1. This Back in Focus resource was developed and funded by AbbVie.. Date of preparation: June 2015; AXHUR150807p The Impact of Back Pain

2. Who gets back pain? How many patients consult you each day for back pain? How many patients keep coming back to see you because of back pain? How does back pain affect the people you treat? When is back pain ‘just back pain’? –When could it mean something more? A few thoughts…

3. 60-80% of adults report lower back pain at some point in their life 1 Approximately 6–9% of UK adults consult their GP about lower back pain each year 2,3 Back pain: burden of disease 1. Waddel et al. Occup Med. 2001; 51:124–135. 2. Dunn and Croft. Spine, 2005; 16:1887–1892. 3. Cremin and Finn. Ir Med J 2002; 95141–95142.

4. Prevalence of inflammatory back pain 1. Hamilton et al. Clin Exp Rheumatol 2012; 30;4 p621. Results presented from a UK study in 2012 on prevalence of inflammatory back pain in a UK primary care population Questionnaire issued to patients who had consulted on at least one occasion with low back pain (total population=978, total respondents=505)

5. The economic burden of back pain 1. de Souza and Frank, Disability and rehabilitation 2011;33:310–318. 2. Maniadakis and Gray. Pain 2000; 84:95–103. 3. van Tulder et al. Eur Spine J 2006; 15 (Suppl. 2):S169–S191. £0£2,000£4,000£6,000£8,000£10,000£12,000£14,000 Back pain Coronary heart disease Rheumatoid arthritis Lower respiratory tract infections Alzheimer's disease Stroke Diabetes Arthritis Multiple sclerosis Deep vein thrombosis & pulmonary embolism Depression Insulin dependent diabetes Critical limb ischaemia Epilepsy Benign prostatic hyperplasia Multiple sclerosis Migraine Indirect costsDirect costs Cost in 1998 ~ £1632 million 75-85% workers’ absenteeism

6. Over half of chronic back pain patients may suffer with insomnia 1 Back pain also has psychosocial effects –Emotional stresses –Relationship breakdowns –Severe emotional distress to partners –Limitations in fulfilling their family role 2 The impact of back on patients’ lives 1. Tang et al. J Sleep Res. 2007;16:85–95. 2. de Souza and Frank. Disability and rehabilitation 2011;33:310–318.

7. Chronic back pain is defined as pain which occurs for >3 months 1 Identifying back pain as acute or chronic is one of the key processes in determining the source of the pain: –Acute back pain Usually mechanical, often acute in onset, arising from structural changes that may be in the spinal joints, vertebrae or soft tissues –Chronic back pain Can be either mechanical or inflammatory, resulting in chronic back pain lasting >3 months 1 Back pain: acute vs. chronic 1. Sieper et al. Ann Rheum Dis 2009; 68:784–788. It is important to distinguish inflammatory from mechanical back pain as early as possible as the underlying causes are usually different as is subsequent management and treatment

8. Comparison of inflammatory and mechanical back pain 1. Sieper, J et al. Ann Rheum Dis 2009; 68:784-788 2.Chien, JJ and Bajwa, ZH. Current pain and headache reports 2008; 12:406-411 IBP Age at onset <40 years Insidious onset; less likely to be acute Pain improves with exercise Pain does not improve with rest Pain at night that may wake patient during second half of the night Morning stiffness >30 minutes MBP Age at onset; any age Variable onset; may be acute Pain may worsen with movement Pain often improves with rest

9. How long has the patient had back pain? 1 How old was the patient when the back pain started? 1 Is there a family history of AS? 2 Does the pain improve with the use of NSAIDs? 1,3 Has the patient experienced any leg pain, numbness or tingling? Does the patient have a history of other musculoskeletal problems? 4 Has the patient experienced anterior uveitis (iritis), psoriasis, IBD or peripheral arthritis? 3 What is the usual pattern over a 24 hour period? 1 Has the patient experienced alternating buttock pain? 1,5 Important questions to ask a patient with chronic back pain 1. Sieper et al. Ann Rheum Dis. 2009; 68:784–788. 2. Evnouchidou, J Immunol, 2011; 186:1909–13. 3. Braun et al. Ann Rheum Dis, 2011; 70:896–904. 4. Mander, M et al. Ann Rheum Dis 1987; 46:197–202. 5. Rudwaleit et al. Arthritis Rheum 2006; 54:569–578

10. 1 1 1 1 ASAS criteria for identifying inflammatory back pain Adapted from Sieper et al. Ann Rheum Dis. 2009; 68:784–788. Inflammatory back pain requiring further investigation is usually indicated if the answer is ‘yes’ to 4 or more of these parameters

11. Non-radiographic disease (X-ray –ve) Radiographic disease X-ray +ve sacroiliitis Radiographic disease X-ray +ve sacroiliitis and/or spinal changes Time (years) Estimated proportion of affected individuals Axial SpA (ASAS criteria) Ankylosing Spondylitis (mNYC) MRI -ve MRI +ve sacroiliitis Patients with chronic back pain ≥3 months and aged <45 years Axial SpA spectrum of disease Isdale A, et al. Rheumatology (Oxford). 2013 Dec;52(12):2103-5. The figure depicts the spectrum of disease in patients with axSpA. The severity of disease progresses with time in a proportion of patients and the sizes of the boxes are estimates of the proportion of patients in each tertile. The first tertile represents early non-radiographic disease, the second and third tertiles represent radiographic disease (AS) with the most severe end of the spectrum including spinal involvement (syndesmophyte formation, fusion or posterior element involvement).

13. Interval between symptom onset and first consultation with GP in patients with AS Adapted from Hamilton L. et al. Rheumatology 2011;50:1991–1998. MonthsYears Time + Although ~60% of patients consult their GP within 1 year of symptom onset, ~40% wait between 1 and 10+ years

14. Interval between symptom onset and diagnosis of AS <11-33-66-121-33-55-77-1010 + MonthsYears Time Nearly 40% of patients experience a delay over >5 years between symptom onset and diagnosis of AS Over 20% experience a delay of 10+ years Mean delay is 8.57 years Adapted from Hamilton L, et al. Rheumatology 2011;50:1991–1998

15. Red flag symptoms of more serious conditions 1–3 Source of back painHistoryObservation/examination Abdominal aortic aneurysm Sudden onset of intermittent/ continuous abdominal pain radiating to the back History of cardiovascular disease Previous collapse Pulsating abdominal mass Low or high blood pressure Tachycardia (rapid heart beat) TumoursAge ≥50 years History of cancer Back pain at night and at rest; may have neurological deficits (if tumour destruction is extensive and causes neurological compression) Neurological deficits Swollen lymph nodes Systemic symptoms, including fever/chills and malaise Unexplained weight loss Renal diseaseRecent UTI History of kidney stones History of polycystic kidney Associated with history of frequent kidney infections UTI: back tenderness, fever/chills, urinary urgency/burning Kidney stones: nausea/vomiting, pain radiating to the groin, blood in the urine, possible fever Polycystic kidney: back and abdominal tenderness, blood in the urine, increased abdomen size 1. Adapted from BMJ Best Practice. Assessment of back pain. Accessed June 2015. Last updated September 2014. 2. Bangle SD et al. Cleveland Clinic Journal of Medicine. 2009;76:393–399. 3. Differentiating back pain from kidney pain. Available at http://www.integrative- healthcare.org/mt/archives/2006/02/differentiating.html. Accessed June 2015. Last updated February 2006.

16. Red flag symptoms of more serious conditions (cont.) 1,2 Source of back painHistoryObservation/examination Gastrointestinal diseaseHistory of peptic ulcers Epigastric, burning pain radiating to the back Pain associated with meal times Vomiting blood or blood in the stool (advanced disease) Epigastric tenderness InfectionFever/chills Recent UTI, spinal surgery, epidural anaesthesia or skin infection Immunosuppression Injection drug use Diabetes Weight loss Fever (temperature >38°C/100F) Back tenderness Neurological findings absent 1. Adapted from BMJ Best Practice. Assessment of back pain. Available at http://bestpractice.bmj.com/bestpractice/ monograph/189/diagnosis/differentialdiagnosis.html. Accessed June 2015. Last updated September 2014 Accessed 15.01.2013. Last updated April 2012. 2. Bangle SD et al. Cleveland Clinic Journal of Medicine. 2009;76:393–399. If a patient has red flag symptoms consider urgent referral to Oncology/ Gastroenterology/ Urology/ A&E as appropriate

17. Examination findings in patients with mechanical back pain Positive straight leg raise test Specific tenderness around the lumbar spine Absent reflexes Observe for scoliosis Restricted range of movement Neurological examination For more information refer to ‘Principles of examination’ in The Oxford Textbook of Rheumatology

18. Physical examination is often unremarkable in patients with inflammatory back pain Examination findings in patients with inflammatory back pain Look for other inflammatory conditions such as psoriasis, uveitis, peripheral arthritis, enthesitis Neurological examination is essential Tenderness over enthesitis sites Observed postural changes Reduction in the range of movement in the lumbar spine Loss of hip abduction Pain or tenderness over the sacroiliac joint, lumbar spine and/or thoracic spine

19. Inflammatory back pain Who to refer to Mechanical back pain Based on Braun, J et al. Ann Rheum Dis 2011; 70:896–904. If IBP is suspected refer to rheumatology If MBP is suspected refer to local musculoskeletal interface service If MBP is suspected refer to local musculoskeletal interface service

20. Back pain is a common reason for primary care consultations It is important to be able to distinguish between back pain of mechanical and inflammatory origin as the referral pathways and treatments differ ‘Red flags’ should be investigated immediately Summary