Musculoskeletal & Rheumatology
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[text size=5] years old [select value="male|female"] patient with previous history of [text size=100]

[text default="Allergy NKA" size=100]

SUBJECTIVE:
Patient complains back pain past [text] days.
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Hx of injury_[select name="hi1" value="no|YES"]
[textarea default="No apparent hx of back injury."]
The pain is [checkbox name="cb1" value="intermittent|constant"], worst in the_ [checkbox name="cb2" value="back/buttock predominantly|leg predominantly"][text size=50][conditional field="cb1" condition="(cb1).is('constant')"][comment memo="Rule out RED FLAGS"][/conditional]
The pain worse with_ [checkbox name="cb3" value="flexion, possibly also extension|extension only|all movements|walking and/or standing|cant identify pattern"][conditional field="cb1|cb2 |cb3" condition="(cb3).is('flexion, possibly also extension')&& (cb2).is('back/buttock predominantly')&&(cb1).is('constant')"] This hx is consistent with Pattern 1[/conditional][conditional field="cb1|cb2 |cb3" condition="(cb3).is('flexion, possibly also extension')&& (cb2).is('back/buttock predominantly')&&(cb1).is('intermittent')"] This hx is consistent with Pattern 1[/conditional] [conditional field=" cb1|cb2 |cb3" condition="(cb3).is('extension only')&& (cb2).is('back/buttock predominantly')&&(cb1).is('intermittent')"] This hx is consistent with Pattern 2[/conditional][conditional field=" cb1|cb2 |cb3" condition="(cb3).is('all movements')&&(cb2).is('leg predominantly')&& (cb1).is('constant')"] This hx is consistent with Pattern 3[/conditional][conditional field="cb1|cb2 |cb3" condition="(cb3).is('walking and/or standing')&&(cb1).is('intermittent')&&(cb2).is('leg predominantly')"] This hx is consistent with Pattern 4[/conditional][conditional field="cb3" condition="(cb3).is('cant identify Pattern')"] This may indicate nonmechanical pain[/conditional]

Is there anything you can NOT do now that you could do before the onset of your low back pain?-->[select name="cf0" value="no|YES"][conditional field="cf0" condition="(cf0).is('YES')"]
What?__ [text size=50] Why?__[checkbox name="cb4" value="Back/Buttock Pain|Leg Pain"] [comment memo="Confirm this is consistent with the initial history"]Note: Rule out Yellow Flags on f/u appointment if no improvement at 2 weeks; use Keele STarT Back Tool to stratify risk.[link url="https://www.soapnote.org/musculoskeletal/core-back-tool-yellow-flags/" memo="YELLOW FLAGS"] [link url="https://www.soapnote.org/musculoskeletal/keele-start-back-screening-tool-2/" memo="Keele STarT"] [/conditional]

RED FLAG evaluation:[comment memo="Always review Neurological and Inflammatory RED FLAGS! Review Infection, Fracture, or Tumor RED FLAGS if clinically appropriate."]
Neurological-Acute Cauda Equina syndrome sx: Unexpected accidents with bowel or bladder function/or Distinct loss of saddle/perineal sensation --> [select name="rf0" value="no|YES"][conditional field="rf0" condition="(rf0).is('YES')"] = Urgent MRI indicated![/conditional] [text size=50]
Inflammation: chronic low back pain > 3 months, age of onset < 45, morning stiffness > 30 minutes, improves with exercise, disproportionate night pain --> [select name="rf5" value="no|YES"][conditional field="rf5" condition="(rf5).is('YES')"] = Rheumatology Consultation [link url="http://acreu.ca/pdf/Best-Practice-Guidelines.pdf" memo="Systemic Inflammatory Arthritis Screen"],[link url="https://www.soapnote.org/musculoskeletal/inflammatory-vs-non-inflammatory-arthropathy-the-arthritis-society-2004/" memo="Inflammatory vs noninflammatory"][/conditional][text size=50]

[comment memo="Always review Neurological and Inflammatory RED FLAGS! Review Infection, Fracture, or Tumor RED FLAGS if clinically appropriate."]

Infection: fever, IV drug use,immune suppressed --> [select name="rf2" value="no|YES"][conditional field="rf2" condition="(rf2).is('YES')"] = X-ray and MRI[/conditional] [text size=50]
Fracture: trauma, osteoporosis risk/ fragility fracture --> [select name="rf3" value="no|YES"][conditional field="rf3" condition="(rf3).is('YES')"] = X-ray and may require CT scan[/conditional][text size=50]
Tumor: hx of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue --> [select name="rf4" value="no|YES"][conditional field="rf4" condition="(rf4).is('YES')"] = X-ray and MRI[/conditional][text size=50]


OBJECTIVE: [comment memo="NOTE: Below tests are the suggested minimum requirements of the exam. Additional tests can be considered Gait- Heel Walking (L4-5) Toe Walking (S1) Trendelenburg test (L5) Repeated toe raises (S1) Sitting - Quadriceps power (L3-4) Ankle dorsiflexion power (L4-5) Ankle reflex (S1) Supine - Passive hip range of motion Prone - Femoral nerve stretch (L3-4) Gluteus maximus power (S1) Passive back extension when pt uses arms to elevate upper body"]
[comment memo="NOTE: Palpation of the spine in mechanical syndromes is not diagnostic and is often unreliable since this is referred pain and the tenderness may be located at a distance from the site of the pain generator(s). Palpation cannot identify the position of or the pathology in the discs, joints or deep ligaments."]
[textarea default="General Appearance: No distress. Patient able to ambulate well. Gait is not antalgic. Walks and stand with a stiff back. Can still get on and off bed independently. Preferred position of comfort_ No deformities, discolourations, scars or abnormal posture noted."]
[comment memo="As a rule: subtle alterations are not significant."]
Standing: [textarea default="Movements testing in flexion = wnl. Movements testing in extension= wnl"]
[comment memo="In the standing position, have the patient bend forward into flexion and arch backward in extension. The patient is asked if the movements aggravate or ease their pain. The reproduction of the typical pain should coincide with the report on history. The range of movement is not diagnostic but patterns of abnormal movement may reflect the severity of the pain and suggest the level of functional ability. Asking the patient to side flex or rotate does not help establish a pattern but may be of use in determining the limits of activity."]
Sitting: [textarea default="Knee reflexes (L3-4) are normal and symmetric. Great toe extension power (L5) is normal and symmetric. Great toe flexion power (S1) is normal and symmetric. Plantar response, upper motor test is normal and symmetric"]
[comment memo="Conducting an upper motor neuron test is mandatory to ensure that any neurological symptoms or signs are not stemming from an upper motor neuron lesion. The presence of an upper motor lesion completely negates a mechanical lumbar pattern.
The plantar response reflex, Babinski reflex, can be performed in sitting or supine lying. A positive test demonstrates an upward movement of the great toe and a fanning of the four other toes. A clonus test can also be used. Sustained beats are indicative of an upper motor lesion."]
Supine: [textarea default="Straight leg raising negative bilaterally for radicular symptoms."]
[link url="https://www.soapnote.org/musculoskeletal/straight-leg-test-instructions/" memo="SLR instructions"]
Prone: [textarea default="Saddle sensation testing (S2-3-4) is normal."]
[comment memo="Every low back exam must include a check for saddle sensation. This assesses sacral nerve function, the same nerves that supply the bladder and bowel. It is essential that you do not miss a Cauda Equina Syndrome. The simplest method is to test light touch in the midline between the upper buttocks. This is easily accessible in prone lying just below the belt line."]

ASSESSMENT:
[select name="as0" value="Mechanical back pain Pattern 1 (Disc Pain)|Mechanical back pain Pattern 2 (Facet Joint Pain)|Mechanical back pain Pattern 3 (Compressed Nerve Pain/Sciatica)|Mechanical back pain Pattern 4 (Symptomatic Spinal Stenosis/Neurogenic Claudication)|Non-mechanical back pain"][conditional field="as0" condition="(as0).is('Non-mechanical back pain')"] [checkbox name="cb6" value="Non-spine related pain|Spine pain does not fit mechanical pattern"][/conditional]
[textarea default=""]
[comment memo="Back dominant (back, buttocks, tip of a tailbone, around hips, or groing):
- Pattern 1 back dominant and pain is aggravated when pt is flexing. Pain can be constant or intermittent, but always aggravated when pt bends forward. PE pain on flexion. No neuro deficit. Not a root involved pain. It is purely mechanical pain.Pattern1 can be either PEP or PEN: Pattern 1 Prone Extension Positive (PEP)= better with 5 prone passive extensions Pattern 1 Prone Extension Negative (PEN) = no change/worse with 5 prone passive extensions. The fact that there is more pain on extension does not change the Pattern. Any pain on flexion makes it a Pattern 1.
- Pattern 2 is also back dominant. Pain is never aggravated on forward bending. Always on extending pain and sometimes better on bending forward. PE pain on extension only. Never on flexion. No neurological sx as no nerve root involvement.Pattern 2 is always intermittent.
Leg dominant (from gluteal fold, down to the thigh, the calf, ankle and the foot):
- Pattern 3 is leg dominant. It is constant. The pattern is represented by a word sciatica. Sciatica is not leg pain. Pain is generated by irritation of roots of sciatic nerve by inflammation. PE pain aggravated by all back movements, particularly by flexion. There will be a positive neurological findings = straight leg limitation, loss of reflexes, power or sensation.
- Pattern 4 is leg dominant. It is intermittent leg pain. Leg pain that is brought on by walking, activity, extension and relived by flexion by sitting by resting in a forward bent position. The pain is always intermittent as distinct by pattern 3 when pain is always constant. Neurogenic claudication is a problem brought on by the nerve root as well, but it is not by inflammation. It is by a loss of blood supply. Because the nerve is safe at rest , the PE is often normal. Dx is made for Pattern 4 entirely on Pt’s Hx."]

PLAN:[textarea default=""]
[conditional field="cb6" condition="(cb6).is('Non-spine related pain')"] Likely non-spine related pain. Consider other etiologies prior to pain medications.Consider internal organ pain referral such as kidney, uterus, bowel, ovaries. [textarea default=""][/conditional][conditional field="cb6" condition="(cb6).is('Spine pain does not fit mechanical pattern')"] Likely spine related that does not fit mechanical pattern. Consider centralized pain medications (i.e. anti-depressants, anti-seizure, opioids). Consider pain disorder. [textarea default=""][/conditional][conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 1 (Disc Pain)')"][checkbox value="Ibuprofen 400 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Naproxen 500 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Acetaminophen 650 mg QID prn for pain as needed|Discussed massage and acupuncture|Cyclobenzaprine 5-10 mg od at HS prn for pain/spasm x 3 days only (sedation s/e discussed)|Medications key message discussed and handout given"][checkbox value="Discussed postural exercises such as walking/swimming 3 times a week for 40 minutes|Discussed Recovery position Starter exercises and hand-out given|Discussed stretching&strengthening exercises and handouts given (SASK Pattern 1 ISAEC HealthLinkBC)|Discussed functional activities|Self-management discussed and key messages handout given|If no improvement in next week, call or return to clinic for Physical Therapy referral"][/conditional][conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 1 (Disc Pain)')"] Follow-up_ [checkbox value="2 weeks as pt is referred to therapy, and/or prescribed medication|PRN as pt was given home program and relief noted in office visit today"][textarea default=""] Pt advised to RTC or ER with any red flag symptoms, i.e. saddle sensation paresthesia, acute muscle weakness, bowel or bladder function changes[/conditional]

[conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 2 (Facet Joint Pain)')"][checkbox value="Ibuprofen 400 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Naproxen 500 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Acetaminophen 650 mg QID prn for pain as needed|Discussed massage and acupuncture|Cyclobenzaprine 5-10 mg od at HS prn for pain/spasm x 3 days only(sedation s/e discussed)|Medications key message discussed and handout given"][checkbox value="Discussed postural exercises such as walking/swimming 3 times a week for 40 minutes|Discussed Recovery position Starter exercises and hand-out given|Discussed stretching&strengthening exercises and handouts given (SASK Pattern 2, ISAEC, HealthLinkBC)|Discussed functional activities|Self-management discussed and key messages handout given|If no improvement in next week, call or return to clinic for Physical Therapy referral"][/conditional][conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 2 (Facet Joint Pain)')"] Follow-up_[checkbox value="2 weeks as pt is referred to therapy, and/or prescribed medication|PRN as pt was given home program and relief noted in office visit today"][textarea default=""] Pt advised to RTC or ER with any red flag symptoms, i.e. saddle sensation paresthesia, acute muscle weakness, bowel or bladder function changes[/conditional]

[conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 3 (Compressed Nerve Pain/Sciatica)')"][comment memo="Note: May require opioids if
1st line pain meds not sufficient"][comment memo="Patient is not usually suitable for self management due to high pain levels and possible surgical intervention"][checkbox value="Ibuprofen 400 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Naproxen 500 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Acetaminophen 650 mg QID prn for pain as needed|Cyclobenzaprine 5-10 mg od at HS prn for pain/spasm x 3 days only (sedation s/e discussed)|Tramacet two tablets every 4 to 6 hours as needed for pain relief maximum 8 tablets per day x 5 days only (s/e counselled)|Gabapentin 100 mg po BID x 14 days(s/e counselled) |Medications key message discussed and handout given"][checkbox value="Discussed Recovery position Starter exercises|Discussed management and handouts given (SASK Pattern 3, ISAEC, HealthLinkBC)|Discussed functional activities|Self-management discussed and key messages handout given|Follow up in 2 weeks for pain management and neurological review"][textarea default=""] Pt advised to RTC or ER with any red flag symptoms, i.e. saddle sensation paresthesia, acute muscle weakness, bowel or bladder function changes.[/conditional]

[conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 4 (Symptomatic Spinal Stenosis/Neurogenic Claudication)')"][checkbox value="Ibuprofen 400 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Naproxen 500 mg TID with food prn for pain s/e counselled avoid other NSAIDs|Acetaminophen 650 mg QID prn for pain as needed|Discussed massage and acupuncture|Cyclobenzaprine 5-10 mg od at HS prn for pain/spasm x 3 days only (sedation s/e discussed)|Medications key message discussed and handout given"][checkbox value="Discussed postural exercises such as walking/swimming 3 times a week for 40 minutes|Discussed Recovery position Starter exercises and hand-out given|Discussed stretching&strengthening exercises and handouts given (SASK Pattern 4, ISAEC, HealthLinkBC)|Discussed functional activities|Self-management discussed and key messages handout given|If no improvement in next week, call or return to clinic for Physical Therapy referral"][/conditional][conditional field="as0" condition="(as0).is('Mechanical back pain Pattern 4 (Symptomatic Spinal Stenosis/Neurogenic Claudication)')"] Follow-up_[checkbox value="6 weeks for sx management and functional impact assessment"][textarea default=""]Pt advised to RTC or ER with any red flag symptoms, i.e. saddle sensation paresthesia, acute muscle weakness, bowel or bladder function changes[/conditional]

[link url="https://www.soapnote.org/musculoskeletal/referral-criteria-core-back-tool/" memo="Referral Criteria"] [link url="http://www.isaec.org/isaec-exercise-videos.html" memo="ISAEC"] [link url="http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=tr5948" memo="HealthLink BC"] [link url="http://www.sasksurgery.ca/pdf/healthy-back-exercises1.pdf" memo="SASK Pattern 1"] [link url="http://www.sasksurgery.ca/pdf/healthy-back-exercises2.pdf" memo="SASK Pattern 2"] [link url="http://www.sasksurgery.ca/pdf/healthy-back-exercises3.pdf" memo="SASK Pattern 3"] [link url="http://www.sasksurgery.ca/pdf/healthy-back-exercises4.pdf" memo="SASK Pattern 4"] [link url="https://choosingwiselycanada.org/imaging-tests-low-back-pain/" memo="Choosing Wisely Imaging"] [link url="https://www.cfpc.ca/clinically-organized-relevant-exam-core-back-tool/" memo="CORE Back Tool"] [link url="http://www.topalbertadoctors.org/cpgs/885801" memo="Alberta LBP Guideline"][link url="https://courses.mskcourses.net/moodle/course/index.php?categoryid=12​" memo="CORE Back tool CME course"]
years old patient with previous history of



SUBJECTIVE:
Patient complains back pain past days.
Severity now (0-10):
Severity at worst (0-10):
Hx of injury_

The pain is , worst in the_
The pain worse with_

Is there anything you can NOT do now that you could do before the onset of your low back pain?-->

RED FLAG evaluation:Always review Neurological and Inflammatory RED FLAGS! Review Infection, Fracture, or Tumor RED FLAGS if clinically appropriate.
Neurological-Acute Cauda Equina syndrome sx: Unexpected accidents with bowel or bladder function/or Distinct loss of saddle/perineal sensation -->
Inflammation: chronic low back pain > 3 months, age of onset < 45, morning stiffness > 30 minutes, improves with exercise, disproportionate night pain -->

Always review Neurological and Inflammatory RED FLAGS! Review Infection, Fracture, or Tumor RED FLAGS if clinically appropriate.

Infection: fever, IV drug use,immune suppressed -->
Fracture: trauma, osteoporosis risk/ fragility fracture -->
Tumor: hx of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue -->


OBJECTIVE: NOTE: Below tests are the suggested minimum requirements of the exam. Additional tests can be considered Gait- Heel Walking (L4-5) Toe Walking (S1) Trendelenburg test (L5) Repeated toe raises (S1) Sitting - Quadriceps power (L3-4) Ankle dorsiflexion power (L4-5) Ankle reflex (S1) Supine - Passive hip range of motion Prone - Femoral nerve stretch (L3-4) Gluteus maximus power (S1) Passive back extension when pt uses arms to elevate upper body
NOTE: Palpation of the spine in mechanical syndromes is not diagnostic and is often unreliable since this is referred pain and the tenderness may be located at a distance from the site of the pain generator(s). Palpation cannot identify the position of or the pathology in the discs, joints or deep ligaments.

As a rule: subtle alterations are not significant.
Standing:
In the standing position, have the patient bend forward into flexion and arch backward in extension. The patient is asked if the movements aggravate or ease their pain. The reproduction of the typical pain should coincide with the report on history. The range of movement is not diagnostic but patterns of abnormal movement may reflect the severity of the pain and suggest the level of functional ability. Asking the patient to side flex or rotate does not help establish a pattern but may be of use in determining the limits of activity.
Sitting:
Conducting an upper motor neuron test is mandatory to ensure that any neurological symptoms or signs are not stemming from an upper motor neuron lesion. The presence of an upper motor lesion completely negates a mechanical lumbar pattern.
The plantar response reflex, Babinski reflex, can be performed in sitting or supine lying. A positive test demonstrates an upward movement of the great toe and a fanning of the four other toes. A clonus test can also be used. Sustained beats are indicative of an upper motor lesion.

Supine:
SLR instructions
Prone:
Every low back exam must include a check for saddle sensation. This assesses sacral nerve function, the same nerves that supply the bladder and bowel. It is essential that you do not miss a Cauda Equina Syndrome. The simplest method is to test light touch in the midline between the upper buttocks. This is easily accessible in prone lying just below the belt line.

ASSESSMENT:


Back dominant (back, buttocks, tip of a tailbone, around hips, or groing):
- Pattern 1 back dominant and pain is aggravated when pt is flexing. Pain can be constant or intermittent, but always aggravated when pt bends forward. PE pain on flexion. No neuro deficit. Not a root involved pain. It is purely mechanical pain.Pattern1 can be either PEP or PEN: Pattern 1 Prone Extension Positive (PEP)= better with 5 prone passive extensions Pattern 1 Prone Extension Negative (PEN) = no change/worse with 5 prone passive extensions. The fact that there is more pain on extension does not change the Pattern. Any pain on flexion makes it a Pattern 1.
- Pattern 2 is also back dominant. Pain is never aggravated on forward bending. Always on extending pain and sometimes better on bending forward. PE pain on extension only. Never on flexion. No neurological sx as no nerve root involvement.Pattern 2 is always intermittent.
Leg dominant (from gluteal fold, down to the thigh, the calf, ankle and the foot):
- Pattern 3 is leg dominant. It is constant. The pattern is represented by a word sciatica. Sciatica is not leg pain. Pain is generated by irritation of roots of sciatic nerve by inflammation. PE pain aggravated by all back movements, particularly by flexion. There will be a positive neurological findings = straight leg limitation, loss of reflexes, power or sensation.
- Pattern 4 is leg dominant. It is intermittent leg pain. Leg pain that is brought on by walking, activity, extension and relived by flexion by sitting by resting in a forward bent position. The pain is always intermittent as distinct by pattern 3 when pain is always constant. Neurogenic claudication is a problem brought on by the nerve root as well, but it is not by inflammation. It is by a loss of blood supply. Because the nerve is safe at rest , the PE is often normal. Dx is made for Pattern 4 entirely on Pt’s Hx.


PLAN:








Referral Criteria ISAEC HealthLink BC SASK Pattern 1 SASK Pattern 2 SASK Pattern 3 SASK Pattern 4 Choosing Wisely Imaging CORE Back Tool Alberta LBP GuidelineCORE Back tool CME course
Result - Copy and paste this output: