CCE-CE-009

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Task 1: Take an appropriate history, including occupational and functional impact, red flag symptoms, and previous treatments.

The competent candidate should:

• Clarify the pain characteristics:
  • Onset (acute vs chronic), duration (6 weeks), and progression.
  • Location (lower back, no radiation to legs).
  • Nature (dull, aching, stiffness in the morning, worsens with lifting and prolonged standing).
• Assess red flag symptoms (which are absent in this case):
  • Neurological symptoms (numbness, weakness, saddle anaesthesia).
  • Bowel/bladder dysfunction (cauda equina syndrome).
  • Unintentional weight loss, fever, night pain (infection, malignancy).
• Evaluate occupational and functional impact:
  • Work limitations due to pain.
  • Concerns about future ability to work.
  • Psychosocial stressors and financial concerns.
• Explore previous treatments and coping strategies:
  • Use of paracetamol/NSAIDs (limited relief).
  • Exercise/activity modification.
  • Physiotherapy or ergonomic adjustments at work.
• Assess risk factors for persistent pain (yellow flags):
  • Fear-avoidance behaviour, catastrophising, low mood, work-related stress.

---

Task 2: Explain the likely diagnosis of mechanical low back pain and discuss indications for imaging.

The competent candidate should:

• Explain mechanical low back pain in simple terms:
  • Pain arises from muscle strain, ligament stress, or facet joint dysfunction.
  • It is common in physical jobs and usually improves with movement and exercise.
• Reassure that serious causes are unlikely due to absence of red flags.
• Discuss when imaging is required:
  • Red flag symptoms (e.g., unexplained weight loss, neurological deficit, infection risk).
  • Pain persisting >6 weeks despite appropriate management.
  • History of trauma in older adults or osteoporosis (concern for fracture).
• Explain why routine imaging is NOT recommended initially:
  • May not change management.
  • Findings like disc degeneration are common and may not correlate with symptoms.

---

Task 3: Develop a structured management plan, including pain relief, exercise, physiotherapy, and workplace modifications.

The competent candidate should:

• Encourage activity and graded return to work:
  • Avoid prolonged bed rest—movement is beneficial.
  • Modify tasks (e.g., avoid heavy lifting, use ergonomic supports).
  • Gradual return to full duties with WorkCover support if needed.
• Non-pharmacological strategies:
  • Physiotherapy referral for strengthening and mobility exercises.
  • Heat therapy, massage, stretching exercises.
  • Core strengthening and postural training.
• Pharmacological options:
  • Paracetamol (first-line for mild pain).
  • NSAIDs (short-term use if no contraindications).
  • Avoid opioids and muscle relaxants unless absolutely necessary.
• Follow-up plan:
  • Review in 2-4 weeks to assess progress and modify treatment.
  • Consider psychological support if significant stress or avoidance behaviour.
  • Refer to a multidisciplinary pain team if pain persists beyond 12 weeks.

---

Task 4: Address the patient’s concerns about returning to work and long-term back health.

The competent candidate should:

• Acknowledge the patient’s frustration and job-related worries.
• Reassure that most cases resolve within weeks to months with the right approach.
• Explain that staying active is key—resting too much can worsen stiffness and prolong recovery.
• Discuss injury prevention:
  • Proper lifting techniques and core strengthening.
  • Workplace ergonomic adjustments (e.g., height-adjustable benches).
  • Weight management and general fitness.
• Offer strategies for a safe return to work:
  • Lighter duties initially.
  • Regular breaks and posture changes.
  • Gradual increase in physical workload over time.

---

SUMMARY OF A COMPETENT ANSWER

• Takes a thorough pain history, screening for red and yellow flags.
• Explains mechanical low back pain clearly, including indications for imaging.
• Develops a multimodal treatment plan, prioritising activity, physiotherapy, and short-term pain relief.
• Addresses work-related concerns and provides a return-to-work strategy.
• Educates on long-term back health and injury prevention.

---

PITFALLS

• Over-reliance on imaging when no red flags are present.
• Failing to address occupational impact, which may lead to job dissatisfaction or avoidance behaviour.
• Not reinforcing movement and activity, leading to prolonged recovery.
• Prescribing opioids unnecessarily, increasing risk of dependency.
• Failing to consider psychosocial factors contributing to chronicity.

---

REFERENCES

• RACGP – Best Practice Care for Acute Low Back Pain
• Australian WorkCover Guidelines on Return-to-Work
• GP Exams – Back complaint

---

MARKING

Each competency area is assessed on a 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 Engages effectively with the patient to understand the impact of low back pain on daily life.
1.3 Provides clear and practical advice about pain management and work modifications.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a comprehensive history, assessing red and yellow flags.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates mechanical low back pain from serious pathology.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a multimodal management plan, incorporating physiotherapy, exercise, and pharmacological options.

5. Preventive and Population Health

5.1 Educates the patient on injury prevention and back care strategies.

6. Professionalism

6.2 Provides patient-centred care while addressing work-related concerns empathetically.

7. General Practice Systems and Regulatory Requirements

7.1 Engages with WorkCover, medical certificates, and return-to-work planning.

9. Managing Uncertainty

9.1 Recognises when further investigations (e.g., MRI, specialist referral) are required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages complications of chronic low back pain.

---

Competency at Fellowship Level

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