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.