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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
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