how we think about back pain
TRANSCRIPT
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How we think about back pain
Dr Adrian Nowitzke
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Graphic from www.hibiscusflowershop.blogspot.com
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ACUTE CHRONIC
Duration
Themovetowardchronicity.Treatments. Work.
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ACUTE
CHRO
NIC
Durationandfrequency
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SPECIFIC
NONSPECIFIC
Specificity
Causation.Localisation. Radicularnature.Investigation.Treatments.
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SPECIFIC
NONSPECIFIC
Specificityandfrequency
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ACUTESPECIFIC
ACUTENONSPECIFIC
CHRONICSPECIFIC
CHRONICNONSPECIFIC
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Toolsyoumayfindhelpful
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FACTOR GOOD BAD
pain intensity low high
symptomduration short long
disability mild-moderate severe-crippling
distress low high
depression/anxiety absent present
fear-avoidance absent present
well being high low
opiates no yes
compensation absent present
litigation absent present
abn.illness.behavior absent present
degenerate levels single multiple
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Waddell’snonorganicsigns
Tenderness:Superficial(lumbarskintendertolighttouch)andnonanatomical (deeptendernessoverawideareathatcrossesmusculoskeletalboundaries)
Simulation:Axial loading(lightdownwardpressureontheheadcausespain)andsimulatedrotation(backpainonpseudorotation ie.rotationofpelvisandspinetogether)
Distraction:Supinevs seatedSLR(significantdifferencebetweeen straightlegraisingwhenlyingdowncomparedwithwhensittingup)
Regionalchanges:Weakness(cog-wheeltypeweaknesswithgivingwayofseveralmusclegroups)andsensorychange(widespreadnonanatomical alterationoflighttouchsensation)
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Threetakehomestrategies
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1.Understandandexplainthecause
80%ofpeoplegetbackpain.90%improvewithin3months.Forthosewhodonotimprove(chronicnon-specific)
Mostpeoplehavenothingseriouswrong.Multipleinvestigationsandacutetreatmentsareunhelpful.Thereislikelytobeacentralcausethatisnotwellunderstood.
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2.Provideevidence-basedtreatmentadvice
ImprovefunctiondespitepainratherthancurepainMaintenancevs acutedeteriorationprograms• Move• Corestrength,backstrength,backflexibility• Psychologysupport• Simpleanalgesia- zeroopioidsinmostcases• PrimaryratherthanspecialistcareNosurgeryinmostcases
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3.Avoidmakingthingsworse
Recognise thoseatriskofchronicity.Minimise theuseofopiates.Discourageprolongedpassivetreatments.Ensureimagingdonewithcontextualinterpretation.Refer judiciouslytoexcludetreatablecause.Facilitatereturntoactivityandwork.Trytohelpinthecompensationprocess.Donotencouragelitigation.
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Thankyou