Low Back Pain Test Answers
You may like to retake the Pre-Test Questionnaire and compare the results. Further explanations around the correct and incorrect answers follow.
1. With regards to the impact of low back pain, tick which of the following statements are true:
a. If an individual has been off sick with back pain for 1 month, there is a 20% chance of them still being off work one year later (true)
b. If an individual has been off sick with back pain for 6 months, there is a 10% chance of them being off work one year later (false)
c. Low back pain is estimated to affect at least 60% to 80% of the population at some time in their lives and most of these patients will have resolution of their back pain with simple measures including simple analgesia, manipulation and exercise advice (true)
These facts are based on a number of studies. Frank et al (1996) showed that there are three stages of development of chronic disability.
As pain becomes chronic attitudes and beliefs, distress and illness behaviour plan an increasing role in the development of chronicity and disability. This illustrates the importance of concentrating resources into this crucial period to reduce these maladaptive behaviours.
Frank JW, Kerr MS, Brooker A-S, et al. Disability resulting from occupational low back pain. Spine 21: 2908-2929.
2. What is the repeat consultation rate after 3 month following the initial consultation for an acute episode of low back pain?
a. Less than 10% (false)
b. 11 – 28% (false)
c. More than 29% (true)
Croft et al (1998) found that of the 32% who presented with back pain re-consulted within three months and only 21% of those interviewed three months after seeing their GP were free from symptoms. The authors concluded that ‘low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations and recurrences.’ Croft PR, MacFarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316(7141): 1356-59.
3. Which of the following statements are true?
a. Low back pain (LBP) is defined as pain and/or discomfort below the costal margin and above the superior gluteal folds, with or without leg pain. This is false as it is above the inferior gluteal fold.
b. Non-specific LBP is defined as tension, soreness and/or stiffness in the lower back that is not attributed to a known specific pathology. This is the true answer.
c. In clinical practice, there are very sharp distinctions between acute, subacute and persistent LBP. This is false, the distinctions are not clear at all and defining pain along time scales can be unhelpful as progress from acute to chronic can vary depending on psychosocial factors including catastrophising and anxiety produced by unhelpful and inaccurate messages.
4. Mrs Jones comes to see you with a six week history of back pain. She is fit and healthy and has no past medical history. Her pain is confined to the low back and with no radiation to either leg. What would you NOT do?
a. Examine Mrs Jones. You would examine Mrs Jones but the yield from a clinical examination is low in the absence of signs of nerve root compression and with no reason to suspect a serious reason for her low back pain. Most data on the sensitivity and specificity of examination for pain comes from secondary care and this may not be appropriate to primary care (Jarvik et al 2002, van den Hoogan et al 1995). The available data do not support the use of straight leg raising, spinal palpation and range of motion tests for diagnosing pathological changes (Airaksinen et al 2006). However, while the evidence is weak, not examining Mrs Jones may suggest you are not taking her problem seriously and compromise the advice, reasurrance and self-management messages your provide. Jarvek JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals Intern Med 2002 137 (7): 586-97. van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria based review of the literature. Spine 1995 120 (3): 318-27.
Airaksinen O, Brox JI, Cedraschi C, et al. Chapter Four. European Guidelines for the Management of Chronic, Non-Specific Low Back Pain. Eur Spine J 2006 15(supple 2): S192-S300.
b. Prescribe/advise a short course of simple analgesia. Providing a short course of analgesia is proposed in Welsh Back’s guidence and will help to relieve Mrs Jones’ pain, help keep her mobile and may speed recovery.
c. Arrange for Mrs Jones to have x-ray or MRI. You WOULD NOT arrange for an X-ray or MRI scan unless you have reason to suspect a serious cause for her back pain. Abnormalities are present on both x-ray and MRI scans in people who do not have any physical back pain. NICE guidance advises against the use of imaging in the management of non-specific low back pain.
d. Refer Mrs Jones for physiotherapy. You WOULD NOT refer Mrs Jones for physiotherapy. NICE guidelines advise that patients should have a choice of physical treatments which includes exercise, acupuncture and manual therapies. European and NICE guidance do not support the use of interferential therapy, laser therapy, lumbar supports, shortwave diathermy, therapeutic ultrasound, thermotherapy, traction or transcutaneous electrical nerve stimulation.
e. Reassure Mrs Jones and advise her to stay active. You would reassure Mrs Jones to stay active to help her recovery and as indicated in Welsh Back’s guidance. It is important to stress that bed rest for more than a day or two actually prolongs the pain due to stiffness, muscle wasting, reduction in bone density and physical fitness, and leads to depression and difficulties with getting going again.
5. Evidence based treatments for acute low back pain include:
Choose at least one answer.
a. NSAIDs. This is correct, the use of NSAIDs should be short term and is advocated by Welsh Backs.
b. Advice to stay active. This is correct as proposed by Welsh Backs
c. Alternating hot and cold pads. This is correct as proposed by Welsh Backs
d. Muscle relaxants. This is incorrect as these drugs are not helpful
e. Lumbar supports. This is incorrect as these are not helpful
6. Mr Singh has been to see you on a number of occasions with low back pain over a period of a year. He has been managed according to the NICE guidelines having had group exercise and acupuncture and also was referred to the orthopaedic surgeons and had no identifiable lesion requiring surgery. He is keen to get back to running his business full time and asks what else is available. What would be the most appropriate treatment recommendation now? Choose at least one answer.
a. Manual therapy. There is moderate evidence that adding manipulation to GP care is beneficial (Airaksinen et al 2006). NICE guidance for back pain lasting less than one year suggests that patients who have not been helped by one course of physical treatment should be offered a further course of a different treatment. Mr Singh has had pain for over a year but this may be a reasonable option. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter Four. European Guidelines for the Management of Chronic, Non-Specific Low Back Pain. Eur Spine J 2006 15(supple 2): S192-S300.
b. Referral to an outpatient physiotherapy clinic. Few physiotherapy treatments have been shown to benefit patients with back pain. Without knowing which specific treatment would be provided, this may not improve Mr Singh’s outcome. In Frost et al (2004) it was found that routine physiotherapy was no more effective than a single advise session from a physiotherapist. Frost H, Lamb SC, Doll HA, et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004 329 (7468): 708.
c. An intensive back pain treatment programme. Multidisciplinary treatment consisting of intensive psychosocial and physical training, often using a group approach and avoiding passive physiotherapy reduces pain and improves the day to day activity of patients with chronic pain (Henschke et al 2008). The European Guidelines recommend multidisciplinary biopsychosocial rehabilitation with functional restoration for patients with low back pain who have failed mono-disciplinary treatments. NICE advises that patients with back pain lasting for less than one year who have failed to improve after one or more courses of physical therapy and who have significant pain or distress should be referred for an intensive programme of combined psychological and physical treatment lasting around 100 hours. Mr Singh has failed to improve after a course of group exercise and acupuncture and should have been offered a course of rehabilitation much earlier in the course of his back pain. A course such as this exists in Bronllys, Powys for the Welsh population but is not utilised fully due to financial constraints by the Health Boards. This, however, would have been a good choice for him. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009 60 (10): 3072-280.
d. Surgical treatment. European Guidelines advise that surgery should only be considered for patients with severe pain for whom 2 years of conservative treatment have failed. The high complication rate and cost of managing failed back surgery means that only carefully selected patients should be offered surgery. NICE guidance for low back pain lasting for less than one year suggests that referral for consideration of spinal fusion should be reserved for those who continue with severe pain or distress following a programme of combined physical and psychological treatment lasting around 100 hours.
7. What investigations would you consider for Miss Charles, a 30 year old female secretary with simple mechanical low back pain of six week duration?
a. An x-ray of the lumbar spine. It is common to see abnormalities on x-ray films of the lumbar spine and they have no benefit (Kerry et al 2002, Kendrick et al 2001). One study found that they actually have an adverse effect on outcomes. They also expose patients to a large amount of radiation.
b. A full blood count. Unless you are particularly concerned about the cause of the back pain, the diagnostic yield from an FBC is likely to be low. You also risk unnecessarily medicalising the problem.
c. MRI. It is also common to see abnormalities on MRI of the lumbar spine. This is an expensive investigation which is unlikely to improve the patient’s outcome. Jarvik et al (2003) showed that patients who had an MRI had a similar outcome to those that had an x-ray. Jarvik JG, Hollingworth W, Martin B, et al. Rapid MRI versus radiographs for patients with low back pain: a randomised controlled trial. JAMA 2003 289 (21): 2810-18.
d. ESR or plasma viscosity. Measuring ESR or plasma viscosity is the best test for excluding malignancy or ankylosing spondilitis (Jarvik et al 2002, van den Hoogan et al 1995). Unless you are concerned about the cause of the patient’s back pain, the diagnostic yield from these tests, given the patient’s age is likely to be low. Jarvek JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals Intern Med 2002 137 (7): 586-97. van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria based review of the literature. Spine 1995 120 (3): 318-27.
e. You shouldn’t arrange any investigations. This lady has simple mechanical low back pain and evidence suggests that investigating this type of back pain is unnecessary. Very few people presenting in primary care, even those with Red Flags, will have serious pathology spondilitis (Jarvik et al 2002, van den Hoogan et al 1995, Henschke et al 2007, 2008). Underwood (2009) found in a primary care study of 1172 new presentations of back pain found that 87% had one or more red flags, 11 patients had serious cause for their back pain of which 8 were osteoporotic fractures. A careful history and examination, if indicated, should exclude any serious cause. Jarvek JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals Intern Med 2002 137 (7): 586-97.
van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM. On the accuracy of history, physical examination and erythrocyte sedimentation rate in diagnosing low back pain in general practice. A criteria based review of the literature. Spine 1995 120 (3): 318-27. Henschke N, Maher CG, Refshauge KM. Screening for malignancy in low back pain patients: a systematic review. European Spine J 2007 16 (10): 1673-9. Henschke N, Maher CG, Refshauge KM. A systematic review identifies 5 Red Flags to screen for vertebral fracture in patients with low back pain. J Clinical Epidemiol 2008 61 (2): 110-18. Underwood M. Diagnosing acute non-specific low back pain: time to lower the Red Flags? Arthritis Rhem 2009 60 (1): 2855-7.
8. Mrs Evans has a six week history of low back pain and you previously diagnosed simple mechanical back pain. He was referred to physiotherapy who sent him for an MRI scan which showed he had a bulging disc at L 4/5 level and he has returned requesting stronger analgesia. What proportion of people WITHOUT back pain have signs of bulging discs on MRI scans?
a. less than 1%
d. 20% or more Jarvik et al (2002) in review of eight MRI studies in asymptomatic adults found bulging discs in 20-70%, herniated discs in 9-76% and degenerative discs in 46-91%.
Jarvek JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Annals Intern Med 2002 137 (7): 586-97.
9. When should screening for biopsychosocial risks to recovery be undertaken?
a. At initial presentation. STarT Back Pain study suggests that all patients should be screened for low, medium and high risk at initial presentation
Hill JC, Whitehurst DGT, Lewis M, Bryan S, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378 (9802): 1560-71.
b. two weeks following presentation
c. following 3 visits to the GP
d. At six months
10. You see Mr Foster after a three week history of low back pain. He tells you he has been taking his wife’s painkillers which she uses for cramps she gets that accompanies her periods. You dissuade Mr Foster from taking these, he has no history of serious illness and no allergies to medication. Which painkillers should you advise?
a. A weak opioid. If an NSAID and/or paracetamol are contraindicated or ineffective, this may be a useful alternative. The evidence for the use of a weak opioid is limited although they are supported in the European and NICE back pain guidelines. They should only be considered for a short course.
b. A prescription only NSAID such as diclofenac or naproxen. There is no evidence to suggest that one NSAID is more effective than another, they are indicated for low back pain and should be used with gastric protection.
c. Paracetamol, as required. Analgesia is usually more effective if taken regularly rather than only when the pain is at its worst
d. Paracetamol, 2 tablets four times a day. Paracetamol is as effective as NSAIDs and given that paracetamol has a lower risk profile, it would seem reasonable to use paracetamol as first choice and on a regular basis.