1. Are you getting the best treatment for your low back pain? Paula Salmon and Carol Doyle Community Business Unit Physiotherapy Service East Cheshire NHS Trust Health Matters Tuesday 4 th February 2014

2. Who are we? Paula Salmon Extended Scope Practitioner Lead for Physiotherapy Back Pain Service Carol Doyle Clinical Physiotherapist at GP Surgery Physiotherapy Research Facilitator Community Adult Physiotherapy Services East Cheshire NHS Trust

3. Why are we here? To present to you the latest thinking on low back pain To update you on the best evidence for the treatments available To share with you what our physiotherapy service can offer To give you a better understanding on how to help yourself

4. Have you had low back pain? 1.How many of you have ever had back pain? 2.How many of you seek help for your back pain? 3.How many of you have ever had physiotherapy for your back pain? ‘George’s story’

5. What is back pain? Back pain is common 8 out of 10 people will suffer back pain at some time Majority of people have nothing seriously wrong Costs to NHS and Society huge - £10668 million!* *Maniadakis et al. The economic burden of back pain in the UK. 2000

6. How is the back structured? 24 spinal vertebrae 5 lumbar vertebrae Joints Discs Nerves Muscles Strong Natural ageing & stiffness Facet joint Nerve roots from spinal cord to leg Vertebra Disc Cervical spine Thoracic spine Lumbar spine Sacroiliac joint Coccyx

7. What causes back pain? Most cases, cause is unclear  poor posture  lack of exercise  muscle strains and sprains Some conditions have specific causes  Spondylosis – ‘wear and tear’  Sciatica – ‘leg pain’  Stenosis – ‘nerve tightness’

8. Should I see my doctor about my back pain? Immediately If you have problems passing or controlling urine Lose control of bowels Lose sensation around your genitalia or back passage Weakness in your legs/ become unsteady on your feet If your pain Is very severe or persists for a long time Affects your everyday activities

9. How can I help myself? Painkillers can keep you moving Regular exercise e.g. swimming, walking, pilates, yoga, going to gym Check posture frequently Lift things correctly Watch your weight Stay at work if possible Keep positive!

10. Why do back problems become chronic? Not always a reason Common to start avoiding normal movement and activities…….. Not exercising / muscles weaker……… Lose confidence………. Affect work, social and personal relationships…….. Get anxious / depressed…….. Vicious cycle!

11. What is the outlook for back pain? 75 – 90% recover within in a few weeks Relapses are common For those with persistent pain, only a 1/3 fully recover Most lead normal life and able to work Emotional response to back pain important to recovery e.g. worried, depressed

12. How are back problems diagnosed? A thorough assessment should be able to provide a diagnosis. Xray – do I need one? Only a few people with back pain require further investigations: – Magnetic resonance imaging (MRI) – Computerised tomography scan (CT) – Blood tests

13. What treatments are there for back pain? NICE guideline (National Institute for Health and Care Excellence)* specific exercise manual therapy Acupuncture Combined psychological and physical therapy Surgery or injections may be considered *CG88 Low Back Pain: NICE Guideline 2009

14. Myths for treatments! X Bed rest X Lumbar supports X Electrical treatments e.g. Laser therapy, interferential, therapeutic ultrasound X Traction X TENS machines – limited use in low back pain

15. What if my back pain is affecting my work? Work is good for you! – financial and social Stay at work or get back as soon as possible Keep in touch with your employer Discuss what can be done to help you when you return e.g. light duties, changing hours Occupational advisor may help e.g. adjustments to your workplace

16. What exercises can I do? Stretching Strengthening e.g pilates Hurt does not always mean harm! Remember to gradually build up GP’s can give you sheets of exercises Physiotherapists provide individualised exercises which can be supervised and progressed

17. Research and new developments for back pain NEW model in GP practices* –Grouping patients for treatment according to risk factors for persisting back problems –Targeted treatments for different risk groups given by physiotherapists –Clinically and cost effective! What are these risk factors? *Hill et al. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial Lancet 2011

18. Pain on coughing Pain radiating to the leg or sciatica Pain worse on standing Pain worse when lying Physical activity Restricted spinal movements at presentation Self-rated health / Well-being Smoking Somatization Straight-leg raising tests of less than 60° in either leg Unemployment Work absence Workers compensation status Risk Factors (persisting problem) Anxiety / distress / Stress BMI / Obesity Bothersomeness Catastrophising beliefs / Perceived risk of not recovering Coping catastrophising score Coping strategies / styles Days in pain Depression Disability Dissatisfaction with care Duration Duration of sick leave Educational status Expectations of treatment Family history of low back pain or chronic pain Fear avoidance behaviour / beliefs Fear-avoidance work beliefs Female gender Frequent consultation Gradual onset of pain Height (lower) History of low back pain Job dissatisfaction (lack of stimulating work tasks) Manual labour Number of localisations Older age Pain elsewhere Pain intensity

19. Pain on coughing Pain radiating to the leg or sciatica Pain worse on standing Pain worse when lying Physical activity Restricted spinal movements at presentation Self-rated health / Well-being Smoking Somatization Straight-leg raising tests of less than 60° in either leg Unemployment Work absence Workers compensation status Which risk factors? Anxiety / distress / Stress BMI / Obesity Bothersomeness Catastrophising beliefs / Perceived risk of not recovering Coping catastrophising score Coping strategies / styles Days in pain Depression Disability Dissatisfaction with care Duration Duration of sick leave Educational status Expectations of treatment Family history of low back pain or chronic pain Fear avoidance behaviour / beliefs Fear-avoidance work beliefs Female gender Frequent consultation Gradual onset of pain Height (lower) History of low back pain Job dissatisfaction (lack of stimulating work tasks) Manual labour Number of localisations Older age Pain elsewhere Pain intensity

20. Referred leg pain Pain elsewhere Disability Fear avoidance Anxiety Catastrophising Depression Overall impact Items included: The STarT Back Screening Tool

21. Screening for risk factors Brief tool Takes 2 minutes to complete Places patients into low, medium or high risk groups Designed to help clinicians target your treatment

22. Grouping patients At first contact with a GP 55% of patients are at low risk of persisting problems 33% of patients are at medium risk of persisting problems 12% of patients are at high risk of persisting problems

23. NEW model (STarT Back) Screening for Risk Factors into Groups Matched pathways For Targeted Treatment +

24. Low risk 55% Medium risk 33% High 12% Course of physical therapy by physiotherapists Skilled physiotherapists to address emotional factors Matched pathways Risk Minimal treatment of advice & medication GPs and Physiotherapists

25. Targeted treatment 1. Low risk group – Minimal treatment 2. Medium risk - physiotherapy 3. High risk - Enhanced physiotherapy Assessment Discuss any worries or concerns Encourage stay fit and active Use of medication Flare up management As low risk group + Tailored individual programme of physical treatment Promote self management Minimise disability As medium risk group + A combination of physical treatments and treatments to address the emotional responses to back pain

26. Are we working to best practice? NICE guidelines (National Institute for Health and Care Excellence)  Audit 2010 and 2013 – 100% success! New Model (STarT Back)  Audit 2013 – 100% success!

27. ‘The Truth About Back Pain’ www.youtube.com/watch?v=qh7j1xXriVM

28. George’s story Special exercises Help get back moving Help deal with emotions Self management Regular pain relief Keep moving Stretching exercises Keep fit and active Which treatments are the best How to stop my back pain getting worse Nothing serious Bed rest is not good Staying at work is good Keeping positive helps Latest thinking on back pain Best evidence for treatments What can physio offer? How to help yourself?

29. Acknowledgements

30. Questions ? www.arthritisresearchuk.org/arthritis-information/conditions/back-pain.aspx