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