Back Pain:Assessment and Non-

Pharmacological Management

December 8th, 2018Rheumatology ECHO Bootcamp

Toronto Rehab InstituteToronto, Canada

Laura Passalent PT, BScPT, MHSc, ACPACPhysiotherapist PractitionerArthritis Program, Toronto Western Hospital

Disclosures

I have received honouraria from:

• Abbvie

• Amgen

• Janssen

• Novartis

• UCB

Objectives

1. Brief overview of epidemiology

2. Describe common back pain patterns – Core Back Tool

3. Highlight yellow and red flags

4. Present evidence-based, non-pharmacological treatment strategies

5. Case studies

6. Resources

83.8%

Damian Hoy et al. Ann Rheum Dis 2014;73:968-974

©2014 by BMJ Publishing Group Ltd and European League Against Rheumatism

A systematic review of the global prevalence of low back pain, Volume: 64,

Issue: 6, Pages: 2028-2037, First published: 09 January 2012, DOI:

(10.1002/art.34347)

Course of pain in patients with acute and chronic low-back pain.

Luciola da C. Menezes Costa et al. CMAJ 2012;184:E613-

E624

©2012 by Canadian Medical Association

Assessment

• HISTORY

• Physical examination (confirmatory)

• (Investigations)

History – Pattern Recognition

• “Where is your pain the worst?”

https://isinginthekitchen.files.wordpress.com/2016/10/shooting-pain.jpg?w=640

History: Pattern Recognition

• “Is your pain constant or intermittent?”• “Is there ever a time during the day when your pain

stops, even for a brief moment and even though it will return?”

• “When your pain stops, does it disappear completely? Is it totally gone”

History: Pattern Recognition

• “What increases your typical pain?”• “What are the aggravating movements or positions?”

• “Does bending forward make your typical pain worse?”

Red Flags: “NIFTI”

• Neurological

• Infection

• Fracture

• Tumour

• Inflammation

Neurological: Acute CaudaEquina Syndrome

• “Since the start of your current pain, has there been a change in your bladder or bowel function?”

https://images.radiopaedia.org/images/7381143/c62a4e7c86001676306729bb43332b_gallery.jpg

Neurological: Acute CaudaEquina Syndrome

• Bowel and/or bladder symptoms

– Bowel incontinence

– Bladder retention/overflow

• Saddle anesthesia

https://i3.cpcache.com/product/205429850/monopoly_do_not_pass_go_mousepad.jpg?height=460&width=460&qv=90

Infection

• Precipitating infection

• Previous IV drug use

• Latent TB

• History of GU infection

• Recent travel

• Constitutional signs

– Fever, chills, night sweatshttps://images.radiopaedia.org/images/8085963/2aa99d26b40196babe791c212d50ef_thumb.jpg

Fracture

• History of trauma

• History of immunosuppression

• Osteopenia, osteoporosis

https://images.radiopaedia.org/images/143729/25eaa10f218dbefeb2f2760fe0937f_gallery.jpg

http://image.wikifoundry.com/image/1/9cpRudBNcLJ-2sfsTLM6mQ119798/GW338H600

Tumour

• Constitutional symptoms

– Unexplained weight loss

– Night sweats

• History of malignancy

• Disproportionate night pain

• Failure to respond to conventional treatment within days/weeks

http://clinical-mri.com/wp-content/uploads/2013/06/Metastasis-T1T2-0394390-2.375x2.jpg

Inflammation

• > 3 month history of back pain

• Age of onset < 45 yrs old

• Morning stiffness > 30 minutes duration

• Nocturnal symptoms, usually in the second half of the night

• Better with activity, not better with rest https://img.medscapestatic.com/article/753/697/753697-fig-1.jpg

Yellow Flags

• Belief that back pain is harmful or severely disabling

• Fear avoidance behaviour

• Low mood and social withdrawal

• Expectation of passive treatments rather than active participation

Yellow Flags: Functional Enquiry

• “What can’t you do now, that you could do before your back pain and why?”

Yellow Flags: Risk factors for developing chronicity

• “Do you think your pain will improve or become worse?”

• “Do you think you would benefit from activity, movement or exercise?”

• “How are you emotionally coping with your back pain?”

• “What treatments or activities do you think will help you to recover?”

Pain Patterns: lumbar spine

Back Dominant Leg Dominant

Pattern I Pattern II Pattern III Pattern IV

Frequency Constant Intermittent Constant Intermittent

Aggravating positions/activities

Flexion Extension Flexion Extension

Relievingpositions/activities

Extension Flexion Extension Flexion

Anatomical structure

Discogenic(degeneration)

Facet joints Discogenic(herniation)

Spinal stenosis

Pattern 1

Back DominantWorse with FlexionIntermittentNeuro exam normal*

Pattern 2

Back DominantWorse with ExtensionIntermittentNeuro exam normal*

Pattern 3

Leg DominantWorse with Flexion/MovementConstantNeuro exam abnormal*

Pattern 4

Leg DominantWorse with walking/extensionIntermittentNeuro exam normal*

Upper Motor Neuron Testing

• Babinski/plantar response

• Clonus

• Hoffman’s

• (Saddle anesthesia)

Lower Motor Neuron Testing: Reflexes

http://intranet.tdmu.edu.ua/data/kafedra/theacher/nevrology/nevr_shkrobot/English/Lectures/NEUROLOGY/DENTISTRY/4%20year/Sensation.Reflexes.Paresis/N1%20Sensation.%20Reflexes.%20Paresis..files/image105.jpg

Lower Motor Neuron Testing: Myotomes

http://resources.ama.uk.com/glowm_www/graphics/figures/v1/0810/005f.jpg

Lower Motor Neuron Testing: Dermatomes

Nerve Root Tension

• Femoral Nerve Stretch (L2,3,4)

• Straight Leg Raise (L4,5,S1)

http://www.nle.nottingham.ac.uk/websites/rheumatology/fig210-212.gif

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQneZXHlVWL4A7f1JCNlvHz8rErHZTPq5FhFJimpsQ2MjHf_9S0

From: Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice GuidelineAnn Intern. 2017;166(7):493-505. doi:10.7326/M16-2459Med

Copyright © 2016 American Medical

Association. All rights reserved.

JAMA Intern Med.

2016;176(2):199-208.

doi:10.1001/jamainter

nmed.2015.7431

Relative Risk for Low Back

Pain Episode in Controlled

Trials on Efficacy of Low

Back Pain Prevention

Strategies. Studies are

ordered chronologically

within prevention

strategies. Short-term

indicates follow-up of 12

months or less; long-term,

follow-up evaluation of

more than 12 months. aOnly the baseline sample

size was available.

Movement/exercise management

• Positions of relief

• Movements for relief

• Flexibility

• Stability

• Functional adaptation

Patterns 1 and 3 – Positions of relief

https://dynamichealth.je/wp-content/uploads/2017/10/Low-back-rest-position.png

https://i.pinimg.com/originals/a1/2e/fb/a12efb2a764c5014b608d4af21793594.png

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSww60Qa9ecdvwT7is7_8KOPTrw7h0-3d4sC_xMO__4sV4tNRvM

Patterns 1 and 3: Movements of relief

https://drjeffreytucker.com/Fitness/rehabimages/Back1.jpg

http://corydonphysiotherapy.com/images/extension_standing_exercise.jpg

Patterns 2 and 4: Positions of relief

http://static1.squarespace.com/static/539d990ae4b0c98e0b54d395/53eb15ebe4b04bc976721737/566fe93c0e4c117c7c678e13/1450176884086/?format=1000w

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQv7AKSO2cOnhl8iEQBJyn48SDSm-BoxNR1udgQtCGfQbNdbenrQQ

https://theworldoflt.files.wordpress.com/2013/05/childs-pose.jpg

Patterns 2 and 4: Movements of relief

http://138.197.101.48/wp-content/uploads/2016/01/chair.jpg

https://www.physio-pedia.com/images/8/8e/Single_knee_to_chest_stretch.jpg

http://www.activesportschiro.com/uploads/2/7/6/8/27681893/7491886_orig.jpg

Flexibility

https://static1.squarespace.com/static/54b9a577e4b013117e02cef6/t/5526fe32e4b0d622dc2eaac4/1428618807892/

https://static1.squarespace.com/static/5182b24de4b04fc5ce6b214d/t/5672c9d8e0327c81fa951071/1450363352551/

http://www.precisionmassageclinic.com.au/home/wp-content/uploads/2017/11/0290001021spnm026f.png

Stability

http://www.chiropractor.co.za/wp-content/uploads/2016/07/LB-bird-dog-e1469604641290.jpg

http://jan.ucc.nau.edu/mtl8/images/ther_ex_pics/Exercise_Pics/Pics_for_Basic_skills/Spine/pelvic_tilt.jpg

https://slideplayer.com/slide/11883254/66/images/28/Dead+Bug+Exercise.jpg

Functional adaptation: POSTURE!

http://firestonechiroandwellness.com/wp-content/uploads/2015/05/post2.jpg

Functional adaptation

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQTFfAdpPeiYEkc1nnMWcb-F3jdWo1Ytfx7iRN0zqncTgqc-ObSOw

https://d1yboe6750e2cu.cloudfront.net/i/e22c9e7e7237e0655aed0626c7a80b362e61de08

https://machinedragon.com/wp-content/uploads/2018/04/move-height-adjustable-desks-genesys-office-furniture-in-standard-desk-decorations-23.jpg

Case 1:

• 50 year old female works in an office

• Intermittent low back pain bilateral hip pain

• Aggravated by sitting, biking, lifting

• Symptoms are worsening

• Frustrated that pain is affecting her ability to work and participate in gym activities

Case 2:

• 55 year old male hairdresser

• Self-employed works 10 hour days

• Aggravated with working long days

• Walking for exercise limited

• Better after sitting for 5 minutes

Case 3:

• 45 year old female, recurrent hx of LBP

• Insidious onset 6 weeks ago

• Pain down the lateral leg to ankle with paresthesia to the big toe

• Aggravating factors – everything

• Easing factors – nothing

• Unable to work as mail carrier

Case 4:

• 70 year old male

• Started walking to try to get active and noticed lateral leg pain

• Symptoms start after about 10-15 minutes of walking and needs to sit down by 40-45 minutes

• Leg occasionally feels like it will give out

Case 5:

• 31 year old male

• Insidious onset pain, located in the lumbosacral region and R> L buttocks

• Constant pain for last 6 months; worsening

• Aggravating activities: prolonged sitting or standing, lying

• Better with gentle movement (i.e. walking, going about daily routine)

Resources

http://www.isaec.org/contact-us.html

Resources

FAX: 416.603.4348Attention: Spondylitis Screening Clinic

Resources

Resources

Resources

Resources

Acknowledgements

• Marcia Correale, Practice Lead, ISAEC (TCLHIN)

• Dr. Lori Albert, Rheumatologist, TWH