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Back pain – a comprehensive guide Lawrence Pike James Street Family Practice Introduction First, we will discuss the formal medical model: definition, incidence, aetiology, diagnosis, and treatment. Secondly we will look at the recommendations of the RCGP on Acute Back Pain Introduction Back pain is one of the most common ailments of mankind. An estimated 80 percent of people will experience back pain at some point in their lives, and slightly more men suffer from it than women Potent cause of absence from work Causes Musculoskeletal Degenerative Rheumatic Neoplastic Referred Infection Psychological Metabolic Musculoskeletal Ligamentous Muscular Facet joint Sacroiliac strain Prolapsed disc Fracture Scoliosis Degenerative Osteoarthritis Spondylosis Rheumatic Rheumatoid Arthritis Ankylosing Spondylitis Neoplastic Primary Secondary Prostate Lung Renal Breast Thyroid Referred Pain Gynaecological Renal Other abdominal Infection TB Osteomyelitis Herpes Zoster Psychological Depression Malingering Metabolic Osteoporosis Paget’s Osteomalacia History Sometimes a clear cause but often not In a young, fit person then usually: muscle or ligament strain facet joint problem prolapsed disc Muscle or ligament strain Usually can give you the cause Related to posture Episodic Pain worse on movement, helped by rest Facet Joint Sudden backache with a simple movement “I was just picking up a coin off the floor” Often flexion with rotation May have heard a click Prolapsed Disc Shooting pain Pain radiating down the leg below the knee Aggravated by coughing/sneezing Usually sudden onset and often no trauma Red Flags in the History Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use Examination Observation Palpation Movements Straight leg raising Femoral stretch test Power Sensation Reflexes L4/5 Prolapse Straight Leg Raising reduced Ankle Jerk present Weakness Big Toe Foot Dorsiflexion Sensory Loss Medial foot L5/S1 Prolapse Straight leg raising reduced Ankle jerk absent Weakness Plantar flexion Foot eversion Sensory Loss Lateral foot Investigations For simple backache, age 20-50 <4 weeks duration,no red flags no x-rays necessary. Patients expect one. X-ray: recent significant trauma recent mild trauma over 50 prolonged steroid use osteoporosis age over 70 Investigations Plain x-ray with FBC and ESR to rule out tumour, infection if red flags suggest likely If red flags present and plain x-ray normal then bone scan, CT or MRI may still be indicated RCGP Guidelines Acute Low Back Pain Clinical Guidelines for the Management of Acute Low Back Pain First published 1999 Updated yearly Evidence based Management RCGP Guidelines recommends triage into 3 groups 1/ simple backache / low back pain 2/ nerve root pain 3/ possible serious spinal pathology Simple Backache Presents 20-55 years Pain in lumbosacral area, buttocks and thighs “mechanical” pain patient well includes muscle or ligament strain and facet joint problems Nerve Root Pain Unilateral leg pain worse than low back pain Radiates to foot or toes Numbness and paraesthesia in same distribution SLR reproduces leg pain Localised neurological signs reflexes and power Possible Serious Spinal Pathology Symptoms of systemic illness weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use Cauda Equina Syndrome Sphincter disturbance Gait disturbance or widespread motor weakness involving more than on nerve root or progressive motor weakness in the legs Saddle anaesthesia of anus, perineum or genitals Needs emergency referral Red Flags (again) Retention of urine or incontinence Onset over age 55 or under 20 Symptoms of systemic illness weight loss, fever Morning stiffness Severe progressive pain A prior history of cancer Intravenous drug use Prolonged steroid use Yellow Flags RCGP refers to Psychosocial problems “Yellow Flags” as they may predict likelihood of Chronicity May be more important than the physical factors Lets look at these in more detail Psychological Risks Attitudes and Beliefs Distress and Depression Excessive adoption of Sick Role Social Factors Family Work Physical demands of job Job satisfaction Poor health record at work Other factors leading to time off medico-legal proceedings, marital strife and financial problems Psychological Management Encouraging positive attitudes towards recovery Adequate pain relief and continue work Reassurance Encourage to keep active, consider manipulation Back problems become less common after 50-60 Drug Treatment Prescribe analgesics at regular intervals, not prn. Start with paracetamol If inadequate add NSAIDs (Ibuprofen or Diclofenac) Then try Co-proxamol or Codydramol Finally consider muscle relaxant Avoidance of Bed Rest Bed rest has not been shown to be effective in trials of simple backache or nerve root pain Strong evidence that bed rest leads to debilitation, disability and difficult rehabiliation Evidence in favour of activity is strong and unequivocal What to tell the patient Increase physical activity progressively over a few days or weeks Stay as active as possible and continue normal daily activities Stay at work or return to work as soon as possible as beneficial Who to Refer Nerve root pain not resolving after 4 weeks (Orthopaedics) One or more red flags leads to credible evidence of serious pathology Cauda equina syndrome Can have manipulation as long as no progressive neurology Manipulation Strong evidence that manipulation provides better short-term improvement in pain and activity and higher patient satisfaction Moderate evidence that risks are very low in trained hands Back Exercises Strong evidence that back exercises do not produce any significant improvement in acute back pain Moderate evidence that exercise programmes can improve pain and function in chronic low back pain Other Therapies Inconclusive TENS Shoe insoles or lifts Local injections Back schools No evidence corsets or supports acupuncture Other Therapies Evidence of no effect Traction Physical agents (ultrasound, heat, ice, diathermy, massage) Evidence against Narcotics or Benzodiazepines beyond 2 weeks Plaster jackets Steroids Summary Common problem Carry out diagnostic triage Adequate pain relief and early mobility - resolving < 4 weeks Give positive messages to patient Remember yellow and red flags Patients perspective What has happened Why has it happened? Why me? Why now? What would happen if I did nothing? What should I do about it? What can you do about it? How can I stop it happening again?
