Overview

Words Matter!

Goals of the Back Pain Tool Kit

Standardization of acute back pain with Evidence Based Practice
Assist you with your clinical thought process
Help you appropriately assess acute back pain
Help you to decide when you should refer the patient to a specialist and/or further care like physical therapy or chiropractic care
Provide you with patient education that can be printed and/or shared as well as other media that can be used at the point of care

Rule out or address red flags
Use the STarT Back Screening Tool to assess pain & risk level
Refer to the relevant Provider Guidelines for Low, Medium or Acute Risk
Encourage patient education and self-care by sharing and discussing these resources:

Review recommendations for the use of pharmacological options
Remember, words matter! Be aware of your word choice and how your patient may interpret what you say.
Refer to the guides linked below as needed during your assessment and follow-up.

What you say	What the patient hears
Your MRI doesn’t show anything to worry about	There is nothing seriously wrong with my back
The cause of your pain may not show up on an MRI	My pain is real
You should increase activity as tolerated	Activity is good for me
Your back problem should respond to chiropractic or physical therapy	I probably won’t need surgery
Working will not cause damage to your back	I will be able to return to work
There are many things you can do on your own to control your pain	I can learn to handle my pain
Opioid medications are not going to help your pain in the long run and will cause you more problems	These are not good medications for me

What you say	What the patient hears
Your MRI shows degenerative changes/disc herniation/arthritis	I will never get better
There’s nothing wrong with your back	He/she thinks It’s all in my head
Stop when you feel pain	Activity will harm my back
Take it easy and rest	I should stay in bed
If chiropractic or physical therapy doesn’t work you may need surgery	I will need surgery
You should be able to work	He/she thinks I am faking
Pain is normal for someone your age	I’m going to get worse
I cannot prescribe opioid medications because of your history of substance abuse	I am being denied the treatment that will make me feel better

“Movement with some pain is better than not moving at all.”

“Find what position or activity feels good and do more of it.”

“You will have less pain and faster healing with light activity – motion heals!”

Reference: Sherri Weiser-Horwitz, PhD, NYU School of Medicine

ABI Value	Interpretation	Recommendation
Greater than 1.4	Calcification/vessel hardening	Refer to vascular specialist
1.0 - 1.4	Normal	None
0.9 - 1.0	Acceptable	None
0.8 - 0.9	Some arterial disease	Treat risk factor
0.5 - 0.8	Moderate arterial disease	Refer to vascular specialist
Less than 0.5	Severe arterial disease	Refer to vascular specialist

Red Flag	Concerning Dx	Next Steps
Fever, chills, rigors IV drug use Recent infection	Epidural abscess Osteomyelitis Discitis	Stat MRI or transport to ED
History of cancer, new onset of pain Unexplained weight loss Pain not reproducible	Cancer	X-Ray Sed rate, CRP studies MRI w/o labs
Urinary retention/ incontinence Fecal incontinence Motor deficits at multiple levels Perineal numbness Saddle anesthesia Decreased anal sphincter tone	Cauda equine syndrome	Stat Lumbar MRI or transport to ED
Recent severe trauma or less sever trauma with history of osteoporosis, use of corticosteroids and older age Extreme pain with movement	Vertebral compression fracture	Plain film X-Ray or CT

Among patients in the following age groups who are asymptomatic, a lumbar spine MRI will find about...
	20-30 years old	30-40 years old	40-50 years old	50-60 years old	60-70 years old	70-80 years old	80+ years old
Disc Degeneration	37%	52%	68%	80%	88%	93%	96%
Oisc Signal Loss	17%	33%	54%	73%	86%	94%	97%
Disc Height Loss	24%	34%	45%	56%	67%	76%	76%
Disc Bulge	30%	40%	50%	60%	69%	77%	84%
Disc Protrusion	29%	31%	33%	36%	38%	40%	43%
Annular Fissure	19%	20%	22%	23%	25%	27%	29%
Facet Degeneration	4%	9%	18%	32%	50%	69%	83%
Spondylolisthesis	3%	5%	8%	14%	23%	35%	50%