Back Pain Rehabilitation

The Geriatrician’s Perspective

Dr Fiona Harris Dr Anthony French

Back pain – theirs, not yours

Case for illustration Approach to elderly with back pain Diagnostic pathway Differential diagnoses and other referrals Management – Non-pharm, pharm, interventional, future

planning Pre-conditioning Pre-emptive admission Surgical management with planned post-op & restorative care

plan Rehabilitation

THE PACKAGE – ONE STOP SHOP – biopsychosociointerventionalsurgicalrestorative approach

Lawrie, 82 year old married man

Ex-engineer, enjoys fishing from his boat and visiting their beach house on Bribie Island

Back pain slowly progressive over last few years

Old ‘lumbago’ since 50s after slipping on boat

Can’t go shopping with wife any more – she thinks he’s avoiding because he stops early complaining of back and leg pain after being ok to start with

Mornings are ‘a bit stiff’ in all the wrong places so slow to start but gets going well as long as not walking too far

Notes that has trouble sit-to-stand and walking down stairs

Pain radiates down legs R>L when worse, more often

Otherwise well – some ‘prostatism’, HTN, central obesity

Case Study

Approach to the older person with back pain

Considerations- Probable cause – traumatic, degenerative,

radiculopathic, stenotic, disc related, inflammatory, infective, malignant

- Disability / functional impairment / effects- Investigations – past, timing, planned- Level of intervention patient is prepared to

consider / undergo / tolerate- Previous treatment approaches and

successes- Comorbidites

Diagnostic pathway

History – injury, pattern, disability, associated

Examination – neurological, muscular, skeletal, joint, evidence of degenerative disease, malignancy, autoimmune disease etc

Functional assessment – Gait, STS, TUG, flexibility

Investigations should include paraproteins, inflammatory and infective causes, nerve conduction studies and imaging as indicated

Differential diagnoses and other referrals

Degenerative osteopathies and discopathies

Spondyloarthopathies Inflammatory causes including AID Infective causes including discitis and

abscess Compressive causes including

haematoma Vascular including ischaemia and AVM Myeloma and metastatic disease

Likely degenerative changes in spine – multifactorial

Pain pattern suggests spinal stenosis

Radiculopathy and weakness suggest urgency

No talk of previous intervention, investigation, treatment attempts

Possible disc injury in past when slipped

Possible secondary gain per wife’s perception

Functional bottom line likely high – fishing on boat

Essential – examine, imaging, planning

Options include everything from analgesia and reconditioning through all the interventions so patient’s perceptions, time frames, expectations must be clear

Likely picture in this man

Management

Non-pharmacological including Complementary and Alternative / Relaxation / Faith

Psychological adjuncts

Lifestyle planning

Education

Pharmacological – analgesics, co-analgesics, psychological

Interventional including surgical, anaesthetic, ablative and implants

Medium and long term planning Setting limits, preconditioning, planned

reconditioning, function maintenance therapies

Pre-conditioning

Co-morbidity status and medical optimisation

Environmental management Pain management Equipment – assess, provide,

monitor, manage, follow-up Day rehab, inpatient rehab,

planned off-season workup

Pre-emptive admission

Assessment – pain, co-morbidities, psychological

Restorative care Management planning

consultation Multidisciplinary input and

management Intervention Follow up

Surgical management

Pre-operative assessment Planned timing Pathway to

Post-op care Restorative care plan

Rehabilitation

Multidisciplinary assessment Goal setting and education Periodic review and outcome assessment Supports / Caregiver involvement Discharge planning

Environmental modifications

Aids – temporary, long term

Supports - functional, access (permits etc), respite

Ongoing review Driving, progress, day therapy

THE PACKAGE – ONE STOP SHOP

Bio-psycho-socio-interventional-surgical-restorative approach

Create a co-ordinated systematic approach

Multidisciplinary approach from the start

REFER

Questions

Dr Fiona Harris, MBBS, FRACP

Consultant Physician and Geriatrician

0419 664 040

Dr Anthony French, MBBS, B.App.Sc., FRACP

Consultant Physician and Geriatrician

Queensland Geriatric Medicine Group

1300 662 884

dramfrench@qgmg.com.au