Assessing back pain, injuries, interventions
Medical history is first priority
Occupational back injuries are an ongoing hazard in health care, particularly among nurses who have to move patients and perform other tasks that could cause injury.
"Most people with back injuries will get better within two weeks without any medical intervention," notes Melody Rasmor, EdD, FNP, an assistant clinical professor at Washington State University in Vancouver, WA. Rasmor has published articles about neuro-musculoskeletal health assessments for occupational health nurses over the past two decades.
"So it’s really important for health care providers to understand the job the person is doing, their age, and any hobbies or activities of daily life," she says. "Take a good history and listen to their stories to see what kind of lifestyle they have because this tells you about their overall health." In general about 80% of the diagnosis will come from medical history, 10% through diagnostic tests, and 10% is from the physical exam, Rasmor says.
"I don’t order X-rays very often because for the most part you can get a lot of information from the history and the physical exam."
She suggests these five steps for conducting a neuro-musculoskeletal assessment of injured workers:
1. Assess pain: Workers with back pain might complain about pain in the lumbar area that also radiates down the leg. Once the worker describes the pain, then ask these questions:
• Is this is the first time you’ve had an injury?
• Have you ever had surgery?
• How did the injury happen?
• Are they having a tingling sensation and, if so, where?
• Have there been any similar episodes?
• What are their typical activities?
• Are there any bladder problems?
• How is your pain on a scale of zero to 10?
• How well are you sleeping?
"If they’re sleeping like a baby and have pain they describe as a 10, then there’s incongruence there," Rasmor says. "Ask what they’re taking for sleep, and if they’re not taking anything then it makes me think about why their history is not congruent with what they’re telling me about their sleep."
Questions about previous injuries are important because sometimes workers will have an injury that they do not report, thinking it will get better. Then the second time it occurs, they’ll say something, she notes.
Also, bladder problems could indicate a more serious problem, she adds.
"You can hit the bulls-eye if you take a careful history," Rasmor says. "You can discover the mechanism of injury, how the pain feels now, and how long ago the person had that injury and how it manifests."
2. Worker examination: Examine wrists, back, and ankles. Look at the area that’s in pain, searching for signs of previous injuries: scars, swelling, edema, discoloration, and deformities, Rasmor says.
"Palpate for pain, joint swelling, and spasms," she adds.
Assess the person’s range of motion, looking for swelling and a decrease of range of motion from side to side.
"I ask if it’s hurting when they move the back or neck, and you can watch for grimacing to see if the range of motion is decreased," she says.
For example, someone might have had a cervical whiplash of the neck and can’t turn his head. Ask this person how he is driving.
"You watch the person with a back injury walk into the room, get on the table and off the table. Watch the range of motion," Rasmor explains. "All of this gives you information."
3. Test the worker’s strength: For neck injuries, put pressure on one side and have the person turn his or her head to the side. You put your hand on their cheek area and have them turn to the side your hand is on, and see if that causes pain, Rasmor says.
"Then put your hand on the forehead and ask them to push forward, or put your hand on the occipital and have them push back," she adds. "See how much strength they have, and have them turn the head to the left."
Test deep tendon reflexes. These should be consistent. If they’re not then maybe there’s an infringement of the nerve, Rasmor says.
"I have the person get off the table and toe-walk and heel-walk," she says. "With back injuries, that can tell us if there’s problems with the L5 lumbar disk 5 and S12 — sacral area — first vertebrae."
4. Solve the problem: "Now that you have the history and physical assessment, you have to figure out what’s wrong," Rasmor says. "Is it a herniated disk, where most people will get better within two weeks?"
Occupational nurses might place the worker on light duty that involves no heavy lifting. If the worker’s injury is in the wrists, then it’s wise to limit the worker’s repetitive duties that involve their hands, she adds.
5. Follow-up in two weeks: "If workers come back to you and have had pain for two weeks, it’s time to move them along into physical therapy or occupational therapy," she says.
It might also be time to order a diagnostic test, such as an MRI, which is more useful for neuro-musculoskeletal injuries than is an x-ray test, she notes.
"We have to think outside the box and identify the kinds of things that could cause this pain," Rasmor adds.
For instance, some patients can have a long-term, complicated recovery because of other health issues, such as obesity, diabetes, degenerative joint disease, or arthritis, she says.
"If the nurse or health care worker is deconditioned then this can make things more complicated," Rasmor says. "You want to get them into recovery sooner and need to keep track of them."