Transcript LOW BACK PAIN – West Ayton and Snainton Surgeries

LOW BACK PAIN
The GPs Problem
•The GPs Problems
• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Lots of patients
• Back pain reported by 60% people at some time in
their life
• 1993 - 14 million GP consultations
• 1993 - Cost to NHS app £480 million
• 1993 - Lost production costs app £3.8 billion
• 1993 - DSS benefits app £1.4 billion
Prevention
•Change the environment - ergonomics
•Change the individual - morphology
•Change attitudes - education
Improved management
Improved management of Acute LBP
 less time out of action/off work
 fewer patients with chronic or recurrent LBP
Improved management of Chronic LBP
 less long term disability
•The GPs Problems
• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Diagnosis is difficult (1)
Anatomical complexity - vertebrae/discs/ligaments/
muscles/SI joints
“The mobile segment”
- discs
- facet joints
- muscles and ligaments
at each level = indissoluble mechanical entity
Diagnosis is difficult (2)
• Nociceptors in all tissues except disc + synovial
membrane
• Stimulation of any of these may cause muscle
spasm which may or may not be painful
• Referred pain - 2 or more sources may refer to the
same site
• Tenderness - may be produced by local
sensitisation nociceptors but may exist in normal
tissue eg at site of referred pain
Diagnosis is difficult (3)
• Social factors
• Psychological factors
•The GPs Problems
• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Acute LBP - changing guidelines
• Go to bed
• US Agency for Health Care Policy and
Research (AHCPR) 1994
• UK Clinical Standards Advisory Group
(CSAG) 1994
• RCGP 1996
Acute low back pain - Triage
Aims to differentiate between :-
Simple backache (non specific LBP)
Nerve root pain
Possible serious spinal pathology
Simple backache
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Age 20 - 55 years
Lumbosacral, buttocks, thighs
“Mechanical” pain
Patient well
Nerve root pain
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Unilateral leg pain worse than low back pain
Radiation to foot or toes
Numbness and parasthesia in same distribution
SLR reproduces pain
Localised neurological signs (eg loss ankle jerk)
Red flags for possible serious pathology
 age <20 or >55
 Non mechanical pain
 Thoracic pain
 PMH carcinoma, steroids, HIV
 Generally unwell, weight loss
 Widespread neurology
 Structural deformity
Cauda Equina Syndrome
 Sphincter disturbance
 Gait disturbance
 Saddle anaesthesia
Assessment
• Triage based on history and examination
• In simple backache XR not routinely
indicated
• Psychosocial factors are important
•The GPs Problems
• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Rest or Activity
• 9 RCTs show bed rest for 2-7 days is worse
than ordinary activity
• 8 RCTs show advice to continue ordinary
activity gives better results than the
traditional “let pain be your guide” advice
• Aim is to use symptomatic measures to
control pain and so allow activity
Drugs
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Prescribe regularly not prn
start with paracetamol
NSAIDs (differing side effect rates)
NSAIDs less effective for nerve root pain
paracetamol and weak opioid combination
Muscle relaxants (diazepam) are effective
Manipulation
“Within 6 weeks of onset of acute or recurrent low
back pain, manipulation provides better short term
improvement in pain and activity levels and higher
patient satisfaction than the treatments to which it
has been compared”
Back exercises
• “on the evidence available at present, it is doubtful
that specific back exercises produce clinically
significant improvement in acute LBP” but
• “McKenzie exercises may produce short term
symptomatic improvement in acute LBP”
• “Strong theoretical arguments for commencing
exercise programs by 6 weeks”
Other treatments
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Ice and heat
Massage
Ultrasound
TENS
Shoe inserts
Acupuncture
• Trigger point
injections
• Facet joint injections
• Corsets
• Epidurals
Evidence against
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Bed rest with traction
MUA
Plaster jackets
Benzodiazepines >2wks
•The GPs Problems
• Lots of patients
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Risk factors for chronicity
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Previous history low back pain
Nerve root involvement
Poor physical fitness
Self rated health poor
Heavy smoking
Psychological distress and depressive symptoms
Disproportionate illness behaviour
Low job satisfaction
Personal problems eg marital, financial
Ongoing medicolegal proceedings
Aspects of treating chronic pain
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Psychological
Physical
Pharmacological
Procedural
Rehabilitation