Are you getting the best treatment for your low back

pain? Paula Salmon and Carol Doyle

Community Business Unit Physiotherapy Service

East Cheshire NHS TrustHealth Matters

Tuesday 4th February 2014

Who are we?

Paula SalmonExtended Scope Practitioner Lead for Physiotherapy Back Pain Service

Carol DoyleClinical Physiotherapist at GP Surgery

Physiotherapy Research Facilitator

Community Adult Physiotherapy ServicesEast Cheshire NHS Trust

Why are we here?• To present to you the latest thinking on low back

pain• To update you on the best evidence for the

treatments available• To share with you what our physiotherapy service

can offer • To give you a better understanding on how to

help yourself

Have you had low back pain?1. How many of you have ever

had back pain?

2. How many of you seek help for your back pain?

3. How many of you have ever had physiotherapy for your back pain?

‘George’s story’

What is back pain?

• Back pain is common• 8 out of 10 people will suffer

back pain at some time• Majority of people have

nothing seriously wrong• Costs to NHS and Society

huge - £10668 million!*

*Maniadakis et al. The economic burden of back pain in the UK. 2000

How is the back structured?• 24 spinal vertebrae• 5 lumbar vertebrae• Joints• Discs• Nerves• Muscles• Strong• Natural ageing & stiffness

Facet joint

Nerve roots from spinal cord to legVertebra

Disc

Cervical spine

Thoracic spine

Lumbar spine

Sacroiliac joint

Coccyx

What causes back pain?

Most cases, cause is unclear poor posture lack of exercise muscle strains and sprains

Some conditions have specific causesSpondylosis – ‘wear and tear’Sciatica – ‘leg pain’Stenosis – ‘nerve tightness’

Should I see my doctor about my back pain?

• Immediately• If you have problems passing or controlling urine• Lose control of bowels• Lose sensation around your genitalia or back passage• Weakness in your legs/ become unsteady on your feet

• If your pain • Is very severe or persists for a long time• Affects your everyday activities

How can I help myself?

Painkillers can keep you moving Regular exercise e.g. swimming, walking, pilates,

yoga, going to gym Check posture frequently Lift things correctly Watch your weight Stay at work if possible Keep positive!

Why do back problems become chronic?

• Not always a reason• Common to start avoiding normal movement and

activities…….. • Not exercising / muscles weaker……… • Lose confidence……….• Affect work, social and personal relationships……..• Get anxious / depressed……..

Vicious cycle!

What is the outlook for back pain?

• 75 – 90% recover within in a few weeks• Relapses are common• For those with persistent pain, only a 1/3 fully

recover• Most lead normal life and able to work• Emotional response to back pain important to

recovery e.g. worried, depressed

How are back problems diagnosed?

• A thorough assessment should be able to provide a diagnosis.

• Xray – do I need one?• Only a few people with back pain require further

investigations:– Magnetic resonance imaging (MRI)– Computerised tomography scan (CT)– Blood tests

What treatments are there for back pain?

• NICE guideline (National Institute for Health and Care Excellence)*

• specific exercise • manual therapy • Acupuncture • Combined psychological and physical therapy

• Surgery or injections may be considered

*CG88 Low Back Pain: NICE Guideline 2009

Myths for treatments!

X Bed rest

X Lumbar supports

X Electrical treatments e.g. Laser therapy, interferential, therapeutic ultrasound

X Traction

X TENS machines – limited use in low back pain

What if my back pain is affecting my work?

Work is good for you! – financial and socialStay at work or get back as soon as possibleKeep in touch with your employerDiscuss what can be done to help you when you return e.g. light duties, changing hoursOccupational advisor may help e.g. adjustments to your workplace

What exercises can I do?

• Stretching• Strengthening e.g pilates• Hurt does not always mean harm!• Remember to gradually build up• GP’s can give you sheets of exercises • Physiotherapists provide individualised exercises

which can be supervised and progressed

Research and new developments for back pain

• NEW model in GP practices*– Grouping patients for treatment according to

risk factors for persisting back problems– Targeted treatments for different risk groups

given by physiotherapists– Clinically and cost effective!

What are these risk factors?*Hill et al. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial Lancet 2011

Pain on coughingPain radiating to the leg or sciaticaPain worse on standingPain worse when lyingPhysical activityRestricted spinal movements at

presentationSelf-rated health / Well-beingSmokingSomatizationStraight-leg raising tests of less

than 60° in either legUnemploymentWork absenceWorkers compensation status

Risk Factors (persisting problem)Anxiety / distress / StressBMI / ObesityBothersomenessCatastrophising beliefs /

Perceived risk of not recovering

Coping catastrophising scoreCoping strategies / stylesDays in painDepressionDisabilityDissatisfaction with careDurationDuration of sick leaveEducational statusExpectations of treatment

Family history of low back pain or chronic pain

Fear avoidance behaviour / beliefs

Fear-avoidance work beliefsFemale genderFrequent consultationGradual onset of painHeight (lower)History of low back painJob dissatisfaction (lack of

stimulating work tasks)Manual labourNumber of localisationsOlder agePain elsewherePain intensity

Pain on coughingPain radiating to the leg or sciaticaPain worse on standingPain worse when lyingPhysical activityRestricted spinal movements at

presentationSelf-rated health / Well-beingSmokingSomatizationStraight-leg raising tests of less

than 60° in either legUnemploymentWork absenceWorkers compensation status

Which risk factors?Anxiety / distress / StressBMI / ObesityBothersomenessCatastrophising beliefs /

Perceived risk of not recovering

Coping catastrophising scoreCoping strategies / stylesDays in painDepressionDisabilityDissatisfaction with careDurationDuration of sick leaveEducational statusExpectations of treatment

Family history of low back pain or chronic pain

Fear avoidance behaviour / beliefs

Fear-avoidance work beliefsFemale genderFrequent consultationGradual onset of painHeight (lower)History of low back painJob dissatisfaction (lack of

stimulating work tasks)Manual labourNumber of localisationsOlder agePain elsewherePain intensity

Referred leg pain

Pain elsewhere

Disability

Fear avoidanceAnxietyCatastrophising

Depression

Overall impact

Items included:

The STarT Back Screening Tool

Screening for risk factors

• Brief tool• Takes 2 minutes to complete• Places patients into low ,

medium or high risk groups• Designed to help clinicians

target your treatment

Grouping patients

At first contact with a GP

55% of patients are at low risk of persisting problems

33% of patients are at medium risk of persisting problems

12% of patients are at high risk of persisting problems

NEW model (STarT Back)

Screening for Risk

Factors into GroupsMatched pathways

For Targeted Treatment

+

Low risk

55%

Medium risk

33%

High

12%

Course of physical therapy by physiotherapists

Skilled physiotherapists to address emotional factors

Matched pathways

Risk

Minimal treatment of advice & medicationGPs and Physiotherapists

Targeted treatment

1. Low risk group –Minimal treatment

2. Medium risk -physiotherapy

3. High risk - Enhanced

physiotherapy

• Assessment• Discuss any worries

or concerns• Encourage stay fit

and active• Use of medication• Flare up

management

As low risk group +•Tailored individual programme of physical treatment •Promote self management•Minimise disability

As medium risk group +•A combination of physical treatments and treatments to address the emotional responses to back pain

Are we working to best practice?

• NICE guidelines (National Institute for Health and Care Excellence) Audit 2010 and 2013 – 100% success!

• New Model (STarT Back) Audit 2013 – 100% success!

‘The Truth About Back Pain’

www.youtube.com/watch?v=qh7j1xXriVM

George’s story

Acknowledgements

Questions ?

www.arthritisresearchuk.org/arthritis-information/conditions/back-pain.aspx