Primary care management for lower back pain

Question 1

What are the common symptoms with which back problem patients present?

Answer 1

PAIN – localised to lower back.

REFERRED PAIN e.g. sciatica

STIFFNESS

LOSS OF SLEEP

LOSS OF FUNCTION such as walking, lifting, carrying

Question 2

History taking points

Answer 2

Pain
- type
- radiation

Loss of function - subjective (how individual feel affected)

Trauma

Previous surgery

Question 3

What can back symptoms also be indicative of?

Answer 3

Urinary Tract, Gastrointestinal, respiratory, systemic illness.

Question 4

What are the relevant examination in a patient with back pain?

Answer 4

LOOK
- How the patient walks in (and out)
- Deformity e.g. Scoliosis, Kyphosis, Scars – Previous Operations

FEEL
- Spinal Tenderness
- Paravertebral Muscles
- Get the patient to show you where

MOVE
- Flexion Extension, Lateral Flexion.
- Straight Leg Raise
- Tone, Power, Reflexes, Sensation in legs if indicated.

Question 5

Relevant investigations, and how are they indicated?

Answer 5

Usually none

ESR/Viscosity/Calcium/Alkaline Phosphatase

Rarely X-Ray (50% of lumbar spine X-rays in people without back pain have some degree of degeneration - hence not so helpful)

MRI - helpful! but a lot of bulging and protruded discs are not symptomatic

Often not WYSIWYG (what you see is what you get)

Question 6

Common causes of back pain + rare but important causes presenting to primary care

Answer 6

Mechanical/non-specific >90%

Trauma 2%

Tumour/metastases 0.7%

Ankylosing spondylitis (inflammation) 0.3%

Infection (eg. TB) 0.01%

Question 7

Red flags for serious pathology

Answer 7

Age <20 or >50

Thoracic pain

Previous carcinoma (breast, bronchus, prostate)

Immunocompromise (steroids, HIV)

Feeling unwell for one/two months

Weight loss

Widespread neurological symptoms

Structural spinal deformity

Question 8

Yellow flags for chronic low back pain

Answer 8

Low mood

High levels of pain/disability

Belief that activity is harmful

Obesity

Problem with claim/compensation (secondary gain)

Job dissatisfaction
Light duties not available at work
Lot of lifting at work

Question 9

What are the management principles?

Answer 9

1. Do no harm
2. bioPSYCHOSOCIAL

Question 10

What are the managements?

Answer 10

Explanation

Reassurance

Encourage to mobilize

Cultivate PMA (Positive Mental Attitude)

Analgesics – Paracetamol, Co-analgesics, Opiates

NSAID’S – Short term

Muscle relaxants such as Diazepam (short term)

Physiotherapy

Osteopathy, Acupuncture and Chiropractic

Referral (< 2%)

Question 11

What is naproxen and what is its function?

Answer 11

It is a NSAIDS used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formulations

Question 12

When may MRI be helpful in this context?

Answer 12

When some neurological conditions are involved/suspected and not resolving with analgesics or NSAIDS