Transcript Document

Back Pain
Chris Boyles, Physiotherapy
Extended Scope Practitioner A&E
June 2014
1. Around 30 million adults in the UK will experience
back pain this year.
2. 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.
3. Back pain represents half of all chronic pain and
costs the NHS £1.3 million every day.
http://www.backcare.org.uk/
International Guidelines
Low Back Pain; early management of persistent nonspecific 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
Initial consultation
Subjective and objective examination
•
•
•
Diagnostic triage
Red Flags
Yellow flags
Management
Diagnostic Triage
1.
Mechanical Back Pain
2.
Nerve Root pain
3.
Identifiable Pathologies
Important points to consider
All patients with symptoms or signs of Cauda
Equina Syndrome should be referred urgently
for orthopaedic or neurosurgical assessment.
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.
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.
Examination
History
•
History of trauma
•
Location of pain
•
Description of pain
•
Aggravating and easing factors
•
Morning stiffness
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Bladder and bowel Disturbance, Saddle anesthesia
•
Consider salient factors from past medical history
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
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
Yellow Flag screening tools
STarT
http://www.keele.ac.uk/sbst/
Roland Morris Questionnaire
http://www.rmdq.org/
Examination
Physical Tests
1. Observation.
Gait
willingness to move
posture
spasm
deformity eg kyphosis
Examination
Physical Tests
2. Movements
Lumbar spine; Flexion, Extension, Lateral flexion
Hips; Especially rotations
SLR
Examination
Physical Tests
3. Neurological
Myotomal
Dermatomal
Deep tendon Reflexes
PR
Examination
Physical Tests
4. Palpation
Bony tenderness/ deformity
Heat, sweating & temperature
muscle spasm
Abdominal
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.
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.
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.
Identifiable conditions
1. Caudia Equina
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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
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
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
Identifiable conditions
4. Fracture
•1-4% all patients presenting to primary care with LBP
•Trauma
•Older age
•Prolonged use corticosteroids
•Presence of contusion/Abrasion
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
Management
1. 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
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
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.
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
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
Management
3. Other Treatments
b. Manual Therapy
Consider referring for a course of manual
therapy including spinal manipulation.
Up to 9 sessions over 12 weeks
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.
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.
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.
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.
Questions?