1. LOW BACK PAIN The GPs Problem

2. The GPs Problems Lots of patients Precise diagnosis is difficult Changing guidelines - triage - what helps and what doesn’t? Can we help those with chronic pain?

3. Lots of patients Back pain reported by 60% people at some time in their life 1993 - 14 million GP consultations 1993 - Cost to NHS app £480 million 1993 - Lost production costs app £3.8 billion 1993 - DSS benefits app £1.4 billion

4. Prevention Change the environment - ergonomics Change the individual - morphology Change attitudes - education

5. Improved management Improved management of Acute LBP  less time out of action/off work  fewer patients with chronic or recurrent LBP Improved management of Chronic LBP  less long term disability

6. The GPs Problems Lots of patients Precise diagnosis is difficult Changing guidelines - triage - what helps and what doesn’t? Can we help those with chronic pain?

7. Diagnosis is difficult (1) Anatomical complexity - vertebrae/discs/ligaments/ muscles/SI joints “The mobile segment” - discs - facet joints - muscles and ligaments at each level = indissoluble mechanical entity

8. Diagnosis is difficult (2) Nociceptors in all tissues except disc + synovial membrane Stimulation of any of these may cause muscle spasm which may or may not be painful Referred pain - 2 or more sources may refer to the same site Tenderness - may be produced by local sensitisation nociceptors but may exist in normal tissue eg at site of referred pain

9. Diagnosis is difficult (3) Social factors Psychological factors

10. The GPs Problems Lots of patients Precise diagnosis is difficult Changing guidelines - triage - what helps and what doesn’t? Can we help those with chronic pain?

11. Acute LBP - changing guidelines Go to bed US Agency for Health Care Policy and Research (AHCPR) 1994 UK Clinical Standards Advisory Group (CSAG) 1994 RCGP 1996

12. Acute low back pain - Triage Aims to differentiate between :-  Simple backache (non specific LBP)  Nerve root pain  Possible serious spinal pathology

13. Simple backache Age 20 - 55 years Lumbosacral, buttocks, thighs “Mechanical” pain Patient well

14. Nerve root pain Unilateral leg pain worse than low back pain Radiation to foot or toes Numbness and parasthesia in same distribution SLR reproduces pain Localised neurological signs (eg loss ankle jerk)

15. Red flags for possible serious pathology  age 55  Non mechanical pain  Thoracic pain  PMH carcinoma, steroids, HIV  Generally unwell, weight loss  Widespread neurology  Structural deformity

16. Cauda Equina Syndrome  Sphincter disturbance  Gait disturbance  Saddle anaesthesia

17. Assessment Triage based on history and examination In simple backache XR not routinely indicated Psychosocial factors are important

18. The GPs Problems Lots of patients Precise diagnosis is difficult Changing guidelines - triage - what helps and what doesn’t? Can we help those with chronic pain?

19. Rest or Activity 9 RCTs show bed rest for 2-7 days is worse than ordinary activity 8 RCTs show advice to continue ordinary activity gives better results than the traditional “let pain be your guide” advice Aim is to use symptomatic measures to control pain and so allow activity

20. Drugs Prescribe regularly not prn start with paracetamol NSAIDs (differing side effect rates) NSAIDs less effective for nerve root pain paracetamol and weak opioid combination Muscle relaxants (diazepam) are effective

21. Manipulation “Within 6 weeks of onset of acute or recurrent low back pain, manipulation provides better short term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared”

22. Back exercises “on the evidence available at present, it is doubtful that specific back exercises produce clinically significant improvement in acute LBP” but “McKenzie exercises may produce short term symptomatic improvement in acute LBP” “Strong theoretical arguments for commencing exercise programs by 6 weeks”

23. Other treatments Ice and heat Massage Ultrasound TENS Shoe inserts Acupuncture Trigger point injections Facet joint injections Corsets Epidurals

24. Evidence against Bed rest with traction MUA Plaster jackets Benzodiazepines >2wks

25. The GPs Problems Lots of patients Changing guidelines - triage - what helps and what doesn’t? Can we help those with chronic pain?

26. Risk factors for chronicity Previous history low back pain Nerve root involvement Poor physical fitness Self rated health poor Heavy smoking Psychological distress and depressive symptoms Disproportionate illness behaviour Low job satisfaction Personal problems eg marital, financial Ongoing medicolegal proceedings

27. Aspects of treating chronic pain  Psychological  Physical  Pharmacological  Procedural  Rehabilitation