Back pain – a comprehensive guide Lawrence Pike James Street Family Practice

Introduction n First, we will discuss the formal medical model: definition, incidence, aetiology, diagnosis, and treatment. n Secondly we will look at the recommendations of the RCGP on Acute Back Pain

Introduction n 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 n Potent cause of absence from work

Causes n Musculoskeletal n Degenerative n Rheumatic n Neoplastic n Referred n Infection n Psychological n Metabolic

Musculoskeletal n Ligamentous n Muscular n Facet joint n Sacroiliac strain n Prolapsed disc n Fracture n Scoliosis

Degenerative n Osteoarthritis n Spondylosis

Rheumatic n Rheumatoid Arthritis n Ankylosing Spondylitis

Neoplastic n Primary n Secondary u Prostate u Lung u Renal u Breast u Thyroid

Referred Pain n Gynaecological n Renal n Other abdominal

Infection n TB n Osteomyelitis n Herpes Zoster

Psychological n Depression n Malingering

Metabolic n Osteoporosis n Pagets n Osteomalacia

History n Sometimes a clear cause but often not n In a young, fit person then usually: u muscle or ligament strain u facet joint problem u prolapsed disc

Muscle or ligament strain n Usually can give you the cause n Related to posture n Episodic n Pain worse on movement, helped by rest

Facet Joint n Sudden backache with a simple movement I was just picking up a coin off the floor n Often flexion with rotation n May have heard a click

Prolapsed Disc n Shooting pain n Pain radiating down the leg below the knee n Aggravated by coughing/sneezing n Usually sudden onset and often no trauma

Red Flags in the History n Retention of urine or incontinence n Onset over age 55 or under 20 n Symptoms of systemic illness - weight loss, fever n Morning stiffness n Severe progressive pain n A prior history of cancer n Intravenous drug use n Prolonged steroid use

Examination n Observation n Palpation n Movements n Straight leg raising n Femoral stretch test n Power n Sensation n Reflexes

L4/5 Prolapse n Straight Leg Raising reduced n Ankle Jerk present n Weakness u Big Toe u Foot Dorsiflexion n Sensory Loss u Medial foot

L5/S1 Prolapse n Straight leg raising reduced n Ankle jerk absent n Weakness u Plantar flexion u Foot eversion n Sensory Loss u Lateral foot

Investigations n For simple backache, age <4 weeks duration,no red flags - no x-rays necessary. Patients expect one. n X-ray: u recent significant trauma u recent mild trauma over 50 u prolonged steroid use u osteoporosis u age over 70

Investigations n Plain x-ray with FBC and ESR to rule out tumour, infection if red flags suggest likely n 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 n First published 1999 n Updated yearly n Evidence based

Management n RCGP Guidelines recommends triage into 3 groups n 1/ simple backache / low back pain n 2/ nerve root pain n 3/ possible serious spinal pathology

Simple Backache n Presents years n Pain in lumbosacral area, buttocks and thighs n mechanical pain n patient well n includes muscle or ligament strain and facet joint problems

Nerve Root Pain n Unilateral leg pain worse than low back pain n Radiates to foot or toes n Numbness and paraesthesia in same distribution n SLR reproduces leg pain n Localised neurological signs - reflexes and power

Possible Serious Spinal Pathology n Symptoms of systemic illness - weight loss, fever n Morning stiffness n Severe progressive pain n A prior history of cancer n Intravenous drug use n Prolonged steroid use

Cauda Equina Syndrome n Sphincter disturbance n Gait disturbance or widespread motor weakness involving more than on nerve root or progressive motor weakness in the legs n Saddle anaesthesia of anus, perineum or genitals n Needs emergency referral

Red Flags (again) n Retention of urine or incontinence n Onset over age 55 or under 20 n Symptoms of systemic illness - weight loss, fever n Morning stiffness n Severe progressive pain n A prior history of cancer n Intravenous drug use n Prolonged steroid use

Yellow Flags n RCGP refers to Psychosocial problems Yellow Flags as they may predict likelihood of Chronicity n May be more important than the physical factors n Lets look at these in more detail

Psychological Risks n Attitudes and Beliefs n Distress and Depression n Excessive adoption of Sick Role

Social Factors n Family n Work u Physical demands of job u Job satisfaction u Poor health record at work u Other factors leading to time off - medico-legal proceedings, marital strife and financial problems

Psychological Management n Encouraging positive attitudes towards recovery n Adequate pain relief and continue work n Reassurance n Encourage to keep active, consider manipulation n Back problems become less common after 50-60

Drug Treatment n Prescribe analgesics at regular intervals, not prn. n Start with paracetamol n If inadequate add NSAIDs (Ibuprofen or Diclofenac) n Then try Co-proxamol or Co- dydramol n Finally consider muscle relaxant

Avoidance of Bed Rest n Bed rest has not been shown to be effective in trials of simple backache or nerve root pain n Strong evidence that bed rest leads to debilitation, disability and difficult rehabiliation n Evidence in favour of activity is strong and unequivocal

What to tell the patient n Increase physical activity progressively over a few days or weeks n Stay as active as possible and continue normal daily activities n Stay at work or return to work as soon as possible as beneficial

Who to Refer n Nerve root pain not resolving after 4 weeks (Orthopaedics) n One or more red flags leads to credible evidence of serious pathology n Cauda equina syndrome n Can have manipulation as long as no progressive neurology

Manipulation n Strong evidence that manipulation provides better short-term improvement in pain and activity and higher patient satisfaction n Moderate evidence that risks are very low in trained hands

Back Exercises n Strong evidence that back exercises do not produce any significant improvement in acute back pain n Moderate evidence that exercise programmes can improve pain and function in chronic low back pain

Other Therapies n Inconclusive u TENS u Shoe insoles or lifts u Local injections u Back schools n No evidence u corsets or supports u acupuncture

Other Therapies n Evidence of no effect u Traction u Physical agents (ultrasound, heat, ice, diathermy, massage) n Evidence against u Narcotics or Benzodiazepines beyond 2 weeks u Plaster jackets u Steroids

Summary n Common problem n Carry out diagnostic triage n Adequate pain relief and early mobility - resolving < 4 weeks n Give positive messages to patient n Remember yellow and red flags

Patients perspective n What has happened n Why has it happened? Why me? Why now? n What would happen if I did nothing? n What should I do about it? n What can you do about it? n How can I stop it happening again?