Conner Joseph Clay¹, José M. Orenday-Barraza, MD², María José Cavagnaro MD², Leah Hillier MD CCFP (SEM)³, Leeann Qubain¹, Eric John Crawford MD MSc(c) FRCSC⁴, Brandon Hirsch MD⁵, Ali A. Baaj MD², Robert A. Ravinsky MDCM MPH FRCSC⁵

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Abstract: Low back pain (LBP) is one of the most common presenting complaints in the primary care setting, with significant economic implications and impairment of quality of life. Effective treatment of low back pain can frequently be delivered in the primary care setting. Knowledge of common pain generators, and recognition of pain patterns based on the history and physical exam helps guide the treatment of LBP without the need for excessive resource utilization. The majority of patients presenting with LBP can be confidently treated with targeted conservative management, frequently obviating the need for advanced imaging and diagnostic investigations.

Key Words: low back pain, mechanical low back pain, lumbar pain, degenerative disease, clinical evaluation, triage.

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The lumbar spine is designed to be both strong and flexible, but disruption or degeneration of the supporting structures of the spine can result in low back pain without major pathology.

Low back pain can be characterized into one of four pain patterns using a focused history supported by a relevant physical exam.

Lumbar spine MRI is indicated if accompanying Red Flag symptoms, such as recent systemic illness, high suspicion for tumour, or progressive/severe neurological symptoms/signs are present with the back pain.

The presence of "red flag" signs and symptoms must be carefully interpreted as a group and not individually.

Most adults will experience LBP sometime during their life.

Knowledge of common pain generators, and recognition of pain patterns based on the history and physical exam help guide treatment without the need for excessive resource utilization.

The goal of triaging LBP is to determine which cases arise from sinister pathology, and which cases can be safely managed conservatively.

Diagnostic investigations and specialist referral are warranted only when there is suspicion of a specific disease process that would be managed differently than mechanical LBP.

When clearly identified, the four LBP pain patterns should be treated in the primary care setting before undergoing advanced imaging.

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¹Ted Findlay, DO, CCFP, FCFP, ²Dr. Eugene Wai, MD, MSc, CIP, FRCSC,

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Abstract: It has long been recognized that, following an intervention, two patients with very similar or even identical pathophysiology can have dramatically different outcomes. There is increasing recognition of the role and importance of the social determinants of health as a factor in explaining these differences. This article reviews a number of recent studies that explain the impact of these social determinants, specifically in chronic pain and low back pain. It includes commonly used screening tools and advice for interventions.

Key Words: Social determinants of health, chronic pain, low back pain, screening, social prescription.

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1. According the World Health Organization, the impact of the social determinants of health on health and illness may outweigh that of health care or lifestyle choices.

2. The social determinants of health identified as being of the most importance specifically for low back pain include education and job position.

3. Most communities across Canada will include a number of resources that can be readily accessed as part of a "Social Prescription".

1. Incorporating social work support at an early stage may have the potential to improve treatment compliance and outcomes for those low back pain patients who have notable challenges related to the social determinants of health.

2. Well validated and easily utilized screening tools already exist for the routine screening of social determinants of health.

3. Sleep disorders are shown to affect nearly half of all people reporting chronic pain, with a bidirectional relationship.

Proper patient selection and pre-operative optimization of all modifiable factors improve outcomes and decrease the possibility of FBSS.

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Kristen H. Beange BASc,¹ Tianna H. Beharriell BHK,² Eugene K. Wai MD, MSc, FRCSC,³ Ryan B. Graham MSc, PhD,⁴

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Abstract: Impaired neuromuscular control of the spine is widely recognized as an important factor in the development of low back pain (LBP). In this review, we summarize contemporary approaches for the assessment of spinal control variables such as stability, stiffness, coordination, and kinematics as well as the most current definitions within the LBP community. We discuss how these assessments can be incorporated into primary clinical care to improve diagnosis and treatment effectiveness.

Key Words: spinal control, low back pain, kinematics, stability, wearables.

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1. Classification of low back pain (LBP) should continue to be refined to prognosticate and guide treatment.

2. The spinal control model is based on the interaction of the passive (osteoligamentous), active (muscular), and neural feedback subsystems.

3. The spinal control model can be used as a basis to further refine classification and treatment of LBP. Technological advances allows for the development of better kinematic assessments of these subsystems and possible incorporation into clinical care.

1. Identification of specific subgroups of LBP and directing specific treatments has been identified as a future for research and management.

2. The Clinically Organized Relevant Exam (CORE) Back Tool incorporates the identification of patterns of pain based on back or leg dominant, and flexion or extension mediated pain.

3. Spinal fusion for treatment of back dominant LBP (without spondylolisthesis) is not supported by clinical practice guidelines.

4. Within the spinal control model, treatment of LBP should focus on the identification of deficiency in the active (muscular) and neural feedback subsystems and on treatment with spinal muscular strengthening and motor control exercises.

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^1,2Darren M. Roffey PhD; ¹Simon Dagenais DC, PhD, MSc; ³Ted Findlay DO, CCFP; ^4,5Travis E. Marion MD, MSc; ⁶Greg McIntosh MSc; ^1,2,4,5Eugene K. Wai MD, MSc, FRCSC

¹University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, ²Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,

³Department of Family Medicine, University of Calgary, Calgary, AB, ⁴Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, ⁵Department of Surgery, Faculty of Medicine, University of Ottawa, ON, ⁶CBI Health Group, Toronto, ON,

Abstract

Obesity and low back pain are equally complex medical conditions with multi-factorial etiologies. Their clinical practice guidelines both include recommendations for screening and examination that can be easily implemented. There is sufficient information to compile a framework for the primary care provider, partnering with the patient and appropriate specialists, to manage obesity and low back pain in a structured fashion. Weight loss and exercise are paramount and should be recommended as the first options. Cognitive behavioural therapy, pharmacological treatment and bariatric surgery may then be implemented sequentially depending upon the effectiveness of the initial interventions.

Key Words: Obesity, low back pain, exercise, nutrition, cognitive behavioural therapy, bariatric surgery, weight loss, pharmacological, evidence-based guideline.

^1,2Darren M. Roffey PhD; ¹Simon Dagenais DC, PhD, MSc; ³Ted Findlay DO, CCFP; ^4,5Travis E. Marion MD, MSc; ⁶Greg McIntosh MSc; ^1,2,4,5Eugene K. Wai MD, MSc, FRCSC

¹University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, ²Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON,

³Department of Family Medicine, University of Calgary, Calgary, AB, ⁴Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON, ⁵Department of Surgery, Faculty of Medicine, University of Ottawa, ON, ⁶CBI Health Group, Toronto, ON,

Abstract

Recognizing that the increasing incidence of obesity coincides with the rising prevalence of LBP, there is growing interest in establishing the relationship between over-weight and back pain. It is likely that any association is multi-factorial and that the connection is not as mechanistically simple as previously believed. Systemic inflammation associated with obesity may be an important contributor. Proposed treatment options vary from cognitive behavioural therapy to bariatric surgery with none yet fully proven. Despite the ambiguity, it appears prudent for primary care providers treating obese patients with LBP to recommend weight loss and exercise.

Key Words: Obesity, low back pain, inflammation, intervertebral disc, multi-factorial, causality, association.

Dr. Ted Findlay, DO, CCFP, Clinical Assistant Professor, Department of Family Medicine, University of Calgary, Calgary, Alberta.

Abstract
Low back pain is one of the most common conditions for which patients seek medical attention. It can be managed with lifestyle modification, or less commonly medical and surgical intervention. Appropriate selection among various pharmacological options mandates an understanding of the underlying symptomatology and the over-riding treatment plan and objectives. The range of potential medications is substantial: over-the-counter analgesics include acetaminophen and non-steroidal anti-inflammatory drugs, muscle relaxants, and weak opioid combinations including codeine or tramadol. More potent versions of many of the same components are available on prescription, commonly employing stronger opioids either singly or in a combination analgesic. When the pain involves either chronic or neuropathic features, other classes of medications, including anti-epileptic drugs and anti-depressants, may be appropriate.
Key Words: low back pain, acute, chronic, neuropathic pain, nociceptive pain, medications.