Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS.
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Transcript of Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS.
![Page 1: Back Pain Examination, assessment, red flags, Good Back Guide. Jon Dixon, Bradford VTS.](https://reader035.fdocuments.in/reader035/viewer/2022062619/55161321550346a2308b53c6/html5/thumbnails/1.jpg)
Back Pain
Examination, assessment, red flags,
Good Back Guide.
Jon Dixon, Bradford VTS
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Causes of back pain 1
Mechanical - Muscles and ligaments
Local tenderness, muscle spasm, loss of lumbar lordosis, percussion tenderness over spinous process
NO MOTOR/SENSORY/REFLEXIC LOSS
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Causes of back pain 1
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Causes of low back pain 2
Radicular low back pain Herniated intervertebral disc commonest cause
but can be foraminal stenosis sec. OA / tumours / infection (rare)
TOP TIP not all pain referred down leg is sciatica (facet joint disease / hip / SIJ / piriformis syndrome etc.)
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Structures that cause nerve root compression
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L4/L5/S1 Radiculopathy
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Straight Leg Raising
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Piriformis syndrome
Pain from piriformis muscle – irritation of sciatic nerve passing deep or through it
Pain on resisted abduction / external rotation of leg
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Causes of low back pain 3
Lumbar Spinal Stenosis Subtle presentation. Bilateral radicular signs should alert to
possibility. Pain on walking- worse on flat –(eases if
hunched over – shopping trolley sign!) Can be mistaken for Claudication. Admit if progressive / or else CT scan.
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Cauda Equina syndrome (spinal canal compression)
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Spinal Stenosis
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Causes of low back pain 4
Inflammatory – Ankylosing Spondylitis
Difficult to diagnose if early stages but: Morning stiffness for > 30 minutes Pain that alternates from side to side of lumbar spine Sternocostal pain Reduced chest expansion
Schobers test
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Schobers Test
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Fabere test
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Pelvic Compression Test
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Red Flags
Weight loss, fever, night sweats History of malignancy Acute onset in the elderly Neurological disturbance Bilateral or alternating
symptoms Sphincter disturbance Immunosuppression Infection (current/recent) Claudication or signs of peripheral ischaemia Nocturnal pain
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Yellow flags 1
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Yellow Flags 2
Factors prolonging back pain Internal factors-Opioid dependency “External controller” patient-type; learned
helplessness; factitious disorder Mental health- depression or anxiety Interpersonal factors "Sick role“ Stressors in relationships Environmental / societal factors- Disability
payments / Litigation / Malingering
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Causes of back pain
Structural Mechanical
Facet joint arthritisProplapsed intervertebral discSpondylolysis / Spinal stenosis
Inflammatory SacroiliitisSpondyloart
hropathies
Infection Metabolic Osteoporotic
vertebral collapsePaget's diseaseOsteomalacia
NeoplasmCa ProstateCa Breast
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Referred pain
•Pleuritic pain
•Upper UTI / renal calculus
•Abdominal aortic aneurysm
•Uterine pathology (fibroids)
•Irritable bowel (SI pain)
•Hip pathology
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Imaging modalities
Xrays good first line Ix if red flags, osteoporotic fracture
Bone scan (also good initial Ix if Xray nad and red flags) - mets, infection, pagets, PMR
CT Scan bone tumours fractures and spinal stenosis
MRI spinal cord, nerve roots, discs, haemorrhage
Dexa Scan Bone density
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TREATMENTS Simple Back Pain
(over 95% of cases)Aim: to relieve symptoms and mobilise early.
Avoid Bed restParacetamol (+nsaid if insufficient)Avoid opiates if at all possibleNo evidence that co-analgesics better than
paracetamol alone.Muscle relaxants (diazepam / methocarbamol) small
additional benefit.
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No evidence for:
Short wave diathermyTENSSpinal manipulationTractionAcupunctureExercisesSpinal cortisone injections
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Occupational issues
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Occupational issues
More sick leave : Less chance of recovery4-12 w - 40% chance of still being off at 1
year.Don’t need to be pain free to return to
work MDT Rehabilitation programs:
psychological therapies; CBT; graduated return to work (light duties)
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Blocks to returning to work (blue flags!)
perceived work loadlow paymanagement attitudespoor supportloss of confidencedepression
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JD’s top tips for back pain.
Patient who attends a second time with “simple” back pain- get them to strip to their underwear!
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Top tips
True sciatica means that the leg pain is worse than the back pain- start examination with them sitting on the couch.
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Top tips
With radiculopathy re-examine regularly, carefully note findings and refer early if weakness (foot drop can be irreversible)
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Top Tips
Physios are very good at managing the psychological aspects of chronic pain.
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Top Tips
Sending someone to casualty is pointless but can have a very useful ‘placebo’ effect in showing the patient how impressed you are with his or her pain.