Low Back Pain (LBP)
Low back pain is the leading cause of disability worldwide. It is also the second most ‘symptom related reason’ for primary care visits.Low back pain can be due to one of the following four reasons: a referred pain from other part of the body (e.g., nephrolithiasis); a serious condition directly affecting the lumbar spine (e.g., osteomyelitis, malignancy); radicular pain (e.g., related to intervertebral disc herniation) or neurogenic claudication (e.g., due to central spinal canal stenosis); and nonspecific low-back pain. Nonspecific low-back painaccounts for about 90% of all low-back pain seen in primary care (4).It is very important that a detailed history collection and physical examination is performed to rule out red flags and yellow flags. Similarly, pertinent investigations, pharmacological and non-pharmacological interventions, and referral plan should be chosen based on the evidence-based findings.
Abstract Conceptualization—Step-1
Stage- 2
Active Experimentation
History Collection
Collect history regarding the duration of pain, onset, aggravating factors, andh/o trauma. Verify if any presence of radiating pain, impact on function, presence of neurological symptoms, changes in GI/ GU functions, constitutional symptoms etc. Pay special attention on ruling out red flags and yellow flags.
Read flags: Cauda equina syndrome (saddle anesthesia, sudden or progressive low of bladder/ bowel control), severe worsening pain especially at night or when lying down, h/o severe trauma, weight loss, h/o cancer, fever, immune suppression, h/o IV drug use, patients above age with first episode of severe back pain, and morning stiffness more than 30 minutes. Patients with any such s/s need to be screened for spinal fracture, malignancy, and inflammatory process. Patients with prolonged history of steroid use, h/o osteopenia or osteoporosis are at high risk of fracture (4,5)
Additionally, psycho social indicators such as sickness behaviours, claims, low mood, unrealistic treatment expectations, work issues, history of physical labour, over protective family, lack of family support etc. are considered as the ‘yellow flags’ that predict possibility of developing chronic pain and disability (4,5).
Measure pain intensity and functional impairment by using The Brief Pain Inventory Scale https://www.painbc.ca/health-professionals/assessment-tools
Physical Examination
Inspect and palpate spine and paraspinous process. Check range of motion, mid line tenderness, posture, anatomical variations, para spinal muscle tenderness, palpable tumors, or local skin inflammation. Conduct neurological exam for quadriceps strength, patella reflex(L3-L4); heel walking, ankle dorsiflexion, and great toe extension (L5); great toe plantar flexion strength, toe walking, toe raise ad ankle reflex (S1); saddle sensation testing (S2-S4); plantar response; and passive straight leg test.
The following You tube video is an excellent resource for learning comprehensive spinal assessment
Investigations
Evidence does not support the need for imaging in patients with acute or chronic pain without any red flags. A recent RCT confirmed that patients who were aware of their x- ray finding that indicated benign degenerative disc disease had lower sense of well being, compared to those who were not told of their x- ray result. X- ray will be ordered for patients who have strong risk factors for fracture, cancer, or if an inflammatory process such has ankylosing spondylitis is suspected (1).
Patients with acute low back pain and risk factors for spinal infection, cauda equina syndrome, or severe progressive neurologic deficits will benefit from MRI investigation.
Bone scan is ordered to detect fractures, bony metastases, and to differentiate them from degenerative changes.
CT scan will be indicated for patients who are not suitable for MRI.
Non-Pharmacological Management
Physical therapy, and exercise are proven to be effective strategies in managing back pain.
CBT, acupuncture, tai chi, spinal manipulation, andyogahave shown some benefit based on small scale studies.
Capsicum cream application may be a short-term option for patients with acute exacerbation of low back pain.
Pharmacological Interventions
NSAIDS, Acetaminophen, and muscle relaxants (short term use) are considered as the first line medications for LBP management. When using NSAID, consider risk of GI bleeding and CVD risk.
Anti convulsant are used as a first line treatment forLBP associated with radiculopathy, neuropathy.
Anti depressants are usedas second line agents for chronic LBP
Opioids are used as the third line option; carefully consider its risks and benefits when prescribing.
Tramadol (4th line) and long acting opioid formulations (5th line-morphine, hydromorphone, oxycodone) are used with caution for chronic pain management, when other agents are not effective.
To find a list of evidence based non-pharmacological/ pharmacological interventions and their role in pain management, follow the link: https://www.cfpc.ca/uploadedFiles/Directories/Committees_List/Low_Back_Pain_Guidelines_Oct19.pdf
Stage 3
Concrete Experimentation
SOAP notes
c/o low back pain x 2 weeks
Acute onset, however, reported past h/o intermittent low back pain
working as a machine operator
no h/o trauma or fall
dull aching, constant pain across lower lumbar region
no fever, nausea, vomiting, chills, no recent weight loss
no h/o cancer
no change in GI/GU symptoms
no numbness in extremity, no change in gait
pain 5/10
Tylenol ES gives some relief, taking q6h
o/e
nad
L-spine: no paraspinal tenderness, no midline tenderness, noswelling/erythema/eccymosis/effusion, no mass, full ROM, lower limb str/sens/coord/ref grossly normal, gait n. Patella, ankle reflex- wnl, straight leg- negative
No costovertebral tenderness
A
LBP
P
rev natural hx of injury & recovery time
acetaminophen prn, stretches/strengthening exercises, physio/massage therapy
rtc if no improvement in 4-6 weeks
if any gait changes, GI/GU symptoms, fever, chills, severe back pain, should seek immediate medical help
Concrete Experimentation
Reflection
Student Activity
Write a brief reflection on your learning experience with LBP management, by using Kolb’s learning cycle? You may use a case to describe your learning experience. What are your new ideas or abstract concepts which you would like to actively experiment in your future practice?
Clinical Pearl
Patient hand outs for back pain exercises can be found at http://www.sasksurgery.ca/patient/spine.html
Reference
1. Qaseem, A., Wilt, T., McLean, R.,&Forciea,M., Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 166:514–530.Retrieved from https://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice
2. Oliveira, B., Maher, G., Pinto, Z.,Traeger, C., Lin,C., Chenot,F.,Tulder, M.,Koes, W., Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview.Eur Spine J(2018) 27: 2791. https://doi.org/10.1007/s00586-018-5673-2
3. Health Link BC (2018). Low back pain. Retrieved from https://www.healthlinkbc.ca/health-topics/hw56429
4. Traeger, A., Buchbinder, R., Harris, I., Maher, C. (2017). Diagnosis and management of low-back pain in primary care. CMAJ November 13, 189 (45).Retrieved from http://www.cmaj.ca/content/189/45/E1386
5. Toward Optimized Practice Low Back Pain Working Group (2015). Evidence informed primary care management of low back pain: Clinical practice guideline 2015. Retrieved from http://www.topalbertadoctors.org/cpgs/?sid=65&cpg_cats=90&cpg_info=59