international Perspective

•  Dr. Hans J. Poessel, a highly experienced German Orthopaedic Surgeon with over 20 years of expertise, currently practicing in the UAE since 2009.
  Here, he provides you with an easy-to-understand and comprehensive overview of Back-Pain Pearls, with valuable treatment option for various Back Pain conditions.
• Orthopedic Doctors should Perform risk stratification for biomedical conditions requiring urgent imaging or surgical evaluation, as well as psychosocial factors that impact who will likely recover well on their own, or who may require more intensive support.
• Referral to Physical Medicine and rehabilitation Doctors or Physiotherapy provides education and advice regarding prognosis and self-management strategies, with an emphasis on more active strategies (e.g., physical activity and exercise) over passive strategies (e.g. rest, massage, etc.). Explicit exercise prescriptions are more effective than simply telling your patients to “move”.
• Reserve imaging for suspected serious underlying pathology that would require an immediate change in management, such as severe neurological deficits/weakness, spinal infections, malignancies, or fractures. Radicular pain in the absence of neurological deficits does not require immediate imaging and is managed similarly to non-specific back pain.
• Doc Hans is VERY mindful of the language he uses when he discusses back pain with his patients, as the specific diagnostic labels doctors assign, or the way they explain imaging studies and prognosis can have a significant impact on the patients’ perception of their back pain, their expectations, and their long-term outcomes.
• The Pain-Calculator can guide evidence-based shared decision making regarding the use of medications for back pain.
• Many patients believe any degree of pain reflects damage or injury and must therefore be avoided. Instead, it is important to emphasize that it is not necessary to be “pain-free” before returning to movement and activities the person enjoys.

Back Pain Update – Show notes

Approaching Acute Back Pain
Sometimes we WILL see this in the clinic – back pain is the leading cause of disability in the U.S. and other countries; treatment for back pain and related spine disorders now constitutes the most expensive medical problem (Hartvigsen 2018, Stevans 2021). Although it is so common, back pain is quite complicated. Instead of viewing back pain solely through a structural/mechanical paradigm, Doc Hans urges us to view it using a biopsychosocial framework, which accounts for non-mechanical factors that can influence pain, function, and recovery outcomes such as social determinants or psychological stressors (Yang 2016).

The first step in evaluating patients with acute low back pain is to risk stratify patients that may have a serious process that necessitates urgent action or may progress and cause serious disability. This evaluation, commonly framed through the lens of “red flags”, is aimed at determining whether urgent imaging or surgical evaluation is warranted. When evaluating the patient, Doc Hans emphasizes the importance of pre-test probability and environment (for example, a patient with persistent low back in the clinic is different from a patient in the ER following a high-speed motor vehicle collision). A significant proportion of patients presenting with back pain may have one or more “red flag” features, even though they do not have a serious underlying cause for their back pain.

Commonly cited red flags include:

• Recent trauma (especially major, such as a serious motor vehicle crash)
• Older age
• Urinary or bowel incontinence
• History of malignancy or unexplained weight loss
• Chronic corticosteroid use
• Bilateral “sciatica”
• Recent infections
• Injection drug use (Will 2018)

In Doc Hans’s opinion, motor weakness is a significant finding that should raise alarm, as opposed to paresthesia or radicular pain which are not necessarily as concerning.
In the clinic, 90-95% of patients usually  not have a single, nociceptive source for their pain. For any primary care clinician, these can be initially classified under the category of non-specific low-back pain (Bardin et al, 2017).
The next step, and arguably equally important for most patients, is a psychosocial evaluation aimed at finding “yellow flags”. Doc Hans tries to let the patient tell their story in an open-ended manner in order to fully elicit their beliefs, concerns, and expectations about their condition. Focus on the whole patient, rather than viewing them as “just a spine.” This means looking for clues from other organ systems that may indicate the patient’s back pain is a symptom of a bigger or different issue. He also inquires about things like sleep, stress, and other general health factors to help identify other contributors or barriers to recovery (for example, impaired sleep can contribute to increased pain intensity). Doc Hans recommends the STarT Back tool as a guide to risk stratification of those patients with back pain who might need more support, such as earlier referral for physical therapy, pain psychology, or other interventions (Hill et al, 2010; Beneciuk et al, 2013).

Physical Exam
The goal of a physical exam is primarily to determine if the patient’s presentation is consistent with serious systemic disease and/or requires surgical intervention. In Doc Hans’s opinion, using the physical exam to come to a specific diagnostic label is less important for patients without a serious underlying cause of their pain (i.e.., those who would typically be classified as “non-specific low back pain”). There are many exam maneuvers which purport to differentiate one structural cause from another, but if all are non-urgent / non-surgical and can be managed similarly up-front, differentiating one from another is not a good use of time for the primary care clinician. However, the physical exam and physical touch can help establish a strong clinician-patient relationship, which we know is incredibly important!
A common finding of “paraspinal tenderness” is actually far LESS diagnostically useful than we think (Simel DL & Rennie D, 2009)! Exam maneuvers that can be helpful include gait/strength testing, reflex assessment, and to an extent, sensory testing – although there again, sensory abnormalities do not immediately portend badness (as opposed to motor deficits which are much more worrisome)! Assessment of other organ systems – cardiovascular, GI, renal, etc. – should be informed by the patient’s history (such as pyelonephritis causing back pain – which would be expected to have associated GU or systemic symptoms). Range of motion testing and soft tissue tenderness that are commonly assessed, although these are not diagnostically informative, per Doc Hans.
Overall the goal is to facilitate symptom relief and independent daily function. It may make us feel better as clinicians to use a specific diagnostic label and patients may want this – but, much of back pain is multifactorial and difficult to attribute to a single nociceptive source. Using more benign terms to describe non-specific low back pain such as an “episode of back pain” or “lumbar sprain”, as opposed more pathologic terms such as “degeneration” or “disc bulge” has been shown to reduce patients’ perception of the “seriousness” of their condition, improves expectations of recovery, and reduces their need for imaging and second opinions (O’Keefe 2022). Clinicians are susceptible to similar labeling biases! Simply changing the phrasing of a radiology report can prime a clinician to either view the same finding as more benign, with a better prognosis, versus a more serious finding prompting further workup and aggressive management (Rajasekaran 2021, Fried 2018).

A Rational Approach to Imaging
When a patient presentation warrants imaging, there are several options. X-Ray can be helpful to identify basic bony abnormalities such as a compression fracture but lack diagnostic sensitivity for many conditions. In the majority of cases where serious underlying pathology is suspected (e.g. new-onset motor weakness, concern for spinal infection, or cancer) MRI is recommended (Will 2018). If MRI is not an option, CT may be a suitable substitute in certain situations, but this should be determined in concert with a radiologist. Doc Hans reminds us that ordering and interpreting imaging requires a suspected pathology to inform it. In other words, it is inappropriate to ask an imaging question of a radiologist without a specific differential diagnosis, particularly given how common it is to observe various spinal structural abnormalities in asymptomatic patients (Brinjiki 2015).

Appropriate communication is key in relaying imaging findings. It is incumbent upon the clinician to avoid unnecessary biomedical jargon that may falsely bias the patient into thinking something that is age-related or benign is actually much more worrisome, or that it is unsafe for them to move (Rajasekaran 2021, Fried 2018).

Pharmacotherapy – Overview

In Doc Hans’s expert opinion, most patients seen in the clinic do not routinely need pharmacotherapy for their back pain (Traeger 2019). In more severe cases, a multi-modal pain regimen should be considered. This can include Panadol (Acetaminophen), NSAIDs, topical therapies, “muscle relaxants”, and very rare use of opioids. Corticosteroid injections can be used for acute radicular back pain, but in Doc Hans’s expert opinion, systemic steroids should be avoided given their lack of evidence for benefit and increased risk for complications like infection, acne, venous thromboembolism, and hyperglycemia. The goal of these therapies should be to facilitate movement, physical activity, and sleep, as this will in turn facilitate functional recovery and reduce the risk of persistent disability.
Relevant psychosocial factors should be elucidated and addressed. Given the favorable natural history of most episodes of back pain, tincture of time and reassurance may be the most effective “medicine” for many patients. Even intervertebral disc herniations – which carry a significant amount of psychological baggage with them – have a favorable natural history, with evidence of objective reabsorption/healing on their own (Chiu 2015). This reality can equip clinicians with tools to assuage patient fears in the absence of concern for a serious underlying cause of back pain.
In summary, Doc Hans recommends using shared-decision making with patients regarding the use of medications to facilitate specific goals and specific endpoints; stressing the use of medications to facilitate movement and sleep. He also recommends that clinicians who treat back pain review a few resources to help reach patient-centered decisions on management. The PPEER simplified chronic pain guideline is an excellent resource from the College of Family Physicians of Canada that discusses management of chronic low back, osteoarthritic, and neuropathic pain in primary care. They have a visual tool for shared-decision making that can be reviewed during a consultation and is found at: Low Back Pain – PEER Pain Calculator (pain-calculator.com).

Pharmacotherapy – The Nitty Gritty

Acetaminophen and NSAIDs
Acetaminophen (Panadol) is often a first line therapy for back pain (or any pain for that matter) despite a lack of good evidence for efficacy. NSAIDs, such as ibuprofen or naproxen, can be helpful medications in the setting of acute back pain, assuming no strong contraindications (Traeger et al, 2018).

Muscle Relaxants
Doc Hans reminds that “muscle relaxers” tend to be centrally-acting medications with sedative effects, and do not have specific effects on “relaxing muscles”. While these medicines may help reduce pain intensity in the short term, they often have a lot of side effects including significant sedation, orthostasis, cardiovascular depression and even profound hypotension (Will 2018, Chou 2017). Overall, Doc Hans views the role of analgesics and “muscle relaxants” as tools to facilitate movement AND sleep, which are both very important when it comes to recovery. These drugs do not, in and of themselves, “fix” back pain!

SNRIs and Gabapentinoids
SNRIs – specifically duloxetine – have data showing duloxetine may help with back pain in the chronic phase, although this is a small effect (Chou 2017). Medications like gabapentin (Neurontin) and pregabalin (Lyrica) in have been used by many clinicians for radicular back pain, however, the evidence here is very poor and these also have many potential adverse effects (Chou 2017).

Opioids (controlled drugs in UAE)
Doc Hans recommends STRONGLY against the use of opioids in most patients due to their adverse effect profile, potential for dependence, and potential for opioid-induced hyperalgesia (Kum et al, 2020).

Topical Treatment Options
Other interventions which commonly come up include, cold packs, hot packs, topical NSAIDs /capsaicin/lidocaine and CBD products. All of these interventions have minimal, low-quality evidence per Doc Hans . CBD specifically has some studies related to back pain (Xantus et al, 2021) but the generalizability is suspect. His general understanding of the literature is that these topical treatments are generally not harmful, there may be some minor signal for pain-relief and they are certainly going to be safer than chronic opioids. He has no strong objection to any of these in the context of using them to facilitate movement.

Steroid Injections
Epidural corticosteroid injections appear to provide a small, short-term effect on pain intensity for radicular pain (Rivera 2018). In non-radicular pain, epidural and facet joint steroid injections perform similarly to placebo injections (Chou 2015, Stout 2010).

Passive Therapies
Doc Hans’s professional opinion is that spine manipulation, dry needling and acupuncture can be relatively benign, and if the patient feels they are helping, he doesn’t strongly recommend against their use as part of a more comprehensive, active management plan. However, he says there simply is a paucity of quality data for the efficacy of these interventions, and that many practitioners offering them predicate their interventions on a narrative that conflicts with the available evidence (for example, a spine being “out of alignment” requiring manipulation in order to “restore alignment”).

Braces, Belts, and Insoles
Unfortunately, there is no data to support the use of braces, belts and insoles in all-comers for chronic back pain (Sowah et al, 2018). If a patient is using something and they feel it helps and allows them to move with less pain, that’s excellent! However, Doc Hans doesn’t broadly recommend these interventions. Similarly, posture trainers/ practitioners that put intense focus on posture are not supported by evidence.

Back Pain & Movement
Only about 20% of patients who present to clinics with low back pain are given education related to self-management strategies (Williams et al, 2010). This is a huge issue!
There are no exercises that are uniquely beneficial, or that are critical to avoid, for routine back pain management (Owen et al, 2019). This means that we have near-infinite options to employ to get patients moving. So, Doc Hans recommends tailoring your recommendation to the patient’s interests, current fitness level, limitations, and what resources, exercise equipment, etc. they have access to. The key is that the clinician and patient must forge a partnership with the goal of determining a physical activity / exercise prescription that is compelling, feasible and has a good chance of adherence. An explicit “Physical Activity Prescription” is usually helpful to deliver this recommendation to patients. Finally, it is important that patients know it is safe for them to move, and that they do not need to wait until they are pain-free to resume movement and valued activities.

Chronic Back Pain – Where Things Get Tricky
When seeing a patient with chronic back pain, try to determine why they are presenting “today” – i.e. what has changed – and what are their pre-visit beliefs, what have they heard/been told, and what are their expectations moving forward. For example, many patients believe any degree of pain reflects ongoing tissue damage and thus, movements that cause any degree of pain must be avoided. Doc Hans reminds us that this leans on the antiquated biomedical model for pain rather than a more modern biopsychosocial perspective, which is more in line with current evidence. A pearl he leaves us with is that absolutely pain-free movement may not always be a realistic goal, so it is important to facilitate patients’ confidence in the belief that they are safe to move, even if it is associated with discomfort.

Time to Refer
Once you are at the end of your tether, Dr.Hans J. agrees with the team that referral to PM&R may be reasonable to get another opinion/perspective. They can also be helpful in bridging the discussion between medical and surgical management. It’s important to recognize that in carefully selected patients there MAY be a place for surgery, however, it’s an option that should generally be reserved for patients who have undergone evidence-based, non-invasive management with an emphasis on active rehabilitation strategies.

Take Home Points:
This great clinical resource provides a comprehensive, evidence-based guide for the assessment and management of back pain