Nursing

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South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Family Medicine

Family Medicine 10: 45- year-old man with low back pain

Author:Author: Shou Ling Leong, MD

INTRODUCTION CARE DISCUSSION

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

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You discuss your next patient with Dr. Lee.You discuss your next patient with Dr. Lee.

!

You are working with Dr. Lee today. She hands you a triage note from the nurse regarding your next patient, Mr. Payne:

Forty-five-year-old white male truck driver complaining of two weeks of sharp, stabbing back pain. The pain was better after a couple of days but then got worse after playing softball with his daughter. This morning his pain is so bad that he had trouble getting out of bed.

Dr. Lee provides you some background information about low back pain.

Low Back Pain Prevalence, Cost, & Duration Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for treatment of LBP are estimated to be $100 billion

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annually. Fortunately, most LBP resolves in two to four weeks.

References Casazza BA. Diagnosis and Treatment of Acute Low Back Pain Am Fam Phy 2012;85(4):343-350. http://www.aafp.org/afp/2012/0215/p343.html#ref-list-1 Accessed December 12, 2016.

Humphreys SC, Eck JC, Hodges SD. Neuroimaging in Low Back Pain. American Family Physician. June, 2002; 65(11):2299-306. http://www.aafp.org/afp/2002/0601/p2299.htm. Accessed April 26, 2017.

CAUSES OF LOW BACK PAIN 1 CLINICAL REASONING Dr. Lee continues: “There are many causes for LBP. For presenting symptoms that have a broad differential diagnosis, I find it helpful to think of systems of etiologies in which diseases or conditions can be categorized.”

Common Causes of Back Pain Musculoskeletal (MSK) and Non-MSK Causes of Back PainMusculoskeletal (MSK) and Non-MSK Causes of Back Pain

MSK CausesMSK Causes

Axial:

Degenerative disc disease Facet arthritis Sacroiliitis Ankylosing spondylitis Discitis Paraspinal muscular issues SI dysfunction

Radicular:

Disc prolapse

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Spinal stenosis

Trauma:

Lumbar strain Compression fracture

Non-MSK CausesNon-MSK Causes

Neoplastic:

Lymphoma/leukemia Metastatic disease Multiple myeloma Osteosarcoma

Inflammatory:

Rheumatoid Arthritis

Visceral:

Endometriosis Prostatitis Renal lithiasis

Infection:

Discitis Herpes zoster Osteomyelitis Pyelonephritis Spinal or epidural abscess

Vascular:

Aortic aneurysm

Endocrine:

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Hyperparathyroidism Osteomalacia Osteoporosis Paget disease

CAUSES OF LOW BACK PAIN 2 CARE DISCUSSION

Question Dr. Lee tells you: “Working from such a broad list is difficult. Having a shorter list of working diagnoses will help you conduct a more focused initial history and physical exam. What are the three most common causes of back pain?” Select all that apply.

A. Pyelonephritis

B. Lumbar strain

C. Spinal stenosis

D. Disc herniation

E. Kidney stones

F. Degenerative joint disease

SUBMITSUBMIT

Answer Comment The correct answers are B, D, F.The correct answers are B, D, F.

Most Common Causes of Back Pain

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Most Common Causes of Back Pain There are three major categories of back pain: mechanical, visceral, and non-mechanical.

MechanicalMechanical

97% of back pain no primary inflammatory or neoplastic cause

VisceralVisceral

2% of back pain no primary involvement of the spine, usually from internal

organs

Non-mechanicalNon-mechanical

1% of back pain other

The three most common causes of back pain are all mechanical:

1. lumbar strain/sprain1. lumbar strain/sprain – 70%

2. age-related 2. age-related degenerative joint changesdegenerative joint changes in the disks and facets – 10%.

3. herniated disc3. herniated disc – 4%

Acute sciatica is lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks. Sciatica is a common and costly problem, caused by a variety of conditions: disk herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or tumor, or spondylolisthesis.

Less common causes of mechanical back pain:

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osteoporotic fracture – 4% spinal stenosis – 3%

Uncommon causes of back pain:

Pyelonephritis, a visceral cause, accounts for 0.4% of back pain.

RISK FACTORS FOR LOW BACK PAIN CARE DISCUSSION Dr. Lee suggests, “Now, let’s look a bit more at the risk factors for mechanical low back pain that you can review with Mr. Payne during your history.”

Dr. Lee continues, “The major task in treating back pain is to distinguish the common causes for back pain (95% of cases) from the 5% with serious underlying diseases or neurologic impairments that are potentially treatable.”

Risk Factors for Low Back Pain Prolonged sitting, with truck driving having the highest rate of LBP,

followed by desk jobs Deconditioning Sub-optimal lifting and carrying habits Repetitive bending and lifting Spondylolysis, disc-space narrowing, spinal instability, and spina bifida

occulta Obesity Education status: low education is associated with prolonged illness Psycho-social factors: anxiety, depression stressors in life Occupation: Job dissatisfaction, increased manual demands, and

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compensation claims

Red Flags For Serious Illness or Neurologic Impairment with Back Pain

Fever Unexplained weight loss Pain at night Bowel or bladder incontinence Neurologic symptoms Saddle anesthesia

HISTORY 1 HISTORY You and Dr. Lee take a few minutes to review Mr. Payne’s chart:

Vital signs:Vital signs:

Temperature:Temperature: 98.6° Fahrenheit Heart rate:Heart rate: 80 beats/minute Respiratory rate:Respiratory rate: 12 breaths/minute Blood pressure:Blood pressure: 130/82 mmHg Weight:Weight: 170 pounds Body Mass Index:Body Mass Index: 24 kg/m2

Past Medical History:Past Medical History: Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control.

Past Surgical History:Past Surgical History: None

Social History:Social History: Works as a truck driver, which involves lifting 20-35 lbs 4 hours of the day, married with 2 daughters,

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Habits:Habits: Quit smoking two years ago, drinks 1 to 2 beers occasionally on the weekends, no history of IV drug use.

Medication:Medication:

metformin 500mg 2 twice daily glyburide 5mg 2 twice daily amlodipine 2.5 mg daily lisinopril 40 mg daily simavastin 40 mg daily

AllergiesAllergies: No known drug allergies.

Question Before you meet Mr. Payne, you pause to consider the relevant history to gather for back pain. What questions should you include in your history that would help you narrow your differential diagnosis? Select all that apply.

A. Location of the pain

B. What is the duration of the pain?

C. Does the pain radiate?

D. Using a pain scale of 0-10; where 10 is the worst pain:

“How bad does your pain get?”

E. Aggravating or alleviating circumstances

F. What type of pain is it? Is it dull, achy, sharp or

stabbing?

G. Is the pain constant or remitting? Is it present at

night?

H. Any numbness or tingling?

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I. Fever or chills

J. Any weight loss

K. Medical history

L. Surgical history

SUBMITSUBMIT

Answer Comment The correct answers are A, B, C, D, E, F, G, H, I, J, K, L.The correct answers are A, B, C, D, E, F, G, H, I, J, K, L.

Recommended Low Back Pain History 1. History of present illness.1. History of present illness.

What is the location of the pain? Is it upper, middle or lower back?

What is the duration of the pain or how long ago did it start? Is it getting worse or better? Does the pain radiates? Pain that radiates below the knee- more consistent with sciatica; pain around the buttock- more consistent with lumbar strain.

What is the severity of the pain? Use a pain scale of 1-10 to make the severity somewhat more objective. Intensity of the pain

What is the quality of the pain? Is it achy, or sharp, or dull, or throbbing?

Is the pain constant or remitting? Is it present at night or at rest?

Are there associated symptoms? Does the patient have weakness or numbness or tingling?

Are there aggravating or alleviating factors? Aggravating circumstances (active vs. passive motion, day vs. night). Valsalva can increase pain from a herniated disk.

Alleviating circumstances (medication, positioning-sitting, lying, standing) What has the patient tried to relieve the problem

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(what worked, what didn’t) Any history of similar problems?

2. Pertinent past history.2. Pertinent past history. Recent illnesses, history of recent trauma or injury, patient’s occupation, previous history of back injury, cancer, or DM. (Fatigue is a nonspecific finding which may not help you to narrow your differential diagnosis.)

3. Review of systems.3. Review of systems. In order to narrow your differential diagnosis for the patient’s problem, a review of systems, focused on pertinent positives and negatives is important.

Neurologic symptoms

(saddle anesthesia, lower extremity numbness, tingling, muscle weakness particularly in the lower extremities, fecal incontinence)

Urinary symptoms

(urinary incontinence, hesitancy, frequency, dysuria)

Gastrointestinal symptoms

(nausea, vomiting)

Constitutional symptoms

(fever, unexplained weight loss)

4. Current medications and allergies4. Current medications and allergies

HISTORY 2 HISTORY

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You greet Mr. Payne and discuss his back pain.You greet Mr. Payne and discuss his back pain.

!

After introducing yourself to Mr. Payne, you sit down across from him and begin your history, focusing on the key elements.

“Can you tell me about your back pain?” “As I told the nurse, the pain started two weeks ago after I lifted a box at work. Right away, I got this sharp pain on the left side of my back. The box wasn’t even that heavy.

“I talked to the nurse at work; she said to ice it and to take ibuprofen. It got better after three days. But, I was playing softball with my daughter last weekend, and the pain came back. This time it was worse than before. This week, the pain is so bad I can hardly get out of bed. I get a sharp pain in my back which goes down my left leg to my ankle.”

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“On a scale of 0 to 10, 10 being the worst, how severe is the pain?” “It’s probably a 7.”

“Have you found anything that improves the pain?” “Ibuprofen and Naproxen worked at first, but they are not helping much anymore.”

“What about positions that make things better or worse?” “The pain is worse with any movement of my back or sitting for a long time. It is better when I lie down.”

“Have you had back pain before?” “Yes, I have back pain from time to time. But I’m usually better after 2 to 3 days. This is the worst pain I have ever had.”

You complete your history with a review of systems and discover:

Review of SystemsReview of Systems

Mr. Payne does not have numbness or weakness in his legs. The pain is better when he lies down. He denies urinary frequency, dysuria, problems with bowel or bladder control, fever or chills, nausea or vomiting, or weight loss. He denies any specific trauma, except for when he lifted a 10-pound box at work. He denies unrelenting night pain.

You excuse yourself from Mr. Payne to discuss your findings with Dr. Lee.

SUMMARY STATEMENT CLINICAL REASONING

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Question Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

More on summary statements.More on summary statements. Your response is recorded in your student case report.

Patient is a 45 years old male with complaints of lower back pain that started two weeks ago after lifting a no so heavy box as described by the patient. Pain got relieve but came back worse after playing softball. Patient stated having the pain before but not as worse as this one. Pain used to be relived by Naproxen and Ibuprofen but not anymore. Patient described the pain as a sharp pain in scale of 7 that get worse with movement and improve when laying down.

Letter Count: 465/1000

SUBMITSUBMIT

Answer Comment Mr. Payne is a 45-year-old man with a two week history of low back pain that radiates down his left leg. The pain is worse with sitting and improves with the supine position. He denies history of trauma, fever/chills, night pain, urinary symptoms, and bowel or bladder incontinence.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

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The best options are indicated below. Your selections are indicated by the shaded boxes.

1. Epidemiology and risk factors: 45-year-old man

2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

pain present for two weeks pain radiates down left leg pain worse with sitting and improves with supine position no history of trauma no fever/chills no night pain no urinary symptoms no bowel or bladder incontinence

DIFFERENTIAL DIAGNOSIS CLINICAL REASONING

Question From the following, select the top four diagnoses on your differential for low back pain in this patient.

A. Lumbar strain

B. Disc herniation

C. Spinal stenosis

D. Spinal fracture

E. Cauda equina syndrome

F. Pyelonephritis

G. Malignancy

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H. Ankylosing spondylitis

I. Spondylolisthesis

J. Degenerative arthritis

K. Prostatitis

SUBMITSUBMIT

Answer Comment The correct answers are A, B, C, J.The correct answers are A, B, C, J.

DiZerential for Low Back Pain The most appropriate diagnoses on your differentialThe most appropriate diagnoses on your differential include:include:

Lumbar strain, disc herniation, spinal stenosis, andLumbar strain, disc herniation, spinal stenosis, and degenerative arthritisdegenerative arthritis.

Pain worse with movement and sitting is suggestive of a mechanical cause of back pain, such as a lumbar strain, disclumbar strain, disc herniation,herniation,or degenerative arthritisdegenerative arthritis.

Pain radiating down the leg and numbness indicate nerve involvement, such as in disc herniationdisc herniation.

Pain that improves with the supine position suggests spinalspinal stenosisstenosis and disc herniationdisc herniation.

The following diagnoses are less likely:The following diagnoses are less likely:

Spinal fracture Not likely without history of trauma.

Should always be consideredShould always be considered due to the seriousness of the

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Cauda equina syndrome

consequences. Occurs when a large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain radiating down the leg and can be accompanied by weakness and numbness of the leg. True emergency. Decompression should beDecompression should be performed within 72 hoursperformed within 72 hours to avoid permanent neurologic deficits. Low on the differential if the patient denies problem with bowel or bladder control.

Pyelonephritis Unlikely with lack of fever and urinary symptoms.

Malignancy

Important consideration. Important consideration. A very serious, although uncommon, cause of back pain. Unlikely without a history of cancer. Back pain due to malignancy is localized to the affectedlocalized to the affected bonesbones, it is a dull, throbbingdull, throbbing painpain that progresses slowlyprogresses slowly, and it increases withincreases with recumbency or coughrecumbency or cough. More commonly seen in patientspatients over 50over 50.

ChronicChronic, painful, inflammatoryinflammatory arthritisarthritis primarily affecting the spinespine and sacroiliac jointssacroiliac joints,

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Ankylosing spondylitis

causing eventual fusion of the spine. Often seen in patients 15-4015-40 years oldyears old, associated with morning stiffness andmorning stiffness and achiness over the sacroiliacachiness over the sacroiliac joint and lumbar spinejoint and lumbar spine.

Spondylolisthesis

Anterior displacement of aAnterior displacement of a vertebra or the vertebra or the vertebralvertebral columncolumn in relation to the vertebrae below. Can occur at any ageany age. Causes aching back andaching back and posterior thigh discomfortposterior thigh discomfort that increases with activity orincreases with activity or bendingbending.

Prostatitis

Can cause referred LBP in men. (Pelvic inflammatory disease and endometriosis in women can cause referred LBP). Expect to find evidence of infection in the history.

Pancreatitis

Pancreatitis and other gastrointestinal diseases such as cholecystitis and ulcers can cause LBP via visceral pain. Usually associated with other abdominal symptoms.

Based on your differential, you determine that it is highly likely that Mr. Payne is experiencing a mechanical cause of back pain with nerve involvement such as a disc herniation. It is possible that he has spinal fracture, but a lack of trauma history makes the latter

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unlikely. It is important to consider cauda equina syndrome, as it calls for immediate surgical investigation, but it is unlikely in the absence of neurological symptoms like loss of bowel or bladder control. Finally, infectious etiology, such as pyelonephritis, is unlikely without fever and chills, urinary frequency and dysuria.

References Patel A, Ogle A. Diagnosis and Management of Acute Low Back Pain. American Family Physician. March 15, 2000.

COMPONENTS OF MECHANICAL LOW BACK PAIN

PHYSICAL EXAM

Dr. Lee explains the complexities of back pain.Dr. Lee explains the complexities of back pain.

!

Dr. Lee tells you, “On physical exam, you can discover problems with the

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bony structures and muscles of the spine through inspection of posture, contour, and symmetry, palpation of the boney prominences, and range of motion testing.

A solid understanding of the neurological exam of the lower extremity will help you determine if the pain is due to nerve impingement or from muscle and bone.”

Anatomy of Mechanical Lower Back Pain Mechanical lower back pain generally involves one or more of the following:

1. bones of the spinebones of the spine 2. muscles and ligaments surrounding the spinemuscles and ligaments surrounding the spine 3. nervesnerves (the nerves entering and exiting the spinal cord or problems with the cord itself)

STANDING BACK EXAM PHYSICAL EXAM

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Dr. Lee performs the back exam.Dr. Lee performs the back exam.

!

You and Dr. Lee return to examine Mr. Payne together.

Approach to the Physical Exam for Back Pain Perform the back exam systematically in sequential order with the patient:

1. Standing 2. Sitting 3. Supine

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question While the patient is standing, what should be examined? Select all that apply.

A. Inspect the curvature of the spine

B. Palpate the paraspinal muscle

C. Ask the patient to run

D. Check flexion of the spine

E. Ask the patient to walk

F. Ask the patient to squat

SUBMITSUBMIT

Answer Comment The correct answers are A, B, D, E, F.The correct answers are A, B, D, E, F.

Physical Exam for Back Pain – Standing Throughout the whole exam make certain to note how your patient is sitting, standing, and walking in general, asking yourself ‘What is his degree of impairment?’ and ‘How uncomfortable is he?’.

I. Inspection:I. Inspection: Look at posture, contour and symmetry

Check for lordosis Check for kyphosis Check for scoliosis

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Slight scoliosis may be more easily visualized during lumbar flexion. This is performed by having the patient stand with their feet and hands together, like they are about to dive off a diving board, bending forward toward their toes. Look out across the back to see if the shoulders are level.

II. Palpation:II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness over bony prominences. This procedure checks for muscle spasm, vertebral fracture, or infection.

III. Range of Motion (ROM):III. Range of Motion (ROM):

Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm.

Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis.

Lateral motion (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain.

Range of motion may be varied due to the patient’s age and body habitus

IV. Gait:IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation.

Difficulty with heel walk is associated with L5 disc herniation Difficulty with toe walk is associated with S1 disc herniation

V. Stoop Test:V. Stoop Test: Have the patient go from a standing to squatting position.

In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause discomfort to the patient who is already in

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pain.

SITTING BACK EXAM PHYSICAL EXAM

Dr. Lee performs a reflex test on Mr. Payne.Dr. Lee performs a reflex test on Mr. Payne.

!

Dr. Lee walks through the steps for completing a neurologic exam in a patient with back pain.

Back Exam – Standing:Back Exam – Standing:

Mr. Payne has normal curvature, tenderness on palpation on the left lumbar paraspinous muscle with increase tone. Full range of motion, but has pain with movement. His gait is normal. He can walk on his heels and toes. He can do deep knee bends.

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Back Exam – Seated:Back Exam – Seated:

Mr. Payne denies feeling pain when checked for CVA tenderness. He has no pain in his right leg with the modified version of SLR. While he does not exhibit a true tripod sign, he does complain of pain when his left leg is raised. Mr. Payne’s reflexes are 2+ and equal at the knees and 1+ at both ankles. The motor exam reveals no weakness of the muscles of the lower extremities. His sensory exam is normal.

Pulmonary Exam:Pulmonary Exam: His lungs are clear.

Cardiovascular Exam:Cardiovascular Exam: His cardiac exam demonstrates a regular rhythm, no murmur or gallop.

Physical Exam for Back Pain – Seated Position

Overview of the Neurologic ExamOverview of the Neurologic Exam

Nerve Impingement Syndromes

Check for costovertebral angle (CVA) tendernessCheck for costovertebral angle (CVA) tenderness, a sign suggesting pyelonephritis.

Modified version of the straight leg raise (SLR) testModified version of the straight leg raise (SLR) test

While continuing to talk to the patient, raise each leg by extending the knee from 90 degrees to straight. If the pain is due to structural disease, the patient will instinctively exhibit the “tripod sign” by leaning backward and supporting himself with his outstretched arms on the exam table.

(The unmodified version of the straight leg raise (SLR) test is done in the next section of the exam with the patient supine.)

Neurological examNeurological exam

Check reflexes, muscle strength, and sensation of the lower extremities.

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Focus on the L4, L5, and S1 nerve roots because most neuropathic back pain is due to impingement of these. Therefore, check the patellar reflex (L2-4) and Achilles reflex (S1). Check muscle strength for hip flexion, abduction, and adduction; knee extension and flexion; as well as ankle dorsiflexion and plantar flexion. Also, test for sharp and light touch along the dermatomal distribution of the great toe (L5), lateral malleolus and posterolateral foot (S1).

SUPINE BACK EXAM PHYSICAL EXAM

Dr. Lee begins the exam in the supine position.Dr. Lee begins the exam in the supine position.

!

Dr. Lee continues, “The final part of the exam is done in the supine position.”

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question What do you want to check while the patient is supine? Select all that apply.

A. Check for abdominal bruit, especially on elderly

patients.

B. Check for abdominal tenderness only in female

patients.

C. Perform rectal exam on all patients.

D. Perform passive straight leg raise on all patients.

E. Perform FABER test only in elderly patients.

SUBMITSUBMIT

Answer Comment The correct answers are A, D.The correct answers are A, D.

Physical Exam for Back Pain – Supine I. I. Abdominal ExamAbdominal Exam

Auscultation: Check for abdominal bruit, looking for abdominal aortic aneurysm.

Palpation: Check for abdominal tenderness (on all patients, not just female patients), pelvic tenderness (PID), pulsatile mass, unequal femoral/brachial pulses (abdominal aortic aneurysm), or any general tenderness indicating visceral pathology.

II. II. Rectal ExamRectal Exam

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To be done onlyonly on patients with red flags or alarm symptoms, which we will discuss later!

Check for masses, bleeding, or abnormal rectal tone. Bleeding or rectal mass can be signs of cancer with metastasis to the spine causing back pain. Decreased tone can indicate disc herniation and/or cauda equina syndrome.

III. III. Passive Straight Leg RaisePassive Straight Leg Raise (SLR or Lasegue’s sign)

The normal leg can be raised 80 degrees.

If a patient only raises their leg <80 degrees, they have tight hamstrings or a sciatic nerve problem.

To differentiate between tight hamstrings and a sciatic nerve problem, raise the leg to the point of pain, lower slightly, then dorsiflex the foot. If there is no pain with dorsiflexion, the patient’s hamstrings are tight.

The test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc.

This pain will most likely occur between 40 and 70 degrees. Pain earlier than 30 degrees is suggestive of malingering.

Pain less than 30 degrees is not a sign of disc herniation.

IV. Crossed Leg RaiseIV. Crossed Leg Raise: asymptomatic leg is raised

Test is positive if pain is increased in the contralateral leg; this correlates with the degree of disc herniation. Such results imply a large central herniation.

Cross SLR test is much less sensitive (0.25) but is highly specific (about 0.90). Thus, a negative test is nonspecific, but a positive test is virtually diagnostic of disc herniation.

V. V. FABER TestFABER Test: FFlexion, AAbduction, and EExternal RRotation

The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain from sacroiliitisfrom sacroiliitis).

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The test is performed by flexing the hip and placing the foot of the tested leg on the opposite knee. Pressure is then placed on the tested knee while stabilizing the opposite hip.

The test is positive if there is pain at the hip or sacral joint or if the leg cannot lower to the point of being parallel to the opposite leg from pathology of the hip, sacrum or sacroiliac joint.

The FABER test should be done on all patients suspected of having sacroiliac pain, not just in the elderly patients. Sacroiliitis can occur in the young population as well.

VI. Muscle Atrophy:VI. Muscle Atrophy: of quadriceps and calf muscles.

DIFFERENTIAL DIAGNOSIS AFTER EXAM

CLINICAL REASONING

Exam – SupineExam – Supine

Mr. Payne’s abdominal exam is negative. His straight leg raising isstraight leg raising is positive at 75 degrees on the left and negative on the right.positive at 75 degrees on the left and negative on the right. His FABER test is negativeFABER test is negative and sacroiliac joint is nontender.sacroiliac joint is nontender. His motor exam reveals no weakness of the muscles of the lower extremities.

After finishing your exam together, you and Dr. Lee excuse yourselves from the exam room for a moment.

Question What are your top two working diagnoses for Mr. Payne’s back pain?

The suggested answer is shown below.

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Herniated disk and lumbar spine stenosis.

Letter Count: 41/1000

SUBMITSUBMIT

Answer Comment Disc herniation, Lumbar strain

Based on physical exam, you believe that Mr. Payne has back pain with radiculopathy, likely at the L5/S1 level. Given his risk factor as a truck driver and pain radiating down his leg, Mr. Payne’s pain is likely due to disc herniationdisc herniation. However, lumbar strainlumbar strain is still a possibility.

DISC HERNIATION CLINICAL REASONING

Question Dr. Lee then asks you: “Which of the following findings would support the diagnosis of disc herniation?” Select all that apply.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Pain worse with sitting

B. Pain worse with standing

C. Pain worse with cough and sneezing

D. Drop foot

E. Urinary retention

SUBMITSUBMIT

Answer Comment The correct answers are A, C, D.The correct answers are A, C, D.

Symptoms of Disc Herniation When disc herniation is suspected, a very important historical point is the position of comfort or worsening of symptoms.

Classically, disc herniation is associated with exacerbation when sitting or bending; and relief while lying or standing.

Other symptoms of disc herniation include:

increased pain with coughing and sneezing pain radiating down the leg and sometimes the foot paresthesias muscle weakness, such as foot drop

Urinary retention is part of a cauda equina syndrome, which can be caused by a disc herniation but does not support a diagnosis of a disc herniation by itself.

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RED FLAGS CLINICAL REASONING

SciaticaSciatica

!

Dr. Lee reminds you that disc herniation, a condition which is self-limited and usually resolves in two to four weeks, remains a working diagnosis for Mr. Payne. She says, “Let’s take a few minutes, though, to discuss some conditions we still don’t want to miss.”

Question What are the red flags or alarm symptoms that would suggest a more serious underlying condition causing his back pain? Select all that apply.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

A. The worst pain the patient has ever had

B. Fever

C. Loss of bowel/bladder control

D. Severe pain that awakens him from sleep.

E. Numbness of the leg

F. Weight loss

SUBMITSUBMIT

Answer Comment The correct answers are B, C, D, F.The correct answers are B, C, D, F.

Red Flags for Serious Underlying Causes of Back Pain While the majority of back pain has a benign course and resolves within a month, a small number of cases are associated with serious underlying pathology. Timely treatment of these conditions is important to avoid serious consequences. Indications for early diagnostic testing such as x-rays and other imaging and referral are patients with progressive neurological deficits, patients not responding to conservative treatment, and patients with red flags signaling serious medical conditions such as fracture, cancer, infection, and cauda equina syndrome. Knowing this would also help guide the evaluation and treatment of the back pain.

While the worst pain a patient has ever had (A) is concerning and needs to be addressed, it is not by itself indicative of a more serious condition.

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Numbness (E) can be part of cauda equina, but is also common with a simple disc herniation, therefore by itself it is not a red flag.

Red Flags by Serious ConditionRed Flags by Serious Condition

CancerCancer

1. History of cancer 2. Unexplained weight loss >10 kg within 6 months 3. Age over 50 years or under 17 years old 4. Failure to improve with therapy 5. Pain persists for more than 4 to 6 weeks 6. Night pain or pain at rest

InfectionInfection

1. Persistent fever (temperature over 100.4 F) 2. History of intravenous drug abuse 3. Recent bacterial infection, particularly bacteremia (UTI, cellulitis, pneumonia) 4. Immunocompromised states (chronic steroid use, diabetes, HIV)

Cauda Equina SyndromeCauda Equina Syndrome

1. Urinary incontinence or retention 2. Saddle anesthesia 3. Anal sphincter tone decreased or fecal incontinence 4. Bilateral lower extremity weakness or numbness 5. Progressive neurologic deficits

Significant Herniated Nucleus PulposusSignificant Herniated Nucleus Pulposus

1. Major muscle weakness (strength 3 of 5 or less) 2. Foot drop

Vertebral FractureVertebral Fracture

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1. Prolonged use of corticosteroids 2. Mild trauma over age 50 years 3. Age greater than 70 years 4. History of osteoporosis 5. Recent significant trauma at any age (car accident, fall from substantial height) 6. Previous vertebral fracture

Mr. Payne does not have any red flags, so it is safe to wait to do any imaging or lab tests. Even with a disc herniation the pain often resolves on its own in six weeks, and no further work up is necessary.

References Arce D, Sass P, Abul-Khoudoud H. Recognizing Spinal Cord Emergencies. American Family Physician. August 15, 2001;64(4):631-8.

Kinkade S. Evaluation and Treatment of Acute Low Back Pain. American Family Physician. April 15, 2007;75(8):1121-1276.

Casazza, B. Diagnosis and Treatment of Acute Low Back Pain. Am Fam Physician. 2012 Feb 15;85(4):343-350. http://www.aafp.org/afp/2012/0215/p343.html. Accessed February 13, 2017.

DIAGNOSTIC TESTS TESTING While Dr. Lee takes the time to return to the exam room and review mechanical low back pain with Mr. Payne, she asks you to to consider what other testing should be done at this time. Is an MRI indicated?

Indications for Studies to Evaluate Low Back Pain Laboratory tests generally are not needed in the evaluation of acute low back pain.

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CBCCBC

CBC and sedimentation rate should be ordered if tumor or infection is suspected.

X-rayX-ray

Agency for Health Care Policy and Research (AHCPR) guidelines for x-ray:

History of trauma Strenuous lifting in patient with osteoporosis Prolonged steroid use Osteoporosis Age <20 and >70 History of cancer Fever/chills/weight loss Pain worse when supine or severe at night Spinal fracture, tumor, or infection

The American College of Radiology (ACR) has appropriateness criteria for imaging for various conditions. View the ones for low back pain (.pdf).

Lumbar spine filmLumbar spine film

Lumbar spine films are commonly used, but lack specificity and have a high rate of false-positive findings. Patients with symptoms and pathology may have an apparently benign x-ray and asymptomatic patients may have abnormal x-rays.

MRIMRI

An MRI is indicated if the following are present:

Worsening or unremitting neurologic deficit or radiculopathy Progressive major motor weakness Cauda equina compression (sudden bowel/bladder disturbance) Suspected systemic disorder (metastatic or infectious disease) Failed six weeks of conservative care

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The best option is indicated below. Your selections are indicated by the shaded boxes.

However, 75% of herniated discs improve with six weeks of conservative therapy. MRI testing is not associated with clinical benefit in randomized trials. Early MRI is not associated with improved outcomes in patients with acute back pain or radiculopathy (Level 2/mid-level evidence). If surgery is being considered, some physicians recommend, in the absence of red flags, to obtain an imaging study after one month of symptoms.

Electrodiagnostics-ElectromyographyElectrodiagnostics-Electromyography

Electrodiagnostics-Electromyography (EMG) and nerve conduction studies can be used in the evaluation of patients with radicular pain and lumbar spinal stenosis.

Electrodiagnostic tests are useful to confirm the existence of radiculopathy (level of nerve involvement) and to exclude the presence of other peripheral nerve disorders. Electrodiagnostic tests are time sensitive because nerve root abnormalities may not be reliably detectable until three weeks after the onset of symptoms.They are particularly useful as an adjunct to clinical evaluation and Imaging in the following two clinical scenarios: physical examination does not correlate with imaging studies; and to clarify the functional significance of an imaging abnormality.

Question When Dr. Lee returns from her discussion with Mr. Payne, you tell her you would like to order which of the following tests? Choose the single best answer.

A. CBC

B. UA

C. X-ray

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D. MRI

E. None of the above

SUBMITSUBMIT

Answer Comment The correct answer is E.The correct answer is E.

Assessment of Acute Back Pain In the absence of red flags or findings suggestive of systemic disease, diagnostic testing, especially imaging, is not indicated until after four to six weeks of conservative treatment. Ordering tests too early is not only cost ineffective, but can also cause harm to the patient.

Spine x-rays expose patient to radiation. This is particularly concerning in younger women because the radiation exposure to the ovaries in a single plain radiograph of the lumbar spine is equal to getting a daily chest x-ray (CXR) for more than a year.

CT scans expose patients to contrast materials that have renal toxicity, and even higher doses of radiation. Routine imaging of the back using CT or MRI is not associated with improved outcomes, and may identify abnormalities that are unrelated to the patient’s back pain. This can cause anxiety and could lead to more testing and possibly unnecessary intervention.

Algorithm for assessment of acute back pain.

You and Dr. Lee decide that it is not indicated to do imaging at this time for Mr. Payne.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

References Bigos S, Bowyer O, Braen G, Brown K, Deyo R A, Haldeman S., et al. Acute Low Back Problems in Adults. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Clinical Practice Guideline No. 14. Report No. 95-0642. December, 1994.

Chou R, Qaseem A, Snow V, Casey D, Cross J T Jr., Shekelle P, Owens P. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.” Annals of Internal Medicine. 2007;147:478-491.

Deyo RA, Deihl AK. Lumbar spine films in primary care: Current Use and Effects of Selective Ordering Criteria. Journal of General Internal Medicine. 1986;1:20-5.

Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. Edmonton (AB): Toward Optimized Practice; 2009 Mar 2.

Jarvik JG, Deyo, RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Annals of Internal Medicine. October, 2002;137(7):586-97.

INITIAL TREATMENT MANAGEMENT

Question “Now that you have a diagnosis of disc herniation with radiculopathy for Mr. Payne, let’s discuss what would you like to do for him.”

Which of the following are indicated at this time? Select all that apply.

A. Prescribe NSAID and muscle relaxant

B. Strict bed rest

C. Referral to a back surgeon

” DEEP DIVEDEEP DIVE

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D. Order a MRI

E. Moist heat

F. Referral to physical therapy

SUBMITSUBMIT

Answer Comment The correct answers are A, E, F.The correct answers are A, E, F.

Mr. Payne has no red flags and has had pain for only two weeks, so conservative therapy is appropriate for him.

Conservative Therapy for Acute Low Back Pain Conservative therapy for acute low back pain includes:

Pharmacologic therapy:Pharmacologic therapy: Aspirin/NSAID and/or muscle relaxants

Local therapy:Local therapy: Local therapy (heat/cold). Learn more about local therapy here.

Activity:Activity: Advice to stay active or sending patient to physical therapy may help prevent recurrence.

Pharmacologic therapy:Pharmacologic therapy: The first line medications for the treatment of LBP are non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants. A systematic review of randomized controlled studies found strong evidence that NSAIDs and muscle relaxant are helpful in the treatment of LBP. The various NSAIDs and muscle relaxants are equally effective, while some muscle relaxants are more sedating. There is conflicting evidence about the superiority of NSAIDs to acetaminophen.

There is little evidence regarding the benefits of opioid use in

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LBP, and there is significant concern about the risk of the development of addiction. Occasionally, when pain cannot be controlled in other ways or when there are contraindications to other options, opioids are prescribed. Such prescriptions should be time-limited. No studies support the use of oral steroids in patients with LBP.

Learn more about activity here and here.

Strict bed rest has not been shown to be beneficial. Patients should be encouraged to resume normal activities as soon as they are able to.

Referral to a surgeon or advanced imaging, such as MRI/CT scans, should be entertained if back pain is not better in four to six weeks or if progression of neurologic deficits is demonstrated. The “Choosing Wisely” campaign in family medicine has good patient resource material to explain the recommendation to wait for imaging.

References Browning R, Jackson J, O’Malley P. Cyclobenzaprine and Back Pain: A Meta-analysis. Archives of Internal Medicine. July 9, 2001;161:1613-1620.

Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.

Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057.

French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006 Jan 25;(1). http://www.ncbi.nlm.nih.gov/pubmed/16437495. Accessed December 12, 2016.

Goertz M, Thorson D, Bonsell J, Bonte B, Campbell R, Haake B, Johnson K, Kramer C, Mueller B, Peterson S, Setterlund L, Timming R. Institute for Clinical Systems Improvement. Adult Acute and Subacute Low Back Pain. Updated November 2012. https://www.icsi.org/_asset/bjvqrj/LBP.pdf. Accessed December 12, 2016.

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Hagen K B, Hilde G, Jamtvedt G, Winnem M. Bedrest for Acute Low-Back Pain and Sciatica. Cochrane Database System. Revised 2004; (4):CD001254.

Petering, Ryan C. MD and Webb, Charles, DO. Treatment Options for Low Back Pain in Athletes. Sports Health. Nov 2011; 3(6): 550-555. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445234/. Accessed December 12, 2016.

van Tulder M W, Scholten R Jr., Koes B W, Deyo R A. Nonsteroidal Anti-Inflammatory Drugs for Low Back Pain. Cochrane Database Syst Rev. 2007 Jul 18;(2):CD000396.

PHYSICAL THERAPY MANAGEMENT

Question Would physical therapy be helpful for Mr. Payne?

The suggested answer is shown below.

Yes

Letter Count: 3/1000

SUBMITSUBMIT

Answer Comment

EZectiveness of Physical Therapy for Acute Back

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EZectiveness of Physical Therapy for Acute Back Pain There is some data to show that tailored physical therapy is slightly more effective for acute back pain compared to patients who just stay active. At four weeks, patients who received physical therapy had 10-point improvement in a 100-point disability score compared to the control group. There is great variation in physical therapy because various interventions (exercises, traction, massage) and different modalities (heat, ice, ultrasound) may be used. There is also evidence that spinal manipulation is safe and can help in the short term.

References Fritz, JM, Delitto A, Erhard RE. Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain: A Randomized Clinical Trial. Spine. July 1, 2003;28(13):1355-1486, E245-E264.

Machado LA, de Souza MS, Ferreira PH, Ferreira ML. The McKenzie Method for Low Back Pain: A Systematic Review of the Literature with a Meta-Analysis Approach. Spine. 2006 Apr 20;31(9):E254-62.

PROGNOSIS CARE DISCUSSION You and Dr. Lee now return to Mr. Payne’s exam room to talk about treatment options with him. Dr. Lee tells Mr. Payne to avoid strenuous activities but to remain active. Dr. Lee increases the dosage of naproxen to 500 mg BID to take with food. Since his pain is intense (7/10), he is given a prescription for acetaminophen with codeine to take at night, when his pain is severe. Mr. Payne declines a muscle relaxant because they usually make him drowsy. He would like to be referred to physical therapy as it was helpful in the past.

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Question Mr. Payne asks Dr. Lee: “What’s the likelihood that this pain will go away completely?” Select all that apply.

A. Most back pain is improved in 4 to 6 weeks.

B. It is more common for patients with psychosocial

distress to recover.

C. Longer time to recovery is associated with older

patients.

D. Recurrence rate for back pain varies from 35% to

75%.

SUBMITSUBMIT

Answer Comment The correct answers are A, C, D.The correct answers are A, C, D.

Acute Low Back Pain Prognosis Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three months.

For patients who are out of work greater than six months, there is only 50% chance of them returning to work; this drops to almost zero chance if greater than two years.

Patients who are older (>45) and patients who have psychosocial stress take longer to recover.

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Recurrence rate for back pain is high at 35 to 75%.

Dr. Lee tells Mr. Payne that overall his prognosis is good. However, given his job as a truck driver and a history of LBP, he is likely to have recurrence of his back pain. He should maintain good posture and practice good lifting techniques at all times. She gives him a booklet on back care and writes an order for the physical therapist to go over home exercises and show Mr. Payne appropriate lifting techniques.

Dr. Lee concludes by asking Mr. Payne to return for follow-up care in three to four weeks. She also gives him explicit instructions to call if there is no relief or if the pain increases.

References Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute Low Back Pain: Systematic Review of its Prognosis. British Medical Journal. August 9, 2003;327(7410): 323.

PROGRESSION OF PAIN HISTORY

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Mr. Payne returns for a follow-up with increased back pain.Mr. Payne returns for a follow-up with increased back pain.

!

Three weeks later, Mr. Payne returns for his follow-up appointment and you discover the following:

Pertinent HistoryPertinent History

Mr. Payne has had little relief with the treatment prescribed. He is frustrated that he has been in pain for more than a month. His pain has been progressively worse. It radiates down the lateral part of his left leg and side of his left foot. This pain is worse than the back pain. He does not have any problems with bowel or bladder control and there is no weakness of his leg.

Pertinent Exam FindingsPertinent Exam Findings

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The best options are indicated below. Your selections are indicated by the shaded boxes.

Vital signs:Vital signs: stable

Neurologic:Neurologic: Normal gait, but moves slowly due to pain; range of motion is full, with pain on flexion; SLR is positive at 45 degree on the left; motor strength intact; reflexes 2+ bilaterally at the knees, absent at the left ankle, 1+ at the right ankle.

Dr. Lee agrees with your diagnosis of radiculopathy of S1 nerve root with progression. She orders an MRI and sets up an appointment to see Mr. Payne after the MRI.

FOLLOW-UP TREATMENT MANAGEMENT One week later, Mr. Payne returns for follow-up. You review the results of the MRI report.

MRI report:MRI report:

1. Moderate-size, herniated disc at L5-S1 with associated marked impingement on the left S1 nerve root and mild to moderate impingement on the right S1 nerve root. There is mild central canal stenosis. 2. Annular tear with a small central disc herniation at L4-5 causing mild central canal stenosis.

You review the findings with Dr. Lee. She agrees with your diagnosis of radiculopathy of S1 nerve root due to a large herniated disc at L5-S1.

Question What are the treatment options for Mr. Payne? Select all that apply.

A. Surgery

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B. It has only been five weeks, continue with current

treatment

C. Acupuncture

D. Epidural injection

SUBMITSUBMIT

Answer Comment The correct answers are A, B, C.The correct answers are A, B, C.

Treatment After Adequate Trial of Conservative Therapy If a patient has been in pain for five weeks with progression of neurological deficit (such as absent reflex at the ankles) and poor pain control, it is reasonable to refer him to a spine surgeon for surgical consultation.

If the patient doesn’t have any red flags, continuation of conservative treatment is also an option. However, if the patient has already been getting PT, more PT is not likely to help.

There is some evidence that acupuncture can be helpful in low back pain.

Mr. Payne would rather defer surgery if he can. Options for Mr. Payne now include to continue more conservative treatment or manual therapy – usually given by an osteopathic physician or chiropractor – or a trial of acupuncture.

References

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Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001824. DOI: 10.1002/14651858.CD001824.pub3.

Hedron, et. al. Common Questions About Chronic Low Back Pain. Am Fam Physician. 2015;91(10):708-714.

RECOVERY MANAGEMENT

You phone Mr. Payne to see how he is doing.You phone Mr. Payne to see how he is doing.

!

You call Mr. Payne two weeks later to see how he is doing. He reports that he is doing quite a bit better. He went to an osteopathic physician who did some manual therapy and started him on a strict walking program. He is very encouraged and plans on losing weight through exercise and diet.

References Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI:

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