This Back in Focus resource was developed and funded by AbbVie.. Date of preparation: June 2015; AXHUR150807p The Impact of Back Pain.

This Back in Focus resource was developed and funded by AbbVie.. Date of preparation: June 2015; AXHUR150807p

The Impact of Back Pain

• Who gets back pain?

• How many patients consult you each day for back pain?

• How many patients keep coming back to see you because of back pain?

• How does back pain affect the people you treat?

• When is back pain ‘just back pain’?

– When could it mean something more?

A few thoughts…

• 60-80% of adults report lower back pain at some point in their life1

• Approximately 6–9% of UK adults consult their GP about lower back pain each year2,3

Back pain: burden of disease

1. Waddel et al. Occup Med. 2001; 51:124–135. 2. Dunn and Croft. Spine, 2005; 16:1887–1892. 3. Cremin and Finn. Ir Med J 2002; 95141–95142.

Prevalence of inflammatory back pain

1. Hamilton et al. Clin Exp Rheumatol 2012; 30;4 p621.

• Results presented from a UK study in 2012 on prevalence of inflammatory back pain in a UK primary care population

• Questionnaire issued to patients who had consulted on at least one occasion with low back pain (total population=978, total respondents=505)

The economic burden of back pain

1. de Souza and Frank, Disability and rehabilitation 2011;33:310–318. 2. Maniadakis and Gray. Pain 2000; 84:95–103. 3. van Tulder et al. Eur Spine J 2006; 15 (Suppl. 2):S169–S191.

£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000

Back pain

Coronary heart disease

Rheumatoid arthritis

Lower respiratory tract infections

Alzheimer's disease

Stroke

Diabetes

Arthritis

Multiple sclerosis

Deep vein thrombosis & pulmonary embolism

Depression

Insulin dependent diabetes

Critical limb ischaemia

Epilepsy

Benign prostatic hyperplasia

Multiple sclerosis

Migraine

Indirect costsDirect costs

Cost in 1998 ~ £1632 million

75-85% workers’

absenteeism

• Over half of chronic back pain patients may suffer with insomnia1

• Back pain also has psychosocial effects– Emotional stresses– Relationship breakdowns– Severe emotional distress to partners– Limitations in fulfilling their family role2

The impact of back on patients’ lives

1. Tang et al. J Sleep Res. 2007;16:85–95. 2. de Souza and Frank. Disability and rehabilitation 2011;33:310–318.

• Chronic back pain is defined as pain which occurs for >3 months1

• Identifying back pain as acute or chronic is one of the key processes in determining the source of the pain:

– Acute back pain

• Usually mechanical, often acute in onset, arising from structural changes that may be in the spinal joints, vertebrae or soft tissues

– Chronic back pain

• Can be either mechanical or inflammatory, resulting in chronic back pain lasting >3 months1

Back pain: acute vs. chronic

1. Sieper et al. Ann Rheum Dis 2009; 68:784–788.

It is important to distinguish inflammatory from mechanical back pain as early as possible as the underlying causes are usually

different as is subsequent management and treatment

Comparison of inflammatory and mechanical back pain

1. Sieper, J et al. Ann Rheum Dis 2009; 68:784-788 2.Chien, JJ and Bajwa, ZH. Current pain and headache reports 2008; 12:406-411

IBP

Age at onset <40 years

Insidious onset; less likely to be acute

Pain improves with exercise

Pain does not improve with rest

Pain at night that may wake patient during second half of the night

Morning stiffness >30 minutes

MBP

Age at onset; any age

Variable onset; may be acute

Pain may worsen with movement

Pain often improves with rest

• How long has the patient had back pain?1

• How old was the patient when the back pain started?1

• Is there a family history of AS?2

• Does the pain improve with the use of NSAIDs?1,3

• Has the patient experienced any leg pain, numbness or tingling?• Does the patient have a history of other musculoskeletal problems?4

• Has the patient experienced anterior uveitis (iritis), psoriasis, IBD or peripheral arthritis?3

• What is the usual pattern over a 24 hour period?1 • Has the patient experienced alternating buttock pain?1,5

Important questions to ask a patient with chronic back pain

1. Sieper et al. Ann Rheum Dis. 2009; 68:784–788. 2. Evnouchidou, J Immunol, 2011; 186:1909–13. 3. Braun et al. Ann Rheum Dis, 2011; 70:896–904. 4. Mander, M et al. Ann Rheum Dis 1987; 46:197–202. 5. Rudwaleit et al. Arthritis Rheum 2006; 54:569–578

1

1

1

1

ASAS criteria for identifying inflammatory back pain

Adapted from Sieper et al. Ann Rheum Dis. 2009; 68:784–788.

Inflammatory back pain requiring further investigation is usually indicated if the answer is ‘yes’ to 4 or more of these parameters

Non-radiographic disease

(X-ray –ve)

Radiographic disease

X-ray +vesacroiliitis

Radiographic disease X-ray +ve

sacroiliitis and/or spinal changes

Time (years)

Estimatedproportion of affected individuals

Axial SpA (ASAS criteria)

Ankylosing Spondylitis (mNYC)

MRI -ve

MRI +vesacroiliitis

Patients with chronic back pain ≥3 months and aged <45 years

Axial SpA spectrum of disease

Isdale A, et al. Rheumatology (Oxford). 2013 Dec;52(12):2103-5.

The figure depicts the spectrum of disease in patients with axSpA. The severity of disease progresses with time in a proportion of patients and the sizes of the boxes are estimates of the proportion of patients in each tertile. The first tertile represents early non-radiographic disease, the second and third tertiles represent radiographic disease (AS) with the most severe end of the spectrum including spinal involvement (syndesmophyte formation, fusion or posterior element involvement).

0%

10%

20%

30%

40%

< 1month

1-3months

3-6months

6-12months

1-3years

3-5years

5-10years

10years or

more

Perc

en

tag

e o

f p

ati

en

ts

n=791

Interval between symptom onset and first consultation with GP in patients with AS

Adapted from Hamilton L. et al. Rheumatology 2011;50:1991–1998.

Months Years

Time

+

Although ~60% of patients

consult their GP within 1 year of symptom onset,

~40% wait between 1 and

10+ years

Interval between symptom onset and diagnosis of AS

0%

10%

20%

30%

40%

Pe

rce

nta

ge

of

pa

tie

nts

n=778

<1 1-3 3-6 6-12 1-3 3-5 5-7 7-10 10 +

Months Years

Time

Nearly 40% of patients experience

a delay over >5 years between

symptom onset and diagnosis of AS

Over 20% experience a delay

of 10+ years

Mean delay is 8.57 years

Adapted from Hamilton L, et al. Rheumatology 2011;50:1991–1998

Red flag symptoms of more serious conditions1–3

Source of back pain History Observation/examination

Abdominal aortic aneurysm

• Sudden onset of intermittent/ continuous abdominal pain radiating to the back

• History of cardiovascular disease• Previous collapse

• Pulsating abdominal mass• Low or high blood pressure• Tachycardia (rapid heart beat)

Tumours • Age ≥50 years• History of cancer• Back pain at night and at rest; may

have neurological deficits (if tumour destruction is extensive and causes neurological compression)

• Neurological deficits• Swollen lymph nodes• Systemic symptoms, including

fever/chills and malaise• Unexplained weight loss

Renal disease • Recent UTI• History of kidney stones• History of polycystic kidney

• Associated with history of frequent kidney infections

• UTI: back tenderness, fever/chills, urinary urgency/burning

• Kidney stones: nausea/vomiting, pain radiating to the groin, blood in the urine, possible fever

• Polycystic kidney: back and abdominal tenderness, blood in the urine, increased abdomen size

1. Adapted from BMJ Best Practice. Assessment of back pain. Accessed June 2015. Last updated September 2014. 2. Bangle SD et al. Cleveland Clinic Journal of Medicine. 2009;76:393–399. 3. Differentiating back pain from kidney pain. Available at http://www.integrative-healthcare.org/mt/archives/2006/02/differentiating.html. Accessed June 2015. Last updated February 2006.

Red flag symptoms of more serious conditions (cont.)1,2

Source of back pain History Observation/examination

Gastrointestinal disease • History of peptic ulcers• Epigastric, burning pain radiating to

the back• Pain associated with meal times• Vomiting blood or blood in the stool

(advanced disease)

• Epigastric tenderness

Infection • Fever/chills• Recent UTI, spinal surgery, epidural

anaesthesia or skin infection• Immunosuppression• Injection drug use• Diabetes• Weight loss

• Fever (temperature >38°C/100F)• Back tenderness• Neurological findings absent

1. Adapted from BMJ Best Practice. Assessment of back pain. Available at http://bestpractice.bmj.com/bestpractice/monograph/189/diagnosis/differentialdiagnosis.html. Accessed June 2015. Last updated September 2014 Accessed 15.01.2013. Last updated April 2012. 2. Bangle SD et al. Cleveland Clinic Journal of Medicine. 2009;76:393–399.

If a patient has red flag symptoms consider urgent referral to Oncology/ Gastroenterology/ Urology/ A&E

as appropriate

Examination findings in patients with mechanical back pain

Positive straight leg raise test

Positive straight leg raise test

Specific tenderness around the lumbar

spine

Specific tenderness around the lumbar

spine

Absent reflexesAbsent reflexesObserve for scoliosis

Observe for scoliosis

Restricted range

of movement

Restricted range

of movement

Neurological examinationNeurological examination

For more information refer to ‘Principles of examination’ in The Oxford Textbook of Rheumatology

Physical examination is often unremarkable in patients with

inflammatory back pain

Examination findings in patients with inflammatory back pain

Look for other inflammatory conditions such as psoriasis, uveitis, peripheral arthritis,

enthesitis

Neurological examination is essential

Tenderness over enthesitis sites

Observed postural changes

Reduction in the range of

movement in the lumbar spine

Loss of hip abduction

Pain or tenderness over the sacroiliac joint, lumbar spine and/or

thoracic spine

Inflammatory

back pain

Who to refer to

Mechanical

back pain

Based on Braun, J et al. Ann Rheum Dis 2011; 70:896–904.

If IBP is suspected refer to rheumatology

If IBP is suspected refer to rheumatology

If MBP is suspected refer to local musculoskeletal interface service

If MBP is suspected refer to local musculoskeletal interface service

• Back pain is a common reason for primary care consultations

• It is important to be able to distinguish between back pain of mechanical and inflammatory origin as the referral pathways and treatments differ

• ‘Red flags’ should be investigated immediately

Summary