Low Back Pain Essentials Dr Simon Somerville

The problem with back pain.. • Nationally: – LBP now number one cause of long-term disability – Very costly to patients, NHS, society

• However GPs say the following about back pain: – Clinically unimportant / sometimes challenging – Pie in the sky guidelines – Resource barriers (Sanders et al. BMC Medicine 2011, 9:49, Bishop et al Spine 2015 Dec;40(23):1842-50)

Aim of the presentation – Highlight best practice through a case study – Provide tips for your clinical examination – Highlight how the latest evidence can improve the effectiveness of your consultations and save you time in your practice

Case Study 50 year old construction worker Requests urgent appointment to see you Back has ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Case Study 50 year old construction worker Requests urgent appointment to see you Back had ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Diagnostic triage  Specific (10%) vs Non-specific (90%)  Specific examples – prolapsed intervertebral disc, inflammatory, cancer, fracture, medical, surgical, gynae causes  Serious diagnoses rare

GP guidelines for back pain  Categorise patients in 1 of 3 groups  a) ‘red flags’ - possible serious spinal pathology ( back pain usually Radiates below knee Numbness / paraesthesia same distribution Straight leg raise (SLR) induces more LEG pain Localised neurology (one nerve root) Check for upper limb symptoms

Case Study 50 year old construction worker Requests urgent appointment to see you Back had ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Clinical examination in less than 5 minutes • Inspection • Active spinal movement- flexion, extension, side flexion • Functional tests – Knee flexion – Walking on heels (L45) – Walking on toes (SI nerve root) – Straight leg raise if leg pain

Case Study 50 year old construction worker Requests urgent appointment to see you Back had ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Consider Stratified Care Approach

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Stratified Care Model High Psychologically informed physiotherapy Medium risk Course of physiotherapy

Low risk Complexity

Minimal treatment – advice, reassurance and pain relief

Reduced sickness certification £34 health cost

Reduced disability

£675 Societal

Reduced cost

Stratified Care

Improved clinical outcome

Reduced consultations

Improved physio referrals

Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst DGT, Doyle C, Konstantinou K, Main C, Somerville S, Sowden G, Wathall S, Young J, Hay EM, Team IBS. 2014. Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. ANNALS OF FAMILY MEDICINE, vol. 12(2), 102-111

Improved patient satisfaction

Reduced investigations

Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. 2011. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet, vol. 378(9802), 1560-1571

Reduced sickness certification £34 health cost

Reduced disability

£675 Societal

Reduced cost

Stratified Care

Improved clinical outcome

Reduced consultations

Improved physio referrals

Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst DGT, Doyle C, Konstantinou K, Main C, Somerville S, Sowden G, Wathall S, Young J, Hay EM, Team IBS. 2014. Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison. ANNALS OF FAMILY MEDICINE, vol. 12(2), 102-111

Improved patient satisfaction

Reduced investigations

Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. 2011. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet, vol. 378(9802), 1560-1571

“Real life” audit • Locality GP cluster - rural and market town population • 615 referrals in 12 months via GP contact and Physio direct triage service • Reduced Physiotherapy waiting times: Seen within target wait time: Before = 52%, After = 80% • Achieved high levels of patient satisfaction • Reduced referrals for second opinion (1% to Pain Service) • Trained physiotherapists able to provide tailored treatment. (With thanks to Hilary Bradbury, Professional Lead for Physiotherapy, Staffordshire and Stoke-on-Trent Partnership NHS Trust)

GP Feedback on Audit • • • • •

We get the idea but… Make it easier to the right thing IT that works in consultation Streamline referral process Integrated patient information

Low risk management • Low risk ( 0-3) – Manage within your practice – Good quality information – Reassure

EMIS protocol

Back pain – key messages      

Use functional not anatomical labels Find out and address concerns early on Activity not rest Facilitate self-help – early return to work Use written advice Prognosis good, relapse quite likely

Patient information

Medium/High risk management • Medium Risk/ High risk (4+) • Referral onto appropriately trained and supported Physiotherapy

Case Study 50 year old construction worker Requests urgent appointment to see you Back had ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Imaging issues  40-50% have radiological abnormalities on plain film x-ray but no LBP (Koes B., BMJ 2006)  Safety concerns – x-ray Lx spine = 35 Chest (Spratt J., Hands on, ARUK, 2013)

 Asymptomatic disc bulges MRI – 30% of 20 year olds to 84% of 80 year olds (Brinjikji W., Spine 2014)  Many people with LBP have radiology consistent with their age rather than pathology  Reassurance issues - controversial

Imaging in Primary Care  Avoid plain x-ray in non-specific LBP any duration  Suspected fracture – traumatic or osteoporotic, x-ray indicated (RCR)  Suspected serious pathology - refer to secondary care rather than order radiology  Unresolved sciatica /failed primary care management – use local care pathway  Early access to MRI doesn’t improve outcome (Gilbert, 2004)

Case Study 50 year old construction worker Requests urgent appointment to see you Back had ‘gone again’ and wants a diagnosis He wants to be examined properly Frustrated by his problem and wants you to ‘sort it out’ • Wants an X-ray of his back • Wants some strong analgesia • • • • •

Opiates – international problem • • • • •

Review diagnosis – bio psycho social aspects Avoid chronic usage if at all possible But if not… Regular review, agree plan with patient Consider opinion from pain specialist

What tools are available to help you?

Summary • Stratified care promising - patient benefits and cost-effectiveness • Red flags – trust your clinical instincts • Avoid investigation and referral if possible • Care with opiate prescribing • Link advice to patient ICE

Thank you for listening –any questions? Dr Simon Somerville

[email protected]

STarT Back website

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