Back Pain

Chris Boyles, Physiotherapy Extended Scope Practitioner A&E

June 2014

1. Around 30 million adults in the UK will experience back pain this year.

2. Around 10 million of them will experience pain and disability lasting more than 12 months and 6

million of them will be off work for more than three months as a result.

3. Back pain represents half of all chronic pain and costs the NHS £1.3 million every day.

http://www.backcare.org.uk/

International Guidelines

Low Back Pain; early management of persistent non-specific LBP (NICE clinical guideline 88, May 2009)

New Zealand Acute Low Back Pain Guide (New Zealand Guidelines Group, October 2004)

European Guidelines for the Acute and Chronic management of Low Back Pain. Circa 2004

Initial consultation

Subjective and objective examinationDiagnostic triage

Red Flags

Yellow flags

Management

Diagnostic Triage

1. Mechanical Back Pain

2. Nerve Root pain

3. Identifiable Pathologies

Important points to consider

All patients with symptoms or signs of Cauda Equina Syndrome should be referred urgently for orthopaedic or

neurosurgical assessment.

Important points to consider

Investigations in the first 4-6 weeks of an acute low back pain episode do not provide clinical benefit, unless there are Red Flags.

A full blood count and ESR should usually be performed only if there are Red Flags. Other tests may be indicated depending on the clinical situation.

Important points to consider

Many people without symptoms show abnormalities on X-rays and MRI. The chances of finding coincidental disc prolapse increase with age. It is important to correlate MRI findings with age and clinical signs before advising surgery.

Examination

History

History of trauma

Location of pain

Description of pain

Aggravating and easing factors

Morning stiffness

Bladder and bowel Disturbance, Saddle anesthesia

Consider salient factors from past medical history

Red Flags

T

U

N

A

F

I

S

H

Trauma, Thoracic pain

Unexplained weight loss

Neurological signs, Non-mechanical pain, Night pain

Age; <20 >55, Am stiff

Fever, Flexion Loss

IVDU

Steroids; Long term

History of Cancer

Yellow Flags

Attitudes - towards the current problem

Beliefs - Something seriously wrong

Compensation

Diagnosis - Conflicting, emotive

Emotions - co-existing depression, anxiety

Family - Over or under supportive

Graft - Occupation, support from employers

ABCDEFG

Yellow Flag screening tools

STarT

http://www.keele.ac.uk/sbst/

Roland Morris Questionnairehttp://www.rmdq.org/

Examination

Physical Tests

1. Observation.

Gait

willingness to move

posture

spasm

deformity eg kyphosis

Examination

Physical Tests

2. Movements

Lumbar spine; Flexion, Extension, Lateral flexion

Hips; Especially rotations

SLR

Examination

Physical Tests

3. Neurological

Myotomal

Dermatomal

Deep tendon Reflexes

PR

Examination

Physical Tests

4. Palpation

Bony tenderness/ deformity

Heat, sweating & temperature

muscle spasm

Abdominal

Examination

Physical Tests

5. Imaging

Do not routinely offer X-ray of the lumbar spine for the management of non-specific low back pain.

Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion.

Mechanical Back pain

Patients between 25-55 years of age.

Lumbosacral region, buttocks and thighs.

Pain is mechanical in nature.

Prognosis

Excellent. First episode LBP will resolve in 90% patients in 4-6/52. However 25% patients will have recurrence over next 1-2 years and 5% develop chronic symptoms.

Nerve Root pain

Unilateral leg pain may be worse than back pain

Pain may radiate to toes or foot

Numbness and paraesthesia in same distribution

Neuro changes limited to one nerve root

Prognosis

Good. 80% patients will recover in 10-12/52.

Identifiable conditions

1. Caudia Equina

Difficulty with micturition

Loss of anal sphincter tone or faecal incontinence

Saddle anaesthesia – anus, perineum or genitals

Widespread neurological changes (› 1 nerve root) or

progressive motor weakness in the legs or gait disturbance

Identifiable conditions

2. Inflammatory Disorders (ie Ankylosing Spondolysis)Gradual onset before age of 40Marked morning stiffnessPersisting limitation of spinal movements in all directionsPeripheral joint involvementIritis, skin rashes (psoriasis), colitis, urethral dischargeFamily historyRecurrent tendinopathy/esinopathy

Identifiable conditions

3. Infection (Discitis)

Tends to occur in Children under 10, IVDU, post spinal surgery and Immunosuppressed patients.

Presents with pain, stiffness and reduced ROM.

Fever

Identifiable conditions

4. Fracture

1-4% all patients presenting to primary care with LBP

Trauma

Older age

Prolonged use corticosteroids

Presence of contusion/Abrasion

Identifiable conditions

5. Malignancy

Less than 1% patients will have Primary Tumor or metastatic lesion as cause of LBP

Past history Ca most accurate red flag for predicting malignancy as cause of LBP. (7% Primary care, 33% A&E)

Approximately 10% all malignancies have spinal involvement

Most common Multiple Myeloma, non-Hodgkin’s Lymphoma, and secondary's from Lung, Breast and Prostate

Management

1. Advice

Promote self-management: advise people with low back pain to exercise, to be physically active and to carry on with normal activities

as far as possible

Explain expected recovery

Discuss treatment options and develop plan in consultation with patient

Management

2. Medication

a. Regular paracetamol

b. Consider NSAID’s +/- weak opioids

Careful consideration to side effects

For NSAID’s offer PPI for over 45’s

Management

2. Medication

c. Tricyclic antidepressants

Start at low dosage and increase up to max antidepressant dosage until therapeutic effect or unwanted side effects occur.

Management

2. Medication

d. Strong opioids (eg buprenorphine, diamorphine, fentanyl, oxycodone and tramadol)

Consider offering for short term use in patients with severe pain.

Consider referring people requiring prolonged use for specialist assessment

Management

3. Other Treatments

a. Structured exercise programme

Supervised group exercise class (or 1:1 sessions) may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching.

8 sessions over 12 weeks

Management

3. Other Treatments

b. Manual Therapy

Consider referring for a course of manual therapy including spinal manipulation.

Up to 9 sessions over 12 weeks

Management

3. Other Treatments

c. Acupuncture

Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.

Slow to recover

If patients have not regained usual activities at 4 weeks they should be formally reassessed for both Red and Yellow Flags – and again at 6 weeks if progress is still delayed.

Slow to recover

Even if there are no Red Flags and neurological function is normal, you may need to consider full blood count, ESR and plain X-rays of the lumbar spine if pain is not resolving at six weeks.

Conclusion

Discussed diagnostic triage, covering examination as well as screening for red and yellow flags.

Discussed management of acute back pain in Primary care with reference to advice, medication, and other treatment options.

Questions?