Managing Back Pain
The Ontario Initiative
Introducing the CORE Back Tool
Hamilton Hall MD FRCSC
Julia Alleyne MD CCFP
Faculty/Presenter Disclosure
• Faculty: Hamilton Hall
• Relationships with commercial interests:
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Consultant: Stryker Spine USA
Consultant: Medtronic
Consultant: rti Surgical
Medical Director, Pure Healthy Back
Medical Director, CBI Health Group
Disclosure of Commercial Support
• This program has received no financial support.
• This program has received no in-kind support.
• Potential for conflict of interest:
• Hamilton Hall receives compensation as Medical
Director of CBIHG.
Mitigating Potential Bias
• This program does not discuss or recommend
commercial services or surgical devices.
• Dr. Hall acknowledges that the Pattern Approach to
Low Back Pain was developed during his time with
CBIHG and that its development included
contributions from many CBIHG staff members.
Faculty/Presenter Disclosure
• Faculty: Dr. Julia Alleyne
• Relationships with commercial interests:
• Speakers Bureau/Honoraria: Lavin Agency
• Excludes medical education and medical conferences.
Disclosure of Commercial Support
• This program has received no financial support.
• This program has received no in-kind support.
• Potential for conflict of interest:
• Dr. Julia Alleyne has received payment from Centre
for Effective Practice (CEP) as the clinical lead on the
Ministry of Health and Long-Term Care (MOHLTC)
provincial Low Back Pain Strategy
Mitigating Potential Bias
• This program does not discuss or recommend
commercial services or surgical devices.
• Dr. Alleyne acknowledges that she was the clinical
lead in the development of the CORE back tool.
• Payment received by Dr. Alleyne is non-commercial
(received from MOHLTC)
#1 All Musculoskeletal Conditions
Low back pain is the most prevalent of
musculoskeletal conditions; it affects nearly
everyone at some point in time and about
4–33% of the population at any given point.
Anthony Woolfe
Burden of major musculoskeletal conditions
Bulletin of the World Health Organization 2003;81:646-6
What do we do ?
Barriers to Best Practice: Patients with
Low Back Pain
Family physicians perceive that they require additional knowledge
and skills to deal with patient expectations, appropriate imaging
and consultant referrals and patient self-management strategies.
Primary care providers cited patient pressure, both direct and
indirect, as a key reasons to order tests and specialty referrals.
Knowledge gaps exist for patients as well but are often not
addressed within the office visit.
Our current approach isn’t working
• The medical paradigm hasn’t solved the
problem of low back pain.
• Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
• MRI increase use 7.2% to 11.3%
Mafi J et al. JAMA 2013
Our current approach isn’t working
Our current approach isn’t working
• Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
• MRI increase use 7.2% to 11.3%
• NSAID/acetaminophen decrease use 36.9% to
24.5%
• Narcotic increase use 19.3% to 29.1%
• Specialist referrals increase 6.8% to 14.0%
Mafi J et al. JAMA 2013
Our current approach isn’t working
• There is no correlation between degenerative
changes on plain x-ray and back pain.
• CT has a 30% false positive rate.
• MRI has a 60-90% false positive rate.
Early MRI without indication has a strong iatrogenic
effect in acute LBP… it provides no benefits,
and worse outcomes are likely.
Webster BS et al. Spine 2013
Our current approach isn’t working
• With all our technology we can identify the
specific patho-anatomic source of pain in only
20% of back pain patients.
• Everything else is labeled “non-specific” back
pain.
Our current approach isn’t working
• With all our technology we can identify the
specific patho-anatomic source of pain in only
20% of back pain patients.
• Everything else is labeled “non-specific” back
pain. It is treated “non-specifically”,
Our current approach isn’t working
• With all our technology we can identify the
specific patho-anatomic source of pain in only
20% of back pain patients.
• Everything else is labeled “non-specific” back
pain. It is treated “non-specifically”, which
doesn’t work.
And our current approach is wrong
• Most back pain is not the result of
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tumour
infection
major trauma
or any medical problem
• Most back pain begins spontaneously.
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In a study of over 11,000 patients, 2/3rds of the
subjects could not recall any cause for the pain.
Hall et al. Clin J Pain 1998
But we still memorize the Red Flags
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Sphincter disturbance: bowel or bladder
History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
There is another way
• Over 90% of back pain is caused by minor
altered mechanics.
• Most back pain is mechanical.
So why don’t we look there first?
There is another way
• Over 90% of back pain is caused by minor
altered mechanics.
• Mechanical back pain is pain
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related to movement
related to position
related to a physical structure
It means there is a sore thing in the back.
There is another way
We can all recognize there is a sore thing.
We just can’t agree on which sore thing.
And for all the non-invasive treatments
locating the sore thing isn’t even necessary.
There is another way
“Distinct patterns of reliable clinical
findings are the only logical basis
for back pain categorization and
subsequent treatment.”
Patterns of back pain
“Distinct patterns of reliable clinical
findings are the only logical basis
for back pain categorization and
subsequent treatment.”
Syndromes of back pain
“Distinct syndromes of reliable clinical
findings are the only logical basis
for back pain categorization and
subsequent treatment.”
What is a syndrome?
A syndrome is a constellation of signs and
symptoms that appear together in a consistent
manner
and respond to treatment in a predictable
fashion.
A syndrome is a constellation of signs and
symptoms that appear together in a consistent
manner
and respond to treatment in a predictable
fashion.
What is the difference between a disease and a
syndrome?
The only difference is that we know
the etiology of a disease.
• A disease has an etiology.
• Does a syndrome have an etiology?
• Do you think that constellation of signs and
symptoms just appears in exactly the same way
every time merely by chance?
• Of course, a syndrome has an etiology.
• We just don’t know what it is yet.
Syndrome recognition
• The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Where is your pain the worst?
• Is it back or leg dominant?
• Back dominant pain is referred pain from a
physical structure.
• Back dominant:
• back
• buttocks
• coccyx
• greater trochanters
• groin
Where is your pain the worst?
• Is it back or leg dominant?
• Back dominant pain is referred pain from a
physical structure.
• Sites of referred pain can become locally
tender.
• Trochanteric bursitis
Where is your pain the worst?
• Is it back or leg dominant?
• Leg dominant pain is radicular pain from
nerve root involvement.
• Leg dominant:
• Around or below the gluteal fold, to the:
• thigh
• calf
• ankle
• foot
Where is your pain the worst?
• Is it back or leg dominant?
• The patient will often report both.
• But it must be one or the other.
• “ If I could stop only one pain, which one do I
stop?
• “I have a back pill and a leg pill, which one do you
want?”
Syndrome recognition
• The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?
Part A
Is there ever a time when you are in your best
position, in your best time of your day and
everything is going well when your pain stops
even for a moment?
I know it comes right back but is there ever a
time, even a short time when the pain is
gone?
Part B
When your pain stops does it stop completely?
Is it all gone?
Are you completely without your pain?
When the pain is constant consider:
• Malignancy
• Systemic conditions
• Pain disorder
• Constant mechanical pain
Syndrome recognition
• The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain
worse?
1.
Where is your pain the worst?
2.
Is your pain constant or intermittent?
3. Does bending forward make your typical pain
worse?
• What are the aggravating movements/positions?
1.
Where is your pain the worst?
2.
Is your pain constant or intermittent?
3.
Does bending forward make your typical pain worse?
4. Has there been a change in your bowel or
bladder function
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since the start of your pain?
1.
Where is your pain the worst?
2.
Is your pain constant or intermittent?
3.
Does bending forward make your typical pain worse?
4.
Has there been a change in your bowel or bladder function
since the start of your pain?
5. If you are under 45 years, do you have
morning stiffness greater than 30 min?
6. What can’t you do now that you could do
before you were in pain and why?
6.
What can’t you do now that you could do before you
were in pain and why?
7. What are the relieving movements/ positions?
6.
What can’t you do now that you could do before you
were in pain and why?
7.
What are the relieving movements/ positions?
8. Have you had this same pain before?
6.
What can’t you do now that you could do before you
were in pain and why?
7.
What are the relieving movements/ positions?
8.
Have you had this same pain before?
9. What treatment have you had? Did it work?
But we still memorize the Red Flags
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Sphincter disturbance: bowel or bladder
History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
History takes precedence over physical
examination.
But the physical examination must support the
history.
Physical Examination
1. Observation
• general activity and behaviour
• back specific:
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contour
colour
scars
palpation (if you must)
Physical Examination
1.
Observation
2. Movement
• flexion
• extension
Physical Examination
1.
2.
Observation
Movement
3. Nerve root irritation tests
• straight leg raising
A positive straight leg raise:
• Passive test - the examiner lifts the leg
• Reproduction/exacerbation of typical leg
dominant pain
• Back pain is not relevant
• Produced at any degree of leg elevation
To reduce confusion with hamstring tightness,
flex the opposite hip and knee.
Physical Examination
1.
2.
3.
Observation
Movement
Nerve root irritation tests
4. Nerve root conduction tests
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L4
L5
S1
Physical Examination
1.
2.
3.
4.
Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
5. Upper motor test
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plantar response
clonus
Physical Examination
1.
2.
3.
4.
5.
Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
6. Saddle sensation
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lower sacral nerve roots (2,3,4) test
Physical Examination
1.
2.
3.
4.
5.
6.
Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
7. Sensory testing (if indicated)
Physical Examination
1.
2.
3.
4.
5.
6.
7.
Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
Sensory testing (if indicated)
8. Ancillary testing (if indicated)
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hip, abdomen, peripheral pulses
There are four mechanical patterns
Pattern 1
Pattern 1
PEP
Pattern 2
Pattern 1
PEN
Pattern 3
Pattern 4
Pattern 4
PEP
Pattern 4
PEN
Pattern 1
History
• Back dominant pain
• Worse with flexion
• Constant or Intermittent
Physical Examination
• Back dominant pain
• Worse with flexion
• Neurological examination is normal
or unrelated to the pattern
Physical Examination
• Back dominant pain
• Worse with flexion
• Neurological examination is normal
• Better with 5 prone passive extensions
Pattern 1 Prone Extension Positive
PEP
The patient has a directional preference.
Physical Examination
• Back dominant pain
• Worse with flexion
• Neurological examination is normal
• No change/worse with 5 prone passive extensions
Pattern 1 Prone Extension Negative
PEN
The patient has no directional preference.
Management
Pattern 1 PEP – educate and exercise
• Reduce sitting / flexion
• Increase extension
• lumbar roll
• night roll
• Prescribe repeated prone extensions
Management
Pattern 1 PEN – educate and exercise
• Goal oriented therapy referral
• Increase gradually and progressive from
unweighted flexion to extension position then
prone extensions
• When range improves and pain decreases add
core stability
• Analgesics
Pattern 1
Pattern 1
PEP
Pattern 1
PEN
Pattern 2
History
• Back dominant pain
• Worse with extension
• Never worse with flexion
• Always intermittent
History
• Back dominant pain
• Worse with extension
• Never worse with flexion
• Always intermittent
If the pain is constant or if there is any pain
on flexion the patient is Pattern 1
Physical Examination
• Back dominant pain
• Worse with extension
• Neurological examination is normal
or unrelated to the pattern
• No effect or better with flexion
Management
Pattern 2 – educate and exercise
• Relief with sitting / flexion
• Reduce extension, frequent breaks
• Prescribe sitting unweighted flexion
• Posture and positioning in flexion
Pattern 1
Pattern 1
PEP
Pattern 2
Pattern 1
PEN
Pattern 3
History
• Leg dominant pain
• Always constant
• Affected by back movement/position
Physical Examination
• Leg dominant pain
• Leg pain affected by back movement
• Positive irritative test
• and/or conduction loss
Management
Pattern 3 – reassure
• Scheduled rest positions during the day
• Z lie
• prone over pillows
• Change position as pain increases
• Stronger Analgesics
• Refer to surgery (15%)
Pattern 1
Pattern 1
PEP
Pattern 2
Pattern 1
PEN
Pattern 3
Pattern 4
History
• Leg dominant pain
• Always intermittent
• Worse with flexion
Physical Examination
• Rarely a positive irritative test and/or
conduction loss
• Always better with unloaded back extension
movement or position
Leg dominant pain that responds to mechanical
treatment.
Management
Pattern 4 PEP – educate and exercise
• Reduce sitting / flexion
• Increase extension
• lumbar roll
• night roll
• Prescribe repeated unloaded extension
positions and movements
Pattern 4
History
• Leg dominant pain
• Always intermittent
• Worse with activity in extension
• Better with rest in flexion
• May have transient weakness
Physical Examination
• Negative irritative tests
• Possible permanent conduction loss
Management
Pattern 4 PEN – educate and exercise
• Goal oriented therapy referral
• Abdominal strengthening
• Core strengthening
• Posture training - pelvic tilt
• Long term commitment
• Gradual improvement
• Excellent surgical candidates
Back dominant
Constant /Intermittent
Pattern 1
Pattern 1
PEP
Leg dominant
Intermittent
Constant
Intermittent
Pattern 2
Pattern 3
Pattern 4
Pattern 1
PEN
Pattern 4
PEP
Pattern 4
PEN
That’s all there is
Low Back Pain Patterns
Start with the patterns
• There will be a pattern in ninety percent of your
patients.
• The pattern suggests the initial treatment.
• If the pain responds as expected, you have your
solution.
• If there is no syndrome or it doesn’t respond as
anticipated, that is the group that needs to be
investigated.
• That is the time to consider the Red Flags.