happened? Why me?
Why now?
What would happen if I did
nothing?
What should I do about it?
What can you do about it?
How can I stop it happening again?