Are you getting the best treatment
for your low back pain?
Paula Salmon and Carol Doyle
Community Business Unit Physiotherapy Service
East Cheshire NHS Trust
Health Matters
Tuesday 4th February 2014
Who are we?
Paula Salmon
Extended Scope Practitioner
Lead for Physiotherapy Back Pain Service
Carol Doyle
Clinical Physiotherapist at GP Surgery
Physiotherapy Research Facilitator
Community Adult Physiotherapy Services
East 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?
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24 spinal vertebrae
5 lumbar vertebrae
Joints
Discs
Nerves
Muscles
Strong
Natural ageing &
stiffness
Cervical spine
Thoracic spine
Lumbar spine
Sacroiliac joint
Coccyx
Facet joint
Vertebra
Nerve roots from spinal cord to leg
Disc
What causes back pain?
Most cases, cause is unclear
 poor posture
 lack of exercise
 muscle strains and sprains
Some conditions have specific causes
 Spondylosis – ‘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?
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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?
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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?
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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
X
X
Bed rest
X
X
Traction
Lumbar supports
Electrical treatments e.g. Laser therapy,
interferential, therapeutic ultrasound
TENS machines – limited use in low back pain
What if my back pain is affecting my
work?
Work is good for you! – financial and social
Stay at work or get back as soon as possible
 Keep in touch with your employer
 Discuss what can be done to help you when you
return e.g. light duties, changing hours
 Occupational advisor may help e.g. adjustments
to your workplace

What exercises can I do?
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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
Risk Factors (persisting problem)
Anxiety / distress / Stress
BMI / Obesity
Bothersomeness
Catastrophising beliefs /
Perceived risk of not
recovering
Coping catastrophising score
Coping strategies / styles
Days in pain
Depression
Disability
Dissatisfaction with care
Duration
Duration of sick leave
Educational status
Expectations of treatment
Family history of low back pain
or chronic pain
Fear avoidance behaviour /
beliefs
Fear-avoidance work beliefs
Female gender
Frequent consultation
Gradual onset of pain
Height (lower)
History of low back pain
Job dissatisfaction (lack of
stimulating work tasks)
Manual labour
Number of localisations
Older age
Pain elsewhere
Pain intensity
Pain on coughing
Pain radiating to the leg or sciatica
Pain worse on standing
Pain worse when lying
Physical activity
Restricted spinal movements at
presentation
Self-rated health / Well-being
Smoking
Somatization
Straight-leg raising tests of less
than 60° in either leg
Unemployment
Work absence
Workers compensation status
Which risk factors?
Anxiety / distress / Stress
BMI / Obesity
Bothersomeness
Catastrophising beliefs /
Perceived risk of not
recovering
Coping catastrophising score
Coping strategies / styles
Days in pain
Depression
Disability
Dissatisfaction with care
Duration
Duration of sick leave
Educational status
Expectations of treatment
Family history of low back pain
or chronic pain
Fear avoidance behaviour /
beliefs
Fear-avoidance work beliefs
Female gender
Frequent consultation
Gradual onset of pain
Height (lower)
History of low back pain
Job dissatisfaction (lack of
stimulating work tasks)
Manual labour
Number of localisations
Older age
Pain elsewhere
Pain intensity
Pain on coughing
Pain radiating to the leg or sciatica
Pain worse on standing
Pain worse when lying
Physical activity
Restricted spinal movements at
presentation
Self-rated health / Well-being
Smoking
Somatization
Straight-leg raising tests of less
than 60° in either leg
Unemployment
Work absence
Workers compensation status
The STarT Back Screening Tool
Items included:
Referred leg pain
Pain elsewhere
Disability
Fear avoidance
Anxiety
Catastrophising
Depression
Overall impact
Screening for risk factors
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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)
+
Matched pathways
Skilled physiotherapists to address emotional factors
High
12%
Course of physical therapy by physiotherapists
Medium risk
33%
Minimal treatment of advice & medication
GPs and Physiotherapists
Low risk
55%
Risk
Targeted treatment
1. Low risk group –
Minimal treatment
• Assessment
• Discuss any worries
or concerns
• Encourage stay fit
and active
• Use of medication
• Flare up
management
2. Medium risk physiotherapy
As low risk group
+
• Tailored individual
programme of
physical treatment
• Promote self
management
• Minimise disability
3. High risk Enhanced
physiotherapy
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
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Nothing serious
Bed rest is not good
Staying at work is good
Keeping positive helps
Regular pain relief
Keep moving
Stretching exercises
Keep fit and active
• Which treatments are
the best
• How to stop my back
pain getting worse
Latest
thinking
on back
pain
Best
evidence
for
treatments
How to
help
yourself?
What can
physio
offer?
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Special exercises
Help get back moving
Help deal with emotions
Self management
Acknowledgements
Questions ?
www.arthritisresearchuk.org/arthritis-information/conditions/back-pain.aspx