This document provides an overview of a presentation on managing back and joint pain in older patients. The objectives are to differentiate osteoarthritis from other causes of back/joint pain in older adults, discuss principles of medical management, and provide practice pearls. Common etiologies discussed include mechanical causes like muscle strains, degenerative conditions like spinal stenosis, and inflammatory diseases like ankylosing spondylitis. Key aspects of history and physical exam are outlined to aid in diagnosis. Treatment focuses are also mentioned.

1. Life to the Max,
Living with Rheumatic Disease
Navigating Joint and Back
Pain Conditions in the
50-something Patient

2. Introduction
“The Dr. Lourdes A. Manahan Lectures in Rheumatology (LMLR) is a symposium aimed at raising
awareness on developments in Rheumatology, with the student and clinician in mind. Rheumatology
as a field is one of the “smaller” subspecialties in Internal Medicine that encompasses diseases that are
chronic, disabling, as well as fatal in some instances. It was, therefore, not an accident that our very
own Dr. Lourdes A. Manahan, recognizing this enormous gap in the care of victims of chronic
inflammatory joint diseases, set out to become the country’s first expert in the field.”
– Dr Ester Penserga

3. Guide to the Presentation
Objectives
01
What you will learn over the
next 25mins
Diagnosis
02
What you should consider for
back pain in the older adult
Management
03
What you can do to help these
patients
Practice Pearls
04
What is worth remembering
from this talk

4. Objectives
01

5. Objectives
To differentiate osteoarthritis from other causes
of back/joint pain in the older person.
1
To discuss the basic principles in the medical
treatment of these conditions
2

6. 8.49% of total
population in 2022
9,222,672
5.97% of total
population in 2000
4,565,560
Indigent / No pension
50% / 80%
SENIOR CITIZENS
by Philippine Statistics Authority

7. Epidemiology
65-80%
36-70% of MSK pain is from Back Pain
Prevalence of MSK pain
in older adults
LBP prevalence progressively increases from teenage
to 60y/o then declines
>65yo more likely with chronic LBP lasting >3mos
Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk
factors, management options and future directions. Scoliosis Spinal Disord.
2017 Apr 18;12:14. doi: 10.1186/s13013-017-0121-3.

8. Back/Joint Pain in Older Adults
is Usually Undertreated
25% of senior nursing home residents with
chronic pain did not receive analgesics
Only 50%of all analgesics were prescribed as
standing orders at suboptimal doses
<50% of primary care physicians have strong
confidence in diagnosing the causes of chronic LBP
in older adults
Over-reliance on medical imaging or improper LBP
management (e.g., undertreatment)
Won AB, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA. Persistent
nonmalignant pain and analgesic prescribing patterns in elderly nursing home
residents. J Am Geriatr Soc. 2004;52:867–74
Cayea D, Perera S, Weiner DK. Chronic low back pain in older adults: what
physicians know, what they think they know, and what they should be
taught. J Am Geriatr Soc. 2006;54:1772–7

9. Prevalence and treatment of chronic pain in the Philippines
01
Prevalence
10.4 % of
General
Population
3.4% Annual
Incidence
02
Gender and Age
Women and
Elderly
03
Location
Knees, Back
and Lower back
04
Results
50% had daily routine
affected
~60% did not seek advice
due to high OPD fees
Majority reported taking Rx
painkillers that were less
than effective
Lu, H. , & Javier, F. (2011).Prevalence and treatment of chronic pain in the
Philippines. Philippine Journal of Internal Medicine, 49(2), 61-69

10. RISK FACTORS
PHYSICAL
FACTORS
Obesity
Pregnancy
Arthritis or
Osteoporosis
Bad posture
Physically
strenous work
(heavy lifting,
bending and
twisting, or whole
body vibration
such as truck
driving)
INDIVIDUAL
FACTORS
Age >=30
Female Gender
PSYCHOSOCIAL & ORGANIZATIONAL
FACTORS
Smoking
Sedentary work
Psychologically strenous work
Low Educational attainment
Worker’s compensation insurance
Job dissatisfaction
Psychologic factors: somatization disorder, anxiety,
depression
Katz, J Bone Joint Surg Am. 2006;88 Suppl 2:21.
Steffens D. et al., Arthritis Care Res (Hoboken). 2015 Mar;67(3):403-10.

11. Diagnosis
02

12. Classification by
Signs/Symptoms

13. Nociceptive Pain
(mechanical: is it
muscle vs joint/
tendons/
ligaments)
Neuropathic Pain
(radiculopathy)

14. Classification
by Duration

15. ACUTE SUBACUTE CHRONIC
<4 weeks 4-12 weeks >12 weeks
Chou, R. Ann Intern Med. 2014 Jun 3;160(11):ITC6-1

16. Acute Vs Chronic Joint Pain
CHRONIC
> 6 weeks
ACUTE
≤ 6 weeks

17. Classification
by Etiology

18. Back Pain (w/ or w/o joint pains) is a broad topic with many potential etiologies
01 02 03 04 05
MECHANICAL DEGENERATIVE INFLAMMATORY INFECTIOUS ONCOLOGIC

19. 🚩RED FLAGS
• History: History of metastatic cancer,
unexplained weight loss
• Physical exam: Focal tenderness to
palpation in the setting of risk factors
Malignancy
• History: Significant trauma (relative to age),
Prolonged corticosteroid use, osteoporosis, and
age greater than 70 years
• Physical exam: Contusions, abrasions, tenderness
to palpation over spinous processes
Fracture Neurologic
• History: Spinal procedure within the last 12
months, Intravenous drug use,
Immunosuppression, prior lumbar spine surgery
• Physical exam: Fever, wound in the spinal region,
localized pain, and tenderness
Infection
• History: Progressive motor/sensory loss, new
urinary retention or incontinence, new fecal
incontinence
• Physical exam: Saddle anesthesia, anal sphincter
atony, significant motor deficits of multiple
myotomes
Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P,
Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and
fracture in patients with low back pain: systematic review. BMJ. 2013 Dec
11;347:f7095
Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam
Physician. 2012 Feb 15;85(4):343-50

20. Common History and
Physical Examination
Features for Back Pain
Causes
DDx

21. MECHANICAL

22. 01 MECHANICAL
Disease Characteristics on
History
Findings Notes
Lumbosacral
Muscle
Strain/Sprains/
Myofascial Pain
Syndrome
follows traumatic incident
or repetitive overuse,
pain worse with
movement, better with rest
Restricted range of motion,
tenderness to palpation of
muscles
Usually localized at lumbar
region and/or thigh
Sometimes: no definite
pathology; May be altered
by posture, activity or time
of day; may originate
from different pain
sources

23. 01 MECHANICAL
Disease Characteristics on
History
Findings Notes
Sacroiliac joint
disorders
Pain in the buttocks and/or
lower back that is most
intense when sitting or
lying on one side
Burning, sharp pain or
numbness that radiates into
the groin, the back of the
thigh, or the outer side of the
thigh
Stiffness or loss of flexibility in
the lower back and hips
Pain may be aggravated during
trunk extension, ipsilateral
lateral flexion, and/or rotation
Regular activities that use the
sacroiliac joint, such as
bending at the waist or
stair-climbing, tend to
increase the pain.
Activities that are not
symmetrical, such as lifting
weight with one arm, can
also provoke an increase
in pain

24. 01 MECHANICAL
Disease Characteristics on
History
Findings Notes
Spondylolysis,
Spondylolisthesis
back pain with radiation to
the buttock and posterior
thighs
common among women
aged 60 years or older and
is usually associated with facet
hypertrophy
neurologic deficits are usually in
the L5 distribution
presence of degenerative
spondylolisthesis alongside
facet hypertrophy and
thickening of ligamentum
flavum may result in pain,
spinal stenosis, and
neurological deficits in older
adults

25. 01 MECHANICAL
Disease Characteristics on
History
Findings Notes
Cauda Equina
Syndrome
compression of multiple
lumbar and sacral nerve roots
in the spinal canal
may or may not experience
sciatica, depending on the
location of nerve roots
compression,
bowel, bladder, and/or
sexual dysfunction, as well as
perianal region numbness
Potential causes of this
syndrome include central
disc herniation or
spondylolisthesis at the
lower lumber levels,
spinal tumors, dislocated
fracture, and abscess within
the spinal canals
may be secondary to some
rare iatrogenic causes (e.g.,
spinal anesthesia or
postoperative hematoma)

26. 01 MECHANICAL
Disease Characteristics on
History
Findings Notes
Fracture Significant trauma
(relative to age), Prolonged
corticosteroid use,
osteoporosis, and age
greater than 70 years
Contusions, abrasions,
tenderness to palpation over
spinous processes
Always include a hip Xray
with Lumbosacral AP-
lateral Xray in patients
with low back pain (to
evaluate the hip)

27. DEGENERATIVE

28. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Lumbar
Spondylosis/Facet
Joint Syndrome/Facet
Joint Arthritis
patient typically is greater than 40
years old, pain may be present or
radiate from hips
localized LBP with or without
posterior thigh pain during
walking
Most intense first thing in the
morning, and again toward
the end of the day; interrupts
sleep;
aching, steady, or intermittent
pain; aggravated by prolonged
activity
aggravated during trunk extension,
ipsilateral lateral flexion, and/or
rotation
Localized tenderness when the affected
area of the spine is pressed
the neurologic exam is usually
normal
Stiffness or loss of flexibility in the
lower back

29. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Degenerative disk
disease with
herniation
Radiculopathy that radiates
distal to the knee
May include paresthesia,
sensory change, loss of
strength or reflexes depending
on severity and nerve root
involved
Impaired ankle or patella reflex;
positive ipsilateral or
crossed straight-leg raising
test result; great toe, ankle, or
quadriceps weakness; lower
extremity sensory loss
Common cause of nerve
root impingement and
radicular symptoms, most
commonly at L4 and S1
levels

30. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Spinal stenosis Severe leg pain;
pseudoclaudication; no
pain when patient is seated
Unilateral or bilateral
radiculopathy and neurogenic
claudication with or without
LBP
Wide-based gait;
pseudoclaudication; thigh pain
after 30 s of lumbar extension;
numbness and heaviness of legs
after prolonged walking, which can
be eased by a flexed position
(e.g., forward leaning or sitting)
More common with
advancing age; uncommon
before age 50
On the contrary, the presence
of osteophyte/narrowing in
the lateral recess or in the
vertebral foramen may result
in radicular leg pain without
LBP

31. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Osteoporosis with
or without
compression
fracture
May have acute onset of localized
LBP that may or may not present
with paraspinal muscle spasm or
may occur insidiously over time
older age, corticosteroid use, and
significant trauma
may result in radiculopathy
Loss of height
Pain that worsens with
standing or walking
Partial relief of pain when lying
on the back
Localized back pain worse with
flexion, point tenderness on
palpation if vertebral fracture
Thoracolumbar region MC site
Since the posterior vertebral body
remains intact and the collapsed
anterior vertebra heals without
regaining height, it will result in a
kyphotic deformity without
compromising the spinal cord
Approximately 25% of all
postmenopausal women
(VCF); condition increases
with age
only 1/3 correctly diagnosed
because many seniors
assume bone and joint pain
as part of the aging process
most common fracture
mechanism is due to a flexion
movement or trauma that
causes an anterior wedge
fracture

32. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Hip Osteoarthritis Pain felt in the buttocks,
groin, or anterior
thigh, at times
radiating to the knee.
This pattern of pain
resembles that of upper
lumbar (L2 or L3) radicular
pain
can elicit the pain with
internal and external
rotation of the hip. Often,
there is significant loss of
mobility in the hip joint as well
Confirmatory radiographs
demonstrate joint space
narrowing and
subchondral sclerosis with
osteophyte formation in
many patients

33. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
De Novo
Degenerative
Lumbar Scoliosis
(DNDLS)
lumbar scoliotic curve with a
Cobb angle ≥10° in the
coronal plane that develops
after 50 years of age in people
without a history of adolescent
idiopathic scoliosis
Curve progression rate of DNDLS is
higher than that of adolescent
idiopathic scoliosis
Of note, no definitive evidence
that scoliosis causes pain, but
patients with scoliosis have
more frequently reported pain;
therefore the provider should rule
out other causes before attributing
pain to scoliosis
Multifactorial causes:
intervertebral disc
degeneration and genetic
predisposition
asymmetrical biomechanical
load on the vertebral
endplate on the concave side
of the curve may cause
inflammatory responses
which may result in LBP

34. 02 DEGENERATIVE
Disease Characteristics on
History
Findings Notes
Diffuse idiopathic
skeletal hyperostosis
(DISH)
Usually asymptomatic
Stiffness in the back is the
primary symptom.
Dysphagia, hoarseness and
stridor in some patients
Pain, most often in the
thoracolumbar region, occurs
in about half of affected
persons
Plain radiographs that reveal
flowing anterior calcification
along at least four contiguous
vertebrae confirm the diagnosis.
Disk height is preserved.
Sacroiliac joints are not
involved, though the appearance
superficially resembles spondylitis.
Tests for acute-phase reactants
are normal
More common in men, DISH
occurs in persons over age 50
and may be seen
radiographically in up to 10%
of persons over 65
Incidence is higher in persons
with diabetes.

35. INFLAMMATORY

36. 03 INFLAMMATORY
Disease Characteristics on
History
Findings Notes
Ankylosing
Spondylitis
Gradual onset; marked
morning stiffness >30mins;
improves with exercise,
worsens with rest; pain for
>3 mo; pain not relieved
when patient is
supine;alternating buttock
pain; worse at 2nd half of
night; good response to
NSAIDs
Decreased spinal range of motion in
more advance stage
Usual onset before age 40

37. 03 INFLAMMATORY
Disease Characteristics on
History
Findings Notes
Polymyalgia
Rheumatica
sudden (within 2 weeks) onset
of pain and stiffness in the
neck, upper back, shoulders,
lower back, buttocks, and hips,
≥ 50yo.
Women > Men
ESR > 40mm/h
Negative RF/ACPA
Dramatic response to
steroids
Giant cell arteritis is found
in about 40% of patients
with the syndrome,
manifested by headache,
visual disturbances, jaw
claudication, or systemic
signs

38. 03 INFLAMMATORY
Disease Characteristics on
History
Findings Notes
Trochanteric
bursitis
Common nonarticular cause of
aching pain in the lateral
aspect of the hip; in about
40% of patients, this pain
extends down the lateral
aspect of the thigh.
Many patients are unable to lie
on the affected side because of
increased pain.
direct tenderness over and
around the greater
trochanter. Pain may be
provoked by forced hip
abduction
Radiographs occasionally
reveal calcifications
around the trochanter

39. 03 INFLAMMATORY
Disease Characteristics on
History
Findings Notes
Rheumatoid Arthritis persistent symmetric polyarthritis
(synovitis) that affects the hands and
feet
may begin with systemic features (eg,
fever, malaise, arthralgias, and
weakness) before the appearance of
overt joint inflammation and swelling
Extra-articular involvement of organs
such as the skin, heart, lungs, and eyes
can also be significant
Neck pain and occipital headache
if cervical spine is involved
Lhermitte sign: tingling paresthesia that
descends through the thoracolumbar spine
occurs as the cervical spine is flexed
Clinical manifestations of early cervical
spine disease consist primarily of neck
stiffness that is perceived throughout
the entire arc of motion
Neurologic involvement in the cervical
spine ranges from radicular pain to a
variety of spinal cord lesions that may result
in weakness (including quadriparesis),
sphincter dysfunction, sensory deficits, and
pathologic reflexes.
TIAs and cerebellar signs: vertebral
artery impingement from cervical
subluxation or basilar artery
impingement from upward
migration of the dens
Tenosynovitis of the transverse
ligament of C1: C1-C2 instability.
Myelopathy secondary to rupture
of the transverse ligament:
neurologic deficits.
Radiculopathy most common at
the C2 root

40. 03 INFLAMMATORY
Disease Characteristics on
History
Findings Notes
Gout Episodic arthritis
Started out as monoarthritis (usually of
the 1st MTP, foot/ankle) earlier in the
course then becoming oligo- to
polyarticular
Tender or swollen joints during a flare
May or may not find tophi
Tophi common with prolonged disease
course, use of NSAIDs/Steroids without
urate lowering therapy, presence of other
comorbidities (HTN, CKD)
Elevated uric acid; may be normal during a
flare
52% would have elevated Creatinine at
time of consult
Rarely affects the spine; may
have back pain due to changes in
gait and posture while in flare
Spinal tophi are rare. The
presentation may be varied and
diagnosis is difficult as it may
mimic other conditions such
as epidural
abscess, spondylodiscitis, and
neoplasm. The imaging features
are non-specific and when
neurological signs are present,
surgical intervention may be
needed.

41. 03 INFLAMMATORY / 04 INFECTIOUS
Disease Characteristics on
History
Findings Notes
Intra-abdominal
visceral disease
Depends on affected
viscera
Depends on affected viscera Gastrointestinal: peptic
ulcer or pancreatitis
Genitourinary:
nephrolithiasis,
pyelonephritis, prostatitis,
pelvic infection, or tumor
Vascular: aortic dissection
All of these illnesses can
cause back pain

42. INFECTIOUS

43. 04 INFECTIOUS
Disease Characteristics on
History
Findings Notes
Vertebral
Osteomyelitis
unidentified fever and/or
LBP;
Type 2 Diabetes Mellitus, HIV, Prior
or current TB, Chronic disease (CKD
on HD, Liver cirrhosis, IE,
Malignancies, Systemic
Autoimmune Diseases),
Osteoporosis, Trauma, UTI, Recent
infection or history of intravenous
drug use; wound in spinal region
Iatrogenic surgeries (spinal
Surgery or injections)
Fever and localized tenderness
fever, elevated C-reactive protein,
paraspinal muscle spasm, LBP,
neurological deficits, and epidural
abscess
tuberculous osteomyelitis may
have a groin mass because of the
presence of abscess in psoas muscle
Pathogenic bacteria (S. aureus MC)
disseminated hematogenously
from a distant infected source and
multiply at the metaphyseal
arterioles of vertebral bone that
causes microabscess formation,
bone necrosis, and fistula within
bone
Can cause cord compression
Clinical findings, laboratory
results, bone scintigraphy, and/or
spinal biopsy
Granulomatous disease may
represent as high as one-third of
cases in developing countries

44. 04 INFECTIOUS
Disease Characteristics on
History
Findings Notes
Pyogenic
spondylodiscitis,
spinal abscess,
epidural abscess
infection of disc and
adjacent vertebral bones
>70 yo
Clinical presentations and PE of
spondylodiscitis are comparable
VO
S. aureus is the major cause of
pyogenic spondylodiscitis
Magnetic resonance imaging is the
gold standard for imaging
pyogenic spondylodiscitis, which is
visualized as reduced signal
intensity of the affected disc and
adjacent vertebral bodies with
unclear endplates definition on T1-
weighted images and enhanced
signal intensity on T2-weighted
images

45. 04 INFECTIOUS
Disease Characteristics on
History
Findings Notes
Herpes zoster Unilateral pain in
distribution of dermatome
Unilateral dermatomal rash Most common in elderly
or immunocompromised
patients

46. ONCOLOGIC

47. 05 ONCOLOGIC
Disease Characteristics on
History
Findings Notes
Tumors or Cancers Weight loss or other cancer
symptoms; known past or current
cancer diagnosis; failure to improve
after 4 wk
Progressive, unremitting,
localized, or radiating pain that
are aggravated by movement,
worse at night, and cannot be
eased by rest.
Patients may experience weakness
and feel the presence of a lump
Focal/localized tenderness to
palpation in the setting of risk factors
97% are from Metastatic disease,
commonly from prostate, breast,
and lung cancer; can cause cord
compression; more common in
patients aged ≥50
Should keep multiple myeloma in
the differential (Anemia,
bone/back/joint pain,
hypercalcemia)
Primary malignant tumors (e.g.,
chordoma, plasmacytoma, or
lymphoma) are also be found in
older adults

48. OTHERS

49. 06 OTHERS
Disease Characteristics on
History
Findings Notes
Psychosocial
distress
Symptoms do not follow a
clear clinical or anatomical
pattern; psychological and
emotional distress
Physical examination findings
that do not follow a clear
clinical or anatomical
pattern
Patients with psychosocial
distress and low back pain
are at high risk for
delayed recovery, chronic
pain, and poor functional
outcomes
Menopause Headache, mood swings to hot
flashes, fatigue, night sweats,
myalgia, arthralgia (dull ache,
twinge, shooting sensation, stiffness
– worst in the morning), back pain,
neck pain, leg pain
Nonspecific PE
Amenorrhea or Oligomenorrhea
As estrogen drops:
inflammation can
increase, Osteoarthritis
and Osteoporosis increase

50. 06 OTHERS
Disease Characteristics on
History
Findings Notes
Fibromyalgia syndrome of widespread
musculoskeletal pain and
tenderness in a variety of
characteristic sites
Dull, aching, and often described
as flu-like pain
Patients may be sensitive to weather
changes and may have disrupted,
nonrestorative sleep and marked
fatigue. Psychological distress is
common. Headache and irritable
bowel symptoms often coexist
Laboratory studies are unrevealing.
Radiographs are normal. Some patients
with cervical pain demonstrate
straightening of the cervical spine on the
lateral cervical radiograph, characteristic of
muscle spasm
Diagnostic criteria for fibromyalgia were
defined by the American College of
Rheumatology in 1990 and include, first,
widespread pain, and second, pain in at
least 11 of 18 defined tender points

51. Management
03
Imaging, Labs, Treatment

52. When is Imaging
Warranted?

53. VOMIT
Victims
Of
Medical
Imaging
Technology
Radiographic exams are
usually of limited use unless
the Hx or PE suggests a
specific underlying cause.

54. IMAGING
● Weak association between imaging abnormalities and symptoms
● Up to 85%: cannot make precise pathoanatomic Dx with identification of
the pain generator
● Reinforce suspicion of serious disease, magnify the importance of non-specific
findings, and label patients with spurious diagnosis
Deyo RA, Weinstein DO: Low back pain, N Engl J Med 344(5):363– 370, 2001.

55. Although spinal degenerative
changes may induce LBP, not all
anomalies on lumbar medical
imaging are related to LBP
because abnormal imaging
phenotypes are ubiquitous among
asymptomatic older adults
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance
scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone
Joint Surg Am. 1990;72

56. Disk Herniation is Prevalent in Pain-Free Individuals
Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations,
AJNR Am J Neuroradiol. 2015 Apr; 36(4): 811–816.
The demonstration of
anatomical abnormality
should not
automatically lead the
clinician to assume that it
is the cause of pain

57. Earlier use of imaging for low back pain
without associated symptoms is not associated
with improved outcomes but increases the
medical costs and the use of
invasive procedures
Chou R. et al. Clinical Guidelines Committee of the ACP. Ann Intern Med. 2011;154:181-9

58. IMAGING
Imaging is NOT required UNLESS significant symptoms
PERSIST BEYOND 6-8 weeks
Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and treatment in
rheumatology, ed 2, New York, 2007, McGraw-Hill
NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY in the course of LBP
evaluation improves clinical outcome, predicts recovery course, or reduces overall cost
of care
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet 373:463–472, 2009.

59. ACP and
APS (2007)
Imaging
Guidelines
Chou r, et al. Clinical Efficacy Assessment
Subcommittee of the ACP. Ann Intern Med
2007;147:478-91
Imaging is useful as the
pretest probability of
underlying serious disease
requiring surgical or other
intervention increases.

60. What about other diagnostic tests
● Additional diagnostic and lab tests are not indicated
in most patients with (low) back pain
● ELEVATED ESR/CRP: think of systemic problems like
infection, malignancy, autoimmune/inflammatory
diseases – test further as necessary (eg RF, ACPA,
Cultures, Cancer screening)
● EMG-NCV
○ Considered if with diagnostic uncertainty about
the relationship of leg symptoms to anatomical
findings on advanced imaging
○ Assess myelopathy, radiculopathy, neuropathy,
myopathy
○ Do NOT Test if duration of symptoms <4 weeks
(unreliable in limb muscles until significant
symptoms seen >3-4weeks)

61. Overview of Treatment

62. Overview of Treatment
01 Fall prevention/Addressing Osteoporosis
02 Pain medications/DMARDs
03 Conservative treatments
04 Lumbar Surgery

63. 01 Fall Prevention / Addressing Osteoporosis
Wear non-slip shoes
Install handrails on the stairs and in the shower
Remove tripping hazards
Aerobic exercises at least 3hrs per week: stationary bike, water exercises, walking or jogging,
tai chi
Walk for at least 1 hr per week(can be included in the minimum 3h exercise); A habitually
brisk walking speed, at or above 3 miles per hour, is more protective against a fall than a
generally slow walking pace
Screen for Osteoporosis with Bone Mineral Densitometry (Central DXA) and treat accordingly
(Bisphosphonates/Denosumab/Teriparatide)

64. 02 Pain Medications
Always consider the etiology of the pain 1st
Consider/Check hepatic and renal function; if unsure – use kidney friendly drugs initially or
use a lower dose of meds while awaiting test
PRN vs RTC: A standing order of analgesic is recommended for older adults with chronic
pain so that they can have a steady concentration of analgesic in the blood stream;
inflammatory conditions also require continuous meds to control inflammation
Opioids vs NSAIDs: consider need for anti-inflammatory med; comorbid conditions (GI,
Cardiac, Renal, Neurologic, Hepatic disorders)
Use NSAIDs (preferrable COX-2) as adjunctive therapy for non-inflammatory conditions or as
primary therapy for inflammatory conditions (with normal kidney function); add PPI if with
risk of GI bleeding; caution with heart failure; watch out for drug-drug interactions
Woo J, Leung J, Lau E. Prevalence and correlates of musculoskeletal pain in
Chinese elderly and the impact on 4-year physical function and quality of
life. Public Health. 2009;123:549–56.
Tomita Y, Arima K, Kanagae M, Okabe T, Mizukami S, Nishimura T, et al.
Association of physical performance and pain with fear of falling among
community-dwelling Japanese women aged 65 years and older. Medicine
(Baltimore) 2015;94:e1449.

65. 02 Pain Medications/DMARDs
Muscle relaxants, gabapentin/pregabalin, duloxetine, topical analgesics,
and opioids: use on a case-by-case basis (may combine); start low, go
slow with doses
Use ≥2 pain medications with different mechanisms of action or different drug
classes to attain better pain relief with minimal side effects from a high
dose just 1 medication (eg NSAIDs + Opioids, NSAIDs + Muscle relaxants,
NSAIDs + Pregabalin)
Use of csDMARDS +/-bDMARDS in AS/RA
Use of steroids in PMR/RA/Gout with CKD
Musich S, Wang SS, Slindee LB, Keown K, Hawkins K, Yeh CS. Using Pain
Medication Intensity to Stratify Back Pain Among Older Adults. Pain
Med. 2019 Feb 01;20(2):252-266
Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H,
Bowe SJ, Belavy DL. Which specific modes of exercise training are most
effective for treating low back pain? Network meta-analysis. Br J Sports
Med. 2020 Nov;54(21):1279-1287.

66. 03 Conservative Treatment
Most cases of back pain are mechanical in origin and respond to activity
modification, rest, ice, and heat. Physical therapy and core strengthening
exercises also play a role.
Most effective is the McKenzie method (prone lying, prone lying while resting on
elbows, prone push-ups, progressive extension using pillows and standing
extension)
Integrative treatment modalities such as acupuncture, tai chi, and yoga have also
been shown to have a moderate effect on the improvement of back pain
Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H,
Bowe SJ, Belavy DL. Which specific modes of exercise training are most
effective for treating low back pain? Network meta-analysis. Br J Sports
Med. 2020 Nov;54(21):1279-1287.
Qin J, Zhang Y, Wu L, He Z, Huang J, Tao J, Chen L. Effect of Tai Chi alone or as
additional therapy on low back pain: Systematic review and meta-analysis of
randomized controlled trials. Medicine (Baltimore). 2019 Sep;98(37):e17099

67. 03 Conservative Treatment
Aquatic Exercise
Exercises done in a warm
swimming pool are as
effective as other supervised
exercises performed at home,
at physical therapy, or at a
gym
Kim Y, Vakula MN, Waller B, Bressel E. A systematic
review and meta-analysis comparing the effect of
aquatic and land exercise on dynamic balance in older
adults. BMC Geriatr. 2020;20(1):302
Lumbar stabilization exercise
Dynamic stability exercises create
stronger muscles and allow patients to
better avoid injury from falls or
recover balance after a fall
Hamed A, Bohm S, Mersmann F, Arampatzis A. Exercises of dynamic stability
under unstable conditions increase muscle strength and balance ability in the
elderly. Scand J Med Sci Sports. 2018;28(3):961-971.

68. 03 Conservative Treatment
Core Strengthening Exercise
Strengthening the core muscles helps improve
overall stability, posture, and steadiness while
walking
Cruz-Díaz D, Martínez-Amat A, Osuna-Pérez MC, De la Torre-Cruz MJ, Hita Contreras F. Short- and long- term effects
of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back
pain: a randomized controlled trial. Disabil Rehabil. 2016;38(13):1300- 1308.

69. 04 Lumbar Surgery; Decompression
Indicated for older people only if there is a definite diagnosis of lumbar pathology
(e.g., degenerative LSS, cauda equine syndrome, or spinal tumor) that needs to be
treated by surgery or that is unresponsive to conservative intervention.
The objective is to minimize compression of neural tissues and/or enhance spinal
stability.
Laminectomy, laminotomy, and discectomy: partially or completely remove
lumbar structures that are impinging neural tissues
Minimally invasive spine surgery techniques have higher success rate than open
lumbar decompression surgery
Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H,
Bowe SJ, Belavy DL. Which specific modes of exercise training are most
effective for treating low back pain? Network meta-analysis. Br J Sports
Med. 2020 Nov;54(21):1279-1287.
Qin J, Zhang Y, Wu L, He Z, Huang J, Tao J, Chen L. Effect of Tai Chi alone or as
additional therapy on low back pain: Systematic review and meta-analysis of
randomized controlled trials. Medicine (Baltimore). 2019 Sep;98(37):e17099

70. 04 Lumbar Surgery: Spinal Fusion
Bone grafts (autograft or allograft) or surgical devices to fuse adjacent vertebrae
anteriorly, posteriorly, or circumferentially.
Immobilizes the spinal motion segment which removes key pain generating
sources and eliminates intersegmental movement of vertebrae that may
compress neural structures in order to alleviate symptoms
Associated with a higher risk of major complications and postoperative mortality
vs decompression surgery
Smith ZA, Fessler RG. Paradigm changes in spine surgery: evolution of
minimally invasive techniques. Nat Rev Neurol. 2012;8:443–50
Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse:
updated Cochrane Review. Spine. 2007;32:1735–47.
doi: 10.1097/BRS.0b013e3180bc2431.

71. 04 Lumbar Surgery: Others
Recently, disc arthroplasty has been adopted to restore the mobility of an
intervertebral joint by replacing a degenerative disc with an artificial
disc and minimizing the risk of adjacent segment degeneration/disease
Corticosteroid injections, radiofrequency ablative therapy, spinal cord
stimulators, and TENS units, are possible treatments options as well for
refractory cases who do not wish to undergo surgery.
van Tulder MW, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive
treatment modalities on back pain and sciatica: an evidence-based review. Eur
Spine J Springer-Verlag. 2006;15(Suppl 1):S82–92. doi: 10.1007/s00586-005-
1049-5
Shapiro GS, Taira G, Boachie-Adjei O. Results of surgical treatment of adult
idiopathic scoliosis with low back pain and spinal stenosis: a study of long-term
clinical radiographic outcomes. Spine. 2003;28:358–63

72. Practice Pearls
04
What’s worth remembering

73. • Do a good Hx and PE; examine red flags;
differentiate neuropathic vs nociceptive
pain – this is more often enough
• Avoid imaging before six weeks in severe
pain in the absence of red flags; only do
imaging early and/or refer or treat
aggressively if there are red flags
• Address all comorbidities, especially for
refractory back pain and those with red
flags on presentation

74. • RTC over PRN pain control especially for 1.
chronic (inflammatory) conditions and 2. in
patients with cognitive d/o and those who
cannot verbalize pain while considering
safety/comorbidities
• Combine different interventions when treating
back pain to maximize different MOAs of drugs
• Consider Interprofessional approach for a
holistic treatment plan (avoid duplication of tx
and tests, deliver same message to the patient)
• Reserve surgery for refractory cases; inform
patients of risks and benefits and alternatives

75. The pain passes
but the beauty remains
Pierre-Auguste Renoir

76. CREDITS: This presentation template was
created by Slidesgo, including icons by
Flaticon, infographics & images by Freepik
Thanks
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