CCE-CBD-009

Examiner Only Information

Questions

Q1. What are the key features that support a diagnosis of mechanical lower back pain?

• Prompt: What symptoms and examination findings indicate a mechanical cause?
• Prompt: How do you differentiate mechanical back pain from red flag conditions?

Q2. What are the initial management strategies for Daniel’s back pain?

• Prompt: What are the first-line non-pharmacological treatments?
• Prompt: When should pharmacological therapy be considered?

Q3. How would you counsel Daniel on work modifications and return to activity?

• Prompt: How do you balance rest with maintaining function?
• Prompt: What workplace adjustments could help prevent recurrence?

Q4. When would you consider imaging or specialist referral?

• Prompt: What are the red flags for urgent imaging or referral?
• Prompt: When should conservative management be continued?

Q5. What role do physiotherapy and exercise play in managing back pain?

• Prompt: What types of exercise are beneficial?
• Prompt: How does physiotherapy support recovery and prevention?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you differentiate mechanical back pain from serious spinal pathology?

The competent candidate should:

• Identify key features of mechanical back pain:
  • Dull, aching pain localised to the lower back with occasional radiation to the left buttock and posterior thigh.
  • Pain worsens with prolonged sitting and lifting, relieved with movement.
  • No neurological deficits (normal reflexes, intact sensation, full power).
  • Negative Straight Leg Raise (SLR), no red flags (suggests no significant nerve root compression).
• Screen for red flags requiring further investigation:
  • Age >50 with new-onset back pain (risk of malignancy).
  • Unexplained weight loss, night pain, or systemic symptoms (malignancy, infection).
  • Fever, IV drug use, immunosuppression (infection, epidural abscess).
  • Bowel/bladder dysfunction or saddle anaesthesia (cauda equina syndrome – emergency referral).
• When to consider imaging:
  • Symptoms persist >6 weeks despite appropriate management.
  • Presence of red flag symptoms.
  • Progressive neurological deficits.

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Q2: What are the initial management strategies for Michael’s back pain?

The competent candidate should:

• Non-pharmacological management (first-line):
  • Encourage early movement and avoid bed rest.
  • Physiotherapy referral for core strengthening, flexibility exercises.
  • Ergonomic modifications at work (proper lifting techniques, posture support).
• Pharmacological management:
  • Paracetamol (regular, not PRN).
  • Short-term NSAIDs if no contraindications (monitor for gastrointestinal/cardiovascular risks).
  • Consider muscle relaxants (e.g., diazepam short-term) if spasms present.
• Work considerations:
  • Support return to work with modified duties.
  • Provide a medical certificate if short-term rest is required.

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Q3: How would you counsel Michael on the role of imaging in managing back pain?

The competent candidate should:

• Explain that imaging is not routinely required for uncomplicated mechanical back pain.
• Discuss the natural course of back pain:
  • Most cases resolve within 6 weeks with conservative treatment.
  • Imaging does not usually change management.
• Indications for imaging:
  • Persistent symptoms >6 weeks.
  • Red flag symptoms (e.g., weight loss, fever, neurological deficits).
• Risks of unnecessary imaging:
  • Incidental findings may lead to unnecessary interventions.
  • Radiation exposure with X-rays/CT scans.

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Q4: What lifestyle modifications should Michael make to prevent recurrence?

The competent candidate should:

• Exercise and weight management:
  • Regular core strengthening and stretching exercises.
  • Low-impact aerobic activities (e.g., swimming, cycling).
  • Weight reduction if overweight (BMI 29 kg/m²) to reduce spinal stress.
• Smoking cessation:
  • Smoking impairs disc healing and increases chronic pain risk.
  • Offer Quitline referral, nicotine replacement therapy (NRT), or varenicline.
• Workplace ergonomics:
  • Teach proper lifting techniques.
  • Encourage frequent movement breaks to reduce strain.

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Q5: When would you consider referral to a specialist?

The competent candidate should:

• Refer to a physiotherapist if:
  • Persistent pain despite conservative management.
  • Significant functional impairment affecting daily activities or work.
• Refer to a spine specialist if:
  • Progressive neurological symptoms (e.g., weakness, numbness, loss of reflexes).
  • Suspected cauda equina syndrome (emergency referral).
  • Persistent pain >3 months despite optimal management.
• Refer to a pain specialist if:
  • Chronic back pain not responding to standard treatment.
  • Multidisciplinary pain management is needed.

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SUMMARY OF A COMPETENT ANSWER

• Identifies mechanical back pain features and rules out serious spinal pathology.
• Implements a stepwise treatment plan, including physiotherapy, exercise, and analgesia.
• Provides patient-centred education on imaging, prognosis, and return to work.
• Promotes lifestyle modifications (smoking cessation, ergonomic adjustments).
• Recognises indications for referral to physiotherapy, pain specialists, or surgeons.

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PITFALLS

• Over-relying on imaging when not clinically indicated.
• Not addressing work-related concerns, leading to prolonged disability.
• Failing to recommend structured physiotherapy and exercise.
• Missing red flag symptoms requiring urgent investigation.

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REFERENCES

• RACGP Clinical Guidelines for Low Back Pain
• National Institutes of Health Musculoskeletal Conditions
• Australian Commission on Safety and Quality in Health Care – Back Pain Management

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Establishes rapport and discusses patient concerns about work impact.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured musculoskeletal and neurological examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates mechanical back pain from serious spinal conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an effective treatment plan, including exercise and work modifications.

5. Preventive and Population Health

5.2 Encourages smoking cessation, weight management, and ergonomic changes.

6. Professionalism

6.3 Provides patient-centred care and addresses return-to-work concerns.

7. General Practice Systems and Regulatory Requirements

7.2 Manages work-related injury certification and safe prescribing practices.

9. Managing Uncertainty

9.1 Determines when imaging or specialist referral is necessary.

10. Identifying and Managing the Patient with Significant Illness

10.3 Recognises red flags requiring urgent investigation.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD