Chiropractic Health Plan - Diagnosis of Low Back Pain 1 Adult Patient with ot for major Trauma Low back pain 2 Intake Evaluation (Inset 1) Recommendation 1 3 Potentially Serious Condition Strongly Suspected (Inset 1) 4 Perform Additional Diagnostic Studies to Confirm Diagnosis 5 Specific Diagnosis Identified 7 9 Back pain is mild with no substantial functional impairment Advise about self care Discuss non-invasive treatment options 8 Advise about initial treatment and Patient Responsibility Items 6 (Intervention 1) 11 10 Arrive at shared decision regarding therapy trial Educate Patient Treat Specific Diagnosis as indicated (Intervention 2,3,4) 12 13 Patient accepts risks and benefit of therapy Patient on Therapy? 15 14 16 Continue Self Care assess in 1 Go to month. Management Box 17 Go To Management Box 17
Inset 1 Focused History and Physical Examination Duration of Symptoms Risk Factors of potentially serious condition Symptoms Suggestions Radiculopathy, stenosis or claudication Presence and severity of neurologic deficit Psychosocial risk factors (Recommendation 1) Inset 1 Focused History and Physical Examination continued. Physical Examination o Observation o Palpation o Percussion o ROM o Regional Orthopedic Tests o eurologic Tests (Recommendation 1) Possible Cause Cancer Vertebral Infection Cauda Equina Syndrome Vertebral Compression Fracture Ankylosing Spondylitis Severe/progressive neurologic deficits Recommendation 1 - - Diagnostic Work-up Key Features on History or Physical Examination History of Cancer with ew onset of LBP Unexplained weight loss, failure to improve after 1 month, Age >50 years Multiple Risk factors present Fever Intravenous Drug Use Recent infection Urinary Retention Motor Deficits at multiple levels Fecal Incontinence Saddle anesthesia History of Osteoporosis or trauma Use of corticosteroids Older Age Morning Stiffness Improvement with Alternating buttock pain Awakening due to back pain during the second part of the night ounger Age Imaging* Lumbosacral plain Plain or Lumbosacral plain Anterior-Posterior pelvis plain Additional Studies* ESR ESR and/or CRP none none ESR and/or CRP; HLA-B27 Progressive motor weakness Consider EMG/CV Disc Disease Recommendation 2 Back pain with leg pain in an L4, L5 or S1 nerve root distribution Positive Straight Leg raise test
Spinal stenosis or crossed leg raise test Symptoms present > 1 month Consider EMG/CV Radiating leg pain Older age (Pseudocladication a weak predictor) Posterior Joint Syndrome Symptoms present >1 month Low back pain not radiating past the knee History of repetitive bending Consider EMG/CV Sprain/strain Symptoms present > 2 weeks Passive movement pain Percussive recruitment Lumbar plain Instability verified by kinetic palpation present > 2 weeks Lumbar plain Subluxation Palpatory *Level of evidence for diagnostic evaluation is variable
20 23 Chiropractic Health Plan - Management of Low Back Pain 17 Initiate time/visit limited 18 19 trial of therapy Follow-up at 2 weeks Patient improvement >40% 21 Continue Trial Therapeutic Trial for non-neurologic deficit Passive Modalities Spinal Manipulation Stretching Re-evaluate Diagnosis Change Therapeutic Modalities Measure Patient Compliance Consider Co-management or Consider Referral for Multidiscipline management Therapeutic Trial for neurologic deficit Passive Modalities Spinal Manipulation Computerized Axial Distraction Co-management Stretching Massage 22 Follow-up at 30 Days Patient improvement >40% 24 Assess response to treatment 25 Back pain resolved or improved with no significant functional deficits? 26 Patient Responsibility Items only - Reassess in 1 month 27 Signs or symptoms of 28 radiculopathy or spinal stenosis? Consider Imaging () if not already done Consider referral 29 30 Significant nerve root impingement or spinal stenosis present? Consider referral for consideration of surgery or other invasive procedure 31 Reassess symptoms and risk factors and reevaluate diagnosis. Consider Imaging studies. 32 Consider alternative interventions. For significant functional deficit, consider more intensive multidisciplinary approach or referral 33 Return to Box 24
Intervention 1 Patient Responsibility Items Life Style Changes Work Ergonomics Stress Reduction Supplementation Diet Interventions 2,3,4 Low Back Pain Acute Sub-Acute or Chronic Duration <4 weeks >4 Weeks Physiotherapy Modalities * Spinal Manipulation * * Computerized Axial Distraction * * /Stretching * * Behavior Modification * Pharmacologic Co-Management * Acupuncture * * Massage * otes 1. There is no recommendation of self-care only for patients who choose chiropractic medicine as the primary modality of treatment. 2. Chiropractic physicians should be trained and encouraged to use co-management for pain control during the initial therapeutic trial and not instead of. 3. Red Flags for referral include: cauda equine syndrome, progressive motor weakness, paralysis, 4. Reassessment expectations: Time on-eurologic Deficits eurologic Deficits 14 Days 40% subjective improvement, 20% none >ROM, absent percussive pain 30 Days 80% subjective improvement, 60% >ROM, absent palpatory tenderness 20% subjective > Oswestry < 10%, 20 %> ROM, 20% > nerve compression tests, < neurologic findings, 60 days Patient Responsibility Items only 40% subjective>, Oswestry < 20%, 90 Days 80% subjective >, Oswestry < 30%