Additional Material

An 83 year old man presents with low back pain and bilateral leg pain with ambulation that is alleviated with rest.  He reports increasing difficulty with ambulation and performing his activities of daily living.  Lumbar MRI reveals moderate to severe central canal stenosis at L3-4.  Physical examination is remarkable for normal lower extremity strength and reflexes.  He does not believe that he will be able to regain meaningful function as a result of treatment and he is afraid of doing any form of exercise because he believes that this will harm him. The first thing you should recommend is consultation with?

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Correct. Both of these are important psychological constructs that interfere with response to pain management. Decompressive laminectomy would be indicated if there was deteriorating neurological status or refractory pain despite conservative management that involves addressing all contributors to pain and disability. There is no evidence that ultrasound, heat and massage are effective for the treatment of neurogenic claudication (i.e., symptoms associated with lumbar spinal stenosis). Epidural corticosteroid injections are not indicated in the diagnosis of lumbar spinal stenosis.
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A 69 year old woman presents with low back pain for 3 years that has gotten progressively worse.  She has evidence of diffuse degenerative disc and facet disease on plain films of the lumbar spine.  Physical examination is notable for a normal neurological examination including reflex and strength testing.  She walks with a limp and denies leg pain or paresthesias. 

The video shows a physical exam performed on the 63-year-old woman.

The physical examination shown can ascertain the presence of each of the following potential treatment targets EXCEPT:

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Correct. Internal rotation of the hip was not performed. This is an essential part of the clinical evaluation of hip osteoarthritis.
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Realistic treatment expectations for patients with chronic non-cancer pain include:

Correct. Across multiple non-cancer pain conditions it has been demonstrated that 30% reduction in pain, or 2 points less on a 0 to 10 scale, is clinically significant. Further, patients with chronic non-cancer pain should be educated that they can learn to function significantly better despite the persistence of some pain.
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A 75 year old woman presents with low back pain for the past 10 years that has been gradually restricting her function more and more.  She describes her pain as, on average, 7/10 and at least twice a month the severity is 10/10 if she “does too much.”  She takes acetaminophen 650 mg prior to an activity that she knows will exacerbate her pain.  She admits to feeling down and not enjoying activities that were once pleasurable and states with certainty, “I know that I will feel better once my pain is adequately treated.”  She has seen a physical therapist in the past and says that the therapy “didn’t work.”  She denies fever, weight loss, inability to control her bowels/bladder, or lower extremity weakness.  Physical examination reveals normal muscle strength, absent ankle jerks bilaterally, and a depressed affect.  What treatment do you recommend?

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Correct. When patients have comorbid pain and depression, both must be treated to optimize therapeutic response.
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After consulting with the patient with chronic low back pain about their treatment preferences, the following represent the first step in the rational stepped care approach to treatment EXCEPT:

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Correct. This medication is on Beers’ list of medications that should be avoided in older adults because of the multiple potential adverse reactions such as gastrointestinal bleeding, renal insufficiency, precipitation of congestive heart failure and exacerbation of hypertension.
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In the older adult with chronic low back pain, each of the following may represent a “weak link” rather than a treatment target, EXCEPT:

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Correct. Each of the imaging findings that are listed as response options are often asymptomatic in older adults and are not in and of themselves treatment targets. Clinical evidence of depression, by contrast, always should be treated.
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Physical examination of the patient with a tentative diagnosis of lumbar spinal stenosis may help to confirm, refute, or modify the diagnosis. Which of the following statements is INCORRECT?

Correct. Patients with lumbar spinal stenosis typically have pain with prolonged standing or walking that is relieved with sitting or lumbar flexion. Comorbid hip osteoarthritis occurs not uncommonly in older adults with lumbar spinal stenosis. Paralumbar tenderness also is not uncommon in older adults but does not precipitate symptoms of lumbar spinal stenosis.
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You are seeing a 74 year old white female in your office for the first time who has had low back pain present for two years. Pain is present most days of the week. Pain is localized to the right lower back, does not radiate, and is relieved with rest.  The patient would like to know what can be done to get rid of the pain.

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Correct. Complete pain relief is not realistic for patients with chronic non-cancer pain from any cause (e.g., arthritis, neuropathy, fibromyalgia, low back pain). Ibuprofen is on Beers’ list of inappropriate medications for older adults because of the multiple potential adverse effects.

A 92 year old married woman presents with worsening chronic low back pain and radiating right leg pain that she describes as achy and “sickening” when she walks more than one block. She describes her sleep as very poor as she tosses and turns “worrying that she is going to become disabled because of her pain.” Her back and leg pain became worse when her sister died three months ago. Around that time she stopped taking her pain medications (which had been effective and only caused minor constipation which she treated with prune juice) because she was worried about “becoming addicted.” The first step in your treatment plan should include:

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Correct. It is critical to treat all contributors to pain and disability, not just to treat the pain itself. In this patient’s case, she may be grieving over her sister’s loss; she should be evaluated for depression but there is no indication to immediately start an antidepressant. Her poor coping skills (i.e., catastrophizing) unless treated will negatively impact her pain treatment outcomes.
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