Presented by: Dr Adrian Nowitzke — Neurosurgeon Event: Bundaberg GP & Allied Health Education Day - 2015

1. How we think about
back pain
Dr Adrian Nowitzke

2. Graphic from www.hibiscusflowershop.blogspot.com

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

4. ACUTE
CHRONIC
Duration and frequency

5. SPECIFIC
NONSPECIFIC
Specificity
Causation. Localisation. Radicular nature. Investigation. 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 duration 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
compensation absent present
litigation absent present
abn.illness.behavior absent present
degenerate levels single multiple

12. Waddell’s nonorganic signs
Tenderness: Superficial (lumbar skin tender
to light touch) and nonanatomical (deep
tenderness over a wide area that crosses
musculoskeletal boundaries)
Simulation: Axial loading (light downward
pressure on the head causes pain) and
simulated rotation (back pain on
pseudorotationie. rotation of pelvis and
spine together)
Distraction: Supine vsseated SLR (significant
difference betweeen straight leg raising
when lying down compared with when
sitting up)
Regional changes: Weakness (cog-wheel
type weakness with giving way of several
muscle groups) and sensory change
(widespread nonanatomical alteration of
light touch sensation)

13. Three take home strategies

14. 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.
Multiple investigations and acute treatments are unhelpful.
There is likely to be a central cause that is not well understood.

15. 2. Provide evidence-based treatment advice
Improve function despite pain rather than cure pain
Maintenance vs acute deterioration 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

16. 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 interpretation.
Refer judiciously to exclude treatable cause.
Facilitate return to activity and work.
Try to help in the compensation process.
Do not encourage litigation.

17. Thank you