1. Low back pain Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box – Riyadh 11417
Tel: – Fax:

2. Aim: At the end of this presentation, the participants will have knowledge on the management of low back pain.
Objectives: At the end of this session, the trainees should;
be able to discuss the prevalence of disc mediated low back pain and current techniques for diagnosis
be able to develop a structured approach to history taking and physical examination in patients with low back pain
be able to review the major types of mechanical back pain, and describe common etiologies
be able to explain the difference between simple and complex low back pain
be able to describe emerging interventional and biological therapies to treat low back pain

3. Timing Definitions Acute LBP lasts for < 6 weeks
Sub-acute LBP lasts for 6-12 weeks
Chronic LBP lasts for > 12 weeks
Acute & Sub-acute account for 90% of LBP

4. Epidemiology
75% of adults will experience LBP at some point in their lives
5th most common cause of all physician visits
Peak incidence years old; More severe in older patients
85% of patients have no definitive anatomic cause or imaging finding
Most cases are self limited with serious problems in < 5%
Most common cause of work-related disability for individuals < 45 years old

5. Low back pain among Saudi school workers in Jeddah
The results of this study show
a prevalence of 26.2% with low back pain
Saudi medical journal 1998

6. A response was obtained in 5,743 (97. 4%). Their mean age was 34
A response was obtained in 5,743 (97.4%). Their mean age was ± (range 16-99). Back pain was reported by 1,081 (18.8%), wherein 499 (8.8%) were men, and 574 (10%) were women. Back pain was more prevalent in married (23.3%) individuals than unmarried (6.4%).
How common is back pain in Al-Qaseem regoin
Saudi Med J 2003

7. Causes of back pain

8. LBP: Risk Factors Heavy lifting and twisting Obesity
Poor physical fitness/conditioning
History of low back trauma
Psychiatric history(chronic LBP)

9. usually attributable to musculoligamentous injuries or age-related degenerative disease in intervertebral disks and facet joints
Sprain – torn or detached ligament
Strain – torn muscle
Radiculopathy – pain & neurological deficit caused by injury to a nerve root (radix=root)
Sciatica – pain that radiates down posterior or lateral leg; a type of radiculopathy
Spinal Stenosis – narrowing of the spinal column resulting in compression of the nerve root; often resulting in pain or numbness in legs
Degenerative Disk Disease – gradual degeneration of the disk between vertebrae, due to loss of fluid and tiny cracks, part of normal aging process
Compression Fracture – fracture that collapses a vertebrae
Spondylolisthesis - anterior or posterior slipping or displacement of one vertebra over another

10. Serious spinal pathology
The European guidelines also classify acute back pain into three categories. These are1:
Serious spinal pathology
This includes infection, malignancy, fracture, and inflammatory causes such as ankylosing spondylitis
Nerve root pain
The sciatic nerve becomes trapped or irritated either in the lumbosacral spine or the muscles of the lower back or buttock, if they go into spasm secondary to pain
It may take up to two months for the patient's symptoms to resolve
Non-specific low back pain
This is back pain that is not due to either serious spinal pathology or nerve root pain
It is often triggered by a minor sprain or strain of the back
Pain may be mechanical - worsened by certain movement or postures
Pain usually improves within two weeks.

12. When you assess patients who present with back pain you should:
Rule out serious pathology by asking about red flags
Ask about nerve root pain
Examine all patients - usually a brief examination is sufficient
Examine other joints close to the back such as the hip joint for pain
Pain can be referred from the hip joint to the back.

13. Red Flags 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
Knowing the prevalence of various etiologies of back pain, looking for “red flag” findings
B=bowel or bladder dysfunction
A=anesthesia
C=constitutional symptoms/malignancy
K=chronic diseases
P=paresthesia
A=age>50
I=infection, IV drug use
N=neuromotor deficits
History Questions and DDX

14. yellow flags An inappropriate perception of back pain
The belief that back pain is harmful and disabling
The belief that passive activity such as bed rest is better than staying active
Lack of support at home and social isolation
Mental health problems such as depression, anxiety, and stress
Problems at work such as job dissatisfaction
Claims for compensation and benefits.
You can approach the subject of yellow flags by asking patients the following:
Have you had time off work because of back pain?
What do you think is the cause of the back pain?
What do you think will help the pain?
How does your employer respond to your back pain?
Do you plan to return to work?
You can help patients who are at risk of developing chronic back pain by:
Offering information and reassurance about acute back pain
Correcting misconceptions - for example that bed rest is better than staying active
Treating mental health problems such as depression
Avoiding passive treatments such as bed rest
Encouraging active treatment such as a gradual return to normal activities
Setting realistic goals
Offering an exercise programme to patients who have sub-acute back pain - pain that lasts between six and eight weeks
Consider referral to a back school
Back schools educate patients about back care, how to avoid back pain, and exercises that can strengthen the back. A recent Cochrane review showed that back schools in the workplace can help patients with chronic low back pain.

15. Examination LOOK FEEL MOVE STRAIGHT LEG AND FEMORAL STRETCH TEST
POWER,TONE,SENSATION + REFLEXES

16. LOOK
Examine standing-look for deformity such as increased or decreased lordosis, obvius scoliosis, soft tissue abnormalities eg. Hairy patch, scars

17. FEEL
Spinous processes and paraspinal tissues for any local tenderness or spasm
Palpate vertebral column for point tenderness

18. MOVE
Flexion-try to touch toes with your legs straight and note how far eg. To knees,ankles, mid shin
Extension-straighten up and lean back as far as you can
Lateral flexion-reach down to each side touching the outside of each leg and record amount of flexion
rotation

19. Straight Leg Raising L4,5,S1
The straight leg raise test is highly suggestive of nerve root pain.
Patient lies flat with both legs straight raise 1 leg till limited by pain or tight hamstring-slightly lower leg to provide relief then increase tension on nerve by dorsiflexion of foot-this will aggravate or elicit pain radiating down the raised leg if there is nerve root irritation, the pain will be relieved by flexion of the knee
SLR-measure angle off couch for each leg
Flip test-patient sitting with legs over edge of couch and knees flexed, straighten knee as if to perform ankle jerk, no pain if functional overlay

20. Power/tone/sensation/reflexes
Power-grade 0-5, test all joint movements
Tone- should include anal tone esp. if red flags
Sensation- esp. perineal/perianal
Reflexes-knee L3,4 ankle L5,S1 plantar S1,2

22. Motor Testing Toe Walk tests calf muscle (S1)
Deficit should align with areas of pain
Toe Walk tests calf muscle (S1)
Heel Walk tests ankle and toe dorsiflexion (L4, L5)
Single squat and rise (L4)
Ankle Jerk (S1)
Knee Jerk (L4)

23. Sensory Tests Light touch on Medial foot (L4) Dorsal foot (L5)
Deficits should align with areas of pain
Light touch on
Medial foot (L4)
Dorsal foot (L5)
Lateral Foot (S1)

24. When to Image Consider in all ages if any trauma
Consider in older adults with any falls
Pain not improved over 4 to 6 weeks
If there is a history of chronic steroid use or osteoporosis
If there are any “Red Flags” and suspicion for cauda aquina, infection, cancer

25. How to image X-ray CT MRI Fracture, tumour, infection
Suspect disc herniation that is being considered for surgery
Detail an unstable fracture
Clarify abnormality seen on bone scan
If spinal stenosis suspected & want to localize pathology
MRI
Extent of tumour
Recurrent or unremitting post surgery radicular pain
Cauda equina

26. Management of LBP Keep moving! (only a few days rest at most)
Heat/cold
Decrease bending and lifting
Frequent position changes
NSAID/Acetaminophen
Low impact aerobic exercise
Walking, swimming
Education regarding proper lifting, bending techniques
Progression of more specific strengthening exercise
Core muscles
Gradual progression back to normal activity

27. Treatment Options for Mechanical LBP
Scheduled oral NSAIDS are recommended; there is strong evidence that they significantly reduce pain
For NSAIDs – remember ease of use and cost – none more effective than another
Tylenol avoids the GI and renal issues found with NSAIDS, however some studies found it less effective for pain than NSAIDS
May need opioids for severe pain; side affects include drowsiness and addiction; administer for 1-2 weeks only

28. Treatment Options
Strong evidence that muscle relaxants such as Flexeril, Soma or Skelaxin are helpful
most beneficial in first one to two weeks of treatment
most effective when combined with NSAIDS
side affects include drowsiness and dizziness – evaluate risks vs. benefit

29. Treatment Options
Superficial heat therapy has been helpful in reducing LBP – provides muscle relaxation and analgesia
Evidence to support use of ice is inconclusive
Physical Therapy appears to be helpful in sub-acute LBP
2-6 sessions
Beneficial for pateint education and activating exercise programs

30. Treatment Options
Epidural steroid injections may be helpful in patients with radiculopathy who do not respond to 6 weeks of conservative treatment
should be preceded by MRI or CT
recommendation is 1-3 injections
most effective when combined with medication and physical therapy

31. Treatment Options
Bedrest is not recommended, there is strong evidence to stay active, however activity may need to be modified
If bedrest is necessary for severe pain, it should not last longer than 2-3 days
There is insufficient evidence to support massage
There is mixed evidence on efficacy of acupuncture

32. Treatment options
Some evidence that spinal manipulation results in short-term improvement in pain but is less effective than usual methods (analgesics, muscle relaxants, PT)
“Back schools”, lumbar supports, traction and ultrasound have not been shown to be effective

33. Treatment Options
Despite the high rate of spinal surgery, evidence shows only a small number of patients have improvement

34. Non-specific low back pain
23/04/2017
Non-specific low back pain
Summary of treatment recommendations Van Tulder M and Koes B. Low back pain (acute & chronic). Clinical Evidence 2006
Effectiveness
Acute low back pain
Chronic low back pain
Beneficial
Advice to stay active, NSAIDs
Exercise therapy, intensive multidisciplinary treatment programmes
Trade-off
Muscle relaxants
Likely to be beneficial
Multidisciplinary treatment programmes (for subacute low back pain), spinal manipulation
Analgesics, acupuncture, antidepressants, back schools, behavioural therapy, NSAIDs, spinal manipulation
Unknown
Analgesics, acupuncture, back schools, behavioural therapy, electromyographical biofeedback, epidural steroid injections, lumbar supports, massage, multidisciplinary treatment (for acute low back pain), temperature treatments, traction, TENS
Electromyographical biofeedback, epidural steroid injections, local injections, lumbar supports, massage, traction, TENS,
Unlikely to be beneficial
Specific back exercises —
Ineffective, or harmful
Bed rest
Facet joint injections
National Prescribing Centre

35. Pain overview - Approaches
23/04/2017
Pain overview - Approaches
WHO's three step ladder to use of analgesic drugs 3 2 1
National Prescribing Centre

36. Complications Development of chronicity and depression
Disability and loss of employment
CAUDA EQUINA SYNDROME- when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological sequelae can occur if not treated as emergency

37. Prognosis In one month, 35% have no symptoms
In 3 months, 85% have no symptoms
In 6 months, 95% have no symptoms
Remember, the etiology of LBP is usually not identified (85%) but almost all patients get better!

38. When to refer

39. Referrals Not improving in 4 to 6 weeks Deficit in more than one root
Progressive root loss
Loss of bladder and/or bowel function
Red flag suggesting fracture, tumour, infection
Get imaging & refer to spine surgeon

40. Who to refer to?

41. Referrals Joint inflammation and/or other joint involvement
Order baseline labs & refer to rheumatologist
UMN symptoms & signs
Refer to neurologist and/or spine surgeon
Persistent LBP
Refer to physiatrist or spine surgeon
Spinal stenosis suggested
Chronic pain syndrome features
Multidisciplinary pain clinic referral

42. Denniston PL, ed. Official Disability Guidelines. 11th ed.
Encinitas,Calif.: Work Loss Data Institute, 2005.

43. Who needs Surgery? Unstable Spine Severe Stenosis Tumor?
Acute fractures with Neurologic deficit.
Severe Stenosis
After failure of aggressive non-operative tx.
Tumor?
Progressive Neurologic deficit

45. Thank you