Prevention and health promotion

The patient should be informed in a supportive way that he has the following risk factors:

• family history of cardiovascular disease

• family history of diabetes

• hypertension (related to obesity, NSAIDs, alcohol excess and smoking)

• possible hypercholesterolemia (senile arcus noted)

• stress and anxiety

It would be important to stress (despite the fact that he might not be receptive during a depressed state) that for the sake of his future health it was time to change his lifestyle to try to reverse the risk factor process.

Advice on the prevention of recurrence of his back problem is important with advice on daily activities, lifting, bending and so on. The use of a brace is not generally recommended as dependency on the supportive device tends to lead to aggravation of the chronicity of the back.

Lifestyle recommendation

In JR's case, and indeed for many patients, he should receive advice, education, guidelines and support in the basic lifestyle factors, namely:

• diet control o weight reduction o low fat/cholesterol diet o high fibre o alcohol restriction smoking

• exercise and suitable physical activities

• interesting hobbies

• relaxation techniques

Family support and counselling

It would be ideal to include Mrs JR in the next consultation or, better still, arrange a home visit to discuss the role the family can take in his rehabilitation. Explanations and seeking family support would be very helpful.

Other positive suggestions would be to encourage Mrs JR to perform massage (as instructed) on the aching back and co-operate with his diet and other lifestyle issues, and to assess the state of the bed and the chairs as a possible aggravation factor for the back pain.

Anticipatory guidance and special hazards

Possible problems for JR include aggravation of his back pain by inappropriate physical and emotional stressors, marital break-up, loss of job and even suicide. These issues should be diplomatically discussed with the patient in a positive way. It is to be hoped that the interest, encouragement and support he receives can help avert these serious problems.

Recommended treatment for JR

• attention to lifestyle factors

• antidepressant medication

• referral for therapy o hydrotherapy o mobilisation o active exercises

• therapeutic massage

Alternative options

There are many alternative therapies that can be used to help alleviate his painful condition. It is important for GPs to keep abreast of these therapies and their relative success rate based on scientific evidence. (Where known, the relative success rate, based on research by the author, is indicated. 2 ) If the response is slow, one or more of these treatment modalities can be selected and the patient referred to a reputable therapist experienced in the therapy.

• spinal mobilisation and manipulation (64%)

• manipulation under general anaesthesia (34%)

• transcutaneous electrical nerve stimulation (TENS)

• acupuncture

• biofeedback meditation

• epidural injections

• radiofrequency denervation (65%)

• electrotherapy for superficial heating o radiant heat lamps o infra-red lamps for deep heating o short-wave diathermy o ultrasound

Consultation and referral

One of the skills of a responsible general practitioner is to sum up his or her own limitations with a particular problem and consult with and/or refer to a colleague if it is in the patient's best interests. Effective communication and advice is only a phone call away. Patients with a chronic illness should be referred to an expert in the discipline to satisfy patient, family and GP that everything possible is being attempted to help the patient. Patients and their families often judge us by the quality of the referral process and its outcome; so considerable thought has to be given to the most outstanding consultant for that particular problem at a given time. The GP should remain in charge of the team and direct management.

JR could be referred to medical consultants such as an orthopaedic surgeon, an orthopaedic physician or a rheumatologist. It would be inappropriate to refer him to a psychiatrist in the early stage of his pain but if a psychological problem intervened and complicated management (as in this case) referral should be strongly considered. As a rule depression and anxiety can be managed well by a caring family doctor.

Probably the best option for a patient like JR is referral to a pain clinic that is staffed by a multidisciplinary team of specialists including psychiatrists, social workers, physiotherapists, occupational therapists and other medical specialists. They look at the total problem and the whole person. As a patient similar to JR said after attending a pain clinic: 'For the first time all my problems— physical, psychological, drug dependency and other disturbed fragments of my life—have been dealt with by the whole team'.

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