1. Back Pain in General Practice Dr Chris Monella GPSI

2. Back pain Common 50-80% Common 50-80% Diagnosis 15% Diagnosis 15% Benefit claims >10% Benefit claims >10% Risk factors Risk factors

3. Lumber vertebrae

4. disc

6. History Age, occupation,lifestyle Age, occupation,lifestyle Site/spread/segmental Site/spread/segmental Onset Onset Symptoms Symptoms Red flag, yellow flags Red flag, yellow flags PMH, medications,etc PMH, medications,etc

7. Diagnosis Capsular pattern eg degenerative OA Capsular pattern eg degenerative OA Non-capsular pattern eg PID Non-capsular pattern eg PID Mechanical back pain Mechanical back pain PID PID Spinal stenosis Spinal stenosis Sacro-iliac joint pain Sacro-iliac joint pain

8. Lumber spine examination Observation-f,p,g Observation-f,p,g Look-ic,psis,asis,leg length,spine curvature,lordosis Look-ic,psis,asis,leg length,spine curvature,lordosis Lumber active ext,lat flex,flex ?capsular Lumber active ext,lat flex,flex ?capsular Tip-toe:Gastrocnemius root: s1,2 Tip-toe:Gastrocnemius root: s1,2 Hip-passive flex, med rot, lat rot Hip-passive flex, med rot, lat rot SIJ-shear tests, faber SIJ-shear tests, faber

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

10. Lumber spine examination 3 Skin sensation Skin sensation Big toe: l4 Big toe: l4 Toes 1,2,3: l5 Toes 1,2,3: l5 Toes 4,5 : s1 Toes 4,5 : s1

11. Lumber spine examination 4 Reflexes Reflexes Knee :l2,3,4 Knee :l2,3,4 Ankle:s1,2 Ankle:s1,2 Babinski Babinski

12. Lumber spine examination 5 Femoral stretch test:l2,3,4 Femoral stretch test:l2,3,4 Resisted knee ext(Quads) :l2,3,4 Resisted knee ext(Quads) :l2,3,4 Resisted knee flexion(Ham):l5,s1,2 Resisted knee flexion(Ham):l5,s1,2 Gluts (bulk): l5,s1,2 Gluts (bulk): l5,s1,2

13. Lumber spine examination 6 Palpation Palpation ?manipulation- ?manipulation- History recheck, noncapsular pattern,normal plantar,normal reflexes History recheck, noncapsular pattern,normal plantar,normal reflexes Observe, treat or refer? Observe, treat or refer?

14. Treatment Mobilization (grade A) in acute back pain eg. Modified Pretzel technique Mobilization (grade A) in acute back pain eg. Modified Pretzel technique Acupuncture Acupuncture Reassurance, ice Reassurance, ice analgesia,NSAIDs,Amitrip., gabapentin, etc analgesia,NSAIDs,Amitrip., gabapentin, etc Ix, PCT back pain clinic,Back surgeon Ix, PCT back pain clinic,Back surgeon

15. 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

16. 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

17. NICE Feb 2008

18. Treatment options education, advice, information access strengthening exercise aerobic 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

19. Summary History,examination findings & treatments History,examination findings & treatments Mechanical back pain/PID Mechanical back pain/PID Systemic back pain Systemic back pain Spinal stenosis Spinal stenosis Sacroilitis(in ankylosing spondylitis) Sacroilitis(in ankylosing spondylitis)