Transcript 9. What proportion of the population will develop low back pain at

10 minutes for
“I’ve got a bad back”
Kizzy, Vasu, Amer, Ramesh, Audrey,
Ewan and Gill
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.
• LBP results in
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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.
History
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Circumstances of pain
Nature/severity of pain
Associated symptoms
PMH
Exclude other sites of pain
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
Examination
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Deformity
Palpate
Movements
Lower limbs (power, tone, sensation, reflexes,
SLR)
NICE guideline May 2009
Management 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
Advice and education
• Provide advice and information to promote selfmanagement
• 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
Drug treatments
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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
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
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:
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spinal malignancy
cauda equina syndrome
Infection
Ankylosing spondylitis
Fracture
inflammatory disorder
Do Not offer….
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SSRIs for treating pain
Injections of therapeutic substances into the back
Laser therapy
Interferential therapy
Therapeutic ultrasound
TENS
Lumbar supports
Traction
AKT
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
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
Question 7
7. Which of the following are ‘red flags’ for
possible serious spinal pathology?
a)Age over 55
b)Anorexia
c) Systemic steroid therapy
d) Difficulty with micturition
e) Cough-impulse pain
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Question 8
8. How much radiation is involved in a plain
lumbar spine X-ray compared to a chest Xray?
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
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%
Question 10
10. Low back pain is generally understood to
become ‘chronic’ after a period of how long?
a)6 weeks
b)8 weeks
c) 10 weeks
d)12 weeks
e)14 weeks
Answers
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1: B
2: A
3: S1,L4,L5
4: D
5: C
6: B
7: A,C,D
8: D
9: C
10 : D
CSA scenario
• Vasu has prepared a case for the day and will
act as the patient.
Thankyou
Any questions ?