Learning to love back pain presentations to ED Caitlin Farmer Team Leader, Advanced Musculoskeletal Physiotherapy Services Northern Health

NH Advanced Musculoskeletal Physiotherapy Services Orthopaedic screening Osteoarthritis Hip and Knee Service (OAHKS) Northern Arthroplasty Management Service (NOAMS) Emergency Department Caitlin Farmer, Bridget Shaw, Hugh Burch, Kate Lawry Neurosurgery screening

Neurosurgical clinics NH Mr Augusto ‘Gus’ Gonzalvo FRACS Director of Neurosurgery, Austin Hospital Fortnightly clinic (0.05 EFT) Neurosurgery screening (yours truly) Weekly clinic (0.1 EFT) Department of Health Advanced Musculoskeletal Physiotherapy Grant for expansion next year (0.2 EFT extra) Wait list 600+ patients This equates to a current estimated wait time of around 18 months! Currently seeing ED patients approximately 8 months post presentation

LBP radiology ‘Imaging tests are not recommended in acute (less than 12 weeks duration) non-specific low back pain in the absence of clinical ‘red flags’’ NHMRC Emergency Care Evidence in Practice 9/20/2018

CT Lumbar spine High prevalence of Intevertebral disc space narrowing (63.9%) Facet joint OA (64.5%) Spondylolysis (11.5%) No relationship between these factors and pain Spinal stenosis only significant association (OR 3.45, CI 1.12 – 10.68) (Kalichman et al, 2010) Anecdoctally CTs are not useful in determining ongoing neurosurgical treatment for non-specific low back pain

Is there a relationship between disc pathology and pain? Jensen et al, 1994 Scanned 98 asymptomatic people, mean age 42.3 years 36% had normal discs at all levels 52% had a bulge at one level or more 27% had a protrusion 1% had an extrusion **Extrusions are rare in asymptomatic patients**

MRI is harmful in many cases

MRI is harmful in many cases MRI increases the risk of surgery (Flynn et al, 2011) Strong association between increased rates of imaging and spinal surgery Early MRI increases the chance of surgery x 3 with no change in outcome after one year Early MRI is associated with increased risk of disability and its duration in workers with LBP (Graves et al, 2012) Knowledge of MRI results = Lower self-rated general health despite similar outcomes (Ash et al, 2008)

Darlow et al, 2012 Strong evidence that beliefs of the HCP are associated with those of the patient Practitioners with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities HCP attitudes and beliefs are associated with patient education and bed rest recommendations Negative beliefs about LBP and fear of movement (not pain intensity) are related to disability Briggs et al, 2010, Smith et al, 2010

Pain quiz TRUE/FALSE It’s possible to change a patient’s physical findings by explaining pain in a non-threatening way

Pain quiz TRUE/FALSE It’s possible to change a patient’s physical findings by explaining pain in a non-threatening way TRUE Change in pain cognition is associated with changes in physical performance (forward bending and SLR) Moseley (2003)

Pain quiz TRUE/FALSE Pain is produced by peripheral nociceptors

Pain quiz TRUE/FALSE Pain is produced by peripheral nociceptors FALSE Pain is an multifactorial output of the brain

Pain quiz TRUE/FALSE Crossing your arms reduces pain

Pain quiz TRUE/FALSE Crossing your arms reduces pain TRUE (Gallace et al, 2011)

Pain quiz Pain involves which systems? Immune Reproductive Visuomotor Endocrine All of the above

Pain quiz Pain involves which systems? Immune Reproductive Visuomotor Endocrine ALL OF THE ABOVE (Moseley, 2003)

From: Explain Pain, Butler and Moseley, 2003

Pain quiz Definition of pain?

Pain quiz Definition of pain? ‘Pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required’ (Moseley, 2003)

Patient factors associated with chronicity Higher pain intensity Higher levels of anxiety and distress Less certainty that their pain will resolve Longer hospitalisation Less independence in ambulation Trauma diagnosis Less need for surgery (White et al, 1997) We can prevent this in ED!* *(At least some of the time)

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

Some physiotherapy insider tips Thorough examination (including full neuro) reassures patients that nothing is terribly wrong Explanation and reassurance prior to getting people up is helpful Teach people to transfer out of bed properly Place the bulk of the responsibility for getting better on the patient Walking and appropriate regular pain relief is the best evidenced treatment for LBP

The good news Early referral to physiotherapy reduces the rate of: Advanced imaging GP visits Surgery Injections Opioid medications Compared with delayed referral to physiotherapy (Fritz et al, 2012)

SACS MDT Broadmeadows and Bundoora Pain clinic http://www.keele.ac.uk/sbst/

What to do? Appropriate analgesia Clear red flags Explain pain and symptoms in a non threatening way Refer to physiotherapy Clear and comprehensive discharge plan

Referral to Neurosurgery outpatients (TNH) Urgent referral required for new acute nerve root signs, ie dermatomal or myotomal signs, changed reflexes. These should be seen within 2-4 weeks. Static nerve root signs will be seen at the next available appointment. Note that patients without neurological signs or patients with an acute on chronic flare can be managed by physiotherapy alone.