how we think about back pain?
TRANSCRIPT
How we think about back pain
Dr Adrian Nowitzke
Graphic from www.hibiscusflowershop.blogspot.com
ACUTE
CHRONIC
Dura0on
The move toward chronicity. Treatments. Work
ACUTE
CHRO
NIC
Dura0on and frequency
SPECIFIC
NONSPECIFIC
Specificity
Causa0on. Localisa0on. Radicular nature. Inves0ga0on. Treatments
SPECIFIC
NONSPECIFIC
Specificity and frequency
ACUTE SPECIFIC
ACUTE NONSPECIFIC
CHRONIC SPECIFIC
CHRONIC NONSPECIFIC
Tools you may find helpful
FACTOR GOOD BAD
pain intensity low high
symptom dura0on short long
disability mild-‐moderate severe-‐crippling
distress low high
depression/anxiety absent present
fear-‐avoidance absent present
well being high low
opiates no yes
compensa0on absent present
li0ga0on absent present
abn.illness.behavior absent present
degenerate levels single mul0ple
Waddell’s nonorganic signs Tenderness: Superficial (lumbar skin tender to light touch) and nonanatomical (deep tenderness over a wide area that crosses musculoskeletal boundaries) Simula;on: Axial loading (light downward pressure on the head causes pain) and simulated rota0on (back pain on pseudorota0on ie. rota0on of pelvis and spine together) Distrac;on: Supine vs seated SLR (significant difference betweeen straight leg raising when lying down compared with when siSng up) Regional changes: Weakness (cog-‐wheel type weakness with giving way of several muscle groups) and sensory change (widespread nonanatomical altera0on of light touch sensa0on)
Three take home strategies
1. Understand and explain the cause 80% of people get back pain. 90% improve within 3 months. For those who do not improve (chronic non-‐specific) Most people have nothing serious wrong. Mul0ple inves0ga0ons and acute treatments are unhelpful. There is likely to be a central cause that is not well understood.
2. Provide evidence-‐based treatment advice Improve func0on despite pain rather than cure pain Maintenance vs acute deteriora0on programs • Move • Core strength, back strength, back flexibility • Psychology support • Simple analgesia -‐ zero opioids in most cases • Primary rather than specialist care No surgery in most cases
3. Avoid making things worse Recognise those at risk of chronicity. Minimise the use of opiates. Discourage prolonged passive treatments. Ensure imaging done with contextual interpreta0on. Refer judiciously to exclude treatable cause. Facilitate return to ac0vity and work. Try to help in the compensa0on process. Do not encourage li0ga0on.