Low back pain lecture


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  • I will talk about how we reason through the origin of the back pain to come to a diagnosis and how we determine the most appropriate treatment.
  • I should define mechanical LBP: we use the term to describe pain that worsens with movement or postures or exercise, and improves with rest.
    If the pain gets worse with rest, or if the pain gets better with exercise, then it is not truly mechanical. Pain from arthritis is worse in the morning, and improves with movement. It is also worse with rest - it gets stiff.
  • Clincial reasoning involves making judgements for professional practice. The judgements (or hypotheses) we make for patients with LBP include decisions about the
    diagnosis , although this is very difficult with most patients with LBP, as I’ll mention later
    physical examination. We need to decide which tests we’ll perform and how vigorously we’ll test the patient. This information is gleaned from the history. We always have to balance between stirring up the patient and getting enough information. If the condition is easily stirred up, then we have to decide which tests are the most important, and do those first.
    treatment. We need to decide what treatment and the dose - how much treatment
    prevention. We also need to determine whether we can prevent future episodes
    CI/precautions to treatment. It is particularly important to know about CI to physiotherapy, or to specific treatments such as exercise. Some problems may be inappropriate for physiotherapy and should be referred straight away rather than being treated by us.
  • The basis of good clinical reasoning is a good knowledge base. If you don’t have anything to reason with, you can’t make any decisions.
    We need information about the biomedical sciences (anatomy, pathology, biomechanics etc). In addition, when examining a patient with LBP we need information specific to LBP. This includes a deep and broad knowledge base about:
    cause of LBP:
    pathology: eg arthritis, cancer, infection
    tests (sensitivity and specificity): we need to know just how good the tests are that we use. The Sn and Sp tell us how much we can rely on the information. If the test is not very sensitive, then if the test is negative, it doesn’t rule out the disease. If the test is not very reliable, then we can’t be sure if a patient has improved or if the change is due to measurement error.
    treatment effects and efficacy: when selecting a treatment we need to choose the treatments that have been shown to be effective for such patients, and avoid treatments shown to be ineffective or even harmful.
    With this knowledge, and extensive clinical experience, we often recognise a presenting problem with very little information. We call this pattern recognition.
  • I have here 2 diagrams of patients who presented to me with LB and leg pain.
    With every patient, we take a history that begins with getting a description of the symptoms: what symptoms the patient has, where the symptoms are located, a description of the type of symptoms and the intensity.
    The patient on the left has pain in the L/S and leg. The back pain is worse than the leg pain. This is a typical presentation of NSLBP. With our knowledge of pain patterns and anatomy, we know that the pain is likely to arise from either the L/S or the SIJ. Without any further information we already have hypotheses about the diagnosis, physical examination and treatment. We then get a lot more information from the history to check whether these hypotheses are correct.
    On the right, the patient has a more complex pattern of LBP and leg pain. The pain is worse in the leg, and both legs are involved. This is a very unusual pattern of pain, and is unlikely to arise from a single cause, unless it is a large tumour in the spinal canal, compressing the spinal cord. Our hypotheses for this patient, even at this stage in the history, would include serious pathology or some people with chronic pain have this kind of presentation. It is very unlikely that this patient has acute NSLBP.
  • On of the most important decisions to make for patients with LBP is to decide whether they have serious pathology.
    This pathology includes CA, tumours infection, and other less serious pathology such as RA arachnoiditis etc. We do this by asking about specific symptoms or information in the history.
    It is very important because if we miss it there will be serious consequences. So when we are reasoning through a case, we weigh up the seriousness of the condition against the probability that the patient has the disease.
    The questions listed here have been shown to be sensitive in identifying pathology, for example:
  • If from the history, we suspect that the patient has specific pathology that we can’t treat, we refer them on.
    If they have NSLBP, then we can treat using our vast wealth of knowledge (evidence-based practice).
  • Low back pain lecture

    1. 1. EXERCISE AND LBP A/Prof Kathryn Refshauge
    2. 2. Kathryn Refshauge 2
    3. 3. Kathryn Refshauge 3
    4. 4. Kathryn Refshauge 4 Low back pain 15% 85% no specific pathologyspecific pathology NSLBP (mechanical)
    5. 5. Kathryn Refshauge 5 “Mechanical” NSLBP • pain is worsened with movement • pain is improved with rest
    6. 6. Kathryn Refshauge 6 Triage • Is the LBP due to serious pathology? • Duration of the LBP? • What treatment is indicated for the LBP?
    7. 7. Kathryn Refshauge 7 Hypotheses generated about: • diagnosis • physical examination • treatment • prevention • contra-indications/precautions
    8. 8. Kathryn Refshauge 8 Need knowledge about: • causes of LBP • pathology • tests (odds ratio, sensitivity and specificity) • treatment effects and efficacy
    9. 9. Kathryn Refshauge 9 Serious spinal pathology • Cancer • Infection eg osteomyelitis • Cauda equina syndrome • Cord compression • Fracture (osteoporotic) • Inflammatory diseases/arthritides • Abdominal or cardio-thoracic pathology
    10. 10. Kathryn Refshauge 10
    11. 11. Kathryn Refshauge 11 Typical Non-typical Presentation Presentation
    12. 12. Kathryn Refshauge 12 Eliminate serious pathology (red flags) • unexplained weight loss • night pain • poor general health/systemic symptoms • fever • previous history of cancer • no relief with bedrest • failure to improve with therapy
    13. 13. Kathryn Refshauge 13 Red flags (cont’d) • history of trauma • steroid use (osteoporosis) • very severe pain/muscle spasm • bowel/bladder frequency (cauda equina syndrome) • widespread neurological symptoms • non-mechanical behaviour of symptoms
    14. 14. Kathryn Refshauge 14 Red Flags (cont’d) • Age > 50 years • Constant progressive non- mechanical pain • Thoracic pain • Persisting severe restriction of lumbar flexion • Pain that worsens in supine
    15. 15. Kathryn Refshauge 15 Cancer (Deyo 1988) Sensitivity Specificity Age > 50 0.77 0.71 Unexplained weight loss (>5kg in 6/12) 0.15 0.94 Previous history of cancer 0.31 0.98 Not improving with medical care (1/12) 0.31 0.90
    16. 16. Kathryn Refshauge 16 Cancer (cont’d) Sensitivity Specificity No relief with bed rest 1.00 0.46 Insidious onset 0.61 0.42 Duration > 1/12 0.50 0.81 Recent back injury 0.00 0.82 Thoracic pain 0.17 0.84
    17. 17. Kathryn Refshauge 17 Compression fracture Sensitivity Specificity Age > 50 years 0.84 0.61 Age > 70 years 0.22 0.96 Trauma 0.30 0.85 Corticosteroid use 0.06 0.995
    18. 18. Kathryn Refshauge 18 Decisions seriousnesss probability
    19. 19. Kathryn Refshauge 19 • If suspect pathology, refer patient to appropriate health professional • If NSLBP, use knowledge (evidence- based practice)
    20. 20. Kathryn Refshauge 20 Yellow flags • Previous history of LBP • Radiating leg pain, NR involvement • Poor fitness • Poor extensor endurance • Poor general health • Psychological distress (fear avoidance behaviour, depressed)
    21. 21. Kathryn Refshauge 21 Yellow flags (con’td) • Much time lost from work • Disproportionate illness behaviour • Low job satisfaction • Personal problems (alcohol, marital, financial) • Adversarial medico-legal proceedings
    22. 22. Kathryn Refshauge 22 6 weeks 3 months acute sub-acute chronic Time
    23. 23. Kathryn Refshauge 23 acute sub-acute chronic most recover without intervention some recover very few recover psychosocial domain fear of activity
    24. 24. Kathryn Refshauge 24 acute sub-acute chronic Rx: spinal manual therapy McKenzie exercises spinal manual therapy exercises exercise cognitive behavioural therapy
    25. 25. Kathryn Refshauge 25 Routine Tests: • observation • active movements • tension tests *** • palpation As applicable: • stress active movements • neurological examination • muscle performance • passive tests
    26. 26. Kathryn Refshauge 26 Biering-Sorensen test
    27. 27. Kathryn Refshauge 27 Active treatment • acute NSLBP: - McKenzie exercises - specific stabilisation exercises
    28. 28. Kathryn Refshauge 28
    29. 29. Kathryn Refshauge 29 multifidus
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    32. 32. Kathryn Refshauge 32 Active treatment • sub-acute NSLBP - specific stabilisation exercises - McKenzie exercises - general exercises
    33. 33. Kathryn Refshauge 33 Active treatment • chronic NSLBP - general exercises use principles of cognitive- behavioural therapy (CBT)
    34. 34. Kathryn Refshauge 34 Exercise: • chronic NSLBP exercise: supervised graded whole body CBT: quotas goal setting pacing reinforcement (+ job application/CV)
    35. 35. Kathryn Refshauge 35 General aims • Improve physical function • Increase confidence in normal movement • Teach patients how to cope with present and future episodes • Reduce reliance on health professionals
    36. 36. Kathryn Refshauge 36 Specific aims • Strengthen main muscle groups • Stretch main muscle groups • Increase CV fitness with low impact aerobic exercises
    37. 37. Kathryn Refshauge 37 The program • Warm-up and stretching • Individual exercises • Warm-down • Tip for the day • Relaxation session
    38. 38. Kathryn Refshauge 38
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    41. 41. Kathryn Refshauge 41 Treatment • treatments that are harmful: bedrest
    42. 42. Kathryn Refshauge 42 Treatment • Treatments that are ineffective: back school TENS laser
    43. 43. Kathryn Refshauge 43 Treatment • Treatments with unknown effect: massage ice heat short wave diathermy ultrasound
    44. 44. Kathryn Refshauge 44 Conclusion Need broad and deep knowledge base to recognise: • Contraindications and pathology • Stage of LBP • Effective exercise programs
    45. 45. Kathryn Refshauge 45 Conclusions • knowledge of clinical trials to determine the most effective treatment. www.pedro.fhs.usyd.edu.au