10 minutes for “I’ve got a bad back” Kizzy, Vasu, Amer, Ramesh, Audrey, Ewan and Gill

Why it is important LBP is not a homogenous condition LBP is very common in working-age adults ( between the ages of 40 and 60 years ) Treating all types of back pain costs the NHS more than £1000 million per year In 1998 the direct healthcare costs of all back pain estimated at £1623 million -approximately 35% were related to private sector The costs of care for LBP exceed £500 million/year Lost production as a result of LBP costs at least £3500 million/year.

LBP results in impaired quality of life long-term morbidity a higher risk of social exclusion reduced income reliance on sickness benefits Aims of interventions and therapies manage disability and pain, to help people to cope with day-to-day life, to reduce distress, to enable people to remain in or return to work, to minimise risk of recurrence.

History Circumstances of pain Nature/severity of pain Associated symptoms PMH Exclude other sites of pain

Red Flags - age 55, – non mechanical pain, – worse when supine, – night time pain, – thoracic pain, – past hx of carcinoma, HIV, immunosuppression, IVDU, taking steroids, unwell, weight loss, – widespread neurology, structural deformity, saddle anaesthesia, incontinence bowel or bladder or retention of urine

Examination Deformity Palpate Movements Lower limbs (power, tone, sensation, reflexes, SLR)

NICE guideline May 2009 Management of Low Back Pain Principles of management Keep diagnosis under review at all times Promote self-management: advise people with low back pain to exercise, be physically active and to carry on with normal activities as far as possible Offer drug treatments as appropriate to manage pain and to help people keep active Offer one of the following treatments, taking patient preference into account: – exercise programme – course of manual therapy – course of acupuncture

Advice and education Provide advice and information to promote self- management Offer educational advice that: – includes information on the nature of non-specific low back pain – encourages normal activities as far as possible Advise people to stay physically active and to exercise Include an educational component When considering recommended treatments, take into account the person’s expectations and preferences

Drug treatments Option 1: Paracetamol: – Advise regular paracetamol as the first option Option 2: NSAIDS and / or weak opioids – Decision based on individual risk of side effects and patient preference – Give due consideration to risk of opioid dependence and side effects Option 3: Tricyclic antidepressants – Consider offering if other medications are insufficient, starting at a low dose and increase up to the maximum antidepressant dosage until Therapeutic effect is achieved Unacceptable side effects prevent further increases Option 4: Strong opioids (buprenorphine, fentanyl, oxycodone, high dose tramadol) – Consider offering for short-term use to people in severe pain – Consider referral if requires prolonged use – Consider risk of opioid dependence and side effects Co-prescribe a PPI for people over 45 For all medications, base decisions on continuation on individual response

Non-drug treatments Structured exercise programme: – up to 8 sessions over up to 12 weeks – supervised group exercise programme in a group of up to 10 people, tailored to the person – one-to-one supervised exercise programme only if a group programme is not suitable Manual therapy: – course of manual therapy, including spinal manipulation – up to 9 sessions over up to 12 weeks Acupuncture: – course of acupuncture needling – up to 10 sessions over up to 12 weeks

Imaging Do not offer X-ray of the lumbar spine Only offer MRI for non-specific low back pain in the context of a referral for an opinion Consider MRI if one of these diagnoses is suspected: – spinal malignancy – cauda equina syndrome – Infection – Ankylosing spondylitis – Fracture – inflammatory disorder

Do Not offer…. SSRIs for treating pain Injections of therapeutic substances into the back Laser therapy Interferential therapy Therapeutic ultrasound TENS Lumbar supports Traction

AKT

Question 5 An 18 yr old fast bowler presents with sudden onset of pain while extending his hip, and he walks with scoliosis. A) scheurmanns disease B) Spondylolisthesis C) Acute disc prolapse D) TB of spine

Question 6 Following total hip replacement performed via posterior approach, the patient was noted to have a foot drop A) Nuerapraxia of common peroneal nerve B) Neurapraxia of Sciatic nerve C) Neurapraxia of Calcaneal nerve D) Neuropraxia of Femoral Nerve

Question 7 7. Which of the following are ‘red flags’ for possible serious spinal pathology? a)Age over 55 b)Anorexia c) Systemic steroid therapy d) Difficulty with micturition e) Cough-impulse pain

Question 8 8. How much radiation is involved in a plain lumbar spine X-ray compared to a chest X- ray? a) Equal amounts b) Lumbar spine = 2 x Chest X-Ray c) Lumbar spine = 20 x Chest X-Ray d) Lumbar spine = 150 x Chest X-Ray

Question 9 9. What proportion of the population will develop low back pain at some time their lives? a) 20% b) 50% c) 70% d) 90%

Question Low back pain is generally understood to become ‘chronic’ after a period of how long? a)6 weeks b)8 weeks c)10 weeks d)12 weeks e)14 weeks

Answers 1: B 2: A 3: S1,L4,L5 4: D 5: C 6: B 7: A,C,D 8: D 9: C 10 : D

CSA scenario Vasu has prepared a case for the day and will act as the patient.

Thankyou Any questions ?