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Bolton Primary Care Trust Orthopaedic CATS The Bolton MSK CATS Clinic Bolton Primary Care Trust Orthopaedic CATS Lesley Anne Fraser – MSK Service Manager Contact: Email: [email protected] Andy Maskell - Consultant Orthopaedic Surgeon Contact: Tel No: 01204 462831 Email: [email protected] Sunil D’Souza - Consultant Orthopaedic Surgeon Contact: Tel No: 01204 462583 Email: Sunil.D’[email protected] Susan Greenhalgh - Consultant Physiotherapist and Interim Lead Clinician Contact: Tel: 01204 462584 Email: [email protected] GP Training Agenda – Wednesday 6th April 2011 1.30pm – 3.30pm and 6.30pm – 8.30pm Afternoon Agenda Items Session 12.30pm Evening Session Lunch 1.30pm 1. Introduction 6.30pm 1.35pm 2. Film – 6.35pm 1.45pm 3. Investigations – Andy 6.45pm 2.00pm 4. Red Flags and CPM (MSCC) – Sue 7.00pm 2.15pm Tea/Coffee Break 7.15pm 2.30pm 5. Group Work – Examinations 7.30pm 3.00pm 6. Film – recap Interactive discussion Good language – key phrases Good management – back cards 8.00pm 3.30pm Finish 8.30pm Role Play Andy & Sue Top Ten Tips Diagnostic Aids Subjective History - Top Ten Tips 1. When and how did you back pain start? 2. How has it progressed? 3. Where is the pain? 4. Do you have any pins and needles, numbness? 5. Do you have any weakness? Subjective History - Top Ten Tips Con’td… 1. Do you have bladder or bowel symptoms, or pins and needles in the perineum? 2. What helps and what makes it worse? 3. How are you managing your symptoms? 4. If working, are you still at work and managing with activities of daily living 5. Other Red Flag questions, e.g. previous cancer, weight loss etc Diagnostic Aid Simple Mechanical Low Back Pain Diagnostic Aid Nerve Root Irritation Diagnostic Aid Nerve Root Entrapment Pins and Needles Sue Greenhalgh Consultant Physiotherapist Sue Greenhalgh Consultant Physiotherapist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Weight loss Previous history of cancer 163 Red Flags in Night pain the literature Age over 50 yrs Violent trauma Fever Saddle anaesthesia Difficulty with micturition Intravenous drug abuse Progressive neurology Systemic steroids May not have lost weight May not have constant pain May not have night pain May respond to treatment for a short time May attribute the pain to a cause MAY have an undiagnosed non symptomatic primary tumour (e.g.Breast) The subjective examination provides clinicians with clearer indications of serious pathology than the objective examination In 23% of MSCC cases, cord compression was the first presenting symptom of malignancy 3-5% of patients with confirmed malignant disease progress to MSCC. Risk increases with disease duration Mean survival rate of patients who receive no treatment for MSCC is 1 month Multiple studies have consistently identified that diagnosis of MSCC frequently occurs late in the disease process with devastating consequences on the outcome of the patient Levack, Graham, Collie, Grant, Kidd, Kunkler, Gibson, Hurman, McMillan, Rampling, Slider, Statham, & Summers 2002 Lavy et al 2009 Paraplegia has been identified as increasing the risk of earlier than expected death in MSCC patients (Patchell et al, 2005, Levack et al, 2001) 85% are as a consequence of vertebral collapse Sudden onset MSCC worse functional prognosis than gradual Limb weakness can be difficult to detect even when subjective report exists Sensory damage is not necessarily indicative of degree of spinal damage Bladder and bowel dysfunction, signs of significant autonomic nerve damage occurs late in MSCC disease process What would experts in Palliative Care or Oncology tell us to look out for? What have they learned from their patient stories? Objectives To inform the evidence base on Red Flags for malignant spinal pathology By utilising the experiential knowledge of specialists in the palliative care sector to educate staff working in the primary care sector Validated Red Flags Unremitting pain History of current or previous malignancy Absence of previous back pain MSCC Failure to respond to standard treatment Neurological deficit Bladder and bowel symptoms Three New Items Band-like trunk pain Malignant Spinal Cord Compression Vague non-specific lower limb symptoms Decreased mobility Embedded in expert literature, inaccessible to the front-line clinicians The early ones usually say that their legs misbehave somehow, that they won’t do what they want them to do. Their legs won’t behave themselves, but they often won’t present with that until it becomes more severe because they can’t explain, or they’re not sure, or don’t know the significance of the fact that their legs are not doing what they want them to do. So finding their foot drops a little bit, or their right leg drags a bit they don’t know the importance of that until much more serious symptoms and signs have actually developed Low Level of Clinical Suspicion High Level of Clinical Suspicion Definite Clinical Diagnosis Cancer diagnosis with documented bone metastases or myeloma Acute escalation of severe spinal pain Tingling or electric shocks in spine with a cough or sneeze Neurological signs may be equivocal Bilateral nerve root pain especially band-like Unsteady/heaviness in legs Where exactly is your pain? How do your legs feel? Have you noticed any change in your mobility- Can you manage stairs? Urgent MRI within 24 hours-Whole spine If confirmed emergency decompression or radiotherapy MRI of the whole spine is the only suitable investigation, in patients with severe back or nerve root pain and known malignancy CT only if contraindications to MRI Metastatic Spinal Cord Compression NICE Guidelines November 2008 Diagnosis and management of adults at risk of and with MSCC Whole spinal scan image unless contraindication Early diagnosis and treatment offers the best outcome. There is a significant association between the ability to walk at the time of diagnosis and the ability to walk following treatment, however early diagnosis is challenging. Information from guidelines to identify these serious cases, was not reaching frontline clinicians with cases reported Nationally and locally as suffering frequent delays No single alert system that will guide clinicians in Primary (or Secondary care) Early warning signs of MSCC (Undiagnosed Primary Malignancy) GREATER MANCHESTER AND CHESHIRE CANCER NETWORK (serve a population of 3.2 million) R E D F L A G Referred pain that is multi-segmental or band-like Escalating pain which is poorly responsive to treatment (inc medication) DIfferent character or site to previous symptoms Funny feelings odd sensations or heavy legs (multi-segmental) Lying flat increases pain Agonising pain causing anguish and despair Gait disturbance, unsteadiness, especially on stairs not just a limp NB—Established motor/sensory/bladder/bowel disturbances late signs Early Identification of Metastatic Spinal Cord Compression (MSCC) in Primary CareCollaboration in practice In depth period of negotiation between experts in the field of Oncology and musculoskeletal Primary care with close collaboration with one HEI. Negotiation considered the essential minimum data requirements to raise the index of suspicion suggestive of MSCC in the target audience of nonspecialist clinicians. Negotiation concluded with consensus being achieved (following peer review) and the RED FLAG acronym of questions being used to alert the clinician that further reading or indeed timely onward referral may be necessary. Credit card size literature was identified as a useful format from an Experience Based Design project within the Bolton MSK CATS service. R E D F L A G S Referred pain that is multi-segmental or band-like Escalating pain which is poorly responsive to treatment (inc medication) Different character or site to previous symptoms Funny feelings odd sensations or heavy legs (multi-segmental) Lying flat increases pain Agonising pain causing anguish and despair Gait disturbance, unsteadiness, especially on stairs not just a limp Sleep grossly disturbed due to night pain The chronological presentation Date Red Flags Reflection Clinical Presentation Mapping Date Document known dates and profession of clinician e.g. G.p., Physio Red Flags Document known red flags and significant clinical findings at each consultation Reflection Populate above, including Red Herrings THEN REFLECT Clinical Presentation Mapping case 1 Date 27/08/08 GP No 1 •New onset left sided low back pain •Thought to be gallstones Red Flags •New pain not previously suffered •Age 52 years Reflection 29/08/08 GP NO 2 •LBP severe, •Sent to A&E •Admitted In-Patient until 11/09/08 •Lumbar spine x-ray •Abdominal ultrasound •Abdominal x-ray •ALL REPORTED AS NORMAL CAUTION; Do not be reassured by previous investigations being reported as normal. Were they investigating the correct aspect or area? Clinical Presentation Mapping 15/09/08 GP No 3 26/09/08 GP No 4 Date Red Flags •‘No Red Flags’ specifically documented in GP notes •Thought to be musculoskeletal •Advice given Reflection 09/10/08 Physio appointment and GP No 5 •Patient had started to walk with •LBP severe, a stick as legs felt weaker •Referred to •Weight loss Physiotherapy •Stopped work and describes •No Red Flags again documented feeling depressed •reported feeling some improvement CAUTION; Serious pathology appears to respond to physiotherapy in the early stages Clinical Presentation Mapping Date Red Flags 23/10/08 Physio review •Gait re-education •Discussed paced exs approach •Goal to wean off walking aid and return to work Reflection 27/10/08 Gp No 5 •No red Flags Documented •Medication adjusted Good knowledge of Red Flags essential 03/ 11//08 Gp No 6 •Patient reported feeling hot with increased frequency •Gp suspected UTI Clinical Presentation Mapping Date 10/11/08 Gp No 4 home visit •Home visit requested due to pain 13/11/08 DNA Physio appointment 14/ 11//08 Gp No 4 & 6 •Patient reported severe abdominal pain and PV bleeding 2/52 cancer pathway to gyaenocology Red Flags Reflection •Seen by general surgeons •MRI lumbar spine organised •Discharged back to Gp for Ortho referral Clinical Presentation Mapping 16/12/08 Gp No 6 Date •Oromorph prescribed and Orthopaedic referral carried out Red Flags 2/01/09 CATS AOP (Access time around 2 days) •Documented significant weight loss •Non segmental neurology •Band like pain •Severe restriction of lumbar flexion •Poor balance and mobility •Saddle anaesthesia and retention •“Drunken feeling” Fuzzy feeling in legs •“Legs not my own” “Dragging leg •MRI WHOLE spine expedited Reflection Clinical Presentation Mapping 6/01/09 9/01/09 RBH Date •Multiple spinal metastases Primary Breast Cancer Red Flags Reflection •7 Gp’s •1 physio •1 AOP •Approx 5 month patient journey Clinical Presentation Mapping 27/08/08 GP No 1 15/09/08 GP No 2 09/10/08 Physio Date •New pain not previously • suffered •Age 52 years •New pain not previously suffered •Age 52 years •Band-like pain Red Flags •New pain not previously suffered •Age 52 years •Band-like pain •Weight loss •Sudden change in Mobility (began walking with a stick) Red Herrings •Negative investigations for abdo pain as in patient •Normal bloods and lumbar x-ray report •2/52 inpatient stay •Back pain improving •Sleep ok, no night pain •Previous tests including CRP & Myeloma tests negative •Possible emergence of yellow flags Clinical Presentation Mapping Date 03/11/08 GP •New pain not previously suffered •Age 52 years •Band-like pain •Weight loss Red •Sudden change in Flags •Mobility (began walking with a stick) •Fever & chills 02/01/09 CATS AOP •New pain not •previously suffered •Age 52 years •Band-like pain •Weight loss •Sudden change in Mobility (began walking with a stick) •Fever & chills •Non segmental neurology •Severe restriction of lumbar flexion •Poor balance and mobility •Saddle anaesthesia and retention •“Drunken feeling” Fuzzy feeling in legs •“Legs not my own” “Dragging leg Good knowledge of Red Flags essential to aid diagnosis early in disease process Extent of inconsistent Gp contributed to delay in diagnosis Symptom progression not linear. Improving presentation not unusual in early stages and not necessarily reassuring Previous normal investigation reports need to be appropriate to be reassuring Reflective tool Learning process Safety Produce new knowledge-recognise early warning signs Use regularly to understand cases-clinicians thought processes, symptom presentation, patient history Improve patient care Sue Greenhalgh Consultant Physiotherapist NHS Bolton [email protected] Key Phrases 1.Don’t 2.Stay 3.Use best 4.Try 5.Be worry back pain is very common active, try to stay at work analgesics regularly. Paracetamol is one of the a daily paced walk aware that anxiety and stress can increase the pain we feel Warning signs • If you suffer with severe pain which continues to get worse over several weeks, or if you feel unwell with back pain, or being treated for cancer or on steroids, see your doctor. Rarely the following may develop:• • • Difficulty passing urine Numbness around genitals and back passage Numbness, pins and needles or weakness in both legs or unsteadiness on your feet. If these develop seek medical advice urgently BACK FACTS Based on the latest research:Back pain is very common. Most cases are NOT due to anything serious What you do in early stages is very important:· Stay active — do not treat with rest and try to stay at work. · Use simple pain killers if necessary. Paracetamol is a good place to start. Be aware that anxiety and stress can increase the pain we feel. Early warning signs of MSCC (Undiagnosed Primary Malignancy) R E D F L A G Referred pain that is multi-segmental or band-like Escalating pain which is poorly responsive to treatment (inc medication) DIfferent character or site to previous symptoms Funny feelings odd sensations or heavy legs (multi-segmental) Lying flat increases pain Agonising pain causing anguish and despair Gait disturbance, unsteadiness, especially on stairs not just a limp NB—Established motor/sensory/bladder/bowel disturbances late signs WARNING SIGNS · If you suffer with severe pain which continues to get worse over several weeks, or if you feel unwell with back pain, or being treated for cancer or on steroids, see your doctor Rarely the following may develop:· Difficulty passing urine · Numbness around genitals and back passage · Numbness, pins and needles or weakness in both legs or unsteadiness on your feet If these develop seek medical advice urgently METASTATICS SPINAL CORD COMPRESSION (MSCC) KEY RED FLAGS Past Medical History of Cancer But note 25% of patients do not have a diagnosed primary Early Diagnosis is essential As the prognosis is severely impaired once paralysis occurs A combination of Red Flags increases suspicion (The more Red Flags the higher the risk and the greater the urgency) To access the MSCC guidelines go to: www.gmsccn.nhs.uk GREATER MANCHESTER AND CHESHIRE CANCER NETWORK Greenhalgh & Selfe 5 Minute Examination Questions Green Amber Red Look at the spine – Is the patient straight? Straight Deviated Angulated Can they move? Normal Stiff Rigid Leg pain with movement None or Thigh One Leg Two Legs Tip toe standing (L5, S1) Normal Weak Absent Heel walking (L4, 5) Normal Weak Absent Single leg standing Normal or Can’t stand on Collapse Wobbly one leg Distal sensation Normal Segmental Non-segmental Hip flex Normal Stiff Rigid SLR Back pain One leg Both legs Ankle and knee reflex Normal Blunted or Brisk or clonus absent Plantar reflexes Normal Equivocal Upward going None or Mild Localised pain Widespread RED FLAG TESTS Percussion pain pain Spincter tone or anal reflex if indicated Normal Reduced tone only Absent