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My crook back
- 1. “My Crook Back” DrAdrian Nowitzke Acknowledgement: Dr Paul Licina as creator of original slides
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- 3. Today is notabout: the statistics of back pain the “blah blah blah” of back pain management of “garden variety” conditions being “talked at”
- 4. The purpose oftoday: To dissect the pot-pourri of back pain by exploring the evidence, techniques and strategies of examination investigation non-operative treatment operative treatment To provide practical tips and tricks to managing this group of patients
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- 6. CHRONIC SPECIFIC ACUTE SPECIFIC CHRONIC NON SPECIFIC ACUTE NONSPECIFIC Resolves < 3months Surgery rarely indicated w/o neurological change
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- 8. CHRONIC SPECIFIC ACUTE SPECIFIC CHRONIC NON SPECIFIC ACUTE NONSPECIFIC 95% Most patients donot need surgery Most patients do not need radiology Most patients need multidisciplinary care It is key that we diagnose “chronicity” and actively manage it
- 9. http://www.biomedcentral.com/1471-2474/9/11 Chronic non-specific lowback pain sub-groups or a single mechanism? Benedict M Wand and Neil E O'Connell
- 10. CNSLBP patients haveback pain yet no conservative or surgical pain relieving measures directed at the back appear effective. • exercise programme • manipulation • massage • acupuncture • cognitive therapy • functional restoration • steroid injection • radiofrequency neurotomy • spinal fusion similar effects variable and modest improvement not sustained over time
- 11. They display anumber of biomechanical abnormalities, however treatment directed at normalising lumbar biomechanics has little effect and there is no relationship between changes in outcome and changes in spinal mechanics. • exercise is beneficial • no evidence that one type better than another • general physical activity may be better than specific exercises
- 12. They demonstrate somepsychological problems but psychologically based treatments offer only partial solution to the problem. • high levels of distress • presence of depression • fear-avoidance behaviour
- 13. A possible explanationfor these findings is that they are epiphenomena, features that are incidental to a problem of neurological reorganisation and degeneration. • is it in the brain vs the back? • much evidence to suggest changes in brain structure and function • reorganisation of the brain may lead to sensitisation of nociceptive pathways, central pain memories, sensory-motor conflict • may lead to changes in back biomechanics • may alter cortical representation of back and lead to fear-avoidance behaviour • thus biomechanical and psychological changes may be the compensatory rather than causative
- 14. Tools you mayfind helpful
- 15. FACTOR GOOD BAD painintensity 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
- 16. Oswestry Disability Index 0%to 20%: minimal disability: The patient can cope with most living activities. 21%-40%: moderate disability: The patient experiences more pain and difficulty with sitting lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care sexual activity and sleeping are not grossly affected. 41%-60%: severe disability: Pain remains the main problem in this group but activities of daily living are affected. 61%-80%: crippled: Back pain impinges on all aspects of the patient's life. 81%-100%: These patients are either bed-bound or exaggerating their symptoms.
- 18. 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 pseudorotation ie. rotation of pelvis and spine together) Distraction: Supine vs seated 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)
- 19. Three take homestrategies
- 20. Understand and explainthe cause 80% of people get back pain. 90% improve within 3 months. For those who do not improve (CNSLBP) Most people have nothing serious wrong. Multiple investigations and treatments are unhelpful. There is likely to be a central cause that is not well understood.
- 21. Provide evidence-based treatmentadvice Drug treatment does not cure back pain. Opioids only partially relieve the pain and must be used carefully. Massage and manipulation can help relieve pain. Exercises can be beneficial. Multidisciplinary therapy can help improve function, but will not completely cure pain. Surgery can help some patients to various degrees, but most people are not suitable candidates.
- 22. Avoid making thingsworse 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.