Presented by: Dr Adrian Nowitzke — Neurosurgeon Event: The Team Approach to Low Back Pain - 2014

1. How we think about
back pain
Dr Adrian Nowitzke

2. Graphic from www.hibiscusflowershop.blogspot.com

3. ACUTE
CHRONIC
Dura0on
The
move
toward
chronicity.
Treatments.
Work

4. ACUTE
CHRONIC
Dura0on
and
frequency

5. SPECIFIC
NONSPECIFIC
Specificity
Causa0on.
Localisa0on.
Radicular
nature.
Inves0ga0on.
Treatments

6. SPECIFIC
NONSPECIFIC
Specificity
and
frequency

7. ACUTE
SPECIFIC
ACUTE
NONSPECIFIC
CHRONIC
SPECIFIC
CHRONIC
NONSPECIFIC

8. Tools
you
may
find
helpful

9. 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

11. 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)

12. Three
take
home
strategies

13. 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.

14. 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

15. 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.