is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary and he is on the Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.
Abstract: The Choosing Wisely Canada (CWC) initiative is a partner in a global effort to increase the efficiency and effectiveness of medical care by stimulating conversations between patients and care givers about the benefits and risks of commonly done tests and treatments. One of the earliest and broadly publicized recommendations was to stop routine lumbar spine imaging in the absence of clinical red flags. The rationale for discouraging this practice, including the quantification of associated harm, is not as widely known. The CWC initiative includes "Toolkits" for a number of clinical conditions, which extend the conversation beyond what should be avoided to include recommendations for appropriate care. The Alberta CWC partners have developed a Toolkit for low back pain for use by individual clinicians, physician groups, and at the systems level.
Key Words: Low back pain, imaging, overuse, red flags.
Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.
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In the absence of red flags and/or significant chronicity don't order x-rays or advanced imaging for low back pain.
Be cautious about attributing any findings from imaging as the "cause" of low back pain in a particular patient; recognize normal age related changes.
Low back imaging is required in the presence of clinical Red Flags for which invasive intervention is planned. Clinical correlation of the images is mandatory.
The indications for specific interventional treatments either surgical or image guided must be determined by history and physical examination.
Most low back pain patients need treating, not testing.
Patients presenting with low back pain are often anxious and worried that they may have a serious underlying anatomical cause. This anxiety is not relieved by discussions of abnormalities found on routine imaging.
Patients respond to a treatment plan that is supported by pertinent handouts and clear explanations including discussions about when imaging could be considered and when a referral might be the correct course.
Treatment for low back pain should not be delayed until the cause has been "established" by investigation; appropriate treatment can be determined by the history and physical examination and supported by the anticipated positive clinical response.
A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.
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Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.
Abstract: Athletes participating in training and competition for an average of 8 hours a week have a one year prevalence for spine injuries as high as 68%; an average increase of 18-31% compared to non-athletes. Except for young growing athletes at risk for structural deformity, most spine injuries are soft tissue and self-limiting. Risk factors include a sudden increase in training hours, transition in strength and coordination related to growth, sustained back flexion, reduced dynamic core stability and repetitive trunk rotation and hyper extension. Decreased training levels following back injury lead to deconditioning and muscle imbalance increasing the risk of recurrence and prolonging recovery. Core stability testing can identify patients for targeted exercise.
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Frequent repetition and sustained postures in rotation, hyperextension and full flexion require advanced levels of strength and flexibility for the athlete to remain injury-free.
The two most common risk factors for low back pain in training athletes is overuse strain and excessive spinal movements.
Treatment consists of both reducing the demands on the paraspinal muscles and increasing the amount of core stability.
It is important to screen for generalized joint hypermobility syndrome (JHS) affecting all joints using the Beighton Score, as this condition may require investigation and can be an indication of other medical syndromes.
The most specific test with high inter-rater reliability to determine core stability is the single leg standing balance stork test. The patient stands on one leg and raises the other knee to 90 degrees then maintains balance for a minimum of 25 seconds.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
