LOW BACK PAIN STRATEGY This tool will guide the clinician ... · QUICK FACTS A LOOK AT BACK PAIN 4...

This tool will guide the clinician to recognize common mechanical back pain syndromes and screen for other conditions where management may include investigations, referral and specific medications. This is a focused examination for clinical decision- making in primary care.

A. HISTORY

C. PHYSICAL EXAMINATION

B. SCREENING

❑ Neurological: diffuse motor /sensory loss, progressive neurological deficits, cauda equina syndrome

❑ Infection: fever, IV drug use, immune suppressed❑ Fracture: trauma, osteoporosis risk❑ Tumour: hx of cancer, unexplained weight loss, significant unexpected night pain,

significant fatigue❑ Inflammation: chronic low back pain > 3 months, age of onset < 45,

morning stiffness > 30 minutes, improvement with exercise, disproportionate night pain

Heel walking (L4- 5)Toe walking (S1)

Movement testing in flexionMovement testing in extensionTrendelenburg test (L5)Repeated toe raises (S1)Patellar reflex (L3- 4)Quadriceps power (L3- 4)Ankle dorsiflexion power (L4-5)Great toe extension power (L5)Great toe flexion power (S1)Plantar response, upper motor test

Ankle reflex (S1)

SupinePassive straight leg raisePassive hip range of motion

ProneFemoral nerve stretch (L3- 4)Gluteus maximus power (S1)Saddle sensation testing (S2-3-4)Passive back extension (patient uses arms to elevate upper body)

LOW BACK PAIN STRATEGYClinically Organized Relevant

Exam (CORE) Back Tool

Red Flags (check if positive) ❑ No Red Flags

Have you had any previous imaging done?❑ Yes Results:_______________________________________________❑ No

Suggested Imaging for Suspected Pathology:❑ X-Ray: suspected trauma or fragility fracture❑ MRI: functionally significant or progressive neurological deficits, tumour,

unresponsive radicular syndrome, neurogenic claudication, cauda equina syndrome❑ Bone Scan: infection, systemic inflammatory process

Radiology Criteria (check if positive) ❑ No Radiology Criteria

Surgical Referral (check if positive) ❑ No Surgical Criteria

For those with low back pain > 6 weeks or non- responsive to treatment:❑ Belief that pain and activity will cause physical harm Excessive reliance on rest, time off work or dependency on others Persistent low or negative moods, social withdrawal Belief that passive treatment (i.e. modalities) is key to recovery Problems at work, poor job satisfaction Unsupportive / dysfunctional or dependent family relationships Over exaggeration / catastrophyzing of pain symptoms

Barriers / Yellow Flags (check if positive) ❑ No Barriers

Please rate your pain by circling the one number that best describes your pain at its LEAST in the last week:

1. Where is your pain the worst?❑ Back Dominant - Buttock❑ Leg

2. Is your pain:❑ Intermittent❑ Constant Rule out red flags

3. Does bending forward increase your typical back or leg pain?❑ Yes❑ No

4. Have you had any unexpected accidents with your bowel or bladder functionsince this episode of your low back/legpain started?❑ Yes Rule out cauda equina syndrome❑ No

5. If age of onset < 45 years, are you experiencing morning stiffness in yourback > 30 minutes?❑ Yes❑ No

Lyin

gKn

eelin

gSit

ting

ABNO

RMAL

COMMENTS

Stan

ding

Gait

NOTE: Tests above that are in green indicate suggested minimum requirements

NORM

AL

Please rate your pain by circling the one number that best describes your pain at its WORST in the last week:

No pain at all

Pain as bad asyou can imagine0 1 2 3 4 5 6 7 8 9 10

No pain at all

Pain as bad asyou can imagine0 1 2 3 4 5 6 7 8 9 10

What can you NOT do now that you could do before the onset of your low back pain?

Systemic inflammatory arthritis screen

Patient Name: Age:

Provider Name:

Provider: ❑ FP ❑ NP Date:

Emergency Room Referral Acute cauda equina syndrome is a surgical emergency. Symptoms are:

❑ Urinary retention followed by insensible urinary overflow Unrecognized fecal incontinence Distinct loss of saddle/perineal sensation

Surgical Referral❑ Failure to respond to evidence based compliant conservative care of at least 12 weeks Unbearable constant leg dominant painWorsening nerve irritation tests (SLR or femoral nerve stretch) Expanding motor, sensory or reflex deficits Recurrent disabling sciatica Disabling neurogenic claudication

Right RightLeft Left

Consider asking your patients:

D. ASSESSMENT (check most applicable box)

E. PATIENT EDUCATION

Mechanical Back Dominant PainPattern 1 Pattern 2 Pattern 3 Pattern 4

❑ Chiropractic Therapy❑ Physiotherapy

❑ Exercise/Education❑ Weight Management

❑ Massage Therapy❑ Other:_____________

Goal Specific Rehabilitation

Specialist referral

❑ Analgesic❑ Muscle relaxant❑ NSAID❑ Opioid❑ Other

Medication (if required)

❑ Constant leg pain, aggravated by flexion

Positive SLR and/or conduction deficit

❑ Intermittent leg pain, aggravated with walking and relieved with sitting

May have decreased root conduction

Mechanical Leg Dominant Pain

❑ Non-spine related pain

❑ Spine pain does not fit mechanical pattern

F. GOAL SETTING & PATIENT SELFMANAGEMENT

H. FOLLOWUP

Non-Mechanical Pain

Flexion Aggravated ☐ Patient not appropriate for self- management

☐ Patient self- management not discussed at this visit

ExtensionAggravated

Flexion / ExtensionAggravated

Recovery Positions

Starter Exercises

Repeated passiveextension in lyingprogressing to standing

Sitting trunk flexionKnees-to-chest stretch

Neutral positionsSmall progressions

Key Messages for Your Patient Your examination today does not demonstrate that there are any red flags present to

indicate serious pathology, but if your symptoms persist for > 6 weeks, schedule a follow-up appointment.

Imaging tests like X- rays, CT scans and MRIs are not helpful for recovery or management of acute or recurring low back pain unless there are signs of serious pathology.

Low back pain is often recurring and recovery can happen without needing to see a healthcare provider. You can learn how to manage low back pain when it happens and use this information to help you recover next time.

You may need pain medication to help you return to your daily activities and initiate exercise more comfortably. It is activity, however, and not the medication that will help you recover more quickly.

If you are feeling symptoms of sadness or anxiety, this could be related to your condition and could impact your recovery, schedule a follow-up appointment.

G. RECOMMENDATIONS

Name Dose Frequency Duration

❑ PRN❑ 3 months

❑ 2 weeks❑ 6 months

❑ 4 weeks❑ 1 year

❑ 6 weeks❑ Other:_______

Notes:

This tool was created through the Government of Ontario's Provincial Low Back Pain Strategy under the clinical leadership of Drs. Julia Alleyne, Hamilton Hall and Raja Rampersaud with the review and advice of the Education Planning Committee and primary care focus groups facilitated by Centre for Effective Practice. This tool and further information on the development of the Low Back Pain Toolkit, including

committee membership and additional tools, are available at www.effectivepractice.org/lowbackpain and ontario.ca/lowbackpain.

January 2013

❑ Intermittent or constantback pain, flexion aggravated, extension relieved

❑ Intermittent or constantback pain, flexion & extension aggravated

Normal neurological

❑ Intermittent back pain, extension aggravated, flexion relieved/no change

Normal neurological

❑ Cognitive Behavioural Therapy❑ Rheumatologist

❑ Multi- disciplinary Pain Clinic❑ Spine Surgeon

❑ Physiatrist❑ Other:_________

Resources, references and additional information on how to use this tool in your practice can be found in the CORE Back Tool Guide,

available at www.effectivepractice.org/lowbackpain and ontario.ca/lowbackpain.

1. What is it about your low back pain that worries you the most?

2. Is there anything you feel you can do to improve your low back pain?

3. How confident are you that you can carry out your goal?

Not at allconfident

Very confident0 1 2 3 4 5 6 7 8 9 10

Comment

The CORE Back Tool is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 2.5 Canada License.

http://health.gov.on.ca/en/pro/programs/ecfa/action/primary/lower_back.aspx

http://health.gov.on.ca/en/pro/programs/ecfa/action/primary/lower_back.aspx

http://creativecommons.org/licenses/by-nc-nd/2.5/ca/deed.en_US

Your Interactive Partner in Essential Clinical LearningJanuary 2013

In association with

Educational Supplement

urrent Clinical Care


Your Interactive Partner in Essential Clinical LearningJanuary 2013

In association with




Published by:

He althPlexusjoin. get ahead. www.healthplexus.net

ForewordLow Back Pain: It’s Time for a Different Approach

Clinical ReviewMaking Sense of Low Back Pain

Clinical Review Managing Back Dominant Pain

Clinical Review Managing Leg Dominant Pain

BACK PAIN

the latest in

Back Pain Management

Published by:


ForewordLow Back Pain: It’s Time for a Different Approach

Clinical ReviewMaking Sense of Low Back Pain

Clinical Review Managing Back Dominant Pain

Clinical Review Managing Leg Dominant Pain

Back Pain

the latest in

Back Pain Management

QUICK FACTS

A LOOK AT BACK PAIN

4 o u t o f 5 a d u l t s will experience at least 1 episode of back pain at some time in their l ives.

IT’S TIME FOR ANEW APPROACH“ ”

THE GOAL IS CONTROL, NOT CURE, AND CONTROLIS NOT ONLY POSSIBLE, IT IS READILY ACHIEVABLE“ “

Just 25% of patients with LBP generate

75% of the financial and social costs.1

Back pain is one of the most common reasons for missed work.

Back pain is the second most common medical reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.

Magnetic resonance imaging carries a lack of specificity that can exceed 80%.

25%=75%

$

5%

Fewer than 5% of people with back pain are good candidates for surgery.

5%

Most patients complaining of low back pain experience symptoms from a minor mechanical malfunction. Fewer than 5% have a more sinister explanation. 2,3

4

Patients with back pain receive con�icting information and advice from medical specialists, allied health professionals, family members and friends, and, of course, the Internet. 5,6

7

8

Optimal patient management is best delivered in a shared- care model with consistent messaging by primary care, specialist and rehabilitation professionals.

About 80% of nerve root compromise associated with low back pathology occurs at L5 or S1, so it makes sense to screen L5 and S1 functions as part of the examination.

Low back pain (LBP) is one of the most prevalent and costly complaints in North America. A recent survey in Canada found that back pain was one of the most common health complaints of 12 – 44 year olds.

Medication has a limited and secondary role in uncomplicated mechanical low back pain. There is no place for the routine use of narcotics or psychotropic drugs.

References: 1. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8–20. 2. Deyo RA, Weinstein JN. Low back pain [review]. N Engl J Med 2001;344(5):363–70. 3. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80. 4. John P. Kostuik, MD, and Simeon Margolis, MD, Ph.D. Low Back Pain and Osteoporosis. The John Hopkins White Paper on Low Back Pain and Osteoporosis, 2002. 5. Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine (Phila Pa 1976) 2011;36(21 Suppl):S1-9. 6. Scott NA, Moga C, Harstall C. Managing low back pain in the primary care setting: the know-do gap. Pain Res Manag 2010;15(6):392-400. 7. Hall H, Rampersaud YR, Alleyne J. Low Back Pain: It’s Time for a Di�erent Approach. Journal of Current Clinical Care Educational Supplement • January 2013. 8. Hall H, Rampersaud YR, Alleyne J. Making Sense of Low Back Pain Journal of Current Clinical Care Educational Supplement • January 2013. 9. McPhillips-Tangum CA, Cherkin DC, Rhodes LA, Markham C. Reasons for repeated medical visits among patients with chronic back pain. J Gen Intern Med 1998; 13: 289–295. 10. Mayo Clinic. What Is Back Pain? [Online]. Available at: http://www.mayoclinic.com/invoke.cfm?id=DS00171. Accessed December 2004. 11. Hicks GS, Duddleston DN, Russell LD, Holman HE, Shepherd JM, Brown A. Low back pain. The American Journal of the Medical Sciences 2002; 324 (4): 207–211. 12. Wheeler AH, Stubbart JR, Hicks B. Pathophysiology of chronic back pain. eMedicine [Online]. Available at: http://www.emedicine.com/neuro/topic516. Accessed December 2004. 13. Canadian Institute for the relief of pain and disability. http://www.cirpd.org/PainManagement/HealthTopics/BackPain/Pages/Default.aspx 14. Hall H, Rampersaud YR, Alleyne J. Managing Back Dominant Pain Journal of Current Clinical Care Educational Supplement • January 2013. 15. American Chiropractic Association http://www.acatoday.org/level2_css.cfm?T1ID=13&T2ID=68 16. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain [review]. Radiol Clin North Am 2012;50(4):569–85. 17. You JJ, Purdy I, Rothwell DM, et al. Indications for and results of outpatient computed tomography and magnetic resonance imaging in Ontario. Can Assoc Radiol J 2008;59(3):135–43.

9-12

13

14

15

15

16,17

Brought to you by: www.healthplexus.net and the Journal of Current Clinical Care

QUICK FACTS

A LOOK AT BACK PAIN

4 o u t o f 5 a d u l t s will experience at least 1 episode of back pain at some time in their l ives.

IT’S TIME FOR ANEW APPROACH“ ”

THE GOAL IS CONTROL, NOT CURE, AND CONTROLIS NOT ONLY POSSIBLE, IT IS READILY ACHIEVABLE“ “

Just 25% of patients with LBP generate

75% of the financial and social costs.1

Back pain is one of the most common reasons for missed work.

Back pain is the second most common medical reason for visits to the doctor’s office, outnumbered only by upper-respiratory infections.

Magnetic resonance imaging carries a lack of specificity that can exceed 80%.

25%=75%

$

5%

Fewer than 5% of people with back pain are good candidates for surgery.

5%

Most patients complaining of low back pain experience symptoms from a minor mechanical malfunction. Fewer than 5% have a more sinister explanation. 2,3

4

Patients with back pain receive con�icting information and advice from medical specialists, allied health professionals, family members and friends, and, of course, the Internet. 5,6

7

8

Optimal patient management is best delivered in a shared- care model with consistent messaging by primary care, specialist and rehabilitation professionals.

About 80% of nerve root compromise associated with low back pathology occurs at L5 or S1, so it makes sense to screen L5 and S1 functions as part of the examination.

Low back pain (LBP) is one of the most prevalent and costly complaints in North America. A recent survey in Canada found that back pain was one of the most common health complaints of 12 – 44 year olds.

Medication has a limited and secondary role in uncomplicated mechanical low back pain. There is no place for the routine use of narcotics or psychotropic drugs.

References: 1. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8–20. 2. Deyo RA, Weinstein JN. Low back pain [review]. N Engl J Med 2001;344(5):363–70. 3. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80. 4. John P. Kostuik, MD, and Simeon Margolis, MD, Ph.D. Low Back Pain and Osteoporosis. The John Hopkins White Paper on Low Back Pain and Osteoporosis, 2002. 5. Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach. Spine (Phila Pa 1976) 2011;36(21 Suppl):S1-9. 6. Scott NA, Moga C, Harstall C. Managing low back pain in the primary care setting: the know-do gap. Pain Res Manag 2010;15(6):392-400. 7. Hall H, Rampersaud YR, Alleyne J. Low Back Pain: It’s Time for a Di�erent Approach. Journal of Current Clinical Care Educational Supplement • January 2013. 8. Hall H, Rampersaud YR, Alleyne J. Making Sense of Low Back Pain Journal of Current Clinical Care Educational Supplement • January 2013. 9. McPhillips-Tangum CA, Cherkin DC, Rhodes LA, Markham C. Reasons for repeated medical visits among patients with chronic back pain. J Gen Intern Med 1998; 13: 289–295. 10. Mayo Clinic. What Is Back Pain? [Online]. Available at: http://www.mayoclinic.com/invoke.cfm?id=DS00171. Accessed December 2004. 11. Hicks GS, Duddleston DN, Russell LD, Holman HE, Shepherd JM, Brown A. Low back pain. The American Journal of the Medical Sciences 2002; 324 (4): 207–211. 12. Wheeler AH, Stubbart JR, Hicks B. Pathophysiology of chronic back pain. eMedicine [Online]. Available at: http://www.emedicine.com/neuro/topic516. Accessed December 2004. 13. Canadian Institute for the relief of pain and disability. http://www.cirpd.org/PainManagement/HealthTopics/BackPain/Pages/Default.aspx 14. Hall H, Rampersaud YR, Alleyne J. Managing Back Dominant Pain Journal of Current Clinical Care Educational Supplement • January 2013. 15. American Chiropractic Association http://www.acatoday.org/level2_css.cfm?T1ID=13&T2ID=68 16. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain [review]. Radiol Clin North Am 2012;50(4):569–85. 17. You JJ, Purdy I, Rothwell DM, et al. Indications for and results of outpatient computed tomography and magnetic resonance imaging in Ontario. Can Assoc Radiol J 2008;59(3):135–43.

9-12

13

14

15

15

16,17

Brought to you by: www.healthplexus.net and the Journal of Current Clinical Care

The Journal of Current Clinical Care publishes 6 regular issues annually and from time to time we publish educational supplements to partner publications such as this one. Each regular issue is presented in a CME format and is structured in a way that maximizes learners’ engagement with the presented materials through Biomedical Animations, Key Points, and Clinical Pearls and measures the success of knowledge transfer via the pre- and post-test CME quizzes.

While every attempt is made to ensure that drug dosages provided within the text of this journal are accurate, readers are urged to check drug package inserts before prescribing. Views and opinions in this publication are of the authors and not necessarily endorsed

All practicing Canadian physicians can request a complimentary subscription to www.healthplexus.net and the Journal of Current Clinical Care via the following link: www.healthplexus.net/physician

ABOUT JCCC AND WWW.HEALTHPLEXUS.NET

HOW TO SUBSCRIBE

DISCLAIMER

This supplement was supported by an unrestricted educational grant from Medtronic Canada

JCCC Editor-in-Chief D’Arcy Little, MD, CCFP, FRCPC

Editorial Director Susan Harrison

Managing Editor Regina Starr

Art Director Robin Soloy

Illustrations Christine Kenney

System Engineering Gennady Kucheruk

Publisher Mark Varnovitski

Contact Information:Journal of Current Clinical Care71 Dewlane Dr. North York, ON M2R 2P9Email: [email protected]

Copyright © 2012. All rights reserved. Published by:


STAFF

34 TOPIC HUBS

arthritis cancer cardio-/cerebrovascular dementiadiabetes/endocrine drug safetygastrointestinal diseaseslung diseases mental health men’s health

musculoskeletal neurology nutrition osteoporosis pain preventive health women’s health addiction biology of aging caregiving ear and eye

dermatologygenetichematologic incontinence

>>

Register for your free subscription to have access to the following additional

resources:

Animations Videos

Illustrations

Digital Editions of this Supplement Available at:

www.healthplexus.net/physician


FREE Subscriptions forPractising Canadian Physicians

DIGITAL EDITIONS

6 LOW BACK PAIN: IT’S TIME FOR A DIFFERENT APPROACH

Foreword

-cial issues and potentially serious pathologies.

back pain categorization and subsequent treatment. This article describes how to identify these patterns, beginning

with the physical examination.

Mechanical back dominant pain responds to posture adjust-

Leg dominant pain suggests direct nerve root involvement. This article describes how to distinguish sciatica, neurogenic claudica-tion, and acute cauda equina syndrome, and the appropriate steps to take for their respective treatments.

24

12

32

MAKING SENSE OF LOW BACK PAIN

MANAGING LEG DOMINANT PAIN

MANAGING BACK DOMINANT PAIN

“ The goal is control, not cure, and control is not only possible, it is readily achievable. ”

“ The goal is control, not cure, and control is not only possible, it is readily achievable. ”

CONTENTS

AuthorsYoga Raja Rampersaud, MD, FRCSC, Julia Alleyne, BHSc (PT), MD, CCFP, Dip. Sport Med MScCH, Hamilton Hall, MD, FRCSC

AuthorsHamilton Hall, MD, FRCSC, Julia Alleyne, BHSc (PT), MD, CCFP, Dip. Sport Med MScCH, Yoga Raja Rampersaud, MD, FRCSC

AuthorsHamilton Hall, MD, FRCSC, Julia Alleyne, BHSc (PT), MD, CCFP, Dip. Sport Med MScCH, Yoga Raja Rampersaud, MD, FRCSC

AuthorsYoga Raja Rampersaud, MD, FRCSC, Julia Alleyne, BHSc (PT), MD, CCFP, Dip. Sport Med MScCH, Hamilton Hall, MD, FRCSC

INSIDE THE ISSUE

Low back pain (LBP) is one of the most prevalent and costly complaints in North America.1

It is among the most common medi-cal reasons to see a family physi-cian and is an enormous burden to society in general and the delivery of health care in particular.2,3 Whether it is the failure of our current medical

paradigm, the widely accepted mis-conceptions, or misguided policies of third-party payers, the fact remains that unlike many other debilitat-ing conditions and despite great efforts, the problem of LBP contin-ues to grow.3,4 Many patients suffer brief, self-limiting episodes of LBP, but these are not the challenge.5,6

In spite of great effort, low back pain (LBP) remains a significant burden on society and one of the most common reasons to see a primary care provider. The conventional medical mes-sage about acute LBP is inconsistent with its actual clinical course. There is little agreement on the cause or best treatment. Back pain is “over-medicalized.” Routine care is fragmented and episodic. We propose shifting to a practical, stratified approach based on rapid clinical recog-nition of mechanical syndromes with early identification of psychosocial issues and potentially serious pathologies. LBP is a chronic condition; the goal is control, not cure.

Key words: low back pain, LBP, natural history, medicalization, psychosocial issues, routine back care

Abstract

Low Back Pain: it’s Time for a Different approach

6 Journal of Current Clinical Care Educational Supplement • January 2013

Hamilton Hall, MD, FRCSC; Professor, Depart-ment of Surgery, Univer-sity of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

Yoga Raja Rampersaud, MD, FRCSC, Associate Professor Department of Surgery, University of Toronto, Divisions of Ortho-paedic and Neurosurgery, University Health NetworkMedical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.

Julia Alleyne, BHSc (PT), MD, CCFP, Dip. Sport Med MScCH,Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.

About the Authors

Journal of Current Clinical Care Educational Supplement • January 2013 7

Low Back Pain: it’s time for a Different aPProach

It is persistent or recurrent LBP that strains the system, disrupts society, and adversely impacts the individual. Just 25% of patients with LBP gener-ate 75% of the financial and social costs.7

To better manage these complex patients, we need to distinguish sev-eral key aspects of LBP. First, the con-ventional medical message about acute LBP is inconsistent with its actual presentation.8,9 The current guidelines are correct that LBP is a benign condi-tion with a favourable natural history, but this statement is often misinter-preted by patients and providers to mean that every attack will end quickly and all will be well.5 The majority of patients with a favourable course do not seek care from a physician.6 Grow-ing evidence demonstrates that for patients requiring help, the symptoms are likely to return and, in a number of patients, to become chronic.8 Although this is acknowledged in many guide-lines, it is not emphasized and no guideline adequately addresses how to deal with the fear and uncertainty of persistent or repeated LBP.5 Not unreasonably, for the patient who has been told, “Don’t worry, it will get better,” and for the physician who has followed the initial recommendation of current guidelines, continuing or recurring symptoms raise the spectre of an ominous pathology or serious illness.

Second, there is little agreement on the source of pain or the best man-agement for a large number of suffer-ers of LBP, particularly those who have dominant back pain with minor leg symptoms and no neurological find-ings.10 The unhelpful and misleading

term non-specific low back pain leads to the initial treatment of acute LBP as a homogeneous entity using simple, standardized, “one size fits all” rou-tines that are frequently ineffective.5,10 LBP is a heterogeneous affair, and all

current research points to significantly better outcomes with a more specific and stratified clinical approach.11,12 Although there is no uniform agree-ment as to the best non-surgical management, it is agreed that doing something active is better than adopt-ing a passive, dependent approach.13

This heterogeneity leads to a third problem, the “medicalization” of LBP.4 Medical training and soci-etal expectations dictate that we must establish a cause for the pain and base our therapy on a recognized pathol-ogy. This makes sense for diseases for which there are reliable means of diagnosis and an associated remedy. But most patients complaining of LBP experience symptoms from a minor mechanical disturbance, not a disease. The severity of the pain, which can be extreme, does not reflect the serious-ness of the underlying problem.

In the majority of cases, the issue is nothing more than the inevitable consequence of “wear and tear,” with or without a specific aggravating event. The limited nature of the derangement makes a definitive diagnosis impos-sible.4,10,14,15 Looking for the source of back pain with computed tomography

Just 25% of patients with LBp generate 75% of the financiaL and sociaL costs.



scans results in a 30% false-positive rate—the identification of genuine findings that are irrelevant to the patient’s pain. Magnetic resonance

imaging carries a lack of specificity that can exceed 80%.14,16 These imag-ing “abnormalities” generally do not correlate to the specific symptoms, pain severity or degree of disability. Ultimately, for the majority of low back complaints, obtaining spinal imaging does not improve patient out-comes.4,15 The demand for a test that tells us what is wrong is often driven by the patient and directly or indirectly by third-party payers who require a structural diagnosis even when none is available.4,17 The physical origins of back dominant pain are well recog-nized, but pinpointing the pain genera-tor in a particular individual may not be possible.

Spinal imaging does, however, substantially increase resource uti-lization.4,14,18 The direct cost of the investigation is compounded by the subsequent unnecessary expense of a specialist consultation or further investigations. Unfounded concerns produce the indirect costs of lost work time and needless restrictions. It is dif-ficult and time consuming to explain to a patient why a reported abnormality is not necessarily abnormal or in need of treatment or even related to the pain.18

Although current guidelines appropriately recommend a bio-psy-chosocial approach to LBP, as a result of their training, physicians tend to spend an inordinate amount of time and expense on the “bio” portion, particularly in trying to identify the source of pain.4,19 Yet the psychosocial aspects, the yellow flags of maladaptive behaviour and social dysfunction, are the most predictive factors for chronic-ity.20 Identifying and addressing the yellow flags is labour intensive. These steps may be outside the comfort zone of the primary care provider or seem unfeasible in a busy primary care prac-tice.5,21 Unfortunately, the necessary services such as cognitive behavioural therapy are generally not covered by health care systems or insurance companies; as a result, many patients requiring these types of therapy do not get them in a timely manner or at all. It is difficult to resolve well-established maladaptive behaviours and easy to question the efficacy of a treatment applied too late.

The fourth issue is the frag-mented and episodic nature of care.22 Patients with back pain receive con-flicting information and advice from medical specialists, allied health professionals, family members and friends, and, of course, the Inter-net.10,19 Optimal patient management is best delivered in a shared-care model with consistent messaging by primary care, specialist and rehabilita-tion professionals. Patients select what resonates with them or do nothing in the face of so many contradictory opinions. Many continue to search for something that is going to “fix” their back pain.

the goaL is controL, not cure, and controL is not onLy possiBLe, it is readiLy achievaBLe.



Recognizing the pitfalls in our current medical approach to LBP, we propose a paradigm shift to a more practical, stratified approach that changes the messaging and manage-ment of LBP to reflect what LBP is—a chronic human condition.4,11,12 We must be both proactive and preventa-tive. The first step is convincing the patient that LBP is manageable albeit likely to recur. The goal is control, not cure, and control is not only possible, it is readily achievable. It consists of phases of symptomatic treatment while engaging the patient in self-management maintenance and pre-ventative strategies. Most LPB arises from minor mechanical derange-ments that produce an identifiable compilation of symptoms suggesting a probable anatomical source and, more importantly, an initial patient-specific management strategy.11 Appropriate expectations, a primary focus on the return of function and as well as pain reduction, and long-term, self-directed control should reduce both the chronicity and health

care utilization.4,12,23–25 Individuals without a specific mechanical pat-tern, who fail to respond or become less specific over time, or who have a concurrent non-spinal complaint require further attention. Up to 30% of patients with LBP have associated yellow flag psychosocial issues.12,20,26 Less commonly, there may be a red flag for non-mechanical causes such as inflammatory disease, infection, or tumour.27,28,29 Reliably screening for these unusual presentations is possible by through a precise, back-specific history and physical examina-tion. The next three articles provide a practical approach that will enable you to confidently assess and initiate patient-specific management within the continuum of LBP.

References

1. Hoy DG, Bain C, Williams G, et al. A systematic review of the global preva-lence of low back pain. Arthritis Rheum 2012;64(6):2028–37. doi: 10.1002/art.34347.

1. Your low back pain does not indicate serious damage even though it may be very painful, recur and, and in some cases, become chronic. 2. Not all patients have the same triggers to their low back pain. Your health care professional can help you understand the best activities and exercises for your recovery.

3. MRI will show many structural alterations in the spine that are related to common anatomical changes. This information does not help us manage your recovery.

4. Low back pain is a common condition and not a disease. It is best managed by reducing pain in order to increase function.

To better manage complex low back cases, the following key messages apply to the majority of patients;

Key Points



2. Power JD, Perruccio AV, Desmeules M, et al. Ambulatory physician care for musculo-skeletal disorders in Canada. J Rheumatol 2006;33:1.

3. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA 2008;299(6):656–64.

4. Srinivas SV, Deyo RA, Berger ZD. Application of “less is more” to low back pain [review]. Arch Intern Med 2012;172(13):1016–20.

5. Koes BW, van Tulder M, Lin CW, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94.

6. Walker BF, Muller R, Grant WD. Low back pain in Australian adults. Health provider utilization and care seeking. J Manipulative Physiol Ther 2004;27(5):327–35.

7. Dagenais S, Caro J, Haldeman S. A system-atic review of low back pain cost of illness studies in the United States and internation-ally. Spine J 2008;8:8–20.

8. Itz CJ, Geurts JW, van Kleef M, Nelemans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain 2012 May 28. Epub ahead of print.

9. Donelson R, McIntosh G, Hall H. Is it time to rethink the typical course of low back pain? PM R 2012;4(6):394–401.

10. Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heterogeneous con-dition with challenges for an evidence-based approach. Spine (Phila Pa 1976) 2011;36(21 Suppl):S1–9.

11. Hall H, McIntosh G, Boyle C. Effectiveness of a low back pain classification system. Spine J 2009;9(8):648–57.

12. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care man-agement for low back pain with current best practice (STarT Back): a randomised con-trolled trial. Lancet 2011;378(9802):1560–71.

13. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis

of efficacy, cost-effectiveness, and safety of selected complementary and alterna-tive medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139. Epub 2011 Nov 24.

14. Chou R, Deyo RA, Jarvik JG. Appropriate use of lumbar imaging for evaluation of low back pain [review]. Radiol Clin North Am 2012;50(4):569–85.

15. Chou R, Qaseem A, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Diagnos-tic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181–9. Erratum in: Ann Intern Med 2012;156(1 Pt 1):71.

16. You JJ, Purdy I, Rothwell DM, et al. Indi-cations for and results of outpatient com-puted tomography and magnetic resonance imaging in Ontario. Can Assoc Radiol J 2008;59(3):135–43.

17. You JJ, Levinson W, Laupacis A. Attitudes of family physicians, specialists, and radiolo-gists about the use of computed tomography and magnetic resonance imaging in Ontario. Healthc Pol 2009;15:54–65.

18. You JJ, Bederman SS, Symons S, et al. Pat-terns of care after magnetic resonance imag-ing of the spine in primary care. Spine (Phila Pa 1976) 2012 May 30. Epub ahead of print.

19. Scott NA, Moga C, Harstall C. Managing low back pain in the primary care set-ting: the know-do gap. Pain Res Manag 2010;15(6):392–400.

20. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010;303(13):1295–302.

21. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev 2010;(7):CD002014.

22. Foster NE, Hartvigsen J, Croft PR. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis. Arthritis Res Ther 2012;14(1):205.

23. Whitehurst DG, Bryan S, Lewis M, et al. Exploring the cost-utility of stratified



primary care management for low back pain compared with current best prac-tice within risk-defined subgroups. Ann Rheum Dis 2012;71(11):1796–802.

24. Lambeek LC, van Mechelen W, Knol DL, et al. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ 2010;340:c1035. doi: 10.1136/bmj.c1035.

25. Lambeek LC, Bosmans JE, Van Royen BJ, et al. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation along-side a randomised controlled trial. BMJ 2010;341:c6414.

26. Toward Optimized Practice. Alberta primary care low back pain guideline: updated and revised November 2011.

Edmonton (AB): Toward Optimized Practice, 2011; http://www.topalbertadoc-tors.org/cpgs.php?sid=63&cpg_cats=85. Accessed November 9, 2012.

27. Henschke N, Maher CG, Refshauge KM. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80.

28. Powell G, and the Peterborough Back Rules Working Group. The Peterborough Back Rules chart template. September 1997; http://www.iwh.on.ca/pocket-red-yellow-flag-cards. Accessed November 9, 2012.

29. Deyo RA, Weinstein JN. Low back pain [review]. N Engl J Med 2001;344(5):363–70.

Most patients complaining of low back pain experience symptoms from a minor

mechanical malfunction. Fewer than 5% have a more sinister explana-tion such as inflammatory disease, infection, or malignancy.1,2 Faced with a patient in acute distress and

grounded in a medical paradigm that emphasizes the serious but uncom-mon causes of back pain, most physi-cians hesitate to offer reassurance. Given the relative rarity of back pain resulting from a systemic illness or grave local pathology, investigat-ing all patients with back pain for a

In 1987, the Quebec Taskforce noted, “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Identify-ing these patterns begins with the patient’s history: “Where is your pain the worst?” “Is your pain constant or intermittent?” “Has there been any change in your bowel or bladder function?” This questioning establishes the mechanical nature of the pain, and a physical examination verifies or refutes the pattern established in the history. The examination involves two essential tests to detect upper motor and low sacral root involvement. A fail-ure of the results to fit into one of four syndromes—two back dominant and two leg domi-nant—suggests a non-mechanical or more complex problem.

Key words: patterns of back pain, pain location, pain characteristics, history, physical examination

Making Sense of Low Back Pain


Abstract




About the Authors

range of inflammatory back diseases (spondyloarthropathies), for exam-ple, will generate unnecessary con-cern, add unjustified expense, and give minimal return for the effort. Yet these potentially significant diag-noses must not be missed; no one wants to be guilty of overlooking a spinal metastasis.3,4

There is another way. In 1987, the Quebec Taskforce noted, “Dis-tinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”5 The use of syndromes in the initial assess-ment of back pain is gaining renewed interest and clinical acceptance. It avoids many of the pitfalls of the conventional medical model, which requires obtaining a patho-anatomi-cal diagnosis before proceeding with management.6 The use of syndromes allows the great majority of patients with back pain to be sorted into four clearly defined groups that have rec-ognizable mechanical characteristics, and it sets apart the much smaller number who present with atypical, possibly ominous symptoms.

A syndrome can be defined as a constellation of signs and symptoms that appear together in a consistent manner and respond in a predict-able fashion. With low back pain, the key is to identify the correct pat-tern.6 This identification depends on a precise history and a concord-ant physical examination. The third component of the process is the anticipated positive response. A mechanical syndrome will respond to the appropriate mechanical therapy within weeks, often within days. The

failure to distinguish a clear pattern or failure of a syndrome to improve with the specified therapy demands reassessment, including a review of the symptoms, additional physical tests, and, perhaps, ancillary investi-gations.3,4,7–11

In the example of spondyloar-thropathy, the patient who lacks a clear-cut mechanical presentation or who continues to experience sig-nificant symptoms after four weeks of suitable care demands particular observation.3,4,7–11 The filtering out of those patients with low back pain who have been accurately identified and successfully managed (over 90% of the total) greatly increases the probability of discovering potentially menacing non-mechanical diagnoses among the remainder. Syndrome recognition is a rapid, reliable, and efficient triage technique that increases diagnostic accuracy, ena-bles patient-specific management, and decreases needless investiga-tions.

The History Identifying the pattern begins with a concise history, which starts with two questions: “Where is your pain the worst?” and “Is your pain constant or intermittent?” Two of the syndromes are back dominant, with the pain felt most intensely in the low back, in the buttocks, or over the outer aspects of the hips. The other two syndromes exhibit leg dominant pain, where the symptoms are worst around and below the inferior gluteal fold: in the thigh, calf, or foot. Patients frequently have pain in both the back and leg; but with careful question-ing, it is possible to determine which site


making sense of Low Back Pain

Key Point

The use of syndromes in the initial assessment of back pain is gaining renewed interest and clinical acceptance.

predominates. This can be challenging, but distinguishing the site of dominant pain is essential for pattern recognition. Axial (back dominant) pain arises from

a spinal structure but may have accom-panying referred pain into the leg. When forced to choose, patients with axial pain will acknowledge that the back pain is worse. Radicular (leg dominant) pain indicates direct nerve root involvement in addition to the mechanical malfunc-tion. Again, patients often report pain in the back as well as in the leg; but for those with radicular pain, leg pain below the buttock will be the chief complaint.

Determining if the pain is con-stant or intermittent can be equally or more difficult. Most patients who endure prolonged discomfort describe their symptoms as con-stant. The inquiry, therefore, must be clear and specific. It is best asked in two parts: “Is there ever a time in the day when your pain stops, for a brief moment, even though it quickly returns?” and “When your pain stops, does it disappear com-pletely? Are you then totally free of pain?” Truly intermittent back domi-nant pain is never the result of spi-nal malignancy or an infection. The power of these questions, properly asked and answered, is enormous. They can eliminate the chance of the clinician missing a sinister pathol-ogy, one of the commonest concerns

about relying so heavily on the his-tory and physical examination.

The third mandatory ques-tion is, “Since the start of your back trouble, has there been any change in your bowel or bladder function?” Rather than initially searching for a detailed description, the query is deliberately vague in nature. Speci-fying changes only since the start of the attack avoids unnecessary worry about previous, unrelated disorders. A report of “no change” removes the necessity to go further. Any positive response requires a more thorough investigation. Uri-nary retention followed by insen-sible, uncontrolled overflow and fecal incontinence is indicative of an acute cauda equina syndrome: a surgical emergency.3,12

Five remaining questions com-plete the clinical picture and estab-lish a link to the past history and the level of present disability:

1. “What are the aggravating movements or positions?”

2. “What are the relieving movements or positions?”

3. “Have you had this same pain before?”

4. “What treatment have you had in the past, and did it work?”

5. “What can’t you do now that you could do before you had the pain?”

Mechanical back pain is responsive to movement and position. Discover-ing the aggravating and relieving fac-tors helps identify the syndrome and suggests a pain control strategy. Back


PhthaLates in 5-aminosaLicyLatesmaking sense of Low Back Pain

Key Point

Syndrome recognition is a rapid, reliable, and efficient triage technique that increases diagnostic accuracy, enables patient-specific management, and decreases needless investigations.

determining if the pain is constant or intermittent can Be equaLLy or more difficuLt.


The PaTienT wiTh newly DiagnoseD UlceraTive coliTis

pain is a recurrent complaint that tends to worsen with time.13 In a sur-vey of patients seeking care, over half had suffered more than 10 attacks and over 60% believed that their present attack was, in at least one respect, worse than the preceding one.14 The degree of physical limita-tion and the value of past therapies influence the current choices.

The Physical ExaminationThe history defines the syndrome. But the history must be supported by a con-cordant physical examination. The back examination is not an independent event. Its components are chosen in response to the patient’s story, and its goal is to verify or refute the diagnostic assumptions made on the basis of the history.

Your examination begins with observation including their gait, posture and preferred position in the office. The patient’s general behaviour and level of activity should correspond to what has already been described. Look at the contour of the spine; note any discoloration or scars. Palpation is not diagnostic. It can locate areas of tenderness unre-lated to any local pathology that may mislead the examiner.

Having the patient bend for-ward and backward to reproduce the typical back pain, described in the history, usually confirms the syndrome. The other spinal move-ments are assessed as dictated by the patient’s functional requirements. Note whether there is a break in the normal rhythm of movement. Recording the range of movement is of little value in an isolated back examination.

Straight leg raising is a meas-ure of sciatic nerve root irritation (L4, L5, S1, S2). Lift the supine patient’s leg while the patient’s knee

is extended. To minimize hamstring tightness and a possible misinterpre-tation of the results, the contralat-eral hip and knee should be flexed. If positive, the test aggravates the patient’s typical leg dominant pain. The production of back pain is not relevant and merely reflects the underlying mechanical difficulty. The test results are positive when straight leg raising causes the typical leg pain, no matter the degree of eleva-tion. Obviously, pain when lifting the leg 30 degrees is more clinically significant than pain occurring at 80 degrees, but both constitute a posi-tive result. Although the test should be performed on every patient, it can be positive only in someone with a true history of leg dominant pain.

A significant but fortunately rare finding with straight leg rais-ing is the “crossover” sign. When the affected leg is passively elevated, the patient feels not only the antici-pated increase in the typical pain in the elevated leg but also pain radiating into the other leg as well. Lifting one leg produces bilateral symptoms. This crossing over of the pain from one to both sides sug-


Key Point

A concise history starts with two questions: “Where is your pain the worst?” and “Is your pain constant or intermittent?”

the production of Back pain with straight Leg raising mereLy refLects the mechanicaL proBLem; it is not a positive test.


The PaTienT wiTh newly DiagnoseD UlceraTive coliTis


Figure 1:Physical Examination to Assess Low Back Pain

Observation

Sitting

StandingExtension

Hip Abduction(Trendelenburg)

Test (L5 NerveRoot Conduction)

Heel Walking Test(L4-L5 Nerve Root Conduction)

Toe Walking Test(S1 Nerve Root Conduction)

Normal Abnormal

Ankle Dorsi�exion Test(L4 and L5 Nerve Root

Conduction)

Great ToeExtension Test(L5 Nerve Root

Conduction)

Flexion

Gait

Movement toReproduce Pain

Great ToeFlexion Test

(S1 Nerve RootConduction)

Upper MotorTest

NormalAbnormal

* 5 steps at maximum elevation

Journal of Current Clinical Care Educational Supplement • November 2012 17


Classi�cation of Mechanical Patterns of Low Back Pain

ReportedPain Location

Pain Constancy Pain Improved Pain Worsened NeurologicalFindings

1 Constant orintermittent

One of 2 cohorts willimprove on extension

Unaected or may beimproved on �exion

By immobility andrecumbent rest

By all back movement, usually more by�exion

Back, buttocksor around hips

Back dominant

Leg dominant

Leg dominant

Forward �exion,one of the 2 cohorts’pain also worsens onextension

Worsens on extension

Activity in extension(walking)

May havepositiveconduction test;no irritative test.

Relieved by rest in�exion (sitting)

Normal

Normal

Positiveirritative test and/or conduction loss

PainOrigin

Most likely discogenic

Most likely posterior spinalelements

Sciatic (or occasionallyfemoral) nerveroot irritation

Neurogenicclaudication, often mislabelledspinal stenosis

Constant

Intermittent

Intermittent

2

3

4

Hip Extension Test(Palpate Gluteus Maximus Tone)

(S1 Nerve Root Conduction)

SaddleSensation Test

(Lower SacralNerve Roots)

Ankle Re�exTest

(S1 Nerve RootConduction)

Straight Leg Raise Test(Sciatic Nerve Root Irritation)

Femoral Stretch Test(Femoral Nerve Root Irritation)

Kneeling

Lying Prone

Lying Supine

gests nerve root irritation from a centrally placed intrusion. A central disc herniation can compress the sacral roots controlling bowel and

bladder function and may trigger an acute cauda equina syndrome.12 The crossover sign should not be confused with the reproduction of typical leg pain on the affected side when lifting the unaffected leg. This manoeuvre, correctly desig-nated “well-leg lifting,” confirms an extremely irritated nerve root but signifies unilateral compres-sion incapable of provoking a cauda equina syndrome.

Femoral stretch is a root irri-tation test for the femoral nerve (L2, L3, L4). It is carried out with the patient prone and the affected leg extended. Lift the patient’s leg into extension; a positive test result reproduces the typical leg pain, in this case in the anterior distal thigh. The manoeuvre frequently induces back pain, an incidental albeit unpleasant finding. Because the femoral nerve is so infrequently affected, the test can be limited to those patients who present with an account of constant anterior thigh dominant pain.

About 80% of nerve root com-promise associated with low back pathology occurs at L5 or S1 (L4 adds approximately another 8%), so

it makes sense to screen L5 and S1 functions as part of the examination. Motor testing is preferred. Once lost, reflexes may not return, and slight variations can give an erroneous pic-ture of the current problem. Sensory testing is largely subjective.

For patients with back domi-nant pain, an adequate motor test of L5 is the power of the long extensor of the big toe. For S1, it is sufficient to test the strength of the great toe’s long flexor. If indicated, for exam-ple in leg dominant pain, additional neurological tests include quadri-ceps power and the knee reflex for L3 and L4; heel walking, ankle dorsiflexion (tested with the patient seated and attempting to elevate the forefoot against resistance) and hip abduction (Trendelenburg test) for L5; toe walking, hip extension (tested by palpating the muscle tone in the gluteus maximus as the patient repeatedly tenses and relaxes the muscle) and the ankle reflex for S1. Both L4 and L5 innervate ankle dorsiflexion but, since L4 is only occasionally involved with low back pain, the test is generally employed for the latter root.

Every low back examina-tion must include an upper motor test and a check of saddle sensa-tion. The upper motor examina-tion, usually the plantar response, is always negative in low back pathol-ogy. Any indication of direct spinal cord involvement warrants a more detailed proximal neurological examination. This finding negates a mechanical diagnosis. Saddle sensa-tion is subtended by the same lower sacral nerves that supply the bowel



Key Point

The goal of the physical examination is to verify or refute the diagnostic assumptions made on the basis of the history.

every Low Back examination must incLude an upper motor test and a check of saddLe (perineaL) sensation.

and bladder. An altered response to sensory testing in this area raises the possibility of an acute cauda equina syndrome, which must be carefully pursued including, when indicated, a rectal examination.

The Four SyndromesAt the conclusion of the history and physical examination, the overwhelm-ing majority of patients can be classified into one of four mechanical patterns.

In the first and most common syndrome, patients describe pain that is most excruciating in the back, in the buttocks, or around the hips and is increased by bending forward. The pain may be constant or intermittent. The neurological findings will all be normal.

Within this group, there are two well-defined cohorts: one gains relief with extension, the other has pain with movement in either direction. The physical examination will support the history, with the patient’s typical back pain aggravated on flexion and either improved or further exacerbated on extension. For some patients, the extension movement must be per-formed in a non-weight bearing posi-tion of prone lying. This is an ideal time to educate these patients on the

use of this manoeuvre for pain man-agement.

The goal of syndrome recogni-tion is to dispense with the need to establish a pathological diagnosis before proceeding to primary treat-ment; but it is impossible not to speculate on the most likely source of the pain. In this case, the picture strongly suggests a discogenic origin. The focus, however, should remain on the clinical presentation and not on the putative pain generator. A degenerative disc seen on magnetic resonance imaging does not nec-essarily equate with this first syn-drome.7,10

The second mechanical pattern is also back dominant but is much less common. Patients report pain on bending backward but have no trou-ble, and are often more comfortable, bending forward. The pain is inter-mittent. Again, the physical exami-nation reinforces the history. The patient’s usual back pain is worsened on extension but is either unaffected or improves on flexion. The neuro-logical examination is normal.

The source of pain in this syndrome is less clear, possibly the posterior elements of the spine. But



90% of Low Back Pain is not related to serious pathology and does not require surgical intervention

Mechanical Low Back Pain can be categorized to patterns that are identified in history and confirmed in the physical examination

Findings on radiological imaging including x-ray, CT scan and MRI have not been found to correlate to pain-generating pathology, can increase patient anxiety and detract from successful recovery

Key Points

Key Point

Managing low back pain is not a one-time event. Low back pain is a chronic condition that demands ongoing care and follow-up.



while the location of the pain genera-tor is uncertain, the pattern of the pain is obvious.

The next two syndromes involve leg pain dominant, and both

correspond to well-established diag-noses. Here the challenge is the con-tamination of the terminology, with the resultant blurring of the clinical picture.

The third syndrome is one of constant leg dominant pain with associated positive neurological findings, indicated by either irrita-tive tests such as the straight leg raise or a loss of motor, reflex, or sensory function. This is the exact description of sciatica: constant leg dominant pain with a necessarily positive neurological examination.15 This most accurately equates to radiculitis, inflammation of a spinal nerve root. But sciatica has come to mean simply leg pain. Patients and too many health care providers are convinced that any time the pain spreads to the leg, there must be a pinched nerve. As a result, many patients with referred leg pain from a back dominant pattern are given the wrong diagnosis.

The final syndrome also has leg dominant pain. Here the pain is intermittent, comes on with activity in extension (walking), and is relieved

by rest in flexion (sitting). Since the patient is not active during the assess-ment, the physical examination is usually normal. The correct diagnosis for this pattern is neurogenic clau-dication, but in clinical practice, it is often mislabelled spinal stenosis.16 Spinal canal narrowing is a structural abnormality that may induce neuro-genic claudication but that may be asymptomatic. Spinal stenosis is not a diagnosis, and its presence on an image does not predict the patient’s symptoms. Syndrome recognition, which emphasizes the clinical presen-tation, is the proper approach.

Conclusion Low back pain is not an impenetrable morass. Recognizing a syndrome within a myriad of other complaints requires a meticulous history, a precise support-ing physical examination, and practice, but it enables immediate mechanically based treatment without misleading and unnecessary spinal imaging. Managing low back pain is not a one-time event. Low back pain is a chronic condition that demands ongoing care and follow-up.13,14 When the clinician can reliably separate nine of 10 patients into one of the four groups, each with its own distinct characteristics and appropriate treatment, and when the outliers can be quickly and clearly identified, low back pain begins to make sense.

References

1. Deyo RA, Weinstein JN. Low back pain [review]. N Engl J Med 2001;344(5):363–70.

2. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for

managing Low Back pain is not a one-time event. Low Back pain is a chronic condition that demands ongoing care and foLLow-up.



+

Questions: Interpretation:

“Where is your pain worst?” Back Dominant Pattern I or II Leg Dominant Pattern III or IV

“Is your pain intermittent or constant?” Intermittent is a mechanical syndrome Constant LBP – rule out Red Flags •Neurological •Infection •Fracture •Tumour •Inflammation •PossiblePainDisorder(Yellowflags)

“Has there been any change in your bowel or bladder If yes, inquire about further neurological symptoms to functionsincetheonsetofyourbackpain?” ruleoutCaudaEquina(SurgicalEmergency).

“What are the aggravating movements or positions?” Pattern 1 Pattern 2 Pattern 3 Pattern 4

a)Flexion Extension Flexion Extension Aggravated Aggravated Aggravated Aggravated

“Whataretherelievingmovementsorpositions?” B)Flexion/ Flexion Extension Relieved or Aggravated Unchanged

Management Strategies:

“Have you had this same pain before?” Reinforce the key messages that recurrence is typical and is not linked to worsening pathology

“What treatment have you had in the past and did Dispel myths of passive treatment. it work?” Identify active approaches related to the mechanical patterns

“What can’t you do now that you could do before Begin self-management strategies focused on the patients you had the pain?” needs.

Clinical Pearls



serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80.

3. Toward Optimized Practice. Alberta primary care low back pain guide-line: updated and revised Novem-ber 2011. Edmonton (AB): Toward Optimized Practice, 2011; http://www.topalbertadoctors.org/cpgs.php?sid=63&cpg_cats=85. Accessed November 9, 2012.

4. Powell G, and the Peterborough Back Rules Working Group. The Peter-borough Back Rules chart template. September 1997; http://www.iwh.on.ca/pocket-red-yellow-flag-cards. Accessed November 9, 2012.

5. Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians [review]. Report of the Quebec Task Force on Spinal Disor-ders. Spine (Phila Pa 1976) 1987;12(7 Suppl):S1–59.

6. Hall H, McIntosh G, Boyle C. Effectiveness of a low back pain classification system. Spine J 2009;9(8):648–57.



9. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected comple-mentary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139. Epub 2011 Nov 24.

10. Chou R, Qaseem A, Owens DK, Shek-elle P; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from

+

Physical Examination

To minimize patient discomfort and maximize efficiency, progress from tests done standing to those in sitting and finally to lying down. The minimum assessment is marked**

Gait

•Heelwalking(L4-5) •Toewalking(S1)

Standing Position

•**Movementtesting—flexionandextension •Trendelenburgtest(L5) •Repeatedtoeraises(S1)

Sitting Position

•**Patellarreflex(L3-4) •Quadricepspower(L3-4) •Ankledorsiflexionpower(L4-5) •**Greattoeextensionpower(L5) •**Greattoeflexionpower(S1) •**Plantarresponse,uppermotortest

Kneeling Position •Anklereflex(S1)

Supine Lying Position •**Passivestraightlegraise

Prone Lying Position

•Femoralnervestretch(L3-4) •Gluteusmaximuspower(S1) •**Saddlesensationtesting(S2-3-4) •Passivebackextension(patientusesarmstoelevateupperbody)

Clinical Pearls



the American College of Physicians. Ann Intern Med 2011;154(3):181–9. Erratum in: Ann Intern Med 2012;156(1 Pt 1):71.

11. Chou R, Qaseem A, Snow V, et al.; Clini-cal Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; Ameri-can Pain Society Low Back Pain Guide-lines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Soci-ety. Ann Intern Med 2007;147(7):478–91. Erratum in: Ann Intern Med 2008;148(3):247–8.

12. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the cur-rent clinical and medico-legal position [review]. Eur Spine J 2011;20(5):690–7.

Epub 2010 Dec 31.13. Itz CJ, Geurts JW, van Kleef M, Nele-

mans P. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in pri-mary care. Eur J Pain 2012 May 28. Epub ahead of print.

14. Donelson R, McIntosh G, Hall H. Is it time to rethink the typical course of low back pain? PM R 2012;4(6):394–401.

15. Valat JP, Genevay S, Marty M, et al. Sciatica [review]. Best Pract Res Clin Rheumatol 2010;24(2):241–52.

16. Suri P, Rainville J, Kalichman L, Katz JN. Does this older adult with lower extremity pain have the clinical syn-drome of lumbar spinal stenosis? [review] JAMA 2010;304(23):2628–36.

Back dominant, or axial, pain is chiefly mechanical in nature.1

When the principle site of pain is the trunk rather than the lower limbs, the source of the symptoms is a physical structure or structures within the spine.2 The pain’s cen-tral location virtually eliminates the direct irritation of the neural elements, particularly an involve-

ment of a nerve root, as a major contributor.2,3

Distinguishing pain arising in the spine from pain referred to the spine from a distance demands close attention to the history and physical findings. Many non-spinal condi-tions, from influenza to gallbladder disease, generate back pain; an oste-oarthritic hip can easily be mistaken

Back dominant pain is either intensified by flexion or is not aggravated by bending forward. The most common pattern, probably discogenic, subdivides into two groups: one with pain on flexion but relief on extension, the other with pain in both directions. The second pattern has symptoms with extension only. Treatment begins with education about the true benign nature of the prob-lem. Mechanical pain responds to posture adjustment and pattern-specific movement. Medication has a secondary role. Imaging is not required for the responding patient. The inability to detect a pattern or a lack of anticipated response combined with non-mechanical findings indicates the need for appropriate referral.

Key words: back dominant pain, education, medication, imaging, specialist referral

Managing Back Dominant Pain


Abstract




About the Authors


managing Back Dominant Pain

for a back problem.1 Mechanical back dominant pain is consistently modified by particular spinal move-ments or positions. It is not associ-ated with systemic symptoms such as fever, widespread joint pain, or unexplained weight loss. It does not equate with findings indicative of a remote pathology, such as shortness of breath or focal abdominal tender-ness. It exhibits a predictable, often rapid response to the correct active therapy.

Presentations The specific point of pain can vary. It is generally most intense in the low back or buttocks but can extend to the tip of the coccyx, radiate over the greater trochanters, and even spread into the groin and genitals. Broadly speaking, back dominant pain can be divided into two presentations: pain that is induced or aggravated with flexion, and pain that is reduced or unaffected by bending forward. The former pattern is much more com-mon and likely has the intervertebral disc as the pain generator. The origin of the latter presentation is less clear and may encompass a number of ele-ments in the posterior spine.

Patients whose pain worsens with flexion can be further separated into two subgroups.3 The first group improves with extension and exhib-its what has been called “directional preference.” There is a recognizable difference in their response to par-ticular movements, both in the pro-duction and the elimination of their pain. This preference is the funda-mental basis of mechanical therapy.

The second group experiences pain not only in flexion but with all other movements and positions as well. Their symptoms are more likely to be constant and, due to the lack of a straightforward mechanical solution, their management tends to be more demanding. These patients have a higher incidence of psychosocial fac-tors to be addressed.3,4

Treatment Treatment begins with education. The patient must accept the inher-ently benign nature of the symptoms and their connection to a probably minor physical change within the spine.5,6 When delivered in the face of excruciating pain, this message is understandably rejected. Convinc-ing the patient that the severity of the pain is not a reflection of the seriousness of the problem requires considerable skill.5,7 It is imperative that the clinician be confident in the diagnosis and have a coherent, effec-tive treatment plan.8,9

Mechanical pain responds to mechanical therapy. Since there is no sinister pathology and no disease to be eradicated, the goal is control, not cure. Anything that reliably relieves the pain and helps to restore func-tion is valuable.10 Ideally, it should be evidence based. It needn’t be expen-sive or necessarily professionally administered. Self-applied heat, cold, and counter-irritants may all have a place depending upon their results and the patient’s preference.

Posture is important. Most people sit in a flexed position and, for the majority of patients who find flexion increases the pain, using a

Key Point

Mechanical back dominant pain is consistently modified by particular spinal movements or positions. It exhibits a predictable, often rapid response to the correct active therapy.



large foam roll to maintain the lum-bar lordosis is remarkably beneficial. In spite of the fact that nothing more may be needed to stop the pain, it

can be difficult to persuade someone that something so mundane is the only answer needed.

Central to the management of back dominant pain is a program built on the patient’s reaction to spe-cific activities.7 Every case involves subtle modifications, but overall the approach is surprisingly uniform.

Patients aggravated by bend-ing forward but who have relief with extension typically benefit from fre-quent repetitions of a passive lumbar extension; lying prone, they use their arms to slowly raise and lower their upper body while their hips remain down and fixed. Five to 10 exten-sions every waking hour or 2 for 2 or 3 days may be all that is needed to curb the pain.

In contrast, patients with the opposite directional preference, those who have pain only with exten-sion and are more comfortable with flexion, can gain relief by sitting in a chair and repeatedly slumping forward, trying to lower their torso between their knees. To straighten up, they put their hands on their thighs and push up with their arms, minimizing the use of the back

muscles. Again, multiple sessions of repeated movements are the key to pain reduction and control.

Most cases of mechanical back dominant pain can be handled with a large measure of education, advice, self-help, and common sense. Once patients understand the true nature of the condition, overcome the fear of serious disease, experience even transient pain relief with unsophis-ticated, self-directed physical treat-ment, and gain confidence in their ability to control the situation, they no longer need professional inter-vention.7,11

It is the patient without an obvious physical means of gaining symptom relief and who has pain on both flexion and extension who tests the ingenuity of the health care practitioner. Treatment typically begins with repeated short periods of rest in whatever position offers the greatest amount of pain con-trol—usually recumbent and flexed. It progresses to gentle, limited move-ments in the least painful direction, often a passive flexion such as pull-ing the knees up to the chest. As the acute episode subsides, a directional preference generally appears and therapy continues in a standard fashion. The target is the establish-ment of self-reliance and withdrawal of supervised care. Sustained self-management employs the same techniques as acute control: avoiding aggravating activities and practicing regular back exercises dictated by the directional preference.

Medication has a limited and secondary role. With the proper instruction and support, most

most cases of mechanicaL Back dominant pain can Be handLed with a Large measure of education, advice, seLf-heLp, and common sense.

Key Point

Treatment begins with education. The patient must accept the inherently benign nature of the symptoms and their connection to a probably minor physical change within the spine.



Figure 1:Mechanical Management of Back Dominant Pain

Postural SupportFor patients with pain on �exion, maintain lumbar lordosis when sitting using large foam roll

“Z” PositionPatient lies down with a pillow under head and legs resting on a chair. Hips can also be on a pillow

Lean ForwardWhile SeatedFor patients with pain only on extension, gain relief by sitting in chair and slumping forward with arms hanging between legs

Recumbent and FlexedFor the patient without obvious means of symptom relief and who has pain on both �exion and extension, or pain on extension only, begin by lying supine and perform passive �exion such as pulling knees up to the chest Passive Lumbar

ExtensionFor patients with pain on �exion and relief on extension, lie prone and use arms to slowly raise and lower upper body while hips remain on �oor



patients with back dominant pain can manage their symptoms with physical activity and self-admin-istered modalities. If they require

additional pain relief, over-the-counter analgesics are almost always enough. There is no place for the routine use of narcotics or psycho-tropic drugs.6,12,13

Imaging and Specialist Referral Imaging is not required during the initial management of uncompli-cated back dominant pain. There is little or no correlation between what is seen with plain radiography and the nature of a patient’s symptoms. Computed tomography and magnetic resonance imaging (MRI) produce significant numbers of false-positive results.14 Early imaging can divert attention from the more relevant clinical findings, adversely affecting the treatment and outcome.5,12 But when the presentation lacks a clear mechanical pattern, follows a story of substantial trauma, or contains elements suggestive of a specific pathology, preliminary imaging is reasonable. Getting an image is not a substitute for making a diagnosis, but visualizing a recognized problem is sound judgement.

Two of the three prerequisites for a syndrome-based approach are

a precise history and a concord-ant physical examination. The third is the anticipated positive treat-ment result. Properly identified patients receiving the correct therapy respond in a predictable fashion within a defined time frame. A lack of improvement is a warning that something is amiss and alerts the clinician to fully review the situation and initiate the necessary imaging, investigations, or referral.

Specialist referral is initiated for several reasons. There may be uncertainty with the diagnosis or concern over a lack of progress with treatment. The patient may be dis-satisfied with the current care and desire to see an expert. The referral may arise as the result of an ominous MRI report. To be helpful, the refer-ral needs a clearly defined goal. A vague call for help rarely elicits the desired result.15,16

Different specialists offer various sorts of assistance. Select-ing the most useful opinion requires the primary care provider to for-mulate specific questions about the patient’s immediate problem and to identify who is most likely to have the answer.2 A clinical picture sug-gesting inflammatory disease or the involvement of the central nervous system would interest a rheumatolo-gist or a neurologist, respectively. A physiatrist might assist with a failure to respond to apparently appropri-ate therapy for seemingly mechani-cal pain. Most spine surgeons, both orthopedic and neurosurgical, are interested in conditions for which there is a surgical solution, and they have little time for or expertise in

in the aBsence of maJor trauma, tumour, infection, or a cLear-cut structuraL aBnormaLity, Back dominant pain rareLy demands an operation.

Key Point

The goal is control, not cure. Anything that reliably relieves the pain and helps to restore function is valuable.



Back Dominant pain can be divided into two presentations: painthatispredominantlyreproducedwithflexionorpainthatisreducedorunaffectedbyflexion.

The recognition of mechanical low back pain is based on a precise history, a validating physical examination and a positive treatment result.

Referred pain to the leg may occur with back dominant pain but, unlike radicular pain, the neurological examination will be normal.

Facilitating the patient to engage in activity that does not aggravate pain is the key to pain management and recovery.

Key Points

+

Pain Management Directional Directional Non-Directional Strategies Preference Preference Preference

Flexion Aggravated Extension Aggravated All Movements Aggravate

Recovery Positions

Daily Positions Standing Sitting Frequent changes to position of comfort Walking Limited walking may need support Reducedsittingusing Usestepstooltoflex Nosustainedpostures a Lumbar Roll one leg

StarterExercises Repeatedpassive Sittingtrunkflexion Smallrangemovementsin extension in lying direction of least pain progressing to standing Knees-to-chest stretch Low repetitions of any exercise movement

Clinical Pearls



non-operative care.16 In the absence of major trauma, tumour, infection, or a clear-cut structural abnormality, back dominant pain rarely demands an operation. The surgical outcomes for patients with back dominant pain, in the absence of deformity or instability, have not been proven to be more beneficial than outcomes of non-surgical care.17 This is especially true in cases compounded by psy-chosocial issues.18

Chronic low back dominant pain usually has an underlying mechanical component, but it can be greatly exaggerated by a variety of social and psychological factors. The back is an emotional target, and stresses and conflicts can be played out along the spine. The likelihood of persistent, disabling low back pain increases with high levels of maladaptive pain-coping behaviours.4 It is associated with a belief that back pain is harmful and potentially catastrophic, leading to a fear of movement and no expec-tation of recovery.9,11 The patient becomes depressed and socially withdrawn. These destructive per-sonal attitudes are reinforced by negative life experiences such as low job satisfaction, financial dis-tress, and marital discord. The magnitude of these problems can make management in a primary care setting almost impossible, and referral for cognitive behavioural therapy or other specialist interven-tion is warranted.19,20

References1. Deyo RA, Weinstein JN. Low

back pain [review]. N Engl J Med 2001;344(5):363–70.

2. Fourney DR, Andersson G, Arnold PM, et al. Chronic low back pain: a heteroge-neous condition with challenges for an evidence-based approach. Spine (Phila Pa 1976) 2011;36(21 Suppl):S1–9.

3. Hall H, McIntosh G, Boyle C. Effective-ness of a low back pain classification system. Spine J 2009;9(8):648–57.




7. Toye F, Barker K. ‘I can’t see any reason for stopping doing anything, but I might have to do it differently’ – restoring hope to patients with persistent non-specific low back pain – a qualitative study. Disabil Rehabil 2012;34(11):894–903.

8. Scott NA, Moga C, Harstall C. Managing low back pain in the primary care set-ting: the know-do gap. Pain Res Manag 2010;15(6):392–400.

9. Werner EL, Côté P, Fullen BM, Hayden JA. Physicians’ determinants for sick-listing LBP patients: a systematic review. Clin J Pain 2012;28(4):364–71.

10. Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative

Key Point

Medication has a limited and secondary role. There is no place for the routine use of narcotics or psychotropic drugs.

medicine for neck and low-back pain. Evid Based Complement Alternat Med 2012;2012:953139. Epub 2011 Nov 24.

11. Hallegraeff JM, Krijnen WP, van der Schans CP, de Greef MH. Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review. J Physiother 2012;58(3):165–72.

12. Toward Optimized Practice. Alberta primary care low back pain guideline: updated and revised November 2011. Edmonton (AB): Toward Optimized Practice, 2011; http://www.topalber-tadoctors.org/cpgs.php?sid=63&cpg_cats=85. Accessed November 9, 2012.

13. Furlan AD, Reardon R, Weppler C; National Opioid Use Guideline Group. Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ 2010;182(9):923–30.

14. Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181–9. Erratum in: Ann Intern Med 2012;156(1 Pt 1):71.

15. You JJ, Bederman SS, Symons S, et al. Patterns of care after magnetic reso-nance imaging of the spine in primary

care. Spine (Phila Pa 1976) 2012 May 30. Epub ahead of print.

16. Cheng F, You J, Rampersaud YR. Rela-tionship between spinal magnetic reso-nance imaging findings and candidacy for spinal surgery. Can Fam Physician 2010;56(9):e323–30.

17. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guide-line [review]. Spine (Phila Pa 1976) 2009;34(10):1094–109.

18. Mroz TE, Norvell DC, Ecker E, et al. Fusion versus nonoperative manage-ment for chronic low back pain: do sociodemographic factors affect out-come? [review] Spine (Phila Pa 1976) 2011;36(21 Suppl):S75–86.

19. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378(9802):1560–71.

20. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Data-

base Syst Rev 2010;(7):CD002014.



Leg dominant pain occurs much less frequently than does axial back pain.1,2 Most patients with

back pain have episodic radiation into the legs but predominant proxi-mal pain. True leg dominant pain puts the area of maximum intensity around and below the inferior gluteal

fold, in the thigh, calf, ankle, or foot. Back, buttock, or groin pain may be present, but the lower limb symp-toms are clearly the major complaint. This distribution strongly suggests pathology directly involving the lum-bar nerve roots producing radicular, not referred, pain.

Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain trig-gered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.

Key words: leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery

Managing Leg Dominant Pain


Abstract




About the Authors


managing Leg Dominant Pain

Obviously, not all leg pain comes from the back. The pain of an osteoarthritic hip can spread to the knee and be mistaken for nerve root irritation. Intermittent clau-dication from peripheral vascular disease can be confused with leg pain caused by spinal stenosis.3 True spine-generated leg dominant pain is consistently reproduced, exacer-bated, or relieved by particular spinal movements or positions. It is not associated with local findings such as absent pulses or typical thigh pain on flexion and internal rotation of the hip. Radicular symptoms can occa-sionally coexist with non-spinal pain, but an accurate history and a precise physical examination almost always distinguish between them.

The location and the presenta-tion of leg dominant pain can vary. The pain may be felt in the thigh or settle in the lower leg and foot. It may begin in the lower buttock near the gluteal fold. Leg dominant pain may be accompanied by tingling or numbness in a dermatomal pattern. When associated with minimal axial back pain, this is also considered leg dominant. The pain can shift, and more than one site can be affected at once. It may be constant or inter-mittent. Constant leg dominant pain usually results from the herniation of an intervertebral disc, produc-ing inflammation and nerve root compression. It is the inflammation, not the mechanical pressure, that accounts for most of the early symp-toms and the constant pain. Onset is often rapid and may be preceded by an episode of back dominant pain, presumably as the disc fails prior to

the frank rupture. This constant leg pain is correctly designated radicu-lopathy or sciatica.4

Age-related osteoarthritis of the posterior spinal structures leads to a narrowing of the lumbar spi-nal canal, labelled spinal stenosis.3 Intermittent leg dominant pain with or without associated numbness and weakness is produced by bony compression interfering with blood flow to the nerve roots.5 Because the canal dimensions vary with posture, the symptoms increase as space for the nerve decreases in extension, typically upon standing or walking, and subside as the available room increases in flexion, with bending forward or sitting. Ordinarily insidi-ous in onset, this pattern is slowly progressive. Leg dominant pain aggravated by activity in extension and eliminated by rest in flexion is termed neurogenic claudication.3

Both constant and intermittent leg dominant pain can be associ-ated with neurological symptoms. A diagnosis of sciatica must have supporting physical findings, either a positive irritative test or, less fre-quently, decreased power, sensation, or reflex response. Very rarely, the disc protrusion produces only a brief period of leg pain but leaves a con-tinuing neurological deficit.

For patients with intermit-tent leg pain of spinal origin, the neurological assessment is typi-cally normal, particularly when the patient is examined at rest. Transient weakness can occur during activity. Because they lack the inflammatory component of sciatica, patients with neurogenic claudication do not dem-

Key Point

Involving the patient reduces the sense of helplessness that can accompany disabling pain.



onstrate irritative findings but as the condition progresses may develop a permanent local loss of motor or sen-sory function.

Treatment begins with educa-tion and reassurance. The clinician must be confident of the diagnosis in order to appreciate and share the generally favourable natural his-tory.3–6 In the absence of a progres-sive neurological deficit or cauda equina syndrome, leg dominant pain warrants a trial of non-operative treatment.7 It can also be effectively treated with injections or surgical intervention when simpler methods fail.8,9

Treatment of SciaticaDue to the chemical irritation, sci-atica rapidly escalates and can be excruciating. The initial treatment goal is to reduce the inflammation while managing the pain through a program of scheduled rest. This is not merely putting the patient to bed. It starts in the office or clinic by identifying the position or positions that most effectively diminish the leg pain. Given the nature of the pathol-ogy, stopping the leg pain completely is impossible.

The most effective position is commonly the “Z” lie. The patient

lies supine with the lower legs sup-ported on the seat of a chair. The amount of flexion is critical and as a rule, the more, the better; therefore, the hips are generally flexed beyond 90 degrees. The patient remains in the optimal posture for as long as the leg pain remains reduced. The results of this manoeuvre form the basis of a directed, self-treatment routine. An identical rest position is created at home. Based on the observed response time, the patient spends the same period of every daytime hour at rest, while the remainder of each hour is used for necessary functions. The target is to decrease the leg pain to the same level achieved in the office.

Involving the patient reduces the sense of helplessness that can accompany disabling pain. Sched-uled rest offers a measure of pain relief and a sense of progress, but this must be reinforced by confident reassurance from the clinician that the acute phase customarily resolves within 4–6 weeks.4 Trying various rest positions, such as lying prone over several pillows, to find one that works poses no risk. There is no indi-cation for movement-based routines, stretches, or exercise, but any pas-sive modality that provides relief can be useful.

Because of the intensity of the pain, analgesic medication is nor-mally required. Non-prescription pain relievers may not be sufficient, and the anti-inflammatory effect of nonsteroidal anti-inflammatory drugs (NSAIDs) may be inadequate to deal with the inflammation. A brief course of high-dose oral ster-

in contrast to the Back dominant cases, there is a definite roLe for short-acting narcotics or psycho-tropic drugs for uncontroLLed pain.



Figure 1:Pathological Basis of Leg Dominant Pain

Lumbar Spinal Stenosis

Intervertebral Disc HerniationHerniated

intervertebral disc

Herniatedintervertebral

disc

Intervertebraldisc

Compressed nerve root

Lumbarvertebra

Lumbarvertebra

Lumbarvertebra

Lumbarvertebra

Bone spurs

Bone spurs

Cauda equina

Caudaequina

Narrowedspinalcanal

In�ammation

Narrowedspinal canal

Narrowedspinal canal

Narrowedspinalcanal

In�ammation and nerve root compression lead to constant leg dominant pain designated as radiculopathy or “sciatica”

Boney compression interfering with blood �ow to nerve roots leads to intermittent leg dominant pain termed “neurogenic claudication”



oids addresses the problem, but there is no convincing evidence of its positive effect.10 In contrast to the back dominant cases, there is a defi-

nite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.6,8,11,12

Obtaining a computed tomog-raphy scan or magnetic resonance imaging is a precursor to inva-sive treatment. No investigation is required for a patient present-ing an unequivocal clinical picture and exhibiting steady predictable improvement.6,13 Visualizing the her-niation does not speed recovery and should not change the management.

Over 80% of attacks of acute sciatica resolve with time and appropriate care; surgery is infre-quently indicated.9 The initial acute episode is normally followed by a progressive decline in the intensity of the leg pain and the resolution of any residual neurological defi-cits. Full recovery can take a year or more. For those whose disabling leg symptoms persist, selective nerve root or epidural steroid injections may lessen the pain and hasten the return to function but have not been shown to alter the long-term out-come.14

Surgery for sciatica carries a success rate above 90%. Studies

suggest that the final disposition of patients treated non-operatively is about the same as for those man-aged with surgery, although the recovery rate may be faster with an operation.9 The decision for surgery should be based not only on the clini-cal findings and how well they match with an appropriate image but also on patient preference. An inability to cope with the pain and a willingness to accept surgery are both important considerations.

Treatment of Cauda Equina SyndromeCauda equina syndrome is a rare and serious neurological disorder that demands urgent intervention.7 It is caused by compression of the nerve roots within the central lumbar spinal canal, most often by a mas-sive posterior disc herniation. The striking features are bilateral sciatica on single straight leg raise, saddle anaesthesia, and sudden urinary retention followed by insensible overflow and fecal incontinence. The treatment of acute cauda equina syndrome is surgical decompression. Patients operated within 48 hours of onset are more likely to have better outcomes.

Treatment of Neurogenic ClaudicationManaging neurogenic claudication is more about maintaining or restor-ing function than about controlling the intermittent leg pain.5 Sitting in a flexed posture for a few minutes usually controls the symptoms. Dis-tinguishing neurogenic claudication from peripheral vascular claudica-tion can be challenging.3 The clinical difference lies mainly in the symp-

over 80% of attacks of acute sciatica resoLve with time and appropriate care; surgery is infrequentLy indicated.

Key Point

Managing neurogenic claudication is more about maintaining or restoring function than about controlling the intermittent leg pain.



tom response to position change, and the diagnosis is confirmed with normal vascular studies and images of a narrow spinal canal. Neuro-genic claudication affects about 20% of people over 65 years of age, and about half of that group suffer seri-ous restrictions in their daily rou-tines.5,15

Because the volume of the lumbar canal is greatest in flexion, exercise therapy focuses on abdomi-nal strengthening to allow patients to sustain a flexed posture by tilting the pelvis as they stand or walk. While this is a reasonable concept, in an older age group often unaccustomed to physical activity, commitment is difficult and compliance is poor.16

Medication has a limited role. Analgesics are seldom required as pain control is easily achieved. Since the problem is a lack of space in the canal, epidural steroid injections have not proven particularly effec-tive.16 Advice on lifestyle modifica-tion may be constructive but cannot eliminate the patient’s existing limitations.

Treatment success is measured by improvement in symptoms and function and an increase in walking distance or standing tolerance. For patients who have maintained an acceptable routine in spite of their reduced capacity, no treatment is necessary. For those who can no longer accomplish the tasks of daily

Key Point

Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.

MRI Scans Demonstrating the Pathological Basis of Leg Dominant Pain

Lumbar Spinal Stenosis Disc Herniation

Compressednerve

Hypertrophy ofligamentum avum

Disc

SagittalView

AxialView

Axial ViewAxial View

SagittalView

Normal Stenotic

*MRI scans courtesy of Dr. Rampersaud

Non-compressed nerves

Facet joint

Facet jointosteoarthritis

Central canalCentral canalstenosis



living, non-operative care achieves limited benefits.16

Of the four back pain syn-dromes, only neurogenic claudica-tion is consistently best treated by surgery.17,18 For the ideal surgical candidate—a healthy patient who is significantly disabled with one-, two-, or three-level stenosis—sur-gery produces a sustained improve-ment in quality of life, equivalent to a lower limb total joint replace-ment.19

References1. Hall H, McIntosh G, Boyle C. Effective-

ness of a low back pain classification system. Spine J 2009;9(8):648–57.

2. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60(10):3072–80.

3. Suri P, Rainville J, Kalichman L, Katz JN. Does this older adult with lower extremity pain have the clinical syn-drome of lumbar spinal stenosis? [review] JAMA 2010;304(23):2628–36.

4. Valat JP, Genevay S, Marty M, et al. Sciatica [review]. Best Pract Res Clin Rheumatol 2010;24(2):241–52.

5. Genevay S, Atlas SJ. Lumbar spinal

stenosis [review]. Best Pract Res Clin Rheumatol 2010;24(2):253–65.


7. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the cur-rent clinical and medico-legal position [review]. Eur Spine J 2011;20(5):690–7.

8. Lewis R, Williams N, Matar HE, et al. The clinical effectiveness and cost-effectiveness of management strate-gies for sciatica: systematic review and economic model. Health Technol Assess 2011;15(39):1–578.

9. Jacobs WC, van Tulder M, Arts M, et al. Surgery versus conservative manage-ment of sciatica due to a lumbar herni-ated disc: a systematic review. Eur Spine J 2011;20(4):513–22.

10. Roncoroni C, Baillet A, Durand M, et al. Efficacy and tolerance of systemic ster-oids in sciatica: a systematic review and meta-analysis. Rheumatology (Oxford) 2011;50(9):1603–11.

11. Toward Optimized Practice. Alberta primary care low back pain guideline:

True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.

No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.

Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery. In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.

Key Points

updated and revised November 2011. Edmonton (AB): Toward Optimized Practice, 2011; http://www.topalber-tadoctors.org/cpgs.php?sid=63&cpg_cats=85. Accessed November 9, 2012.

12. Furlan AD, Reardon R, Weppler C; National Opioid Use Guideline Group. Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ 2010;182(9):923–30.

13. Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: advice for high-value health care from

the American College of Physicians. Ann Intern Med 2011;154(3):181–9. Erratum in: Ann Intern Med 2012;156(1 Pt 1):71.

14. Radcliff K, Hilibrand A, Lurie JD, et al. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am 2012;94(15):1353–8.

15. Battié MC, Jones CA, Schopflocher DP, Hu RW. Health-related quality of life and comorbidities associated with lumbar spinal stenosis. Spine J 2012;12(3):189–95.

16. Ammendolia C, Stuber K, de Bruin LK, et al. Nonoperative treatment of lumbar spinal stenosis with neurogenic claudi-cation: a systematic review. Spine (Phila Pa 1976) 2012;37(10):E609–16.

17. Issack PS, Cunningham ME, Pumberger M, et al. Degenerative lumbar spinal stenosis: evaluation and manage-ment [review]. J Am Acad Orthop Surg 2012;20(8):527–35.

18. Tosteson AN, Tosteson TD, Lurie JD, et al. Comparative effectiveness evi-dence from the spine patient outcomes research trial: surgical versus nonopera-tive care for spinal stenosis, degenera-tive spondylolisthesis, and intervertebral disc herniation. Spine (Phila Pa 1976) 2011;36(24):2061–8.

19. Rampersaud YR, Wai EK, Fisher CG, et al. Postoperative improvement in health-related quality of life: a national comparison of surgical treatment for focal (one- to two-level) lumbar spi-nal stenosis compared with total joint arthroplasty for osteoarthritis. Spine J 2011;11(11):1033–41.



+

Criteria for Surgical Referral

Emergency Referral

The symptoms of Cauda Equina Syndrome are: • Urinaryretentionfollowedbyinsensible urinaryoverflow. • Unrecognizedfecalincontinence. • Lossordecreaseinsaddle/perinealsensation.Acute Cauda Equina Syndrome is a surgical emergency.

Consider Elective Referral

Failure to respond to a trial of conservative care: • Unbearableconstantlegdominantpain • Worseningnerveirritationtests (SLRorfemoralnervestretch) • Expandingmotor,sensoryorreflexdeficits • Recurrentdisablingsciatica • Disablingneurogenicclaudication

Clinical Pearls

34 TOPIC HUBSarthritis cancer cardio-/cerebrovascular dementia diabetes/endocrine drug safetygastrointestinal diseaseslung diseases mental health men’s health

musculoskeletal neurology nutrition osteoporosis pain preventive health women’s health addiction biology of aging caregiving ear and eye falls and �tness dermatologygenetic hematologic incontinence infectious law/ethics liver diseases oral health perioperative renal diseases technology urogenital disorders


>>

6 issues / year

FREE Subscriptions forPractising Canadian Physicians

DIGITAL EDITIONS

Register for your free subscription to have access to the following additional resources:

Animations • Videos • Illustrations

Digital Editions of this Supplement Available at:

www.healthplexus.net/physician

Date post:	06-Aug-2020
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

LOW BACK PAIN STRATEGY This tool will guide the clinician ... · QUICK FACTS A LOOK AT BACK PAIN 4...

Documents