Chronic Low Back Pain Assessment & Screening - PowerPoint Presentation

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Chronic Low Back Pain

Assessment & ScreeningEric J. Visser

CLBP is common & consequential

CLBP: pain ≥ 3M in low back region (ribs, buttocks, flanks)10% of population

2.2 million Australians right now

10% of GP visits

50% of pain clinic visits

Top 10 health care burdens worldwide

(disability)

$35 billion per year (health care, productivity)

Causes of LBP

Acute LBP

‘chronic’ in 20% of cases

Acute low back pain

Injury (work, sports)

(lifting, twisting, straining

,

repetitive loading)

Spondy

l

osis (‘spinal’ ‘degeneration’) (discs, facets) Pathology (red flags) Surgery (‘failed back surgery syndrome’) Pregnancy Fitness ( BMI, deconditioning, smokers) Genetics (disc pain, connective tissue/hypermobility) Parreira P, Maher CG, Latimer J, Steffens D, Blyth F, Li Q, Ferreira ML. Can patients identify what triggers their back pain? Secondary analysis of a case-crossover study. Pain 2015 Jun 1. PMID: 26039901

Assessment

Bio-medical-psycho-social approachHistory

Classification of LBP

Questionnaires

Examination

Special tests

MRI

History

Who is the patient?What

type of LBP; ± leg pain;

neuropathic pain

What

is the cause?

When (timing)?How did it happen?

(nature of injury, mechanisms & forces involved)

Why

is the patient presenting NOW?

Red flags

(screening questions) (T.I.N.T)Yellow flags (psycho-social predictors of chronic pain & disability) (C.H.A.M.P.S)

Classifying CLBP

Timing?

- chronic ≥3M - acute-on-chronic (‘flare ups’)

Type of LBP?

-

non-specific?

(80%) - specific? (‘pain generator’ identified) (20%)

± Leg pain?

(20%)

- referred pain (musculoskeletal structures) (2/3

rd

) - radicular pain (‘sciatica’) (1/3rd) (10% of cases overall)± Neuropathic pain? (up to 80% of CLBP) Chronic non-specific low back with leg pain

Specific causes of CLBP The search for pain generators

Discs (40%)

- internal disc disruption (IDD)

- high intensity zone (HIZ)

- Modic changes (‘inflamed’ end plates)

Facet joints (20%)

Sacro

-iliac joints (20%)

Specific CLBP

Spinal stenosis - back pain - leg pain

- claudication

- tight canal on imaging

- supermarket trolley test

Pars defects

Specific CLBP

Cluneal neuralgia (10%)

Unilateral low back

Buttock pain (leg)

Tender over iliac crest

Altered sensation over buttock

Due to rotation

, twisting?Vertebral fractures?

Specific CLBP

Myofascial pain

- trigger points

- gluteal muscles

- latissimus

dorsi

fascia - greater trochanters

Radicular leg pain (‘sciatica’)

Neuropathic leg pain

due to a nerve root lesion

Not common

(10%)

L5

or S1

nerve root (90%)Sensory signs & symptoms

(foot numbness, allodynia, paresthesiae)Motor signs & symptoms

(foot/ankle, big toe weakness, ankle reflexes)

+ SLR & slump tests

Clinical & MRI (CT) needed to make diagnosis

Lumbar disc protrusion compresses nerve root below it - L4/L5 disc = L5 nerve root - L5/S1 disc = S1 nerve root

Red flags T.I.N.T

T

umour

I

nfection

(discitis, IVDU, Hep C) Inflammation (spondyl

itis) (spinal ‘inflammation’)

N

eurological

(cauda equina: saddle, bladder & bowel, weak/numb legs) Trauma (fractures) Most important screening questions: - cancer? - age > 70 or < 20? - steroids? - fall? - injecting drugs?

Yellow flags (CHAMPS)

Predict chronic pain & disability

C

atastrophizing

(ruminating, injustice

,

work dissatisfaction

)

H

yper-vigilant

A

nxious (panic & PTSD) MedicalizedPassive (‘fix me’, compensation) Substance overuse - chemical coping, addiction - smoking, OTCs, opioidsS

tress SZ George, JM

Beneciuk

MC Musculoskeletal Disorders 2015

LBP examination

Keep it simpleLook for the 4Rs…

Reasons

for

pain?

- physical examination does

not reliably ID spinal pain generators

- may ID peripheral pain generators?

R

adicular leg pain?

R

estrictions? (functional impairments: can they walk & work?)Red flags?

LBP examination

Watch, walk & weakness (gait, power foot/ankle, big toe)

Poke & prick

-

cluneal

nerves (iliac crest tenderness, ∆ in sensation over buttock)

- trigger points (latissimus dorsi fascia, gluteal compartment)

- greater trochanters (lateral thigh)

- L4-S1 dermatomes (sensation in shin & foot)

Slump & stretch

(provocation tests)

- straight leg raise (SLR) - slump test Hammer & hit - ankle & knee reflexes)

Straight leg raise & slump testRadicular leg pain

Bigos

S, Bowyer 0,

Braen

G, et al. Acute low back pain problems in adults: Clinical Practice Guideline, Quick Reference Guide Number. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 95-0643. December 1994.

Available from:

http://www.chirobase.org/07Strategy/AHCPR/clinicians.pdf

Lumbar MRI

Only order to identify red flags or radiculopathy

MRI not that helpful in identifying ‘pain generators’

Severity of MRI changes ≠ severity of back pain

MRI is best screening test for;

-

T

umour -

Infection (discitis)

-

I

nflammation (ankylosing spondylitis)

- Neurological (cauda equina, cord, root) - Trauma (may miss fractures)2nd line: CAT scan

Questionnaires

DN4

or

PainDETECT

Q

(identifies

neuropathic pain)

STarTBack Q (yellow flags, chronicity & disability)

CLBP: key messages

Leading cause of chronic pain

& disability

Classify by timing

,

type of LBP, leg pain, neuropathic pain?

Mostly ‘

non-specific’ CLBP (80%)

Radicular leg pain is not

that common

(10% of cases)

T.I.N.T

(red flags) C.H.A.M.P.S (yellow flags) (predict chronic pain & disability) Examination (watch, walk, poke, prick, slump, stretch, hammer) MRI (only for red flags or radiculopathy)

Thank you

Risk of developing CLBP increases by 10% for every life-stress (yellow flag) around the time of injury

Risk of

chronic pain

over 12M

90% risk if 6 stressors

10% risk

if

0 stressors

Stresses