HPE Chronic pain – part one - Page 8

TABLE 2 Warning signs and risk factors for chronification of low back pain Extravertebral causes of low back pain Somatic warning signs (‘red” flags’) Psychosocial risk factors for chronification (‘yellow” flags’) Workplace/employee perceptions about work and health (‘blue flags’) Processes affecting neighbouring organs: • Abdominal/visceral processes • Vascular changes • Gynaecological causes • Urological causes • Neurologic diseases • Mental and psychosomatic disorders • Fracture/osteoporosis • Infection • Radiculopathy/ • Depressive mood/ Concerns about whether employee is able to meet demands of the job Low job satisfaction Little or poor support at work A perception that the job is very stressful An accommodating approach in the workplace to providing altered duties or modified work options to facilitate a return to work Poor communication between employer and employee neuropathy • Tumours/metastases • Axial spondylarthritis Adapted from reference 23 majority of patients will present with somatic low back pain of musculoskeletal origin – low back symptoms are non-specific for most patients, meaning that the pain is localised to the back/ buttocks and is due to a presumed musculo- ligamentous process. – ruling out these ‘red-flag’ conditions is paramount (Table 2). More specific radiological and neurophysiological tests can be applied to determine the presence of a nerve lesion or compression, but they do not always provide conclusive results and/or might lack specificity. Abnormalities in X-rays and magnetic resonance imaging (MRI) and the occurrence of non-specific low back pain do not seem to be strongly associated. Therefore, self-assessment screening tools such as painDETECT aim to identify potential patients with neuropathic back pain and can be tremendously helpful in clinical practice, because they can be easily applied and interpreted by non-specialists. 2,11 The use of these tools, especially in combination with pain drawings, which are often more sensitive than conventional imaging techniques such as MRI, can assist in the delineation and recording of a patient’s pain category. The painDETECT questionnaire helps in the identification of spatial patterns of pain radiation, thus contributing to the determination of the underlying type of pain and, with this, to treatment optimisation based on this assumption (Figure 1). 12 It is essential to determine during the examination whether the pain is musculoskeletal (paradigm of ‘look, move, feel’) or an indicator to search for non-musculoskeletal causes and red flag conditions.Musculoskeletal patients need plenty of reassurance (and not a multitude of diagnostic tests such as radiography/CT/MRI), which can be provided during a careful examination without excessive effort. This approach has the potential to be of great therapeutic benefit in its own right, and staying active speeds up recovery and reduces chronic disability. Therefore, when ordering an imaging study, it is important to keep in mind the limitations of the technique and to consider how the information obtained will actually influence the 8 | 2019 | hospitalpharmacyeurope.com distress • Pain-related conditions • Passive pain behaviour • Pain-related cognitions • Tendency to somatisation