Back Pain Flashcards by Jordan Cyr

What are some of the likely causes of back pain?

osteoarthritis
muscle strain
hip joint problem
sciatica
osteoporosis
slipped disk
WITHIN THE REALM OF MD, PHYSIO, CHIRO

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Where is sciatica pain usually more severe?

usually more severe in your leg compared to your lower back
-nerve pain at the top of the pathway
-neuropathic pain

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How does osteoporosis contribute to back pain?

as you shrink and slouch, your bones start to crumble which will hit some things in your back
compression fractures become common

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What are some conditions where we develop referred back pain?

disorder of large bowel
dysmenorrhea
renal condition
prostate
UTI

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What are some factors that can contribute to the development of back pain?

sedentary lifestyle
bursts of activity/improper lifting
pregnancy
poor posture
bad shoes
excess weight

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What is often the reason for chronic back pain?

some muscles being in play, while others arent=problem
-ex: weak abdominals, tight erector spinae, tight rectus
femoris–>pelvis pulls forward, exaggerated lumbar curve
-ex: tight rectus abdominus, tight glutes, tight hamstrings
–>flattened lumbar curve, pelvis tilts backward

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What can be a pain amplifier of back pain?

psychological aspects

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What percentage of cases of back pain lack a definitive cause?

85%
-MDs try to rule out red flags

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True or false: getting an x-ray done is considered standard of care for early on back pain

false
-substantial risk of uncovering irrelevant and misleading
findings

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When would radiology come into play for back pain?

if red flags are absent, delay radiology until 6th week of conservative (including drugs) management

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What are the symptoms of back pain?

tightness in lower back/back spasms
-spasms are the bodys way of protecting an injury
difficulty bending, moving, sitting

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When asking a patient to describe their back pain, what are some questions to ask?

shooting? dull? constant?
back pain vs leg pain?
any numbness in bum area?
when worse? better?
how long has it been and how bad is the pain?
just in your lower back or higher up? sore neck?
any chance it was due to a fall?
worse when lying down/sleeping?
besides pain, any fever, chills, weight loss?

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What are some red flags with back pain that require referral? How soon should an MD be seen for each case?

pain located in high spine (beyond simple sore neck)
-2 days
trauma (fell from height)
-ASAP
fever, chills, unexplained weight loss
-ASAP
pain worse when lying down/numbness
-2 days
numbness in bum area
-ASAP
bladder/bowel dysfunction
-ASAP
young kids or eldery
-make appointment (chronic=new appt, new case=2 days)
leg pain>back pain
-make appt
increasing pain
-2 to 7 days
oral steroid usage
-ASAP

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True or false: neuropathic pain is more common in chronic cases

true

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What are some signs of neuropathic pain?

burning or tingling
hypersensitivity to touch or cold

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What can cause neuropathic pain?

compression of a nerve (ex: ruptured intervertebral disk)
nerve damage (ex: diabetes)

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Differentiate between neuropathic and nociceptive pain.

neuropathic: damage to or dysfunction of the nerves
nociceptive: injury to body tissues

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What are some signs of nociceptive pain?

pain that is aching, sharp, or throbbing
MOST PAIN IS NOCICEPTIVE

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What kind of pain is sciatica?

neuropathic

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Will NSAIDs or opioids be good for sciatica?

not great

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What is something you should always ask in a back pain consult?

what have you tried?

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True or false: most back pain is related to an event or a medical condition

false

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What is our role in back pain management?

safe med use and referring to physiotherapy or massage

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What is cervical spondylotic myelopathy?

one of the most common neck conditions
over time, wear-and-tear effects of aging lead to narrowing of spinal canal, compressing the spinal cord
pain, numbness, weakness
HALLMARK SYMPTOM: weakness/stiffness in leg

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What can nocturnal back pain be a symptom of?

spinal tumors spinal bone infection (osteomyelitis) ankylosing spondylitis (wakes you up in 2nd half of night)

What is cauda equina syndrome?

nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder medical emergency

A patient with one red flag of back pain has a ____% chance of it being something serious

10%

How can you manage back pain?

proper posture/sleep balance of back/abdominal muscles (spine moves in direction of stronger muscles) traction is not helpful chiropractic care most get better on their own

In terms of how much rest we need post-injury, what is the new thinking process?

return to normal activities -not our call to make

True or false: we can recommend stretching for back pain

false

What is the value of acetaminophen (up to 4g/d) for back pain?

analgesia: yes anti-inflammatory: NONE not efficacious for back pain, no impact on osteoarthritis

In regards to acetaminophen for back pain, what is our recommendation?

acetaminophen for 2 weeks, then we re-assess OR try Voltaren first, then ibuprofen or naproxen

What is the value of ASA (up to 4g/d) for back pain?

analgesia: yes anti-inflammatory: yes

What is the value of ibuprofen (200mg 6x/d or 400mg TID) for back pain?

analgesia: yes anti-inflammatory: not at OTC doses

What is the value of naproxen (440mg/d) for back pain?

analgesia: yes anti-inflammatory: not at OTC doses

What is the lowest anti-inflammatory dose of ibuprofen? What about naproxen?

ibu: 400-600mg TID (past OTC max) naproxen: 375mg BID (past OTC max)

What is the MOA of skeletal muscle relaxants?

maybe sedation -supposed to change muscle spasms to relax them -notoriously not effective

True or false: skeletal muscle relaxants are anti-spasmodic

false

What are the side effects of skeletal muscle relaxants?

CNS side effects -sedation -dry mouth

What is are examples of a skeletal muscle relaxants?

methocarbamol -poor agent, hardly any relaxant effect doxylamine orphenadrine chlorzoxazone

What are the agents in the following: Robax Platinum, Robaxacet, Robaxacet ES, Robaxisal, Robaxin

Robax Platinum: methocarbamol 500, ibuprofen 200 Robaxacet: methocarbamol, acet 325 Robaxacet ES: methocarbamol, acet 500 Robaxisal: methocarbamol, ASA 500 Robaxin: methocarbamol 500 2 tabs QID

Which product would you choose first for back pain: plain analgesic, muscle relaxant, or combo?

plain analgesic

What is something you need to mention in every back pain counsel?

use of heat and cold

How are heat and cold used in back pain?

firs 48 hours up to 5 days: cold (anti-inflammatory) recurring episode of chronic LBP: heat (anti-spasmodic)

What are Robax heat wraps?

wrap that goes around the waist with crystals that heat up upon contact with air provides 8hrs of heat and 8hrs of further effects

What is the MOA of topical external analgesics?

counter irritation -irritates skin, there is already pain/irritation there, brain cant handle both signals massage/blood flow psychological (odor)

Are topical external analgesics more helpful for sore muscles or sore back?

sore muscles -expect less for sore back

What are the main agents used in topical external analgesics?

methyl salicylate menthol

At what concentration is menthol a counter-irritant?

>1%

What is a counter-irritant that does not have the Christmas tree odour?

triethanolamine

What should be avoided while using counter-irritants like menthol or methyl salicylate?

heating pad at the same time

Would capsaicin be helpful for back pain?

no for PHN irritating when applied

Which strength would you go for with topical diclofenac?

extra strength (2.3%, BID, drives through skin better) =not a bad move

What is likely the best agent for lower back pain?

topical diclofenac -diclofenac>standard analgesics>A535 products -DOC in patients >75yo

Which areas of the body does Voltaren have its greatest proof of effect?

OA for knees and hands

True or false: Voltaren has more side effects than oral NSAIDs

false

What are the directions for use of Voltaren regular strength?

1 FTU TID-QID (1 FTU will be fine for most cases)

How many times per day is Voltaren extra strength applied?

BID -still an FTU

Are herbals of great use for back pain?

none of great use yet (except turmeric)

True or false: glucosamine is great for back pain

false

What is the difference between curcumin and turmeric?

curcumin is a naturally occurring chemical compound found in the spice turmeric -turmeric is the yellow powder used to flavour foods -curcumin is contained within turmeric

At what dose has curcumin shown efficacy for relief of pain in arthritis? How many grams of turmeric is needed to achieve the effects of curcumin?

1g 30g of turmeric=2g of curcumin

What is the worry with back braces?

may relax the wrong muscles or strengthen the wrong muscles -keep loose when not active -tighten when lifting/pulling

What is an Rx agent that might be a last ditch effort for back pain? How should this agent be used?

cyclobenzaprine -blocks nerve impulses used for short periods (2-3 weeks)

What are the side effects to mention with cyclobenzaprine?

drowsiness dry mouth fatigue DONT MENTION HEADACHE, DIARRHEA, ACID REFLUX, ETC

What is often the most common agent for neuropathic pain?

antidepressants -less valuable than we initially thought

How does Icy Hot work?

hits cool receptors for first half an hour and then kicks into warmth -same drug in both phases (menthol)

Does methyl salicylate have the cooling effect like menthol?

no but still can do the job