1. Assessment of LBP and Hip pain GP Registrar Training 24 th November 2009 Sue Hammersley and Julie James

2. Diagnostic Triage Simple back pain Simple back pain Nerve root pain Nerve root pain Red flags Red flags

3. Simple Back Pain Presents age 25-55 Presents age 25-55 Lumbosacral region, buttocks and thighs Lumbosacral region, buttocks and thighs Mechanical in nature Mechanical in nature Varies with physical activity/time Varies with physical activity/time patient well patient well Prognosis good Prognosis good

4. Nerve Root Pain Unilateral leg pain may be worse than back pain Unilateral leg pain may be worse than back pain Pain may radiate to toes or foot Pain may radiate to toes or foot Numbness and paraesthesia in same distribution Numbness and paraesthesia in same distribution SLR positive SLR positive Neuro changes limited to one nerve root Neuro changes limited to one nerve root Prognosis reasonable – 50% recover within 6 weeks Prognosis reasonable – 50% recover within 6 weeks

5. Red Flags for possible Serious Spinal Pathology Presentation less than age 20 or onset over 55 years Presentation less than age 20 or onset over 55 years Violent trauma Violent trauma Constant, progressive, non-mechanical pain Constant, progressive, non-mechanical pain Thoracic pain Thoracic pain Past history Ca Past history Ca Systemic steroids Systemic steroids Drug abuse, HIV Drug abuse, HIV Systemically unwell Systemically unwell Weight loss Weight loss Persisting, severe restriction of lumbar flexion Persisting, severe restriction of lumbar flexion

6. Red Flags continued Cauda equina syndrome/widespread neurological disorder Cauda equina syndrome/widespread neurological disorder Difficulty with micturition Difficulty with micturition Loss of anal sphincter tone or faecal incontinence Loss of anal sphincter tone or faecal incontinence Saddle anaesthesia – anus, perineum or genitals Saddle anaesthesia – anus, perineum or genitals Widespread neurological changes (› 1 nerve root) or progressive motor weakness in the legs or gait disturbance Widespread neurological changes (› 1 nerve root) or progressive motor weakness in the legs or gait disturbance Refer to A&E at Huddersfield Refer to A&E at Huddersfield

7. Red flags continued Inflammatory disorders (ankylosing spondylitis and related disorders) Inflammatory disorders (ankylosing spondylitis and related disorders) Gradual onset before age of 40 Gradual onset before age of 40 Marked morning stiffness Marked morning stiffness Persisting limitation of spinal movements in all directions Persisting limitation of spinal movements in all directions Peripheral joint involvement Peripheral joint involvement Iritis, skin rashes (psoriasis), colitis, urethral discharge Iritis, skin rashes (psoriasis), colitis, urethral discharge Family history Family history Respond to NSAIDS Respond to NSAIDS Heel pain/Achilles tendinopathies (enthesis symptoms) Heel pain/Achilles tendinopathies (enthesis symptoms)

8. Risk factors for chronicity Previous history LBP Previous history LBP Total work loss (due to LBP) in last 12 months Total work loss (due to LBP) in last 12 months Radiating leg pain Radiating leg pain Reduced SLR Reduced SLR Signs of nerve root involvement Signs of nerve root involvement Poor physical fitness Poor physical fitness Poor health Poor health Heavy smoking Heavy smoking Psychological distress and depressive symptoms Psychological distress and depressive symptoms Disproportionate illness behaviour Disproportionate illness behaviour Low job satisfaction Low job satisfaction Personal problems – alcohol, marital, financial Personal problems – alcohol, marital, financial Medico-legal proceedings Medico-legal proceedings

9. History Consider Consider Age Age Mechanical pattern Mechanical pattern PHM Ca, steroids, HIV etc PHM Ca, steroids, HIV etc Unwell, weight loss Unwell, weight loss Widespread neuro signs Widespread neuro signs Structural deformity Structural deformity Persistent night pain Persistent night pain Cauda equina symptoms Cauda equina symptoms Thoracic pain Thoracic pain Attitudes and beliefs about back pain (fear avoidance, personal responsibility for pain and rehab) Attitudes and beliefs about back pain (fear avoidance, personal responsibility for pain and rehab) Family/ work Family/ work

10. Examination Observation Observation pain pain gait gait willingness to move willingness to move posture posture spasm spasm deformity eg kyphosis deformity eg kyphosis

11. Examination continued Movements and other tests Movements and other tests Lumbar - flexion, extension, lateral flexion Lumbar - flexion, extension, lateral flexion SI joints SI joints SLR SLR Hip movement – flexion, extension, rotation and abd/adduction Hip movement – flexion, extension, rotation and abd/adduction Peripheral pulses Peripheral pulses Neurological examination – reflexes, power, sensation, Babinski, clonus, Rombergs Neurological examination – reflexes, power, sensation, Babinski, clonus, Rombergs

12. Examination continued Palpation – heat, sweat, spasm, tenderness, pain Palpation – heat, sweat, spasm, tenderness, pain Waddell tests for functional back pain Waddell tests for functional back pain Tenderness to touch Tenderness to touch Simulated axial loading Simulated axial loading SLR vs long sitting SLR vs long sitting Non-anatomical regional disturbance Non-anatomical regional disturbance Over-reaction Over-reaction

13. Management Advice – keep active, avoid work loss, information book/simple exercises etc Advice – keep active, avoid work loss, information book/simple exercises etc Pain relief – analgesic ladder, consider amitriptyline or pregabalin/gabapentin with nerve pain Pain relief – analgesic ladder, consider amitriptyline or pregabalin/gabapentin with nerve pain Referral – A&E (Huddersfield), physiotherapy, investigations, MSK, Spinal clinic Referral – A&E (Huddersfield), physiotherapy, investigations, MSK, Spinal clinic

14. Conditions NICE guidelines NICE guidelines Simple mechanical Simple mechanical degenerative degenerative Stenosis Stenosis Acute disc Acute disc osteoporosis osteoporosis Spondylolisis/listhesis Spondylolisis/listhesis Infection Infection Cauda equina Cauda equina

15. Hip Assessment History History Pain weight bearing, limited movement, night pain Pain weight bearing, limited movement, night pain Pain distribution lateral hip, buttock, groin, anterior thigh Pain distribution lateral hip, buttock, groin, anterior thigh May be co-existing back problem May be co-existing back problem Difficulty with socks/dressing Difficulty with socks/dressing Reduced mobility, often rapid deterioration Reduced mobility, often rapid deterioration

16. Hip examination Observe gait, posture, look for Trendelenburgs, muscle wasting, deformity Observe gait, posture, look for Trendelenburgs, muscle wasting, deformity Movement – flexion, extension, rotation, abd/adduction – most restricted – ext/add/med rot Movement – flexion, extension, rotation, abd/adduction – most restricted – ext/add/med rot Modified Thomas’s test Modified Thomas’s test Differentiate from spine problem Differentiate from spine problem

17. Management of Hip problems New Zealand joint score (hip pathway) New Zealand joint score (hip pathway) Referral to physiotherapy – limited benefit if changes are advanced Referral to physiotherapy – limited benefit if changes are advanced Xray Xray MSK or direct consultant referral (xray and New Zealand score over 65) MSK or direct consultant referral (xray and New Zealand score over 65)