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Published on : Mar 14, 2014
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Slide 1 - Back pain – a comprehensive guide Lawrence Pike James Street Family Practice
Slide 2 - 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
Slide 3 - 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
Slide 4 - Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic
Slide 5 - Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis
Slide 6 - Degenerative Osteoarthritis Spondylosis
Slide 7 - Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis
Slide 8 - Neoplastic Primary Secondary Prostate Lung Renal Breast Thyroid
Slide 9 - Referred Pain Gynaecological Renal Other abdominal
Slide 10 - Infection TB Osteomyelitis Herpes Zoster
Slide 11 - Psychological Depression Malingering
Slide 12 - Metabolic Osteoporosis Paget’s Osteomalacia
Slide 13 - History Sometimes a clear cause but often not In a young, fit person then usually: muscle or ligament strain facet joint problem prolapsed disc
Slide 14 - Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped by rest
Slide 15 - 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
Slide 16 - Prolapsed Disc Shooting pain Pain radiating down the leg below the knee Aggravated by coughing/sneezing Usually sudden onset and often no trauma
Slide 17 - 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
Slide 18 - Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes
Slide 19 - L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness Big Toe Foot Dorsiflexion Sensory Loss Medial foot
Slide 20 - L5/S1 Prolapse Straight leg raising reduced Ankle jerk absent Weakness Plantar flexion Foot eversion Sensory Loss Lateral foot
Slide 21 - 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
Slide 22 - 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
Slide 23 - RCGP Guidelines Acute Low Back Pain
Slide 24 - Clinical Guidelines for the Management of Acute Low Back Pain First published 1999 Updated yearly Evidence based
Slide 25 - Management RCGP Guidelines recommends triage into 3 groups 1/ simple backache / low back pain 2/ nerve root pain 3/ possible serious spinal pathology
Slide 26 - 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
Slide 27 - 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
Slide 28 - 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
Slide 29 - 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
Slide 30 - 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
Slide 31 - 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
Slide 32 - Psychological Risks Attitudes and Beliefs Distress and Depression Excessive adoption of Sick Role
Slide 33 - 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
Slide 34 - 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
Slide 35 - 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
Slide 36 - 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
Slide 37 - 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
Slide 38 - 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
Slide 39 - 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
Slide 40 - 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
Slide 41 - Other Therapies Inconclusive TENS Shoe insoles or lifts Local injections Back schools No evidence corsets or supports acupuncture
Slide 42 - 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
Slide 43 - 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
Slide 44 - 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?