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

2. 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

3. 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

4. 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

5. 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

6. 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**

7. MRI is harmful in many cases

8. 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)

9. 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

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

11. 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)

12. Pain quiz
TRUE/FALSE
Pain is produced by peripheral nociceptors

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

14. Pain quiz
TRUE/FALSE
Crossing your arms reduces pain

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

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

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

18. From: Explain Pain, Butler and Moseley, 2003

19. Pain quiz
Definition of pain?

20. 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)

21. 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)

22. 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

23. 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

25. 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

26. 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

30. 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

31. 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

32. 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)

35. SACS MDT
Broadmeadows and Bundoora
Pain clinic

36. 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

38. 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.