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Back Pain Rehabilitation The Geriatrician’s Perspective. Dr Fiona Harris Dr Anthony French. Back pain – theirs, not yours. Case for illustration Approach to elderly with back pain Diagnostic pathway Differential diagnoses and other referrals - PowerPoint PPT Presentation
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Back Pain Rehabilitation
The Geriatrician’s Perspective
Dr Fiona Harris Dr Anthony French
Back pain – theirs, not yours
Case for illustration Approach to elderly with back pain Diagnostic pathway Differential diagnoses and other referrals Management – Non-pharm, pharm, interventional, future
planning Pre-conditioning Pre-emptive admission Surgical management with planned post-op & restorative care
plan Rehabilitation
THE PACKAGE – ONE STOP SHOP – biopsychosociointerventionalsurgicalrestorative approach
Lawrie, 82 year old married man Ex-engineer, enjoys fishing from his boat and visiting
their beach house on Bribie Island Back pain slowly progressive over last few years Old ‘lumbago’ since 50s after slipping on boat Can’t go shopping with wife any more – she thinks
he’s avoiding because he stops early complaining of back and leg pain after being ok to start with
Mornings are ‘a bit stiff’ in all the wrong places so slow to start but gets going well as long as not walking too far
Notes that has trouble sit-to-stand and walking down stairs
Pain radiates down legs R>L when worse, more often Otherwise well – some ‘prostatism’, HTN, central
obesity
Case Study
Approach to the older person with back pain
Considerations- Probable cause – traumatic, degenerative,
radiculopathic, stenotic, disc related, inflammatory, infective, malignant
- Disability / functional impairment / effects- Investigations – past, timing, planned- Level of intervention patient is prepared to
consider / undergo / tolerate- Previous treatment approaches and
successes- Comorbidites
Diagnostic pathway
History – injury, pattern, disability, associated
Examination – neurological, muscular, skeletal, joint, evidence of degenerative disease, malignancy, autoimmune disease etc
Functional assessment – Gait, STS, TUG, flexibility
Investigations should include paraproteins, inflammatory and infective causes, nerve conduction studies and imaging as indicated
Differential diagnoses and other referrals Degenerative osteopathies and
discopathies Spondyloarthopathies Inflammatory causes including AID Infective causes including discitis and
abscess Compressive causes including
haematoma Vascular including ischaemia and AVM Myeloma and metastatic disease
Likely degenerative changes in spine – multifactorial Pain pattern suggests spinal stenosis Radiculopathy and weakness suggest urgency No talk of previous intervention, investigation,
treatment attempts Possible disc injury in past when slipped Possible secondary gain per wife’s perception Functional bottom line likely high – fishing on boat Essential – examine, imaging, planning Options include everything from analgesia and
reconditioning through all the interventions so patient’s perceptions, time frames, expectations must be clear
Likely picture in this man
Management Non-pharmacological including
Complementary and Alternative / Relaxation / Faith Psychological adjuncts Lifestyle planning Education
Pharmacological – analgesics, co-analgesics, psychological
Interventional including surgical, anaesthetic, ablative and implants
Medium and long term planning Setting limits, preconditioning, planned
reconditioning, function maintenance therapies
Pre-conditioning
Co-morbidity status and medical optimisation
Environmental management Pain management Equipment – assess, provide,
monitor, manage, follow-up Day rehab, inpatient rehab,
planned off-season workup
Pre-emptive admission
Assessment – pain, co-morbidities, psychological
Restorative care Management planning
consultation Multidisciplinary input and
management Intervention Follow up
Surgical management
Pre-operative assessment Planned timing Pathway to
Post-op care Restorative care plan
Rehabilitation Multidisciplinary assessment Goal setting and education Periodic review and outcome assessment Supports / Caregiver involvement Discharge planning
Environmental modifications Aids – temporary, long term Supports - functional, access (permits etc),
respite Ongoing review
Driving, progress, day therapy
THE PACKAGE – ONE STOP SHOP
Bio-psycho-socio-interventional-surgical-restorative approach
Create a co-ordinated systematic approach
Multidisciplinary approach from the start
REFER
Questions
Dr Fiona Harris, MBBS, FRACP Consultant Physician and Geriatrician 0419 664 040
Dr Anthony French, MBBS, B.App.Sc., FRACP Consultant Physician and Geriatrician Queensland Geriatric Medicine Group 1300 662 884 [email protected]