1. Community presentation: Low back pain

2. Overview Case history Case history Low back pain Low back pain Role of primary care Role of primary care Indicators for chronicity, management guidelines, referral criteria, imaging Indicators for chronicity, management guidelines, referral criteria, imaging Prognosis Prognosis Summary Summary

3. Low back pain Low back pain (pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds, with or without sciatica) is a common symptom Low back pain (pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds, with or without sciatica) is a common symptom Often traumatic or work related Often traumatic or work related Most commonly treated in primary healthcare Most commonly treated in primary healthcare A GP can expect 20 out of every 1000 patients on the list to consult with back pain A GP can expect 20 out of every 1000 patients on the list to consult with back pain Episodes are generally short-lived and self-limiting. Most pain and related disability resolve within weeks (Pengel 2003) Episodes are generally short-lived and self-limiting. Most pain and related disability resolve within weeks (Pengel 2003) However, important to rule out sinister cause of back pain However, important to rule out sinister cause of back pain Chronic back pain accounts for 120 million lost working days/ year in the UK Chronic back pain accounts for 120 million lost working days/ year in the UK

4. Causes of low back pain Age determines the most likely cause 15-30: Trauma, prolapsed disc, fractures, pregnancy, ankylosing spondylitis 15-30: Trauma, prolapsed disc, fractures, pregnancy, ankylosing spondylitis 30-50: Degenerative joint disease, prolapsed disc, malignancy 30-50: Degenerative joint disease, prolapsed disc, malignancy >50: Degenerative, osteoporosis, Paget’s, malignancy, myeloma >50: Degenerative, osteoporosis, Paget’s, malignancy, myeloma

5. Back pain and primary care Main function of GP is diagnostic Main function of GP is diagnostic Diagnostic triage: Simple lumbosarcal pain, nerve root pain, sinister pathology Diagnostic triage: Simple lumbosarcal pain, nerve root pain, sinister pathology History To detect ‘red flag’ and ‘yellow flag’ (psychosocial) signs Samanta et al. BMJ 2003; 326; 535 Red flag Yellow flag Thoracic pain Fever and unexplained weight loss Bladder/ bowel dysfunction history of carcinoma Progressive neurological deficit, disturbed gait, saddle anaesthesia Age of onset 55 A negative attitude that back pain is harmful Fear avoidance behaviour Expectation that passive rather than active treatment is beneficial A tendency to depression, social withdrawal

6. Examination Inspect for signs of trauma, inflammation Inspect for signs of trauma, inflammation Assess for localised tenderness and increased temperature Assess for localised tenderness and increased temperature Define exact site of pain Define exact site of pain Examine spine movements Examine spine movements Neurological exam of lower limbs Neurological exam of lower limbs Straight leg raise (To test for mechanical cause of sciatic pain) Straight leg raise (To test for mechanical cause of sciatic pain)

7. Prognostic indicators for chronicity GPs aim to prevent acute back pain becoming chronic GPs aim to prevent acute back pain becoming chronic Important to identify those at risk for long term disability as recovery increasingly less likely the longer the problem persists Important to identify those at risk for long term disability as recovery increasingly less likely the longer the problem persists Transition from acute to chronic simple backache is multifactorial (individual and workplace associated factors) Transition from acute to chronic simple backache is multifactorial (individual and workplace associated factors) Pyschosocial factors are important in this process (Croft 1998) Pyschosocial factors are important in this process (Croft 1998) Distress, depressive mood, and somatisation are associated with chronicity (Pincus 2002) Distress, depressive mood, and somatisation are associated with chronicity (Pincus 2002)

8. Management To gradually increase activity over days/ weeks, be as active as possible. Stay at work/ return to work as soon as possible To gradually increase activity over days/ weeks, be as active as possible. Stay at work/ return to work as soon as possible Bed rest not recommended as treatment of simple back pain Bed rest not recommended as treatment of simple back pain Some evidence that behaviour therapy, antidepressants, back schools, back manipulation can be effective (Koes 2006) Some evidence that behaviour therapy, antidepressants, back schools, back manipulation can be effective (Koes 2006) Regular analgesia Regular analgesia Paracetamol + NSAIDs e.g. diclofenac Paracetamol + NSAIDs e.g. diclofenac Paracetamol-opioid compound e.g. co-codamol Paracetamol-opioid compound e.g. co-codamol Consider muscle-relaxant for short term use e.g. diazepam Consider muscle-relaxant for short term use e.g. diazepam No evidence that alternative interventions such as lumbar supports, massage, acupuncture are effective (Koes 2006) No evidence that alternative interventions such as lumbar supports, massage, acupuncture are effective (Koes 2006)

9. Referral criteria from primary care (NICE) 1. Cauda equina syndrome features (bilateral lower limb root pain, saddle anaesthesia, abnormal bladder/ bowel function) 2. Spinal pathology 3. Progressive neurological deficits 4. Underlying inflammatory disorder suspected 5. Unresolved root pain after 6/52 6. Not resumed normal activities in 3 months – referral to a multidisciplinary back pain team

10. Imaging Low association between abnormality on X-ray and MRI and non-specific low back pain – abnormalities in those without back pain just as common as in those with back pain Low association between abnormality on X-ray and MRI and non-specific low back pain – abnormalities in those without back pain just as common as in those with back pain Many patients with back pain show no abnormalities Many patients with back pain show no abnormalities Therefore, most guidelines suggest only referring for imaging if there are red-flag signs Therefore, most guidelines suggest only referring for imaging if there are red-flag signs MRI is most effective for detecting spinal pathology (Jarvik 2002) MRI is most effective for detecting spinal pathology (Jarvik 2002)

11. Prognosis Clinical course favourable in most cases Clinical course favourable in most cases Widely believed that 90% of patients cease to consult GP about low back pain after 3 months Widely believed that 90% of patients cease to consult GP about low back pain after 3 months In one study, only 25% of patients had fully recovered after 12 months (Croft 1998) In one study, only 25% of patients had fully recovered after 12 months (Croft 1998) Recurrences are common, however the severity is generally less and does not always lead to a new visit Recurrences are common, however the severity is generally less and does not always lead to a new visit Only about 5% of people with an acute episode will develop chronic lower back pain (Koes 2006) Only about 5% of people with an acute episode will develop chronic lower back pain (Koes 2006)

12. Summary Conservative management Conservative management Investigations not useful in most cases Investigations not useful in most cases Always consider psychosocial factors Always consider psychosocial factors Note red flag signs, cauda equina syndrome is a neurosurgical emergency! Note red flag signs, cauda equina syndrome is a neurosurgical emergency!

13. References 1. Croft et al. Outcome of low back pain in general practice: a prospective study. BMJ. 1998; 316; 1356-59 2. Jarvik et al. Diagnostic evaluation of low back pain with emphasis on imaging. Am Int Med. 2002; 137; 586-97 3. Koes et al. Diagnosis and treatment of low back pain. BMJ. 2006; 332; 1430-34 4. Kumar and Clark 5. Oxford handbook of clinical medicine 6. Pincus et al. A systematic review of psychological factors as predictors of chronicity / disability in prospective cohorts of low back pain. Spine 2002; 27; 109-20 7. Samanta et al. 10-minute consultation: chronic low back pain. BMJ. 2003; 326; 535

14. Questions?