Managing Back Pain in General Practice Its a pain in the'

1
Managing Back Pain in General PracticeIts a
pain in the.

• Presented by
• - North East Valley Division of General Practice
• - Northern Division of General Practice
• - Melbourne Division of General Practice
• - The National Prescribing Service

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Program

• Two case studies
• Initial presentation
• Acute case study
• Discussion in small groups
• Presentation discussion
• Subsequent presentation
• Chronic case study
• Group discussion
• Panel Discussion
• Resources for GPs patients

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Back Pain

• Most frequent musculoskeletal condition seen in
  GP
• 7th most common reason for seeking care
• around 85 have a non-specific cause of pain
• serious conditions are rare
• Recovery time
• 80 and 90 of patients with acute back pain
  recover within 6 weeks

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Back Pain

• Most common presentation
• is non-specific low back pain associated with
  decreased spinal movement
• Less common causes of back pain
• include trauma, disorders producing neurological
  lesions
• Infection
• neoplasm
• metabolic bone disease

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Acute Back Pain

• Aim of management
• Identify potentially serious causes of acute low
  back pain
• Promote effective self-management of symptoms
  through the provision of timely and appropriate
  advice
• Maximise functional status
• Minimise disability.

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Acute Low Back pain

• DEFINITION
• Refers to an episode of pain of less than 3
  months duration
• ASSESSMENT should differentiate between
• Acute low back pain (non-specific or simple)
• Spinal pathology
• Nerve root pain

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Initial Presentation

• Brett
• 32 year old air conditioning technician
• New to your practice
• Consults you at midday
• He has hurt his back

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Initial Presentation continued

• Brett hurt his back while working in the roof
  space of a building
• Twisted around to lift equipment
• Felt sharp pain in lower back
• Took a few minutes before he could move
• Had considerable difficulty getting back down the
  ladder
• He lay down for about 1/2 an hour until the pain
  lessened
• Came straight to the clinic

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Initial Presentation continued

• Brett has asthma
• Uses a salbutamol inhaler when he needs it
• Airmir, Asmol, Epaq, Ventolin
• No other significant history

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Initial Presentationdiscuss in small groups

• Case update in 10 -15 minutes

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Initial Presentation case update

• Brett rates his current pain at 6/10
• After assessment
• you conclude Bret has work related acute
  non-specific low back
• Brett has been prescribed paracetamol 500mg and
• codeine 30mg (Codalgin Forte, Dymadon Forte,
• Panadeine Forte) in the past for pain and says
  the only
• thing the codeine does to him is to make him
• constipated.

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Initial Presentation continued

• Question 1
• How would you assess the severity of Bretts
  pain?

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Initial Presentation continued

• Question 1
• How would you assess the severity of Bretts
  pain?
• Also .
• How often should you measure pain?
• Apart from pain severity, what else do you look
  for in the pain history?

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Initial Presentation continued

• Question 1
• Key message
• Assess document characteristics of pain to
  individualise monitor effectiveness of
  treatment.

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Initial Presentation continued

• Question 2
• What is the analgesic of first choice for acute
  low back pain?

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Initial Presentation continued

• Question 2
• What is the analgesic of first choice for acute
  low back pain?
• Also .
• If you were to use paracetamol what dosage is
  appropriate for acute low back pain?

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Initial Presentation continued

• Question 2
• Key message
• Use paracetamol first, as it is effective when
  taken regularly in appropriate doses and has a
  good safety profile.

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Initial Presentation continued

• Question 3
• What about an NSAID?

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Initial Presentation continued

• Question 3
• What about an NSAID?
• Also .
• Is a conventional NSAID appropriate for Brett?
• Is a COX-2 selective NSAID appropriate for Brett?
• What about a paracetamol/codeine combination?

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Initial Presentation continued

• Question 3
• Key messages
• Before prescribing COX-2 selective or
  conventional NSAIDS, review risk of peptic ulcer,
  cardiac disease or renal impairment.
• COX-2 selective NSAIDS are not more effective
  than conventional NSAIDS and have a similar range
  of adverse effects.

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Initial Presentation continued

• Question 4
• What about tramadol?

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Initial Presentation continued

• Question 4
• What about tramadol?
• Also .
• Is tramadol an opioid?
• What is tramadol's adverse event profile
• What about drug interactions with tramadol?
• If you did decide to prescribe tramadol for Brett
  what dose would you use?
• Would a sustained release preparation be helpful
  for Brett?

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Initial Presentation continued

• Question 4
• Key message
• Consider the range of adverse effects and serious
  drug interactions with tramadol when selecting
  therapy where pain requires an opioid or
  opioid-like analgesic.

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Initial Presentation conclusion

• As Brett is not on any interacting medications
• you decide to prescribe Brett tramadol 50mg four
  times/day for pain relief.
• You have provided him with information on the
  potential adverse effects of tramadol
• Brett is happy to give it a try.
• You ask Brett to come back in 3 days
• so that you can monitor his progress and if
  improving reduce/cease his tramadol.

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Subsequent Presentation.4 months later

• Group discussion

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Subsequent Presentation.4 months later

• Brett returns
• He has persistent lower back pain and has been
  unable to return to work.
• Brett was prescribed Oxycontin 20mg capsules 6
  hourly PRN by another doctor 2 wks ago. However,
  Oxycontin has not really helped and it makes him
  nauseas.

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Subsequent Presentation.4 months later

• persistent lower back pain
• unable to return to work.
• prescribed Oxycontin
• Oxycontin has not helped
• makes him nauseas
• Brett is finding himself irritable tired.
• His workplace has been unable to to offer him
  light duties.
• He also informs you at this visit that his wife
  is heavily pregnant with their third child.

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Subsequent Presentation.4 months later

• Questions
• How would you assess Bretts pain now?
• What else might you assess?
• What pharmacological solutions are there?
• Is it appropriate to continue Oxycontin?
• What non-pharmacological solutions are there?

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Summary

• Contrast b/w Acute Chronic Back Pain
• Acute pain generally improves and psycho-social
  factors are rarely an issue
• Chronic pain rarely has a recognisable
  pathological cause and psychosocial factors
  predominate
• Patients with chronic pain need to learn to cope
  with the pain and move forward in their lives

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Summary

• Key messages Assessment
• Assess document characteristics of pain to
  individualise monitor effectiveness of
  treatment (same for acute chronic pain).
• Consider other morbidity
• Psychological issues eg self esteem, depression
• Social impact eg family relationships
• ADL disability eg unable to look after garden etc

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Summary

• Key messages Pharmacotherapy
• Use paracetamol first, as it is effective when
  taken regularly in appropriate doses and has a
  good safety profile.
• Before prescribing COX-2 selective or
  conventional NSAIDS, review risk of peptic ulcer,
  cardiac disease or renal impairment.
• COX-2 selective NSAIDS are not more effective
  than conventional NSAIDS and have a similar range
  of adverse effects.

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Summary

• Key Messages Non-pharmacological
• Physical psychological therapies
• Yellow red flags
• When to refer