September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
NWH Community Pain Clinic
How can we
support
people with
spinal pain?
Mags Wigram, ESP, Pain Management
6th September 2013, N Spine, Nottingham
The Clinical Team
Pain Consultant
Dr Greg Hobbs
Advanced Physiotherapy Practitioner
Mags Wigram
Nursing Team:
Advanced Nurse Practitioner
Paula Banbury
Advanced Nurse Practitioner and
Cognitive Behavioural Psychotherapist
Kate Feenan
Clinical Nurse Specialist
Julie Conners
The Admin Team
Heidi Lewis
NWH Primary Care Patient Services Co-ordinator
Jo Faulkner and Alicia Shaw
NWH Administrators
David Hale
NWH Information and
Governance Co-ordinator
Face to face triage
• Pain Consultant or
Advanced Physiotherapist
Practitioner,
• 30 or 40 minute assessments,
• History taking and physical examination,
• Triage decision in agreement with patient.
Face to face triage options
•
Urgent imaging or urgent referral direct to appropriate specialist,
•
Routine imaging (MRI, nerve conduction studies, x-ray),
•
Physiotherapy (Community or NUH),
•
Nottingham Back and Pain Team (via Advanced Nurse Practitioners),
•
Analgesia review, recommendations to GP,
•
Spinal injections (Dr Greg Hobbs),
•
Acupuncture (direct referral) or TENS (clinical nurse specialist),
•
Non urgent referrals to Spinal Surgeons,
•
Other e.g. Orthotics, NUH falls team.
Recommendations for GP to instigate
• from analgesia review,
• regarding blood screening,
• regarding urgent or routine referrals on to other
specialists (non-spinal) e.g. rheumatology,
orthopaedics, vascular or medical specialties,
oncology, mental health team,
• Any other recommendations e.g. referral to
dietician/nutritionist, local exercise schemes,
community falls team.
Two stories of low back
pain and right leg pain
Neil - History
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47 year old police officer.
6/12 history of LBP with right buttock to calf pain.
GP ordered bloods (NAD) and x-ray (L5/S1 changes).
Able to remain at work but duties limited.
Avoids prolonged sitting and driving due to pain.
Affecting sleep, although amitriptyline helps.
Paracetamol ineffective, previous gastric ulcer (avoids
NSAIDs), and didn’t like side effects of codeine.
• Temporary relief only with chiropractor (massage) and
physiotherapy (exercise advice).
Neil - Physical examination
• Lumbar flexion increases buttock and leg pain.
• Unable to fully straighten right hip/knee in
standing or lying due to buttock and leg pain.
• Slight reduction in right calf bulk.
• Right hamstrings relatively weaker.
• Right achilles reflex slightly dull, but present.
• Reduced sensation great toe and sole of foot.
Neil - Triage discussion
• Lumbar MRI: Possible L5/S1 disc bulge with right S1
nerve root impingement.
• Neil would consider nerve root block, but wants to avoid
surgery and prefers not to use strong medication
because he needs to concentrate at work.
• Discussed possible diagnosis and prognosis, and
agreed following MRI, options could be nerve root
block if indicated and/or further physiotherapy.
• For telephone review with results of MRI scan.
Neil - Key considerations
• Relatively acute – manage fears and expectations,
explain diagnosis and reassure re prognosis.
• Keep him out of secondary care, whilst this can still be
managed conservatively.
• Acknowledge and discuss concerns
• Work demands and worries
• Issues re analgesia use, side effects and work
demands.
• Support with advice, physiotherapy and nerve root
block if indicated.
• Longer term telephone follow-up via Clinical Nurse
Specialist if required.
Kathryn - History
• 62 year old lady with long history of low back and right
leg pain.
• 2004 L4/5 discectomy.
• 2008 developed right foot drop.
• MRI showed L3/4 disc impinging right L4 nerve root.
• Nerve conduction studies showed degeneration in the
right peroneal nerve suggestive of proximal (spinal
roots or plexus) lesion.
• Under spinal clinic, had injections and eventually an
L3/4 microdiscectomy 2010, with no improvement.
Kathryn - Symptoms
• No new symptoms since discharge from the spinal
clinic in 2011.
• Describes aching LBP radiating to thighs and knees in
a generalised distribution.
• Also has constant right dorsal ankle/foot pain, with
episodes of numb spasm.
• Pain worse with walking and walking distance limited to
¼ mile.
• Owns a foot drop splint but never wears it because it is
very uncomfortable with a poor fit.
• Sleep disturbed by back, leg and foot pains.
Kathryn – Treatment
• Physiotherapy: Since discharge from the spinal clinic
two full courses, including manual therapy, exercises,
TENS and acupuncture. At the end of her last course 10
months ago, was told there wasn’t any more that
physiotherapy could offer.
• Analgesia:
• Codeine based medication caused constipation.
• Still takes paracetamol and ibuprofen prn, but doesn’t
think it helps.
• Currently weaning off gabapentin to change to
pregabalin. She has had previous M.I. so has not
been prescribed amitriptyline.
Kathryn – Social and emotional impact
• Kathryn owned a greengrocers, but had to give this up
due to her back pain, and has not worked since.
• She lives alone and her social contacts have reduced
considerably in the last few years.
• She keeps occupied by visiting her elderly father, and
manages small spurts of housework resting between
activities. She enjoys reading.
• Her levels of pain concern her, because of how they
limit her mobility and activity levels and her ability to
care for her father.
• She feels lonely and has been feeling very low
recently.
Kathryn – Physical examination
• Limited lumbar range of movement all
directions.
• 0/5 power in right EHL and dorsiflexors.
• All other right lower limb muscle groups 4/5.
• Right achilles reflex dull but present.
• Reduced sensation in her right great toe and
lateral calf.
• Loss of passive dorsiflexion in her right ankle.
• Borderline allodynia dorsal right foot.
Kathryn - Triage discussion
• Discussion of mood, and whether she would like to
access counselling or antidepressants via her GP.
• Referral to Advanced Pain Nurse Specialist for
assessment for CBT or ACT input including possible
attendance at Nottingham Pain Management Programme.
• Discussion with Pain Consultant regarding any further
changes to analgesia, to be recommended to her GP.
• Referral to Orthotics, NUH, for refitting of foot drop splint.
Advice today re dorsiflexion stretches.
• TENS was previously helpful but lost it. Book with
Clinical Nurse Specialist for TENS issue and advice.
Kathryn – Key considerations
• Is just about coping but mood deteriorating.
• Is despondent because thinks all treatment
options have been exhausted, and because she
feels people have given up on her.
• Recognises there is no cure, but is hoping for
improvements in her pain.
• Has not fully explored CBT/ACT approaches.
• Via community pain clinic, can access a wide
range of services tailored to her particular needs.
Questions?