Mechanical Low Back Pain (PEN)
Case 2: Sudha
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Objectives
When working with CPP, you will be able to:
 Identify the yellow flags in the patient history to
indicate increased risk of developing chronicity
 List 3 assessment tools that may be useful
 Provide appropriate referral for rehabilitation
therapy
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Mechanical Low Back Pain
 “Sudha”, 51 year old female, Legal Assistant,
presenting with 6 month history of persistent low
back pain
 She has complained of 3 recurrent episodes of
low back pain lasting 2-3 weeks over the last 5
years but the most recent episode started 6
months ago and has persisted without relief
 She has tried OTC medications, heat and ice
and she has tried to remain active with daily
walks
 She is feeling very discouraged and would
like to know what else can be done to
alleviated her pain.
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What are your Key Questions?
 How do you determine if
this is mechanical back
pain ?
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What are your Key Questions?
 How do you determine if
this is mechanical back
pain ?
How do you identify
Yellow Flags ?
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On History, we found…
 Pain is constant and located
in the bilateral back and
buttock area.
 She rates her pain as 9/10
and it radiates to the bilateral
lateral thigh area
intermittently
 Her pain is worse with
bending and is present with
extension.
 Morning stiffness is 30
minutes
 There are no changes in his
bowel and bladder habits
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How would Sudha rate her functional abilities?
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Physical Exam
 What physical examination techniques would you use?
We found:
Flexion aggravated low back pain
Extension caused pain also but not as much as flexion
 Strength testing was inconsistent with giving way
 Normal Neurological exam
SLR reproduces low back pain
Palpation tenderness of Para spinal muscles
Hip Range of motion tight bilaterally with a stretch
sensation
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Psychosocial History
What would you want to know?
We found:
 Lives with husband and 23 year old daughter in Lower Mainland
 College education as Legal Assistant, worked for last 10 years
 Previously liked doing craft work and hiking
 Has not done any hobbies in last 6 months due to pain
 Mood is “anxious and stressed”
 Concerned that she will not be able to keep working due to pain
 Has had 40 sick days in the last 6 months.
 Saddened that husband has to do all domestic chores for family
 Denies alcohol
 No prior mental health diagnoses
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How would you interpret her yellow flag risk ?
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How can you screen for depression?
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PHQ9 – Patient Health Questionairre
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Pain Medication History
 Sudha initially found that she was in so much pain
that she needed Acetominophen with Codeine 4-5
times a day, totally 6-8 tablets.
 Her pain has continued to escalate and she now
takes a muscle relaxant for spasm 3 x day.
 She has had trouble sleeping in the last month, so
is taking some of her husband’s sleeping pills
most nights of the week.
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How would you manage her medication ?
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Goal: Decrease Pain, Increase Function
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Management Tools
 How would you approach Self Management with this
patient ?
We used:
a) What is it about your current health that worries you?
b) How do you feel about this ?
c) What can you do about this issue?
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Facilitating your patient to set Goals
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How do you assess Confidence Levels ?
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Providing information accurately when asked
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Clinical Impression
 Pattern 1 – PEN
 Back dominant and prone extension negative
 Positive Yellow flags identifying risk of chronicity
 She is anxious and showing signs of sadness
 Her pain management includes self prescribed
medications at inappropriate dosing
 She requires some education on best recovery
 She needs the opportunity to engage in self
management
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Key Clinical Information
 What are the key criteria of yellow flag identification?
 Fear of Activity
 Sadness and anxiety
 Dependency on others
 How do you engage in Self Management ?
 Patient identifies issues and feelings
 Facilitation of goal setting
 Self rating of confidence
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Summary
When working with Mechanical Back Pain, it is important
to:
1.Take a targeted history
2.Do a movement examination even if pain is
reproduced.
3.Identify assessment tools that may be helpful
4.Promote patient education on activation and recovery.
5.Facilitate Patient Self Management
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References
 January 2013, Current Clinical Care, Low Back
Pain
 White paper on Self Management
 New Zealand Yellow Flags Guideline
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