Back Pain in General Practice

Dr Chris MonellaDr Chris Monella

GPSIGPSI

Back pain

Common 50-80%Common 50-80% Diagnosis 15%Diagnosis 15% Benefit claims >10%Benefit claims >10% Risk factorsRisk factors

Lumber vertebrae

disc

History

Age, occupation,lifestyleAge, occupation,lifestyle Site/spread/segmentalSite/spread/segmental OnsetOnset SymptomsSymptoms Red flag, yellow flagsRed flag, yellow flags PMH, medications,etcPMH, medications,etc

Diagnosis

Capsular pattern eg degenerative OACapsular pattern eg degenerative OA Non-capsular pattern eg PIDNon-capsular pattern eg PID

Mechanical back painMechanical back pain PIDPID Spinal stenosisSpinal stenosis Sacro-iliac joint painSacro-iliac joint pain

Lumber spine examination

Observation-f,p,gObservation-f,p,g Look-ic,psis,asis,leg length,spine Look-ic,psis,asis,leg length,spine

curvature,lordosiscurvature,lordosis Lumber active ext,lat flex,flex ?capsularLumber active ext,lat flex,flex ?capsular Tip-toe:Gastrocnemius root: Tip-toe:Gastrocnemius root: s1s1,2,2 Hip-passive flex, med rot, lat rotHip-passive flex, med rot, lat rot SIJ-shear tests, faberSIJ-shear tests, faber

Lumber spine examination 2

SLR- dural sign :SLR- dural sign :l4,5,s1,2l4,5,s1,2 Resisted hip flex: Resisted hip flex: l1,2l1,2,3,3 Resisted dorsiflexion(TA): Resisted dorsiflexion(TA): l4l4,5,5 Resisted ext big toe (EHL) :Resisted ext big toe (EHL) :l5,s1l5,s1 Resisted eversion (PB/L): Resisted eversion (PB/L): l5,s1l5,s1,2,2

Lumber spine examination 3

Skin sensationSkin sensation

Big toe: l4Big toe: l4 Toes 1,2,3: l5Toes 1,2,3: l5 Toes 4,5 : s1Toes 4,5 : s1

Lumber spine examination 4

ReflexesReflexes

Knee :l2,Knee :l2,3,43,4 Ankle:Ankle:s1,2s1,2 BabinskiBabinski

Lumber spine examination 5

Femoral stretch test:l2,Femoral stretch test:l2,33,4,4 Resisted knee ext(Quads) :l2,Resisted knee ext(Quads) :l2,3,43,4 Resisted knee flexion(Ham):Resisted knee flexion(Ham):l5,s1l5,s1,2,2 Gluts (bulk): Gluts (bulk): l5,s1,2l5,s1,2

Lumber spine examination 6

PalpationPalpation ?manipulation?manipulation-- History recheck, noncapsular History recheck, noncapsular

pattern,normal plantar,normal reflexespattern,normal plantar,normal reflexes Observe, treat or refer?Observe, treat or refer?

Treatment

Mobilization (grade A) in acute back pain Mobilization (grade A) in acute back pain eg. Modified Pretzel techniqueeg. Modified Pretzel technique

AcupunctureAcupuncture Reassurance, iceReassurance, ice analgesia,NSAIDs,Amitrip., gabapentin, etcanalgesia,NSAIDs,Amitrip., gabapentin, etc Ix, PCT back pain clinic,Back surgeonIx, PCT back pain clinic,Back surgeon

Jarvik et al . JAMA 2004

RCT-380

X-ray 167

MRI 170

3,6,12/12 fu

Increased reassurance, surgery/cost of care

Overall disability,pain, general health -same

Gilbert et al. Health Tech assess 2004

782 patients, 14 hospitals

393 early imaging

389 delayed

8 & 12/12 better outcome

0.07 QALY for £61 over 24 months

NICE Feb 2008

Holistic assessment of person with OA

Social

Comorbidity

Existing thoughts

Occupational

Mood

Quality of sleep

Support network

Effect on life

Lifestyle expectations

Activities of daily living

Family duties

Hobbies

Concerns

Expectations

Current knowledge about OA

Attitudes to exercise

Ability to perform job

Adjustments to home or workplace

Short term

Long term

Screen for depression

Other current stresses in life

Ideas, concerns and expectations of main carer

How carer is coping

Isolation

Fitness for surgery

Assessment of most appropriate drug therapy

Interaction of two or more morbidities

Falls

Other musculo-

skeletal pain

Evidence of a chronic pain syndrome

Other treatable source of pain

e.g. periarticular pain

e.g. trigger finger, ganglion etc.

e.g. bursitis

Pain assessment

Self-help strategies

Analgesics

Drugs, doses, frequency, timing

Side effects

Treatment options

education, advice,information access

strengthening exerciseaerobic fitness training

weight loss if overweight/obese

topical NSAIDs

paracetamol

supports and braces

intra-articular corticosteroid

injections

opioids

joint arthroplasty

oral NSAIDs including COX-2

inhibitors

TENS

local heat and cold

capsaicin

manual therapy (manipulation and

stretching)

assistive devices

shock-absorbing shoes or insoles

Summary

History,examination findings & treatmentsHistory,examination findings & treatments Mechanical back pain/PIDMechanical back pain/PID Systemic back painSystemic back pain Spinal stenosisSpinal stenosis Sacroilitis(in ankylosing spondylitis)Sacroilitis(in ankylosing spondylitis)