Low back pain is the single leading
cause of disability worldwide, according to the Global Burden of Disease 2010. In fact, 31 million Americans experience low-back pain at
any given time1
and one-half of all working Americans admit to having back pain
symptoms each year.2
Back pain is one of the most common reasons for missed work
and is the second most common reason for visits to the doctor’s office,
outnumbered only by upper-respiratory infections. Most cases of back pain are mechanical or non-organic—meaning
they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer.3
Experts estimate that Up to 84 percent of adults have
low back pain at some time in their lives.4,5
Fortunately, most episodes of
back pain resolve with time: approximately 50% of patients will
experience back pain relief within two weeks and 90% within three months. While most episodes of back pain are
self-limited, 5% to 10% of cases will become chronic (i.e., long-lasting and
recurrent). Chronic back pain accounts for 90% of the healthcare expenditures
for back pain and amounts to $50 to $80 billion dollars annually. 6
This discussion will focus on
how a multidisciplinary chiropractic practice (Pain Relief Centre) will approach
to the initial evaluation of a patient presenting with back pain.
CLINICAL EVALUATION —
History of
Present Illness (HPI)/Chief Complaint(CC)
Obtaining
an accurate history is the critical first step in determining the etiology of a
patient's problem. The patient initiates this process by describing their
symptoms and what caused them. The
patient's reason for presenting to the clinician is usually referred to as the
"Chief Complaint." The patient describes the problem in his or her
own words.
Follow-up Questions: OPQRST is the mnemonic used for learning about the patient’s
pain complaint. Here
are some of the OPQRST questions asked by the physician:
·
Onset: “Did
your pain start suddenly or gradually get worse and worse?” This is also a
chance to ask, “What were you doing when the pain started?”
·
Provokes or Palliates: “What makes your pain better or worse?”
·
Quality: “What
words would you use to describe your pain?” or “What does your pain feel like?”
·
Radiates: “Point to where it hurts the most. Where does your pain go from
there?” “Does your pain radiate?”
·
Severity: On a scale of 0 to 10 with 10 being the worst pain you've
ever experienced, what number would you assign to your discomfort?
·
Time: When did this pain start and has it changed in any way since
it came on? How long has this condition lasted? Is it similar to a past
problem? If so, what was done at that time?
REVIEW OF SYSTEMS (ROS)
A ROS is an inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms which the patient may be
experiencing or has experienced.
For purposes of ROS, the following systems are recognized:
• Constitutional symptoms (e.g., fever, weight loss) • Eyes
• Ears, Nose,
Mouth, Throat
• Cardiovascular • Respiratory
• Gastrointestinal
•
Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast) •
Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
•
Allergic/Immunologic
PAST MEDICAL, FAMILY AND/OR SOCIAL HISTORY (PFSH)
The PMFSH consists of a review of three areas:
•
past medical history (the patient's past experiences
with illnesses, operations, injuries and treatments);
•
family history (a review of medical events in the
patient's family, including diseases which may be hereditary or place the
patient at risk); and
•
social history (an age appropriate review of past
and current activities).
ELEMENTS
OF A MUSCULOSKELETAL EXAMINATION —
Constitutional:
Measurement of any three of the
following seven vital signs: 1) sitting or standing blood pressure, 2)
supine blood pressure, 3) pulse rate and regularity, 4) respiration,
5)
temperature, 6) height, 7) weight.
General
appearance of patient (eg, development, nutrition, body habitus, deformities,
attention to grooming)
Cardiovascular:
Examination of peripheral vascular system by observation (eg, swelling,
varicosities) and palpation (eg, pulses, temperature, edema, tenderness)
Lymphatic:
Palpation of lymph nodes in neck, axillae, groin and/or other location
Musculoskeletal:
Examination
of gait and station
Examination
of joint(s), bone(s) and muscle(s)/ tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs
and pelvis; 3) right upper extremity; 4) left upper extremity;
5) right lower extremity;
and 6) left lower extremity. The examination of a given area includes:
• Inspection,
percussion and/or palpation with notation of any misalignment, asymmetry,
crepitation, defects, tenderness, masses or effusions
• Assessment
of range of motion with notation of any pain (eg, straight leg raising),
crepitation or contracture
• Assessment
of stability with notation of any dislocation (luxation), subluxation or laxity
• Assessment
of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of
any atrophy or abnormal movements
Skin: Inspection and/or palpation of skin and
subcutaneous tissue (eg, scars, rashes, lesions, cafe- au-lait spots, ulcers)
in four of the following six areas: 1) head and neck; 2) trunk; 3) right
upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left
lower extremity.
Neurological/ Psychiatric: Test coordination (eg,
finger/nose, heel/ knee/shin, rapid alternating movements in the upper and
lower extremities, evaluation of fine motor coordination in young children)
Examination of deep tendon reflexes and/or nerve
stretch test with notation of pathological reflexes (eg, Babinski)
Examination of sensation (eg, by touch, pin,
vibration, proprioception) Brief assessment of mental status including
• Orientation
to time, place and person
•
Mood
and affect (eg, depression, anxiety, agitation)
MEDICAL DECISION
MAKING/ASSESMENT/PLAN — Recommended
level of care (duration, frequency, re-exam time frame) and Specific treatment
goals.
RADIOGRAHIC IMAGING — Medically
X-rays, MRI, or CT scan are not recommended for routine evaluation of patients
with acute back problems within the first 4-6 weeks of symptoms unless a red
flag and high index of suspicion is noted on clinical evaluation. However,
Chiropractors deals with a special population of patient, this population gets
manipulation. When manipulating the spine the physician needs to have imaging
as a safety precaution and to rule out a more serious disease process.
IF INDICATIONS FOR REFERRAL — Referral
to primary physician or other specialist is performed when needed.
SUMMARY
●Back pain is the second most common symptomatic reason for
medical office visits in the US. Risk factors include age, general health,
occupation, lifestyle, psychosocial, and cultural factors.
●Patients with low back pain should undergo a complete HPI/OPQRST,
PMFS history and examination.
●After the assessment/diagnoses has been made the
chiropractic physician will suggest a treatment plan including recommended level of care (duration, frequency,
re-exam time frame) and specific treatment goals.
REFERENCES
1. Jensen M, Brant-Zawadzki M,
Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People
Without Back Pain. N Engl J Med 1994; 331: 69-116.
2. Vallfors B. Acute, Subacute and Chronic Low
Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab
Med Suppl 1985; 11: 1-98.
6.
http://www.spine-health.com/conditions/lower-back-pain/introduction-back-pain-and-neck-pain.
