PATIENTS IN PAIN
From the 31st Semi-Annual Family Practice Review, sponsored by Temple University School of Medicine, Philadelphia,
PA, and Lancaster General Hospital, Lancaster, PA
| BACK PAIN —Elliott B. Sterenfeld, MD, Lancaster Neuroscience and Spine Associates, Lancaster, PA
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| Epidemiology: lifetime prevalence ≈85%; 14% have significant episode lasting ≥2 wk; annual incidence ≈5%; at any
given time, 1% of population has disabling back pain; back pain leading cause of disability in patients <45 yr of age; one
of most common reasons for visits to physicians
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| Natural history: benign; ≈90% of patients return to work in ≈12 wk; 75% of patients with radiculitis (eg, sciatica) get
significantly better within 6 mo, but 80% have persistent or recurring pain within any given year; point—tell patients
they must accept some degree of pain
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| Clinical assessment: ≈85% of patients cannot be given definitive diagnosis for acute pain; acute phase typically considered
first 6 wk of pain, and subacute phase next 6 wk; specific diagnosis not usually required to provide relief (most patients
get better few days later if simply told to take 2 aspirin tablets and call next morning); specific diagnosis achievable
in majority of patients beyond acute phase; history and physical examination most useful in office setting
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| Etiology: muscle strain (most common cause; often due to injuries to disc or facet joint); annular tear of disc more common
reason for acute episode; disc herniation more often seen in subacute and chronic phases; degenerative disc disease (due to
age-related changes in spine); facet syndrome (common in golfers; resolves in few weeks); spinal stenosis (causes claudication
and leg symptoms, not back pain); stenosis of aorta (can cause back pain); questions to ask in history—anything serious
going on? any neurologic dysfunction? any psychosocial distress?
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| Cancer: responsible for <1% of back pain cases; two-thirds of cancerous back pain cases due to metastatic disease (usually
breast, lungs, prostate, or kidneys); multiple myeloma most common primary tumor causing back pain; history, signs
and symptoms—age >50 yr; history of cancer; constant pain, not relieved by position change; presence of night pain or
unexplained weight loss
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| Infectious forms of back pain: include osteomyelitis, discitis, and epidural abscess; uncommon; infection usually
blood borne; urinary tract infections and skin infections common sources; often occur in immunosuppressed people who
have undergone interventional procedures (eg, surgery, epidural injection) or have had sepsis; history, signs and
symptoms—immunosuppressed state; use of corticosteroids; recent spinal intervention; fever; in discitis, pain constant
awakens patient, and increases with slightest motion; in discitis and vertebral osteomyelitis pain occurs with percussion;
neurologic findings present with epidural abscess
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| Vascular back pain: abdominal aortic aneurysm (AAA)—examine and listen to abdomen; palpate abdominal aorta;
typically occurs in people >50 yr of age with history of atherosclerosis, peripheral vascular disease, or hypertension; male
predominance
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| Back pain due to compression fracture: suspect in elderly woman with osteoporosis; may not be associated with
trauma
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| Ankylosing spondylitis: uncommon cause of back pain; usually develops in young men; onset slow and insidious;
characterized by dull aching in morning, morning stiffness, and pain that improves with exercise and activity; Schober
test not very specific for making diagnosis; diagnosis usually made with x-rays and blood studies
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| Neurologic causes of back pain: cauda equina syndrome—rare; signs and symptoms include urinary retention,
bowel and bladder incompetence, sexual dysfunction, diminished perineal sensation (saddle anesthesia; key sign), and bilateral
lower extremity symptoms (eg, numbness, paresthesias, weakness); lumbar radiculopathy (nerve dysfunction) and
radiculitis (nerve pain)—lumbar radiculopathy characterized by myotomal weakness, dermatomal sensory changes, and
diminished or absent reflexes; lumbar radiculitis refers to pain in nerve distribution; 95% of cases of lumbar radiculopathy
occur at L5 and S1 nerves; peak incidence in people 30 to 55 yr of age; pain in distribution of spinal nerve, usually
sharp burning pain but may be aching sensation; S1 radiculitis sometimes feels like hamstring pull; aggravation of pain
with sitting, flexion, Valsalva maneuver, coughing, or sneezing; cross straight leg raise test highly sensitive and specific;
check for muscle weakness and sensory changes in dorsal foot (L5), medial foot (L4), and lateral foot (S1); elicit ankle
jerk reflex for SI radiculopathy; patellar reflex (L4)
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| Spinal stenosis: occurs typically in people >55 yr of age; manifestations include neurogenic claudication, intact peripheral
pulses, and variety of nonspecific symptoms (eg, cramping, aching, fatigue, cold tingling sensations); in vascular
claudication patients obtain relief by standing still, while in neurogenic claudication, pain relieved by bending forward
while walking, not by standing still
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| Back pain associated with psychosocial distress: causes include depression, drug and alcohol abuse, chronic pain
syndromes (eg, fibromyalgia), job dissatisfaction (number 1 reason for not going back to work after injury), and litigation
(reduces all outcomes by one-third)
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| Other conditions that mimic spine pain: various gynecologic and gastrointestinal (GI) disorders; rheumatologic
problems (eg, fibromyalgia, polymyalgia rheumatica, seronegative spondyloarthropathies; piriformis syndrome; greater
trochanteric bursitis (patients claim they cannot lie on side at night; moving helps relieve pain; to inject greater trochanteric
bursa needle must be 3.5”); osteomalacia; Paget’s disease; diabetic amyotrophy
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| Key elements of history: demographic—age, sex, ethnicity; review of systems—weight loss, fever, chills, night
sweats; social issues; past medical history; characteristics of pain; mechanism of injury
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| Key elements of physical examination: fever; pain with percussion; lumbar mobility; presence of muscle spasm;
root tension signs; neurologic examination
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| Diagnostic tests: imaging studies—generally not indicated during first 4 wk, unless trauma involved or osteoporosis
suspected; magnetic resonance imaging (MRI) not initial test for L5 radiculopathy (reserve for patient who fails to respond
to therapy and getting worse); electromyelography (EMG) and nerve conduction velocity (NCV)—reserve for patients
with radicular symptoms
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| Treatment options: many, but evidence limited; oral corticosteroids—use limited and often ineffective for lumbar
problems (more useful for cervical problems); nonsteroidal anti-inflammatory drugs (NSAIDs)—eg, acetaminophen
(Tylenol) mainstays of treatment; opioids—use questionable for acute episodes, but consider short-acting opioids if
NSAIDs fail; muscle relaxants—central nervous system depressants; baclofen only true muscle relaxant, but even low-
doses debilitating; reasonable to use in acute phase
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| Indications for referral: cauda equina syndrome; progressive neural deficits; refractory pain
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| FIBROMYALGIA —Steven N. Berney, MD, Professor Emeritus and Chief, Rheumatology Section, Department of Medicine,
Temple University School of Medicine, Philadelphia
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| Clinical pearls: 1) fibromyalgia widespread chronic pain syndrome (patients typically say they hurt everywhere; pain
not on basis of inflammation or deteriorative process); 2) characterized by typical sites of tenderness; 3) pain often accompanied
by fatigue and poor quality of sleep; 4) no objective disease markers exist; 5) treatment empirical
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| Pathophysiology: unknown; appears to involve amplification of sensory impulses, ie, patients hypersenitive to perception
of pain, perhaps as result of brain function (central hypersensitization) and defect in pain perception process
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| Clinical points: fibromyalgia typically seen in middle-aged women; symptoms frequently begin after physical or emotional
trauma; patients usually tense and demanding, present with voluminous medical records, and typically tell physician,
“you are my last hope” (characteristically praising physician, then box him or her into corner to demand pain relief);
often associated with depression (but not all fibromyalgia patients depressed)
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| Symptoms to inquire about: “hurting all over” for ≥3 mo; fatigue; insomnia and disturbed sleep; periods of morning
stiffness (consider rheumatoid arthritis [RA] in differential); dry mouth (but they often have pools of saliva in mouth);
paresthesias, particularly tingling and numbness in hands (but no sensory deficits found on neurologic examination);
headaches
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| Factors to ask about in probing possible sleep disturbance: difficulty falling asleep; frequent nighttime awakenings;
early morning awakening; nonrestorative sleep (always tired)
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| Typical findings: healthy appearing; normal muscle tone and strength; lack of physical abnormalities on musculoskeletal
or joint examination (may find signs of osteoarthritis [OA] in older patients); dermatographia (erythema typically develops
within short time after pen marks applied to skin); presence of or tender points
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| Typical tender points: base of occiput; base of neck muscles; anterior chest wall area; border of scapula (bilaterally);
medial or lateral epicondyle of elbows; episacral brim; trochanteric bursa; medial or lateral border of knee; points—
tender points situated in scattered areas and involvement usually bilateral; insignificant nodular areas (collection of soft
tissue, fat, fascia, and nerve endings) often felt on palpation
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| Differential diagnosis: other rheumatoid disorders (eg, RA; systemic lupus erythematosus [SLE], Sjögren’s syndrome,
polymyalgia rheumatica); viral illnesses (most short lived, except for hepatitis B and C); Lyme disease (strict laboratory
criteria); hypothyroidism; hypovitaminosis D (often due to lack of sun exposure); sleep apnea (suspect especially in overweight
people); abrupt withdrawal of corticosteroids, with development of Addisonian-type syndrome; narcotic withdrawal;
psychogenic pain
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| Laboratory studies to rule out primary causes of diseases: complete blood count (CBC), sedimentation rate,
and C-reactive protein (to rule out inflammation); autoantibodies and rheumatoid factor (primarily to rule out RA and
SLE); muscle enzymes (eg, creatine phosphokinase [CPK], aldolase); protein electrophoresis (to rule out multiple myeloma,
particularly in elderly); comment—laboratory results typically normal in fibromyalgia patients
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| Treatment: no approved treatment and no cure; recommended approaches—vigorous physical activity (eg, aerobic exercise,
physical therapy, water therapy); analgesics (narcotic and nonnarcotic); NSAIDs; trigger point injections; psychotropic
agents; sleeping aids
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| HIP AND PELVIC PAIN DUE TO TRAUMA —William R. Vollmar, MD, Medical Director, Sports Medicine Program,
Lancaster General Hospital, Lancaster, PA
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| Overuse injuries: occur when breakdown from exercise exceeds rebuilding
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| Physical examination of hip: assess internal and external rotation of hips and joints in standing and seated positions;
assess vascular and neurologic function; assess range-of-motion in supine position; check abduction, adduction, flexion,
and external rotation; look for symptoms and piriformis pain on straight-leg raising; strike heels to look for leg tenderness;
turn patient on opposite side and assess flexibility, then lie patient on stomach, pick up leg and check for contractions
or tightness on front of leg
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| Differential diagnosis by age: immature skeleton—apophyseal injuries; slipped capital femoral epiphysis (SCFE),
Legg-Perthes disease; mature skeleton—OA; claudication; lumbar disc disease; teenage to adult years—stress fractures;
soft tissue injuries; sciatica; labral tears; femoral-acetabular impingement; athletic pubalgia
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| Differential diagnosis by pain site: anterior groin—arthritis of hip; lesser trochanteric bursitis; iliopsoas bursitis;
non-overuse injuries; anterior inguinal region—hernias; athletic pubalgia; skeletal and muscular injuries associated with
ischial tuberosity; lateral side of hip—trochanteric bursitis; iliotibial band syndrome; apophyseal injuries; posterior aspect
of hip—sacroiliac joint pain; nerve disorders (including sciatica); piriformis syndrome; hamstring syndrome; lumbar
disc disease; overall diffuse pain—stress fracture, especially in female athlete
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| Apophyseal injuries: cause of anterior pain; typically occur in people <25 yr of age (most pelvic apophyses do not
close until 20 to 25 yr of age); can be overuse or avulsion injuries; treatment generally conservative, ie, decreasing intensity
and duration of activity with pain control (functional rehabilitation), followed by cross-training activities; surgery reserved
for severe displacement and avulsion of large fragment
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| Slipped capital femoral epiphysis: prevalence highest in males with higher body mass index (BMI); average age
≈11 yr; tends to be bilateral; surgery only therapeutic option
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| Legg-Perthes disease: occurs in younger children; male predominance; slower onset; usually characterized by painless
limp; pain often in knee, not hip; treatment options variable
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| Osteoarthritis: associated with limited and painful internal and external rotation and Trendelenburg gait; pain in anterior
groin referred to knee; usually diagnosed by plain x-rays; treatment usually surgical
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| Claudication symptoms: not necessarily due to overuse but can occur in hip; could be due to circulatory problem of
spine or extremity; ask about coronary artery disease, carotid stenosis, stroke, and myocardial infarction (MI); surgical
and nonsurgical treatments
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| Lumbar disc disease: characterized by pain in anterior groin and inguinal regions, along with back pain; pain radiating
below knee key to diagnosis; pain worse in sitting position; bowel and bladder symptoms not associated with hip pathology;
surgical and nonsurgical treatments available
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| Femoral-acetabular impingement: 2 types (cam impingement, pincer impingement); associated with pain on hip
flexion and internal rotation; overuse injury, seen particularly in martial arts athletes and golfers; obtain plain x-rays before
getting MRI; treatment—activity adjustments and physical therapy indicated before considering surgery; arthroscopic
procedures preferred to open hip surgery for athletes wishing to return to sport
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| Labral tears: often associated with femoral-acetabular impingement; also seen with congenital dysplasias in which acetabulum
smaller than normal; most occur in anterior-superior portion of hip; patients with anterior tears have pain on hip
flexion and internal rotation; pain with Faber testing (flexion, abduction, external rotation) more suggestive of posterior
labral tear; treatment involves surgery, arthroscopic if possible; diagnosed with plain films, followed by magnetic resonance
arthrography
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| Athletic pubalgia: controversial entity; prevalence probably highest among soccer players; characterized by hyperextension
of hip and exertional pain; pain typically where abductor longus originates and rectus abdominis inserts; imaging
studies usually negative; male predominance; pain often occurs with adduction of legs against resistance; <50% have tenderness
on palpation; treatment—first try conservative measures (eg, rest, ice, NSAIDS, massage, steroid injections);
surgery indicated if conservative measures fail over 2 to 3 mo
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Suggested Reading
Ammendolia C et al: Back belt use for prevention of occupational low back pain: a systematic review. J Manipulative
Physiol Ther 28:128, 2005; Anderson K et al: Hip and groin injuries in athletes. Am J Sports Med 29:521, 2001; Boal
RW, Gillette RG: Central neuronal plasticity, low back pain, and spinal manipulative therapy. J Manipulative Physiol
Ther 27:314, 2004; Boswell MV et al: Epidural steroids in the management of chronic spinal pain and radiculopathy.
Pain Physician 6:319, 2003; Busch A et al: Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev
(3):CD003786, 2002; Chen J, Liu C: Sulfasalazine for ankylosing spondylosis. Cochrane Database Syst Rev
(2):CD004800, 2005; Dvorak C: Common complaints, difficult diagnosis: multiple myeloma. J Am Acad Nurse Pract
18:190, 2006; Erlich GE: Back pain. J Rheumatol 67(Suppl):26, 2003; Goldenberg DL et al: Management of fibromyalgia
syndrome. JAMA 292:2388, 2004; Hagen LB et al: Bed rest for acute low-back pain and sciatica. Cochrane
Database Syst Rev (4):CD001254, 2004; Hoffman BM et al: Meta-analysis of psychological interventions for chronic
back pain. Health Psychol 26:1, 2007; Kinkade S: Evaluation and treatment of acute low back pain. Am Fam Physician
75:1181, 2007; Lapp JM: Pelvic stress fracture: assessment and risk factors. J Manipulative Physiol Ther 23:52, 2000;
Macintyre J et al: Groin pain in athletes. Curr Sports Med Rep 5:293, 2006; Malliou P et al: Measurements and
evaluations in low back pain patients. Scand J Med Sci Sports 16:219, 2006; Mannerkorpi K: Exercise in fibromyalgia.
Curr Opin Rheumatol 17:190, 2005; Mansour M et al: Ankylosing spondylitis: a contemporary perspective on diagnosis
and treatment. Semin Arthritis Rheum 36:210, 2007; Maquet D et al: Benefits of physical training in fibromyalgia
and related syndromes. Ann Readapt Med Phys 50:363, 2007; Martell BA et al: Systematic review: opioid treatment for
chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 146:116, 2007; Tofferi JK et al:
Treatment of fibromyalgia with cyclobenzaprine: a meta-analysis. Arthritis Rheum 15:51, 2004; Van der Roer N et al:
What is the most cost-effective treatment for patients with low back pain? A systematic review. Best Pract Res Clin Rheumatol
19:671, 2005.
Educational Objectives
| The goal of this program is to update the listener about back pain, fibromyalgia, and hip and pelvic pain due to trauma. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Perform a rational clinical evaluation for patients complaining of back pain.
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| 2. Offer reasonable treatment options for back pain patients, and know when to refer patients.
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| 3. Workup the patient suspected of having fibromyalgia.
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| 4. Consider options for treating patients with fibromyalgia.
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| 5. Evaluate and treat patients with hip and pelvic pain due to trauma.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Berney, Sterenfeld, and Vollmar were recorded March 29, 2007, at the annual Family Practice Review, sponsored by
the Temple University School of Medicine and Lancaster General Hospital, and held in Lancaster, PA. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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