A. DESCENDING MODULATORY INFLUENCES HISTORY

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Wesley Barton
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1 Chronic Low Back +/- Leg Pain in Older Adults: Essential Clinical Contributors Screen NOTE: The following should be performed on all older adults with chronic low back pain in whom red flags of serious underlying illness have been ruled out (e.g., fever, weight loss, suspicion of metastatic disease, rapidly progressive weakness, cauda equina syndrome, antecedent trauma, changed character or location of typical pain). A. DESCENDING MODULATORY INFLUENCES HISTORY Question Disorder Screened Interpretation/Question Source Do you often feel like you hurt all over? Fibromyalgia Sensitivity of hurt all over validated in older adults with low back pain and depression, with American College of Rheumatology 1990 Criteria as comparison standard (1). A positive response should prompt further evaluation for fibromyalgia, starting with the fibromyalgia self-report survey (2). If positive, see fibromyalgia algorithm (3). Over the last 2 weeks, how often have you been bothered by: 1. Feeling nervous, anxious or on edge? 2. Not being able to stop or control worrying? 3. Little interest or pleasure in doing things? 4. Feeling down, depressed, or hopeless? Do you agree or disagree with the following statements? 1. It s not really safe for a person with my back problem to be physically active. Generalized anxiety disorder (GAD) Depression Fear-avoidance beliefs 0 = not at all 1 = several days 2 = more than half the days 3 = nearly every day Screen is positive for GAD if response to questions > 3: Evaluate and treat for Anxiety disorder (algorithm to be published in Pain Medicine, September 2016). Screen is positive for Depression if response to questions > 3: See Depression algorithm (4) PHQ-4 Lowe B, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010; 122(1-2): If patient agrees with any of these statements, they may have maladaptive pain coping skills: See Maladaptive Coping algorithm (5).

2 2. I feel that my back pain is terrible and it s never going to get any better. 3. Due to my chronic back pain, I no longer engage in activities that are enjoyable and pleasant. Do you feel that you get good quality sleep? Mini-Cog (3-word recall + clock drawing test [CDT]) Catastrophizing Behavioral disengagement Insomnia PHYSICAL EXAMINATION If patient responds no, evaluate and treat cause of insomnia. Algorithm on Insomnia to be published in Pain Medicine, May Dementia 0 recalled words OR 1-2 recalled words + abnormal CDT suggests possible cognitive impairment Should refer these patients for further evaluation Dementia algorithm to be published in Pain Medicine, November recalled words OR 1-2 recalled words + normal CDT suggests lack of cognitive impairment No further assessment needed unless high index of suspicion based on clinical data.

3 B. NOCICEPTIVE INPUT 1. Does your back/buttocks/leg hurt when you are sitting? 2. Do you have pain in your buttocks/legs when standing or walking? 3. Does your pain lessen when you bend forward? Lumbar spinal stenosis (LSS) HISTORY Supportive of lumbar spinal stenosis: Absence of pain with sitting Pain with standing/walking that is alleviated with forward lumbar flexion. If history is consistent with LSS, see Lumbar Spinal Stenosis algorithm (6). Do you have hip pain? Hip osteoarthritis (OA) If patient responds yes, evaluate for hip OA: See hip exam below. PHYSICAL EXAMINATION Physical Exam Disorder Screened Associated Findings/Comments Examination for taut bands/trigger points of erector spinae, quadratus lumborum, gluteus medius Myofascial pain Active trigger points are those that when palpated reproduce patient s spontaneously reported pain. See Myofascial Pain algorithm (7). Latent trigger points are those that are not associated with spontaneously reported pain. Internal hip rotation Hip flexion Standing: Assess symmetry of pelvic brim height Supine (direct): Measure distance between anterior superior iliac spine and medial malleolus. Supine (apparent): Measure distance between umbilicus and medial malleolus. Hip OA Leg length discrepancy (LLD) Clinical criteria for hip OA include: 1) hip pain (patient report) AND EITHER: 2) internal hip rotation <15 + hip flexion < 15 OR 3) internal hip rotation > 15 and painful + hip AM stiffness < 60 minutes. If clinical criteria fulfilled, then confirm with hip x-ray. If hip OA present, refer to hip OA algorithm (8). If LLD is found, refer to physical therapy for further assessment and treatment recommendations. LLD algorithm to be published in Pain Medicine, October 2016.

4 Compression test Thigh thrust FABER Gaenslen test Distraction test Palpation over greater trochanter Ober s test Sacroiliac joint (SIJ) syndrome Greater trochanteric pain syndrome Iliotibial band syndrome Perform physical exam maneuvers if supportive history for SIJ syndrome: i.e., pain in the SIJ region +/- pain referred to the buttock, groin or proximal leg, worse with transitions (e.g., sit to stand, stepping off curb) and without radicular symptoms. Presence of > 3 positive physical exam tests provides optimal diagnostic sensitivity and specificity. If supportive history and physical examination findings, evaluate contributors to SIJ syndrome (e.g., leg length discrepancy, scoliosis, hip OA, knee OA). SIJ algorithm to be published in Pain Medicine, August Evaluate in CLBP patients that also report lateral hip and/or thigh pain. Lateral Hip/Thigh Pain algorithm for approach to differential diagnosis and treatment to be published in Pain Medicine, July Seated slump test Radiculopathy May be helpful in sorting through differential diagnosis of patients with unilateral leg pain and possible radiculopathy (9).

5 REFERENCES 1. Jochum J, Begley A, Dew MA, Weiner DK, Karp JF. Advancing the screening and diagnosis of fibromyalgia in late-life: Practical implications for psychiatric settings. International Psychogeriatrics. 2015;27(9): Clauw D. Fibromyalgia: a clinical review. JAMA. 2014;311(15): Fatemi G, Fang MA, Breuer P, Cherniak PE, Gentili A, Hanlon JT, et al. Deconstructing recommendations for evaluation and treatment. Part III: Fibromyalgia syndrome. Pain Medicine. 2015;16: Carley JA, Karp JF, Marcum ZA, Reid MC, Rodriguez E, Rossi MI, et al. Deconstructing recommendations for evaluation and treatment. Part IV: Depression. Pain Medicine. 2015;16: DiNapoli EA, Craine M, Dougherty P, Gentili A, Kochersberger G, Morone NE, et al. recommendations for evaluation and treatment. Part V: Maladaptive coping. Pain Medicine. 2016;17: Fritz JM, Rundell SD, Dougherty P, Gentili A, Kochersberger G, Morone NE, et al. recommendations for evaluation and treatment. Part VI: Lumbar Spinal Stenosis. Pain Medicine. 2016;17: Lisi AJ, Breuer P, Gallagher RM, Rodriguez E, Rossi MI, Schmader K, et al. Deconstructing recommendations for evaluation and treatment. Part II: Myofascial pain. Pain Medicine. 2015;16: Weiner DK, Fang M, Gentili A, Kochersberger G, Marcum ZA, Rossi MI, et al. recommendations for evaluation and treatment. Part I: Hip osteoarthritis. Pain Medicine. 2015;16: Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008;14(2):87-91.

Examination of the lumbosacral spine. Dr Lucy Holtzhausen Rotorua GP CME June 2015

Examination of the lumbosacral spine Dr Lucy Holtzhausen Rotorua GP CME June 2015 Diagnostic Algorithm Presenting symptoms Diagnostic decisions Diagnostic triage LOW BACK PAIN Mechanical NON-SPECIFIC LBP