10 minutes for “I’ve got a bad back”

1. 10 minutes for “I’ve got a bad back” Kizzy, Vasu, Amer, Ramesh, Audrey, Ewan and Gill

2. Why it is important • LBP is not a homogenous condition • LBP is very common in working-age adults ( between the ages of 40 and 60 years ) • Treating all types of back pain costs the NHS more than £1000 million per year • In 1998 the direct healthcare costs of all back pain estimated at £1623 million -approximately 35% were related to private sector • The costs of care for LBP exceed £500 million/year • Lost production as a result of LBP costs at least £3500 million/year.

3. LBP results in • impaired quality of life • long-term morbidity • a higher risk of social exclusion • reduced income • reliance on sickness benefits • Aims of interventions and therapies • manage disability and pain, • to help people to cope with day-to-day life, • to reduce distress, to enable people to remain in or return to work, • to minimise risk of recurrence.

4. History • Circumstances of pain • Nature/severity of pain • Associated symptoms • PMH • Exclude other sites of pain

5. Red Flags - age <20 or >55, • non mechanical pain, • worse when supine, • night time pain, • thoracic pain, • past hx of carcinoma, HIV, immunosuppression, IVDU, taking steroids, unwell, weight loss, • widespread neurology, structural deformity, saddle anaesthesia, incontinence bowel or bladder or retention of urine

6. Examination • Deformity • Palpate • Movements • Lower limbs (power, tone, sensation, reflexes, SLR)

7. NICE guideline May 2009Management of Low Back Pain Principles of management • Keep diagnosis under review at all times • Promote self-management: advise people with low back pain to exercise, be physically active and to carry on with normal activities as far as possible • Offer drug treatments as appropriate to manage pain and to help people keep active • Offer one of the following treatments, taking patient preference into account: • exercise programme • course of manual therapy • course of acupuncture

8. Advice and education • Provide advice and information to promote self-management • Offer educational advice that: • includes information on the nature of non-specific low back pain • encourages normal activities as far as possible • Advise people to stay physically active and to exercise • Include an educational component • When considering recommended treatments, take into account the person’s expectations and preferences

9. Drug treatments • Option 1: Paracetamol: • Advise regular paracetamol as the first option • Option 2: NSAIDS and / or weak opioids • Decision based on individual risk of side effects and patient preference • Give due consideration to risk of opioid dependence and side effects • Option 3: Tricyclic antidepressants • Consider offering if other medications are insufficient, starting at a low dose and increase up to the maximum antidepressant dosage until • Therapeutic effect is achieved • Unacceptable side effects prevent further increases • Option 4: Strong opioids (buprenorphine, fentanyl, oxycodone, high dose tramadol) • Consider offering for short-term use to people in severe pain • Consider referral if requires prolonged use • Consider risk of opioid dependence and side effects • Co-prescribe a PPI for people over 45 • For all medications, base decisions on continuation on individual response

10. Non-drug treatments • Structured exercise programme: • up to 8 sessions over up to 12 weeks • supervised group exercise programme in a group of up to 10 people, tailored to the person • one-to-one supervised exercise programme only if a group programme is not suitable • Manual therapy: • course of manual therapy, including spinal manipulation • up to 9 sessions over up to 12 weeks • Acupuncture: • course of acupuncture needling • up to 10 sessions over up to 12 weeks

11. Imaging • Do not offer X-ray of the lumbar spine • Only offer MRI for non-specific low back pain in the context of a referral for an opinion • Consider MRI if one of these diagnoses is suspected: • spinal malignancy • cauda equina syndrome • Infection • Ankylosing spondylitis • Fracture • inflammatory disorder

12. Do Not offer…. • SSRIs for treating pain • Injections of therapeutic substances into the back • Laser therapy • Interferential therapy • Therapeutic ultrasound • TENS • Lumbar supports • Traction

13. AKT

18. Question 5 • An 18 yr old fast bowler presents with sudden onset of pain while extending his hip, and he walks with scoliosis. • A) scheurmanns disease • B) Spondylolisthesis • C) Acute disc prolapse • D) TB of spine

19. Question 6 • Following total hip replacement performed via posterior approach, the patient was noted to have a foot drop • A) Nuerapraxia of common peroneal nerve • B) Neurapraxia of Sciatic nerve • C) Neurapraxia of Calcaneal nerve • D) Neuropraxia of Femoral Nerve

20. Question 7 7. Which of the following are ‘red flags’ for possible serious spinal pathology?   • Age over 55 • Anorexia c) Systemic steroid therapy d) Difficulty with micturition e) Cough-impulse pain

21. Question 8 8. How much radiation is involved in a plain lumbar spine X-ray compared to a chest X-ray? a) Equal amounts b) Lumbar spine = 2 x Chest X-Ray c) Lumbar spine = 20 x Chest X-Ray d) Lumbar spine = 150 x Chest X-Ray

22. Question 9 9. What proportion of the population will develop low back pain at some time their lives?  a) 20% b) 50% c) 70% d) 90%

23. Question 10 10. Low back pain is generally understood to become ‘chronic’ after a period of how long? • 6 weeks • 8 weeks • 10 weeks • 12 weeks • 14 weeks

24. Answers • 1: B • 2: A • 3: S1,L4,L5 • 4: D • 5: C • 6: B • 7: A,C,D • 8: D • 9: C • 10 : D

25. CSA scenario • Vasu has prepared a case for the day and will act as the patient.

26. Thankyou Any questions ?