1. Back Pain and the Evidence Dr Sue Greenhalgh, Consultant Physiotherapist

2.  Nothing certain but death, taxes  …and back pain  80% of people will suffer from acute back pain at some point in their lives

3.  The symptom of back pain is no different and no more frequent or severe than it has ever been. However, the rate of disability due to back pain continues to rise  Once begun there is an 85% chance of recurrent episodes  700 double decker bus loads in Bolton Incidence of Back Pain

4.  Serious Pathology<1%  Nerve Root Entrapment <5%  Simple Mechanical 95% Diagnostic Triage Serious pathology <1% Nerve Root Entrapment <5% Simple Mechanical 95%

5. SMLBP Causes (pathogenesis)  Degeneration of the intervertebral disc  Mechanical loading  Age  Biochemical influences  smoking

6.  Genetics (90-100% degeneration in people aged more than 63 years)  Ethnicity  Infection (HSV-1, CMV)

7. PAIN GENERATORS  Annulus fibrosus (outer third)  Periosteum  Neural membranes  Ligaments/Facet joint capsule  Muscles

8. Features of Back Pain  If present for greater than one year few people return to long term activity

9.  8% of those with recurrent back pain will become chronically disabled due to back pain  These patients take up 90% of resources Recurrent Back Pain

10.  Before the 19th century few people became chronically disabled by back pain  Now back pain is the second most common cause of long-term sickness in the UK after stress  About 7.6 million working days were lost due to work- related back pain and other musculoskeletal disorders from 2010 to 2011. Morbidity of Back Pain

11.  Pain is a combination of biological, psychological and social factors (even from day one)  Biopsychosocial framework; Identify those at risk of a poor outcome ABCDEFW Pain; A Perceptual Process

12. Is The Amount Of Pain Proportional To The Extent Of Tissue Damage?

13. Attitudes and beliefs Behaviour Compensation/benefits Diagnosis Emotion Family Work                                              Biopsychosocial Approach; Yellow flags Psychological or behavioural factors

14.  Strong evidence that bed rest should be as brief as possible, and generally not recommended  Longer than 2/7 bed rest prolongs recovery in SMLBP  If radicular pain-no longer than 1/52 Evidence

15.  Advise to return to normal ASAP  Reassure- ‘Hurt does not mean harm’  Absence from work should not be encouraged  Work does not have to be pain free  Normal activity as far as feasible in acute sciatica Evidence

16.  Physical Activity and Exercise-Staying active ASAP  Avoid bed rest  Maintain or return to work  Patient centred; Advice and information to promote self-management e.g. pain relieving medication and modalities Low Back Pain Early Management

17.  Recurrences are common-correct long term management is essential  Use of long term opioid medication use is growing  Use of emergency services is increasing-those attending hospital are in a distressed category (STarT Back approach) Early Advice and Evidence Based Management Key

18.  Restoring normal movement and function  No evidence for particular exercise  Self management-lifestyle change Exercise Therapy

19.  Manipulation works short-term  Treatment benefits confined to back pain only and pain of short duration Mobilisation /Manipulation

20.  Reassurance  Address fears ASAP; Kinesophobia,‘Is something really wrong?’  Simple OTC analgesia; Paracetamol  Heat/Ice  TNS  Sleep hygiene Pain Relieving Advice

21.  Drugs: Do not roller coaster  More than staying active: Paced walking,  Relaxation: Reassurance, Resting positions Acute phase

22.  Modify lifestyle: 85% chance of recurrence, ongoing fitness regime eg gym (paced cv exercise without pounding), swimming  Hurt does not always mean harm: Blue and white back book, back and neck cards  Work: stay or return asap (modify activities if necessary) Sub-acute

23.  40yr old fire-fighter  6year history of episodes of LBP  RBH X 2 by ambulance  LBP, right buttock pain, intermittent P&N R leg  Movement decreases P&N Case Study

24.  Subjective history; symptom history, concerns, expectations, previous treatments, health seeking behaviour-Sedated due to medication  Objective examination-Suspected Annular tear L5/S1 ? L5/s1  Medication Management  Self management advice and reassurance  MRI as 5 episodes of incontinence during night as falling asleep-No other S or S of CES First Consultation

25.  Better-back pain spreading across but only occasional shooting pains into buttocks-Anxious about current situation  Medication adjusted-reduce Oromorph!  Increased activity-walking programme  Discussed resting positions-give patient control  Discussed progressing to long term management  REASSURED Second consultation

26.  MRI Confirmed annular tear L5/S1  Patient continuing to improve  Medication adjusted again, rehab increased, discussed return to work  Mood beginning to drop  Discussed self management when another episode of pain occurs  REASSURED 3 rd Consultation

27.  Returned to work on adapted duties at 6/52-still had LBP  Reassured how to self manage LBP in future  Explored knowledge of LBP and health seeking behaviour-advice given  Discharged Long Term Management

28.  Back Book  Arthritis Research UK advice sheets/booklets  DVD developed btn Keele University and AXAPPP  http://www.youtube.com/watch?feature=player_emb edded&v=ZumxS6DX-50 Patient Advice

29. Thank You Sue Greenhalgh Consultant Physiotherapist NHS Bolton POD CAST http://www.knowledge.scot.nhs.uk/msk/education al-resources/red-flags-for-back-pain.aspx