Prevalence of Back Pain
Point prevalence 12-35%
Lifetime prevalence 49-80%
Annual prevalence in UK
(OPCS surveys 1997) 37% (3.5 million/year)
Male=female
No regional differences
Increases with age
Prevalent population 17.3 million
Economic Burden
Approx 9% adults visit GP every year with back pain, average 1.66 consultations with doctor, 0.06 with nurse (OPCS 1996)
1997-8 cost of a consultation with doctor in surgery £14, home £46; nurse £9 surgery/ £12 home.
Total primary care cost in 1998 £140 million
Other costs of Back Pain
Out patient attendances £ 159 million
Day cases £ 109
In patient care £ 218
NHS Radiology £ 77
Osteopaths £ 173
Physiotherapy NHS £ 151
Physiotherapy private £ 100
Total direct cost £1632
Total costs including work days lost, informal care, incapacity £6,650 million -£12,300 million
Maniadakis and Gray, Pain 2000
Disability related to Back Pain
Non specific lower back pain typically improves over 2-3 months but 79% are still symptomatic at 3 months and 75% at one year
After 6 months off work with back pain less than 50% chance of returning to work. Increases to no chance after 2 years (Waddell 1998)
Rising trend of social security payments for back pain has begun to reverse with a 42% decrease in annual new awards for back pain since 1990s (www.dwp.gov.uk)
Risk Factors for Low Back Pain
Age (peak between 40 and 60)
Occupational factors
Heavy manual work, lifting, twisting, sitting, driving
Poor job satisfaction
Poor physical fitness
Lower social class
Smoking
Risk Factors for Chronicity (Prognostic chronic pain risk score; Von Korff
2008)
Pain intensity
Interference with usual activities
Interference with work/household activities
Interference with family/social activities
Days of activity limitation from pain
Depression score
Number of other pain sites
Number of days with pain in preceding six months
Department of Health
What to do at the First Visit
History
Examination
Identify red flags
Encourage activity as soon as possible
Analgesia
Paracetamol, “weak opioids”, NSAIDs, gabapentin, pregabalin, amitriptyline, topical agents
Physiotherapy
Which scales to use and when?
Numerical rating scale (0-10)
Verbal descriptor scale (None, mild, moderate, severe, very severe)
Pain drawing
HAD or PDQ
Brief Pain Inventory
Role of MRI in Back Pain
To show or exclude serious spinal pathology
Infection, tumour, cauda equina, ank spond, spondylolisthesis
Possibly nerve compression (false positives)
Reassurance?
No evidence that MRI will improve outcome in mechanical low back pain
NICE: “only offer MRI for non specific low back pain within the context of a referral for an opinion on spinal fusion”
When the Pain becomes Persistent
Agree that there are no cures
Move on to the concept of management, not a cure
Start to move the patient from “I can solve your problem” to “We can work on it together”
Pose the idea of a holistic approach with psychological approaches
Do not refer for yet another opinion/ further investigations
The Interdisciplinary Team
Doctor
Nurse
Assessment and treatment planning, information, flare ups, telephone help lines, medication, TENS, acupuncture
Psychologist
Physiotherapist
Occupational therapist
Others
Pharmacist, podiatrist, complementary therapist, osteopath, chiropractor, pilates, prescribed exercise, rehab programmes
Pain Management Programme
A psycho-educational rehabilitation group to:
improve coping strategies
lessen emotional distress
reduce analgesic consumption
Improve self confidence
Improve physical function
Reduce fear avoidance
Enable socialisation
Improve understanding in the family
Role of Secondary Care
Red flag pathology
Where there are diagnostic difficulties
Increasing symptoms
Increasing distress
Lack of response to initial management
Dependency on drugs, especially opioids
Complex cases; co-morbidities
Second opinion
To whom to refer?
Specialist physiotherapists
ICATS
Rheumatology
Orthopaedics
Neurosurgery
Pain management
What does Pain Management have to offer?
Holistic assessment
Pain management advice
TENS, acupuncture
Medication, withdrawal from medication
Nerve blocks
Epidural steroids
Facet joint injections
Nerve root injections
Radiofrequency lesions
Neuromodulation e.g, spinal cord stimulator
Interventional techniques: the evidence
Epidural corticosteroid v transforaminal “nerve root block”
No comparisons with translaminar epidurals
Few RCTs
Case reports of spinal cord infarction and injury
“Transforaminal injection of steroids: should we continue?” Rathmell 2004
Radiofrequency techniques• Dorsal Root Ganglion: one RCT showed no advantage
over sham treatment with LA. – Guerts, Lancet 2003
• Facet joint denervation– Evidence for temporary efficacy, minor complications only 1%
Kornick, Spine 2004– Comparison with sham procedure, 15 patients in each group,
67% v 38% successful at 8 weeks. 46% v 13% at 9 months• Van Kleef, Spine 1999
• Pulsed radiofrequency– Limited evidence for efficacy. Niemisto, Spine 2003
Opioids may cause harm in some with painSEATTLE, Sept. 29 (UPI) -- A U.S. study suggests that in certain individuals with
chronic disabling back pain, opioids may cause harm in unexpected ways. "Giving prescription opioids to patients with chronic disabling back pain is fraught with
risk," said Dr. Tom Mayer of the Productive Rehabilitation Institute in Dallas.
Mayer and colleagues studied 1,200 patients who successfully completed an intensive functional rehabilitation program. Although most were using substantial
amounts of opioids when they entered the program, all patients had tapered off the drugs by graduation.
However, one year later 15 percent were opioid-dependent, and that nearly doubled the risk that a patient would be out of work and the likelihood that a patient had
engaged in excessive healthcare-seeking behavior, apparently to find a physician willing to provide opioids, according to Mayer.
Physicians who treat patients with chronic disabling back pain "must be cautious in prescribing chronic opioid medication, and be alert to the de-motivating effect such
medication can have," advises Mayer. Despite their disability and functional limitations, patients found doctors who were
willing to give them the opioids and, more importantly, keep them on opioids, according to Mayer.
The findings were presented at the 21st annual meeting of the North American Spine Society in Seattle.
Opioids
Weak v strong
Codeine phosphate 240 mgs/day
What is morphine equivalent?
Metabolism of codeine?
Which strong opioid?
Long or short acting?
Morphine, oxycodone, fentanyl, buprenorphine, tramadol?
Long term effects?
NICE LBP Guidelines: the early management of persistent non specific low back pain
More than 6 weeks, less than 1 year
Non specific low back pain is tension soreness and/or stiffness in the lower back for which it isn’t possible to identify a specific cause of the pain
Not covered; low back pain from
Malignancy, infection, fracture, ankylosing spondilitis
Pain from nerve compression
Care pathway
Promote self management
Advise exercise, physical and normal activities
Offer drug treatments as appropriate
Offer one of the following treatments, taking patient preference into account
Exercise programme
up to 8 sessions over 12 weeks
Course of manual therapy
Up to 9 sessions over 12 weeks
Course of acupuncture
Up to 10 sessions over 12 weeks
Consider offering another of these options if the chosen treatment does not result in satisfactory improvement
If no progress….
Significant psychological distress and/or high disability
Consider referral for a combined physical and psychological treatment programme which
Comprises around 100 hours over up to 8 weeks
Should include a cognitive behavioural approach and exercise
If no progress or pain for more than 1 year…..
Consider referral for an opinion on spinal fusion
Give due consideration to the possible risks
Refer to a specialist spinal surgical service
Do not offer
SSRIs for treating pain
Injections of therapeutic substances into back
Laser therapy
Interferential therapy
Therapeutic ultrasound
TENS
Lumbar supports
Traction
Do not refer for…..
Radiofrequency facet joint denervation
IDET
PIRFT
Reference Sources
Cole F et al. Overcoming chronic pain; a self help guide using CBT. London. Constable and Robinson
The Expert Patient. The Stationery Office
Recommended Guidelines for Pain Management Programmes for Adults. The British Pain Society 2007
Winterowd F 2003. Cognitive Therapy with Chronic pain Patients. New York: Springer
Recommended Resources for Patients (DH)
The Back Book (The Stationery Office, www.tsoshop.co.uk))
The Whiplash Book
Prodigy Clinical Guidelines: The Back Book
CCI Scotland
www.welshbacks.com
www.patient.co.uk
www.backpaineurope.org
www.backcare.org.uk
www.action-on-pain.org
www.nice.org.uk
Further Information
The Back Pain Revolution. G Waddell (2004)
Back and Neck Pain: the scientific evidence. A. Nachemson (2000)
www.faccomed.ac.uk
Manage your Pain Michael Nicholas
The Pain Survival Guide: how to reclaim your life. Dennis Turk and Frits Winter