How long has it been? When worse? Better? Shooting? Dull? Constant? Back pain vs leg pain? Any numbness? - Not helpful to us. Do not get the chance to reproduce

Low Back Pain Flashcards by Tony Ward

How common is back pain?

Very common

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What is back pain likely due to?

Osteoarthritis
Muscle Strain
Hip Joint Problem
Sciatica
Osteoporosis
Slipped Disk

realm of MD, physio and chiropractor

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Describe what an osteoarthritic spine?

Bone Spurs
Narrowed disks
Knee/hand joints likely have OA to

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What is responsible for lower leg numbness?

Sciatica nerve firing at the wrong time
Numbness from the lower back down the whole leg
NSAID’s are not good for neuropathic pain

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Signs of Osteoporosis

Shortened height
Stooped or hunched over
Have developed back pain

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With increased age, what is common?

Compression fractures are common with age

See abrupt onset of back pain, but many can be asymptomatic

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Conditions for referred pain in the back area?

disorder of large bowel
dysmenorrhea
renal condition
prostate
urinary tract infection

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What is the etiology/common causes of back pain?

Sedentary Lifestyle
Bursts of activity/improper lifting
Pregnancy
Poor Posture
Bad Shoes
Excess Weight

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Is the cause of back pain usually identified?

most likely cannot recall a specific possible cause

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Chronic low back pain may be due to what muscles….

Spinal Column muscles
Abdominal Muscles
Glutes

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What are two major causes of back pain?

Inactivity and heavy lifting

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Is there a psychological aspect of back pain?

Pain Amplifier - If think will not get better, make things worse

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Is the cause usually idetnfied?

No –> MD’s rule out red flags

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Are X-rays useful for back pain?

X-rays find stuff. In the analysis of this stuff, as backs get older, you will find things (kinicks and bruises but the vats majority is not the reason for the pain)

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What is the risk of X-rays? When should they be used?

Substantial risk of uncovering irrelevant misleading findings

If Red Flags are absent, delay radiology until 6th week of conservative (inc drug) management

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What are the sx of lower back pain?

tightness in lower back / muscle spasm (bodys way of protecting from injury)

difficulty bending, moving, sitting

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Questions to ask:

How long has it been?
When worse? Better?
Shooting?
Dull?
Constant?
Back pain vs leg pain?
Any numbness?

Not helpful to us. Do not get the chance to reproduce

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In chronic cases, the pain origin is more likely….

Neuorpathic –> NSAID will not work

Nociceptive –> NSAID may work

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What is neuropathic pain?

Damage to or dysfunction of the nerves
- Burning or tingling
- Ruptured intravertebral disk

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What is nociceptive pain?

Injury to body tissues
- Most pain is nociceptive
- Aching, sharp, or throbbing

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Sciatica is what type of pain? Are NSAIDs useful?

Sciatica = neuropathic

NSAIDs and opitaes are not that great of agents

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What is one question that is very important to ask about back pain?

What have you tried so far?

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Are most cases a serious medical problem?

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What is a pharmacists role in back pain?

Safe med use

Recommend phsyio and massage

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Red Flags. When to refer?

Pain located high in spine (beyond a sore neck) - 2 days Trauma (esp. fall from height) - ASAP fever, chills, unexplained weight loss - ASAP Pain worse when laying down/sleeping - 2 days Numbness in bum area - ASAP Bladder/Bowel Dysfunction - ASAP Young Kids/Elderly - Make appt (chronic), 2 days for acute Leg > back Pain - Make appt Increasing pain - 2-7 days Oral steroid usage - ASAP No TIGERS FIND LIONS, NOTHING BEATS ALPHA LIONS IN OHIO

One red flag has a what % chance of being something serious?

10%

What should a patient try to fix first?

How to Sleep/Stand Balance of back/abdom muscles (spine moves in direction of stronger muscles)

How does the spine move?

The spine moves in direction of the stronger muscles

When do cases of back pain get better?

Most get better on their own --. Most resolved by 3 months

How much rest should a person have post-injury?

Rest - Old thinking Return to Normal Activities - Current thinking (may seem counter-intuitive to most pt's) Exercise --> Not our domain

What is a typical patient of back pain?

Not have any red flags Will be >40 Long history of back pain

Acet Back Pain

Analgesia, but not anti-inflamm Not efficacious for back pain

ASA for Back Pain

Not common, but a very good agent - ASA brings it at OTC doses, the other guys do not Analgesia and anti-inflammatory

Ibu for Back Pain

- Analgesia - Questionable for anti-inflammatory at OTC doses

Naproxen for Back Pain

- Analgesia - Questionable for anti-inflamm at OTC doses

To achieve anti-inflammatory actions of NSAID's, one needs

HIGHER DOSES --> RX territory

What is often used in patients?

Stronger prescribed NSAID's are often used in many patients

What are skeletal muscle relaxants?

Sedation --> Not well known - Sedation in brain; not in muscles - Do not appear to be anti-spasmodic

What are s/e of muscle relaxents?

CNS s/e (sedation, dry mouth, constipation)

Are muscle relaxents useful?

NOT EFFECTIVE

Example of Muscle Relaxent and Product

Methocarbomol - Robax

What are some muscle relaxents? Do we care which ones?

Methocarbamol Chlorzoxazone Orphenadrine Methocarbamol Do not care which one. All bad.

As a pharmacist, we should recommend (oral stuff)

Plain analgesic (main) Muscle relaxent (No) Combo (if pt wants, need analgesic in there)

Does the muscle aches and body pain label have different ingredients?

No --> if pt says works for them, good enough

What is another thing we should recommend as pharamacists?

Heat and cold

When should cold be used?

First 48 hours

In the first 48 hours ______ should used

Cold

If chronic or recurring episode of low back pain ______ is recommended. What is its benefit?

Heat Heat can be anti-spasmodic

Cold should be used for.....

Acute Injury

Heat should be used for.....

Chronic Injury

How many times a day should heat be used?

2-3 times a day for however long you can - Every 2-3 hours

What is the MOA of topical external analgesics?

Counter-irritation Massage/blood flow Psychological (odour)

Is voltaren a topical external analgesic?

Where are external topical analgesics more effective at?

More effective on larger muscles and sore muscles rather than back pain

What are the two agents in external topical analgesics?

Methyl Salicylate Menthol

How does menthol work?

First 1/2 --> menthol hits cool receptors (not actually lowering temp) After 1/2 hour --> Becomes warmth

What is the % of menthol for what purpose?

<1% - anti-itch >1% - Counter irritant

What is an important counselling tip to tell a patient with topical external analagesics?

Don’t use a heating pad at same time with any of these products!

Is lidocaine used for back pain?

No --> Numbing agent Does not get deep into the skin

What is used for neuropathic pain? Is it useful?

Capsaicin - Gnerally for post-herpetic neuralgia (post-shingles) - Needs continous use to decrease substance P - Irritating when applied

DOC for Back Pain

Topical Diclofenac 1% - TID or QID Extra Strength - BID May be drug of choice in patients > 75 yo if not younger

What is the algorithm for back pain?

Topical Diclofenac Standard (Oral) Rub A535

Topical diclofenac has more proof for....

More proof for OA knee and hand than back area

Topical Diclofenac vs. NSAID's

Less side effects than oral NSAIDs. Little systemic absorption

Topical Diclofenac Amount to Use

1 FTU

What is the only herbal that may be useful for back pain?

Tumeric

is glucosamine useful for back pain?

NO - A disease modifying agent --> Only works on synovial joints - No synovial joints in the back

Is tumeric the actual agent or not?

Curcumin --> Active ingredient Turmeric --> Delivery device

What is the amount of curcumin used for releif of pain in arthritis?

1-2 g

Are back braces useful for back pain?

In 2-3 weeks, gait may be changed that can cause wrong relaxation of the wrong muscles If walking around, should be unsinched --> will not affect the gait if unsinched

Are opiods good for back pain?

What is cyclobenzaprine?

- Blocks nerve impusles - MD realm not us - Relief of muscle spasms

Cyclobenzaprine Length of Usage

Short periods (up to two or three weeks)

What are some s/e of cyclobenzaprine?

Drowsiness, dry mouth, fatigue

Antidepressants use in Low Back Pain

Amitryptyline --> Neuropathic Pain - SNRI's and TCA's

Low Back Pain Flashcards

(75 cards)