Evidence-Informed Best Practice Low Back Pain

1. Evidence-Informed Best PracticeLow Back Pain Dr. Julia Alleyne

2. Clicker Time

3. Which key clinical features are NOT suggestive of mechanical low back pain ? • Morning stiffness less than 30 minutes • Pain associated with movement such as bending • Occasional night waking with moderate pain • Urinary retention followed by overflow incontinence • Pain associated with arching backwards

4. In the absence of red flags, what are the most common reasons for you to refer your patient with low back pain to a spinal surgeon? • Presence of chronic back pain not responsive to conservative treatment after 8 weeks • Presence of non-radicular referred leg pain • Presence of tingling sensation in affected leg • CT/MRI indicating any disc pathology • CT/MRI indicating clinically significant nerve root compression • Clarification of work related modifications and restrictions • Patient would like second opinion on diagnosis and management

5. A patient who demonstrates positive yellow flags would fit the following behaviours. • Vegetative signs of clinical depression • Fear and avoidance of activities associated with discomfort • Frequent disruptive sleep disturbance • Dependency on passive pain management modalities • 1 and 2 • 2 and 4 • All of the above

6. In which of the following situations would the low back pain guidelines recommend goal-specific rehabilitation? • Acute low back pain of 1 week duration in avid athlete • Persistent low back without response to medication and exercise • Use of lumbar traction for chronic low back pain • Low back pain triggered by a motor vehicle accident

7. Which of the following patient key messages is Not true? • Your assessment today does not indicate any serious pathology so there is no need to order an xray or any investigations. • Keep moving! Staying active helps and most acute low back pain will go away, without treatment, in 4 to 6 weeks. • Returning to your usual activities including work as soon as you can and at a gradual pace will help you recover. • If you are in pain and feeling stiff, use muscle relaxants for the first six weeks so you can maintain your activities of daily living. • For pain management, start with over-the-counter medicine, your doctor can prescribe other medication if your pain is interfering with activity or is severe.

8. Objective • Describe the key patient features as presented through the continuum of acute, sub-acute, persistent, recurrent and chronic low back pain supported by current Clinical Guidelines and Key Messages

9. Acute Low Back Pain

10. Ms. Espina • 42 year old • Occupation: Nurse • Early season tennis lessons linked to onset of pain, 3 weeks ago • Bilateral, radiating to buttock • Difficult to sit • Prolonged positions aggravate

11. Acute Low Back Guidelines • Duration 4-6 weeks • History, physical, neurological assessment • Screen for red and yellow flags • No imaging unless red flags • Educate, exercise, activity prescription • Self-care strategies • Consider analgesics • 2009 TOP Alberta Guidelines “Guideline for the Evidence-Informed Primary Care Management of LBP” • 2007 American College of Physicians and American Pain Society “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline”

14. Key Messages Provider • Rule out fed flags that may indicate serious pathology. If present, proceed with immediate investigation and/or urgent referral. Patient • If your pain persists beyond 6 weeks, contact your health care provider for a follow up appointment to reassess and possibly consider additional treatment, investigations or referral to a specialist.

15. Sub-Acute Low Back Pain

16. Mr. Ryggrad • 39 year old, sedentary worker • 10 weeks of low back pain of gradual onset with “good days and bad days” • Attended some therapy with temporary symptomatic relief • Intermittent but common medication use

17. Sub-Acute Guidelines • Ongoing from acute to subacute without full resolution • 6-12 week duration • Re-evaluate red flags/ yellow flags • Trial of goal specific therapy • Consider stenosis / radiculopathy • Re-consider imaging needs • Short-acting opioid management • Guidelines cover acute and subacute • 2009 TOP Alberta Guidelines “Guideline for the Evidence-Informed Primary Care Management of LBP” • 2007 American College of Physicians and American Pain Society “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline

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30. Key Messages Provider • Reassure the patient there is no reason to suspect a serious cause. Most episodes of low back pain will improve in 1-6 weeks, but recurrence within 12 months is common. Patient • It is important to keep moving when you have back pain. Lying in bed for prolonged periods will not cure this problem and it will cause you to become stiffer and weaker, making it more difficult for you to resume your normal activities later on.

31. Persistent and Recurrent Low Back Pain

32. Ms. Coluna • 10 month history of low back pain • Initially a 2 week self resolving episode • 3 recurrences in 6 months progressing in length • Pain constantly x 4 months • Feeling frustrated • Unable to work or self manage

33. Recurrent & Persistent Guidelines • < 6 weeks but > 12 months • Treatment • Education • Exercise • Manual Therapy • Acupuncture • Consider Psychological Referral • 2009 National Institute for Health and Clinical Excellence (NICE) “Low back pain: Early management of persistent non-specific low back pain”

37. Key Messages Provider For the acute or recurrent low back pain patient, consider analgesics • Acetaminophen • Anti-inflammatories • Short duration muscle relaxants • Short-acting opioids Patient • You may initially need pain medication to help you resume your daily activities more comfortably. • It is activity however, and not the medication, that will help you recover more quickly. It is important to keep moving when you have back pain.

38. Chronic Low Back Pain

39. Mr. Slabinski • 12 months of low back pain • Modifies most activities due to pain • Daily frequent medication • Intermittent massage therapy for pain relief • Feels discouraged

40. Chronic Low Back Pain Guidelines • 2009 TOP Alberta Guidelines “Guideline for the Evidence-Informed Primary Care Management of LBP” • 2004 EUROPEAN GUIDELINES “Management of Chronic Non-specific Low Back Pain” • Exercise • Graduated • Directional preference • Core stability • With pain • Daily

45. Key Messages Provider • Educate the patient and describe the typically benign, long-term course of low back pain at most visits. • Provide education materials that are consistent with this advice to reduce fear and anxiety, and emphasize active self-management Patient • You do not always need a Health Care Provider to manage your back • Frequently however, low back pain episodes may recur. When you learn how to manage one of these episodes, you can use this information to help you to recover the next time.

47. Summary • Consistent messaging • Limited and Specific Imaging and Investigations • Exercise, Education and Activity Prescription • Patient Self-management • Focused Treatment