Back to Backs Trent Occupational Medicine Symposium Philip Sell UHL and NUH 6 th October 2011

Population based intervention to change back pain beliefs and disability:three part evaluation Rachelle Buchbinder et al BMJ no June 2001

Time course of back pain  LBP is a recurrent phenomenon at all ages  Untidy pattern across the life course with variable periodicity and severity.  Coexisting symptoms (physical and mental) common  Are chronic cases such from beginning or are they result of failed early treatment?? Adams et al 2006 Episode Lifetime

Epidemiology in low back pain  Symptom not a disease cause unexplained in 85%cause unexplained in 85% data are self-reported - questionnaires: data are self-reported - questionnaires: tell us about how people experience LBPtell us about how people experience LBP different questions give different numbersdifferent questions give different numbers  Consequences more of a problem than symptoms care seeking care seeking sick leave sick leave disability disability  Low back pain is a common complaint among adolescents. similar pattern to adults similar pattern to adults

Health problem does NOT equal a medical problem Reasons for care seeking are complex Reasons for care seeking are complex Person not always seeking a fix Person not always seeking a fix Reassurance may be enough Reassurance may be enough 'My back hurts, but the reason I'm here is that I can't cope on my own any longer' (Hadler 1999)'My back hurts, but the reason I'm here is that I can't cope on my own any longer' (Hadler 1999)

Genetics / Individual  Twins studies, controlling for environmental (occupational) factors: 70% of disc degeneration associated with genetic factors 70% of disc degeneration associated with genetic factors Heritability of back pain possibly >50% Heritability of back pain possibly >50%  Muscle strength and level of fitness have little influence

The overall perspective  Societal burden equal to depression, heart diseases or diabetes  Production loss (due to absenteeism and disability) far greatest impact

Back Pain Epidemiology Key Messages LBP- Data demonstrate substantial nonbiologic influences LBP- Data demonstrate substantial nonbiologic influences  Heritability of back pain possibly higher than 50% 70% of disc degeneration associated with genetic factors 70% of disc degeneration associated with genetic factors Production loss (due to absenteeism and disability) has the greatest impact on the ecmonic burden of back pain Production loss (due to absenteeism and disability) has the greatest impact on the ecmonic burden of back pain An early investment in correct evidence based care can generate long term cost saving. An early investment in correct evidence based care can generate long term cost saving.

A RCT of a novel Educational booklet in Primary Care Spine Vol 24 Number 23 Dec 1999  reduced re-attends  clinically important improvement in disability  Improved beliefs

Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain : EM Haland Haldorsen et al.

Cascade of care  Simple to complex  Bothersomeness and function  Effective therapies  NICE CG 88 Non specific low back pain  Evidence based  FUNCTIONAL RESTORATION PROGRAMS

UK occupational health guidelines  Individual psychosocial findings are a risk factor for the incidence (onset) of LBP, but overall the size of the effect is small.  Unsatisfactory psychosocial aspects of work are risk factors for reported LBP, health care use, and work loss, but the effect size is modest.  Individual and psychosocial aspects of work play an important role in persisting symptoms and disability, and also influence response to treatment. Carter & Birrell 2000:

Work caused or work-relevant? Whilst some (episodes of) low back pain may be caused by work, most are not. Whilst some (episodes of) low back pain may be caused by work, most are not. Yet, symptoms may affect workability Yet, symptoms may affect workability work can be difficult/painful because of symptoms work can be difficult/painful because of symptoms consequences are driven more by psychosocial than physical factors.consequences are driven more by psychosocial than physical factors. LBP may be highly work-relevant, irrespective of cause. LBP may be highly work-relevant, irrespective of cause.

Acute Low Back Pain  Simple Back ache  Nerve root pain  Possible serious spine pathology  Cauda equina syndrome

Flags  Red Physical risk factors Serious Spine Disorders  Yellow The person Psychosocial obstacles  BlueWork Workplace  BlackAdministrative obstacles Context

Red Flags  Age above 55 and new onset back pain  Widespread neurology  Progressive and unremitting pain  Previous history of cancer  Weight loss  Deformity  Failure to improve

Red Flags Cancer Sensitivity Specificity Sensitivity Specificity Age >= Previous cancer31 98 Unexplained weight loss15 94 Failure to improve 1/ No relief in bed>90 46

Tackling Musculoskeletal Problems a guide for clinic and workplace identifying obstacles using the psychosocial flags framework Kendall, Burton, Main, & Watson: TSO Books, PERSON WORKPLACE CONTEXT

YELLOW FLAGS  ATTITUDES AND BELIEFS  EMOTIONS  DIAGNOSIS AND TREATMENT  FEAR AND BELIEFS  WORK  FAMILY AND CARERS  COMPENSATION ISSUES

Catastrophising Evaluation  Identify interpretations of symptoms bodily sensations or persons situation that are out of proportion  This leads the patient to a sense of unease  A lack of feeling of control Questions to ask  When you are in pain do you think it is terrible and will never get better?  Does pain feel overwhelming to you?

MIXED MESSAGES MIXED MESSAGES  Cconflicting diagnosis or explanations for back pain  Dramatisation of back pain by health professionals

Work  Belief that work is harmful or will do damage  Work history job dissatisfaction, frequent changes

Behaviors  Use of extended rest  Withdrawal from activities of daily living  Poor compliance with exercise  High intensity pain (VAS 10)

Action  Positive expectation  Review progress  Keep the individual active and at work  Communicate that time off work reduces probability of successful return to work

Action  Acknowledge difficulties  Encourage ‘well behaviors’  If complex obstacles to management refer to multidisciplinary team

All players onside  shared beliefs  shared goal  flexible approach  coordinating their actions……

Functional Restoration Programs

SPINE Volume 36, Number 21S, pp S1– S9 October 2011 Chronic Low Back Pain A Heterogeneous Condition With Challenges for an Evidence- Based Approach

Degenerative MRI Changes in Patients With CLBP  There is insufficient evidence to support the routine use of MRI Strength of recommendation: Strong Strength of recommendation: Strong  Surgical treatment of CLBP based exclusively on MRI findings of degenerative changes is not recommended. Strength of recommendation: Strong Strength of recommendation: Strong

Key Points  Current low back pain management is fragmented into five major management spheres, which have little or no interactions with one another.  Chronic LBP is a heterogeneous condition and this affects the way it is diagnosed, classified, treated,and studied.  While nonoperative approaches are the mainstay of management of LBP, surgery offers improved outcomes in carefully selected patients.  There is an urgent need for large national registries to track the natural history and outcomes of treatments for chronic LBP.