1. Caring for patients with low back pain
Sadia A. Ali,MD

2. OBJECTIVES Understanding patient’s concerns and assessing disability
Anatomy of low back
Conduct a focused, evidence-based medical history and physical examination.
Tailoring low back pain management plan on individual case basis for acute and sub-acute back pain.

3. OUTLINE Background and Anatomy Classification, Etiology, History
Physical exam
Practice session
Management scenarios

4. STATS 2nd most common cause for office visit
60-80% of population will have lower back pain at some time in their lives
Most common cause of disability for persons < 45 years
Costs to society: $20-50 billion/year

5. UNDERSTANDING PTS
Mr. Joe has had lower back pain for the past 24 hours that he feels is related to carrying heavy boxes at work 2 days ago.  He missed work today, Thursday. He wants to know what can be done for his back pain?

6. ACTION PLAN
Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain.
Provide information, advice, and a management plan.

7. ANATOMY

8. ANATOMY

9. CLASSIFICATION ACUTE---- < 6wks SUB-ACUTE------ 6-12wks
CHRONIC >12wks

10. CAUSES Lumbar “strain” or “sprain” – 70% Degenerative changes – 10%
Herniated disk – 4%
Osteoporosis compression fractures – 4%
Spinal stenosis – 3%
Spondylolisthesis – 2%
Spondylolysis, diskogenic low back pain or other instability – 2%
Traumatic fracture - <1%
Congenital disease - <1%
Cancer – 0.7%
Inflammatory arthritis – 0.3%
Infections

11. HISTORY
DEMOGRAPHICS: Age, gender, co-morbidities , social and occupational history.
PAIN: Onset, location, duration, intensity and frequency of pain, any past episodes of LBP, activities inc.pain, bladder or bowel dysfunction.
FUNCTIONAL STATUS:

12. HISTORY cont GOAL: Nonspecific LBP
No specific patho-anatomical diagnosis
Back pain with radicular symptoms
Radicular
Radiculopathy
Spinal stenosis (neurogenic claudication)
Another specific spinal cause
Cancer, infection or cauda equina syndrome.

13. RED FLAGS Hx of CA Age > than 50 with other s/s or risk factors
Fever, IVD, recent infection
Urinary retention, multiple level motor deficits
Osteoporosis, steroid use
Abd pulsating mass
Significant weakness, progressive weakness

14. YELLOW FLAGS
Reflect chronicity, poor pt. outcome and psycho-social distress
BELIEF SYSTEM
COMORBIDITIES
AFFECTIVE FACTORS
WADDLLE’S SIGNS

15. PHYSICAL Inspection---Asymmetry, rash Palpation----Fx, spasm
ROM----Flexion, extension, lat bending
Motor/Sensory/Reflexes
Provocative tests---SLR, FABER test
Waddell Signs
Gait
Abd/rectal

16. PRACTICE SESSION Divide in 3 groups and practice back exam
(refer to handout 1)

17. CASE 2
Sam, a 30-year-old man who works at the local home and garden center, strained his back three days ago while loading some plants. He tells his physician that he has been using a local heat wrap and ibuprofen (Motrin, Advil) 800 mg four times a day without relief. Sam denies any history of LBP, bowel or bladder dysfunction, radicular pain or weakness. A careful physical examination reveals limited flexibility and range of motion. Sam is locally tender over the right (R) paraspinal muscles. The lower extremity neurologic examination is otherwise within normal limits and shows a negative SLR test. Sam asks his physician whether he should initiate disability paperwork at this time.

18. ACTION PLAN!
Goal: PAIN CONTROL & DISABILITY LIMITATION----ACUTE BACK PAIN
Hx & Physical
Red/yellow flags
Imaging????
BED REST
Pharmacologic rx---
Non pharmacologic modalities

19. PHARMACOLOGIC MODALITIES
NSAIDS VS Acetaminophen
Muscle relaxants (first 2 wks in NS LBP)
Opioids (mod to severe, d/c if not impr)
Benzodiazepines ( muscle spasm-not FDA approved)
Systemic steroids (case reports-radicular symptoms)
TCA and Gabapentin (radicular pain)

20. NON-PHARMACOLOGIC MODALITIES
Heat (level II)/Cold packs
PT (2-6 sessions in Sub-acute)
Exercise (individualize plan)
Chiropractic/Spinal manipulation(level II)
Acupuncture(inconclusive)
Brace, support(not effective)

21. FOLLOW UP Improves out-comes Questions chronicity
Return to work and disability issues
Communication with family and employer

22. Sam again! 6 wk f/u
Sam is back at you office with no improvement---SUB ACUTE BACK PAIN
Re-evaluate pt
Imaging:
Plain X-ray:
Age>50 years
No improvement after 6 weeks
Other worrisome findings
MRI:
After 6 weeks if have sciatica
Pharmacologic

23. INTERVENTION RX Epidural injections: Facet joint injections:
Insufficient and conflicting evidence
Helpful in sub-acute LBP and radicular pain
Should be part of comprehensive plan
Facet joint injections:
No improvement
Local/Trigger point injections:
Possibly some benefit

24. RECAP Beware of red and yellow flags, assess disability
Non-specific/ nerve distribution/Sp. Cause
NSAIDs and Acetaminophen mainstay
Acute LBP- spinal manipulation
Imaging and bed rest not necessary in most cases
Closer f/u
Pt education

25. REFERENCES CORE CONTENT AAFP(
ESSENTIALS OF MUSCULOSKELETAL CARE
NEJM 2001