GP Guide Acute Back Pain pathway AJ Welcome This is the follow on session to the PLT that took lace in July, as a “taster” for the North East Acute back Pain pathway. I am joined in the presentation by Diarmaid Ferguson-title, Phyio champion for the regional pathway and MSK physiotherapy practitioner Northumbria Trust We also have in the room some of the other people supporting the regional project and also some of the practitioners working in the Virgin MSK service and CDDFT who will be the key individuals in supporting you and your patients As I shared at the last PLT, this pathway has been developed on a regional basis, the rationale for being at scale, to avoid postcode lottery and variation in outcomes and to ensure the provision of NICE recommended CPPP element to the pathway that has up to now not been available as a therapeutic option. The pathway and services to support has been implemented in the South Tees and HRW area in July this year and as part of the roll out we are incorporating the learning form these early sites. We are also very grateful for 2 of the Spinal practitioners for also joining us today. Darlington and HAST are part of the next Phase and we go live with the pathway ?date December. As I mentioned previously this pathway has been supported in its early implementation by the NE AHSN and the roll out is being supported by the HF Scaling up Programme, who support a small number of projects nationally.

Back Pain and Radicular Pain Pathway v1.2

Back Pain and Radicular Pain GP Pathway v1.2

What’s in scope? 1st episode of acute back pain or a recurrence but has been pain free for preceding 6 months Acute radiculopathy What's Out of scope Chronic back pain and acute exacerbations of ongoing back pain Carl

Summary of Primary Care role Screen for red flags De-medicalise acute simple back pain by right messages from onset-all primary care team including receptionists Promote self management with standardised information and advice Sign-post the patient to self refer for physiotherapy assessment if still struggling with symptoms after 2weeks Use the StarT Back tool at 2 weeks or 2nd attendance by GP Do not refer for Xrays or MRIs unless red flags AJ

Red flags Trying to identify Central disc prolapse-cauda equina Spinal tumours and metastases Spinal infection Osteoporotic fractures Inflammatory disorders Vascular pain AJ

Red flags- make you think! H/O cancer Recent unexplained weight loss Progressive neurological symptoms, limb weakness Bilateral leg sciatica Positive Babinski ( upgoing plantars) Altered perineal sensation with reduced anal tone and squeeze Recent change in bladder/bowel control and or sexual function Fever/patient feeling systemically unwell Prolonged steroid use Unrelieved, continuous night pain New onset back pain < 16 and >60 Immunocompromised- steroids, diabetes, biologics and other immunosuppressants AJ

Second Presentation (1st presentation if had for 2/52 or more) GP or Self referral physio appointment Use 2nd page template Repeat red flags assessment If true radiculopathy and no improvement at review refer now to TTP STarT back questionnaire completed STarT scoring determines management Patient information leaflet to be given Obtain consent for patient contact details to be shared for the purposes of the survey AJ

Second Presentation continued STaRT Back – quick 9 questions decision aid – on template LOW RISK- 3 or less: no referral, be positive, reassure, continue activity, advise on return if concerns if worsens or goes on longer than 6/52 MEDIUM RISK-3+/9: refer routine TTP, but be positive they have still good chance of recovery naturally, continue encouraging movement, patient cancel appt if they do improve, otherwise if not they will be seen at 6/52 for TTP assessment with a view to appropriate therapy HIGH RISK- 4+ High pysch score/9: Urgent referral TTP ( 2 weeks), Often psychological obstacles to recovery. Remain positive and challenge avoidance behaviour. if GP concerned request TTP contact patient by phone either on form or by GP contacting TTP by phone

Subsequent attendances Ideally, the patient should not need to return to the GP, though may need fit notes if awaiting seeing TTP however, should the patient re-present, please use the 3rd page of the template title 3rd attendance/follow up so we can capture and quantify these attendances as part of the evaluation AJ

Timely return to work Return to work is more than a goal; work is therapeutic and aids recovery, it restores physical and mental capacity and improves self esteem and confidence Once a worker off for 4 – 12 weeks, have a 10%-40% risk of still being off work at one year. After 6 months of sickness from LBP, less than 50% chance of returning to their job Try and encourage to remain at work unless impractical or unsafe to do so RTW should be a major goal of rehabilitation (Hazard et al 1996)

GP Template Click below for EMIS WEB template Click below for SystmOne VISION - COMING SOON

Evaluation of pathway Consent for releasing contact details on template for 1st attendance or if late 1st presentation on 2nd page template Inhealthcare will be collecting patient information as part of the evaluation process via an app that will be installed on each computer Further details to follow…. This stage of the pathway rollout is subject to a robust evaluation process by Teesside University funded by the Health Foundation who are supporting the whole project. Learning the lessons whether we are successful or not. The patient and practitioner experience will be sought as part of this work. Those seen in MSK services will have their journey captured by the services they attend, however to get a population view we are trying to capture a proportion of everyone who attends in the 1st 7 days of symptoms anf then they will be approach if the consent, to being re-surveyed at 6 months. The output is only as good as the input. Please remember to ask the patient if they consent to a contact number or e mail being taken PURELY to inform them of what the survey will entail, usually on line and these numbers will be assimilated on a weekly basis from the practices. The patient will then on contact be in formed of what the survey will entail and they can agree or not to take it any further at this stage.

Resources/Help available GP Template Regional Back Pain website live from January 2015 http://www.noebackpainprogramme.nhs.uk Your local TTPs!! CSO’s within your practice RBPP Project Team - rbpp.project@nhs.net