Download LBP Algorithm

Recommended Management of Low Back Pain
Self Monitoring & Management
version 8.8 March 2017
Clinical
Presentation
Pt Questionnaire
Physical Exam
Hx/Px Core Tool
Any Red Flags?
Investigate and
Refer to Specialist
YES
Rule out Inflammation
Initial
Presentation
Acute (within 24 hrs)
Sub-Acute
Chronic
Patient Handout
Y
E
L
L
O
W
Pattern Assessment
& Management
Low Back Pain
Initial
1–4
weeks:
Expect
improvement
Review
weekly
Give Patient
the Green Light
·
Patient Questionnaire
·
History & Physical
·
Differential Diagnosis
·
Management Options
·
Monitoring & Followup
·
Referral Options
Patient Handout
·
·
·
·
·
Self Management
Assessment &
Treatment Options
Exercises
Medications
Physician Resources
Moderate to Severe Pain
· Opioids
· Referral Options
More
than
12
weeks
From
pain
onset
Tools
F
L
A
G
S
Symptoms
Improving
YES
Reinforce Green
Light Advice
NO
4–6
week
follow up
Recheck for
Red Flags
Investigations
Refer to a
specialist
Adapted from: New Zealand Low Back Pain Guide, October 2004 Edition, p 12 and
Alberta Institute of Health Economics, Guideline for the Evidence-Informed Primary Care Management of Low Back Pain
·
Dermatome Map
·
DN4 Neuropathic
Pain Questions
·
Opioid
Management
·
Pain Inventory
·
Patient Handouts
·
PHQ-9
·
Support Letter
·
Urine Drug Screen
·
Patterns LBP
·
LBP Core Tool
Return to page 1
Print
PSM Action Plan
Supporting Self-Management
Goal Setting
The 3 questions:
1) What is it about your current health
that bothers or worries you?
2) How do you feel about this?
3) What is it that you can personally
do about this issue?
Brief Action Planning
1 of 2
NEXT
Return to page 1
Print
Brief Action Planning for Health Is there anything you would like to do for your health in the next week or two?
I have an idea about what I want to do I can’t think of any, I need ideas. Make a SMART plan Perhaps you’d like to work on one of the suggestions below or you have some own ideas of your own to put in the empty boxes: My idea is: Answer these questions about your idea: 1. What exactly do I want to do? Eating habits Physical activity 2. How long will I do this or how much will I do it? Stress 3. How often will I do it and when? 4. Where will I do it? Smoking Sleep 5. When will I start? Medications Example: I will walk 15 minutes five times a week on Mon-­‐Fri around the block starting tomorrow. OR I will measure portion sizes every dinner 3 nights a week on M, W, F starting Monday. Repeat your plan out loud beginning with “I will……” How confident on a scale from “0 to “10” do you feel about carrying out your plan?
(“0” means no confidence or not sure and “10” means you are very confident or very sure.) 0 | 1 | 2 | 3 | 4 | 5 | Confidence less than 7 What might increase your confidence? Consider these options or an idea of your own: o Adjust your goal if it is too big. o Think about barriers and how to overcome them. o Ask others to support you. o Think about the specifics of your plan and adjust it. o Maybe this plan isn’t a good place to start, or maybe now is not a good time and waiting is a good idea. If you modify your plan then ask yourself again, “How confident am I to carry out my plan?” if you are 7 or higher, move to checking on your plan (next box). 6 | 7 | 8 | 9 | 10 | Confidence 7 or higher You’ve made a good plan that is likely to b e successful for you! Checking in on your plan is important for learning and success. Consider a check-­‐in date: ___________ Would you like to involve someone to review your plan with you? If you decide to check in with someone else, who is it? __________________ . When you review your plan, think about your next steps and start again at the top. Based on a form c reated by M.Wiebe (2011) from Cole S, Gutnick D, Davis C, Reims K. Brief Action Planning, Centre for Comprehensive Motivational Interventions, www.centreCMI.ca Next Page
Return to page 1
The Brief Action Planning Guide (8 Nov 2012) A Self-­‐Management Support Tool for Chronic Conditions, Health and Wellness Brief Action Planning is structured around 3 core questions, below. Depending on the response, other follow-­‐up questions may be asked. If at any point in the interview, it looks like it may not be possible to create an action plan, offer to return to it in a future interaction. Follow-­‐up is addressed on page 2. Question #1 of Brief Action Planning can be introduced in any clinical interaction when rapport is good. 1.
Ask Question #1 to elicit ideas for change. “Is there anything you would like to do for your health in the next week or two?” a.
If an idea is shared, specify details as they apply to the plan (Help the person make the plan SMART -­‐ Specific, Measurable, Achievable, Relevant and Timed). “What?” “When?” (time of day, day of week, start date) “How much/long?” “How often?” “Where?” b.
c.
2.
3.
For individuals who want or need suggestions, offer a behavioral menu. i.
First ask permission to share ideas. “Would you like me to share some ideas that others I’ve worked with have tried?” ii.
Then share two to three ideas. “Some people I have worked with have ________, others have had success with _______ or _________.” iii.
Then ask what they want to do. “Do any of these ideas work for you, or is there something else I haven’t mentioned that you would like to try?” iv.
If an idea is chosen, specify the details in order to make the plan SMART (above). After the individual has made a specific plan, elicit a commitment statement. “Just to make sure we both understand the details of your plan, would you mind putting it together and saying it out loud?” Ask Question #2 to evaluate confidence. “I wonder how confident you feel about carrying out your plan. Considering a scale of 0 to 10, where ‘0’ means you are not at all confident and ‘10’ means you are very confident, about how confident do you feel about your plan?” The word “sure” may be substituted for the word “confident”. a.
If confidence level >7, go to Question #3 below. “That’s great. It sounds like a good plan for you.” b.
If confidence level <7, problem solve to overcome barriers or adjust plan. “5 is great. That’s a lot higher than 0, and shows a lot of interest and commitment. We know that when confidence is a 7 or more, people are more likely to be successful. Do you have any ideas about what might raise your confidence?” c.
If they do not have any ideas to modify the plan, ask if they would like suggestions. “Would you like to hear some ideas from other people I’ve worked with?” d.
If the response is “yes,” provide two or three ideas. “Sometimes people cut back on their plan, change their plan, or make a new plan. Do you think any of these might work for you or something else you’ve thought of?” e.
If the plan is altered, repeat Question #2 to evaluate confidence with the new plan. Ask Question #3 to arrange follow-­‐up or accountability. “Sounds like a plan that’s going to work for you. Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” Make the follow-­‐up plan SMART. www.centreCMI.ca 1 Next Page
Return to page 1
Follow-­‐up for Brief Action Planning 1. First ask, “How did it go with your plan?” 2.
a.
If successful recognize (affirm) their success. b.
If partially successful, recognize (affirm) partial success. c.
If little or no success, say, “This is something that is quite common when people try something new.” Then ask, “What would you like to do next?” a.
If the person wants to make a new plan, follow the steps on page 1. Use problem solving and a behavioral menu when needed. b.
They may want to talk about what they learned from their action plan. Reinforce learning and adapting the plan. c.
If the person does not want to make another action plan at this time, offer to return to action planning in the future. The Spirit of Motivational Interviewing The Spirit of Motivational Interviewing underlies Brief Action Planning. 1. Partnership: Work in collaboration. 2. Acceptance: Respect autonomy and the right to change or not change. 3. Evocation: Ideas come from the person, not the clinician or helper. 4. Compassion: Act with heart when providing assistance. This tool was developed by Steven Cole, Damara Gutnick, Kathy Reims and Connie Davis. www.centreCMI.ca 2 Next Page
Return to page 1
Brief AcCon Planning Flow Chart Developed by Steven Cole, Damara Gutnick, Connie Davis, Kathy Reims “Is there anything you would like to do for your health in the next week or two?” Have an idea? Not sure? Behavioral Menu Not at this Cme 1) Ask permission to share ideas. 2) Share 2-­‐3 ideas. 3) Ask if any of these ideas or something else might work. SMART Behavioral Plan Specific Measureable Achievable Relevant Timely “That’s fine, if it’s okay with you, I’ll check next Cme.” Elicit a Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” Confidence ≥7 “That’s great!” Confidence <7 “A __ is higher than a zero, that’s good!” Problem Solving: “Any ideas about what might raise your confidence?” No Yes Specific Measureable Achievable Relevant Timely Behavioral Menu Restate new plan and ask about confidence again “Would you like to set a specific Cme to check back in with me so we can review how things have been going with the plan?” www.centreCMI.ca
Next Page
Return to page 1
Follow-­‐up on the Brief AcCon Plan “How did it go with your plan?” Success ParCal success Did not try or no success Recognize success Recognize parCal success Reassure that this is common occurrence “What would you like to do next?” The Spirit of MoCvaConal Interviewing is the foundaCon of Brief AcCon Planning Partnership Acceptance Evoca5on Compassion Miller W, Rollnick S. MoCvaConal Interviewing: Preparing People for Change, 3ed. 2013. www.centreCMI.ca
8 Nov 2012 Next Page
Return to page 1
Print
PSM Action Plan
Personal Action Plan for__________________________ Date________________
1. Something you want to change: (“what is your biggest concern”)
2. Describe:
How:
What:
When:
Where:
How Often:
3. Barriers:
4. Plans to overcome barriers:
5. My confidence level rating should be 7 or higher to be successful:
I know I won’t do it
1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
I know I will do it
6. Follow- up plan I will review this plan of action on (date):
________________________________
Via:




Follow up call from clinic
Follow up with group sessions
Follow up with appointment
other
2 of 2
NEXT
Return to page 1
Health Passport Overview
What is the Health Passport?
The Health Passport is a comprehensive tool that has been designed to support individuals in
the management of their health care conditions. It can be used for any state of health from
healthy living choices for those who are generally healthy to people that are living with one or
more chronic illnesses such as arthritis.
How is the Health Passport useful to patients?
The Health Passport has a number of tools to support patient self management, including goal
setting, tracking the progress of a condition, preparing for medical visits and helping to find
information or education resources. Individuals will use the passport differently; some may fill it
out in its entirety or just use the sections that are most meaningful to them.
The Heath Passport has the following sections:
Section
Purpose
1. Introduction
1. To provide information on the Health Passport including
why and how to use it
2. To discuss some common health care terms such as
prevention and self management
2. About Me
3. To provide patients with a one page information sheet to
record their personal and health care information,
including allergies, medical conditions and medications
3. Working with My Health Care Team
4. To provide various self management tools including a
tracking diary, information on how to set goals, recording
test results and finding education resources
4. My Community Contact Information
5. To provide contact information for a list of national and
provincial health care resources
5. Miscellaneous
6. To provide some useful websites with information on
symptoms, tests, medications and making medical
decisions
6. Retired Health Records
7. To provide a section for patients to store older health
records for safekeeping and future reference
7. Forms for Photocopying
8. To provide a section for patients to store forms that are
used on a regular basis
How is the Health Passport useful to family physicians?
Although a patient-focused tool, the Health Passport can be useful to family physicians in two
ways: (1) as an optional tool to help patients coordinate and direct their self management
efforts; and (2) to serve as a reference point for various self management discussions and
interventions such as goal setting, tracking symptoms and drug interactions, recording test
results and finding community resources.
NEXT
Return to page 1
Discussion Points with Patients
Important Things to Know
 The pain will settle – most people make an excellent recovery
 There is no sign of anything serious – and radiology tests are not
needed
 Movement and activity will not cause harm – it is important to stay
active
Activities of Daily Living




Continue to do all the things you usually do
Activity will not harm your back
Increase activity levels as soon as you can
Take sufficient pain relief to be active
Sports
 Vigorous activity is unlikely to be harmful, but may cause some pain
 Avoid heavy contact sports and strenuous sports that place a heavy
load on the back in early stages of recovery
Work (paid and unpaid)
 Work is important to both physical and mental recovery.
 Planned early return to work is likely to lead to less time off and
reduce the risk of long-term problems and chronic back pain.
 Avoid heavy lifting, bending or twisting, and modify some tasks for
awhile.
Acute LBP
Handout
Chronic LBP
Handout
NEXT
Return to page 1
Print
You
What
Should Know
About
Acute
Low Back Pain
Facts about acute low back pain:
•
•
•
•
•
Family doctors, chiropractors, physical
therapists, and osteopathic physicians are
trained to evaluate people with acute low back
pain
Will I need X-Rays, an MRI, or laboratory tests?
•
•
•
•
Since most low back pain is caused by muscle
or ligament strain, these tests will not reveal
anything and therefore are not needed
Your doctor will order tests only if another
cause of low back pain is suspected and can be
verified by these tests
Keep moving! Staying active helps and most
acute low back pain will go away, without
treatment, in 4 to 6 weeks.
If needed, take Acetaminophen or antiinflammatory medication for the pain.
See a health care professional if the pain
is getting worse instead of better or if new
symptoms appear.
What will help me recover?
•
When it’s severe
When it’s getting worse not better
When you’re having trouble controlling your legs
or bodily functions (bowel and bladder control)
When you’re over 50 and it’s your first episode
of low back pain
Who is qualified to evaluate me?
•
•
Low back pain is very common. Most of us will
have an episode of low back pain at some point
in our lives
Low back pain is most often caused by back
strain and resolves within a few weeks without
medical treatment
Recurrent or repeated episodes of low back
pain are quite common
The best way to prevent recurrences of low
back pain is to be physically active
When should I seek professional
help for acute low back pain?
•
•
•
What should I do?
•
Research has shown that the following actions
speed recovery:
- Remain active
- Return to your usual activities (bit by bit)
including work as soon as you can. You may
have to modify your activities to start with if
they make your pain worse
- Supervised exercise may be helpful.
Most people recover within 4 to 6 weeks without
any specific treatment
Should I take pain medicines?
•
•
•
Many people do not take any pain medicines for
acute low back pain
Acetaminophen (Tylenol) and anti-inflammatory
medication called NSAIDs (such as Ibuprofen,
Advil or Motrin) can be effective
Your doctor can prescribe other medicines if
your pain is interfering with activity or is severe
When should I go back to my doctor
or health care provider?
•
•
•
If you aren’t improving after 6 weeks
If your pain is getting worse
If you have new symptoms
NEXT
Return to page 1
Print
You
What
Should Know
About
Chronic
Low Back Pain
“Chronic” means the pain has lasted for more than
3 months
The longer you’ve had the pain, the less likely it
can be cured or will go away completely
Emotional distress and depression can be caused
by chronic low back pain and make pain harder
to deal with
People with chronic low back pain can improve
their daily functioning and overall quality of life
The most effective course of action is a combination of self-management approaches in addition
to care from health care providers
What should I do?
• Improve your pain and wellbeing by focusing
on improving your day-to-day functioning.
Stay active and exercise. Use pain coping
skills, relaxation, and stress management to
moderate your pain.
• Get involved in rehabilitation, multidisciplinary
pain programs, and a support group.
• Consider acupuncture, massage and TENS.
• Take Acetaminophen or anti-inflammatory
medication if needed for the pain. Your
doctor can prescribe other medications as
needed.
How do I know that my doctor hasn’t
missed something that can be cured?
What can I do and what can be done
for me?
Facts about chronic low back pain:
•
•
•
•
•
•
•
Family doctors, chiropractors, physical therapists,
and osteopathic physicians are trained to identify
both serious and curable causes of low back pain
While it is possible that a curable cause of your
low back pain has been overlooked, that is less
and less likely as time passes
•
•
Who is qualified to help me?
•
•
Family doctors, chiropractors, physical therapists,
and osteopathic physicians are trained to evaluate
and treat people with chronic low back pain
Treatment by other providers has not been scientifically studied and has unknown benefits and
risks
Do I need X-Rays, an MRI, or
laboratory tests?
•
•
•
•
Most people with chronic low back pain do not
need these tests
Your doctor will order tests only to clarify specific
diagnoses
•
There is no treatment that helps everyone. Most
people benefit from using several approaches
Research has shown that the following ‘selfmanagement’ approaches can help:
- Stay active and exercise
- Learn and use pain coping skills, relaxation,
and stress management
- Participate in active rehabilitation and multidisciplinary pain programs
The following treatments have been studied and
shown to help:
- Acupuncture.
- Massage and TENS, if combined with activity
and exercise therapy
- Specialized treatments for people with specific
diagnoses
These medications have been studied and can
be helpful:
- Acetaminophen (Tylenol) and anti-inflammatory
medication (NSAIDs such as Ibuprofen,
Advil or Motrin)
- Low dose tricyclic antidepressants (such as
amitriptyline or nortriptyline)
- Short courses of muscle relaxants for pain
flair-ups with muscle spasms
Narcotic medications for severe pain under close
medical supervision
Return to page 1
Print
Clinically Organized Relevant Exam
(CORE) Back Tool
This tool will guide the family physician and/or nurse practitioner to recognize common mechanical back pain
syndromes and screen for other conditions where management may include investigations, referrals and specific
medications. This is a focused examination for clinical decision-making in primary care.
Overview of Tool and Key Points
Throughout this tool, key messages for your patient are embedded in each section as indicated by a key symbol (
Section A: History
• A patient’s history can help identify:
Back or leg dominant pain
Intermittent or constant pain
Associated aggravating movement
Non-mechanical vs. mechanical pain
Red flags ( ) and yellow flags ( )
Ȏ
Ȏ
Ȏ
Ȏ
Ȏ
Red Flags
•
•
•
•
•
•
identified in history
Referred leg pain will have a normal neurological exam
Radicular (nerve) pain will have a positive straight leg raise
(SLR) with reproduction of leg pain and possible abnormal
neurological signs
Interpretation of range of motion includes the pain
response to flexion and extension movements
NIFTI is a mnemonic for common red flags
Red flags indicate the potential presence of an
underlying serious pathology
Cauda Equina symptoms require urgent surgical
evaluation
Yellow Flags
•
•
•
Section B: Physical Examination
• An examination refutes or supports the back pain pattern
).
Yellow flags indicate the potential of psychosocial
risk factors for developing chronic pain
Yellow flags can be picked up on any visit
If significant, CBT or 1:1 psychoeducation
counselling may be necessary for pain management
Supporting Material
The materials below can be accessed at
effectivepractice.org/lowbackpain.
Supporting Tools
Opioid Risk Tool 1
Patient Education Inventory 2
Personal Action Planning for Patient Self Management 3
The Keele STarT Back Screening Tool 4
1
3
2
Section C: Initial Management
• Goals may include “to reduce pain” and “to increase activity”
• Frequent movement in small doses recommended
• Self management involves patient driven goals for motivating
•
behaviour change like exercise, medication compliance or
activity modification
Remember that all recovery positions and/or exercises should
be customized to the individual patient. This section offers a
starting point with links to additional resources
Additional Tools For Providers
Pharmacy Table: Acute and Subacute Low Back Pain –
Phamacological Alternatives 5
Pharmacy Table: Acute and Subacute Low Back Pain –
Topical and Herbal Products 6
Evidence Summary for Management of Non-specific
Chronic Low Back Pain 7
Opioid Manager Switching Opioids Form 8
Additional Tools For Patients
Back Book 9
General Recommendations for Maintaining a Healthy
Back 10
Section D: Referrals (if required)
• Based on your findings, the patient may require referral to:
Ȏ
Ȏ
Ȏ
Ȏ
-# 2016
rehabilitation
surgery
specialist(s)
imaging or laboratory tests
effectivepractice.org/lowbackpain
So Your Back Hurts... 11
What You Should Know About Acute Pain 12
What You Should Know About Chronic Pain 13
Imaging Tests for Lower Back Pain: When You Need Them –
And When You Don’t 14
Dr. Mike Evans’ Low Back Pain Patient Self-Management
Video 15
Page 1 of 4
NEXT
Return to page 1
Stamp or fill in
Section A: History
Patient Name: ___________________________________
Work through questions 1–6 to evaluate the patient’s history.
Question 1:
Where is your
pain the worst? 16
Chart #: ________________________________________
q Back/ Buttock Dominant
Date of Birth: ____________ Date of Visit: ____________
q Leg Dominant
Red Flags (check if positive)
Question 2:
Is your pain
constant or
intermittent? 16
The acronym NIFTI can help you remember red flags. 21, 22, 42, 43
q Constant
q Intermittent
Rule out red flags
Question 3:
q Flexion (possibly
also Extension)
What increases
improved with
your typical pain? 16 Ifprone
extension, will
q Extension only
Flexion relieved.
Pattern 2
q All movements
hurt
q Walking and/or
Standing
If improved with rest
positions, surgical
treatment less likely.
Relieved with sitting
or flexion.
Pattern 3
Pattern 4
If pattern of pain is not identified, patient has
Question 4:
q Intermittent
Rule out red flags
respond faster.
Pattern 1
q Constant
q Yes
What?
non-mechanical pain
Rule out Yellow Flags
Why? q Back/Buttock Pain q Leg Pain
Confirm this is consistent with Question 1
Question 5:
Have you had any unexpected accidents with your bowel or bladder function
since this episode of your low back pain started? 16
q No
Question 6:
q Yes
q Yes
q Neurological: diffuse motor/sensory
loss, progressive neurological deficits,
cauda equina syndrome
Urgent MRI
indicated
q Infection: fever, IV drug use,
immune suppressed
X-ray and MRI
q Fracture: trauma, osteoporosis risk/
fragility fracture
X-ray and may
require CT scan
q Tumour: hx of cancer, unexplained
weight loss, significant unexpected
night pain, severe fatigue
X-ray and MRI
q No red flags 2
1
Rule out Cauda Equina Syndrome
2
Systemic Inflammatory Arthritis Screen 18
Gait
Standing
Sitting
Kneeling
Lying
Additional Findings
Abnormal
Imaging tests like X- rays, CT scans and MRIs are not helpful
for recovery or management of acute or recurring low back
pain unless there are signs of serious pathology. 14, 41
Your examination today does not demonstrate that
there are any red flags present to indicate serious
pathology, but if your symptoms persist for > 6 weeks,
schedule a follow-up appointment. 14, 41
L
R
3
Psychosocial Risk Factors for Developing Chronicity
For those with low back pain > 6 weeks or non-responsive to
treatment, consider asking:
Heel Walking (L4-5)
Toe Walking (S1)
Movement testing in flexion
Movement testing in extension
Trendelenburg test (L5)
Repeated toe raises (S1)
Patellar reflex (L3-4)
Quadriceps power (L3-4)
Ankle dorsiflexion power (L4-5)
Great toe extension power (L5)
Great toe flexion power (S1)
Plantar response, upper motor test
Ankle reflex (S1)
Supine
Passive straight leg raise (SLR)
Passive hip range of motion
Prone
Femoral nerve stretch (L3-4)
Gluteus maximus power (S1)
Saddle sensation testing (S2-3-4)
Passive back extension (patient uses arms to
elevate upper body)
Continue reviewing history
Yellow Flags 21, 22, 24
Section B: Physical Examination 19
NOTE: Bolded green-coloured tests are the suggested
minimum requirements of the exam.
1
Acute Cauda Equina syndrome is a surgical emergency. 23
Symptoms are:
q Urinary retention followed by insensible urinary overflow
q Unrecognized fecal incontinence
q Distinct loss of saddle/perineal sensation
If age of onset < 45 years, are you experiencing morning stiffness in your back
> 30 minutes? 17
q No
Investigation
q Inflammation: chronic low back pain Rheumatology
> 3 months, age of onset < 45, morning Consultation and
Guidelines
stiffness > 30 minutes, improves with
exercise, disproportionate night pain
Is there anything you can NOT do now that you could do before the onset of
your low back pain? 16
q No
Indication
Questions to ask
Look for
“Do you think your pain
will improve or become
worse?”
Belief that back pain is harmful or
potentially severely disabling.
“Do you think you would
benefit from activity,
movement or exercise?”
Fear and avoidance of activity
or movement.
“How are you
emotionally coping with
your back pain?”
Tendency to low mood and
withdrawal from social
interaction.
“What treatments or
activities do you think will
help you recover?”
Expectation of passive
treatment(s) rather than a belief
that active participation will help.
A patient with a positive yellow flag will benefit from education
and reassurance to reduce risk of chronicity. If yellow flags persist,
consider additional resources: Keele StarT Back 4 ; The Patient
Health Questionnaire for Depression and Anxiety (PHQ-4). 25
q No yellow flags
3
Continue reviewing history
If you are feeling symptoms of sadness or anxiety, this
could be related to your condition and could impact
your recovery, schedule a follow-up appointment.
: Key message for your patient
-# 2016
effectivepractice.org/lowbackpain
Page 2 of 4
NEXT
Return to page 1
Section C: Initial Management 16, 19, 26
Commonly
Called 27
Medication 5, 6, 7
4
Pattern 1
Pattern 2
Pattern 3
Pattern 4
Non-Mechanical Pain
Disc Pain
Facet Joint Pain
Compressed Nerve Pain
Symptomatic Spinal Stenosis
(Neurogenic Claudication)
q Non-spine related pain
q Acetaminophen
q NSAID
q Acetaminophen
q NSAID
q May require opioids if
1st line pain meds not
5
sufficient
q Acetaminophen
q NSAID
Consider other etiologies
prior to pain medications
Recovery
Positions 28
Starter
Exercises 29
Repeated prone lying
passive extensions (i.e.
hips on ground, arms
straight).
10 reps, 3 x day
Sitting in a chair, bend forward
and stretch in flexion. Use
hands on knees to push
trunk upright. Small frequent
repetitions through the day
“Z” lie (see image above)
Caution: exercise will
aggravate the pain so
start with pain reducing
positions
Rest in a seated or other
flexed position to relieve the
leg pain
Exercises
ISAEC 35; HealthLink BC 34;
SASK Pattern 1 30
ISAEC 35; HealthLink BC 34;
SASK Pattern 2 31
ISAEC 35; HealthLink BC 34;
SASK Pattern 3 32
ISAEC 35; HealthLink BC 34;
SASK Pattern 4 33
q Encourage short
frequent walking
q Encourage sitting or
standing with foot stool
q Reduce sitting activities
q Reduce back extension
and overhead reach
q Change positions
frequently from sit to
stand to lie to walk
q Use support with walking
or standing. Use frequent
sitting breaks
q 2 weeks for pain
management and
neurological review
q 6–12 weeks for
symptom management
and determination of
functional impact
Functional
Activities 36
Follow-up
q Use extension roll for
short duration sitting
q 2–4 weeks if referred to
therapy, or prescribed
medication
q 2–4 weeks if referred to
therapy, or prescribed
medication
q PRN if given home
program and relief
noted in office visit
q PRN if given home
program and relief noted
in office visit
Once pain is reduced,
Self
Management 37-40 engage patient for self
management goals
6
Self management can be
initiated in 1st or 2nd
session with most patients
Patient is not usually suitable
for self management due to
high pain levels and possible
surgical intervention
Consider internal organ
pain referral such as kidney,
uterus, bowel, ovaries
q Spine pain does not
fit mechanical pattern
Consider centralized pain
medications (i.e.
anti-depressants,
anti-seizure, opioids)
Consider pain disorder
Self management can be
initiated in 1st or 2nd
session with most patients
ISAEC = Inter-professional Spine Assessment and Education Clinics; SASK = Saskatchewan Spine Pathway Group Healthy Back Exercises
4
You may need pain medication to help you return to your daily activities and initiate exercise more comfortably. It is activity, however, and not the medication that
will help you recover more quickly. 14, 22, 41
5
Short acting opioid medication may be used for intense pain such as leg dominant constant symptoms related to nerve radiculopathy. 14, 22, 41
6
Low back pain is often recurring and recovery can happen without needing to see a healthcare provider. You can learn how to manage low back pain when it
happens and use this information to help you recover next time. 14, 22, 41
Notes:
Section D: Referrals (if required)
q Rehabilitation referral
Rehabilitation Referral Criteria (4–12 treatments)
q Absence of red flags
q Pain is managed well so that patient can tolerate treatment
q Pain has mechanical directional preference – varies with movement, position or activity
q Patient is ready to be an active partner in goal setting and self management
q Surgical referral
Surgical Referral Criteria 23
q Failure to respond to evidence based compliant conservative care of at least 12 weeks
q Unbearable constant leg dominant pain
q Worsening nerve irritation tests (SLR or femoral nerve stretch)
q Expanding motor, sensory or reflex deficits
q Recurrent disabling sciatica
q Disabling neurogenic claudication
q Specialist referral
Provider Name:
Provider Signature:
: Key message for your patient
-# 2016
q Physiatry
q Cognitive Behavioural Therapy
q Pain specialist
q Imaging (Refer to
effectivepractice.org/lowbackpain
red flags)
q Multidisciplinary Pain Clinic
q Rheumatologist
q Other:
q Laboratory tests (Refer to
red flags)
Page 3 of 4
NEXT
Return to page 1
References
[1] Centre for Effective Practice, Government of Ontario. Opioid Risk Tool [Internet]. 2013 Jan [cited 2016 Jan 6]. Available from: www.effectivepractice.org/lowbackpain
[2] Centre for Effective Practice, Government of Ontario. Patient Education Inventory [Internet]. 2013 Jan [cited 2016 Jan 6]. Available from: www.effectivepractice.org/lowbackpain
[3] Practice Support Program, Centre for Effective Practice, Government of Ontario. Personal Action Planning for Patient Self Management [Internet]. 2013 Jan [cited 2016 Jan 6]. Available from: Available from:
www.effectivepractice.org/lowbackpain
[4] Keele University, Arthritis Research UK. The Keele STarT Back Screening Tool [Internet]. 2013 Jan [cited 2015 Nov 20]. Available from: http://www.effectivepractice.org/lowbackpain
[5] Chang B, Wang D, St. Michael’s Hospital, Department of Family and Community Medicine. Acute and subacute low back pain (LBP) – Pharmacological alternatives [Internet]. 2013 Jan [cited 2015 Nov 24]. Available
from: www.effectivepractice.org/lowbackpain
[6] Chang B, Wang D, St. Michael’s Hospital, Department of Family and Community Medicine. Acute and subacute low back pain (LBP) – Topical and herbal products [Internet]. 2013 Jan [cited 2015 Nov 24]. Available
from: www.effectivepractice.org/lowbackpain
[7] Physicians of Ontario Collaborating for Knowledge Exchange and Transfer (POCKET), Institute for Work & Health. Evidence summary for management of non-specific chronic low back pain [Internet]. 2009 Apr
[cited 2015 Nov 19]. Available from: www.effectivepractice.org/lowbackpain
[8] Toronto Rehab, University Health Network, Centre for Effective Practice, Michael G. DeGroote National Pain Centre. Opioid manager: Switching opioids [Internet]. [cited 2016 Jan 6]. Available from: http://
nationalpaincentre.mcmaster.ca/opioidmanager/documents/opioid_manager_switching_opioids.pdf
[9] Bigos S, Roland M, Waddell G, Klaber Moffett J, Burton K, Main C. The Back Book [Internet]. 2002 [cited 2016 Feb 19]. Available from: http://www.newtonplacesurgery.nhs.uk/website/G82039/files/
BackBookEnglish.pdf
[10] Saskatchewan Ministry of Health. General recommendations for maintaining a healthy back: Patient information [Internet]. 2010 Apr [cited 2016 Jan 6]. Available from: http://www.sasksurgery.ca/pdf/
recommendations-for-back-health.pdf
[11] Institute for Work & Health. So your back hurts… [Internet]. 2010 [cited 2016 Jan 6]. Available from: http://www.iwh.on.ca/system/files/documents/so_your_back_hurts_2010.pdf
[12] Toward Optimized Practice, Institute of Health Economics. What you should know about your acute low back pain [Internet]. 2015 [cited 2016 Feb 19]. Available from: http://www.topalbertadoctors.org/
cpgs/?sid=65&cpg_cats=90
[13] Toward Optimized Practice, Institute of Health Economics. What you should know about your chronic low back pain [Internet]. 2015 [cited 2016 Feb 19]. Available from: http://www.topalbertadoctors.org/
cpgs/?sid=65&cpg_cats=90
[14] Choosing Wisely Canada. Imaging tests for lower back pain: When you need them – and when you don’t [Internet]. 2014 Apr 2 [cited 2015 Nov 25]. Available from: http://www.choosingwiselycanada.org/
materials/imaging-tests-for-lower-back-pain-when-you-need-them-and-when-you-dont/
[15] Evans M. Low back pain [video file]. 2014 Jan 24 [cited 2016 Feb 19]. Available from: https://www.youtube.com/watch?v=BOjTegn9RuY
[16] Hall H. Effective spine triage: Patterns of Pain. Ochsner J. 2014 Spring; 14(1): 88-95.
[17] General Practice Services Committee. Patterns of low back pain: MSK resource [Internet]. 2013 Jan [cited 2015 Nov 24]. Available from: http://www.gpscbc.ca/what-we-do/professional-development/psp/
modules/musculoskeletal-msk/tools-resources
[18] The Arthritis Society. Getting a grip on arthritis: Best practice guidelines [Internet]. 2004 [cited 2015 Nov 27]. [Figure], Inflammatory vs. Non-Inflammatory Disorders; p. 1. Available from: http://acreu.ca/pdf/
Best-Practice-Guidelines.pdf
[19] Hall H, Alleyne J, Rampersaud YR. Making sense of low back pain. J Current Clinical Care. 2013 Jan; Educational Suppl.: 12-23.
[20] MD Anderson Cancer Center. Brief Pain Inventory (Short Form) [Internet]. 1991 [cited 2015 Nov 24]. Available from: http://www.mdanderson.org/education-and-research/departments-programs-and-labs/
departments-and-divisions/symptom-research/symptom-assessment-tools/brief-pain-inventory.html
[21] Physicians of Ontario Collaborating for Knowledge Exchange and Transfer (POCKET), Institute for Work & Health. POCKET Card for Red & Yellow Flags [Internet]. 2006 [cited 2015 Nov 19]. Available from: www.iwh.on.ca
[22] Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. Edmonton, AB: Toward Optimized Practice; 2011. Appendix A: Red and Yellow Flags. Available from:
http://www.topalbertadoctors.org/cpgs/?sid=65&cpg_cats=90
[23] Rampersaud YR, Alleyne J, Hall H. Managing leg dominant pain. J Current Clinical Care. 2013 Jan; Educational Suppl.: 32-39.
[24] New Zealand Guidelines Group. New Zealand acute low back pain guide: Incorporating the guide to assessing psychosocial yellow flags in acute low back pain [Internet]. 2004 Oct [cited 2015 Nov 25]. Available
from: http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_communications/documents/guide/prd_ctrb112930.pdf
[25] Kroenke K, Spitzer RL, Williams JBW, Lowe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics [Internet]. 2009 Nov-Dec [cited 2015 Nov 20]; 50(6): 613-621. Available from:
http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/scale-PHQ4.pdf
[26] Hall H, McIntosh G, Boyle C. Effectiveness of a low back pain classification system. Spine J. 2009 Aug; 9(8): 648-657.
[27] CBI Health Group. Self-help guide to Back Pain [Internet]. [cited 2015 Nov 19]. Available from: https://www.cbi.ca/web/cbi-health-group
[28] Images adapted and reproduced with permission from CBI Health Group.
[29] Hall H, Alleyne J, Rampersaud YR. Managing back dominant pain. J Current Clinical Care. 2013 Jan; Educational Suppl.: 24-31.
[30] Saskatchewan Spine Pathway Working Group, Saskatchewan Ministry of Health. Pattern 1 – Patient Education [Internet]. 2010 Apr [cited 2015 Nov 19]. Available from: http://www.sasksurgery.ca/pdf/healthy-back-exercises1.pdf
[31] Saskatchewan Spine Pathway Working Group, Saskatchewan Ministry of Health. Pattern 2 – Patient Education [Internet]. 2010 Apr [cited 2015 Nov 19]. Available from: http://www.sasksurgery.ca/pdf/healthy-back-exercises2.pdf
[32] Saskatchewan Spine Pathway Working Group, Saskatchewan Ministry of Health. Pattern 3 – Patient Education [Internet]. 2010 Apr [cited 2015 Nov 19]. Available from: http://www.sasksurgery.ca/pdf/healthy-back-exercises3.pdf
[33] Saskatchewan Spine Pathway Working Group, Saskatchewan Ministry of Health. Pattern 4 – Patient Education [Internet]. 2010 Apr [cited 2015 Nov 19]. Available from: http://www.sasksurgery.ca/pdf/healthy-back-exercises4.pdf
[34] Health Link British Columbia. Low Back Pain: Exercises to Reduce Pain [Internet]. 2014 Mar [cited 2015 Nov 19]. Available from: http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=tr5948
[35] Inter-professional Spine Assessment and Education Clinics (ISAEC). Positions of Relief, Stretches and Exercises [Internet]. 2015 [cited 2015 Nov 19]. Available from: http://www.isaec.org/positions-stretches-and-exercises.html
[36] Verwoerd AJ, Luijsterburg PA, Timman R, Koes BW, Verhagen AP. A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study. J Physiother.
2012; 58(4): 249-254.
[37] Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002 Nov 20; 288(19): 2469-2475.
[38] Johnston S, Liddy C, Ives SM, Soto E. Literature review on chronic disease self-management. Champlain LHIN. 2008 Apr 15; 1-23.
[39] McGowan P. Self-management: a background paper. New Perspectives: International Conference on Patient Self-Management. 2005 Sep; 1-10.
[40] Reims K, Gutnick D, Davis C, Cole S. Brief action planning: A white paper [Internet]. Centre for Comprehensive Motivational Interventions. 2013 Jan [cited 2016 Jan 6]. Available from: http://www.centrecmi.ca
[41] Health Quality Branch, Ontario Ministry of Health and Long-Term Care. Bulletin 4569: Provincial strategy for X-Ray, Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI) for low back pain
[Internet]. 2012 Aug 28 [cited 2015 Nov 23]. Available from: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4000/bul4569.pdf
[42] Busse J, Alexander PE, Abdul-Razzak A, Riva JJ, Alabousi M, Dufton J, et al. Appropriateness of spinal imaging use in Canada [Internet]. 2013 Apr 25 [cited 2016 Feb 19]. Available from: http://www.cihr-irsc.gc.ca/e/47175.html
[43] University Health Network, Health Quality Ontario, Ministry of Health and Long-Term Care. Low back pain imaging pathway. Developed as part of the Diagnostic Imaging Appropriateness (DI-APP) Tools in
Primary Care. 2015.
This Tool was developed by the Centre for Effective Practice (“CEP”) with clinical leadership from Drs. Julia Alleyne, Hamilton Hall and Y. Raja Rampersaud. In addition, this Tool was informed by advice from our Education Planning Committee, Clinical Working Group and target end-users engaged throughout the development process. The development of this Tool was originally funded by the Government of Ontario (2012) and the
current 2016 revision was funded by Centre for Effective Practice.
This Tool was developed for licensed health care professionals in Canada as a guide only and does not constitute medical or other professional advice. Primary care providers and other health care professionals are
required to exercise their own clinical judgment in using this Tool. Neither the Centre for Effective Practice (“CEP”), the Canadian Spine Society, the Nurse Practitioners’ Association of Ontario, The College of Family
Physicians of Canada, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment
services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers or entity,
including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any external
sources referenced in this Tool (whether specifically named or not) that are owned or operated by third parties, including any information or advice contained therein.
The CORE Back Tool is a product of the Centre for Effective Practice under copyright protection with all rights reserved to the Centre for Effective Practice. Permission to use, copy, and
distribute this material for all non-commercial and research purposes is granted, provided the above disclaimer, this paragraph and the preceding paragraphs, and appropriate citations
appear in all copies, modifications, and distributions. Use of the CORE Back Tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated
with the Centre for Effective Practice (Email: [email protected]).
For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool. Please use the below
citation when referencing the tool:
Reprinted with Permission from Centre for Effective Practice (-# 2016). CORE Back Tool. Toronto. Centre for Effective Practice.
Developed by:
Endorsed by:
THE COLLEGE OF
FAMILY PHYSICIANS
OF CANADA
-# 2016
effectivepractice.org/lowbackpain
LE COLLÈGE DES
MÉDECINS DE FAMILLE
DU CANADA
Page 4 of 4
Return to page 1
Print
Patient Questionnaire
Patient name: _________________________________ PHN: _________________________________
Date: _________________________________ Date of birth: _________________________________
Answering these questions will help your doctor with today’s visit.
1. What is the #1 problem you are seeing your doctor for today:
________________________________________________________________________________
________________________________________________________________________________
Is this problem the result of a:
Work-place injury
Car accident
Accident, including falls
(Date of injury:
(Date of injury:
(Date of injury:
)
)
)
2. Please describe the symptoms you are having:
_______________________________________________________________________________
3. Have you experienced any of the following in the last 1 to 4 weeks?
Fever
Weight loss
Night sweats
Night pain that wakes you up
Fatigue
Bowel or bladder problems
Tingling / numbness
Other (please describe below)
4. On the following picture, mark the area where you are having these symptoms:
Please turn over the page
NEXT
Return to page 1
5. How long have you had these symptoms? Please write the number of days, weeks, months, or
years: Days ___ Weeks ___ Months ___ Years ___
6. How did your symptoms start: ________________________________________________________
________________________________________________________________________________
7. Are any of your joints swollen?
Yes
No
8. Are your joints stiff when you get out of bed in the morning?
Yes
No
If yes, how long does this stiffness last? ________________________________________________
9. Do you have any pain?
Yes
No
If yes, is the pain always there or does it come and go?
Always there
Comes and goes
10. If you have pain, please use the following scale to rate how bad your pain is in each of the following
categories (at its, worst, at its least, etc.). Pick one number that best describes your pain.
0 = no pain
1
2
At its worst: ___
3
4
5
6
7
At its least ___
8
9
10 = worst pain
On average ___
Not applicable
Right now ___
11. If you have low back pain, which of these positions makes your pain feel better:
Rest
Activity
Sitting
Standing
Lying Down
Other ______________________
12. If you have low back pain, which of these positions makes your pain feel worse:
Rest
Activity
Sitting
Standing
Lying Down
Other ______________________
13. Using the following scale, please rate to what extent your symptoms interfere with your general
activity, mood, relationships, etc.:
0 = Does not interfere
1
Your general activity
Your ability to walk
Relationships
2
3
_
4
5
6
7
8
9
10 = Completely interferes
Your mood
Normal work
Sleep
Not applicable
Enjoyment of life
14. What have you tried for relief? ________________________________________________________
_________________________________________________________________________________
15. What currently gives you relief? _______________________________________________________
_________________________________________________________________________________
16. Are you currently getting treatment for any other health problems? If so, please describe:
_________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
Thank you for answering these questions.
Please turn over the page
Return to page 1
Print
History and Physical Exam
The following physical exam can be used to assist family physicians in identifying any relevant
abnormal neurological signs and assessing the degree of functional limitation caused by pain.
1. Focused General Physical Examination
Temperature
Pulse
Rash
Thyroid
Lymph nodes
__________ °C
__________ BPM
___________________________________
___________________________________
___________________________________
2. Standing - Lumbar Range of Motion (Restrictions in motion and pain sensation)
Flexion
______ degrees - effect on pain pattern? ____________________________
Extension
______ degrees - effect on pain pattern? ____________________________
Schöber Test
__________cm increase from 10cm measurement
3. Walking – Observation
Gait (Limp, Ataxic, Foot Drop)
Alignment and posture (Lordosis, scoliosis)
Motor Toe walking, foot eversion – L5-S1
Heel Walking – L4-5
1st Toe extension – L5
Quad (Squat & Stand) – L3-4, Hip flexion L2-3
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
4. Sitting - Neurologic Examination
Reflexes (Patellar – L3-4, Achilles – S1-2)
Sensory (Heat, vibration, pinprick)
____L____R Patellar ____L____R Achilles
___________________________________
5. Lying Down - Musculoskeletal Examination
Straight leg raise and femoral stretch tests _______Right _______Left ____________
ASIS levels
___________________________________
PSIS levels
___________________________________
Muscle spasm or ligament tenderness
___________________________________
Enthesitis (inflammation of tendon at bone)
___________________________________
Hip range of motion and pain
___________________________________
FABER
________Right _______Left ___________
Vertebral spine point tenderness?
___________________________________
6. Abdominal Examination
Mass (palpate aorta)
Tenderness
Abdominal or femoral bruits
___________________________________
___________________________________
___________________________________
7. Peripheral Vascular Examination
Femoral, Posterior tibial, Dorsal pedis
___________________________________
NEXT
Return to page 1
Print
Patient Name_____________________________________ Date/Time of Exam _____________________________
INTERNATIONAL STANDARDS FOR NEUROLOGICAL
CLASSIFICATION OF SPINAL CORD INJURY
(ISNCSCI)
RIGHT
Examiner Name ___________________________________ Signature _____________________________________
SENSORY
SENSORY
MOTOR
KEY MUSCLES
KEY SENSORY POINTS
Light Touch (LTR) Pin Prick (PPR)
C2
C3
C4
C5
C6
C7
C8 0 = absent
altered
T1 21 == normal
NT = not testable
T2
Comments (Non-key Muscle? Reason for NT? Pain?):
T3
T4
T5
T6
0 = absent
1 = altered
T7
2 = normal
NT = not testable
T8
T9
T10
T11
T12
L1
Hip flexors L2
Knee extensors L3
LER
Ankle dorsiflexors L4
(Lower Extremity Right)
Long toe extensors L5
Ankle plantar flexors S1
S2
S3
(VAC) Voluntary anal contraction
S4-5
(Yes/No)
KEY MUSCLES
C2
C3
C4
C2
Elbow flexors
UER
Wrist extensors
(Upper Extremity Right)
Elbow extensors
Finger flexors
Finger abductors (little finger)
C5
C6
C7
C8
T1
C3
C4
T2
T3
C2
C5
T4
T5
T6
T7
C3
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
T8
T1
T9
0 = absent
1 = altered
C4
T10
2 = normal
NT = not testable T11
C6
T12
L1
S3
L2
S4-5
Palm
• Key Sensory
Points
L3
S2
C6
C8 6 C8
C 7
C7
C
MOTOR
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, gravity eliminated
3 = active movement, against gravity
4 = active movement, against some resistance
5 = active movement, against full resistance
5* = normal corrected for pain/disuse
NT = not testable
SENSORY
(SCORING ON REVERSE SIDE)
Return to page 1
UER
L2
L3
L4
L5
S1
L4
L5
S1
MAX (25)
Steps 1-5 for classification
as on reverse
Knee extensors
LEL
Ankle dorsiflexors
(Lower Extremity Left)
Long toe extensors
Ankle plantar flexors
S2
S3
S4-5
(DAP) Deep anal pressure
(Yes/No)
(MAXIMUM)
(MAXIMUM)
SENSORY SUBSCORES
LER
(25)
NEUROLOGICAL
LEVELS
Hip flexors
LEFT TOTALS
= UEMS TOTAL
+ UEL
2 = normal
NT = not testable
0 = absent
1= altered
RIGHT TOTALS
MOTOR SUBSCORES
Elbow flexors
Wrist extensors
UEL
(Upper Extremity Left)
Elbow extensors
Finger flexors
Finger abductors (little finger)
(SCORING ON REVERSE SIDE)
Dorsum Dorsum
L5
LEFT
MOTOR
KEY SENSORY POINTS
Light Touch (LTL) Pin Prick (PPL)
MAX (25)
(50)
1. SENSORY
2. MOTOR
R
L
= LEMS TOTAL
+ LEL
(25)
3. NEUROLOGICAL
LEVEL OF INJURY
(NLI)
LTR
(50)
MAX (56)
= LT TOTAL
+ LTL
(56)
4. COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-5
5. ASIA IMPAIRMENT SCALE (AIS)
PPR
(112)
= PP TOTAL
+ PPL
MAX (56)
(56)
R
(In complete injuries only)
ZONE OF PARTIAL
PRESERVATION
Most caudal level with any innervation
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
(112)
L
SENSORY
MOTOR
REV 02/13
NEXT
Return to page 1
(click on title to link to details) Disc Herniation
Facet Syndrome Foraminal Stenosis Osteoporotic Compression Fracture Degenerative Disc Disease Inflammatory Arthropathies Discitis Osteomyelitis Arachnoiditis Acute Spondylosis Spondylolithesis Scoliosis
Spinal Stenosis SIJ Dyscentral Syndrome Sacroiliitis Muscle Strain Ligamentous Strain Short Leg Syndrome To Differential Dx
Return to page 1
The following document may be used as another reference for determining specific clinical features of low back pain, along with suggested
management of each condition and indications for referral.
SPECIFIC DIAGNOSIS
FEATURES
GP MANAGEMENT
MUSCLE STRAIN
-
Pain with flexion
Limited flexion relieved by
hand support
Spasm & tenderness to palpation of involved
muscle
Pain with prone isometric contraction
Unilateral lumbar spasm will cause pelvic
torsion and lumbar lateral shift
Look for vertebral myofascial strain
patterning and spinous process offset
Acute (<2wks)
Ice and rest
Gentle Stretching
Analgesia
Muscle Relaxant
Subacute (>2wks)
Home exercise (eg: stretching after
appropriate warm-up, swimming, rowing
machine, etc.)
-
LIGAMENTOUS STRAIN
(Mechanical Enthesitis)
-
Aggravated by prolonged sitting or standing
Constant shifting while sitting or standing
Relief with stretching or walking
Localized ligamentous tenderness to
palpation of ligament attachments
Acute (<3mos)
Activity within pain tolerance
Range of motion exercises for 5 min 3
times per day to prevent adhesions
Chronic (>3mos)
Steroid injections of ligament
attachments
DISC PROTRUSION
(Posterolateral)
-
Pain with flexion
Limited flexion not relieved with hand
support
No palpable spasm or ligamentous
tenderness
Lower limb symptoms +/- low back pain
Positive straight leg raise or femoral stretch
tests
Pain increased with coughing, sneezing, or
straining at stool
Aggravated by jarring movements (i.e.: car
ride)
Acute (<6wks)
Rest
Narcotic Analgesia
Avoid bending or sitting
Avoid manipulation
> 6 weeks or progressive neurologic
signs, do CT or MRI
Chronic (>6wks)
Ergonomic or activity modifications
(eg: avoid sitting, bending, lifting)
Alexander Technique or trial of
traction of no dural signs
-
Note: Consider central disc protrusion if no
lateralizing signs
REFERRALS
-
-
-
If apparent vertebral strain
patterning and muscle imbalance,
consider referral for manipulative
therapy.
Physiotherapy, IMS, or massage if
persistent focal muscle spasm.
Consider referral for epidural steroid
injections q 2wks x 3 if persistent pain
greater than 6 wks
Urgent surgical opinion if loss of
bowel or bladder control (cauda
equina syndrome), significant motor
deficit (foot drop), large central L5S1 disc protrusion with bilateral leg
symptoms
Elective surgical referral if severe
intractable pain beyond 6 weeks
despite 3 epidural injections or
progressive neurologic deficit
Alert: Monitor for development of Cauda
Equina Syndrome
DDx: Consider facet joint ganglion or intraspinal
mass lesion
ACUTE SPONDYLOLYSIS
-
-
Typical onset in youth involved in sports
causing repetitive hyperextension or
jumping
Pain may not be acute
Pain worse with extension
Muscle spasm and guarding
-
-
Lateral and oblique x-ray projections
may reveal pathology. If not clear,
consider nuclear bone scan and CT/MRI
scan
Rest from strenuous
NSAID for relief of pain.
-
-
Acute lesion without separation of
pars interarticularis should be
referred for Boston brace or similar
product
Refer for orthopedic opinion if acute
lesion with separation at pars
interarticularis.
NEXT
To Differential Dx
Return to page 1
SPECIFIC DIAGNOSIS
FEATURES
GP MANAGEMENT
REFERRALS
SPONDYLOLISTHESIS
-
-
-
-
Pain worse with extension activities or high
impact activities and relieved by sitting
Muscle spasm and guarding
May be visible or palpable step deformity if
significant spondylolisthesis
Hamstring muscle spasm
Note: Pain does not originate from pars
interarticularis lesion. Pain is due to ligamentous
strain, facet joint capsule strain, lateral
foraminal stenosis, or central canal stenosis if
significant slip
-
-
-
Lateral x-ray projection will confirm
pathology.
Rest and avoid extension or high
impact activities when symptomatic
(eg: yoga, running, etc.)
Brace for sport activities and acute
symptoms
Monitor periodically for neurologic
compromise or progressive
spondylolisthesis
NSAID for relief of pain
Refer for orthopedic opinion if
progressive slip, progressive
symptoms, or development of
neurologic deficit
Note: for other related pathology such as
foraminal or central canal stenosis, see
appropriate diagnostic section
FACET SYNDROME
-
Pain with extension
Relieved with flexion
Prefer to sit
Usually history of activity causing extension
Look for increased lumbar lordotic posture
-
FORAMINAL STENOSIS
(UNILATERAL or BILATERAL)
-
Pain with extension
Relieved with flexion
Prefer to sit
Usually history of activity causing extension
Look for increased lumbar lordosis
Sharp electric shot like radicular pain (Most
commonly L5)
-
Note: 1/3rd with symptoms of neurogenic
claudication
-
X-ray to assess for DDD or Facet DJD
D/C extension activities
Flexion stretches
Reduce lordotic posture
Avoid sleeping supine or prone (sleep on
side in fetal position)
Review activities to minimize
hyperextension
NSAID
Consider bone scan to assess for facet
joint inflammation and possible
fluoroscopic guided facet joint steroid
injection.
Referral for fluoroscopic guided
injection if persistent pain and
positive bone scan.
X-ray to assess for DDD and foraminal
narrowing
D/C extension activities
Flexion stretches
Reduce lordotic posture
Avoid sleeping supine or prone (sleep on
side in fetal position)
Review activities to minimize
hyperextension
NSAID
Trial of traction with physio or home
inversion table
If radicular leg pain, consider CT scan to
assess foraminal stenosis and consider
fluoroscopic guided nerve root block.
If persistent radicular pain, consider
referral for fluoroscopic guided
foraminal nerve root block
Consider surgical opinion for
foraminal stenosis with lower
extremity pain if failure of
conservative therapy and persistent
severe leg pain or neurologic
compromise, unresponsive to 3
epidural injections.
NEXT
To Differential Dx
Return to page 1
SPECIFIC DIAGNOSIS
FEATURES
GP MANAGEMENT
TRANSITIONAL VERTEBRA
(Bertolotti’s Syndrome)
-
-
+/- Pseudoarticulation
SPINAL STENOSIS
-
Note: Transitional vertebra without pseudoarticulation may have several associated
anatomical variants
-
-
Low back +/- bilateral leg pain with
ambulation
Aggravated by walking
Walking limited by pain and weakness
(Neurogenic Claudication)
Immediately relieved by sitting ≤ 5 min
Not relieved by standing still
Circulation in lower extremities is normal
-
Morning stiffness > 1hr (< 1 hr if mild)
which improves with stretching exercises
Tender to palpation over SI joints
Sacroiliac stress tests positive with high ESR
+/- FABER positive
-
Chronic recurrent low back pain without
underlying pathology
Temporary improvement with manual
therapy and exercise
Leg length discrepancy on standing
assessment
Pain relieved with correction of leg length
inequality
-
-
SACRO-ILIITIS
-
SHORT LEG SYNDROME
Pain with extension and side bending to side
of pseudoarticulation
Prefer to sit
Usually history of activity causing extension
Look for increased lumbar lordotic posture
-
-
Rest and activity modification
CT or MRI for assessment
Monitor neurologic, bowel & bladder
function
Watch for development of balance or
gait disturbance
Use of assistive walker for ambulation
Epidural steroid injections q2wk
x 3 if needed
Alert: CT/MRI may be normal in case of
venous congestion causing spinal stenosis.
Also consider arachnoiditis )see below)
-
-
REFERRALS
X-ray to confirm diagnosis
D/C extension activities
Flexion stretches
Reduce lordotic posture
Avoid sleeping supine or prone (sleep on
side in fetal position)
Review activities to minimize
hyperextension
NSAID
Consider injection of associated
ligamentous structures causing pain
(i.e.: iliolumbar ligament medial and
lateral attachments)
-
Consider surgical opinion for severe
pain, neurologic compromise, or
significant loss of functional capacity
and unresponsive to 3 epidural
steroid injections.
X-ray AP view of pelvis
Bone scan
ESR, CRP, Platelets
NSAID
-
Referral for CT guided S.I. joint
injections q2wks x 3 if needed
Refer to Rheumatologist for diagnosis
and management
Assess degree of length discrepancy
(Standing pelvic crest & levels of
greater trochanters)
Corrective heal lift (up to 3/8” max in
footwear, otherwise apply to sole of
shoe)
Trial with heel lift recommended and
may require only 50% and up to 100%
correction for relief of symptoms
-
-
Consider orthopedic opinion if child
with significant discrepancy
NEXT
To Differential Dx
Return to page 1
SPECIFIC DIAGNOSIS
FEATURES
GP MANAGEMENT
REFERRALS
DEGENERATIVE DISC
DISEASE
-
-
Consider surgical opinion for spinal fusion
following failure of conservative
treatment
OSTEOPOROTIC
COMPRESSION FX
Chronic and recurrent low back pain with or
without lower extremity pain
Precipitated or aggravated by heavy lifting or
carrying
Morning stiffness < 20 min
Reduced lumbar mobility and muscle
guarding
Note: 80 to 90% of adults over 50 y/o will have
asymptomatic DDD
-
IDIOPATHIC SCOLIOSIS
-
Acute onset
Severe pain aggravated by movement
History of lift, fall, or minor trauma
History of steroid use, osteoporosis or
malignancy
Thoracic kyphosis (Gibbus Deformity)
Height loss
Aggravated by jarring movements (i.e.: car
ride)
Often asymptomatic
Gradual onset of symptoms
Screen all children annually with physical
exam
-
Light to moderate exercise only (eg:
cycle, walk, swim)
Limit lifting, running, jumping, or jarring
movements
Flexion stretching exercises (avoid
extension movements)
Home traction with inversion table
Analgesic or NSAID as needed
+/- back support for use during
moderate activity
Acute:
x-ray (AP & Lat)
Narcotic analgesia
Calcitonin to assist with pain control
Rest
Temporary brace if necessary
Bone Densitometry
R/O Metastatic Disease
Review diet and medication regarding
osteoporosis
Chronic:
Significant pain after 3 months, consider
Vertebroplasty or Kyphoplasty
Alert: Consider Multiple Myeloma if <50yrs
(Serum protein electrophoresis and spot
urine electrophoresis)
-
Annual scoliosis x-ray if sign of
progression
Consider yoga for scoliosis, swimming,
and cycling
-
INFLAMMATORY
ARTHROPATHIES
-
Morning stiffness >1hr diagnostic
Improved with stretching exercises
Morning stiffness <1hr (mild SpA)
Onset usually <40 years of age
Gradual onset
Pain > 3 months
Reduced spinal range of motion
Relieved by NSAID
Sacroiliitis, Iritis, IBD, Enthesitis, Psoriasis,
FHx of AS/ReA/SpA
-
Consider ESR or CRP, Bone Scan
Analgesics, NSAID
Range of motion exercises
Pool exercise
Arthritis Society website
3 wk trial of Flurbiprofen 150mg BID,
Ibuprofen 600mg QID, or other NSAID
(q3-6mo BUN/Creatinine/eGFR/
AST/ALT)
-
-
Consider surgical opinion if pain
unresponsive to conservative
treatment measures after 3 months.
Refer to community scoliosis clinic
Refer to physiotherapy for scoliosis
exercise protocol
Refer for bracing if curvature > 20
degrees or progressive
Consider surgical opinion if significant
and progressive curvature
Refer to Rheumatologist if not
responding to GP management,
developing systemic manifestations,
or diagnosis of psoriatic arthritis,
Ankylosing Spondylitis, Reactive
Arthritis
Urgent ophthalmology referral if Iritis
Dermatology referral for psoriasis
Alert: Onset may be triggered by trauma
NEXT
To Differential Dx
Return to page 1
SPECIFIC DIAGNOSIS
FEATURES
GP MANAGEMENT
DISCITIS, OSTEOMYELITIS,
SPINAL EPDURAL ABCESS
-
Severe unremitting pain
Fever, chills, tachycardia
+/- drenching night sweats
Complains of feeling and appears unwell
Night pain
Hx of Infection, STD, or IV drug use
Hx of spinal surgery
Aggravated by jarring movements (i.e.: car
ride)
-
Urgent admission to hospital
WBC, ESR/CRP, Blood Cultures
Urgent Consult with Infectious Disease specialist
Urgent Consult with Spinal Surgeon
MRI
Pain management
ARACHNOIDITIS
-
Severe unremitting back pain
+/- lower limb symptoms
History of spinal surgery
-
MRI
PAGET’S DISEASE
-
Isolated elevated Alkaline Phosphatase
PELVIC AND VERTEBRAL
ASYMMETRY
-
Usually caused by physical strain, postural
strain,or injury
Vertebral segmental or S.I. motion
restrictions
Vertebral spinous process misalignment
Pelvic asymmetry with PSIS and ASIS
misalignment
-
Alert: Monitor for Cauda Equina Syndrome
-
-
If leg length discrepancy identified,
consider corrective heel lift
If congenital structural abnormality
suspected, consider standing A-P x-ray
of lumbar spine and pelvis.
Referral to osteopathic physician,
chiropractor, or physiotherapist trained
in spinal manipulation for further
assessment and management in all
other cases.
CONSIDER OTHER
DIAGNOSES
-
-
-
Other intraspinal lesions
(tumor, facet ganglion cysts,
other mass or erosive lesions)
Metastatic disease
Vascular claudication
Abdominal aortic aneurysm
Renal/Ureteral lithiasis
Other abdominal pathology
Psycho-social factors (Stress
reaction, drug seeking,
litigation, financial gain?)
Enthesitis
Tarlov Cysts
(Source: GPSC - MSK Initiative - Expert Group for Low Back Pain – April 2011)
REFERRALS
-
Referral to pain management clinic
Return to page 1
Monitoring & Follow-up
Proactive involvement in managing recovery can help prevent long-term
problems.
At each follow-up visit:
 Give green light advice to stay or become active and resume usual
activities. (Please refer to details in following section).
 Provide specific advice on activities that may cause problems
 Support return to activity with optimal pain control
 Identify and address any barriers to recovery such as:
o Changes in pain and function.
o Excessively heavy or prolonged work
o Problems with treatment, rehabilitation or compensation
 Review physical findings for red flag issues
 Review effectiveness of patient education and self-directed treatment
plans

Agree on a plan and encourage autonomy and self-management
NEXT
Return to page 1
Print
Patient Follow-up Assessment - Brief Pain Inventory
Patient name: _________________________________ PHN: _________________________________
Date: _________________________________ Date of birth: _________________________________
Completion of this questionnaire will help your physician with today’s visit.
1. If you have pain, indicate areas of your body where the pain is located.
2. Pain intensity – if you have multiple areas of pain – which area gives you the most pain or discomfort ?
_________________________________________________________________________________
a. For this area of pain – please circle the one number that best describes your pain at its worst
in the past 24 hours.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
b. For this area of pain – please circle the one number that best describes your pain at its least
in the past 24 hours.
No pain
c.
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
For this area of pain – please circle the one number that best describes your pain on the
average.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
Turn over the page
NEXT
Return to page 1
d. For this area of pain – please circle the one number that tells how much pain you have right
now.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
3. What makes your pain feel better? ____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
4. What makes your pain feel worse? ____________________________________________________
________________________________________________________________________________
________________________________________________________________________________
5. In the last 24 hours, how much relief have your pain treatments or medications provided? Please
circle the one percentage that shows most how much relief you have received.
No relief
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complete relief
6. Circle the one number that describes how, during the past 24 hours, your pain level has interfered
with your:
a. General Self-Care Activities (e.g., dressing, bathing, etc.):
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
1
2
3
4
5
6
7
8
9
10
Completely interferes
b. Mood:
Does not interfere
c.
Walking Ability:
Does not interfere
0
d. Normal work (includes both work outside the home and housework):
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
e. Relations with other people:
Does not interfere
f.
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
2
3
4
5
6
7
8
9
10
Completely interferes
Sleep:
Does not interfere
g. Enjoyment of life
Does not interfere
0
1
Thank you for completing this questionnaire.
Return to page 1
Referral Options
Referral
Criteria
Physiotherapist:




For advice on an exercise program to improve function, support participation in daily
activities / leisure and maintain or improve body movement, strength, and flexibility
For use of non-pharmacological treatments to improve pain
Education and support for physical activities and healthy lifestyle
www.bcphysio.org
Occupational Therapist:




For assessment of activities of daily living
For an ergonomic assessment of work
For work site and home adaptation
www.bcsot.org
Dietitian:



To provide information about food and dietary concerns
For weight management if increased risk of CVD
Health Link BC: Dial 811 (Hearing impaired 711)
Social Worker:




To help connect patients and their families with supportive community resources
To provide support and advice to patients experiencing difficulties coping with low back
pain or with emotional or social difficulties
To provide advice regarding work if a vocational counselor is not available
www.bccollegeofsocialworkers.ca
Vocational Counselor:



To assess work situation and recommend job accommodations if necessary
To provide career counseling
To advise regarding available resources for employment issues
GP to
Specialist
Acknowledgement
of Referral
RACE
Referral
Specialist
to GP
Return to page 1
Referral Criteria

Patients with disabling back or leg pain, or significant limitation of function including
job related activities should be referred within 2-6 weeks to a trained spinal care
specialist such as a physical therapist, chiropractor, osteopath physician or physician
who specializes in musculoskeletal medicine.

Consult or refer to a spinal surgeon if the patient has neuromotor deficits that persist
after 4 to 6 weeks of conservative treatment or sciatica for longer than 6 weeks
with positive straight leg raise.
Three optional tools are offered to guide the type of information required in communicating
between GPs, Specialists and other health care providers. The template forms could be printed
and completed or used as a guide for the type of information to be included in a dictated letter.
They include:
 MSK Referral Form – GP to Specialist or other health care provider
 Specialist Acknowledgement of Referral
 MSK Specialist Consult Report – Response to Referring GP
In addition to the referral tools, there is also information on Rapid Access to Consultative
Expertise (RACE) for pain.
Access to Pain Specialists can be facilitated through the RACE Line (Rapid Access to Consultant
Expertise). RACE means timely telephone advice from specialists for family practitioners, Community
Specialists or House staff, all in one phone call.
Monday to Friday 0800-1700 Local Calls: 604-696-2131 Toll Free: 1-877-696-2131
RACE provides:
 Timely guidance and advice regarding assessment, management and treatment of patients
 Assistance with plan of care
 Learning opportunity – educational and practical advice
 Enhanced ability to manage the patient in your office
 Calls returned within 2 hours and commonly within an hour
 CME credit through “Linking Learning to exercises”
http://www.cfpc.ca/Linking_Learning_to_Exercises/
RACE does not provide:
 Appointment booking
 Arranging transfer
 Arranging for laboratory or diagnostic investigations
 Informing the referring physician of results of diagnostic investigations
 Arranging a hospital bed.
Unanswered Calls?
If you call the RACE line and do not receive a call back within 2 hours – call the number below. All
unanswered calls will be followed up. For questions or feedback related to RACE, call: 604-682-2344,
extension 66522 or email [email protected]
BACK
NEXT
Return to page 1
Print
MSK Referral Form – GP to Specialist
Reason for referral: ________________ ____________________________________ Consult 2nd Opinion Diagnosis Level of Urgency: Emergency Referred by: _________________________________ GP Walk‐in Clinic Emergency Dept. Urgent Elective
Preferred Specialist: ______________________ First Available: ____________________________ Funding Source / Payer Coverage : WCB ICBC PRIVATE OTHER Patient Name: PHN: Date of birth: Referring Physician: Phone: Fax: Most Responsible Physician: Phone Fax: Pain Levels / Symptoms & Duration of Symptoms: Abnormal Findings on Physical Exam: Functional Limitations: Relevant Family History: Relevant Lab and X‐ray Results: (Please attach) Co‐morbidities: Recent relevant consultations: FOLLOW‐UP RESPONSIBILITY: Advice Only from Specialist Ongoing Specialist Care Shared Care Current Medications / Drug name: Start Dose Frequency Taking as Prescribed Comments GP SIGNATURE: ____________________________________________ DATE: ________________ NEXT
Return to page 1
Print
Acknowledgment of Referral
Patient Information (place sticker here)
Thank you for your referral to ____________________.
Acknowledgement of Referral within 48 hours (to be completed by specialist clinic)
Our office will make the appointment with your patient within the next _________ week(s)
Your patient is booked to see a specialist on ____________________________
Please notify your patient of the above appointment
We will notify your patient of the above appointment
Attached is additional information for you to give to your patient
We require additional information
before we can book the patient
prior to the patient’s appointment
NEXT
Return to page 1
Print
MSK Specialist Consult Report – Response to Referring GP
BACKGROUND
Patient Name:
PHN:
Date of birth:
Date Seen by Specialist:
Symptoms and functional limitations:
TREATMENT
DIAGNOSIS
Rationale for diagnosis / level of severity:
Alternatives for treatment (costs / benefits/ drawbacks):
RESPONSIBILITIES
Responsibility for treatment and follow-up care:
Advice Only from Specialist
Ongoing Specialist Care
Shared Care
Most Responsible Physician:
Specialist:
FOLLOW UP ACTION
Investigations / tests required:
Follow-up visit with Specialist:
Copy to:
Referring Physician:
Most Responsible Physician:
Fax :
Date:
Fax:
Date:
SPECIALIST SIGNATURE: _______________________________________ DATE: ____________________
NEXT
Return to page 1
Print
RACEconnect.ca
Monday to Friday 0800-1700
Local Calls: 604-696-2131
Toll Free: 1-877-696-2131
RAPID ACCESS TO
CONSULTATIVE EXPERTISE
Telephone advice for:
Nurse
Practitioners
Family
Physicians
• family physicians
• community specialists
• nurse practitioners
• house staff
S
Connect
Community
Specialists
RACE can help you:
• simplify the patient journey
• improve patient outcomes
• reduce system costs
• connect with specialists
RACE Specialists
TImely
House
Staff
RACE provides:
An opportunity to speak directly with specialists
Timely guidance and advice
Enhanced ability to manage the patient in your office
2
HRS
Assistance with plan of care
Learning opportunity
CME
Calls returned within 2 hours and commonly
within an hour
CME credit through “Linking Learning to Practice”
www.cfpc.ca/Linking Learning_to_Practice
Speak directly to a specialist:
VCH
• Nephrology
• Heart Failure
• Psychiatry
• Respirology
• Endocrinology
• Cardiovascular
• Risk & Lipid Management
• General Internal Medicine
• Geriatrics
• Geriatric Psychiatry
• Gastroenterology
VCH & FHA
Provincial Services
• Cardiology
• Rheumatology
• Child & Adolescent Psychiatry
• Chronic Pain
• Treatment Resistant Psychosis
Unanswered Calls?
If you call the RACE line and do not receive a call back within 2 hours, call: 604-682-2344 ext. 66522.
RAPID ACCESS TO
CONSULTATIVE EXPERTISE
Return to page 1
Print
Red Flags
At the initial assessment the critical role of the family physician is to screen for red flags. These
may indicate serious disease (not always confined to the back) that can cause back pain. They
include:

Features of Cauda Equina syndrome including sudden onset or loss of bladder / bowel
control, saddle anaesthesia (emergency)









Severe worsening pain, especially at night or when lying down (urgent)
Significant trauma (urgent)
Weight loss, history of cancer, fever, rash, infection (urgent)
Use of steroids or intravenous drugs (urgent)
Patient with first episode over 50 years old (soon)
Pain in child < 10 years old (soon)
Abdominal pain
Inter-menstrual or rectal bleeding
Balance or gait disturbance
Features of Inflammatory Low Back Pain:



Morning stiffness >1hr diagnostic

Onset usually <40 years of age



Pain > 3 months
Improved with stretching exercises or movement
Night pain
Reduced spinal range of motion
Sacroiliitis, Iritis, IBD, Enthesitis, Psoriasis, FHx of AS/ReA/SpA
If red flags are present, referral for specialist management should be considered where an
emergency case requires referral within hours; an urgent case requires referral within 24-48
hours and a non-urgent case requires referral within weeks.
Factors to consider include:
 The history of the acute episode
 Activities that may be associated with pain
 How limiting the symptoms are
 If there have been similar episodes before
 Any factors that might limit recovery and an early return to activities of daily living (work,
home, leisure)
(Source: Alberta Toward Optimized Practice Guideline, 2009)
NEXT
Return to page 1
Rule out red flag conditions
for acute low back pain
Symptoms:
❐ Neurological: major motor weakness,
disturbance of bowel or bladder
control, saddle numbness
❐ Infection: fever, risk of UTI, IV drug
use, immune suppressed
❐ Fracture: trauma, osteoporosis risk
❐ Tumor: history of cancer, weight loss,
fever, pain worse supine or at night
❐ Inflammation: morning stiffness >
1 hour, Age: < 20 years or > 50 years
Adapted from: The Peterborough Back Rules chart template.
G. Powell and The Peterborough Back Rules Working Group.
September, 1997.
This is a POCKET tool. www.pocketdocs.ca
NEXT
Return to page 1
Print
RedFlag
Flag Investigations
Investigations
Red
If Red Flags are present, this is the recommended approach:

All patients with symptoms or signs of Cauda Equina Syndrome should be referred
urgently to hospital for orthopedic or neurosurgical assessment.

If cancer or infection is suspected, order the appropriate blood tests. In the absence of
red flags, no laboratory tests are recommended.

Patients with red flags should be investigated appropriately and referred to a specialist if
indicated by clinical findings and test results.

Investigations in the first 4-6 weeks of an acute low back pain episode do not provide
clinical benefit, unless there are red flags.

A full blood count and ESR should usually be performed only if there are red flags. Other
tests may be indicated depending on the clinical situation.

Radiological investigations (x-rays and CT scans) carry the risk of potential harm from
radiation related effects and should be avoided if not required for diagnosis or
management.

Remember red flag pathology may lie outside the lumbar region and may not be
detected by radiology.

For non-specific acute low back pain (no red flags), diagnostic imaging tests, including xray, CT and MRI, are not indicated.

Many people without symptoms show abnormalities on x-rays and MRI. The chances of
finding coincidental disc prolapse increase with age. It is important to correlate MRI
findings with age and clinical signs before advising surgery.

In chronic low back pain, x-rays of the lumbar spine are very poor indicators of serious
pathology. Hence, in the absence of clinical red flags spinal x-rays are not encouraged.
More specific and appropriate diagnostic imaging should be performed on the basis of
the pathology being sought (e.g. DEXA scan for bone density, bone scan for tumors and
inflammatory diseases).

However, lumbar spine x-rays may be required prior to more sophisticated diagnostic
imaging, for example prior to performing a CT or MRI scan. In this case, the views
should be limited to anterior-posterior (AP) and lateral (LAT) without requesting oblique
views.
(Source: New Zealand Guidelines to Acute Low Back Pain, October 2004 edition)
Return to page 1
Immediate Treatment of Low Back Pain
 Use of hot or cold compresses has never been proven scientifically to
speed symptom resolution, but some patients may experience brief
relief.
 Gentle flexion/extension exercises are helpful.
 Pharmacologic therapy involves both anti-inflammatory medication
and muscle relaxants.
o Unless the patient is allergic to the medicine or it is otherwise
contraindicated, severe low back pain can be improved
significantly with a combination of nonsteroidal antiinflammatory drugs (NSAIDs) and muscle relaxants.
o Narcotics may be used initially to gain relief, but their long-term
use is associated with increased functional impairment.
Return to page 1
Print
Giving Patients the Green Light
During the course of initial presentation, diagnosis and treatment, patients may have a
number of anxieties and questions that they may not necessarily raise or share with their
family physician. There is clear evidence that the following strategies also improve
outcomes for people with acute low back pain:





Advise patients to ‘stay active’ and continue their usual activities
Provide them with an explanation and reassurance, rather than a diagnosis
Control their pain with simple analgesics, or manipulation if necessary
Promote staying at work – or an early return to work, with modifications if needed
Provide ongoing management and review.
Staying Active and Continuing Activities - Key Points: Pain does not equate to
damage. Staying active and continuing usual activities, within tolerable pain limits, helps
recovery
 Increase activity according to a plan
 Modify activities if necessary and use pain relief – but stay active
 Avoid bed rest
 Continue usual daily activities and resume work as soon as possible
Explanation and Reassurance - Key Points:
 The pain will settle – most people make an excellent recovery
 There is no sign of anything serious – and radiology tests are not needed
 Movement and activity will not cause harm – it is important to stay active
Planned & Safe Return to Work - Key Points:
 Paid and unpaid work is important to both physical and mental recovery.
 Planned early return to activity / work is likely to reduce the risk of long-term
problems and chronic back pain.
 Avoid heavy lifting, bending or twisting, and modify some tasks for awhile.
 Provide a plan for progressive return to work / activity
 Encourage ongoing contact with employer
 Support return to activity with pain relief, if needed
 Give advice on monitoring and managing activities that cause pain
 Provide advice on changes to the rate, duration and nature of work
 Identify barriers to recovery – and involve other providers if required
Return to page 1
Print
Return to Work Letter – Recovery Planning for Low Back Injury
To Whom It May Concern
Re: _________________________________________________________________________
This letter is to inform the reader about the medical factors that should guide return to work for my patient named above, using evidence based strategies shown to improve outcomes for people with acute low back pain. This is based on my evaluation of his/her medical condition on: ______________________________(date) I recommend return to usual activity including work as soon as possible. However, as a result of his/her medical condition, he/she is anticipated to be unable to perform or perform only with difficulty and pain, tasks such as: 


Lifting from below knee level, Sitting or standing still for more than a few minutes Carrying more than a few pounds 

Bending, stooping and twisting ______________________________________
While some activities may result in temporary pain, this is not an indication that these will cause permanent harm or delay the expected recovery, which is usually within a few weeks. The following types of work activity will likely help recovery and are recommended: 



Frequent walking Change of position Ability to sit or stand intermittently Working at own pace 

Consideration of temporary reduction in work hours _________________________________ Medications to reduce pain levels and thus improve tolerance to activity may be taken as directed, and while these are not expected to result in any impairment in performance, if there is evidence of such, he/she should be advised to review with me as soon as possible. I plan to review his/her condition on ____________________________________(date ) or in _____________ ( weeks) when I will advise further at that time, if necessary. Your input as below would be helpful. ____________________________________ MD ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Employer Feed‐Back to Physician To the Physician: __________________________(name) has worked _________ hrs from _____________date to _____________date. He/she is tolerating the assigned hours and tasks better /about the same / less than before. (circle one) and has / has not been able to increase the level of work activity. We have discussed future options and would suggest as follows: _______________________________Employer ________________________________Date NEXT
Return to page 1
Deciding how to Access
Psychosocial Yellow Flags
Initial presentation of acute low
back pain – note Yellow Flags
Initial
Presentation
YES
Making expected progress
(eg 2 to 4 weeks)?
NO
Using screening questionnaire
Proceed directly to further
assessment if there are
significant factors
YES
At risk
Clinical assessment of
Psychosocial factors
RECOVERY
2 – 4 weeks
follow up
Not at risk
NO
Monitor progress
·
·
·
NO
Do you have the skills and
resources required to develop and
implement a management plan?
Satisfactory restoration of
activities?
Returning to work?
Satisfactory response to
treatment?
YES
Refer to suitable clinician
Specify date for progress report
YES
Proceed with management
Target specific issues to prevent
long-term distress, reduced activity
and work loss
Adapted from: New Zealand Low Back Pain Guide, October 2004 Edition, p 36
NEXT
Return to page 1
Clinical Assessment of
Psychosocial Yellow Flags
The information presented here is taken entirely, without any content modification from: Kendall, N A S,
Linton, S J & Main, C J (1997). Guide to Assessing Psycho-social Yellow Flags in Acute Low Back Pain: Risk
Factors for Long-Term Disability and Work Loss. Accident Compensation Corporation and the New Zealand
Guidelines Group, Wellington, New Zealand. (Oct, 2004 Edition).
These headings (Attitudes and Beliefs about Back Pain, Behaviors, Compensation
Issues, Diagnosis and Treatment, Emotions, Family and Work) have been used for
convenience in an attempt to make the job easier. They are presented in alphabetical
order since it is not possible to neatly rank their importance. However, within which
category the factors are listed with the most important at the top of the list.
Attitudes and Beliefs about Back Pain
• Belief that pain is harmful or disabling resulting in fear-avoidance behavior,
eg, the development of guarding and fear of movement
• Belief that all pain must be abolished before attempting to return to work or
normal activity
• Expectation of increased pain with activity or work, lack of ability to predict
capability
• Catastrophising, thinking the worst, misinterpreting bodily symptoms
• Belief that pain is uncontrollable
• Passive attitude to rehabilitation
Behaviours
• Use of extended rest, disproportionate ‘downtime’
• Reduced activity level with significant withdrawal from activities of daily living
• Irregular participation or poor compliance with physical exercise, tendency for
activities to be in a ‘boom-bust’ cycle
• Avoidance of normal activity and progressive substitution of lifestyle away from
productive activity
• Report of extremely high intensity of pain, eg, above 10, on a 0-10 Visual Analogue
Scale
• Excessive reliance on use of aids or appliances
• Sleep quality reduced since onset of back pain
• High intake of alcohol or other substances (possibly as self-medication), with an
increase since onset of back pain
• Smoking
Compensation Issues
•
•
•
•
Lack of financial incentive to return to work
Delay in accessing income support and treatment cost, disputes over eligibility
History of claim/s due to injury or other pain problem
History of extended time off work due to injury or other pain problem (eg, more
than 12 weeks)
1
NEXT
Return to page 1
• History of previous back pain, with a previous claim/s and time off work
• Previous experience of ineffective case management (eg, absence of interest,
perception of being treated punitively)
Diagnosis and Treatment
• Health professional sanctioning disability, not providing interventions that will
improve function
• Experience of conflicting diagnosis or explanations for back pain, resulting in
confusion
• Diagnostic language leading to catastrophising and fear (eg, fear of ending up
in a wheelchair)
• Dramatization of back pain by health professional producing dependency of
treatments, and continuation of passive treatment
• Number of times visited health professional in last year (excluding the present
episode of back pain)
• Expectation of a ‘techno-fix’, eg, requests to treat as if body were a machine
• Lack of satisfaction with previous treatment for back pain
• Advice to withdraw from job
Emotions
•
•
•
•
Fear increased pain with activity or work
Depression (especially long-term low mood), loss of sense of enjoyment
More irritable than usual
Anxiety about and heightened awareness of body sensations (includes
sympathetic nervous system arousal)
• Feeling under stress and unable to maintain sense of control
• Presence of social anxiety or disinterest in social activity
• Feeling useless and not needed
Family
• Over-protective partner/spouse, emphasizing fear of harm or encouraging
catastrophising (usually well-intentioned)
• Solicitous behavior from spouse (eg, taking over tasks)
• Socially punitive responses from spouse (eg, ignoring, expressing frustration)
• Extent to which family members support any attempt to return to work
• Lack of support person to talk about problems
2
NEXT
Return to page 1
Work
• History of manual work, notably from the following occupational groups:
- Fishing, forestry and farming workers
- Construction, including carpenters and builders
- Nurses
- Truck drivers
- Labourers
• Work history, including patterns of frequent job changes, experiencing stress at
work, job dissatisfaction, poor relationships with peers or supervisors, lack of
vocational direction
• Belief that work is harmful; that it will do damage or be dangerous
• Unsupportive or unhappy current work environment
• Low educational background, low socioeconomic status
• Job involves significant bio-mechanical demands, such as lifting, manual
handling heavy items, extended sitting, extended standing, driving, vibration,
maintenance of constrained or sustained postures, inflexible work schedule
preventing appropriate breaks
• Job involves shift work or working unsociable hours
• Minimal availability of selected duties and graduated return to work
pathways, with unsatisfactory implementation of these
• Negative experience of workplace management of back pain (eg, absence
of a reporting system, discouragement to report, punitive response from
supervisors and managers)
• Absence of interest from employer
Remember the key question to bear in mind while conducting these clinical assessments is
“What can be done to help this person experience less distress and disability?”
3
NEXT
Return to page 1
Yellow flags indicate psychosocial barriers to recovery. Identifying yellow flags in
patients can be challenging. Yellow Flags indicate psychosocial barriers to recovery
that may increase the risk of long-term disability and work loss. Identifying any Yellow
Flags may help when improvement is delayed. Yellow Flags include:
Yellow Flag
Intervention
Belief that pain and activity are harmful
Educate and consider referral to active rehab
“Sickness behaviors” (like extended rest)
Educate and consider pain clinic referral
Low or negative moods, social withdrawal
Assess for psychopathology and treat
Treatment beliefs do not fit best practice
Educate
Problems with claim and compensation
Connect with stakeholders and case manage
History of back pain, time-off, other claims
Follow-up regularly refer if recovering slowly
Problems at work, poor job satisfaction
Engage case management through disability
carrier
Heavy work, unsociable hours (shift work)
Follow-up regularly refer if recovering slowly
Overprotective family or lack of support
Educate patient and family
NEXT
Return to page 1
Psychosocial Yellow Flags: Helping Someone at Risk
Suggested steps to better early behavioral management of low back pain problems
 Provide a positive expectation that the individual will return to work and normal activity. Organize
for a regular expression of interest from the employer. I
 Be directive in scheduling regular reviews of progress. When conducting these reviews shift the
focus from the symptom (pain) to function (level of activity). Instead of asking “How much do you
hurt?” ask “What have you been doing?”
 Keep the individual active and at work if at all possible, even for a small part of the day. This will
help to maintain work habits and work relationships.
 Acknowledge difficulties with activities of daily living, but avoid making the assumption that these
indicate all activity or any work must be avoided.
 Help to maintain positive cooperation between the individual, an employer, the compensation
system, and health professionals. Encourage collaboration wherever possible. Please refer to the
template letter to employers – Return to Work as an example of collaboration.
 Make a concerted effort to communicate that having more time off work will reduce the likelihood
of a successful return to work. At the 12-week point consider suggesting vocational redirection,
permanent job changes
 Be alert for the presence of individual beliefs that he or she should stay off work until treatment
has provided a ‘total cure’. Watch out for expectations of simple ‘techno-fixes’.
 Promote self-management and self-responsibility. Encourage the development of self-efficacy to
return to work.
 Be prepared to ask for a second opinion, provided it does not result in a long and disabling delay.
Use this option especially if it may help clarify that further diagnostic work is unnecessary.
 Avoid confusing the report of symptoms with the presence of emotional distress. Exclusive focus
on symptom control is not likely to be successful if emotional distress is not dealt with.
 Avoid suggesting (even inadvertently) that the person from a regular job may be able to work at
home, or in their own business because it will be under their own control. Self employment nearly
always involves more hard work.
 Encourage people to recognize, from the earliest point, that pain can be controlled and managed
so that a normal, active or working life can be maintained. Provide encouragement for all ‘well’
behaviors—including alternative ways of performing tasks, and focusing on transferable skills.
The information presented here is taken entirely, without any content modification from: Kendall, N A S, Linton, S J &
Main, C J (1997). Guide to Assessing Psycho-social Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term
Disability and Work Loss. Accident Compensation Corporation and the New Zealand Guidelines Group, Wellington, New
Zealand. (Oct, 2004 Edition).
Return to page 1
Treatment Considerations for Acute Low Back Pain
Acute low back pain is common and episodes by definition last less than 12 weeks. In a few
cases there is a serious cause but generally the pain is non-specific and precise diagnosis is not
possible or necessary.
Acute Low Back Pain Recommendations
Laboratory Testing
If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no
laboratory tests are recommended.
Reassessment of Patients Whose Symptoms Fail to Resolve
Reassess patients whose symptoms are not resolving. Follow-up in one week if pain is severe and has
not subsided. Follow-up in three weeks if moderate pain is not improving. Follow-up in 6 weeks if not
substantially recovered. If serious pathology (red flag) is identified, consider further appropriate
management. Identify psychosocial risk factors (yellow flags) and address appropriately.
Information and Reassurance
Educate the patient and describe the benign long-term course of low back pain. Provide education
materials that are consistent with your verbal advice, to reduce fear and anxiety and emphasize active
self-management.
Cold Packs or Heat
In the first 72 hours recommend cold packs (ice), after that, alternate cold and heat as per patient’s
preference.
Heat or cold should not be applied directly to the skin, and not for longer than 15 to 20 minutes. Use with
care if lack of protective sensation.
Advice to Stay Active
Patients should be advised to stay active and continue their usual activity, including work, within the
limits permitted by the pain. Physical exercise is recommended.
Return to Work
Encourage early return to work.
Refer workers with low back pain beyond 6 weeks to a comprehensive return-to- work rehabilitation
program. Effective programs are typically multidisciplinary and involve case management, education
about keeping active, psychological or behavioral treatment and participation in an exercise program.
Working despite some residual discomfort poses no threat and will not harm patients.
Analgesia
Prescribe medication, if necessary, for pain relief preferably to be taken at regular intervals. First choice
acetaminophen; second choice NSAIDs. Only consider adding a short course of muscle relaxant
(benzodiazepines, cyclobenzaprine, or antispasticity drugs) on its own, or added to NSAIDs, if
acetaminophen or NSAIDs have failed to reduce pain.
Narcotic Analgesics
There is evidence that the effect of opioid or compound analgesics is similar to NSAID treatment of
acute low back pain.
Oral opioids may be necessary to relieve severe musculoskeletal pain. It is preferable to administer a
short-acting agent at regular intervals, rather than on a pain-contingent basis. Ongoing need for opioid
analgesia is an indication for reassessment.
In general, opioids and compound analgesics have a substantially increased risk of side effects
compared with acetaminophen alone.
NEXT
Return to page 1
Acute Low Back Pain Recommendations
Spinal Manipulation
Patients who are not improving may benefit from referral for spinal manipulation provided by a trained
spinal care specialist such as a physical therapist, chiropractor, osteopathic physician or physician who
specializes in Musculoskeletal (MSK) medicine.
Risk of serious complication after spinal manipulation is low (estimated risk: cauda equina syndrome
less than 1 in one million). Current guidelines contraindicate manipulation in people with severe or
progressive neurological deficit.
Multidisciplinary Treatment Programs
Encourage early return to work. Refer patients who have difficulty returning to work to a multidisciplinary
treatment program.
Traction
Do not use traction. Traction has been associated with significant adverse events.
The following adverse effects from traction were reported: reduced muscle tone, bone demineralization,
and thrombophlebitis.
Massage Therapy
Massage therapy is not recommended as a treatment for acute low back pain.
Transcutaneous Electrical Nerve Stimulation (TENS)
TENS is not recommended for the treatment of acute non-specific low back pain.
Oral and Epidural Steroids
Oral Steroids
Do not use oral steroids for acute non-specific low back pain
Epidural Steroids
Do not use epidural steroid injections for acute non-specific low back pain without radiculopathy. It is
reasonable to use epidural steroid injections for patients with radicular pain for greater than 6 weeks
who have not responded to first line treatments.
Adverse effects are infrequent and include headache, fever, subdural penetration and more rarely
epidural abscess and ventilatory depression.
Bed Rest
Do not prescribe bed rest as a treatment.
If the patient must rest, bed rest should be limited to no more than 2 days. Prolonged bed rest for more
than 4 days is not recommended for acute low back problems. Bed rest for longer than two days
increases the amount of sick leave compared to early resumption of normal activity in acute low back
pain.
There is evidence that prolonged bed rest is harmful.
Return to page 1
To Assessment Page
Treatment Considerations for Chronic Low Back Pain
Chronic low back pain is defined as pain lasting more than 12 weeks. It may cause severe
disability. Chronic back pain may be associated with psychosocial barriers to recovery.
Patients with symptoms lasting more than 8 weeks have a rapidly reducing rate of return to
usual activity.
Chronic Low Back Pain Recommendations
Diagnostic Tests
In chronic low back pain, X-rays of the lumbar spine are very poor indicators of serious pathology.
Hence, in the absence of clinical red flags spinal X-rays are not encouraged. More specific and
appropriate diagnostic imaging should be performed on the basis of the pathology being sought (e.g.
DEXA scan for bone density, bone scan for tumors and inflammatory diseases). However, lumbar spine
X-rays may be required prior to more sophisticated diagnostic imaging, for example prior to performing a
CT or MRI scan. In this case, the views should be limited to anterior-posterior (AP) and lateral (LAT)
without requesting oblique views.
Oblique view X-rays are not recommended; they add only minimal information in a small percentage of
cases, and more than double the patient’s exposure to radiation.
Laboratory Testing
If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no
laboratory tests are recommended.
Self-management Programs
Where available, refer to a structured community-based self-management group program for patients
who are interested in learning pain coping skills. These programs are offered through chronic disease
management and chronic pain programs. Self-management programs focus on teaching core skills
such as self monitoring of symptoms to determine likely causal factors in pain exacerbations or
ameliorations, activity pacing, relaxation techniques, communication skills, and modification of negative
‘self talk’. These programs use goal setting and ‘homework assignments’ to encourage participants’ self
confidence in their ability to successfully manage their pain and increase their day-to-day functioning.
Most community-based programs also include exercise and activity programs that are also
recommended.
Where structured group programs are not available, refer to a trained professional for individual selfmanagement counseling.
Physical Exercise and Therapeutic Exercise
Patients should be encouraged to initiate gentle exercise and gradually increase their exercise level
within their pain tolerance.
Sophisticated equipment is not necessary. Low cost alternatives include unsupervised walking and
group exercise programs such as those offered though chronic disease management programs. The
outcome for group exercise is likely better in terms of peer support, giving people improved confidence
and empowering patients to manage with less medical intervention.
If exercise persistently exacerbates their pain, patients should be further assessed by a knowledgeable
physician to determine if further investigation, medications, other interventions, and/or consultation are
required.
The exercise program should also be assessed by a knowledgeable physical therapist or qualified
exercise specialist if the exercises exacerbate the patient’s pain.
NEXT
Return to page 1
To Assessment Page
Chronic Low Back Pain Recommendations
Active Rehabilitation
Active rehabilitation program includes:

Education about back pain principles

Self-management programs (see Self-management section of Toolkit)

Gradual resumption of normal activities (including work and physical

exercise) as tolerated

Therapeutic exercise - there is strong evidence that therapeutic exercise is effective for chronic
low back pain. There is no conclusive evidence as to the type of therapeutic exercise that is
best. A client-specific, graded, active, therapeutic exercise program is recommended
Massage Therapy
Massage therapy is recommended as an adjunct to an overall active treatment program.
Acupuncture
Acupuncture is recommended as a stand-alone therapy or as an adjunct to an overall active treatment
program.
No serious adverse events were reported in the trials. The incidence of minor adverse events was 5% in
the acupuncture group.
Transcutaneous Electrical Nerve Stimulation (TENS)
The research evidence does not support the use of TENS as a sole treatment for chronic low back pain.
However, clinical experience suggests that TENS may be useful in select patients for pain control to
avoid or reduce the need for medications. A short trial (2 to 3 treatments) using different stimulation
parameters should be sufficient to determine if the patient will respond to this modality.
Acetaminophen and Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Acetaminophen and NSAIDs are recommended. No one NSAID is more effective than another.
NSAIDs are associated with mild to moderately severe side effects such as: abdominal pain, diarrhea,
edema, dry mouth, rash, dizziness, headache, tiredness. There is no clear difference between different
types of NSAIDs.
Muscle Relaxants
Some muscle relaxants (e.g., cyclobenzaprine) may be appropriate in selected patients for symptomatic
relief of pain and muscle spasm.
Caution must be exercised with managing side effects, particularly drowsiness, and also with patient
selection, given the abuse potential for this class of drugs.
Antidepressants
Tricyclic antidepressants have a small to moderate effect for chronic back pain, at much lower doses
than might be used for depression.
Possible side-effects include drowsiness and anticholinergic effects.
NEXT
Return to page 1
To Assessment Page
Chronic Low Back Pain Recommendations
Opioids
Long-term use of weak opioids, like codeine, should only follow an unsuccessful trial of non-opioid
analgesics. In severe chronic pain, opioids are worth careful consideration. Long acting opioids can
establish a steady state blood and tissue level that may minimize the patient’s experience of increased
pain from medication withdrawal experienced with short acting opioids.
Careful attention to incremental changes in pain intensity, function, and side effects is required to
achieve optimal benefit. Because little is known about the long-term effects of opioid therapy, it should
be monitored carefully.
Opioid side-effects (including headache, nausea, somnolence, constipation, dry mouth, and dizziness)
should be high in the differential diagnosis of new complaints.
A history of addiction is a relative contraindication. Consultation with an addictions specialist may be
helpful in these cases.
Consult the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain
endorsed by the CPSA.
Multidisciplinary Treatment Program
Referral to a multidisciplinary chronic pain program is appropriate for patients who are significantly
affected by chronic pain and who have failed to improve with adequate trials of first line treatment. Get to
know the multidisciplinary chronic pain program in your referral area and use it for selected cases of
chronic low back pain.
Prolotherapy
Prolotherapy is only appropriate in carefully selected and monitored patients who are participating in an
appropriate program of exercise and/or manipulation/ mobilization.
The most commonly reported adverse events were temporary increases in back pain and stiffness
following injections. Some patients had severe headaches suggestive of lumbar puncture, but no serious
or permanent adverse events were reported.
Epidural Steroid Injections
For patients with leg pain, epidural steroid injections can be effective in providing short-term pain relief.
Transient minor complications include: headache, nausea, pruritis, increased pain of sciatic distribution,
and puncture of the dura.
Behavioural Therapy / Progressive Muscle Relaxation
Where group programs are not available, consider referral for individual cognitive behavioural treatment
provided by psychologist or other qualified provider
Referral
Refer patients with severe persistent disability who have not responded to an exercise-based active
rehabilitation program to interdisciplinary rehabilitation, a multidisciplinary chronic pain program or a
physiotherapy clinic with consultation services.
Spinal Manipulation
There is insufficient evidence to recommend for or against spinal manipulative therapy.
(Source: Alberta Guideline for the Evidence-Informed Guideline for non-specific, non-malignant
low back pain in adults, TOP, 2009 www.topalbertadoctors.org)
In addition, refer to the MSK Patient Self Management Toolkit for more
information on education and information resources.
Return to page 1
Print
General Recommendations for
Maintaining a Healthy Back:
Patient Information
The following information was developed as part of the Saskatchewan Provincial Spine
Pathway. Consult your health care provider before you start an exercise program.
Factors that Contribute
to Lower Back Pain
Understanding Your Back
Smoking
Your spine features three compensating curves made up of vertebrae that work with
discs, muscles and ligaments to balance the weight of your body. If the curves lose
their proper relationship, additional pressure is placed on the vertebras and discs. This
pressure can cause back pain.
Smoking inhibits the body’s
ability to supply nutrients and
oxygen to the spinal discs,
which can cause their aging
and deterioration.
Reduce Your Chances of Back Pain
Practice good back care habits to keep your spine in correct alignment. Use correct
standing, sitting and walking postures as well as good lifting and carrying techniques.
Good spine care also involves strengthening muscles in your back and abdomen.
Studies show that well-balanced core muscles stabilize the spine and create support for
all other movement.
Proper
Standing
Posture
Proper
Sitting
Posture
• Chest raised
• Shoulders back
• Neck, shoulder
and relaxed
• Abdomen and
buttocks
pulled in
• Chin and
knees relaxed
• Feet slightly
apart with
weight evenly
distributed
•
•
•
•
•
•
and upper back
muscles relaxed
Shoulders
rounded back
Feet flat on the floor
Knees bent at 90˚ angle
Thighs level with hips
Back comfortably pressed against
chair back.
Small lumbar support at the small
of back for extra support.
Age
Back pain becomes more
common as people age. The
discs between the vertebrae
dry out and lose some of their
cushioning ability as the spine
becomes stiffer.
Fitness Level
Weak abdominal and back
muscles increase the chance of
back pain.
Diet
A high calorie diet combined
with an inactive lifestyle can
lead to obesity. This extra
weight puts stress on the
spine.
1
NEXT
Return to page 1
General Recommendations for
Maintaining a Healthy Back:
Patient Information
Exercises to Increase Muscle Strength
Exercises may be modified at first. Your goal is to keep moving and gradually return to full activity.
Q
Partial Sit-up or Crunch: strengthens abdominal
muscles
• Lie on back with knees bent, feet flat on floor and arms
crossed over chest.
• Raise head and shoulders slightly until shoulder blades are
just off floor. (You may not be able to get far at first.)
Hold for ___ seconds. Relax to the floor.
Do ___repetitions.
Q
Reverse Crunch:
• Lie on back with hands at sides and knees bent.
• Raise feet off floor with ankles crossed so knees create
a 90˚ angle.
• Tighten abdominal muscles, lift tail bone off floor.
• Raise hips towards rib cage. (You may need to use hands
for stabilization at first, but rely on them less as you
get stronger.)
Hold for ___ seconds. Relax to the floor.
Do ___repetitions.
Q
Pelvic Lift: strengthens buttocks and abdomen.
• Lie on back with knees bent, feet flat on floor and arms
at sides.
• Raise hips upwards without arching back.
• Keep body in a straight line from shoulders to knees.
Hold for ___ seconds. Do____ repetitions.
Before starting an exercise program, talk to your therapist or primary care clinician.
2
NEXT
Return to page 1
General Recommendations for
Maintaining a Healthy Back:
Patient Information
Exercises to Increase Muscle Strength
Q
Arm and Leg Reach: strengthens buttocks,
abdomen and shoulders
• Kneel on hands and knees with neck parallel to floor.
• Keep weight evenly distributed, knees hip-width apart and
back straight.
• Stretch one arm straight.
Hold for ___ seconds. Return arm to start.
Do ___ repetitions. Switch arms and repeat.
• Next, lift one leg straight.
Hold for _____seconds. Return leg to start.
Do ____repetitions. Switch legs and repeat.
• As you get stronger, raise opposite arm and leg at the
same time.
Hold for ____seconds.
Q
Bicycle: strengthens buttocks, abdomen
and shoulders
• Lie flat on back. Place fingers on head.
• Tighten abdominal muscles and bring knees to a 45˚ angle.
• Lift shoulders off the ground. Turn upper body to the
left, bringing the right elbow toward the left knee and
extending right leg in a cycling motion.
• Switch sides and repeat.
Do ___ repetitions. Switch to the other arm and repeat.
Before starting an exercise program, talk to your therapist or primary care clinician.
3
NEXT
Return to page 1
General Recommendations for
Maintaining a Healthy Back:
Patient Information
Exercises to Increase Muscle Strength
Q
Exercise Ball Crunch: strengthens abdominal
muscles, improves balance
• Sit on ball with feet flat on the floor, about
hip-width apart.
• Let ball roll back slowly until thighs and hips are parallel
to the floor.
• Place fingers on head. Keeping lower body motionless,
contract abdominal muscles.
• Slowly flex forward and lift shoulders off the ball.
Do ___ repetitions.
Comments
Before starting an exercise program, talk to your therapist or primary care clinician.
Republished with permission from the Saskatchewan Ministry of Health brochure,
General Recommendations for Maintaining a Healthy Back.
4
Return to page 1
Pain Type
Acute low back
pain or flare-up
of chronic low
back / spinal
pain
Chronic low back
/ spinal pain
Print
Medication
Dosage Range
1st line - Acetaminophen
2nd line –
Ibuprofen
NSAIDs
Diclofenac
Add: Cyclobenzaprine for
prominent muscle spasm
If taking controlled release (CR)
opioids add a short-acting opioid or
increase CR opioid by 20 - 25%
1st line
Acetaminophen
Up to 1000 mg QID (max of 4000 mg / day)
Up to 800 mg TID (max of 800 mg QID)
Up to 50 mg TID
10 to 30 mg per day; greatest benefit seen within
one week; therapy up to 2 weeks may be justified
2nd line
NSAIDs
Up to 800 mg TID (max of 800 mg QID)
Up to 50 mg TID
Slow titration; max of 400 mg/day, short acting
form is only in combination with acetaminophen
Note – Monitor for total combined daily
acetaminophen dose
OPIOIDS
Consider Tricyclics also 3rd line –
see Neuropathic pain
Ibuprofen
Diclofenac
3rd line - Tramadol*
Neuropathic
pain if coemergent with
musculoskeletal
complaints
Sleep
disturbance
accompanying
chronic pain
th
4 line
Strong
Opioids
(CR)
Morphine sulfate
Hydromorphone HCl
Oxycodone HCl
Fentanyl patch
See opioids below
Up to 1000 mg QID (max of 4000 mg / day)
Contra-indications/
Precautions
These are time limited
strategies typically several
days to a week and rarely up
to a month
Monitor judiciously
Liver disease. Concomitant
long term use with NSAIDs
may inc. risk of ulcers (suggest
max 3000 mg/day)
Elevated risk of GI
complications;
coagulation defects
Slow titration then convert to a
CR product. Possible loss of
analgesia when combined with
high dose opioid. Caution if
adding to TCAs or SNRIs
Side Effects
Ongoing monitoring
Negligible
See NSAIDs below
See Acetaminophen below
See NSAIDs below
Sedation, dry
mouth
Related to the TCAs but without robust
evidence to support long term use
See opioids below
See opioids below
Negligible
Primarily liver toxicity with long term,
high dose consumption. Increased
risk of high BP associated with long
term use
Primarily GI,
possible fluid
retention or CNS
effects such as
dizziness or fatigue
at higher doses
Dizziness,
drowsiness,
asthenia,
gastrointestinal
complaints
Anticipate
constipation
and nausea; treat
accordingly
CNS side effects.
Tolerance occurs
Drowsiness,
anti-cholinergic
effects
Patients may need gastric protection
with a PPI. Monitor for CV risk factors
and renal function if long term use
Hepatic and / or renal dysfunction
or pre-existing seizure risk
15 to 100 mg BID
3 to 24 mg BID
10 to 40 mg BID-TID
25 to 50 μg Q3days
Assess addiction potential.
Use an opioid agreement
Observe and assess for a
dose-response relationship
10 to 100 mg HS
Start low & go slow; TCAs
have positive effects on sleep
architecture
Significant renal impairment
requires dose adjustment
Slower titration required for
pregabalin
Sedation, dizziness
and other CNS side
effects
Occasional renal function tests
3rd line - Add opioids or tramadol
Gabapentin: 100 mg HS up to a suggested
maximum of 1200 mg TID. Higher doses have
been used
Pregabalin: 75 to 300 mg BID; may need to start
@ 25 mg for elderly or sensitive patients
See opioids or tramadol as above
10 to 100 mg take 2+ hours before bed time
Trazodone
25 to 100 mg HS
Mirtazapine
15 to 45 mg HS
See opioids or
tramadol as above
Drowsiness,
anti-cholinergic
effects
Drowsiness,
dizziness
Drowsiness, inc.
appetite,
dizziness
See opioids or tramadol as above
Amitriptyline
See opioids or tramadol as
above
Dosing should be
individualized and concurrent
mood disturbances treated
1st or
2nd line
Tricyclics
Amitriptyline
Nortriptyline
fewer adverse effects
1st or 2nd line
Anticonvulsants (Gabapentin or
Pregabalin*)
Pain, function, behaviour. Monitor for
end-of-dose failure; some patients
may require Q8h dosing
Precautions in patients with preexisting cardiac abnormalities and
glaucoma
Precautions in patients with preexisting cardiac abnormalities and
glaucoma
Excessive sedation
Excessive sedation, weight gain
Return to page 1
Pain
Toolkit
Brief Pain
Inventory
DN4
Neuropathic Pain Tool
PHQ-9
Depression Questionnaire
Opioid Manager
Tools
Urine Drug
Screen Information
Pain
Diary
Treatment
Options
Return to page 1
To Assessment Page
Print
Treatment Options for Pain – Beyond Medications, Surgery and Injections.
Options for Developing a Personal Toolbox of Pain Solutions.
Dr. Pam Squire, Dr. Owen Williamson, Dr. Brenda Lau, Diane Gromala, Ph.D, Neil Pearson, April 2011
Use knowledge about
chronic pain to validate
your experience, understand treatment options,
and empower you to be
your own best advocate.
Optimize your sleep —
it may improve energy
levels, pain coping and
mood.
Cognitive-based
psychotherapy (CBT)
cannot alter pain but
many, many people find
it dramatically alters how
much they suffer from
their pain. Use this and
other resources to help
with anxiety, depression,
anger, and fear.
Use gentle exercise
and progressively
increase activity to
optimize weight, reduce
stress and to improve
tolerance, fatigue, and
sleep.
Lifestyle changes
Eat well, use appropriate
alternative and complimentary medicine, find
help to quit smoking
and more.
Getting the right kind
of support from your
spouse and from others
who have chronic pain
can reduce the burden of
chronic pain and offer
alternative perspectives.
In this section, find
provincial phone numbers
for housing, help with
work, and help with
disability forms & options.
Mindfulness, yoga,
and breathing
exercises will reduce
your pain, calm your
nervous system, reduce
stress & improve
your sleep.
TABLE OF CONTENTS
Pain Self-Management & Pain Education Courses . . . p.2
Improving Sleep . . . p.5
Changing Your Mind – Changing Your Pain . . . p.5
Mind-Body Medicine for Pain Relief . . . p.7
Getting Help — Support for People With Pain & Disability . . . p.8
Exercise & Progressive Activity . . . p.10
Lifestyle Changes . . . p.11
1
NEXT
Return to page 1
To Assessment Page
HOW TO USE THIS BOOKLET
Chronic pain is overwhelming, period.
No matter who you are, everyone with chronic pain feels this way at some point.
This information is about trying to change that. We recommend that you try things ONE SMALL BIT AT A TIME.
Otherwise, it may feel like an insurmountable challenge to try to address everything all at once.
However you came to have this pain Lous Heshusius says something that healthcare workers don't always consider.
Communities, homes, and workplaces can and do influence people's health decisions and experience. Your experience is
happening in a society that isn't ready for you. It will stigmatize you and in many ways can contribute to your disability. !0 years
ago obesity was labeled an personal problem and treatment focused solely on controlling what a person ate and how they
exercised. Today we understand the important contribution from society - food industry that promotes excessive portions, food
outlets that make high calorie, low nutrition choices the most available and communities and work places that make exercise
difficult.
People who report feeling the best find empathetic but slightly pushy specialists (this includes your doctor, physio, occupational
or exercise therapist, psychologists, etc). Like our top athletes, you need someone who knows how to push you a little bit when
you don't really feel like doing anything more . . . This is just like our athletes who have found that physical coaching wasn't
enough to do their best – they needed that PLUS psychological coaching, a great diet AND community support. Our athletes
had access to great coaching and programs but it wasn't until we as a country really supported our athletes Canada that we
"Owned the Podium".
So, you are unlucky to live now when society does more TO you than FOR you. BUT you can help us change that. START by
becoming a member of PainBC (It's free! All we need is your email address and name http://www.painbc.ca/ ) and help us
convince governments and Health Authorities to support people with pain.
Everyone who wrote this document believes that you will can have the best life possible when you use BOTH medication and
some of the things we talk about in this booklet.
So . . .
Pick ONE area to start with and try something. Didn't help? At all? . . . DON’T GIVE UP ! ! !
When you feel the time is right, try again or try something new.
People who live well with chronic pain tell us that they did best when they felt like they were equal partners in managing their
pain. Most said that in the early days, they relied heavily on medications, surgery and needles, because they were anxious to
find a cure for the pain that had started to control and destroy their life. We don't for a minute want to tell you that you should
give up on that route BUT if you are doing this and are still struggling here are some things many patients have found helpful. As
Pete Moore writes about his pain toolkit,
“Pain self management is about learning new (or using old) skills, trying them out and see what works for you.
Pain is like a fingerprint, so each person may need to have individual skills to suit him or her.
Acceptance is not about giving up but recognizing that this is your pain to manage and you need to take more control.
Acceptance is also a bit like opening a door – a door that will open to allow you in to lots of self-managing
opportunities. The key that you need to open this door is not as large as you think.
All you have to do is to be willing to use it and try and do things differently.”
We hope that each week you and your health care partner can look at one “tool” you would like to work on and using the
resources provided in the next few pages, find some help to achieve your goals.
2
NEXT
Return to page 1
To Assessment Page
PAIN SELF-MANAGEMENT AND PAIN EDUCATION COURSES
These courses offer information in pain education, coping strategies and support all in one place.
1. The Chronic Disease Self-Management Programs
In British Columbia go to this website:
http://www.coag.uvic.ca/community.htm
> click on the [community] button and then
> click on [CDSMP] and then click on the pink province shaped button labelled schedules on the top right side of the page
and choose the appropriate Health Authority for workshop schedules and the opportunity to volunteer as Leader.
These are free and consist of six, 90-minute sessions on pain self-management.
2. The Pain Toolkit. This is a great place to get started! It’s free and can be downloaded in a few minutes.
(But it is based in the United Kingdom, so it makes reference to links that are there.)
http://www.paintoolkit.org/
3. Private pain clinics often offer pain education sessions. WCB or ICBC or private insurance companies (the ones funding the
disability payments) can be contacted for payment options. Some examples of these clinics include: Orion Health:
http://www.orionhealth.ca/
4. St. Paul’s Hospital Pain Clinic offers pain education day programs. Click on Programs and Services to see available
programs. Patients may be referred there:
http://www.providencehealthcare.org/pain-outpatient-clinics
5. Fraser Health will be opening the new outpatient pain clinic in the spring of 2011 (604-585-4450). For information on that
and other programs CALL General Information at 1-877-935-5669. The Fraser Health website is hopeless for pain information.
http://www.fraserhealth.ca/about_us/building_for_better_health/surrey_outpatient_care_and_surgery_centre/benefits_and_servi
ces
6. On Vancouver Island: go to the VIHA website on chronic pain at:
http://www.viha.ca/pain_program
VIHA has 3 pain clinic locations under a regional program in Victoria, Nanaimo and Comox.
The phone number for the Victoria Program is 250-519-1836 . The Nanaimo Pain Clinic has a pain education program. Call 1(250)-739-5978.
7. The Victoria Pain Clinic is a separate private clinic that offers individual, customized programs.They focus on non
medication solutions for pain. Contact the office at 1-(250)-727-6250 for details.
8. The BC Arthritis Society sponsors workshops on chronic pain & Fibromyalgia AND on all the types of arthritis and some
associated conditions ie. osteoporosisToll free phone 1-(800)-321-1433.
http://www.arthritis.ca
> search under [Fibromyalgia] for newsletters, library resources and forums.
9. Overcome Pain Live Well Again. These are presented as archived webcasts to help people understand pain and provide
optimistic guidance about pain self-management techniques. The podcasts include video footage of Neil Pearson speaking and
copies of his slides. They are available on the Canadian Pain Coalition (CPC) website under archived podcasts
http://www.canadianpaincoalition.ca/index.php/en/help-centre/conquering-pain
3
NEXT
Return to page 1
To Assessment Page
PAIN EDUCATION WEBSITES
It is important to understand why pain can become chronic, why it doesn’t improve with time and why medications or surgery
often provide only partial and often temporary relief. We HAVE NOT included resources and websites for specific types of pain
as it would make this document a textbook but these sources of information are perfect for anyone who can’t get to a face-toface workshop.
1. Med School for You has 8 video modules giving an overview of the whole CPSMP program which is available online for a
fee. To access very good info on the site click on Pain Syndromes underneath the Med School title for info on a complete list of
chronic pain conditions. This site is supported by the Canadian Pain Society (CPS) & the Canadian Pain Coalition (CPC).
http://www.medschoolforyou.com/
2. The Canadian Pain Coalition’s Conquering Pain for Canadians booklet and Conquering Your Pain video offer important
information for managing pain effectively.
http://www.canadianpaincoalition.ca/index.php/en/help-centre/conquering-pain
3. The Calgary Pain Centre has this lecture series online.
http://www.albertahealthservices.ca/services/Page2790.aspx
BOOKS ON PAIN SELF-MANAGEMENT
1. Managing Pain Before it Manages You by Margaret Caudill
This is a wellspring of wisdom and practical approaches that can help transform your life as well as your pain. Dr Caudill’s
enormous wealth of knowledge, extensive clinical experience and compassionate understanding combine to make this
the single best book on pain available today.
http://www.amazon.com/Managing-Pain-before-Manages-You/dp/0898622247
2. Fibromyalgia & Chronic Myofascial Pain: A Survival Manual by D. Starlanyl and M.E. Copeland
(New Harbinger Publications, 2001).
3. The Fibromyalgia and Chronic Fatigue and Life Planner Workbook: Healing Resources for Patients, Family and Friends
by Dawn Hughes (Universal Publishers, 2001).
4. Yoga for Pain Relief: Simple Practices to Calm Your Mind and Heal Your Chronic Pain by Kelly McGonigal.
New Harbinger Publications Inc, 2009.
5. Mindfulness Meditation for Pain Relief: Guided practices for reclaiming your body and your life by Jon Kabat-Zinn.
6. Break Through Pain: A Step-by-Step Mindfulness Meditation Program for Transforming Chronic and Acute Pain by
Shinzen Young. Sounds True Inc., 2007.
7. Unlearn Your Pain. by Dr Howard Schubiner look at the website http://www.unlearnyourpain.com/
4
NEXT
Return to page 1
To Assessment Page
BOOKS ON PAIN PATHOPHYSIOLOGY
Books for anyone who needs to understand more about the mechanisms of chronic pain.
1. Painful Yarns by Dr. Lorimer Moseley
This is a compilation of hilarious stories and images intended to help explain the complexity of pain.
These stories, while entertaining, are used as metaphors to explain key aspects of the biology of pain.
Painful Yarns is a perfect pre-read for Explain Pain.
http://www.amazon.com/Painful-Yarns-Lorimer-Moseley/dp/0979988004
2. Explain Pain by David Butler and Lorrimer Moseley
A humorous and maybe slightly irreverent explanation about chronic pain pathophysiology,
http://www.amazon.com/Explain-Pain-David-Butler/dp/097509100X
This links to a you tube video by the authors which discusses the book:
http://www.youtube.com/watch?v=qv7Y26miLDA
3. The Brain that Changes Itself: Stories of Triumph from the Frontiers of Brain Science by Norman Doidge. Penguin Books
2007.
BOOKS ON LIVING WITH PAIN FROM A PATIENT’S PERSPECTIVE (These are great books)
1. The Pain Chronicles by Melanie Thurnstrom (A U.S. author)
2. Inside Chronic Pain: An Intimate and Critical Account by Lous Heshusius. (A Canadian author) Cornell Press 2009.
3. Pain: The Fifth Vital Sign by Marni Jackson see http://marnijackson.com/
4. My Imaginary Illness: A Journey Into Uncertainty and Prejudice in Medical Diagnosis by Chloe Atkins
IMPROVING SLEEP
Chronic pain may interfere with the ability to sleep. Yet many people have terrible sleep habits or have sleep problems that are
sometimes overlooked, and those can also interfere with sleep. (Think of sleep apnea - a problem that causes you to briefly stop
breathing and maybe also snore because of opioids, restless legs, jerking limbs or have medication that causes insomnia)
Because the importance of sleep cannot be stressed enough, we strongly urge you to address any sleep-related issues you
may experience.
For more information on how to sleep well, look at the National Sleep Foundation’s webpage:
http://www.sleepfoundation.org
1. A Sleep Diary
To document your sleep so your health care provider can help determine your problem, complete a sleep diary.
A copy of one you can use is available at:
http://sleepeducation.org/docs/default-document-library/sleep-diary.pdf
2. Everything you ever needed to know to sleep well.
CBT For Insomnia is an online program recommended by sleep experts at the University of British Columbia (UBC).
It costs $35.00, similar to the cost of 2 weeks of sleeping pills. It is for problems falling asleep and waking during the
night/early morning, for individuals who are not, and those who are, using sleeping pills. This program replicates the
5
NEXT
Return to page 1
To Assessment Page
5-session cognitive behavioral program (CBT) for insomnia developed and tested at Harvard Medical School.
CBT has been shown to be one of the most effective and long-lasting treatments for people who don’t sleep well.
http://www.cbtforinsomnia.com/
3. To find a sleep lab near you, see: http://www.css.to/centers.html
If you are trying to stop sleeping pills that are benzodiazepines (like zopiclone/Imovane, clonazepam/Rivotril diazepam/Valium,
lorazepam/Ativan), go to this website and you can purchase the amazing manual for patients and physicians. The manual
contains all of the practical advice you and your physician need to help you stop these medications. It is written by Professor
Ashton, a world authority on the subject. And it costs less than the cost of one visit with a counselor.
http://www.benzo.org.uk/manual/index.htm
CHANGING YOUR MIND – CHANGING YOUR PAIN
Pain can destroy your life. Many patients feel like pain, like a mad dictator, is controlling their entire life.
Even with the best medical advice, the effect chronic pain can have on your life can be devastating.
Medications are often initially effective but for reasons not well understood, the effectiveness often wears off
over time, especially with opioid medications.
What patients have taught all of the health care providers who work with pain is that how much an individual
suffers from their pain is not always related to how severe the pain is. We don't mean to say that severe pain does not cause
suffering. It does. Eric Cassell writes that suffering occurs when there is a threat to the integrity of a person and if the person
cannot be made whole again then the suffering will continue. There are many different kinds of integrity (psychological, physical,
social, financial, spiritual.
Some times it is easier to change your concept of what you will accept - physically, financially, socially- and look for options to
cope with the change, than it is to regain what you had before.
To control the effect pain has on your life you need to first accept it is here for the time being.
We know that people who have spinal cord injuries, for example, have an injury that cannot be fixed.
For the ones who accept their disability, a wheelchair can be a life expanding solution. (ASSUMING that as a community we
have provided wheelchair access...back to how CRUCIAL social acceptance of a problem can be)
For those who cannot accept that they will never walk again, using a wheelchair is only a mark of failure.
Sometimes, chronic pain can be just as irreversible as a spinal cord injury.
We are not suggesting that you give up trying to find pain relieving or curing strategies.
But if you only rely ONLY on medications, surgery or injections to manage your pain, you might be missing out.
Psychologists can teach you a lot about how to have a life with chronic pain. See if you can get a referral to a
psychologist who has experience and knowledge about pain. Pain programs also have psychologists on staff —
if you can get into one of the good ones you are lucky (if you live in BC). Life coaches can also help you if you are feeling
stuck. Not everyone can use these strategies, but they have helped many of our patients.
Please try some of this before you say “not for me ”
Remember . . . START with ONE Change . . .
1. Ask about a referral to a good psychologist. Your employer may have an employee assistance program you can access
for free. Many extended health care plans will cover a referral to a psychologist with a masters or PhD if your physician writes
you a referral. Call the BC Psychological Association phone number: 604 730 0522, or email address at:
http://www.psychologists.bc.ca. They don't have all the psychologists listed in the Province.
6
NEXT
Return to page 1
To Assessment Page
2. Centre for Clinical Interventions. This is a resource centre with many handouts that help people to change the way
they think. It also has psychotherapy course material for family physicians and might be helpful for physicians who are
interested in running group sessions on coping with pain.
http://www.cci.health.wa.gov.au/resources/consumers.cfm
3. The following are a list of some PhD psychologists who have had extensive experience with chronic pain. This IS
NOT a comprehensive list and our patients have found many other excellent psychologists to help them. Many
extended health plans and WCB will cover referrals for a few brief sessions to help get you started or give you a few
refresher points when you need them.
Dr. Elizabeth Bannerman 1-(604)-592-8348
Dr. Wesley Buch 1-(604)-592-8348
Dr. Ingrid Federoff 604-506-8112
Dr. Owen Garrett 1-(604)-294-4295
Dr. Judy Le Page 1-(604)-803-4761
Dr.Tony Le Page 1-(604)-803-4578
Dr. Brian Grady 1-(250)-592-4281 (on Vancouver/Gulf Islands)
4. For a list of other Vancouver area counselors and psychologists with an interest in Pain Management:
http://counsellingbc.com/counsellors/practice/chronic-pain-111
5. Life Coaching. We like Dr Rahul Gupta, a family physician who has additional expertise working with patient's with
chronic pain and is an ICF certified life coach. Contact him for more information wherever you live at:
http://www.voice2vision.net
6. Here to Help. This site provides comprehensive information on mental health and addiction issues and focuses on providing
information that is based on the best research possible.
http://www.heretohelp.bc.ca/about
DOWNLOADABLE INFORMATION
1. Psychology of Pain is a blog created by Gary B. Rollman, Professor of Psychology at the University of Western Ontario
and the former President of the Canadian Pain Society. This blog contains links to many useful pain resources and
discussions on a number of pain issues.
http://psychologyofpain.blogspot.com/
2. Centre for Clinical Interventions. This is a resource centre with many handouts that help people to change the way
they think. It also has psychotherapy course material for family physicians and might be helpful for physicians who are interested
in running group sessions on coping with pain.
http://www.cci.health.wa.gov.au/resources/consumers.cfm
3. Cognitive behavioural therapy (CBT). Because of the chronic and persistent pain and fatigue, it is easy to get into habits
of activity and rest that may not be the best way to deal with the pain and fatigue. Cognitive behavioural therapy (CBT) can
help to identify if you have unhelpful ways of thinking and acting, and help you make healthy and positive changes that can
reduce pain and fatigue. This is a self-help website for people that feel stuck that offers people strategies for change.
http://www.getselfhelp.co.uk/chronicfp.htm
HELP WITH MOOD
7
NEXT
Return to page 1
To Assessment Page
1.Mental Health Support through the Bounce Back Program in British Columbia. It requires a referral by a physician.
Bounce Back: Reclaim Your Health is a new program designed to help people experiencing symptoms of depression
and anxiety that may arise from stress or other life circumstances. The BC Ministry of Health Services funds the project.
Call 1-(604)-688-3234 or 1-(800)-555-8222 extension 235.
http://www.cmha.bc.ca/bounceback
Bounce Back offers two forms of help:
1. The first is a DVD video providing practical tips on managing mood and healthy living.
2. The second is a guided self-help program with telephone support. A 6-minutes preview of the video is on the
webiste.
2. Positive Coping with Health Conditions: A Self-Care Workbook (Dan Bilsker, PhD, RPsych, Joti Samra, PhD,
RPsych, Elliot Goldner, MD, FRC(P), MHSc) is a free self-care manual authored by scientist-practitioners with expertise in issues
relating to coping with health conditions such as low mood, worry and tensions. This manual is designed for individuals who
deal with health conditions, including patients, physicians, psychologists, nurses, rehabilitation professionals and researchers.
http://www.comh.ca/pchc/index.cfm
MIND–BODY MEDICINE FOR PAIN RELIEF
.
MINDFULNESS-BASED STRESS REDUCTION
I once asked one of my patients if doing meditation made her pain any better. She was a 65-year-old grandmother
who had severe pain from spine arthritis. She thought for a moment and then said this:
"Dear, I'm not sure if my pain is any better but I am much better with my pain." (Note from Dr Squire-I think she was
actually talking about combining meditation with marijuana but then many things we do have synergy and she did live in Sechelt)
Meditation
Learning meditation is like learning to play an instrument. It takes coaching and practice.
Books and CD’s are helpful, but are no replacement for face-to-face teaching. Going to group meditation courses is a
great way to get out. Many yoga studios, community recreation centres and libraries offer these kinds of courses.
Search online for local courses and practice!
Mindful Living is in Vancouver. Contact them at:
http://mindful-living.ca/contact/
Yoga & Tai Chi
Gentle, and restorative yoga practices have been shown effective for helping to decrease pain, improve function and decrease
the psychological and social impact of pain. Many centres have designed classes to accommodate people who have limitations.
Tai Chi has also been demonstrated to be helpful.
BOOKS AND GUIDED CD’S
When face-to-face learning is not an option.
1. Pain Speaking by Jackie Gardner-Nix. Jackie is a Canadian physician with a special interest in pain management. These two
CDs are a companion to The Mindfulness Solution to Pain book. We really like them.
Both CDs and book can be ordered through:
https://neuronovacentre.com/books-and-audio/
8
NEXT
Return to page 1
To Assessment Page
2. Dissolving Pain by Les Fehmi PhD and Jim Robbins. This book also includes a CD of guided exercises:
http://www.amazon.com/Dissolving-Pain-Brain-Training-Exercises-Overcoming/dp/1590307801
3. Mindfulness Meditation for Pain Relief: Guided Practices for Reclaiming Your Body and Your Life by Jon Kabat-Zinn.
This two-CD Audio book, with short meditation exercises, is available to buy through Chapters. Many libraries carry all of the
books written by Kabat-Zinn. These are links to YouTube videos on Kabat-Zinn and mindfulness:
http://www.youtube.com/watch?v=3nwwKbM_vJc
http://www.youtube.com/watch?v=rSU8ftmmhmw&feature=channel
MIRROR THERAPY
For patients with phantom limb pain or complex regional pain syndrome there is published evidence that using mirror boxes
can reduce pain and improve function. A special mirror box is used. The normal arm or leg moves in the mirror box but
what your eyes and brain see looks is the abnormal limb moving (the mirrors reverse the image so your left arm looks like your
right arm. How this works is not well understood. Physiotherapists provide this therapy. Call your local hospital physio
department or the provincial physiotherapist association to find out if it's available in your community. More explanation is on
the NOI group's website (NOI is the Neuro Orthopedic Institute in Sydney Australia lead by some of the world-renowned
physiotherapists who pioneered this work):
http://www.noigroup.com/
GETTING HELP – SUPPORT FOR PEOPLE WITH PAIN AND DISABILITY
We HAVE NOT included resources and websites for specific types of pain as it would make this document a textbook but links
for many different kinds of pain (i.e. Fibromyalgia, Complex Regional Pain Syndrome, Diabetic Neuropathy) can be found on
central websites like the Canadian Pain Society's PainExplained and others listed below.
WEBSITES BY PATIENTS FOR PATIENTS TO PROVIDE SUPPORT AND INFORMATION
1. The Chronic Pain Association of Canada (CPAC) is committed to advancing the treatment and management of chronic
intractable pain, developing research projects to promote the discovery of a cure for this disease, and educating both the health
care community and the public to accomplish this mission. The cost is $15.00 per year.
Phone: 1-(780)-482-6727 Email: [email protected]
http://www.chronicpaincanada.com/
2. The Canadian Pain Coalition (CPC) is a partnership of patient pain groups, health professionals who care for people in pain,
and scientists studying better ways of treating pain. The CPC's purpose is to promote sustained improvement in the treatment
of all types of pain and its main goal is to have pain recognized as a health priority in Canada.
http://www.canadianpaincoalition.ca/
GENERAL WEBSITES for CHRONIC PAIN INFORMATION
1. The Canadian Pain Society has a website for pain information for patients and healthcare providers:
http://www.canadianpainsociety.ca/
2. PainBC. The website of the BC pain Society. Look for new information every month:
http://www.painbc.ca/
9
NEXT
Return to page 1
To Assessment Page
3.The Association Quebecoise de la Douleur Chronique (AQDC), (The Quebec Pain Association), is committed to improving
the condition of people suffering from chronic pain in Québec and reducing their isolation. http://www.chronicpainquebec.org
4. The international Association for the Study of Pain (IASP)
http://www.iasp-pain.org
GENERAL SUPPORT FOR A VARIETY OF PROBLEMS IN THE LOWER MAINLAND, BRITISH COLUMBIA
1. Patient Voices Network. Peer-counseling and family support.
1-(604)-742-1772 Toll free: 1-(888)-742-1772
http://www.patientvoices.ca
2. Sources. Community centres – support for patients and families.
1-(604)-531-6226
http://www.sourcesbc.ca
3. Family Caregiver Network Society. Support for families of patients with disabilities.
Support is available Monday through Friday between 8:30 a.m. and 4:30 p.m.
1-(877)-520-FCNS (3267)
http://www.fcns-caregiving.org
4. The Social Planning and Research Council of BC (SPARC BC) – who you contact to get a Disability Parking pass.
1-(604)-718-7744 Parking Permit
http://www.sparc.bc.ca
5. Workers Advisor Group. Please call for an appointment ONLY for issues related to Worksafe BC.
Office Hours: 8:30 – 4:30 Monday to Friday.
1-(800)-663-4261
http://www.labour.gov.bc.ca/wab
6. BC Coalition of People with Disabilities’ Advocacy Access Program.
Their mission is to raise awareness around issues that affect the lives of people who live with a disability.
They also work to secure the necessary income supports for people with disabilities to live with dignity, and increase their
ability to participate and contribute in their communities. They provide individual and group advocacy for people with
disabilities and develop educational publications for people with disabilities, governments and the public, and sharing
self-help skills with individuals and disability groups. They also help you fill in forms for tax rebates or government disability.
Please call for an appointment. Office Hours: 8:30 – 4:30, Monday to Friday.
1-(604)-872-1278 Toll free: 1-(800)-663-1278
http://www.bccpd.bc.ca/contactus.htm
7. BC Housing. Information on rental subsidies and light housekeeping. 1-(800)-257-7756
http://www.bchousing.org
8. Disability Resources Guide. Below are a summary of some helpful contacts from a useful book called the Disability
Resources Guide. It is produced by the group Opportunities for the Disabled Foundation, who can be reached at
1-(604)-437-7780. Disability is not just about changed physical abilities. It is about changed personal situation which creates
barriers to what you want to achieve.
10
NEXT
Return to page 1
To Assessment Page
Because financial concerns become part of those barriers, please also consider contacting the PLAN institute for Caring
Citizenship, where creative and practical solutions can be learned from others who have conquered your same issues.
1-(604)-439-9566.
www.planinstitute.ca
www.PLAN.ca
9. SEEDS. An Employment Insurance (EI)-based funding program for starting up a business.1-(604)-590-4144
http://www.seedsbdc.com
10. The Neil Squire Society. The Neil Squire Society is the only national not-for-profit organization in Canada that has for over
twenty-five years empowered Canadians with physical disabilities through the use of computer-based assistive technologies,
research and development, and various employment programs. Through our work, we help our clients remove barriers so that
they can live independent lives and become active members of the workplace and our society. Specializing in education and
workplace empowerment, the Society has served over 20,000 people since 1984.
www.neilsquire.ca Toll free: 1-877-673-4636
EXERCISE AND PACING
Our patients and studies both tell us that for many people who have chronic pain, trying to get regular exercise is a challenge,
because of the uncertainty of how it will affect their pain levels. This phenomenon is termed “kinesiophobia” and means fear fof
movement. However, just as we need food, we also need exercise – you will be strengthening your body so it can fight pain.
You may also find that it will increase your stamina, reduce fatigue and help with depression. So if you start to exercise regularly
and you have a setback, don’t be discouraged! Try different kinds of low-impact exercises – such as walking or yoga – to see
which ones work best for you. On “bad days,” it is also helpful to visualize yourself exercising, and try breathing exercises – this
helps to keep your body ready for exercise in small but regular steps.
Exercise guideline
These are some simple guidelines to assist you with being more successful when you exercise and work towards increasing
your activities.
1. The first thing is to find your baseline.
This is the amount of activity or exercise that you know is safe for your body, and you know will not make you “pay for it later.”
Even if this is a very small amount of activity, this is where you need to start.
2. Push yourself just a bit, to where there is a small increase in your pain. Then, to make it successful you need to do three
things: work on keeping your breath calm, your body tension low, and at the same time monitor your pain.
If you ignore your pain, you won't know if you are pushing too much.
If you pay too much attention to it, that will increase your pain.
To help find that balance, try dividing your attention between the activity you are doing, keeping your breathing calm, keeping
your body relaxed and attending to your pain a little bit.
If you are like most people, you will have noticed that ignoring the pain doesn't help you get better. You just pay for it later.
3. Practice this more and more. Then you can try pushing further into the pain. Keep working on calm breath and calm body to
get good benefits.
4. Choose an activity you want to do. If you don't want to do any activity, pick something that will make your life easier, more
fun, or help you reconnect with friends. Then do it a little bit.
11
NEXT
Return to page 1
To Assessment Page
Everyday.
When it gets a little easier, do a little more. Take your time.
Be persistent and patient.
It takes practice to change your nervous systems and your body when you have persistent pain.
1. Restorative yoga is available at many different yoga centers and is designed to accommodate people who cannot
do the common poses. Call your local recreation centre or yoga studio to find courses offered near you. If you need to do this
from home, you can order DVD's that have follow along programs. Neil Pearson has developed one that is designed specifically
for people with chronic pain (see his website lifeisnow) but our patients have tried others and many have really enjoyed the
sense of peace and accomplishment. To read about one patients' experience with how yoga transformed her pain:
http://myyogamypain.blogspot.com/2011/03/my-roots.html
2. BC Leisure Access Program
This program provides subsidized access to recreation centres. Sign up for anything that looks appealing.
Hours of operation: Monday to Friday, 8:30am–4:30pm. 1-(604)-257-8497.
http://vancouver.ca/parks/rec/lac/index.htm
LIFESTYLE CHANGES
IMPROVING GENERAL LIFESTYLE CHOICES
BestLifeRewarded™ is the first-ever Canadian loyalty program that actually rewards people for getting healthy. There is no
cost to join or stay in the program and they state they have zero tolerance for sharing your private information.
http://www.bestliferewarded.com
DIET
There is evidence from a few small trials that patients with nerve pain from diabetes had reduced pain when they followed
a low-fat, high-fiber, total vegetarian diet. Nerves and other tissues need nutrients to rebuild and a good diet is a great
place to start.
LOCAL RESOURCES FOR EATING WELL
Harvest box program. This provides low cost fresh produce for families in Delta, Surrey, White Rock and Langley.
Harvest Box occurs once a month (last Thursday of the month), except December.
1-(778)-228-6614
https://www.harvestbox.com/
STOP SMOKING
QuitNow By Phone is a confidential, quit smoking support service available to British Columbians. Call Toll-Free to 1-877-4552233 and speak to a professional quit specialist who will guide and support you through your quitting process. Translation
services are available. The BC Ministry of Health has a great web site filled with the same resources- everything you'll need to
12
NEXT
Return to page 1
To Assessment Page
help you quit smoking! http://www.health.gov.bc.ca/tobacco/cessation.html
SUPPLEMENTS THAT MAY RELIEVE NERVE PAIN
These supplements are the only ones that have some medical evidence to support this recommendation.
1. Alpha Lipoid Acid (ALA) is an antioxidant that protects nerves and their blood supply. There are at least 3 good trials that
show pain relief in patients with nerve damage from neuropathy. Most of the studies used 600mg once a day. Do a 3-week trial
to assess it, increasing it if you need to and can tolerate it up to 600 mg three times a day. Side effects included nausea,
vomiting and diarrhea. In high doses (>600mg/day), it can lower blood sugars so diabetics may have to be careful. It is found
naturally in liver, broccoli and spinach.
2. Acetyl-L carnitine (ALC) has multiple mechanisms. There is some evidence that it may help you if you have diabetic
neuropathy or nerve damage after chemotherapy. Other causes of nerve pain have not yet been researched, but it may be
helpful. The doses in studies have ranged from 1000–2000mg per day. Side effects were mild but included stomach discomfort,
restlessness and headaches.
3. Vitamin E is another antioxidant. At least 3 trials have demonstrated that using it while receiving (not after) a nervedamaging chemotherapy agent called paclitaxel significantly reduced nerve pain. The doses used ranged from 400mg once
a day to 300mg twice a day.
GENERAL SUPPLEMENT ADVICE
These supplements have research that supports these recommendations.
1. Vitamin D is technically a hormone but almost everyone in Canada has lower than recommended levels. It is important for
building strong bones.Recommendations are to take 1000 IU per day. This is especially important if you take opioids for pain as
they can affect your hormones and lower your body's ability to effectively build bone.
2. Calcium is also important for maintaining good bone health For more information on measuring your bone density go to
http://www.bcguidelines.ca/patient_guides.html. For information on calcium in food and supplements go to
http://www.osteoporosis.ca If you are on opioids it is probably a really good idea to take at least one calcium tablet containing
500mg of elemental calcium per day. We recommend you take on combined with magnesium as the magnesium counteracts
the constipating effect of the calcium.
3. Omega 3 Fatty Acids have been shown to reduce the amount of anti-inflammatories needed by patients with rheumatoid
arthritis and was helpful when used by patients with neck and low back pain. The recommended dose is 500mg per day of EPA
and to but molecularly distilled versions to avoid mercury and PCB's (such as webber naturals Omega-3 premium).
4. Magnesium Citrate 250 mg bid. Magnesium is necessary to relax smooth muscles and plays an important function in
blocking pain transmitting receptors called NMDA receptors. One study demonstrated that patients with Fibromyalgia who had
low levels of magnesium were more likely to report fatigue.
DENTAL CARE
Dentistry from the Heart. Free dental work on Saturday 8:30am to 5:00pm.
1-800-518-3109.
http://www.dentistryfromtheheart.org
RECREATION – THINGS YOU CAN DO
13
NEXT
Return to page 1
To Assessment Page
Pain management from a recreational perspective.
1. Vancouver Park Board’s Leisure Access Card — subsidized access. Phone 604-257-8497 to apply.
http://vancouver.ca/parks/rec/lac/index.htm
2. The Kansas Foundation for Medical Care has a great brochure you can download. It has suggestions for recreational
ideas that may help you feel better – including laughter, aromatherapy, stress management, aquatics, pets, music and many
other topics and ideas. This is primarily aimed at older individuals. Go to:
[Non-Pharmacological Approaches to Pain Management]
14
Return to page 1
To Assessment Page
Print
Brief Pain Inventory
Date: ____________________________________ Time: _____________________________________
Patient name: ________________________________________________________________________
1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and
toothaches). Have you had pain other than these everyday kinds of pain today? ___ Yes ___ No
2. On the diagram below, shade in the areas where you feel pain. Put an “X” on the areas where it hurts the
most.
3. Please rate your pain by circling the one number that best describes your pain at its WORST in the past
24 hours.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
4. Please rate your pain by circling the one number that best describes your pain at its LEAST in the past 24
hours.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
5. Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
6. Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
No pain
0
1
2
3
4
5
6
7
8
9
10
Worst pain you can imagine
NEXT
Return to page 1
To Assessment Page
7. What treatments or medications are you currently receiving for your pain:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. In the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one
percentage that shows most how much RELIEF you have received.
No relief
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complete relief
9. Circle the one number that describes how, during the past 24 hours, your pain level has interfered with
your:
a. General Self-Care Activities (e.g., dressing, bathing, etc.):
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
b. Mood:
Does not interfere
c.
Walking Ability:
Does not interfere
d. Normal work (includes both work outside the home and housework):
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
e. Relations with other people:
Does not interfere
f.
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
Sleep:
Does not interfere
g. Enjoyment of life
Does not interfere
Source: Pain Research Group, MD Anderson Cancer Center, 1997
Return to page 1
Print
DN4 – QUESTIONNAIRE
To Assessment Page
To estimate the probability of neuropathic pain, please answer yes or no
for each item of the following four questions.
INTERVIEW OF THE PATIENT
QUESTION 1:
Does the pain have one or more of the following characteristics?
Burning
................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Painful cold
............................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Electric shocks
.......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
❏
❏
❏
❏
❏
❏
YES
NO
❏
❏
❏
❏
❏
❏
❏
❏
YES
NO
❏
❏
❏
❏
YES
NO
❏
❏
QUESTION 2:
Is the pain associated with one or more of the following
symptoms in the same area?
Tingling
................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pins and needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Numbness
Itching
.............................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EXAMINATION OF THE PATIENT
QUESTION 3:
Is the pain located in an area where the physical examination
may reveal one or more of the following characteristics?
Hypoesthesia to touch
................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hypoesthesia to pinprick
................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
QUESTION 4:
In the painful area, can the pain be caused or increased by:
Brushing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES = 1 point
NO = 0 points
Patient’s Score:
/10
NEXT
Return to page 1
To Assessment Page
Return to page 1
To Assessment Page
Print
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
NAME: ______________________________________________________________
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(use “✓” to indicate your answer)
t
ta
No
all
DATE:_________________________
alf
n hs
a
h
y
t a
re e d
Mo th
ys
da
al
r
ve
Se
y
er
ev
ly
r
a
Ne
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep,
or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that
you are a failure or have let yourself
or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could
have noticed. Or the opposite — being so fidgety
or restless that you have been moving around a lot
more than usual
0
1
2
3
9. Thoughts that you would be better off dead,
or of hurting yourself in some way
0
1
2
3
add columns:
(Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card.)
10. If you checked off any problems, how
difficult have these problems made it for
you to do your work, take care of things at
home, or get along with other people?
+
y
da
+
TOTAL:
Not difficult at all
_______
Somewhat difficult
_______
Very difficult
_______
Extremely difficult
_______
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an
educational grant from Pfizer Inc. For research information, contact Dr Spitzer at [email protected]. Use of the PHQ-9 may only be made in
accordance with the Terms of Use available at http://www.pfizer.com. Copyright ©1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a
trademark of Pfizer Inc.
ZT242043
NEXT
Return to page 1
To Assessment Page
Fold back this page before administering this questionnaire
INSTRUCTIONS FOR USE
for doctor or healthcare professional use only
PHQ-9 QUICK DEPRESSION ASSESSMENT
For initial diagnosis:
1. Patient completes PHQ-9 Quick Depression Assessment on accompanying tear-off pad.
2. If there are at least 4 ✓s in the blue highlighted section (including Questions #1 and #2), consider a
depressive disorder. Add score to determine severity.
3. Consider Major Depressive Disorder
— if
there are at least 5 ✓s in the blue highlighted section (one of which corresponds to Question #1 or #2)
Consider Other Depressive Disorder
—if
there are 2 to 4 ✓s in the blue highlighted section (one of which corresponds to Question #1 or #2)
Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician and a definitive diagnosis
made on clinical grounds, taking into account how well the patient understood the questionnaire, as well as other relevant
information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,
occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic
Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms.
To monitor severity over time for newly diagnosed patients
or patients in current treatment for depression:
1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home
and bring them in at their next appointment for scoring or they may complete the questionnaire during
each scheduled appointment.
2. Add up ✓s by column. For every ✓: Several days = 1
More than half the days = 2
Nearly every day = 3
3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Card to interpret the TOTAL score.
5. Results may be included in patients’ files to assist you in setting up a treatment goal, determining degree
of response, as well as guiding treatment intervention.
PHQ-9 SCORING CARD FOR SEVERITY DETERMINATION
for healthcare professional use only
Scoring—add up all checked boxes on PHQ-9
For every ✓: Not at all = 0; Several days = 1;
More than half the days = 2; Nearly every day = 3
Interpretation of Total Score
Total Score
1-4
5-9
10-14
15-19
20-27
Depression Severity
Minimal depression
Mild depression
Moderate depression
Moderately severe depression
Severe depression
Return to page 1
To Assessment Page
Print
OPIOID MANAGER
Initiation Checklist
Goals decided with patient:
The Opioid Manager is designed to be used as a point of care tool for providers
prescribing opioids for chronic non cancer pain. It condenses key elements from
the Canadian Opioid Guideline and can be used as a chart insert.
Are opioids indicated for this
pain condition
A
Explained adverse effects
Item score Item score
if female if male
Item (circle all that apply)
Patient given information sheet
Signed treatment agreement (as needed)
Urine drug screening (as needed)
Overdose Risk
Provider Factors
- Incomplete assessments
- Rapid titration
- Combining opioids and
sedating drugs
- Failure to monitor dosing
- Insufficient information
given to patient and/or
relatives
- Start low, titrate gradually,
monitor frequently
- Codeine & Tramadol - lower risk
- Careful with benzodiazepines
- CR formulations - higher doses than IR
- Higher risk of overdose - reduce initial
dose by 50%; titrate gradually
Prevention
- Avoid parenteral routes
- Assess for Risk Factors
- Adolescents; elderly - may need
- Educate patients /families about risks
consultation
& prevention
- Watch for Misuse
Opioid Factors
Stepped Approach to Opioid Selection
Mild-to-Moderate Pain
First- line: codeine or tramadol
Opioid Risk Tool
By Lynn R. Webster MD
Explained risks
Patient Name:
Pain Diagnosis:
Date of Onset:
- Elderly
- On benzodiazepines
- Renal impairment
- Hepatic impairment
- COPD
- Sleep apnea
- Sleep disorders
- Cognitive impairment
Date
Explained potential benefits
Before You Write the First Script
Patient Factors
Y N
Severe Pain
Second-line: morphine, oxycodone or hydromorphone First-line: morphine, oxycodone or hydromorphone
Second-line: fentanyl
Third-line: methadone
1. Family History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
1
2
4
3
3
4
2. Personal History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
3
4
5
3
4
5
3. Age (mark box if 16-45)
1
1
4. History of Preadolescent
Sexual Abuse
3
0
5. Psychological Disease
Attention Deficit Disorder,
Obsessive-Compulsive Disorder,
or Bipolar, Schizophrenia
2
2
1
1
Depression
Total
B
Initiation Trial A closely monitored trial of opioid therapy is recommended before deciding whether a patient is prescribed opioids for long term use.
Suggested Initial Dose and Titration (Modified from Weaver M., 2007 and the e-CPS, 2008) Notes: The table is based on oral dosing for CNCP.
Brand names are shown if there are some distinct features about specific formulations. Reference to brand names as examples does not imply endorsement of
any of these products. CR = controlled release, IR = immediate release, NA = not applicable, ASA: Acetylsalicylic Acid
Minimum time
Suggested
interval for increase dose increase
Opioid
Initial dose
Codeine (alone or in
combination with
acetaminophen or ASA)
15-30 mg q.4 h.
as required
7 days
CR Codeine
50 mg q.12 h.
2 days
50 mg/day up to maximum of
300 mg q.12 h.
7 days
1-2 tab q. 4-6 h. as needed
up to maximum 8 tablets/day
Tramadol (37.5 mg) +
1 tablet q.4-6 h.
acetaminophen (325 mg) as needed up to 4/day
CR Tramadol
IR Morphine
CR Morphine
IR Oxycodone
CR Oxycodone
IR Hydromorphone
CR Hydromorphone
15-30 mg/day up to maximum of
600 mg/day (acetaminophen dose
should not exceed 3.2 grams/day)
Minimum daily dose
before converting IR to CR
100 mg
Initiation Trial Chart
3 tablets
a) 7 days
b) 2 days
c) 5 days
Maximum doses:
a) 400 mg/day
b) 300 mg/day
c) 300 mg/day
5-10 mg q. 4 h. as needed
maximum 40 mg/day
10-30 mg q.12 h.
Kadian®: q.24 h.
Kadian® should not be started in
opioid-naïve patients
7 days
5-10 mg/day
Minimum 2 days,
recommended: 14 days
5-10 mg/day
5-10 mg q. 6 h. as needed
maximum 30 mg/day
10-20 mg q.12 h.
maximum 30 mg/day
1-2 mg q. 4-6 h. as needed
maximum 8 mg/day
3 mg q. 12 h.
maximum 9 mg/day
7 days
5 mg/day
Minimum 2 days,
recommended: 14 days
10 mg/day
NA
7 days
1-2 mg/day
6 mg
Minimum 2 days,
recommended: 14 days
2-4 mg/day
NA
400
300
200
100
Yes, No, Partially
Goals achieved
Pain intensity
Functional status
Adverse effects
20-30 mg
NA
0 = None
1 = Limits ADLs
2 = Prevents ADLs
20 mg
NA
D/M/Y D/M/Y D/M/Y D/M/Y
Date
Opioid prescribed
Daily dose
Daily morphine equivalent
NA
a) Zytram XL®: 150 mg q. 24 h.
b) Tridural™: 100 mg q. 24 h.
c) Ralivia™: 100 mg q. 24 h.
Total Score Risk Category:
Low Risk: 0 to 3, Moderate Risk: 4 to 7, High Risk: 8 and above
Complications?
Other Monitoring
Watchful Dose
> than 200
Improved, No Change, Worsened
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
(Reviewed:Y/N)
To access the Canadian Guideline for Safe and Effective Use for Non Chronic Cancer Pain, to download the
Opioid Manager and to provide feedback visit http://nationalpaincentre.mcmaster.ca/opioid/
May 2010
NEXT
Return to page 1
C
Maintenance & Monitoring
Maintenance & Monitoring Chart
Morphine Equivalence Table
Opioid
Equivalent Conversion
Doses (mg) to MEQ
Morphine
30
1
Codeine
200
0.15
Oxycodone
1.5
20
Hydromorphone
6
5
Meperidine
300
0.1
Methadone & Tramadol Dose Equivalents unreliable
60 – 134 mg morphine = 25 mcg/h
135 – 179 mg = 37 mcg/h
180 – 224 mg = 50 mcg/h
225 – 269 mg = 62 mcg/h
270 – 314 mg = 75 mcg/h
315 – 359 mg = 87 mcg/h
360 – 404 mg = 100 mcg/h
Transdermal
fentanyl
Switching Opioids:
If previous opioid
dose was:
Then, SUGGESTED
new opioid dose is:
High
50% or less of previous opioid
(converted to morphine equivalent)
Moderate or low
60-75% of the previous opioid
(converted to morphine equivalent)
D
To Assessment Page
D/M/Y D/M/Y
Date
Opioid prescribed
Daily dose
Daily morphine equivalent
Goals achieved
Pain intensity
Functional status
Adverse effects
0 = None
1 = Limits ADLs
2 = Prevents ADLs
Complications?
Other Monitoring
400
300
200
100
Yes, No, Partially
D/M/Y
D/M/Y
Improved, No Change, Worsened
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
(Reviewed:Y/N)
Examples and Considerations
Pain Condition Resolved
Patient receives definitive treatment for condition. A trial of tapering is warranted
to determine if the original pain condition has resolved.
Risks Outweighs Benefits
Overdose risk has increased.
Clear evidence of diversion.
Aberrant drug related behaviours have become apparent.
Adverse Effects
Outweighs Benefits
Adverse effects impairs functioning below baseline level.
Patient does not tolerate adverse effects.
Medical Complications
Medical complications have arisen (e.g. hypogonadism, sleep apnea,
opioid induced hyperalgesia)
Opioid Not Effective
D/M/Y
Watchful Dose
> than 200
When is it time to Decrease the dose or Stop the Opioid completely?
When to stop opioids
D/M/Y
Opioid effectiveness = improved function or at least
30% reduction in pain intensity
Pain and function remains unresponsive.
Opioid being used to regulate mood rather than pain control.
Periodic dose tapering or cessation of therapy should be considered to confirm
opioid therapy effectiveness.
How to Stop – the essentials
Aberrant Drug Related Behaviour (Modified by Passik,Kirsh et al 2002).
Indicator
Examples
*Altering the route of delivery
• Injecting, biting or crushing oral formulations
How do I stop? The opioid should be
tapered rather than abruptly discontinued.
*Accessing opioids from
other sources
How long will it take to stop the
opioid? Tapers can usually be completed
between 2 weeks to 4 months.
• Taking the drug from friends or relatives
• Purchasing the drug from the “street”
• Double-doctoring
Unsanctioned use
• Multiple unauthorized dose escalations
• Binge rather than scheduled use
Drug seeking
•
•
•
•
Repeated withdrawal symptoms
• Marked dysphoria, myalgias, GI symptoms, craving
Accompanying conditions
• Currently addicted to alcohol, cocaine, cannabis or other drugs
• Underlying mood or anxiety disorders not responsive to treatment
Social features
• Deteriorating or poor social function
• Concern expressed by family members
Views on the opioid
medication
•
•
•
•
When do I need to be more cautious
when tapering? Pregnancy:
Severe, acute opioid withdrawal has been
associated with premature labour and
spontaneous abortion.
How do I decrease the dose?
Decrease the dose by no more than 10% of
the total daily dose every 1-2 weeks. Once
one-third of the original dose is reached,
decrease by 5% every 2-4 weeks. Avoid
sedative-hypnotic drugs, especially
benzodiazepines, during the taper.
Recurrent prescription losses
Aggressive complaining about the need for higher doses
Harassing staff for faxed scripts or fit-in appointments
Nothing else “works”
Sometimes acknowledges being addicted
Strong resistance to tapering or switching opioids
May admit to mood-leveling effect
May acknowledge distressing withdrawal symptoms
* = behaviours more indicative of addiction than the others.
National Opioid Use Guideline Group (NOUGG)
To access the Canadian Guideline for Safe and Effective Use for Non Chronic Cancer Pain, to download the Opioid Manager and to provide feedback visit http://nationalpaincentre.mcmaster.ca/opioid/
Return to page 1
To Assessment Page
Print
NAME:
List Your Prescribed
Pain Medications: A) ______________________________
B) ______________________________
MEDICATION
D AY
Date
Day 1:
Day 2:
Day 3:
Day 4:
Day 5:
Day 6:
Day 7:
C) ______________________________
PAIN LEVEL/ACTIVITY
WHAT
WHEN
PAIN SCORE
Prescribed Medication/Dose
Time Taken
Level (1 lowest - 10 highest)
DAILY
ACTIVITY
SIDE EFFECTS
Constipation (C) Nausea (N)
Vomiting (V) Other (O)
Return to page 1
To Assessment Page
LengthofTimeDrugscanbeDetectedinUrine
Alcohol
712h
Amphetamine
48h
Methamphetamine
48h
Barbiturate
Shortacting(eg,pentobarbital)
24h
Longacting(eg,phenobarbital)
3wk
Benzodiazepine
Shortacting(eg,lorazepam)
3d
Longacting(eg,diazepam)
30d
Cocainemetabolites
24d
Marijuana
Singleuse
3d
Moderateuse(4times/wk)
57d
Dailyuse
1015d
Longtermheavysmoker
>30d
Opioids
Codeine
48h
Heroin(morphine)
48h
Hydromorphone
24d
Methadone
3d
Morphine
4872h
Oxycodone
24d
Propoxyphene
648h
Phencyclidine
8d
NEXT
Return to page 1
To Assessment Page
DRUG DETECTION TIMES
Substance
Street Names
Urine Test
Amphetamines
Biphetamine, Dexedrine; Black Beauties,
Crosses, Heart
5 days
Amphetamine
Variants
DOB, DOM, MDA, MDMA, Adam, Ecstasy,
STP, XTC
5 days
Methamphetamines
Desoxyn, Crank, Crystal, Class, Ice, Speed
5 days
Coke, Crack, Flake, Rocks, Snow
7 days
Ritalin
5 days
Habitrol Patch, Nicorette Gum, Nicotrol
Spray, Prostep Patch; Cigars, Cigarettes,
Smokeless Tobacco, Snuff, Spit Tobacco
5 days
Hair Test
Saliva Test
Blood Test
Stimulants
Cocaine
Methylphenidate
Nicotine
Hallucinogens and Other Compounds
LSD
Mescaline
Phencyclidine &
Analogs
Psilocybin
Marijuana
Acid, Microdot
8 hours
Buttons, Cactus, Mesc, Peyote
5 days
PCP, Angel Dust, Boat, Hog, Love Boat
5 days
Magic Mushroom, Purple Passion,
Shrooms, Peyote, Mescaline
8 hours
Blunt, Grass, Herb, Pot, Reefer, Sinsemilla, Casual 30d
Smoke, Weed,Cananbis, THC
Daily 42d
NEXT
Return to page 1
To Assessment Page
DRUG DETECTION TIMES
Hashish
Tetrahydrocannabinol
Anabolic Steroids
Hash
5 weeks
Marinol, THC
5 weeks
Testosterone (T/E ratio), Stanazolol,
Nandrolene
Oral 2 wks
Inject 3 mo
Opiates and Morphine Derivatives
Codeine
Tylenol w/codeine, Robitussin A-C, Empirin
w/codeine, Florinal w/codeine
5 days
Heroin
Diacetylmorphine, Horse, Smack
5 days
Methadone
Amidone, Dolophine, Methadose
5 days
Roxanol, Duramorph
4 days
Laudanum, Paregoric, Dover's Powder
5 days
Beer, Wine, Liquor
24 hrs
Amytal, Nembutal, Seconal, Phenobarbital,
Barbs
21 days
Activan, Halcion,
Librium, Rohypnol, Valium, Roofies,
Tranks,Xanax
6 wks
Quaalude, Ludes
2 wks
Morphine
Opium
Depressants
Alcohol
Barbiturates
Benzodiazepines
Methaqualone
Return to page 1
Inventory Overview of Canadian MSK Patient Resources
Patient Resources
General
Information
Pain
Back Care Canada


Canadian Institute for the Relief
of Pain and Disability


Exercise
and
Nutrition
Weight
Mgmt.


Canadian Mental Health
Association

Guidelines and Protocols
Advisory

HealthLink BC



Hospital Programs
*Programs and service offerings
may vary by location
*
*
*
*
Pain BC




Patient Voices Network



Recreation / Community Centres
*Programs and service offerings
may vary by location
*
*
*
University of Victoria Centre on
Aging
Professional Resources
Peer
Support
Groups
General
Information
Click to Link to Resource
Lifestyle
(including
Mental Health)
Activities of
Daily Living
Medication
and
Treatment




Language
Diversity





Pain
Exercise
and
Nutrition
Weight
Mgmt.


Accident Compensation
Corporation – New Zealand
CHARD

Toward Optimized Practice


Pain BC Toolbox


*
*







*




(1 Punjabi
Session in
FHA)
Peer
Support
Groups
Lifestyle
(including
Mental Health)
Activities of
Daily Living
Medication
and
Treatment
Language
Diversity



Click to Link to Resource

NEXT
Print
Return to page 1
Inventory of Canadian LBP Patient Resources
1. Back Care Canada

http://www.backcarecanada.ca/
Program / Resource
Website Links
Description
Information addressing topics for
people suffering from back and leg
pain in an easy-to-read and focused
format.
o
o
o
o
o
Topics
Key Facts on Back and Leg Pain
Non-Surgical Treatment
Back Surgery Options
Seeking Professional Advice
Managing Symptoms and Recovery
2. Canadian Mental Health Association

http://www.cmha.bc.ca/services/bounceback
Program / Resource
Bounce Back
Description
Community based mental health
support to patients to help improve
their mood and quality of life through
free psycho-education and guided selfhelp.
o
o
Topics
“Living Life to the Full” DVD
Overcoming Depression, low Mood
and Anxiety via telephone coaching
Available in English and Chinese.
3. Canadian Institute for the Relief of Pain and Disability




www.cirpd.org
Mission is to prevent and reduce chronic pain, chronic pain-related suffering and disability by creating and
sharing evidence-based resources and information.
Covers 5 main health topics including arthritis, back pain, chronic pain, fibromyalgia and neck pain.
Maintains a database of BC consumer resources:
http://www.cirpd.org/PainManagement/WhatIsChronicPain/Pages/Default.aspx#canada
4. Guidelines and Protocols Advisory Committee (GPAC) – Patient Guidelines


http://www.bcguidelines.ca/gpac/patient_guides.html
Non – professionals can also access health care professional guidelines, but guidelines are not to be a
substitute for the advice or professional judgment of a health care professional.
Program / Resource
Patient Information Guides
Description
Downloadable PDF files available on a
number of health related issues and
topics for non-professionals.
o
o
o
o
o
o
Topics
Rheumatoid Arthritis
Patient Guide for People Living
with Osteoarthritis
Guide for People with Hip
Osteoarthritis
Guide for People with Knee
Osteoarthritis
Guide for People with Hand
Osteoarthritis
Choosing a Complementary
Therapy
NEXT
Return to page 1
5. HealthLink BC



http://www.healthlinkbc.ca/ or 8-1-1 on your telephone to speak to a nurse, pharmacist or dietician
Large online database offering general information on Osteoarthritis, Rheumatoid Arthritis and Low Back
Pain among hundreds of other health issues.
Translation services available in over 130 languages by request.
6. Hospital Programs / Services



Hospitals may offer independent programs and services for patients with arthritis or MSK issues and
these offerings will vary across the province.
Contact your local hospital to enquire about available programs.
The following table is an example of services that can be offered at hospitals.
Program / Resource
Richmond Hospital
Holy Family Hospital
“Arthritis Get Up and Go”
Program
Description
Offers inflammatory and osteoarthritis
hand classes in an interactive and
informative manner.
There are two sessions each week.
One is a land-based exercise class
with an education component. The
second has land based exercise class
and pool exercise component.
o
o
o
o
o
Topics
Introduction to Osteoarthritis
Role of Medications
Joint Protection and Splinting
Hand Exercise
Pain Management
o
o
o
o
o
Introduction to Arthritis
Land and Water Exercise
Joint Protection
Chronic Pain Management
Stress Management and Relaxation
Clients must be assessed by a
physiotherapist before attending
exercise component.
7. Pain BC



www.painbc.ca
Non-profit organization aiming to furthering support and education for patients and promoting
engagement of patients in health care decision making.
Has a Pain Toolbox for patients and providers which provides treatment options for pain beyond
medications, surgery and injections: https://www.painbc.ca/chronic-pain/connect-for-health
8. Patient Voices Network



www.patientvoices.ca
PVN is an initiative of Impact BC, with support from the BC Ministry of Health Services’ Patients as
Partners initiative.
Creates mechanisms for patients, their families and other community stakeholders to participate in
primary healthcare changes that will positively affect their lives.
Program / Resource
Peer Coaches Program
Description
Telephone based model where people
can phone in to get support and
motivation towards healthy lifestyle
changes.
Topics
o
o
o
o
Exercise
Healthy Eating
Quitting Smoking
Losing Weight
Free but requires registration.
NEXT
Return to page 1
9. Recreation / Community Centres


http://oasis.vch.ca/
OASIS offers an extensive search engine linking patients to hundreds of programs, organizations and
resources throughout BC to help patients manage their osteoarthritis.
10. University of Victoria – Centre on Aging

http://web.uvic.ca/research/centres/aging/
Program / Resource
Chronic Disease Self –
Management Program
Description
Free general education program for
adults experiencing chronic health
conditions (e.g., hypertension, arthritis,
heart disease, stroke, diabetes, etc.).
Chronic Pain SelfManagement Program
Free education program developed
specifically for persons experiencing
chronic musculoskeletal pain.
o
o
o
o
o
o
o
o
o
o
o
Topics
Developing an Exercise Program
Healthy Eating
Breathing Exercises
Communication Skills
Medications
Dealing with Emotions
Cognitive Symptom Management
Appropriate Exercise and Nutrition
Communication
Dealing with MSK Related Issues
Medication and Treatments
NEXT
Return to page 1
Physician Resources
A number of resources and treatment options are available to physicians to assist patients in dealing with
acute and chronic low back pain.
Program / Resource
Accident Compensation
Corporation – New Zealand
New Zealand Acute Low Back
Pain Guide
http://www.acc.co.nz/PRD_EX
T_CSMP/groups/external_com
munications/documents/guide/
prd_ctrb112930.pdf
http://www.annals.org/content/
147/7/478.full
Diagnosis and Treatment of
Low Back Pain: A Joint Clinical
Practice Guideline from the
American College of
Physicians and the American
Pain Society (2007)
http://www.bcmj.org/worksafeb
c/clinical-practice-guidelinelow-back-pain
Sep 2011 BCMJ article
summarizing above guidelines
CHARD
Description
The Accident Compensation Corporation
(ACC) provides comprehensive, no-fault
personal injury cover for all New Zealand
residents and visitors to New Zealand.
Their Acute Low Back Pain Guide is
endorsed by the New Zealand Guidelines
Group.
Annals of Internal Medicine – American
College of Physicians Clinical practice
guidelines
Based on Systematic Literature Review,
Evidence Based Guide to Assessment
and Management LBP in 18-50 yr olds.
WorkSafeBC page review article
o
o
o
o
o
BC Medical Journal – WorkSafe BC
Clinical practice guidelines
Topics
Best practice approach, taking into
account relevant evidence, for the
effectiveness of treatment of acute low
back pain for the prevention of chronic
pain and disability.
The accompanying Guide to Assessing
Psychosocial Yellow Flags in Acute
Low Back Pain provides an overview of
risk factors for long-term disability and
work loss, and an outline of methods to
assess these.
Practice guideline for the investigation
and treatment of low back pain.
Evidence based recommendations
from the American College of
Physicians and American Pain Society
7 key recommendations for
assessment, imaging indications, and
treatment
Summary of clinical practice guidelines
with recommendations for dealing with
low back pain
NO LONGER AVAILABLE
Community Healthcare and
Resource Directory
Toward Optimized Practice
Management of Low Back Pain
http://www.topalbertadoctors.or
g/informed_practice/cpgs/low_
back_pain.html
Pain BC Toolbox
Treatment Options for Pain –
Beyond Medications, Surgery
and Injections
Guidelines for Albertan primary care
providers provided by TOP, a health
quality improvement initiative from the
Government of Alberta, for care of
patients with non-specific, non-malignant
low back pain.
o
o
Evidence Based Management of Low
Back Pain
Chronic Low Back Pain Patient
Handout
Acute Low Back Pain Patient Handout
Provides treatment options for pain
beyond medications, surgery and
injections.
o
o
o
o
o
o
Pain self management
Sleep
Mind-Body medicine
Support
Exercise and activity
Lifestyle
Developed by a group of pain specialists,
researchers and people living with pain including Dr. Pam Squire, Dr. Brenda Lau,
Dr. Owen Williamson, Diane Gromala,
PhD. and educator and physiotherapist
Neil Pearson.
o
Return to page 1
Back
THE SCIENCE
OF BACK PAIN
The Truth of About Low Back Pain
- Acute pain usually resolves in several days
or a few weeks for the large majority of
individuals
- A very minor percentage of low back pain
ends up being a serious condition that
requires a surgery. It is very rare.
For those few conditions that occur
rarely, the signs are relatively easy for
your health care provider to identify.
- Xrays and MRI’s are not often needed to
determine how to manage your back
pain
- Surgery is very rarely needed
- The majority of people can and
should get moving early
even if there is some pain
- Your spine is very resilient and
strong. You may be
surprised at how difficult
it is to damage your
spine.
- Even severe pain does not
necessarily indicate likely
injury or serious damage.
- A large majority of adults
experience an episode of
low back pain
“This is more
than just a
method to manage
your low back
pain, it’s a new
way to think
about your back
pain, based on the
latest current
science of back
pain”
LOW BACK PAIN
MANAGEMENT
What Causes Back Pain
- Discs?
- Joints?
- Muscles?
- Nerves?
- Spinal Cord?
- Vertebrae?
The truth is that a specific
anatomical cause can only be
reliably identified in 10-15% of all
cases of low back pain. It could be
a combination of factors, but
knowing the true cause will likely
not change your outcome
ULTIMATE GOAL
“GET UP AND
GET MOVING”
† ANXIETY & STRESS ¢
- Has been shown to aggravate and
prolong low back pain
- Attitudes of fear and
worry over your back
have been shown to
delay recovery
NEXT
Return to page 1
Activity Recommendations
what to do?
MEDICATIONS
- Stay with your normal routine, and just move a
little further and faster each day. Change the
way you perform some of your activities if
necessary, but don’t stop doing those activities.
If you feel that you need some pain medication
you should always start with simple over the
counter analgesics such as ibuprofen or aspirin
(always check with your doctor before taking
any medication). Commonly prescribed
medications such as ibuprofen and muscle
relaxers have shown to provide a slight benefit
over placebo for both acute and chronic low
back pain, but the benefit should not be
expected beyond short term. Some of these
medications can have side-effects. Your doctor
may prescribe either depending on what they
think may be best for you. Neither of these
medications have been shown to provide long
term relief.
- Try to move around a few times every hour.
- Remember, even in the presence of pain,
exercise is recommended.
- Think about your smoking habits and weight
and how they may impact your recovery.
xrays and MRIs
You may think your doctor needs an X-ray or
MRI to understand your the nature of your
problem, however routine radiographs for low
back pain are not recommended. The gonadal
radiation received from one lumbar X-ray is
equivalent to getting 1 chest xray daily for an
entire year. Often the findings from the MRI
will not tell your doctor information relevant
to your treatment plan, or add to what they
can determine from the clinical examination.
Anywhere from 30-40% of individuals
without low back pain have abnormal
findings on MRI (degenerative discs or joints,
herniated discs, annular tears, etc.). These
finding are often not the best predictors of
your prognosis.
WHEN SHOULD I SEE MY
DOCTOR?
- Severe pain that gets worse for several
weeks instead of better
- If you feel sick in addition to your
back pain
- If your leg pain is as bad or worse then
your back pain
- Take frequent breaks from prolonged sitting
- Ice for the first 48 hours and then after that
moist heat
WHAT CAN MY PROVIDER DO FOR ME?
- Rule out any serious diseases
Type to enter text
- Suggest treatments and medications
- Provide advice for the best way to deal with the pain
WHAT I SHOULD NOT EXPECT FROM MY
PROVIDER?
- A “quick fix” or “miracle cure”
HARM WITH
RESTING
BENEFITS OF
ACTIVITY
DECONDITIONING
natural endorphins
for pain relief
WEAKENING OF
BONES
STRENGTHEN
MUSCLE & BONES
LOSS OF
FLEXIBILITY
PREVENT BACK
STIFFNESS
SOCIAL
WITHDRAWAL
STIMULATE BODY’S
OWN ABILITY TO HEAL
- A prescription of bed rest or inactivity
SEEK A MEDICAL PROFESSIONAL
IMMEDIATELY IF YOU HAVE:
- Pins and needles or severe weakness in BOTH legs
- Difficulty walking
- Pain that does not get better when move or change
positions
- Pain that wakes you up at night
- Night sweats
- Difficulty passing or controlling urine
DEPRESSION
The American College of Physicians and the American Pain Society highly
recommend that patients with nonspecific low back pain receive evidence-based
information with advice to stay active, the expected course of their symptoms, and
effective self-care options.
Return to page 1
Patterns of Low Back Pain
MSK Resource
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
Journal of Current Clinical Care Educational Supplement The Latest in Back
Pain Management January 2013.
Q1 - Where is your pain the worst?
LEG DOMINANT
BACK DOMINANT
Q2 - Is your pain constant or intermittent?
Constant
Intermittent
Constant
Intermittent
Flex Pain
PATTERN 3
PATTERN 4
flex pain
ext pain
flex pain
ext pain
<<< Q3 - Does bending forward make your typical pain worse? >>>>
Also determine patients’s typical pain response
to extending backward
Q4 - Has there been a change in your bowel or bladder function
Flex Pain
PATTERN 1
Flex Pain
PATTERN 2
Q5 - What can’t you do now that you could do before you were in pain and why?
Q6 - What are the relieving movements/ positions?
Q7 - Have you had this same pain before?
ext
pain
ext
pain
PEP
PEN
Prone
Extension
Positive
Prone
Extension
Negative
Q8 - What treatment have you had before? Did it work?
FA
FR
Flexion
Aggravated
Flexion
Relieved
Q9 - If age of onset<45, are you experiencing morning stiffness
in your back > 30 minutes?
TWO TESTS TO RULE OUT RED FLAGS
TEST 1
TEST 2
Test upper motor function.
Test lower sacral sensation.
• Sphincter disturbance: bowel or bladder
RED FLAGS
• Non-mechanical pattern of pain
- Disproportionate night pain
- Wide spread neurological signs or
symptoms
- Thoracic dominant pain
• Constant pain
- History of cancer
- Unexplained weight loss
- Fever
- Recent or on-going infection
www.pspbc.ca
• Lack of treatment response
• Immunosuppression
• Intravenous drug use
• Palpation
- is more helpful in cases of
suspected fracture, infection,
tumour or pain disorder.
Return to page 1
Return to Menu
Where is your pain the worst?
You must determine if the pain is back or leg dominant. Back
symptoms usually involve both the back and the leg but one
site will predominate. That distinction is essential for pattern
recognition. Back dominant pain is referred pain while leg
dominant pain is radicular pain.
The pain is considered back dominant if it is worst in the low
back, buttocks, coccyx, and groin or over the outer aspects of
the hips. The pain is considered leg dominant when the pain is
worst around and below the lower buttocks at the gluteal fold,
in the thigh, calf or foot.
It may be easier to determine the dominant location by stating
that only one site will be treated and asking which pain the
patient wants abolished.
Axial (back dominant) pain arises from a spinal structure but
may have accompanying referred pain into the leg. When
forced to choose, patients with axial pain will acknowledge that
the back pain is worse. Radicular (leg dominant) pain indicates
direct nerve root involvement in addition to the mechanical
malfunction. Again, patients often report pain in the back as
well as in the leg; but for those with radicular pain, leg pain
below the buttock will be the chief complaint.
Return to page 1
Return to Menu
Is your pain constant or intermittent?
Determining if the pain is constant or intermittent can be
equally or more difficult. Most patients who endure prolonged
discomfort describe their symptoms as constant.
The inquiry, therefore, must be clear and specific. It is best
asked in two parts:
“Is there ever a time during the day when your pain stops, even
for a brief moment and even though it may quickly return?”
“When your pain stops, does it disappear completely; is it
totally gone?”
Truly intermittent back dominant pain is never the result of
spinal malignancy or active infection.
The power of these questions, properly asked and answered, is
enormous. They can eliminate the chance of the clinician
missing a sinister pathology, one of the commonest concerns
about relying so heavily on the history and physical
examination.
Return to page 1
Return to Menu
The Pattern question:
“Does bending forward make your typical pain worse?”
This is the essential element of the broader question, “What are the aggravating
movements or positions?” It is the specific pain producing movement that
confirms pattern recognition for Patterns 1, 2 and 3. Pattern 4 is identified on
history alone but separating Pattern 4 FA from FR depends on the response to
flexion.
In the physical exam, it is the determining question to differentiate between:
Pattern 1 Pain is reproduced or increased in back flexion.
Prone Extension Positive PEP
 Pain is reduced after the patient performs up to ten prone passive
back extensions. Raise the upper body by pushing up with the arms.
Move the hands far enough forward to fully extend the arms and lock
the elbows while the hips remain down.
 There is a “directional preference”.
Prone Extension Negative PEN
 Pain is either unchanged or increased after the patient performs up
to ten prone passive back extensions.
 There is no “directional preference”.
Pattern 2
 Pain is reproduced or increased in back extension.
 Pain is never increased in back flexion.
Pattern 3
 Leg pain is affected by position and all back movements including
flexion.
Pattern 4
Flexion Aggravated
FA
 Leg pain is worse with flexion.
Flexion Relieved
FR
 Leg pain is relieved with rest in flexion.
 Leg pain is increased with activity in extension.
Return to page 1
Return to Menu
Bowel or Bladder function change?
The fourth mandatory question is, “Since the start of your back
trouble, has there been a change in your bowel or bladder
function?”
Asking the question in this way avoids confusion with long
standing and unrelated urinary or GI problems. The changes
that suggest a possible Acute Cauda Equina Syndrome are:
 urinary retention followed by insensible overflow
 faecal incontinence
o perineal numbness is the other significant finding
Rather than initially searching for a detailed description, the
query is deliberately vague in nature. Specifying changes only
since the start of the attack avoids unnecessary worry about
previous, unrelated disorders. A report of “no change” removes
the necessity to go further.
Any positive response requires a more thorough investigation.
Urinary retention followed by insensible, uncontrolled overflow
and fecal incontinence is indicative of an acute cauda equina
syndrome: a surgical emergency.
Return to page 1
Return to Menu
Five remaining questions
Five remaining questions complete the clinical picture and establish a
link to the past history and the level of present disability:
1. “What can’t you do now that you could do before you were in
pain and why?”
The reason for the limitation (“why?”) should be the same as
the response to the first question, “Where is your pain the
worst?”
2. “What are the relieving movements or positions?”
3. “Have you had this same pain before?”
4. “What treatment have you had before, and did it work?”
5. If patient under 45 yrs. old, “Are you experiencing morning
stiffness in your back that lasts greater than 30 minutes?”
Mechanical back pain is responsive to movement and position.
Discovering the aggravating and relieving factors helps identify the
syndrome and suggests a pain control strategy.
Inflammatory back pain is suggested by the last question and should be
investigated further. Other symptoms include:
 Morning stiffness >1hr diagnostic if age < 40yr old
 Persistence of pain in spite of treatment over several months
 Disproportionate night pain
 Onset usually <40 years of age
 Peripheral joint involvement
 Other systemic symptoms (e.g. iritis)
Consider: Sacroiliitis, Iritis, IBD, Enthesitis, Psoriasis, Family History of
Ankylosing Spondylosis/Rheumatoid or Spinal Osteo Arthritis
Back pain is a recurrent complaint that tends to worsen with time. In a
survey of patients seeking care, over half had suffered more than 10
attacks and over 60% believed that their present attack was, in at least
one respect, worse than the preceding one. The degree of physical
limitation and the value of past therapies influence the current choices.
Return to page 1
Print
Return to Menu
The Physical Examination
The physical examination is not an independent event. It should be designed to verify or refute the history.
Performing the examination in the most efficient manner usually means starting with the patient standing then
progressing to kneeling, sitting on a chair, sitting on the examining table, lying supine and lying prone. Select the
optimum position for each test.
Observation:
General activity and behaviour
Back specific:




Gait
Contour – subtle malalignments are not relevant
Colour – areas of obvious inflammation
Scars
Palpation:
Of limited value – briefly palpate for tenderness and gross deformity
Movement:
Flexion – reproduction of the typical back pain and rhythm of movement
Extension – reproduction of the typical back pain and rhythm of movement
Prone passive extensions – up to 10 when suggested by the history
Other spinal movements – when suggested by the history
Pain is reduced after the patient performs five prone passive back extensions. Raise the upper
body by pushing up with the arms. Move the hands far enough forward to fully extend the arms
and lock the elbows while the hips remain down.
There is a “directional preference”.
Nerve root irritation tests:
Straight leg raise test





Patient lies with the other hip and knee flexed
Passive test - the examiner lifts the leg
Reproduction or exacerbation of the typical leg pain
Reproduction of back pain is not relevant
Produced at any degree of leg elevation
Femoral stretch test – when suggested by the history




Passive test - the examiner lifts the leg
Patient prone with the knee extended
Reproduction or exacerbation of the anterior thigh pain
Back pain is common but not relevant
Next Page
Return to page 1
Return to Menu
Nerve root conduction tests:
The first test in each group (in italics) is all that is required for a basic screen.
L3-L4
Knee reflex
Test with the patient seated, lower leg hanging free
Quadriceps power
Test with patient seated – extend knee against resistance
L5
Extensor hallucis longus
Test with the patient seated, foot on floor – elevate great toe against resistance
Heel walking (L4)
Walk five steps at maximum elevation
Ankle dorsiflexion (L4)
Test with the patient seated, foot on floor – elevate forefoot against resistance
Hip abduction
Trendelenburg test – the patient stands on one leg and then on the other. The hip abductors
are tested for the leg on which the patient is standing. The movement of the contralateral crest
is the marker. A normal test is symmetrical.
S1
Flexor hallucis longus
Test with the patient seated, foot on floor – curl great toe against resistance
Toe walking
Walk five steps at maximum elevation
Plantar flexion
Toe raise on both feet and then on the affected side – examiner supplies balance
Ankle reflex
Test with the patient kneeling
Gluteus maximus muscle tone
Test with patient prone – palpate buttocks as patient tenses and relaxes
Mandatory tests:
Upper motor tests
Plantar response, clonus – any upper motor finding negates a low back mechanical diagnosis.
Saddle sensation
Lower sacral (S2,3, 4) nerve root test – the same roots that supply saddle sensation supply bowel and
bladder function.
Tested in the mid-line between the upper buttocks
Sensory testing:
As required - Sensory findings will mirror the motor findings but are more subjective.
Ancillary testing:
Hip examination – typical pain on flexion-internal rotation– when suggested by the history
Peripheral pulses– when suggested by the history
Abdominal examination– when suggested by the history
Next Page
Return to page 1
1
Return to Menu
Observation
2
Standing
Normal
Extension
Abnormal
Movement to
Reproduce Pain
Hip Abduction
(Trendelenburg)
Test (L5 Nerve
Root Conduction)
Flexion
Gait
Toe Walking Test
(S1 Nerve Root Conduction)
Heel Walking Test
(L4-L5 Nerve Root Conduction)
* 5 steps at maximum elevation
3
Great Toe
Flexion Test
(S1 Nerve Root
Conduction)
Sitting
Great Toe
Extension Test
(L5 Nerve Root
Conduction)
4
Kneeling
Ank
x
Test
(S1 Nerve Root
Conduction)
Normal
Abnormal
Ank
Test
(L4 and L5 Nerve Root
Conduction)
Upper Motor
Test
5
Lying Surpine
Saddle
Sensation Test
(Lower Sacral
Nerve Roots)
Straight Leg Raise Test
(Sciatic Nerve Root Irritation)
6
Lying Prone
Femoral Stretch Test
(Femoral Nerve Root Irritation)
As required: Sensory findings will mirror the motor findings but are more subjective.
Hip Extension Test
(Palpate Gluteus Maximus Tone)
(S1 Nerve Root Conduction)
Next Page
Courtesy of Journal of Current Clinical Care Educational Supplement The Latest in Back Pain Management January 2013.
Return to page 1
Return to Menu
Making Sense of Low Back Pain
Kneeling
Lying Supine
Straight Leg Raise Test
(Sciatic Nerve Root Irritation)
Ankle Reflex
Test
(S1 Nerve Root
Conduction)
Saddle
Sensation Test
(Lower Sacral
Nerve Roots)
Lying Prone
Hip Extension Test
(Palpate Gluteus Maximus Tone)
(S1 Nerve Root Conduction)
Femoral Stretch Test
(Femoral Nerve Root Irritation)
Classification of Mechanical Patterns of Low Back Pain
Reported
Pain Location
Pain Constancy
Pain Improved
Pain Worsened
Neurological
Findings
1
Back, buttocks
or around hips
Constant or
intermittent
One of 2 cohorts will
improve on extension
Forward flexion,
one of the 2 cohorts’
pain also worsens on
extension
Normal
Most likely
discogenic
2
Back dominant
Intermittent
Unaffected or may be
improved on flexion
Worsens on extension
Normal
Most likely
posterior spinal
elements
3
Leg dominant
Constant
By immobility and
recumbent rest
By all back movement,
usually more by
flexion
Positive
irritative test
and/or
conduction loss
Sciatic (or
occasionally
femoral) nerve
root irritation
4
Leg dominant
Intermittent
Relieved by rest in
flexion (sitting)
Activity in extension
(walking)
May have
positive
conduction test;
no irritative test.
Neurogenic
claudication,
often mislabelled
spinal stenosis
Pain
Origin
Journal of Current Clinical Care Educational Supplement • November 2012 17
Return to page 1
Print
Pattern 1: Back Dominant Pain Aggravated by Flexion
Return to Menu
Descriptive Symptoms
Low back dominant pain: felt most intensely in the back, buttock, over the trochanter or in the groin.
Pain is always intensified by forward bending or sustained flexion.
Pain may be constant or intermittent
No relevant neurological symptoms
Findings on Objective Assessment
This pattern is divided into two groups:

PEP (Prone Extension Positive): Increased pain on flexion and relief with up to ten prone passive lumbar extensions.

PEN (Prone Extension Negative): Increased pain on flexion and unchanged or increased with up to ten prone
extensions.
Initial Treatment
1. Handout: Back Pain: Patient Information and Pattern 1: Patient Handout
2. Follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies
Positions:
PEN: Constant Pain:
“Z” lie
Knees to Chest
Lie prone: pillow under pelvis
Movement:
PEN: Constant Pain:
Progress to Sloppy Pushup
Avoid loaded flexion
Typical Therapy Options:
Pharmacologic Therapy
Acetaminophen
NSAIDS
PEN: Intermittent Pain:
”Z” lie
Minimal lumbar support
Lumbar night roll
Prone Lie
PEP:
”Z” lie
Use lumbar support when sitting
Place one foot on stool when
standing
PEN: Intermittent Pain:
Progress to Sloppy Pushup
PEP:
Sloppy Pushup is mainstay of
activity (Perform 10 reps every
hour as the benefits are shortlived).
Non-Pharmacologic (Adjunct) Therapy
Spinal Manipulation
Exercise Therapy
Massage
Acupuncture
Yoga
Apply Ice/Heat
Progressive Relaxation
Schedule 1: Follow Up: One to two days after beginning therapy
1. Has there been clinical improvement?
Significant Improvement
It is anticipated that there will be considerable resolution of symptoms within seven days.

If necessary, consider gradual return to work program
Limited Improvement

Continue to treat – see Schedule 2

If experiencing intermittent pain at reassessment continue to treat as Fast Responders
No Improvement

Patients with increased pain or radiation of pain into the legs should be reassessed.
Schedule 2: For patients with limited improvement in first week of treatment
Positions:
PEN
Maintain a rigid schedule of rest and movement
Movement:
PEN
In addition to initial therapies add asymmetric
movements and core stability exercises (Back
Pain: Patient Information)
Avoid flexion
PEP
Increase lumbar support
Use lumbar support when recumbent
PEP
Improve techniques and increase frequency
Schedule Sloppy Pushup
Next Page
Return to page 1
Return to Menu
> Physical Therapist Comments to Patient:
PATTERN 1 BACK PAIN:
At-Home Exercises
> Other General Recommendations
Pure HealthyBack (PHB) is committed to providing you an
exceptional experience and improving your health. To
diagnose and best treat you, we use a simple and elegant
method called Patterns of Pain (POP), which was created
by world-renowned spine surgeon and best-selling back
and neck pain author Hamilton Hall, MD, FRCSC, who is
PHB’s medical director. The POP method has been shown
to be effective because it allows us to focus on the symptoms
you have identified and the problems as you describe them.
• Your back will feel better when you walk or stand
rather than sit. Schedule ________ minutes of walking
every ________ hour(s).
• When standing, place one foot on a stool to relieve
pressure on your back. Switch feet every 5 to 15 minutes.
Maintain good posture.
• Avoid rolling your spine forward. This may put more
pressure on the painful areas and increase your discomfort.
Patterns of Pain include four distinct patterns for patients
with chronic back pain and four for those with neck pain.
You are receiving treatment according to your distinct
Pattern of Pain.
Pattern 1 Symptoms
> Committed to Your Care
If you have any questions, please ask a member of your health
care team, call, or email us at info @purehealthyback.com.
We are each committed to providing you an exceptional
experience and improving your health.
Your physical therapist may prescribe other
exercises and stretches. Please see the General
Recommendations for Maintaining a Healthy Back
Patient Information handout.
You’ve been diagnosed as having Pattern 1
symptoms, including:
• Pain is worst in the back, buttocks, around the hips,
or in the groin but may radiate to the legs.
• Pain may be constant or intermittent.
• Pain is worse when sitting or bending forward.
• Pain may be eased by bending backwards. Walking
and standing are better than sitting.
> Rest Positions and Excercises
The rest positions and excercises outlined in this handout
can be used to reduce your pain. Your physical therapist
will check the boxes next to each recommendation and
cross out the rest positions and excercises that are not
suitable for your diagnosis and treatment.
Next Page
734.404.7300 | info @ purehealthyback.com | PureHealthyBack.com
A Pure Solution for those with chronic back and neck pain
Return to page 1
Return to Menu
Pattern 1
Start Slowly
For the first few days, you may only be able to lie
on your stomach (see Prone Lie below) and then progress
to prone extension using your arms at your physical
therapist’s recommendation.
LUMBAR ROLL: SITTING
Use a straight-backed chair and ___ -inch lumbar roll to
support the curve of your back.
Rest for ________ minutes every ________ hour(s).
PRONE LIE
“Z’ LIE
• Lie with your back flat on the floor and support your
head with a pillow (you may also support your buttocks
with a pillow).
• Place your feet on a chair with your knees bent at more
than a 90-degree angle.
Rest for ________ minutes every ________ hour(s).
Lie on your stomach and use three pillows to support
your hips (you may also support your head with pillows).
Sometimes just lying on your stomach without any pillows
feels best.
Rest for ________ minutes every ________ hour(s).
SLOPPY PUSH-UP
PRONE LIE ON ELBOWS
• Lie face down on the floor or bed.
• Bend your elbows and relax.
Rest for ________ minutes every ________ hour(s).
• Lie on your stomach with your hands on either side
of your head.
• Keep your lower body on the floor and use your arms to
slowly raise your upper body. (Your hands may need to be
positioned above your head to fully extend your elbows,
and your pelvis should remain on the floor.)
• Keep your back muscles relaxed.
• Move slowly up. Lock elbows. Sag back. Down.
• Do not hold the position.
Repeat ______ times every ______ hour(s) during the day.
www.pspbc.ca
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
NIGHT ROLL: LYING DOWN
Lie on a long sponge roll running across your body
between your hips and your ribs to support your back
and stop it from sagging.
Return to page 1
Print
Return to Menu
Pattern 2: Back Dominant Pain Aggravated by Extension
Descriptive Symptoms
Low back dominant pain; felt most intensely in the back, buttock, over the trochanter or in the groin.
Pain is never intensified with flexion.
Pain is always intensified by extension
Pain is always intermittent.
No relevant neurological symptoms.
Findings on Objective Assessment
Increased or reporduced pain on back extension
Pain is unchanged or reduced in back flexion
The neurological examination is normal or non-contributory
Initial Treatment
1. Handout: Back Pain: Patient Information and Pattern 2: Patient Handout
2. Instruct patient to follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies.
Positions:
”Z” Lie
Supine knees to chest
Correct sitting and standing postures
Typical Therapy Options:
Pharmacologic Therapy
Movement:
Repeated supine flexion (Knees to chest)
Repeated seated flexion (Use hands on thighs to push upper body into
upright position)
Avoid extension as required
Non-Pharmacologic (Adjunct) Therapy
Acetaminophen
NSAIDS
Spinal Manipulation
Exercise Therapy
Massage
Acupuncture
Yoga
Apply Ice/Heat
Follow Up: One to two days after beginning therapy
1. Assess treatment response

Assess pain medication and treatment modalities

Assess improvement:
Better = decreased pain or pain is becoming more centralized
Worse = increased pain or pain moving towards the periphery
2. Has there been clinical improvement?
Significant Improvement

Movement should begin to restore within one or two days. Full function is expected in two to three weeks

If necessary, consider gradual return to work program
Limited Improvement

Continue treatment. Use Pattern 1: Slow Responder

Improve techniques

Introduce manual therapies
No Improvement

Reconsider pattern selection

If patient has no improvement, reassess
Next Page
Return to page 1
> Physical Therapist Comments to Patient:
Return to Menu
PATTERN 2 BACK PAIN:
At-Home Exercises
Pure HealthyBack (PHB) is committed to providing you an
exceptional experience and improving your health. To
diagnose and best treat you, we use a simple and elegant
method called Patterns of Pain (POP), which was created
by world-renowned spine surgeon and best-selling back
and neck pain author Hamilton Hall, MD, FRCSC, who is
PHB’s medical director. The POP method has been shown
to be effective because it allows us to focus on the symptoms
you have identified and the problems as you describe them.
Patterns of Pain include four distinct patterns for patients
with chronic back pain and four for those with neck pain.
You are receiving treatment according to your distinct
Pattern of Pain.
Pattern 2 Symptoms
> Committed to Your Care
If you have any questions, please ask a member of your health
care team, call, or email us at info @purehealthyback.com.
We are each committed to providing you an exceptional
experience and improving your health.
You’ve been diagnosed as having Pattern 2
symptoms, including:
• Pain is worst in the back, buttocks, around the hips,
or in the groin but may radiate to the legs.
• Pain is always intermittent.
• Pain is worse when bending backward and when
standing or walking for extended periods.
• Bending forward or sitting may ease pain.
> Rest Positions and Excercises
The rest positions and excercises outlined in this handout
can be used to reduce your pain. Your physical therapist
will check the boxes next to each recommendation and
cross out the rest positions and excercises that are not
suitable for your diagnosis and treatment.
Next Page
734.404.7300 | info @ purehealthyback.com | PureHealthyBack.com
A Pure Solution for those with chronic back and neck pain
Return to page 1
Return to Menu
Pattern 2
KNEES TO CHEST
• Lie on your back with your knees bent and your
feet flat on the floor.
• Raise one knee to your chest and slowly raise the
other to meet it (you may use your hands to lift your
knees if necessary).
• Wrap your arms behind your knees and gently pull both
knees toward your chest.
• Hold for a few seconds, relax, and repeat.
Repeat ______ times every ______ hour(s) during the day.
TRUNK FLEXION STRETCH (SUSTAINED FLEXION)
• Kneel on your hands and knees.
• Tuck in your chin and let your back bend forward.
• Slowly sit back on your heels while dropping your
shoulders toward the floor.
Hold for ______ seconds. Repeat ______ times
every ______ hour(s) during the day.
SITTING FLEXION
• Sit with your feet flat on the floor about hip-width apart.
• Lean forward and allow your head and shoulders to drop
between your knees.
• For added stretch, grab your ankles and pull down.
• With your hands on your knees, use your arms to raise
your upper body.
• Hold the stretch for a few seconds, sit up, and repeat.
Repeat ______ times every ______ hour(s) during the day.
Other General Recommendations
• When standing, reduce unnecessary load on the spine by using your arms
on your thighs to push your upper body into an upright position.
• Avoid extension: Do not bend your back backward. This may cause more
pain.
Note: Your physical therapist may prescribe other exercises and stretches.
www.pspbc.ca
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
Return to page 1
Print
Pattern 3: Constant Leg Dominant Pain
Return to Menu
Descriptive Symptoms
Leg dominant pain: felt most intensely below the gluteal fold above and can extend to the thigh, calf, ankle, foot.
Pain is always constant and is affected by back movement or position.
Neurological symptoms must be present
Findings on Objective Assessment
Neurological examination must be positive for either an irritative test or a newly acquired focal conduction deficit.
Initial Treatment
NOTE: Pattern 3 will not respond to exercise. Treatment consists of prescribed REST positions.
Track progress over six weeks (Neurological deficit beyond seven days does not happen unless it is Cauda
Equina Syndrome).
1.
2.
Handout: Back Pain: Patient Information and Pattern 3: Patient Handout
Follow appropriate treatment schedule: position, pharmacology and adjunct therapies.
Positions:
Basis of treatment is scheduled rest: 20-40 minutes every hour
“Z” lie
Prone lying on pillows
Prone lying on elbows
Rest on hands and knees
Lumbar support
Night roll
Typical Therapy Options:
Pharmacologic Therapy
Acetaminophen
NSAIDS
Tramadol, Opiods
Non-Pharmacologic (Adjunct) Therapy
Progressive Relaxation
Massage
Professionally administered invasive therapies
Acupuncture
Spinal Manipulation(if there is no inflammation)
Apply Ice/Heat
Follow Up: One to two weeks after beginning therapy
1. Assess treatment response

Assess pain medication and treatment modalities

Assess improvement:
Better = decreased leg pain
Worse = increased leg pain
2. Has there been clinical improvement?
Significant Improvement

Focus on symptom reduction for up to six weeks.

Pain should begin to resolve within four weeks

Once leg symptoms become intermittent or pain becomes back dominant continue treatment as per Pattern 1.
No Improvement

If no improvement, reassess
Next Page
Return to page 1
> Physical Therapist Comments to Patient:
Return to Menu
PATTERN 3 BACK PAIN:
At-Home Exercises
Pure HealthyBack (PHB) is committed to providing you an
exceptional experience and improving your health. To
diagnose and best treat you, we use a simple and elegant
method called Patterns of Pain (POP), which was created
by world-renowned spine surgeon and best-selling back
and neck pain author Hamilton Hall, MD, FRCSC, who is
PHB’s medical director. The POP method has been shown
to be effective because it allows us to focus on the symptoms you have identified and the problems as you describe
them.
Patterns of Pain include four distinct patterns for patients
with chronic back pain and four for those with neck pain.
You are receiving treatment according to your distinct
Pattern of Pain.
Pattern 3 Symptoms
> Committed to Your Care
If you have any questions, please ask a member of your health
care team, call, or email us at info @purehealthyback.com.
We are each committed to providing you an exceptional
experience and improving your health.
You’ve been diagnosed as having Pattern 3
symptoms, including:
• Pain is mainly in the legs but back pain may be present.
• Pain is constant.
• Pain is often worse when sitting or bending but in the
acute stage can be made worse by any movement.
• Pain may be lessened in some resting positions.
> Rest Positions
The rest positions outlined in this handout can be used
to reduce your pain. Your physical therapist will check
the boxes next to each recommendation and cross out
the rest positions that are not suitable for your diagnosis
and treatment.
Next Page
734.404.7300 | info @ purehealthyback.com | PureHealthyBack.com
A Pure Solution for those with chronic back and neck pain
Return to page 1
Return to Menu
Pattern 3
“Z’ LIE
• Lie with your back flat on the floor and support your
head with a pillow (you may also support your buttocks
with a pillow).
• Place your feet on a chair with your knees bent at more
than a 90-degree angle.
Rest for ________ minutes every ________ hour(s).
LUMBAR ROLL: SITTING
Use a straight-backed chair
and ___ -inch lumbar roll to
support the curve of your back.
Sitting is usually very painful
for Pattern 3 patients.
PRONE LIE ON ELBOWS
PRONE LIE
• Lie face down on the floor or bed.
• Bend your elbows and relax.
Rest for ________ minutes every ________ hour(s).
REST ON HANDS AND KNEES
Kneel on your hands and knees on the floor or bed.
Rest for ________ minutes every ________ hour(s).
NIGHT ROLL: LYING DOWN
Lie on a long sponge roll running across your body
between your hips and your ribs to support your back
and stop it from sagging.
Lie on your stomach and use pillows to support your
hips to find the position that reduces the leg pain (you
may also support your head with a pillow).
Rest for ________ minutes every ________ hour(s).
Other General Recommendations
The best treatment is to schedule rest periods throughout
the day. Lie down for ________ minutes and find the rest
position(s) that best reduce(s) your leg pain. Long-term
bed rest is not recommended and can hinder recovery.
The best position is the one that most reduces the leg pain.
There is no place for exercises or repeated movements
during the acute attack.
www.pspbc.ca
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
Note:
Your physical therapist may prescribe
other exercises and stretches.
Return to page 1
Print
Pattern 4: Intermittent Leg Dominant Pain
Return to Menu
FA - Flexion Aggravated (residual nerve root involvement)
Descriptive Symptoms and Physical Exam
Leg dominant pain: felt most intensely below the gluteal fold above or below the knee.
Leg pain is worse with flexion.
Pain is always intermittent.
May have a positive irritative test and/or a conduction loss.
Always better with unloaded back extension movement or position: (leg dominant pain that responds to mechanical back
Tx) – Prone extension will reduce the pain.
FR – Flexion Relieved (neurogenic claudication)
Descriptive Symptoms and Physical Exam
Pain is leg dominant
Leg pain is intermittent
Leg pain is increased with activity in extension
Leg pain is relieved with rest in flexion.
The irritative tests are always negative
May be a conduction loss in long standing cases: prone extension will aggravate the symptoms
Initial Treatment
1. Handout: Back Pain: Patient Information and Pattern 4: Patient Handout
2. Follow appropriate treatment schedule: position, movement, pharmacology and adjunct therapies
3. Because it is leg dominant, radicular pain, a gentle, gradual approach is recommended.
Positions:
Generally relieved rapidly with rest and flexion
Pelvic tilt
Correct sitting and standing postures
Typical Therapy Options:
Pharmacologic Therapy
Acetaminophen
NSAIDS
Movement:
Modification of daily routine
Regular, continued flexion-strengthening exercises is the most
effective physical treatment
Increase trunk strength in the abdominal oblique and paraspinal
muscles
Non-Pharmacologic (Adjunct) Therapy
Exercise Therapy
Massage
Acupuncture
Yoga
Apply Ice/Heat
Progressive Relaxation
Follow Up: Treat for one to two months before follow-up
1. Assess treatment response

Assess pain medication and treatment modalities

Assess improvement:
Better = Increased walking distance
Worse = Decreased walking distance
2. Has there been clinical improvement?
Significant Improvement

Treatment requires an extended period of increasing strength and range of motion

Should have a quick return to work with no modification or review
Limited Improvement

Continue with treatment

Improve exercise techniques

Stationary cycling in flexion

Increase frequency of rest/exercise cycles
No Improvement

If patient has no improvement, reassess
Next Page
Return to page 1
Return to Menu
Pattern 4 Flexion Relieved (FR)
SINGLE LEG ABDOMINAL PRESS
CAT/CAMEL
SITTING FLEXION
• Sit with your feet flat on the
floor about hip-width apart.
• Lean forward and allow your
head and shoulders to drop
between your knees.
Hold for ________ seconds.
Do ________ repetitions.
• Lie on your back with your knees bent.
• Keep your back in a neutral position and tighten
your abdominal muscles.
• Lift one leg so your knee and hip are at a 90-degree angle.
• Press one hand against your knee while pulling it toward
the hand. Keep your elbow straight.
Hold for ________ seconds. Return to start position and
repeat with your opposite leg. Do ________ repetitions.
• Kneel on your hands and knees.
• Arch your back, letting your head drop slightly.
• Keep your abdomen and buttock muscles tightened.
Hold for ________ seconds.
• Let your back sag toward the floor while keeping your
arms straight and your weight evenly
distributed between your legs and arms.
Hold for ________ seconds. Do ________ repetitions.
PELVIC TILT
PARTIAL SIT-UP OR CRUNCH
• Lie on your back with your knees bent, feet flat on
the floor, and arms crossed over your chest.
• Using your lower stomach muscles, raise your head
and shoulder slightly until your shoulder blades are
just off the floor (you may not be able to get up this
far in the beginning).
Hold for ________ seconds. Do ________ repetitions.
• Lie on your back with your knees bent and your
arms on your chest or at your side.
• Place your feet flat on the floor, hip-width apart, with
your knees slightly closer together than your feet.
• Tighten your abdominal muscles.
• Press the small of your back against the floor causing
the front of your pelvis to tilt forward.
Hold for ________ seconds. Do ________ repetitions.
The most effective treatment for your condition is a long-term regular exercise program focused on
increasing strength in core muscles. Your physical therapist may prescribe additional
exercises and stretches.
Next Page
www.pspbc.ca
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
Return to page 1
Return to Menu
Pattern 4 Flexion Aggravated (FA)
SLOPPY PUSH-UP
• Lie on your stomach with your hands on either side
of your head.
• Keep your lower body on the floor and use your arms to
slowly raise your upper body. (Your hands may need to be
positioned above your head to fully extend your elbows,
and your pelvis should remain on the floor.)
• Keep your back muscles relaxed.
• Move slowly up. Lock elbows. Sag back. Down.
• Do not hold the position.
Repeat ______ times every ______ hour(s) during the day.
A) It is the leg pain that is the focus and which will decrease
with the sloppy push-ups.
B) Because it is leg dominant, radicular pain, a gentle, gradual
approach is recommended.
NIGHT ROLL: LYING DOWN
LUMBAR ROLL: SITTING
Use a straight-backed chair and ___ -inch lumbar roll to
support the curve of your back.
Rest for ________ minutes every ________ hour(s).
“Z’ LIE
• Lie with your back flat on the floor and support your
head with a pillow (you may also support your buttocks
with a pillow).
• Place your feet on a chair with your knees bent at more
than a 90-degree angle.
Rest for ________ minutes every ________ hour(s).
PRONE LIE
PRONE LIE ON ELBOWS
• Lie face down on the floor or bed.
• Bend your elbows and relax.
Rest for ________ minutes every ________ hour(s).
Lie on a long sponge roll running across your body
between your hips and your ribs to support your back
and stop it from sagging.
Next Page
www.pspbc.ca
Courtesy of Dr Hamilton Hall, CBI Heath Group, Pure Healthy Back,
Lie on your stomach and use three pillows to support
your hips (you may also support your head with pillows).
Sometimes just lying on your stomach without any pillows
feels best.
Rest for ________ minutes every ________ hour(s).
Return to page 1
Print
Return to Menu
Pattern 1
SLOPPY PUSH-UP
PRONE LIE ON ELBOWS
“Z” LIE
PRONE LIE
LUMBAR ROLL: SITTING
NIGHT ROLL: LYING DOWN
Pattern 2
KNEES TO CHEST
SITTING FLEXION
TRUNK FLEXION STRETCH
courtesy of Pure Healthy Back
Next Page
www.pspbc.ca
Return to page 1
Return to Menu
Print
Pattern 3
“Z” LIE
REST ON HANDS & KNEES
PRONE LIE
PRONE LIE ON ELBOWS
NIGHT ROLL: LYING DOWN
LUMBAR ROLL: SITTING
Pattern 4
SLOPPY PUSH-UP
FA
A) It is the leg pain that is the focus and
which will decrease with the sloppy
push-ups.
Pattern 1
B) Because it is leg dominant, radicular
pain, a gentle, gradual approach is
recommended.
(Exercises)
SINGLE LEG ABDOMINAL PRESS
PARTIAL SIT-UP OR CRUNCH
SITTING FLEXION
LUMBAR ROLL: CAT & CAMEL
FR
PELVIC TILT
before
after
courtesy of Pure Healthy Back
www.pspbc.ca