Transcript l5,s1,2 - Epsom VTS

Back Pain in General Practice
Dr Chris Monella
GPSI
Back pain
Common 50-80%
 Diagnosis 15%
 Benefit claims >10%
 Risk factors

Lumber vertebrae
disc
History
Age, occupation,lifestyle
 Site/spread/segmental
 Onset
 Symptoms
 Red flag, yellow flags
 PMH, medications,etc

Diagnosis
Capsular pattern eg degenerative OA
 Non-capsular pattern eg PID

Mechanical back pain
 PID
 Spinal stenosis
 Sacro-iliac joint pain

Lumber spine examination
Observation-f,p,g
 Look-ic,psis,asis,leg length,spine
curvature,lordosis
 Lumber active ext,lat flex,flex ?capsular
 Tip-toe:Gastrocnemius root: s1,2
 Hip-passive flex, med rot, lat rot
 SIJ-shear tests, faber

Lumber spine examination 2
SLR- dural sign :l4,5,s1,2
 Resisted hip flex: l1,2,3
 Resisted dorsiflexion(TA): l4,5
 Resisted ext big toe (EHL) :l5,s1
 Resisted eversion (PB/L): l5,s1,2

Lumber spine examination 3

Skin sensation
Big toe: l4
 Toes 1,2,3: l5
 Toes 4,5 : s1

Lumber spine examination 4

Reflexes
Knee :l2,3,4
 Ankle:s1,2
 Babinski

Lumber spine examination 5
Femoral stretch test:l2,3,4
 Resisted knee ext(Quads) :l2,3,4
 Resisted knee flexion(Ham):l5,s1,2
 Gluts (bulk): l5,s1,2

Lumber spine examination 6
Palpation
 ?manipulation History recheck, noncapsular pattern,normal
plantar,normal reflexes
 Observe, treat or refer?

Treatment
Mobilization (grade A) in acute back pain
eg. Modified Pretzel technique
 Acupuncture
 Reassurance, ice
 analgesia,NSAIDs,Amitrip., gabapentin, etc
 Ix, PCT back pain clinic,Back surgeon

Jarvik et al . JAMA
2004
RCT-380
X-ray 167
MRI 170
3,6,12/12 fu
Increased reassurance,
surgery/cost of care
Overall disability,pain, general
health -same
Gilbert et al.
Health Tech assess
2004
782 patients, 14 hospitals
393 early imaging
389 delayed
8 & 12/12 better outcome
0.07 QALY for £61 over
24 months
Activities of daily
living
Effect on life
Social
Family duties
Hobbies
Lifestyle
expectations
NICE Feb 2008
Concerns
Existing
thoughts
Expectations
Current knowledge
about OA
Short term
Ability to perform
job
Long term
Occupational
Adjustments to
home or workplace
Screen for
depression
Mood
Other current
stresses in life
Quality of sleep
Holistic assessment
of person with OA
Ideas, concerns and
expectations of main carer
Support
network
How carer is coping
Isolation
Other
musculoskeletal pain
Evidence of a chronic
pain syndrome
Other treatable
source of pain
Attitudes to
exercise
e.g. periarticular
pain
e.g. trigger finger,
ganglion etc.
e.g. bursitis
Fitness for surgery
Assessment of most
appropriate drug therapy
Comorbidity
Pain
assessment
Interaction of two or more
morbidities
Falls
Self-help strategies
Drugs, doses,
frequency, timing
Analgesics
Side effects
Treatment options
oral NSAIDs
including COX-2
inhibitors
opioids
capsaicin
intra-articular
corticosteroid
injections
paracetamol
supports
and braces
topical
NSAIDs
education, advice,
information access
shock-absorbing
shoes or insoles
strengthening exercise
aerobic fitness training
assistive
devices
weight loss if
overweight/obese
TENS
manual therapy
(manipulation and
stretching)
local heat and
cold
joint
arthroplasty
Summary
History,examination findings & treatments
 Mechanical back pain/PID
 Systemic back pain
 Spinal stenosis
 Sacroilitis(in ankylosing spondylitis)
