My Management of Back pain North/0830 Room 5 Sat Armstrong - Ma… · Management of Back pain Dr...
Transcript of My Management of Back pain North/0830 Room 5 Sat Armstrong - Ma… · Management of Back pain Dr...
Management of Back
painDr Stuart Armstrong
Sports and Exercise Physician
Hamilton
Introduction
Differential diagnosis
History and examination
Investigation
Management
Prevention
Summary
Differential diagnosis
4 main diagnostic groups
Facet joint
Disc bulge
Sacroiliac joint
Other
Annular tear, spinal stenosis, discitis, rheumatological, paediatric, athlete
History
Back position at onset of pain or injury
Night pain – grade severity
Morning stiffness
Aggravating activities
Back or leg predominate
Cauda Equina or Red Flags
Examination
Volunteer?
Flexion/extension range
Slump
SLR with cross sciatic stretch
Muscle tightness
Tenderness on palpation – adds nothing to diagnosis
Power, sensation, reflexes
SIJ
Core strength
Back to differential – Facet joint pain
Typically hyperextension injury
Pain in back not leg
Worse with extension activity
Can be on return from flexion
Twisting
Only valid examination finding is reproduction of pain on extension
Palpation is useless
Disc bulge
Usually occurs in flexed position
Pain initially in back then down leg and back pain goes
Radicular pain – electric shock in continuous line
Numbness, tingling, weakness
Slump test – improve with cervical extension
SLR and cross sciatic stretch test
Power, Sensation, Reflexes
Red Flags, Cauda Equina
Prev Hx Malignancy
Age <16 >50 with new pain
Unexplained weight loss
Previous steroid use
Recent infection or ongoing infective symptoms
Cauda Equina
Bilateral pain
Urinary retention
Perianal sensory loss
Reduced anal tone
Erectile dysfunction
Sacroiliac
20% of back pain diagnosis
Posterior pelvic pain (below the belt)
Can have neurology down leg
Worse rolling over in bed/impact activity
Tender over SIJ
My examination
Active Straight leg raise
Femoral thrust
Faber test
Other
Annular tear
Nonspecific, muscle tightness, some peripheral neurology
Spinal stenosis
Worse with exercise, claudicant in nature
Rheumatological
Young, morning stiffness, other joints, skin, eye involvement
Paediatric
Incredibly difficult, No clear referral pattern for discs
Discitis
Easily missed, always ask for fevers/sweats
Athlete
Pars interarticularis fractures
Hyperextension sports
Prolonged recovery and time out of sport
High index of suspicion in any athlete with back pain
Classically in cricketers, tennis players, gymnastics
Investigation
90% improve within 4-6 weeks
If 6+ weeks, or any red flags then image with x-ray
AP and lateral consider pelvic
No diagnostic benefit from oblique or coned SIJ and high radiation
MRI should be considered for all with >3 months back pain, progressive
neurological deficit or suspicion cancer
Management - Acute
Reassure and keep active
Avoid aggravating activity
Analgesics – Paracetamol, NSAIDs, muscle relaxants, Opioids if needed
Massage, Chiropractor, Acupuncture, Heat pack, stretches
Physiotherapist for prevention
Little benefit from braces, multiple wallet-ectomy practitioners
Patient education costs little and nearly effective as above
Management - Chronic
As per acute
Add in central acting medications – nortriptylline, gabapentin
Physio has a greater role in strengthening
Further investigation for cause
Referral on for further management
Consider cortisone injection
? Surgical management
Facet pain further management –
What I do
Educate
2 week course of voltaren 75mg BD
Avoid extension activity
Work of strengthening and stretching
If ongoing pain MRI with a view to CT guided cortisone facet joint injection
If temporary benefit refer Muskuloskeletal physician or surgeon
Disc bulge specific management
Educate
McKenzie Extensions
MRI to confirm disc bulge and nerve root compression
Cortisone epidural or nerve sleeve injection
If temporary benefit consider repeat
If no benefit and >6 months symptoms - surgeons
SIJ specific management
Educate
SIJ periarticular steroid injection Vs 2 week voltaren 75mg BD
Strengthening specific core, gluteal and pelvic
If no benefit MRI – expect to be normal
MRI normal or SIJ pathology
Guided cortisone injection
Temporary benefit consider prolotherapy
Alternative therapies
Physiotherapy
Acupuncture
TENS
Chiropractor
Osteopath
Prevention
Exercise, Exercise, Exercise
Movement patterns
Work Station
Frequent Breaks
Special shout out to the core
Front Plank
Side Plank
Supermans
Gluteal Strengthening
Diaphragm
Pelvic floor
Summary
Back pain is normal
Flexion – disc, extension – facet, below belt line– Sacroliac
Rule out serious underlying pathology
Settle pain then physio for strengthening
Consider work and leisure factors
Core is key