Assessment & Screening Eric J. Visser Chronic Low Back Pain Assessment & Screening Eric J. Visser

CLBP is common & consequential CLBP: pain ≥ 3M in low back region (ribs, buttocks, flanks) 10% of population 2.2 million Australians right now 10% of GP visits 50% of pain clinic visits Top 10 health care burdens worldwide (disability) $35 billion per year (health care, productivity)

Causes of LBP Acute LBP → ‘chronic’ in 20% of cases Acute low back pain Injury (work, sports) (lifting, twisting, straining, repetitive loading) Spondylosis (‘spinal’ ‘degeneration’) (discs, facets) Pathology (red flags) Surgery (‘failed back surgery syndrome’) Pregnancy Fitness (↑ BMI, deconditioning, smokers) Genetics (disc pain, connective tissue/hypermobility) Parreira P, Maher CG, Latimer J, Steffens D, Blyth F, Li Q, Ferreira ML. Can patients identify what triggers their back pain? Secondary analysis of a case- crossover study. Pain 2015 Jun 1. PMID: 26039901

Assessment Bio-medical-psycho-social approach History Classification of LBP Questionnaires Examination Special tests MRI

History Who is the patient? What type of LBP; ± leg pain; neuropathic pain What is the cause? When (timing)? How did it happen? (nature of injury, mechanisms & forces involved) Why is the patient presenting NOW? Red flags (screening questions) (T.I.N.T) Yellow flags (psycho-social predictors of chronic pain & disability) (C.H.A.M.P.S)

Classifying CLBP Timing? Type of LBP? - non-specific? (80%) - chronic ≥3M - acute-on-chronic (‘flare ups’) Type of LBP? - non-specific? (80%) - specific? (‘pain generator’ identified) (20%) ± Leg pain? (20%) - referred pain (musculoskeletal structures) (2/3rd) - radicular pain (‘sciatica’) (1/3rd) (10% of cases overall) ± Neuropathic pain? (up to 80% of CLBP) Chronic non-specific low back with leg pain

Specific causes of CLBP The search for pain generators Discs (40%) - internal disc disruption (IDD) - high intensity zone (HIZ) - Modic changes (‘inflamed’ end plates) Facet joints (20%) Sacro-iliac joints (20%)

Specific CLBP Spinal stenosis Pars defects - back pain - leg pain - claudication - tight canal on imaging - supermarket trolley test Pars defects

Specific CLBP Cluneal neuralgia (10%) Unilateral low back Buttock pain (leg) Tender over iliac crest Altered sensation over buttock Due to rotation, twisting? Vertebral fractures?

Specific CLBP - trigger points Myofascial pain - gluteal muscles - latissimus dorsi fascia - greater trochanters

Radicular leg pain (‘sciatica’) Neuropathic leg pain due to a nerve root lesion Not common (10%) L5 or S1 nerve root (90%) Sensory signs & symptoms (foot numbness, allodynia, paresthesiae) Motor signs & symptoms (foot/ankle, big toe weakness, ankle reflexes) + SLR & slump tests Clinical & MRI (CT) needed to make diagnosis Lumbar disc protrusion compresses nerve root below it - L4/L5 disc = L5 nerve root - L5/S1 disc = S1 nerve root

Red flags T.I.N.T Tumour Infection (discitis, IVDU, Hep C) Inflammation (spondylitis) (spinal ‘inflammation’) Neurological (cauda equina: saddle, bladder & bowel, weak/numb legs) Trauma (fractures) Most important screening questions: - cancer? - age > 70 or < 20? - steroids? - fall? - injecting drugs?

Yellow flags (CHAMPS) Predict chronic pain & disability Catastrophizing (ruminating, injustice, work dissatisfaction) Hyper-vigilant Anxious (panic & PTSD) Medicalized Passive (‘fix me’, compensation) Substance overuse - chemical coping, addiction - smoking, OTCs, opioids Stress SZ George, JM Beneciuk MC Musculoskeletal Disorders 2015

LBP examination Keep it simple Look for the 4Rs… Reasons for pain? - physical examination does not reliably ID spinal pain generators - may ID peripheral pain generators? Radicular leg pain? Restrictions? (functional impairments: can they walk & work?) Red flags?

LBP examination Watch, walk & weakness (gait, power foot/ankle, big toe) Poke & prick - cluneal nerves (iliac crest tenderness, ∆ in sensation over buttock) - trigger points (latissimus dorsi fascia, gluteal compartment) - greater trochanters (lateral thigh) - L4-S1 dermatomes (sensation in shin & foot) Slump & stretch (provocation tests) - straight leg raise (SLR) - slump test Hammer & hit - ankle & knee reflexes )

Straight leg raise & slump test Radicular leg pain Bigos S, Bowyer 0, Braen G, et al. Acute low back pain problems in adults: Clinical Practice Guideline, Quick Reference Guide Number. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 95-0643. December 1994. Available from: http://www.chirobase.org/07Strategy/AHCPR/clinicians.pdf

Lumbar MRI Only order to identify red flags or radiculopathy MRI not that helpful in identifying ‘pain generators’ Severity of MRI changes ≠ severity of back pain MRI is best screening test for; - Tumour - Infection (discitis) - Inflammation (ankylosing spondylitis) - Neurological (cauda equina, cord, root) - Trauma (may miss fractures) 2nd line: CAT scan

Questionnaires STarTBack Q (yellow flags, chronicity & disability) DN4 or PainDETECT Q (identifies neuropathic pain)

CLBP: key messages Leading cause of chronic pain & disability Classify by timing, type of LBP, leg pain, neuropathic pain? Mostly ‘non-specific’ CLBP (80%) Radicular leg pain is not that common (10% of cases) T.I.N.T (red flags) C.H.A.M.P.S (yellow flags) (predict chronic pain & disability) Examination (watch, walk, poke, prick, slump, stretch, hammer) MRI (only for red flags or radiculopathy)

Thank you

Risk of developing CLBP increases by 10% for every life-stress (yellow flag) around the time of injury 90% risk if 6 stressors Stresses Risk of chronic pain over 12M 10% risk if 0 stressors 22 22