Back Pain
OVERVIEW
Back problems affect virtually everyone at some time in life. Surveys indicate a yearly prevalence of symptoms in 50% of working-age adults. Lower back problems are among the most frequent reasons for patients to visit their physician, and back problems are costly in terms of medical treatment, lost productivity, and non-monetary costs such as diminished ability to perform or enjoy usual activities.
Acute lower back problems are defined as an inability to perform usual activities due to lower back or back-related symptoms of less than three months' duration. About 90% of patients with acute lower back pain spontaneously recover activity tolerance within one month.
Students should become familiar with the diagnosis and treatment of back pain and understand the important public health and workforce implications of this highly prevalent condition. Balancing the use of conservative treatment with imaging and interventions is a major issue that has implications for the individual patient as well as the economic state of our health care system.
Blue objectives: Advanced clerkship and SubInternship
TOPIC
LEARNING GOALS AND OBJECTIVES (Organized by ACGME Competencies)
[i]
Patient
Care
GOAL: Students will recognize the importance of empathic communication and patient education in caring for patients with back pain.
OBJECTIVES: Students will be able to:
 |
Provide
patient education verbally along with appropriate handouts on back pain. |
|
Discuss
the role of stress in the exacerbation of back pain. |
|
Describe
appropriate management for acute mechanical lower back pain. |
|
Discuss
the relative value of medications commonly prescribed for lower back pain.
|
|
Discuss
the limitations and risks of prolonged bed rest. |
|
Discuss
the value of returning to normal activities as tolerated. |
|
Predict
prognosis for a patient presenting with acute mechanical lower back pain. |
Medical
Knowledge
GOAL: Students will understand the differential diagnosis for back pain along with the appropriate anatomy and pathophysiology of the major causes of back pain.
OBJECTIVES: Students will be able to:
|
Describe
the key elements of the history for lower back pain. |
|
Detail
the differential diagnosis for lower back pain. |
|
Differentiate
between musculoligamentous strain and acute radicular back pain. |
|
Identify
"red flags" for potentially serious causes of lower back pain
(fracture, tumor, infection, or cauda equina syndrome). |
|
Describe
and perform a complete back examination to determine the cause of the back
pain. |
|
Identify
specific nerve root or spinal cord compression based on the results of the
exam. |
|
Describe
and perform a complete neurological exam of the lower extremities
including the straight leg raise (SLR) maneuver. |
|
Discuss
the issue of sensitivity and specificity with regards to ipsilateral and
contralateral SLR. |
Practice-Based
Learning and Improvement
GOAL: Students will understand the barriers to dealing with back pain patients around disability issues and pain medications.
OBJECTIVES: Students will be able to:
|
Discuss
why physicians have difficulty interacting with patients who claim
disability based upon lower back pain. |
|
Discuss
why physicians have difficulty providing adequate pain control for fear of
addicting patients to narcotics, being manipulated, causing harm, or
getting investigated by the DEA or state medical board. |
Interpersonal
and Communication Skills
GOAL: Students will communicate effectively with patients concerning the diagnosis and treatment of back pain.
OBJECTIVES: Students will be able to:
|
Approach
patients with an optimistic attitude, because 90% of patients with acute
lower back pain spontaneously recover activity tolerance within one month.
|
|
Discuss
the use of conservative management for lower back pain while reserving
surgery as the treatment of last resort. |
|
Demonstrate
how to teach patients the fundamentals of proper body mechanics as a means
of preventing lower back pain. |
|
Communicate
effectively with patients who have worries or concerns about the effect of
back pain on their function at work, home, or recreation. |
Professionalism
GOAL: Students will establish and adhere to high personal standards in the care of patients with back pain.
OBJECTIVES: Students will be able to:
|
Communicate
honestly and openly with patients about the prognosis for back pain. |
|
Balance
"the art and the science of medicine" when considering a
patient's back pain disability request. |
Systems-Based
Practice
GOAL: Students will appraise and utilize the best evidence in caring for patients with back pain.
OBJECTIVE: Students will be able to:
|
Describe
use of EBM to determine a cost-effective use of diagnostic imaging in the
evaluation of lower back pain.
| ||
|
Describe the limitations of the MRI in evaluating lower back pain |
Resources
| Pre-clerkship workshop: Blue Docs | ||||
| Evaluation and Treatment: LBP
|
Supplemental Reading
| Diagnosis and Management of Acute Low Back Pain
|
| Neuroimaging in low back
pain.
|
| Evaluation and
management of HNP
|
| Patient education materials
|
SOAP Template
Resources:
Joyce A.Copeland, M.D.
Duke Family Medicine
Clerkship Director
Lead
Author: Richard Usatine, MD
Clerkship/Post-Clerkship
Workgroup members: Ann O'Brien-Gonzales, PhD (Chair), Alexander Chessman, MD
(EC Liaison), Caryl Heaton, DO, Janice Nevin, MD, MPH, Lauren Oshman, MD,
Deborah McPherson, MD, Mark. E Quirk, EdD, David Schneider, MD, MSPH,
William B. Shore, MD, Richard Usatine, MD
Resource
Title: Back pain
Current
URL: http://fammed.musc.edu/fmc/data/Back_Pain.htm
Family Medicine Curriculum Resource (FMCR) Project
HRSA Contract (Contract No. 240-00-0107) to the Society of Teachers of Family Medicine
October 2004