Biopsychosocial approach Your patient is not a machine!!! : What - - PowerPoint PPT Presentation

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Sep 25, 2023 20 likes •354 views

Biopsychosocial approach Your patient is not a machine!!! : What does he think about his illness?-cause, effect on lifestyle, what does he want done? What are the social issues that impact his condition? work, compensation, family, sex life

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Biopsychosocial approach

Your patient is not a machine!!!: What does he think about his illness?-cause, effect on lifestyle, what does he want done? What are the social issues that impact his condition? – work, compensation, family, sex life What is wrong? – try to create a common understanding

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Patient Centeredness Treat pt. as unique individual-not a case of….

Welcome him Smile at him, exchange greetings, give him time to tell his story Ask him questions – let him ask questions Respect - his story, his body, his views/values Discuss/explain - diagnosis, investigations, treatment plans (as appropriate) Create rapport/friendship/a healing relationship

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Low back pain

Very common condition – 49% to 70% life prevalence, 12% to 30% point prevalence Health care costs – about $6,000 per year, per patient (2005) Compromises- mobility, productivity, attendance at work Can be excruciatingly painful NB – pancreatitis, nephrolithiasis, pyelonephritis, aortic aneurysm, endocarditis, impotence, work compensation

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85% of low back pain has no major underlying disease (body pathology) - non specific LBP

Rule out: compression fracture – 4% herniated disc (disc prolapse) – 4% ankylosing spondylitis - 0.3-4% symptomatic spinal stenosis – 3% cancer – 0.7% cauda equina syndrome – 0.04% spinal infections – 0.01% (may be different in Africa)

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Physical Examination to determine

A. Is there specific condition or pathology?
B. Is there neurological involvement; progressing,

severe? Based on findings:

i. Non specific LBP – manage
ii. Radiculopathy or spinal stenosis – refer
iii. Specific cause e.g. TB or compression fracture -

manage or refer as appropriate

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Non specific LBP There is no significant underlying pathology Most patients will get well There is no need for investigations – X-rays, ultra sound, MRI, CT scans (drives unnecessary interventions and costs) (Investigate only – severe/progressive nerve problems, suspected pathology)

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Pharmacological treatment – non specific LBP

Most patients recover in 4 weeks – short course analgesics No bed rest - encourage patient to remain active Post 12 weeks and pain improvement minimal – reassess, give analgesics as required, multidisciplinary treatment programs, may refer for spine manipulation, consider psycho-social problems Paracetamol, NSAIDs, Opioids, muscle relaxants, (anti depressants, topical medications, heat)

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Paracetamol

Analgesic, antipyretic, no anti inflammatory properties Small or no effect as analgesic in non specific LBP Less effective than NSAIDS but better SE profile

SE. Hepatotoxicity even at 4g/day (seems uncommon)
chronic hepatitis in Botswana
traditional medicine
chronic headache

Pain is a social construct – is pain experienced similarly by Americans, Indians, Latinos, Africans???

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NSAIDS

Analgesic and anti inflammatory properties – block cyclo-oxygenase (Cox) 1 and 2 (non selective), 2 (selective) Cox-1 protects stomach lining Suggested 1st line treatment Selective and non selective equally effective In Bots consider costs: Cox 2 vs. non selective with proton pump inhibitor (ibuprofen +omeprazole)

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NSAIDs SE profile

Hepatotoxicity Gastric ulcers/ perforation Myocardial infarction CCF (elderly) Complicate BP treatment

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Opioids

For pain not controlled with paracetamol or NSAIDs Use for severe, disabling pain – who judges? How? For patients with high risk for side effects of NSAIDs treatment Starting patients on opioids should be considered carefully – abuse Substance abuse – personal or family history of substance abuse

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Opioids

Side effects
Nausea
Constipation
Somnolence
Myclonus
Pruritis

Abuse is a problem

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Tramadol

Affinity for opioid α receptors Not first line treatment Has similar effects as NSAIDS SE - potential for serotonin syndrome: agitation,

confusion, fever, tachycardia, hypertension, rigidity, seizures, diarrhoea, sweating, shivering

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Antidepressants

Tricyclic anti depressants (TCAs) commonly used for chronic nsLBP Doubtful efficacy for pain relief Side effects: dry mouth, dizziness, arrhythmias, QRS prolongation

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Skeletal Muscle Relaxants

Have modest effect on pain relief Use in acute cases Combine with paracetamol or NSAIDs SE – sedation, hepatotoxicity (some)

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Other Medications

Anti-epileptics – insufficient evidence to recommend Systemic Corticosteroids – not recommended In Botswana – consider topical treatments; methyl salicylate, deep heat rub, and other skin preparations

Ref.

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