Low Back Pain: S.O.A.P discussion (Holistic discussion)
Words in english used by patients: low back pain, sciatica, lumbar pain, muscle ache, pelvic ache
Spanish: dolor de espalda, ciática, dolor lumbar , dolor muscular, dolor de pelvis, dolor de huesos
Low back pain: a comprehensive S.O.A.P (Beyond the physical examination) by: Yura Casanas (IMG and MSN)
S.O.A.P (subjective, objective, Assessment, Plan)
Chief Complaint: low back pain
History of Present Illness: The patient is a 42 years old female who came to the clinic complaining of low back pain starting two weeks ago. The pain is constant, and associated with having loaded some boxes of 30 pounds approximately. Now, the pain is 8-9/10, It is also sharp, with radiation to the upper part of the right thigh.. She took Tylenol and Advil for pain, feeling relief for some minutes reappearing again. She also feels a light relief after resting. The patient denies a history of previous injury in the same body site and other symptoms.
words in english used by patients: low back pain, sciatica, lumbar pain, muscle ache, pelvic ache
Spanish: dolor de espalda, ciática, dolor lumbar , dolor muscular, dolor de pelvis, dolor de huesos
Past history
PMH: Denies past medical history
Past Psychiatric Hx: Denies depression, anxiety history or other mental disorders.
Obstetrical history: pregnancy: 3 term: last c-section 9 years ago, the first deliveries: transvaginal without complication
Social history:
SMOKING: The patient has no history of smoking.
ALCOHOL INTAKE: The patient drinks alcohol occasionally
SEAT BELT USE: The patient uses a seat belt when driving.
Activities of Daily Living/Hobbies/Interests: runs and walk 2 miles 2 days in a week
Parental Status: mother
Work History: middle school teacher
Functional medicine and nursing: we asked her what is her sense of life, if any project, creations, worries. She expressed concern regarding her time management and financial issues since she is a single mother with three kids . She loves gardening and visits a market farm frequently to sell and buy some plants. She sleeps well but 6 hours approximately. She denies visiting any country during the last 6 months. When she feels a headache she tries to use relaxing techniques, applying Bengay or another analgesic cream to her forehead, so usually does not use analgesic pills.
Denies history of thyroid disorder.
Family History: mother : alive: high blood pressure, father: alive Glaucoma
Not history of cancer in family members
no screening tests yet
Vital Signs:
Oxygen Saturation: 99% blood pressure: 110/70mmHg, pulse:68bpm temperature: 98.8 F
BMI: 27..9 (overweight) waist circumference: 49 cms
Constitutional:
General: Alert, appearance according to age , gender and ethnicity, apparently good personal hygiene , no antalgic position, well ability to communicate, also slight grimace expression (pain expression)
Chest: The lungs are clear to percussion and auscultations, with equal bilateral expansion. There are no rales, ronchi or wheezes.
Heart: There is a regular rate and rhythm. There are no murmurs, rubs or gallops.
Abdomen: The abdomen is soft without distention. Bowel sounds are normal. No hepatosplenomegaly, hernias or abnormal masses are appreciated. There is no tenderness to palpation. The femoral pulses are equal.
Extremities: within normal limits WNL, Musculoskeletal exam reveals no joint deformities and full range of motion. Tenderness noted in sacral area and right thigh (posterior region).
Neurological: The patient is alert and oriented to time, person, and place. Cranial nerves II through XII are within normal limits. There is normal gait, negative Rhomberg sign and good coordination. Muscle strength is 5/5. Sensory is intact. Tendon deep reflexes are 2/4 and equal bilaterally.
OLDCARTS Approach for the pain.: onset, location, duration, characteristic, association, timing and severity.
LUMBOSACRAL SPINE ASSESSMENT
Visual assessment: Skin intact, no scars, no swelling, no discoloration.
Gait: Non-antalgic; heel and toe walks normal, no foot drop.
Range of motion and reflexes WNL
Palpation: Tenderness on the lumbar site. No tenderness to spinous processes, interspinous ligaments,
Circulation: Distal pulses intact.
Strength: 5/5 bilaterally.
Radiation: No loss of sensation to painful stimuli in either lower extremity. No demonstrable weakness in either lower extremity.
Negative the test to rule out nerve compression: Straight leg test (SLT) (Lasague test). frequently performed in the primary, orthopedic, neurologic, oncology, and women services.
Patient in supine position, and the nurse or a help provider raises one leg flexing the hip, and keeping the knee extended. A positive test is if the patient complains about pain in the lower limb and back region due to radicular compression between 30 and 70 degrees and pain is reproduced below the posterior thigh and the knee
Bragard test (Braggard’s test) It's a straight leg test (SLT) adding dorsiflexion to the ankle:
Patient in supine position with back and buttocks over a hard table or surface.
Flexing at the hip, the health provider raises the patient leg (first one, and then the other one)
When the patient complains or feels the pain, lower the leg 10 to 15 degrees until it decreases the intensity.
Apply dorsiflexion of the ankle in the ipsilateral leg leg) until [patient reports pain). Positive test: when the angle is between 30 and 70 degrees and pain is reproduced below the posterior thigh and the knee. A positive test can indicate neural tension of the L5 and S1 roots (Custers P, Van de Kelft E, Eeckhaut B, Sabbe W, Hofman A, Debuysscher A, Van Acker G, Maes G,2024)
Crossed straight leg: or the “well leg: test associated to herniated lumbar in high percent (80 to 90 %)
ASSESSMENT
a) Main Diagnosis/Problem: Acute low back pain: Lumbar sprain/strain
b) Differential Diagnoses verses Main Diagnosis/Problem: After ruled out red flags for a complicated acute low back pain: (less than 12 weeks of evolution)
1. Urinary tract infection (renal stones)
2. Herniated nucleus pulposus
3. Drug seeking behavior
It is suggested that Not specific acute low back pain due to Sprains and strains account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in the tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
Intervertebral disc degeneration is one of the most common mechanical causes of low back pain, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back.
Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
Radiculopathy is a condition caused by compression, the patient complaining of pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
This is a 42 year old Hispanic female with apparently good health, overweight body mass index and this is a risk factor for this kind of musculoskeletal disorder along her occupation. The conclusion: acute low back pain, not specific account for 90 % of cases after ruling out the red flags of a complicated low back pain: New bladder or bowel disorder, saddle numbness, lower motor neuron weakness (consider cauda equina syndrome) also, new reported fever and history of intravenous drug use, spinal procedure, immunosuppression (considering vertebral infection)
History of cancer (that metastasizes to bone: e.g., breast, lung, prostate) (consider metastatic disease)
History of osteoporosis, systemic steroid use, trauma, older age (more than 65 years of age) (consider vertebral fracture if multiple features present)19
Persistent symptoms (more than 12 weeks), age at onset is less than 45 years, inflammatory features (insidious onset, no improvement with rest, pain at night and/or early morning that improves with exercise or activity). The straight leg rising in this patient was negative (pain appeared after elevating the leg 70 grade). It is frequent that a patient with low back pain exaggerates the symptoms seeking treatment with opiates drugs, but in this patient the face, grimace, and physical examination are according to the described pain, and she denies to be treated with opiates.
In addition, pain as a complex symptoms should be evaluated though a biopsychosocial model as emphasized by World Health Organization (2023) and
Mescouto, Olson, Hodges, & Setchell (2022) since pain is associated with multiple factors beyond the anatomical and physiological functions of the tissues and cells.
Management:
Non-Pharmacologic Management: i.e. hot packs, ice, position changes, TENS unit etc.
Complementary Therapies: i.e. Cognitive behavioral therapy and mindfulness therapy have shown moderate to low improvement until 4 to 12 visits, including relaxation techniques, acupuncture, imagery, behavioral activation, and improvement of quality of life.
Education: discussed with patients the recommended positions to lift any object. Also discussed side effects of NSAID, that can take this with food or milk., discussed the reaction with other drugs as: Aspirin, Naproxen and Celecoxib. resting or doing exercise while having pain.
Nutritional recommendations: patient is overweight, thus she should increase hypocaloric diet (low fat milk, or almond, fish, salmon, brown rice, and bread (mediterranean diet) 1,5 to cups of fruits and 2 cups of vegetables daily, sodium or salt, less than 2 grams or 2000 mgrs daily. And less than 1200 calories daily: with polyunsaturated fat and l;ess cholesterol. Reading the label helps to eat healthy and continue walking and doing aerobic exercise at least 150 min weekly.
Pharmacological management: NSAID, Ibuprofen. Ibuprofen at 200 mg and 400 mg produces a high level of pain relief in about half of those with moderate or severe acute pain (Buelt, McCall,& Coster, 2023)
The guidelines for treatment of back pain emphasizes that the assessment, and treatment should be individualized, with a holistic approach, and avoid using Acetaminophen because of the risk of hepatotoxicity, and not demonstration of benefit. Benzodiazepines, and Opioids should be avoided because there not demonstration of function improvement on Tramadol, Diazepam and Oxycodone (Buelt, McCall, & Coster, 2023)
Referrals: none
Follow-up Appointment: Within 15 days
Discuss how this case can develop into chronic disease management?
Most low back pain is acute, 10 percent are considered not specific as in this case and lasts a few days to a few weeks. It tends to resolve on its own with self-care . The majority of acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move.
Chronic back pain is considered when it persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. (Buelt, McCall, & Coster.2024)
What was the evidence that supported the intended outcomes for this patient scenario?
Tahernejad S, Hejazi A, Rezaei E, Makki F, Sahebi A, Zangiabadi Z(2024) & the National Institute of Neurological disorders, 2020) that chronic back pain is considered when it persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. It is considered that a small percent (20 %) of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. A focused history and physical examination is used to identify those with a greater likelihood of serious disease or a specific cause of low-back pain. All other cases are considered to be nonspecific low-back pain (90 % of the cases). It is recommended that patients with radicular pain or radiculopathy related to suspected disc herniation or neurogenic claudication related to suspected central spinal canal stenosis, do not need to be referred for immediate imaging, because the results will not change primary care management; Patients with clinical features of cauda equina syndrome or spinal infection require urgent referral to a spine surgeon or infectious disease specialist, respectively. A strong suspicion of metastatic disease warrants referral for definitive diagnosis. A strong suspicion of spondyloarthritis warrants referral to a rheumatologist; osteoporosis who may have a stable vertebral fracture, immediate specialist referral is not warranted unless an initial trial of treatment has been unsuccessful. However, the decision to refer will depend on individual circumstances.
Other updated and useful researches information:
Tahernejah, Hejazi, Rezaei,Makki,Sahebi,& Zangiabadi(2024) found through a systematic review and metaanalyses of 44 studies that there is a prevalence of 68% of musculoskeletal disorders in teachers, and 47% reported low back pain.
Low back pain is one of the most common causes of visit to the emergency, primary, orthopedic, occupational and neurologic specialists, and the initial examination should be focused on identifying and rule out the red flag presence linked with serious neurologic underlying conditions (Buelt,, McCall, & Coster 2023)
References
1.Buelt A, McCall S, Coster J. Management of Low Back Pain: Guidelines From the VA/DoD. Am Fam Physician. 2023 Apr;107(4):435-437. PMID: 37054430. ‘National Institute of Neurological disorders. (2020). Low Back Pain. Retrieve from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/
2. Cifu D., Eapen B.C., Johns J.S., Kowalske K., Lew H.L., Miller M.A., Worsowicz G. Braddom’s Physical Medicine and Rehabilitation. 6th ed. Elsevier; Philadelphia, PA, USA: 2021. [Google Scholar]
3.Lucha-López MO, Hidalgo-García C, Monti-Ballano S, Márquez-Gonzalvo S, Ferrández-Laliena L, Müller-Thyssen-Uriarte J, Lucha-López AC. Body Mass Index and Its Influence on Chronic Low Back Pain in the Spanish Population: A Secondary Analysis from the European Health Survey (2020). Biomedicines. 2023 Aug 2;11(8):2175. doi: 10.3390/biomedicines11082175. PMID: 37626672; PMCID: PMC10452522.
4. Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2022). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 44(13), 3270–3284. https://doi.org/10.1080/09638288.2020.1851783
4.Tahernejad S, Hejazi A, Rezaei E, Makki F, Sahebi A, Zangiabadi Z. Musculoskeletal disorders among teachers: a systematic review and meta-analysis. Front Public Health. 2024 Oct 4;12:1399552. doi: 10.3389/fpubh.2024.1399552. PMID: 39430711; PMCID: PMC11486748.
5. World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO; 2023 (https://www.who.int/publications/i/item/9789240081789. [PubMed]
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