1. Back Pain RehabilitationThe Geriatrician’s Perspective Dr Fiona Harris Dr Anthony French

2. Back pain – theirs, not yours • Case for illustration • Approach to elderly with back pain • Diagnostic pathway • Differential diagnoses and other referrals • Management – Non-pharm, pharm, interventional, future planning • Pre-conditioning • Pre-emptive admission • Surgical management with planned post-op & restorative care plan • Rehabilitation THE PACKAGE – ONE STOP SHOP – biopsychosociointerventionalsurgicalrestorative approach

4. Case Study • Lawrie, 82 year old married man • Ex-engineer, enjoys fishing from his boat and visiting their beach house on Bribie Island • Back pain slowly progressive over last few years • Old ‘lumbago’ since 50s after slipping on boat • Can’t go shopping with wife any more – she thinks he’s avoiding because he stops early complaining of back and leg pain after being ok to start with • Mornings are ‘a bit stiff’ in all the wrong places so slow to start but gets going well as long as not walking too far • Notes that has trouble sit-to-stand and walking down stairs • Pain radiates down legs R>L when worse, more often • Otherwise well – some ‘prostatism’, HTN, central obesity

5. Approach to the older person with back pain Considerations • Probable cause – traumatic, degenerative, radiculopathic, stenotic, disc related, inflammatory, infective, malignant • Disability / functional impairment / effects • Investigations – past, timing, planned • Level of intervention patient is prepared to consider / undergo / tolerate • Previous treatment approaches and successes • Comorbidites

6. Diagnostic pathway • History – injury, pattern, disability, associated • Examination – neurological, muscular, skeletal, joint, evidence of degenerative disease, malignancy, autoimmune disease etc • Functional assessment – Gait, STS, TUG, flexibility • Investigations should include paraproteins, inflammatory and infective causes, nerve conduction studies and imaging as indicated

7. Differential diagnoses and other referrals • Degenerative osteopathies and discopathies • Spondyloarthopathies • Inflammatory causes including AID • Infective causes including discitis and abscess • Compressive causes including haematoma • Vascular including ischaemia and AVM • Myeloma and metastatic disease

8. Likely picture in this man • Likely degenerative changes in spine – multifactorial • Pain pattern suggests spinal stenosis • Radiculopathy and weakness suggest urgency • No talk of previous intervention, investigation, treatment attempts • Possible disc injury in past when slipped • Possible secondary gain per wife’s perception • Functional bottom line likely high – fishing on boat • Essential – examine, imaging, planning • Options include everything from analgesia and reconditioning through all the interventions so patient’s perceptions, time frames, expectations must be clear

9. Management • Non-pharmacological including • Complementary and Alternative / Relaxation / Faith • Psychological adjuncts • Lifestyle planning • Education • Pharmacological – analgesics, co-analgesics, psychological • Interventional including surgical, anaesthetic, ablative and implants • Medium and long term planning • Setting limits, preconditioning, planned reconditioning, function maintenance therapies

10. Pre-conditioning • Co-morbidity status and medical optimisation • Environmental management • Pain management • Equipment – assess, provide, monitor, manage, follow-up • Day rehab, inpatient rehab, planned off-seasonworkup

11. Pre-emptive admission • Assessment – pain, co-morbidities, psychological • Restorative care • Management planning consultation • Multidisciplinary input and management • Intervention • Follow up

12. Surgical management • Pre-operative assessment • Planned timing • Pathway to • Post-op care • Restorative care plan

13. Rehabilitation • Multidisciplinary assessment • Goal setting and education • Periodic review and outcome assessment • Supports / Caregiver involvement • Discharge planning • Environmental modifications • Aids – temporary, long term • Supports - functional, access (permits etc), respite • Ongoing review • Driving, progress, day therapy

14. THE PACKAGE – ONE STOP SHOP • Bio-psycho-socio-interventional-surgical-restorative approach • Create a co-ordinated systematic approach • Multidisciplinary approach from the start • REFER

15. Questions Dr Fiona Harris, MBBS, FRACP • Consultant Physician and Geriatrician • 0419 664 040 Dr Anthony French, MBBS, B.App.Sc., FRACP • Consultant Physician and Geriatrician • Queensland Geriatric Medicine Group • 1300 662 884 • dramfrench@qgmg.com.au