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low back pain

Cannabinoids and Low Back Pain

Teaser: 

Ted Findlay, DO, CCFP, FCFP

is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract:There is a great deal of interest in the use of cannabis-based products including medically authorized marijuana for the treatment of almost any pain condition including low back pain. There are many anecdotal reports of patients who found it an effective treatment for chronic low back pain, one that has allowed them in some cases to discontinue other treatments such as continuing opioid therapy. There is now easy legal access to cannabis-based preparations in Canada with or without medical authorization. However, with some notable exceptions, the evidence that would allow physicians to have a high degree of confidence in selecting this treatment modality is lacking.
Key Words: cannabis; chronic pain; low back pain; evidence.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

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1. Compared to medically authorized cannabis, street sourced products are at high risk of contamination including insect remains, fungi, chemical fertilizers and herbicides.
2. Unlike most plant-sourced medications, the active ingredients are located on the cannabis leaf, which raises the risk of contaminant exposure.
3. Cannabis leaves by themselves are inert until heated in a process known as decarboxylation.
4. While inhaled cannabis has a rapid onset of action, ingested products have a delayed onset producing a risk of overdose if continuing to consume while waiting for an expected effect.
5. Little is yet known about potential drug interactions with cannabis use.
Cannabis authorizing physicians will often recommend a higher THC:CBD ratio product for evening or bedtime use, and a higher CBD:THC ratio or pure CBD for daytime use.
As is true for any potential intoxicant, patients need to be cautioned about the risks of operating a motor vehicle or any machinery while under the influence of cannabinoids, especially higher THC ratio products.
Because it is a lipid soluble chemical, urine, blood, or hair tests can detect THC for many days after use. Standardized tools and principles exist for the appraisal of credible eHealth resources.
Physicians in Canada provide medical "authorization" for cannabis use, verifying that the patient has a medical condition for which cannabis could be a valid therapeutic option. This authorization then allows the patient to purchase from a licensed producer up to a recommended quantity in grams per day. Although the basic patient demographics and birthday are required, unlike a prescription, the exact component percentage and potency, method of ingestion, and frequency are not components of the authorization.
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The Impact of Depressive Symptoms: Considerations for Clinicians Treating Patients with Low Back Pain

Teaser: 

Jessica Wong, DC, MPH,1
Linda Carroll, PhD, 2
Pierre Côté, DC, PhD, 3

1 Research Associate, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).
2Professor Emeritus, School of Public Health, University of Alberta.
3 Professor and Canada Research Chair in Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).

CLINICAL TOOLS

Abstract: A considerable proportion of patients with low back pain (LBP) experience depressive symptoms. A clinical case is used to highlight potential steps that clinicians can take to help manage depressive symptoms in these patients: 1) Assess for depressive symptoms using a valid and reliable questionnaire; 2) Provide education, reassurance, and self-management strategies to initiate the program of care; 3) Adjust care plans if patients also present with depressive symptoms (e.g., ongoing support and education); and 4) Provide ongoing assessment of depressive symptoms, and consider referrals to a specialist or other health care providers (e.g., counselors, clinical psychologists, or psychiatrists) for further evaluation if symptoms are worsening.
Key Words: Low back pain, depressive symptoms, depression, depressive disorder.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

A considerable proportion of patients with low back pain present with depressive symptoms
Depressive symptomatology includes depression that has not been formally diagnosed and symptoms that do not meet the criteria for depression
The presence of depression may indicate poorer recovery from low back pain
Patients experiencing low back pain and concomitant depressive symptoms may benefit from ongoing assessments, education, reassurance, and self-management strategies
Assess for depressive symptoms in patients with LBP using a valid and reliable questionnaire (e.g., Patient Health Questionnaire-9)
Provide education, reassurance, and self-management strategies to all patients with LBP to initiate the program of care
Adjust the care plan accordingly if patients also present with depressive symptoms, including additional support and education (e.g., addressing misconceptions, encouraging activity) on an ongoing basis
Provide ongoing assessment of depressive symptoms, and consider referrals for further evaluation if symptoms are worsening
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The Canadian Spine Surgeon’s Perspective: Avoiding Opioid Use in Spine Patients

Teaser: 

Alexandra Stratton, MD, MSc, FRCSC,1
Dr. Darren Roffey, PhD,2
Dr. Erica Stone, MD, FRCPC,3
Mohamed M. El Koussy, BSc,4
Dr. Eugene Wai, MD,5

1Orthopaedic Spinal Surgeon, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
2University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
3Anesthesiology, PGY 6 Pain Medicine, The Ottawa Hospital, Ottawa, ON.
4Clinical Research Assistant, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
5is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.

CLINICAL TOOLS

Abstract: Opioids are drugs with pain relieving properties; however, there is evidence that opioids are no more effective than non-opioid medications in treating low back pain (LBP), and opioid use results in higher adverse events and worse surgical outcomes. First line treatment should emphasize non-pharmacological modalities including education, self-care strategies, and physical rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered an appropriate introduction into pharmacological treatment when deemed necessary. Non-opioid adjunct medications can be considered for specific features related to LBP such as neuropathic leg pain. Primary care providers should exhaust first and second line treatments before considering low-dose opioids, and only then in consultation with evidence-based clinical practice guidelines.
Key Words: Pharmacological; low back pain; radiculopathy; opioids; analgesia.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. First line treatment for low back and radicular leg pain is non-pharmacological.
2. Second line treatment includes NSAIDs (with or without proton pump inhibitor), and muscle relaxants (3 weeks maximum), gabapentinoids and antidepressants.
3. Exhausting non-opioid analgesics includes trialing different medications within the same class and at different doses since many of these medications have wide therapeutic dose ranges.
A "start low and go slow" approach is recommended for initiating pharmacological treatments for low back and radicular leg pain, especially when using neuroleptics and antidepressants.
When treating low back pain with neuropathic leg pain, patients who fail a trial of pregabalin may tolerate gabapentin, or vice versa.
Antidepressants have a role in managing low back pain, particularly chronic, even in the absence of mood disorder.
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Choosing Wisely Canada and Low Back Imaging: The view from Alberta

Teaser: 

Dr. Ted Findlay, D.O., CCFP,

is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary and he is on the Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract: The Choosing Wisely Canada (CWC) initiative is a partner in a global effort to increase the efficiency and effectiveness of medical care by stimulating conversations between patients and care givers about the benefits and risks of commonly done tests and treatments. One of the earliest and broadly publicized recommendations was to stop routine lumbar spine imaging in the absence of clinical red flags. The rationale for discouraging this practice, including the quantification of associated harm, is not as widely known. The CWC initiative includes "Toolkits" for a number of clinical conditions, which extend the conversation beyond what should be avoided to include recommendations for appropriate care. The Alberta CWC partners have developed a Toolkit for low back pain for use by individual clinicians, physician groups, and at the systems level.
Key Words: Low back pain, imaging, overuse, red flags.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

In the absence of red flags and/or significant chronicity don't order x-rays or advanced imaging for low back pain.
Be cautious about attributing any findings from imaging as the "cause" of low back pain in a particular patient; recognize normal age related changes.
Low back imaging is required in the presence of clinical Red Flags for which invasive intervention is planned. Clinical correlation of the images is mandatory.
The indications for specific interventional treatments either surgical or image guided must be determined by history and physical examination.
Most low back pain patients need treating, not testing.
Patients presenting with low back pain are often anxious and worried that they may have a serious underlying anatomical cause. This anxiety is not relieved by discussions of abnormalities found on routine imaging.
Patients respond to a treatment plan that is supported by pertinent handouts and clear explanations including discussions about when imaging could be considered and when a referral might be the correct course.
Treatment for low back pain should not be delayed until the cause has been "established" by investigation; appropriate treatment can be determined by the history and physical examination and supported by the anticipated positive clinical response.
A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.
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Current Management of Symptomatic Lumbar Disc Herniation

Teaser: 

Parham Rasoulinejad, MD, FRCSC, MSc, 1 Jennifer C. Urquhart, PhD,2 Christopher S. Bailey, MD, FRCSC, MSc, 2

1Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Assistant Professor, Dept. of Surgery, University of Western Ontario, London, ON.
2Research Associate, Division of Orthopaedic Surgery, London Health Sciences Center, and Lawson Health Research Institute, London, ON.
3Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.

CLINICAL TOOLS

Abstract: Lumbar disc herniation is a common cause of low back pain and radiculopathy (sciatica). Diagnosis is initially made based on history and physical examination and ruling out red flags, particularly surgical emergencies such as Cauda Equina Syndrome. A trial of conservative treatment consisting of physical rehabilitation and oral medication is usually successful for back dominant pain. When persistent radiculopathy indicates lumbar discectomy the diagnosis must be confirmed by imaging but, due to very high rates of asymptomatic disc herniation, imaging cannot replace clinical diagnosis. For disabling leg dominant pain discectomy results in faster recovery but has a similar long-term outcomes compared to conservative treatment.
Key Words: lumbar disc herniation, lower back pain, sciatica, radiculopathy.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

Lumbar disc herniation is common and frequently asymptomatic.
Lumbar disc herniation may result in back pain. Much less frequently, when the adjacent nerve root is involved it can cause radiculopathy (sciatica).
Under most circumstances, the symptoms of lumbar disc herniation can be managed conservatively with physical rehabilitation and oral medications.
Red flags and surgical emergencies such as Cauda Equina Syndrome must be considered and should lead to urgent imaging and surgical referral.
Imaging, particularly MRI, has high rates of false positives and should only be used to confirm a diagnosis made based on history and physical examination.
For disabling persistent radiculopathy with good radiological correlation, surgical intervention in the form of a discectomy can be considered.
Lumbar disc herniation (LDH) is common and in most cases asymptomatic. Findings on MRI of lumbar disc herniation are not predictive of future back related disability. MRI findings should be interpreted along with history and physical exam findings to determine the appropriate diagnosis.
LDH can result in back pain and, when the adjacent nerve root is involved, radicular leg pain. The first line of treatment for back dominant pain should be education, lifestyle modification, mechanical therapy and oral medications in the form of acetaminophen, non-steroidal anti-inflammatories.
Radicular leg dominant pain may require opioids and/or epidural corticosteroid injections. The majority of patients will improve without further intervention.
For persistent symptoms of sciatica, surgical intervention can be considered. Lumbar discectomy is the most common procedure performed and has good to excellent outcomes.
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Interventional Radiology Procedures for Chronic Low Back Pain

Teaser: 

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C), 2

1is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary. He is also in a Private Family Medicine practice. In addition he is on Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: There is an increasing availability and clinical use of interventional radiological techniques for patients with low back pain. This can be a valuable additional tool in the management of low back pain that has not responded to conservative treatment. However, the clinical indications and appropriate uses as well as cautions that apply to this treatment modality are in many cases less well understood by the primary care practitioner. The objective of this article is to review clinical scenarios in which these procedures are commonly considered, as well as their limitations. The field of interventional radiology is one that is rapidly evolving and an area of active clinical research. It is important for the primary care practitioner to have a basic understanding of the current state of the art in order to have an informed discussion with their patients who may be seeking advice on this treatment option.
Key Words: Low back pain; treatment; interventional radiology definitions; interventional radiology indications; interventional radiology complications.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

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1. In patients carefully selected by clinical and radiological examination, there can be satisfying clinical gains from the use of currently available interventional radiologic procedures.
2. One must not assume that abnormal findings on radiologic imaging immediately explains the anatomical cause of a patient's low back pain; a corresponding accurate history and physical examination is ideal prior to commencing injections.
3. When successful, the gains from radiological interventions should be considered one portion of a broader clinical treatment plan, rather than the entire plan of management.
4. Unsuccessful interventional procedures should not be repeated.
1. Do not apply repeated interventional procedures with an expectation that one of them will find the target source of the patient's low back pain.
2. Although they may be uncommon, interventional radiology risks can occur and the referring physician should be cognizant of these dangers that accumulate with repeated interventions.
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CORE BACK TOOL 2016: New and Improved!

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

www.cfpc.ca/mainpro-manual
Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,1 Yoga Raja Rampersaud, MD, FRCSC,2 Jess Rogers3Dr. Hamilton Hall, MD, FRCSC,4

1 is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.
2Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Past President Canadian Spine Society, Toronto, ON.
3 is the Director at the Centre for Effective Practice (CEP). Jess' role includes developing evidence-based clinical guidance for providers. Jess was the Project Lead in executing the primary care provider education component of Ontario's Low Back Pain initiative including the CORE Back Tool. CEP is pleased to have funded the update of the CORE Back Tool 2016 to continue supporting primary care providers.
4 is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract: Through the redesign of the already successful Clinically Organized Relevant Exam (CORE) Back Tool, primary care clinicians now have a more comprehensive, user-friendly approach to clinical decision making for patients presenting with low back pain. The key components of the tool include a high yield history connected to mechanical low back pain patterns, embedded key patient messages, clear listing of appropriate radiological indications, criteria for consultant referrals as well as a management matrix geared to office practice. A clinical case will be used to demonstrate the application of the tool to practice and instruct the reader on the key features.
Key Words: Low Back Pain, Tool, Primary Care Providers, Management.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Mechanical Patterns are a logical way to conceptualize, assess and manage low back pain.
2. If pain does not fit a mechanical pattern, the patient may have non-spine referred pain from organs or a chronic pain disorder.
3. Radicular (nerve) pain will have a positive straight leg raise (SLR) with reproduction of the typical leg dominant pain and possible abnormal neurological signs.
Initial patient management should include goals of reducing pain and increasing activity.
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Diagnostic Radiology in Low Back Pain

Diagnostic Radiology in Low Back Pain

Teaser: 

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C),2

1Clinical Assistant Professor, Department of Medicine, University of Calgary, Private Family Medicine practice, Medical Staff, Alberta Health Services, Calgary Zone, Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Many clinicians believe that imaging is necessary to accurately diagnose and manage low back pain. However, there is good evidence that in the absence of "Red Flags", there is an overuse of both routine X-rays and advanced diagnostic imaging such as MRI. When imaging is used without appropriate clinical indications, it is rare for the results to lead to a change in a treatment plan. Management is based on adequate history and confirmatory physical examination. This article uses three actual cases as the basis for exploring the place of diagnostic imaging in treating low back pain.
Key Words: low back pain, diagnosis, radiology, indications, appropriate.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. While imaging may be required in the management of specific cases of low back pain particularly when "Red Flags" are present, it is rare that unexpected findings will result in a change of the treatment plan.
2. Be very cautious about the terminology used to describe the results of imaging studies and whenever possible normalize the results for the patient. Many abnormal findings may be "normal" for patients in older age groups. Many may be present in patients who are pain free.
3. Ensure that the patient understands that the results of the images are not necessarily a barrier to recovery.
4. Except to establish the boney contours of the spine, when advanced imaging is required an MRI examination is often the preferred option.
5. Be very cautious about attributing the cause of a patient's pain to the results found on imaging. Careful correlation with the clinical presentation is required before deciding on any change in treatment.
In the absence of clinical "Red Flags", there is no indication to image the spine before initiating treatment.
It is never appropriate to delay treatment for mechanical low back pain to wait for an imaging procedure.
Prepare the patient, before advanced imaging is performed, that there is a very high likelihood that the investigation will find "abnormalities" but that these changes are usually the result of natural aging and no cause for concern.
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Passive Straight Leg Raise Test: Definition, Interpretation, Limitations and Utilization

Passive Straight Leg Raise Test: Definition, Interpretation, Limitations and Utilization

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

www.cfpc.ca/mainpro-manual
Teaser: 

Dr. Hamilton Hall, MD, FRCSC, is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.
Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto's Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article highlights the myths and misunderstandings surrounding the straight leg raise (SLR) test for sciatica. Unfortunately, neither intra- nor inter-observer reliability of the passive SLR test has ever been agreed upon. In addition, there is poor consensus about what constitutes a positive SLR test in terms of pain location, leg elevation limitation or clinical significance. Until there are stricter performance standards and uniform agreement, researchers and clinicians should interpret the test with caution. We believe a true positive SLR should be the reproduction or exacerbation of the typical leg dominant pain in the affected limb at any degree of passive elevation. Those with only increased back pain or any leg pain other than that presenting as the chief complaint should be regarded as false positives.
Key Words: low back pain, straight leg raise, sciatica, irritative test.

Indications for Rehabilitation in Acute Low Back Pain: Making a Correct Referral

Indications for Rehabilitation in Acute Low Back Pain: Making a Correct Referral

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

www.cfpc.ca/mainpro-manual
Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH, is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.

Greg McIntosh, MSc, completed his Masters in Epidemiology from the University of Toronto’s Faculty of Medicine. He is currently the Director of Clinical Research for CBI Health Group and research consultant to the Canadian Spine Society.

Abstract
This article helps clinicians decide on appropriate referral to rehabilitation professionals while answering some of the common questions that clinicians are often asked by low back patients. The evidence for appropriate rehabilitation techniques will be interwoven into this article to promote a critical appraisal approach to evaluating rehabilitation outcomes. At the conclusion of this paper, clinicians should be able to identify best practices for rehabilitation referral.
Key Words: Low back pain, indications, rehabilitation, inter-professional referral.