Managing Back Pain The Ontario Initiative Introducing the CORE Back Tool

Hamilton Hall MD FRCSC Julia Alleyne MD CCFP

Faculty/Presenter Disclosure

• Faculty: Hamilton Hall • Relationships with commercial interests: • Consultant: Stryker Spine USA • Consultant: Medtronic • • Consultant: rti Surgical Medical Director, Pure Healthy Back • Medical Director, CBI Health Group

Disclosure of Commercial Support

• This program has received no financial support.

• This program has received no in-kind support.

• Potential for conflict of interest: • Hamilton Hall receives compensation as Medical Director of CBIHG.

Mitigating Potential Bias

• This program does not discuss or recommend commercial services or surgical devices.

• Dr. Hall acknowledges that the Pattern Approach to Low Back Pain was developed during his time with CBIHG and that its development included contributions from many CBIHG staff members.

Faculty/Presenter Disclosure

• Faculty: Dr. Julia Alleyne • Relationships with commercial interests: • Speakers Bureau/Honoraria: Lavin Agency • Excludes medical education and medical conferences.

Disclosure of Commercial Support

• This program has received no financial support.

• This program has received no in-kind support.

• Potential for conflict of interest: • Dr. Julia Alleyne has received payment from Centre for Effective Practice (CEP) as the clinical lead on the Ministry of Health and Long-Term Care (MOHLTC) provincial Low Back Pain Strategy

Mitigating Potential Bias

• This program does not discuss or recommend commercial services or surgical devices.

• Dr. Alleyne acknowledges that she was the clinical lead in the development of the CORE back tool.

• Payment received by Dr. Alleyne is non-commercial (received from MOHLTC)

#1

All Musculoskeletal Conditions

Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4

–

33% of the population at any given point. Anthony Woolfe

Burden of major musculoskeletal conditions Bulletin of the World Health Organization 2003;81:646-6

What do we do ?

Barriers to Best Practice: Patients with Low Back Pain Family physicians perceive that they require additional knowledge and skills to deal with patient expectations, appropriate imaging and consultant referrals and patient self-management strategies. Primary care providers cited patient pressure, both direct and indirect, as a key reasons to order tests and specialty referrals. Knowledge gaps exist for patients as well but are often not addressed within the office visit.

Our current approach isn’t working • The medical paradigm hasn’t solved the problem of low back pain.

• Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 • MRI increase use 7.2% to 11.3% Mafi J et al. JAMA 2013

Our current approach isn’t working

Our current approach isn’t working • Guideline: discordant indicators 23,918 primary care visits for back pain Jan 1999 – Dec 2010 • • • • MRI increase use 7.2% to 11.3% NSAID/acetaminophen decrease use 36.9% to 24.5% Narcotic increase use 19.3% to 29.1% Specialist referrals increase 6.8% to 14.0% Mafi J et al. JAMA 2013

Our current approach isn’t working • There is no correlation between degenerative changes on plain x-ray and back pain.

• CT has a 30% false positive rate.

• MRI has a 60-90% false positive rate.

Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely.

Webster BS et al. Spine 2013

Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain.

Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

Our current approach isn’t working • With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

And our current approach is wrong • Most back pain is

not

the result of • • • • tumour infection major trauma or any medical problem • Most back pain begins spontaneously.

• In a study of over 11,000 patients, 2/3 rds of the subjects could not recall any cause for the pain. Hall et al. Clin J Pain 1998

• • • • • • • • • • • • • • • • But we still memorize the Red Flags Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-going infection Fever Night sweats Non-mechanical pattern of pain Constant pain Wide spread neurological signs or symptoms Disproportionate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55

There is another way • Over 90% of back pain is caused by minor altered mechanics.

• Most back pain is mechanical.

So why don’t we look there first?

There is another way • Over 90% of back pain is caused by minor altered mechanics.

• Mechanical back pain is pain • • • related to movement related to position related to a physical structure It means there is a sore thing in the back.

There is another way We can all recognize there is a sore thing.

We just can’t agree on which sore thing.

And for all the non-invasive treatments locating the sore thing isn’t even necessary.

There is another way “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

Patterns of back pain “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

Syndromes of back pain “Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion.

A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion.

What is the difference between a disease and a syndrome?

The only difference is that we know the etiology of a disease.

• • • A disease has an etiology .

Does a syndrome have an etiology?

Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance?

• Of course, a syndrome has an etiology.

• We just don’t know what it is yet.

Syndrome recognition • The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Where is your pain the worst?

• Is it back or leg dominant?

• Back dominant pain is referred pain from a physical structure.

• Back dominant: • back • buttocks • coccyx • greater trochanters • groin

Where is your pain the worst?

• Is it back or leg dominant?

• Back dominant pain is referred pain from a physical structure. • Sites of referred pain can become locally tender.

• Trochanteric bursitis

Where is your pain the worst?

• Is it back or leg dominant?

• Leg dominant pain is radicular pain from nerve root involvement.

• Leg dominant: • Around or below the gluteal fold, to the: • thigh • calf • ankle • foot

Where is your pain the worst?

• Is it back or leg dominant?

• The patient will often report both.

• But it must be one or the other.

• “ If I could stop only one pain, which one do I stop?

• “I have a back pill and a leg pill, which one do you want?”

Syndrome recognition • The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Is your pain constant or intermittent?

Part A Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment?

I know it comes right back but is there ever a time, even a short time when the pain is gone?

Part B When your pain stops does it stop completely?

Is it all gone?

Are you completely without your pain?

When the pain is constant consider: • Malignancy • Systemic conditions • Pain disorder •

Constant mechanical pain

Syndrome recognition • The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Is your pain constant or intermittent?

Does bending forward make your typical pain worse?

1.

Where is your pain the worst?

2.

Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

• What are the aggravating movements/positions?

1.

2.

Where is your pain the worst?

Is your pain constant or intermittent?

3.

Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function • since the start of your pain?

1.

2.

Where is your pain the worst?

Is your pain constant or intermittent?

3.

Does bending forward make your typical pain worse?

4.

Has there been a change in your bowel or bladder function since the start of your pain?

5. I f you are under 45 years, do you have morning stiffness greater than 30 min?

6. What can’t you do now that you could do before you were in pain and why?

6.

What can’t you do now that you could do before you were in pain and why?

7. What are the relieving movements/ positions?

6.

What can’t you do now that you could do before you were in pain and why?

7.

What are the relieving movements/ positions?

8. Have you had this same pain before?

6.

What can’t you do now that you could do before you were in pain and why?

7.

What are the relieving movements/ positions?

8.

Have you had this same pain before?

9. What treatment have you had? Did it work?

• • • • • • • • • • • • • • • • But we still memorize the Red Flags Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-going infection Fever Night sweats Non-mechanical pattern of pain Constant pain Wide spread neurological signs or symptoms Disproportionate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55

History takes precedence over physical examination. But the physical examination must support the history.

Physical Examination 1. Observation • general activity and behaviour • back specific: • • • • contour colour scars palpation (if you must)

1.

Physical Examination Observation 2. Movement • flexion • extension

1.

2.

Physical Examination Observation Movement 3. Nerve root irritation tests • straight leg raising

A positive straight leg raise: • Passive test - the examiner lifts the leg • Reproduction/exacerbation of typical leg dominant pain • Back pain is not relevant • Produced at any degree of leg elevation To reduce confusion with hamstring tightness, flex the opposite hip and knee.

1.

2.

3.

Physical Examination Observation Movement Nerve root irritation tests 4. Nerve root conduction tests • L4 • L5 • S1

1.

2.

3.

4.

Physical Examination Observation Movement Nerve root irritation tests Nerve root conduction tests 5. Upper motor test • plantar response • clonus

1.

2.

3.

4.

5.

Physical Examination Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test 6. Saddle sensation • lower sacral nerve roots (2,3,4) test

1.

2.

3.

4.

5.

6.

Physical Examination Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation 7. Sensory testing (if indicated)

1.

2.

3.

4.

5.

6.

7.

Physical Examination Observation Movement Nerve root irritation tests Nerve root conduction tests Upper motor test Saddle sensation Sensory testing (if indicated) 8. Ancillary testing (if indicated) • hip, abdomen, peripheral pulses

There are four mechanical patterns Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 1 PEP Pattern 1 PEN Pattern 4 PEP Pattern 4 PEN

Pattern 1

History • Back dominant pain • Worse with flexion • Constant or Intermittent

Physical Examination • Back dominant pain • Worse with flexion • Neurological examination is normal or unrelated to the pattern

Physical Examination • Back dominant pain • Worse with flexion • Neurological examination is normal • Better with 5 prone passive extensions Pattern 1 Prone Extension Positive PEP The patient has a directional preference.

Physical Examination • Back dominant pain • Worse with flexion • Neurological examination is normal • No change/worse with 5 prone passive extensions Pattern 1 Prone Extension Negative PEN The patient has no directional preference.

Management • • • Pattern 1 PEP – educate and exercise Reduce sitting / flexion Increase extension • • lumbar roll night roll Prescribe repeated prone extensions

Management • • Pattern 1 PEN – educate and exercise Goal oriented therapy referral Increase gradually and progressive from unweighted flexion to extension position then prone extensions • When range improves and pain decreases add core stability • Analgesics

Pattern 1 Pattern 1 PEP Pattern 1 PEN

Pattern 2

History • Back dominant pain • Worse with extension • Never worse with flexion • Always intermittent

History • Back dominant pain • Worse with extension • Never worse with flexion • Always intermittent If the pain is constant or if there is any pain on flexion the patient is Pattern 1

Physical Examination • Back dominant pain • Worse with extension • Neurological examination is normal or unrelated to the pattern • No effect or better with flexion

Management • • • • Pattern 2 – educate and exercise Relief with sitting / flexion Reduce extension, frequent breaks Prescribe sitting unweighted flexion Posture and positioning in flexion

Pattern 1 Pattern 2 Pattern 1 PEP Pattern 1 PEN

Pattern 3

History • Leg dominant pain • Always constant • Affected by back movement/position

Physical Examination • Leg dominant pain • Leg pain affected by back movement • Positive irritative test • and/or conduction loss

Management • • • • Pattern 3 – reassure Scheduled rest positions during the day • • Z lie prone over pillows Change position as pain increases Stronger Analgesics Refer to surgery (15%)

Pattern 1 Pattern 2 Pattern 3 Pattern 1 PEP Pattern 1 PEN

Pattern 4

History • Leg dominant pain • Always intermittent • Worse with flexion

Physical Examination • Rarely a positive irritative test and/or conduction loss • Always better with unloaded back extension movement or position Leg dominant pain that responds to mechanical treatment.

Management • • • Pattern 4 PEP – educate and exercise Reduce sitting / flexion Increase extension • • lumbar roll night roll Prescribe repeated unloaded extension positions and movements

Pattern 4

History • Leg dominant pain • Always intermittent • Worse with activity in extension • Better with rest in flexion • May have transient weakness

Physical Examination • Negative irritative tests • Possible permanent conduction loss

Management • Pattern 4 PEN – educate and exercise Goal oriented therapy referral • • Abdominal strengthening Core strengthening • Posture training - pelvic tilt • Long term commitment • Gradual improvement • Excellent surgical candidates

Back dominant Constant /Intermittent Intermittent Leg dominant Constant Intermittent Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 1 PEP Pattern 1 PEN Pattern 4 PEP Pattern 4 PEN

That’s all there is

Low Back Pain Patterns

Start

with

the patterns

• There will be a pattern in ninety percent of your patients.

• The pattern suggests the initial treatment.

• If the pain responds as expected, you have your solution.

• If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated.

• That is the time to consider the Red Flags .