back pain – a comprehensive guide
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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. - PowerPoint PPT PresentationTRANSCRIPT
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Back pain – a comprehensive guide
Lawrence Pike
James Street Family Practice
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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
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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
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Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic
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Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis
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Degenerative Osteoarthritis Spondylosis
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Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis
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Neoplastic Primary Secondary
Prostate Lung Renal Breast Thyroid
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Referred Pain Gynaecological Renal Other abdominal
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Infection
TB Osteomyelitis Herpes Zoster
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Psychological
Depression Malingering
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Metabolic
Osteoporosis Paget’s Osteomalacia
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History
Sometimes a clear cause but often not
In a young, fit person then usually: muscle or ligament strain facet joint problem prolapsed disc
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Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped
by rest
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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
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Prolapsed Disc
Shooting pain Pain radiating down the leg below
the knee Aggravated by coughing/sneezing Usually sudden onset and often no
trauma
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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
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Examination
Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes
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L4/5 Prolapse
Straight Leg Raising reduced Ankle Jerk present Weakness
Big Toe Foot Dorsiflexion
Sensory Loss Medial foot
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L5/S1 Prolapse
Straight leg raising reduced Ankle jerk absent Weakness
Plantar flexion Foot eversion
Sensory Loss Lateral foot
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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
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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
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RCGP Guidelines
Acute Low Back Pain
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Clinical Guidelines for the Management of Acute Low Back Pain
First published 1999 Updated yearly Evidence based
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Management
RCGP Guidelines recommends triage into 3 groups
1/ simple backache / low back pain 2/ nerve root pain 3/ possible serious spinal
pathology
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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
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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
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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
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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
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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
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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
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Psychological Risks
Attitudes and Beliefs Distress and Depression Excessive adoption of Sick Role
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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
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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
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Drug Treatment
Prescribe analgesics at regular intervals, not prn.
Start with paracetamol If inadequate add NSAIDs
(Ibuprofen or Diclofenac) Then try Co-proxamol or Co-
dydramol Finally consider muscle relaxant
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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
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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
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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
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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
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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
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Other Therapies
Inconclusive TENS Shoe insoles or lifts Local injections Back schools
No evidence corsets or supports acupuncture
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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
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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
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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?