How we think about back pain

Dr Adrian Nowitzke

Graphic from www.hibiscusflowershop.blogspot.com

ACUTE CHRONIC

Duration

Themovetowardchronicity.Treatments. Work.

ACUTE

CHRO

NIC

Durationandfrequency

SPECIFIC

NONSPECIFIC

Specificity

Causation.Localisation. Radicularnature.Investigation.Treatments.

SPECIFIC

NONSPECIFIC

Specificityandfrequency

ACUTESPECIFIC

ACUTENONSPECIFIC

CHRONICSPECIFIC

CHRONICNONSPECIFIC

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FACTOR GOOD BAD

pain intensity low high

symptomduration short long

disability mild-moderate severe-crippling

distress low high

depression/anxiety absent present

fear-avoidance absent present

well being high low

opiates no yes

compensation absent present

litigation absent present

abn.illness.behavior absent present

degenerate levels single multiple

Waddell’snonorganicsigns

Tenderness:Superficial(lumbarskintendertolighttouch)andnonanatomical (deeptendernessoverawideareathatcrossesmusculoskeletalboundaries)

Simulation:Axial loading(lightdownwardpressureontheheadcausespain)andsimulatedrotation(backpainonpseudorotation ie.rotationofpelvisandspinetogether)

Distraction:Supinevs seatedSLR(significantdifferencebetweeen straightlegraisingwhenlyingdowncomparedwithwhensittingup)

Regionalchanges:Weakness(cog-wheeltypeweaknesswithgivingwayofseveralmusclegroups)andsensorychange(widespreadnonanatomical alterationoflighttouchsensation)

Threetakehomestrategies

1.Understandandexplainthecause

80%ofpeoplegetbackpain.90%improvewithin3months.Forthosewhodonotimprove(chronicnon-specific)

Mostpeoplehavenothingseriouswrong.Multipleinvestigationsandacutetreatmentsareunhelpful.Thereislikelytobeacentralcausethatisnotwellunderstood.

2.Provideevidence-basedtreatmentadvice

ImprovefunctiondespitepainratherthancurepainMaintenancevs acutedeteriorationprograms• Move• Corestrength,backstrength,backflexibility• Psychologysupport• Simpleanalgesia- zeroopioidsinmostcases• PrimaryratherthanspecialistcareNosurgeryinmostcases

3.Avoidmakingthingsworse

Recognise thoseatriskofchronicity.Minimise theuseofopiates.Discourageprolongedpassivetreatments.Ensureimagingdonewithcontextualinterpretation.Refer judiciouslytoexcludetreatablecause.Facilitatereturntoactivityandwork.Trytohelpinthecompensationprocess.Donotencouragelitigation.

Thankyou