Typical profile 6

Age:

• Any age, typical 30-50 History of injury:

• Yes—usually remote in the past; often motor vehicle accident

Site and radiation:

• Low back, central, often bilateral

• May radiate to leg (may be bizarre pattern)

Type of pain:

• Variable, usually deep ache or burning

• Continuous—acute or chronic

Aggravation:

• Work, especially housework, or manual work

• Worse in mornings on waking

• Stress and worry

Relief:

• Better in the evenings and on retiring Associations:

Headache

• Fatigue, exhaustion, tiredness

• Insomnia, inability to cope

• Other aches and pains

Physical examination:

• Diffuse tenderness to palpation

• Possible hyperactive reflexes

This profile is typical of the depressed patient with back pain. A trial of antidepressants for a minimum of 3 weeks is recommended and quite often a positive response with relief of backache eventuates. Failure to consider psychological factors in the assessment of low back pain may lead to serious errors in diagnosis and management. Each instance of back pain poses a stimulating exercise in differential diagnosis. A comparison of organic and non-organic features is presented in Table 33.6 .

Table 33.6 Comparison of general clinical features of organic and non-organic based low back pain 6 7

Organic disorders

Non-organic disorders

Symptoms

Presentation

Pain

Pain radiation Time pattern

Paraesthesia/anaesthesia Response to treatment

Signs

Observation

Tenderness

Spatial tenderness (Magnuson)

Active movements

Axial loading test SLR 'distraction' test Sensation Motor

Reflexes

Appropriate

Localised

Appropriate Buttock, specific sites

Pain-free times

Dermatomal Points with finger

Variable Delayed benefit

Appropriate Guarded

Localised to appropriate level

Consistent

Specific movements affected

No back pain (usually)

Consistent

Dermatomal

Appropriate myotome

Appropriate May be depressed

Often dramatic

Bilateral/diffuse Sacrococcygeal

Inappropriate Front of leg/whole leg

Constant, acute or chronic

May be whole leg Shows with hands

Patient often refuses treatment

Initial improvement (often dramatic) then deterioration (usually within 24 hours)

Overreactive under scrutiny Inconsistent

Often inappropriate level Withdraws from probing finger

Inconsistent

Often all movements affected

Back pain Inconsistent

Non-anatomical 'sock' or 'stocking' Muscle groups, e.g. leg 'collapses'

Brisk hyperactive

Assessment of the pain demands a full understanding of the patient. One must be aware of his or her type of work, recreation, successes and failures; and one must relate this information to the degree of incapacity attributed to the back pain.

Patients with psychogenic back pain, especially the very anxious, tend to overemphasise their problem. They are usually demonstrative, the hands being used to point out various painful areas almost without prompting. There is diffuse tenderness even to the slightest touch and the physical disability is out of proportion to the alleged symptoms. The pain distribution is often atypical of any dermatome and the reflexes are almost always hyperactive. It must be remembered that patients with psychogenic back pain—for example, depression and conversion disorders—do certainly experience back pain and do not fall for the traps set for the malingerer.

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