1. Back Pain Chris Boyles, Physiotherapy Extended Scope Practitioner A&E
June 2014

2. Around 30 million adults in the UK will experience back pain this year.
Around 10 million of them will experience pain and disability lasting more than 12 months and 6 million of them will be off work for more than three months as a result.
Back pain represents half of all chronic pain and costs the NHS £1.3 million every day.

3. International Guidelines
Low Back Pain; early management of persistent non-specific LBP (NICE clinical guideline 88, May 2009)
New Zealand Acute Low Back Pain Guide (New Zealand Guidelines Group, October 2004)
European Guidelines for the Acute and Chronic management of Low Back Pain. Circa 2004

4. Initial consultation Subjective and objective examination Management
Diagnostic triage
Red Flags
Yellow flags
Management

5. Mechanical Back Pain Nerve Root pain Identifiable Pathologies
Diagnostic Triage
Mechanical Back Pain
Nerve Root pain
Identifiable Pathologies

6. Important points to consider
All patients with symptoms or signs of Cauda Equina Syndrome should be referred urgently for orthopaedic or neurosurgical assessment.

7. Important points to consider
Investigations in the first 4-6 weeks of an acute low back pain episode do not provide clinical benefit, unless there are Red Flags.
A full blood count and ESR should usually be performed only if there are Red Flags. Other tests may be indicated depending on the clinical situation.

8. Important points to consider
Many people without symptoms show abnormalities on X-rays and MRI. The chances of finding coincidental disc prolapse increase with age. It is important to correlate MRI findings with age and clinical signs before advising surgery.

9. Examination History History of trauma Location of pain
Description of pain
Aggravating and easing factors
Morning stiffness
Bladder and bowel Disturbance, Saddle anesthesia
Consider salient factors from past medical history

10. Red Flags T U N A F I S H Trauma, Thoracic pain
Unexplained weight loss
Neurological signs, Non-mechanical pain, Night pain
Age; <20 >55, Am stiff
Fever, Flexion Loss
IVDU
Steroids; Long term
History of Cancer

11. Yellow Flags A B C D E F G Attitudes - towards the current problem
Beliefs - Something seriously wrong
Compensation
Diagnosis - Conflicting, emotive
Emotions - co-existing depression, anxiety
Family - Over or under supportive
Graft - Occupation, support from employers

12. Yellow Flag screening tools
STarT
Roland Morris Questionnaire

13. Examination Physical Tests 1. Observation. Gait willingness to move
posture
spasm
deformity eg kyphosis

14. Examination Physical Tests 2. Movements
Lumbar spine; Flexion, Extension, Lateral flexion
Hips; Especially rotations
SLR

15. Examination Physical Tests 3. Neurological Myotomal Dermatomal
Deep tendon Reflexes PR

16. Examination Physical Tests 4. Palpation Bony tenderness/ deformity
Heat, sweating & temperature
muscle spasm
Abdominal

17. Examination Physical Tests 5. Imaging
Do not routinely offer X-ray of the lumbar spine for the management of non-specific low back pain.
Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion.

18. Mechanical Back pain Patients between 25-55 years of age.
Lumbosacral region, buttocks and thighs.
Pain is mechanical in nature.
Prognosis
Excellent. First episode LBP will resolve in 90% patients in 4-6/52. However 25% patients will have recurrence over next 1-2 years and 5% develop chronic symptoms.

19. Nerve Root pain Unilateral leg pain may be worse than back pain
Pain may radiate to toes or foot
Numbness and paraesthesia in same distribution
Neuro changes limited to one nerve root
Prognosis
Good. 80% patients will recover in 10-12/52.

20. Identifiable conditions
1. Caudia Equina
Difficulty with micturition
Loss of anal sphincter tone or faecal incontinence
Saddle anaesthesia – anus, perineum or genitals
Widespread neurological changes (› 1 nerve root) or
progressive motor weakness in the legs or gait disturbance

22. Identifiable conditions
2. Inflammatory Disorders (ie Ankylosing Spondolysis)
Gradual onset before age of 40
Marked morning stiffness
Persisting limitation of spinal movements in all directions
Peripheral joint involvement
Iritis, skin rashes (psoriasis), colitis, urethral discharge
Family history
Recurrent tendinopathy/esinopathy

24. Identifiable conditions
3. Infection (Discitis)
Tends to occur in Children under 10, IVDU, post spinal surgery and Immunosuppressed patients.
Presents with pain, stiffness and reduced ROM.
Fever

26. Identifiable conditions
4. Fracture
1-4% all patients presenting to primary care with LBP
Trauma
Older age
Prolonged use corticosteroids
Presence of contusion/Abrasion

28. Identifiable conditions
5. Malignancy
Less than 1% patients will have Primary Tumor or metastatic lesion as cause of LBP
Past history Ca most accurate red flag for predicting malignancy as cause of LBP. (7% Primary care, 33% A&E)
Approximately 10% all malignancies have spinal involvement
Most common Multiple Myeloma, non-Hodgkin’s Lymphoma, and secondary's from Lung, Breast and Prostate

30. Management
Advice
Promote self-management: advise people with low back pain to exercise, to be physically active and to carry on with normal activities as far as possible
Explain expected recovery
Discuss treatment options and develop plan in consultation with patient

31. Management 2. Medication a. Regular paracetamol
b. Consider NSAID’s +/- weak opioids
Careful consideration to side effects
For NSAID’s offer PPI for over 45’s

32. Management 2. Medication c. Tricyclic antidepressants
Start at low dosage and increase up to max antidepressant dosage until therapeutic effect or unwanted side effects occur.

33. Management 2. Medication
d. Strong opioids (eg buprenorphine, diamorphine, fentanyl, oxycodone and tramadol)
Consider offering for short term use in patients with severe pain.
Consider referring people requiring prolonged use for specialist assessment

34. Management 3. Other Treatments a. Structured exercise programme
Supervised group exercise class (or 1:1 sessions) may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching.
8 sessions over 12 weeks

35. Management b. Manual Therapy 3. Other Treatments
Consider referring for a course of manual therapy including spinal manipulation.
Up to 9 sessions over 12 weeks

36. Management 3. Other Treatments c. Acupuncture
Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.

37. Slow to recover
If patients have not regained usual activities at 4 weeks they should be formally reassessed for both Red and Yellow Flags – and again at 6 weeks if progress is still delayed.

38. Slow to recover
Even if there are no Red Flags and neurological function is normal, you may need to consider full blood count, ESR and plain X-rays of the lumbar spine if pain is not resolving at six weeks.

39. Conclusion
Discussed diagnostic triage, covering examination as well as screening for red and yellow flags.
Discussed management of acute back pain in Primary care with reference to advice, medication, and other treatment options.

40. Questions?