On Monday, June 8th, at 10 am, a 54-year-old certified nurse assistant presented in the Emergency Department (ED) with complaints of severe low-back pain. The patient reported that the pain occurred suddenly after attempting to lift a patient from a bed to a chair. The supervisor confirmed that the incident was work-related. The pain was constant and radiated to the right thigh, worsening with coughing and sneezing.
The patient’s past medical history and review of systems revealed sleep apnea and uncontrolled diabetes. She had recently gained 25 pounds, attributing it to menopause, and complained of mood swings, including periods of depression. She had a history of GI infections, fibromyalgia, arthritic pain in her shoulders, and low-back pain when resting. Recurrent back pain with radiation to the right buttock and leg above the knee had been experienced before. In recent weeks, she had received counseling about poor attendance and work effort.
During the ED examination, the patient’s vital signs were recorded as follows: temperature 98.8, pulse 92, respiration 22, blood pressure 156/92, and a pain scale rating of 9/10. She weighed 188 lbs., measured 5’3″ in height, and had a BMI of 33.3. Due to pain, the exam was limited, but back spasm was noted, and the patient moved gingerly. She received 100 mg of Demerol and 80 mg of Solu-Medrol intramuscularly.
At 15:00, the patient was discharged, accompanied by her supervisor, with a prescription for hydrocodone/acetaminophen (7.5/325, 1 tab every 6 hrs for pain), cyclobenzaprine (10 mg tab, 1 q8 hours for spasms), and a Medrol dose pak. An appointment at the occupational health clinic was scheduled for Wednesday, June 10th, at 1:30 pm. The patient was advised to remain out of work until cleared by the occupational medicine provider.
Response by Nick Vlachos, M.D.
This case history raises enough issues to fill a chapter in an occupational medicine textbook, so I’ll cover just the salient points pertaining to:
- the basic approach to a patient with uncomplicated low-back pain
- commentary on treating spine injuries in your occupational health clinic
- fitness for work
This patient works at a hospital in a capacity that requires lifting patients. She describes a lifting event followed immediately by an acute onset of low-back and leg pain. This is actually a most unusual history. Typically, low-back pain is reported a day or two later with no mention of a specific work event, but in most cases, the worker attributes the pain to the workplace. In truth, most back and neck pain is spontaneous without a specific cause. This is also supported by the research done by many physicians such as Canadian orthopedist Hamilton Hall, M.D. and Vert Mooney, M.D. of San Diego, showing that most back pain is idiopathic and not related to an injury.
So in this instance, there is no question of OSHA recordability and compensability. The injury, as reported and treated, is both.
The examination, or lack of examination, that she gets in the ED is not unusual. Essentially, no exam is conducted due to pain. I see this quite often where the examiner’s comfort level in treating back pain is low. The doctor doesn’t want to touch the patient because the patient can barely move. All focus therefore is on reducing pain via chemical means.
In this instance, the patient is given a hefty dose of Demerol and discharged with even more chemicals including steroids (where’s the inflammation?), and is then told to follow up at the occupational medicine clinic two full days later! She’s also put off work. At least no expensive nuclear imaging or epidural shots were ordered.
In assessing a patient with low-back pain, I first determine the presence of any major red flags that point to back pain that are secondary to a systemic condition or true emergency, for example cancer, vertebral fracture or cauda equina syndrome. You can find a red flag issue in almost every patient with back pain, so it comes down to asking yourself: “how ill is this patient?” This patient is suffering, but unlikely to have an underlying serious medical problem disguising as back pain. So we can proceed with less caution.
My next objective is to determine what the patient does physically that makes her pain decrease or increase. The history alone should tell us if bending, standing, walking, lying down or sitting make the pain increase or decrease, or change its location.
We can also learn from our physical examination. This patient cannot be examined in the upright position, so we must get her on the table. In doing so, I’m going to forego for a minute the neurological assessment that one conducts with the patient standing and sitting. The patient may indeed have a positive straight leg raising test, or decreased Achilles. I’ll determine this later, but for now let’s get her off her feet and see what happens.
If the patient is not kyphotic, and the pain is not below the level of the knee, I will have her assume a flat prone position. If kyphotic, I’ll place several towels under her tummy and remove them one by one over the course of my examination and observation of her until she is fully flat. This sometimes takes an hour or more. So be patient with your patient.
As she lies prone, I will her ask if the pain has increased, decreased or stayed the same. I’ll also ask if the location of the pain has changed. A patient who is in this much pain may need to lie prone for several minutes before they receive relief, but a majority of my patients will have a significant decrease in their pain once they’re prone and the spine off-loaded.
I virtually never use strong narcotics to reduce pain, but if positioning doesn’t bring immediate relief, a good drug to administer is Toradol 60mg given IM, as it will not affect mentation and will relieve the pain and spasm within minutes and for up to eight hours thereafter. I don’t want to knock the patient out with strong pain medication before attempting to relieve the pain by simply changing their position.
I’m looking for some movement or position of the body that reduces the pain and/or moves it to the middle of the back. This is called centralization of the pain, and if we can accomplish that during the first visit, the prognosis for rapid full recovery is virtually 100%. The rapid changeability of pain symptoms affected by movement also confirms that we’re dealing with discogenic pain and not a muscle injury.
If the patient’s pain while in the prone position has centralized or is no worse than it was starting out, I will then have the patient rest on both elbows, arching the back slightly as if they are watching TV in front of them, and hold that position for a few minutes. I then return the patient to the prone position and ask about the level of pain and the location of pain.
If the pain has further decreased and moved closer to the middle of the back, then I can say that extending the back is the direction of preference to reduce the pain. Directional preference in extension will occur in the vast majority of the patients you will see with low-back pain.
We can now go to a more active maneuver whereby the patient performs push-ups from the waist up, keeping the pelvis flat on the table. All the time I’m asking what is the level of pain and the location of pain with these up and down movements. If at any time the pain is peripheralizing, or going down the leg, I’ll stop the examination and try a different position––for example supine with the legs flexed at the knee.
If I can get the patient to centralize their pain, I am confident I can send them home with an order for them to perform the extensions standing or prone hourly until I, or a physical therapist, can see them the next day. This empowers the patient to treat themselves. Sending the patient home, especially with other co-morbidities as this one has), with strong narcotics and bed rest for a couple of days will prolong their recovery.
All spine patients should be reassessed in 24 hours. If the patient is the same or worse, I will refer him or her to a physical therapist certified in mechanical diagnosis and treatment of low back pain, (e.g. Maitland, McKenzie et al). I do not refer patients with back pain to a physical therapist for just palliation. I treat these injuries actively as one would treat a sports injury.
In summary, this case is a good example of what I typically see when a patient presents to a primary care or emergency room doctor, and unfortunately many occupational health clinics. The comfort level of physicians treating spinal pain is frequently quite low. The doctor is afraid to put the patient into any kind of active maneuver. There is overutilization of narcotics, steroids, and imaging, and the patient is discharged with an order to stay in bed, with no follow-up scheduled for days.
Let’s talk now about the occupational health clinic involved with this patient. This patient was discharged from the ED, put off work, and told to follow-up at the occupational health clinic in two days. What does this say about the reputation of this clinic when it comes to treating a common and potentially expensive work injury like back pain? If this is a hospital-based occupational health clinic, I would ask why the patient was sent to the ED in the first place and not the clinic?
Also, why can’t she see the occupational physician the next day? I fear that this clinic does not actively market expertise in treating spine pain. Frequently patients like this, who are likely not having a surgical issue, are referred immediately to the orthopedic back specialist or neurosurgeon––which may not have an appointment for her for days––all the while the patient is in bed and off work.
“Efficiency in the treatment of uncomplicated spine pain should be the cornerstone of all occupational health clinics.”
Efficiency in the treatment of uncomplicated spine pain should be the cornerstone of all occupational health clinics. Your physicians and certainly the physical therapists you employ should take courses in the mechanical diagnosis and treatment of spine pain to the point that they can comfortably handle virtually anything that walks in the door short of major trauma. My people are certified in the McKenzie method, an approach that I’ve used for the past twenty five years. It’s perfect for any occupational health clinic.
Lastly, a few words on this patient’s fitness for work. One gets the impression, from the review of systems, that this employee was not fully fit for work. She’s hypertensive, but it might not be from her back pain, e.g. it could be related to her sleep apnea or be essential hypertension. She’s overweight, has poorly controlled diabetes, has poly-arthralgia and gastrointestinal problems, and she is depressed. She’s also living under the umbrella of the dreaded term fibromyalgia and everything that implies. Plus, she’s having job issues. Each one of these co-morbidities has the potential of prolonging her recovery from back pain. A sedimentation rate would be a good start.
The occupational health clinic cannot fully address the other non-occupational medical issues or the employee’s ability to work until the back pain problem is resolved. It would be of the utmost importance that the patient continues to work in some capacity and not be placed off work for more than 24 hours. If she absolutely cannot work, I’d get her into a physical therapist.
The patient who presents with a work-related spinal injury can be intimidating to the occupational physician and staff who lack the experience and confidence to treat these injuries. If this describes your clinic, then it is paramount to recognize your shortcomings and foster a plan to become proficient quickly. The McKenzie Institute of North America (http://mckenzieinstituteusa.org) offers courses for physicians and therapists, including exercise physiologists and athletic trainers that will raise your comfort level when seeing patients like the one presented here.
In this discussion, I’ve mentioned several terms that may sound foreign to you, such as centralization, peripheralization, directional preference, off-loading, rapid changeability of symptoms, and empowerment. Having the knowledge of each term and the research behind them is a major step in your assessment of the patient with back (and neck) pain.
Dr. Vlachos, a native of Chicago, is a graduate of The University of Illinois Medical School and did a residency at Cook County Hospital. He was Board Certified in Occupational Medicine in 1989. He’s written articles and lectured on the treatment of non-surgical spine pain at Ryan and ACOEM conferences. He was the Conference Chairman of The McKenzie Institute North American Seminar on Spinal Pain, August 9-11, 2002, in Tucson, Arizona. He is currently Medical Director of Occupational Medicine @ Wellstar’s West Georgia Medical Center in LaGrange, GA.
