Hamilton Hall MD FRCSC Julia Alleyne MD CCFP Managing Back Pain The Ontario Initiative Introducing the CORE Back Tool Hamilton Hall MD FRCSC Julia Alleyne MD CCFP

Faculty/Presenter Disclosure Faculty: Hamilton Hall Relationships with commercial interests: Consultant: Stryker Spine USA Consultant: Medtronic Consultant: rti Surgical Medical Director, Pure Healthy Back Medical Director, CBI Health Group

Disclosure of Commercial Support This program has received no financial support. This program has received no in-kind support. Potential for conflict of interest: Hamilton Hall receives compensation as Medical Director of CBIHG.

Mitigating Potential Bias This program does not discuss or recommend commercial services or surgical devices. Dr. Hall acknowledges that the Pattern Approach to Low Back Pain was developed during his time with CBIHG and that its development included contributions from many CBIHG staff members.

Faculty/Presenter Disclosure Faculty: Dr. Julia Alleyne Relationships with commercial interests: Speakers Bureau/Honoraria: Lavin Agency Excludes medical education and medical conferences.

Disclosure of Commercial Support This program has received no financial support. This program has received no in-kind support. Potential for conflict of interest: Dr. Julia Alleyne has received payment from Centre for Effective Practice (CEP) as the clinical lead on the Ministry of Health and Long-Term Care (MOHLTC) provincial Low Back Pain Strategy

Mitigating Potential Bias This program does not discuss or recommend commercial services or surgical devices. Dr. Alleyne acknowledges that she was the clinical lead in the development of the CORE back tool. Payment received by Dr. Alleyne is non-commercial (received from MOHLTC)

#1 All Musculoskeletal Conditions Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4–33% of the population at any given point. Anthony Woolfe Burden of major musculoskeletal conditions Bulletin of the World Health Organization 2003;81:646-6

What do we do ?

Barriers to Best Practice: Patients with Low Back Pain Family physicians perceive that they require additional knowledge and skills to deal with patient expectations, appropriate imaging and consultant referrals and patient self-management strategies. Primary care providers cited patient pressure, both direct and indirect, as a key reasons to order tests and specialty referrals. Knowledge gaps exist for patients as well but are often not addressed within the office visit.

Our current approach isn’t working The medical paradigm hasn’t solved the problem of low back pain. Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 MRI increase use 7.2% to 11.3% Mafi J et al. JAMA 2013

Our current approach isn’t working

Our current approach isn’t working Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 MRI increase use 7.2% to 11.3% NSAID/acetaminophen decrease use 36.9% to 24.5% Narcotic increase use 19.3% to 29.1% Specialist referrals increase 6.8% to 14.0% Mafi J et al. JAMA 2013

Our current approach isn’t working There is no correlation between degenerative changes on plain x-ray and back pain. CT has a 30% false positive rate. MRI has a 60-90% false positive rate. Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely. Webster BS et al. Spine 2013

Our current approach isn’t working With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. Everything else is labeled “non-specific” back pain.

Our current approach isn’t working With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

Our current approach isn’t working With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients. Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

And our current approach is wrong Most back pain is not the result of tumour infection major trauma or any medical problem Most back pain begins spontaneously. In a study of over 11,000 patients, 2/3rds of the subjects could not recall any cause for the pain. Hall et al. Clin J Pain 1998

But we still memorize the Red Flags Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-going infection Fever Night sweats Non-mechanical pattern of pain Constant pain Wide spread neurological signs or symptoms Disproportionate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55 Noseworthy J.N. Neurological Therapeutics

So why don’t we look there first? There is another way Over 90% of back pain is caused by minor altered mechanics. Most back pain is mechanical. So why don’t we look there first?

It means there is a sore thing in the back. There is another way Over 90% of back pain is caused by minor altered mechanics. Mechanical back pain is pain related to movement related to position related to a physical structure It means there is a sore thing in the back.

There is another way We can all recognize there is a sore thing. We just can’t agree on which sore thing. And for all the non-invasive treatments locating the sore thing isn’t even necessary.

There is another way “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Quebec Task Force 1987

Patterns of back pain “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

Syndromes of back pain “Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion.

A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion. What is the difference between a disease and a syndrome?

The only difference is that we know the etiology of a disease. A disease has an etiology. Does a syndrome have an etiology? Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance? Of course, a syndrome has an etiology. We just don’t know what it is yet.

Syndrome recognition The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst?

Where is your pain the worst? Is it back or leg dominant? Back dominant pain is referred pain from a physical structure. Back dominant: back buttocks coccyx greater trochanters groin

Where is your pain the worst? Is it back or leg dominant? Back dominant pain is referred pain from a physical structure. Sites of referred pain can become locally tender. Trochanteric bursitis

Where is your pain the worst? Is it back or leg dominant? Leg dominant pain is radicular pain from nerve root involvement. Leg dominant: Around or below the gluteal fold, to the: thigh calf ankle foot

Where is your pain the worst? Is it back or leg dominant? The patient will often report both. But it must be one or the other. “ If I could stop only one pain, which one do I stop? “I have a back pill and a leg pill, which one do you want?”

Syndrome recognition The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst? Is your pain constant or intermittent?

Part A Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment? I know it comes right back but is there ever a time, even a short time when the pain is gone?

Part B When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

When the pain is constant consider: Malignancy Systemic conditions Pain disorder Constant mechanical pain

Does bending forward make your typical pain worse? Syndrome recognition The key to syndrome recognition is the history. and that begins with three questions. Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse?

Does bending forward make your typical pain worse? Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse? What are the aggravating movements/positions?

Has there been a change in your bowel or bladder function Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse? Has there been a change in your bowel or bladder function since the start of your pain?

Where is your pain the worst? Is your pain constant or intermittent? Does bending forward make your typical pain worse? Has there been a change in your bowel or bladder function since the start of your pain? 5. If you are under 45 years, do you have morning stiffness greater than 30 min?

What can’t you do now that you could do before you were in pain and why?

What are the relieving movements/ positions? What can’t you do now that you could do before you were in pain and why? What are the relieving movements/ positions?

Have you had this same pain before? What can’t you do now that you could do before you were in pain and why? What are the relieving movements/ positions? Have you had this same pain before?

What treatment have you had? Did it work? What can’t you do now that you could do before you were in pain and why? What are the relieving movements/ positions? Have you had this same pain before? What treatment have you had? Did it work?

But we still memorize the Red Flags Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-going infection Fever Night sweats Non-mechanical pattern of pain Constant pain Wide spread neurological signs or symptoms Disproportionate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55 Noseworthy J.N. Neurological Therapeutics

History takes precedence over physical examination History takes precedence over physical examination. But the physical examination must support the history.

Physical Examination Observation general activity and behaviour back specific: contour colour scars palpation (if you must)

Physical Examination Observation Movement flexion extension

Physical Examination Nerve root irritation tests straight leg raising Observation Movement Nerve root irritation tests straight leg raising

A positive straight leg raise: Passive test - the examiner lifts the leg Reproduction/exacerbation of typical leg dominant pain Back pain is not relevant Produced at any degree of leg elevation To reduce confusion with hamstring tightness, flex the opposite hip and knee.

Physical Examination Nerve root conduction tests Observation Movement Nerve root irritation tests Nerve root conduction tests L4 L5 S1 knee reflex great toe extension great toe flexion

Physical Examination Upper motor test Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test plantar response clonus

Physical Examination Saddle sensation Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation lower sacral nerve roots (2,3,4) test

Physical Examination Sensory testing (if indicated) Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation Sensory testing (if indicated)

Physical Examination Ancillary testing (if indicated) Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation Sensory testing (if indicated) Ancillary testing (if indicated) hip, abdomen, peripheral pulses

There are four mechanical patterns Pattern 1 PEP Pattern 1 PEN Pattern 4 PEP Pattern 4 PEN

Pattern 1 Probably discogenic

History Back dominant pain Worse with flexion Constant or Intermittent Pattern 1

Physical Examination Back dominant pain Worse with flexion Neurological examination is normal or unrelated to the pattern Pattern 1

The patient has a directional preference. Physical Examination Back dominant pain Worse with flexion Neurological examination is normal Better with 5 prone passive extensions Pattern 1 Prone Extension Positive PEP The patient has a directional preference. Pattern 1

Physical Examination Back dominant pain Worse with flexion Neurological examination is normal No change/worse with 5 prone passive extensions Pattern 1 Prone Extension Negative PEN The patient has no directional preference. Pattern 1

Management Pattern 1 PEP – educate and exercise Reduce sitting / flexion Increase extension lumbar roll night roll Prescribe repeated prone extensions

Management Pattern 1 PEN – educate and exercise Goal oriented therapy referral Increase gradually and progressive from unweighted flexion to extension position then prone extensions When range improves and pain decreases add core stability Analgesics

Pattern 1 Pattern 1 PEP Pattern 1 PEN

Pattern 2 Have no idea

History Back dominant pain Worse with extension Never worse with flexion Always intermittent Pattern 2

History Back dominant pain Worse with extension Never worse with flexion Always intermittent If the pain is constant or if there is any pain on flexion the patient is Pattern 1 Pattern 2

Physical Examination Back dominant pain Worse with extension Neurological examination is normal or unrelated to the pattern No effect or better with flexion Pattern 2

Management Pattern 2 – educate and exercise Relief with sitting / flexion Reduce extension, frequent breaks Prescribe sitting unweighted flexion Posture and positioning in flexion

Pattern 1 Pattern 2 Pattern 1 PEP Pattern 1 PEN

Certainly nerve root irritation Pattern 3 Certainly nerve root irritation “sciatica”

History Leg dominant pain Always constant Affected by back movement/position Pattern 3

Physical Examination Leg dominant pain Leg pain affected by back movement Positive irritative test and/or conduction loss Pattern 3

Management Pattern 3 – reassure Scheduled rest positions during the day Z lie prone over pillows Change position as pain increases Stronger Analgesics Refer to surgery (15%)

Pattern 1 Pattern 2 Pattern 3 Pattern 1 PEP Pattern 1 PEN

Pattern 4 PEP

History Leg dominant pain Always intermittent Worse with flexion Pattern 4 PEP

Leg dominant pain that responds to mechanical treatment. Physical Examination Rarely a positive irritative test and/or conduction loss Always better with unloaded back extension movement or position Leg dominant pain that responds to mechanical treatment. Pattern 4 PEP

Management Pattern 4 PEP – educate and exercise Reduce sitting / flexion Increase extension lumbar roll night roll Prescribe repeated unloaded extension positions and movements

Neurogenic claudication Pattern 4 PEN Neurogenic claudication

History Leg dominant pain Always intermittent Worse with activity in extension Better with rest in flexion May have transient weakness Pattern 4 PEN

Physical Examination Negative irritative tests Possible permanent conduction loss Pattern 4 PEN

Management Pattern 4 PEN – educate and exercise Goal oriented therapy referral Abdominal strengthening Core strengthening Posture training - pelvic tilt Long term commitment Gradual improvement Excellent surgical candidates

Constant /Intermittent Back dominant Leg dominant Constant /Intermittent Intermittent Constant Intermittent Pattern 1 Pattern 4 Pattern 2 Pattern 3 Pattern 1 PEP Pattern 1 PEN Pattern 4 PEP Pattern 4 PEN

That’s all there is Mechanical Syndromes Unequivocal history Anticipated treatment response Concordant physical examination

Low Back Pain Patterns Another option to see all of the options a little more clearly. 93

Start with the patterns There will be a pattern in ninety percent of your patients. The pattern suggests the initial treatment. If the pain responds as expected, you have your solution. If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated. That is the time to consider the Red Flags.