Back Pain

What is back pain?

Any pain in the back. It is usually Any pain in the back. It is usually characterized by dull, continuous characterized by dull, continuous pain and tenderness in the lower pain and tenderness in the lower lumbar, lumbosacral, or sacroiliac lumbar, lumbosacral, or sacroiliac regions. Sometimes referred to regions. Sometimes referred to the leg, following the distribution the leg, following the distribution of the sciatic nerve.of the sciatic nerve.

How Big Is the Problem? 2nd most common cause for GP visit .2nd most common cause for GP visit . 70% of the world adults will experience 70% of the world adults will experience

at least one disabling episode in their at least one disabling episode in their lives.lives.

Each year, 15-20% will have back pain.Each year, 15-20% will have back pain. Most common cause of disability for Most common cause of disability for

persons < 45 years.persons < 45 years. Disability due to back pain, particularly Disability due to back pain, particularly

work absence, has increased work absence, has increased significantly in the last 30 years.significantly in the last 30 years.

How Big Is the Problem?

8% of US population is disabled.8% of US population is disabled. Costs to society: $20-50 billion/year.Costs to society: $20-50 billion/year.

In US:In US:

In western countries, back pain is the most In western countries, back pain is the most common cause of sickness-related absences from common cause of sickness-related absences from work.work.

In UK:In UK: 7% of adult population consult their GP each year 7% of adult population consult their GP each year

with back pain.with back pain. Costs to society: Costs to society: ££ 500 million/year. 500 million/year.

Back Back PainPain

acuteacutechronicchronic

recurrent recurrent

Classification of back pain

Acute V.S Chronic

Most acute episodes improve regardless Most acute episodes improve regardless of the treatment used, and the patient of the treatment used, and the patient resumes normal activity within 6 weeks.resumes normal activity within 6 weeks.

Chronic pain develops in only 10% to 15% Chronic pain develops in only 10% to 15% of patients but it can cause significant of patients but it can cause significant distress and functional disability and distress and functional disability and requires aggressive treatment.requires aggressive treatment.

Back Back PainPain

uncomplicateduncomplicated

complicatedcomplicated

Systemic causesSystemic causes

Causes of Back Pain

Referred painReferred pain

Psychogenic factorsPsychogenic factors

(somatization)(somatization)

Uncomplicated Back PainUncomplicated Back Pain

Caused by some kind of structural Caused by some kind of structural problem (bone, muscle, joint, disc, nerves problem (bone, muscle, joint, disc, nerves associated with lumber vertebrae or associated with lumber vertebrae or pelvis, tendon or ligament).pelvis, tendon or ligament).

The most common mechanisms seem The most common mechanisms seem to be injury to muscles & ligament, to be injury to muscles & ligament, osteoarthritis, degenerative disc osteoarthritis, degenerative disc disease, & malalignmet of spinal cord.disease, & malalignmet of spinal cord.

Injury to muscle & Injury to muscle & LigamentsLigaments

Includes strain, sprain or contusion of muscle and/or ligaments.Includes strain, sprain or contusion of muscle and/or ligaments. Occur when performing day-to-day activities, or from direct trauma Occur when performing day-to-day activities, or from direct trauma

such as a fall.such as a fall. It the most common cause of acute low back pain, especially in It the most common cause of acute low back pain, especially in

young adults.young adults. Patients with muscle & ligament injuries usually develop pain after Patients with muscle & ligament injuries usually develop pain after

unusual physical activity.unusual physical activity.

Degenerative Joint Degenerative Joint Disease Disease (Osteoarthritis)(Osteoarthritis)

Is the most common cause of chronic low back pain in the elderly.Is the most common cause of chronic low back pain in the elderly. Loss of articular cartilage, osteophyte formation, and articular Loss of articular cartilage, osteophyte formation, and articular

surface irregularity impair joint function and at times can lead to surface irregularity impair joint function and at times can lead to inflammation and pain.inflammation and pain.

Patients can experience pain in different situations (e.g. after Patients can experience pain in different situations (e.g. after unusual positioning or even while sleeping on a soft mattress).unusual positioning or even while sleeping on a soft mattress).

Degenerative Disc Degenerative Disc DiseaseDisease

Weakening of the fibrous outer ring of an intervertebral Weakening of the fibrous outer ring of an intervertebral disc (the annulus fibrosus).disc (the annulus fibrosus).

Can cause the gelatinous center of the disc ( the nucleus Can cause the gelatinous center of the disc ( the nucleus pulposus) to bulge or to herniate (extrude or rupture) into pulposus) to bulge or to herniate (extrude or rupture) into the spinal canal.the spinal canal.

The discs most commonly involved are L3-L4, L4-L5, L5-S1.The discs most commonly involved are L3-L4, L4-L5, L5-S1.

MalaignmentMalaignment

Motion restriction of spinal structures Motion restriction of spinal structures such as the facet joints, the sacroiliac such as the facet joints, the sacroiliac joint and/or the vertebral bodies.joint and/or the vertebral bodies.

Spondylolysis & Spondylolysis & SpondylolisthesisSpondylolisthesis

SpondylolysisSpondylolysis describes any sitution where there is a break in the integrity of describes any sitution where there is a break in the integrity of the neural arch.the neural arch.

The principal cause is an aquired defect in pars interarticularis due to fracture.The principal cause is an aquired defect in pars interarticularis due to fracture.

SpondylolisthesisSpondylolisthesis is where defect causes slippage of vertebra on the on below. is where defect causes slippage of vertebra on the on below.

Other CausesOther Causes

Fractures (usually a compression fracture of the vertebral body, Fractures (usually a compression fracture of the vertebral body, often caused by minor trauma in older people with Osteoarthritis).often caused by minor trauma in older people with Osteoarthritis).

Type of occupations (workers in occupation requiring lifting heavy Type of occupations (workers in occupation requiring lifting heavy objects).objects).

Smoking.Smoking. Obesity.Obesity.

Complicated Back PainComplicated Back Pain

Structural with nerve root compromise (sciatica).Structural with nerve root compromise (sciatica). It is a condition in which pain, numbness, It is a condition in which pain, numbness,

paresthesia &/or muscle weakness reflect injury to paresthesia &/or muscle weakness reflect injury to the spinal root or PN.the spinal root or PN.

The most common cause is herniation of IV disc.The most common cause is herniation of IV disc.

Spinal StenosisSpinal Stenosis

Back & leg symptoms associated with narrowing of the Back & leg symptoms associated with narrowing of the lumbar spinal canal seen on CT or MRI scanning.lumbar spinal canal seen on CT or MRI scanning.

The origin of the pain is may be related to bony pressure The origin of the pain is may be related to bony pressure on multiple nerve roots, leading to ischemia of the nerves on multiple nerve roots, leading to ischemia of the nerves & pain.& pain.

The origin of the narrow canal may be congential.The origin of the narrow canal may be congential.

Systemic CausesSystemic Causes

Are rare (less than 1% of all cases).Are rare (less than 1% of all cases). They include cancer, infections, They include cancer, infections,

inflammatory arthritis and Paget’s inflammatory arthritis and Paget’s disaese.disaese.

Referred PainReferred Pain

Referred pain from abdominal or pelvic structures can Referred pain from abdominal or pelvic structures can arise from structures such as muscle, ligaments, or joint arise from structures such as muscle, ligaments, or joint capsules.capsules.

The most common are: acute pancreatitis, pyelonephritis, The most common are: acute pancreatitis, pyelonephritis, pelvic inflammatory disease, dysmenorrhea, posterior pelvic inflammatory disease, dysmenorrhea, posterior peptic ulcer, abdominal aneurysm & cholecystitis. peptic ulcer, abdominal aneurysm & cholecystitis.

Because the majority of Because the majority of physician visits for low back pain physician visits for low back pain are to the GPs, family physician are to the GPs, family physician must has good skills in must has good skills in approaching, assapproaching, assessing & essing & managing the patient with low managing the patient with low back pain.back pain.

أوزعني أن أشكر نعمتك ِبIر

التي أنعمت علي وعلى والدي

وأن أعمل صالحا ترضاه و

أدخلني برحمتك في عبادك

الصالحين.

History taking in a History taking in a patient with lower patient with lower

back painback pain

Basic information about Basic information about the patientthe patient Name & addressName & address

SexSex

1.1. Male: prostatic cancer, peptic ulcer Male: prostatic cancer, peptic ulcer disease,vertebral osteochondritisdisease,vertebral osteochondritis

2.2. Female:endometrosis,pregnancy,ovarian Female:endometrosis,pregnancy,ovarian cancercancer

Age Age

1.1. young people :endometrosis,Ankolizing young people :endometrosis,Ankolizing spodylitis spodylitis

2.2. old people:multiple myleoma ,prostatic old people:multiple myleoma ,prostatic cancercancer

OccupationOccupation Marital status.Marital status.

Description of the Description of the presenting problempresenting problem

Specify the main complain Specify the main complain LocationLocation

1.1. bilateral pain: sacroiliac joint disease.bilateral pain: sacroiliac joint disease.

2.2. psychogenic pain is not well localised.psychogenic pain is not well localised. Character Character RadiationRadiation

1.1. To the lower limb :nerve root irritation .To the lower limb :nerve root irritation .

2.2. Passing above flank region :kidney Passing above flank region :kidney disease.disease.

Duration of pain :Duration of pain :

1.1. Most mechanical pain is intermittentMost mechanical pain is intermittent

2.2. Medical conditions cause chronic pain Medical conditions cause chronic pain that is persistentthat is persistent

3.3. Tumor of the spine : pain builds in Tumor of the spine : pain builds in intensity over monthsintensity over months

History of the presenting History of the presenting complaincomplain

When did it start\onset of painWhen did it start\onset of pain

1.1. Mechanical :acute sudden onset with Mechanical :acute sudden onset with mechanically disadvantaged position. mechanically disadvantaged position.

2.2. Medical causes: gradual slower onset.Medical causes: gradual slower onset. Why do you thing you got it ?Why do you thing you got it ? Associated symptoms.Associated symptoms.

1.1. Numbness ,burning sensation :neural Numbness ,burning sensation :neural involvement.involvement.

Aggravating factorAggravating factor1.1. Coughing ,sneezing,straining:nerve root Coughing ,sneezing,straining:nerve root

irritation.irritation.2.2. Bed rest: spondyloarthropathy –rolling over Bed rest: spondyloarthropathy –rolling over

bedbed Recumbency :tumor Recumbency :tumor Reliving factors.Reliving factors. bed rest:herniating discbed rest:herniating disc Patients with psychogenic pain have Patients with psychogenic pain have difficulty difficulty

describing factors that relieve or worsen their describing factors that relieve or worsen their pain.pain.

Timing of the problem:Timing of the problem:1.1. symptoms of joint compression is symptoms of joint compression is

more sever by the end of day?more sever by the end of day?2.2. In the morning you are more in danger In the morning you are more in danger

of getting disc herniation.? of getting disc herniation.? 3.3. inflammatory arthropathies :difficulty inflammatory arthropathies :difficulty

getting out of bed.getting out of bed.4.4. Patient with spinal tumors may get up Patient with spinal tumors may get up

during night and walk.during night and walk.

Review of body Review of body systemssystems Completely negative review is added Completely negative review is added

evidence for mechanical nature of the evidence for mechanical nature of the pain.pain.

Positive responses may indicate systemic Positive responses may indicate systemic cause cause

1.1. Weight lossWeight loss2.2. Cough /sputumCough /sputum3.3. Abdominal painAbdominal pain4.4. Bowel frequencyBowel frequency5.5. Rectal bleedingRectal bleeding6.6. DysuriaDysuria7.7. Hematuria.Hematuria.

Fever with acute back pain Fever with acute back pain (pyogenic sacroiliitis)(pyogenic sacroiliitis)

Menstural detailsMenstural details Weakness /numbness/wasting in Weakness /numbness/wasting in

the limbsthe limbs

Previous medical historyPrevious medical history

Malignancy (breast –prostate)Malignancy (breast –prostate) DiabetesDiabetes Previous trumaPrevious truma Surgery(IV prolapse , urter stones )Surgery(IV prolapse , urter stones ) Previous investigationPrevious investigation Obstrectic history.Obstrectic history. ContraceptionContraception History of steroid therapy. History of steroid therapy.

Family historyFamily history

Spondylarthropathies Spondylarthropathies Malignancy Malignancy Ethnic backgroundEthnic background

1.1. Caucasian women of Northern European Caucasian women of Northern European are at greater risk of developing are at greater risk of developing osteoporosis.osteoporosis.

2.2. Omani?Omani?

Social history and Social history and occupational history occupational history

Workers doing heavy lifting are at risk of Workers doing heavy lifting are at risk of developing mechanical low back pain.developing mechanical low back pain.

Drivers tend to develop musculoskeletal Drivers tend to develop musculoskeletal painpain

Smoking and alcohol are associated with Smoking and alcohol are associated with osteoporosis.osteoporosis.

History of travel.History of travel.1.1. may infection.may infection.2.2. may muscle stiffnessmay muscle stiffness

RED Flags RED Flags History of cancer History of cancer History of unexplained weight loss History of unexplained weight loss History of fever, recent infection History of fever, recent infection History of immunosuppression History of immunosuppression History of IV drug use History of IV drug use History of pain when supine; severe night pain History of pain when supine; severe night pain History of major trauma History of major trauma History of minor trauma in elderly patient History of minor trauma in elderly patient History of recent bladder or bowel dysfunction History of recent bladder or bowel dysfunction History of "saddle anesthesia" History of "saddle anesthesia" History of severe or progressive neurologic motor History of severe or progressive neurologic motor

andandsensory deficits in legs sensory deficits in legs

Examination of Examination of the Spinethe Spine

General AssessmentGeneral Assessment

Starts the moment the patient enters Starts the moment the patient enters the room till he sits .the room till he sits .

Includes observation of the following;Includes observation of the following;• Gait; watch the Pt walking (abnormal gaits)Gait; watch the Pt walking (abnormal gaits)• Pt posture including the neck and trunk. (neck Pt posture including the neck and trunk. (neck

stiffness)stiffness)• Assess erect position of head and smooth, Assess erect position of head and smooth,

coordinated neck movement. (Torticollis)coordinated neck movement. (Torticollis)• Way of sitting and facial expressions. (pain)Way of sitting and facial expressions. (pain)

Proceed to system Examination.Proceed to system Examination.• Vital signs, skin. cvs, Rs, abdomen…,(WHY?)Vital signs, skin. cvs, Rs, abdomen…,(WHY?)

Local ExaminationLocal Examination

Pt consentPt consent to fully expose .to fully expose . Includes Includes

InspectionInspection PalpationPalpation Range of motionRange of motion Special maneuversSpecial maneuvers Neurological examination.Neurological examination. Unexpected examinations ?!!!!!!!!!!!!!!!!!!!!Unexpected examinations ?!!!!!!!!!!!!!!!!!!!!

InspectionInspection

Make sure Make sure • Pt is in upright position.Pt is in upright position.• Feet together and arms hanging at the sides.Feet together and arms hanging at the sides.• Head midline in the same plane as sacrum.Head midline in the same plane as sacrum.• Shoulder and pelvis should be level.Shoulder and pelvis should be level.

Inspection of the spinal alignmentInspection of the spinal alignment• From the side. FindingsFrom the side. Findings• From behind.From behind.

Inspection of the skin.Inspection of the skin.• Hairy patch? Pigmentation, dimpling vesicels?Hairy patch? Pigmentation, dimpling vesicels?

PalpationPalpation

Think about the anatomical Think about the anatomical components.components.

Your aim is to palpate ;Your aim is to palpate ;• The Bony prominence (the spine)The Bony prominence (the spine)• The musclesThe muscles

Palpation of the spine is either by Palpation of the spine is either by • Using the thumb FindingsUsing the thumb Findings• Two fingersTwo fingers

Pal of the muscles is by using the two Pal of the muscles is by using the two hands.hands.

• Findings. (painful areas, spasm or tightness). Findings. (painful areas, spasm or tightness).

Range of MotionRange of Motion

Assessed while the patient is still Assessed while the patient is still standing.standing.

The neck than the spinal column.The neck than the spinal column. Flexion (Flexion (smoothness ,symmetry of movement, smoothness ,symmetry of movement,

range of motion and curve in the lumber area)+ the range of motion and curve in the lumber area)+ the degree.degree.

ExtensionExtension Rotation.Rotation. Lateral bending.Lateral bending.

Special ManeuversSpecial Maneuvers

Leg Frezer test (hoover test).Leg Frezer test (hoover test). Straight leg Raising test Straight leg Raising test

(mechanism and purpose )(mechanism and purpose ) The crossed Straight leg Raising The crossed Straight leg Raising

test. test.

Neurological Neurological examinationexamination

Involving the lower extremities Involving the lower extremities specifically (why?)specifically (why?)

InspectionInspection For each neurological level we For each neurological level we

shall testshall test• The muscles power, reflexes and sensory The muscles power, reflexes and sensory

areas.areas.

Additional examinationAdditional examination

The abdomen.The abdomen.

in males what else to be in males what else to be examined and why ?examined and why ?

In females and why? ¼ In females and why? ¼ Bonus.Bonus.

RememberRemember It is never It is never toooooo late toooooo late

for your for your

lunch .lunch .

INVESTIGATION AND INVESTIGATION AND MANAGEMENT MANAGEMENT

OF LOW BACK PAINOF LOW BACK PAIN

INVESTIGATIONSINVESTIGATIONS

• DO YOU THINK THAT ALL PATIENTS DO YOU THINK THAT ALL PATIENTS WITH LOW BACK PAIN PRESENTING WITH LOW BACK PAIN PRESENTING TO PRIMARY CARE PHYSICIAN NEED TO PRIMARY CARE PHYSICIAN NEED INVESTIGATIONS ?INVESTIGATIONS ?

* * MOST PATIENTS WITH LOW BACK MOST PATIENTS WITH LOW BACK PAIN DO NOT NEED INVESTIGATIONS.PAIN DO NOT NEED INVESTIGATIONS.

INVESTIGATIONSINVESTIGATIONS

1- Spinal X-rays1- Spinal X-rays

* Are required only if * Are required only if the pain is associated the pain is associated with certain red flag with certain red flag symptoms or signs, symptoms or signs, which indicate a high which indicate a high risk of more serious risk of more serious underlying problems .underlying problems .

X- raysX- rays• If the pain :If the pain : 1- Starts before the age of 20 or after 50 1- Starts before the age of 20 or after 50 years.years. 2- Is persistent and a serious cause is 2- Is persistent and a serious cause is suspected.suspected.

3- Is worse at night or in the morning , or when 3- Is worse at night or in the morning , or when an inflammatory arthritis (e.g. ankylosing an inflammatory arthritis (e.g. ankylosing spodylitis) , infection or spinal tumour may be the spodylitis) , infection or spinal tumour may be the cause.cause.

4- Is associated with a systemic illness, fever 4- Is associated with a systemic illness, fever or weight lossor weight loss 5- Is associated with neurological symptoms or5- Is associated with neurological symptoms or signssigns..

MRI & CTMRI & CT

Used when suspecting Used when suspecting spinal cancer, herniated spinal cancer, herniated disc or infection.disc or infection.

MRI is preferable toMRI is preferable toCT scanning when CT scanning when

neurological signs and neurological signs and symptoms are present.symptoms are present.

* Note* Note : If red flags are : If red flags are present , MRI should be present , MRI should be undertaken even if X-ray undertaken even if X-ray is normal.is normal.

INVESTIGATIONSINVESTIGATIONS Bone scansBone scans- Useful in infection

and malignancy

Full blood count, ESR and biochemical tests

- Required only when the pain is likely to be due to malignancy , infection or a metabolic disease

MANAGEMENT

ACUTE LOW BACK PAINACUTE LOW BACK PAIN DEPENDS ON THE INDIVIDUAL DEPENDS ON THE INDIVIDUAL

STATUS OF YOUR PATIENTSTATUS OF YOUR PATIENT

– MILD / MODERATE PAINMILD / MODERATE PAIN

PARACETAMOL, ASPIRIN, OTHER NSAIDsPARACETAMOL, ASPIRIN, OTHER NSAIDs SITTING FOR <20 minSITTING FOR <20 min AVOID STRENOUS ACTIVITYAVOID STRENOUS ACTIVITY GENTLE STRETCHING EXERCISESGENTLE STRETCHING EXERCISES PREVENTIVE EDUACTIONPREVENTIVE EDUACTION FOLLOW UP VISIT IN 1 WKFOLLOW UP VISIT IN 1 WK

MANAGEMENT

HOWETHER, SITTING IS MECHANICALLY HOWETHER, SITTING IS MECHANICALLY STRESSFUL FOR THE BACK AND CAN BE STRESSFUL FOR THE BACK AND CAN BE SIGNIFICANT PROBLEM FOR PEOPLE WITH SIGNIFICANT PROBLEM FOR PEOPLE WITH LOW BACK PAIN.LOW BACK PAIN.

INSTRUCTIONS SHOULD INCLUDE:INSTRUCTIONS SHOULD INCLUDE: USING CHAIR WITH GOOD LUMBAR SUPPORTUSING CHAIR WITH GOOD LUMBAR SUPPORT GETTING UP AND STRETCHING FREQUENTLYGETTING UP AND STRETCHING FREQUENTLY TAKING SHORT WALKS THAT HELP LIMBER TAKING SHORT WALKS THAT HELP LIMBER

THE BACKTHE BACK AS SYMPTOMS DECREASE , ACTIVITY SHOULD AS SYMPTOMS DECREASE , ACTIVITY SHOULD

BE GRADUALLY INCREASEDBE GRADUALLY INCREASED

– SEVERE PAINSEVERE PAIN

OPIATE ANALGESICS / MUSCULAR RELAXANTSOPIATE ANALGESICS / MUSCULAR RELAXANTS NSAIDsNSAIDs BED REST (2-4 days) THEN, GRADUAL INCREASE BED REST (2-4 days) THEN, GRADUAL INCREASE

IN ACTIVITYIN ACTIVITY ICE PACK APPLICATION (20 min) FOR (1-2 days)ICE PACK APPLICATION (20 min) FOR (1-2 days) RETURN VISIT IN (3-5 days)RETURN VISIT IN (3-5 days)

MANAGEMENT

IF SYMPTOMS NOT IMPROVEDIF SYMPTOMS NOT IMPROVED– CT / MRI / CONSULT BACK SURGEONCT / MRI / CONSULT BACK SURGEON

MANAGEMENT

– ACTIVITY IS ADVICED (NON-STRENOUS)ACTIVITY IS ADVICED (NON-STRENOUS)

– IF SYMPTOMS PERSIST (>4-6 WK) REFER YOUR IF SYMPTOMS PERSIST (>4-6 WK) REFER YOUR PATIENT TO PHYSIOTHERAPISTPATIENT TO PHYSIOTHERAPIST

– EARLY RETURN TO ACTIVITY AND WORK SHOULD BE EARLY RETURN TO ACTIVITY AND WORK SHOULD BE ENCORAGEDENCORAGED

– RECURRENT PAINRECURRENT PAINREVIEW OF MANAGEMENT IN THE PASTREVIEW OF MANAGEMENT IN THE PAST

FOLLOW-UP SHOULD BE MORE INTENSIVEFOLLOW-UP SHOULD BE MORE INTENSIVE

WITH IMPROVEMENT OF EPISODES,PATIENT SHOULD BE WITH IMPROVEMENT OF EPISODES,PATIENT SHOULD BE ENCOURAGED TO DEVELOP AN EXERCISE AND ENCOURAGED TO DEVELOP AN EXERCISE AND CONDITIONING PROGRAM THAT STRETCHES AND CONDITIONING PROGRAM THAT STRETCHES AND STRENGTHES THE BACK STRENGTHES THE BACK

MANAGEMENT

CHRONIC LOW BACK PAINCHRONIC LOW BACK PAIN MANAGEMENT OF CHRONIC LOW MANAGEMENT OF CHRONIC LOW

BACK PAIN INCLUDES:BACK PAIN INCLUDES:EXERCISEEXERCISEEDUCATIONEDUCATIONPSYCHOSOCIAL SUPPORTPSYCHOSOCIAL SUPPORTMEDICATIONS MEDICATIONS (PARACETAMOL ,NSAIDs ) for mild (PARACETAMOL ,NSAIDs ) for mild and moderate chronic pain; (OPIATES and moderate chronic pain; (OPIATES (for severe chronic pain (for severe chronic pain

PATIENT EDUCATIONPATIENT EDUCATION

EDUCATION AND EMOTIONAL EDUCATION AND EMOTIONAL SUPPORT ARE IMPORTANT SUPPORT ARE IMPORTANT COMPONENTS OF EFFECTIVE COMPONENTS OF EFFECTIVE MANAGEMENT OF LOW BACK MANAGEMENT OF LOW BACK PAINPAIN

PATIENT EDUCATIONPATIENT EDUCATION

ACUTE LOW BACK PAINACUTE LOW BACK PAIN

REASSURE THE PATIENT THAT THE PAIN WILL REASSURE THE PATIENT THAT THE PAIN WILL IMPROVE; DISABILITY IS NOT LIKELYIMPROVE; DISABILITY IS NOT LIKELY

PROVIDE A CLEAR,CONFIDENT EXPLANATION PROVIDE A CLEAR,CONFIDENT EXPLANATION FOR THE PAINFOR THE PAIN

INSTRUCTIONS ABOUT PRESCRIBED ACTIVITY INSTRUCTIONS ABOUT PRESCRIBED ACTIVITY LEVEL AND THERAPYLEVEL AND THERAPY

EXPLAIN LACK OF NEED FOR SPECIAL EXPLAIN LACK OF NEED FOR SPECIAL INVESTIGATIONS UNLESS RED FLAGS ARE INVESTIGATIONS UNLESS RED FLAGS ARE PRESENT OR SYMPTOMS DO RESOLVE IN 6 WEEKSPRESENT OR SYMPTOMS DO RESOLVE IN 6 WEEKS

DATE,TIME AND PURPOSE OF NEXT VISITDATE,TIME AND PURPOSE OF NEXT VISIT

PATIENT EDUCATIONPATIENT EDUCATION CHRONIC LOW BACK PAINCHRONIC LOW BACK PAIN

EMPHASIZE THAT IMPROVING EMPHASIZE THAT IMPROVING FUNCTION IS MORE HELPFUL THAN FUNCTION IS MORE HELPFUL THAN CURINGCURING

EMPHASIZE THAT FUNCTION EMPHASIZE THAT FUNCTION NEARLY ALWAYS IMPROVES WITHH NEARLY ALWAYS IMPROVES WITHH TIME AND PHYSICAL ACTIVITYTIME AND PHYSICAL ACTIVITY

DISCUSS EFFECTS OF BACK PAIN DISCUSS EFFECTS OF BACK PAIN ACTIVITY INSTRUCTIONSACTIVITY INSTRUCTIONS EXERCISE INSTRUCTIONSEXERCISE INSTRUCTIONS