1. Caring, Learning and Growing
Low back pain
PTL
2nd May 2019
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2. Caring, Learning and Growing
STarT back
Endorsed by NICE and the NHS England low Back and Radicular Pain Pathways (2017).
Right treatment for the right patient at the right time.
Stratification tool = Risk = High, Medium and Low
9 simple questions.
Traditionally HCP’s over treat those with Low Back Pain who fall into the Low Risk Category
Approach adopted by 34 clinical partners in the UK a mix of Primary and Secondary care.
Based on research published in the Lancet 2011 = RCT carried out in 10 GP Practices, after an initial Pilot Study.
Conversely we have been mistreating those who have Yellow Flags and a long, persistent history. With these people research has proven they have a better outcome with a CBT approach combined with graded increase in activity. This runs a risk of continual repeat consultations of this group as sysmptoms worsen or flare.
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How do we treat them?
Approach consists of an initial consult where people are given usual care of analgesia, advice and reassurance if all Red Flags and CES screened out.
If no better in 2/52 return and STarT Back done at this appointment.
Low Risk will result in same exam then message and D/C. Again reassurance in this category goes a long way.
Medium Risk = Std NICE Guidelines Rx of usual care + Physio
High Risk would be referral onwards to more ACT / CBT combined with an active approach CCG dependent.
ACT / CBT based around Values based goals for the pt = what would help their LT emotional welfare if they could do / do more of / work towards (pain is put aside). About building coping and resilience long term.
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To summarise
Low – exercise/advise/self mx
Medium – self mx/education/deal with psychosocial issues/HEP, 1:1 or class pain mx, back to fitness
High – Psychological barriers. pain mx with local physiotherapist, education, pacing, relaxation, baseline setting, self mx. Local classes – fitness, relaxation, local pain mx.
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CES/neuro deficit
All clinicians involved with the management of sciatica should be aware of these potential neurological emergencies and know when to refer to an appropriate specialist” ( NG )
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Avoid Medical Jargon / Threatening terms = OA (seen by the layman as a chronic, degenerate condition with no hope), Wear and Tear, Degenerate, Slipped Disc, Trapped Nerve.
Think less threatening = Grey Hair, Natural Ageing, Some Inflammation, Irritated Nerve or Disc.
Grumbles vs Roars – as we get moving it may be a little sore such as when recovering from a sprained Ankle, this should eventually become easier and a grumble that settles is okay a roar isn’t.
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8. Caring, Learning and Growing
The power of language
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9. Caring, Learning and Growing
Key with STarT Back is a consistent message by all clinicians in the chain
80% of us will suffer with LBP +/- Sciatica sometime in our lives and in many it will just come and go = Common Cold / Flu analogy. We don’t worry we just cope, why should this be different with LBP or any MsK pain.
Most acute episodes will spontaneously resolve as long as people manage them correctly. The same can be said for Sciatica.
Pain does not necessarily mean major damage or harm. More it is the bodies way of helping us to protect +/- take action. Paper cut analogy.
Reassure / reassuring Assessments = if there are no Red Flags, CES or Hard Neuro findings then this is good and with the right analgesia, active, optimistic approach most people tend to improve.
Passive treatments and coping do not give a LT good outcome.
Backs are strong and robust and made to move the ways they do.
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10. Caring, Learning and Growing
Do we need to scan
Scan or X ray only if clinically indicated. ‘Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations’ W. Brinjikji et al Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals
‘Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient’s clinical condition.’
Think will it change surgival management?
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conclusion
80% of us will suffer with LBP +/- Sciatica sometime in our lives and in many it will just come and go = Common Cold / Flu analogy. We don’t worry we just cope, why should this be different with LBP or any MsK pain.
Reassure / reassuring Assessments = if there are no Red Flags, CES or Hard Neuro findings then this is good and with the right analgesia, active, optimistic approach most people tend to improve.
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12. Implementing the service in Humber
Physiotherapy team aim to provide up to date approaches, including spinal rehabilitation class, and Cognitive Behavioural Therapy approaches.
Any thoughts??
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