Red flags
Malignancy
Begin low back pain after 50 life years;
Continuous pain (repositioning or movement does not lessen the pain);
Pain during the night (pain is not due the body's position);
Malaise;
Malignancy in the past;
Unexplainable body weight loss;
And/or high erythrocyte sedimentation rate.
Osteoporostic spine fracture
Recent fracture (<2 years);
Spine fracture in the past;
Age above 60 years;
Low body weight (<130 lbs, BMI < 20 kg/m2);
Elderly with hip fracture;
Corticosteroids use for longer period of time;
Local tap (palpation) or pressure pain on the spine;
Remarkable decrease in body length;
And significant thoracic kyfosis.
Spondylitis ankylopoetica
Begin low back pain;
Male;
Iridocyclitis (yellow eyes);
Unexplainable peripherally artritis or inflammatory dermondoining in past;
Mainly nightly pain;
Morning stiffness > 1 hour;
Less pain when laying down/movement/exercises;
Good reaction on NSAID's
And/or high erythrocyte sedimentation rate.
Spine fracture
Severe low back pain after trauma
Severe form of spondylolisthesis
Begin low back pain before age 20;
Pronounced and touchable process spinosus around the level L4-L5.
Anamnesis
Physical symptoms;
Consult question;
Specify begin of the physical symptoms and course over time;
Status presens;
Coping;
And psychosocial factors.
Instruments
Numeric (pain) rating scale: 10 is most pain imaginable; 0 is no pain;
Patient Specific Complaints [patiënt Specifieke Klachten]: Rate the effort of three activities it takes you to execute;
And Quebec Back Pain Disability Scale: evaluate functional status.
Profile 1: Natural history
A natural history means that there is an increase of activities and a decrease of pain with 3 weeks.
Advice:
No need to worry;
Avoid laying in bed to lessen the pain (max. 2 days in case of severe pain);
Resume activities and try to keep working or make adaption so you can keep working;
Increase of activities will not lead to damage of the back;
And max. 3 physical therapy consults needed.
Profile 2: different course
A different course means that there is no increase of activities and no decrease of pain with 3 weeks.
Advice:
Build up activities, keep working or try to resume work;
Increase of activities will not lead to damage of the back;
Use my training schedule adjusted to your wishes;
Consider mobilization (increase the range of movement of the joints);
Consider short massage or warmth therapy for pain releave;
And in case of absenteeism >4 weeks, contact a occupational therapist.
Profile 3: different course with dominant psychological factors
Psychological factors have a negative effect on the physical well being. Dare to talk together about psychological factors.
Discuss psychological factors;
Discuss multidisciplinary with occupational therapist in case of severe physical injury, absenteeism or conflict in workplace;
Start a graded activity program (a slow and steady increase of activities based on time and not based on pain;
In case of absenteeism match the goals of graded activity program with resumption of work;
Evaluate program when there is no progression within 6 weeks.
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