1. Low Back Pain Dr Mike England Medical Director RFU Community Rugby & RFU Injured Players Foundation

3. Outline Assessment –History –Examination – key points Common conditions Postural Control (Practical!!)

4. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Clinicians should conduct a focused history and physical examination to help place patients with ow back pain into 1 of 3 broad categories: –nonspecific low back pain, –back pain potentially associated with radiculopathy or spinal stenosis, –back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain

5. Assessment of LBP Rule out serious pathology ‘Red Flags’ Confirm that the pain: Is in the lower back - always assess the hip joint Is mechanical — aggravated or relieved by certain movements or postures. Is not inflammatory — that is: Not worse in the second half of the night or after waking. Not associated with morning stiffness lasting more than 30 minutes. Not relieved by activity. Not associated with laboratory tests for inflammation Exclude specific causes of low back pain

6. Classification of LBP Conventionally low back pain is categorised according to its duration as: – acute (<6 weeks), –sub-acute (6 weeks - 12 weeks) –chronic (>12 weeks) (Spitzer, W. O. and Leblanc, F. E., 1987).

7. Copyright ©2002 BMJ Publishing Group Ltd. Main, C. J et al. BMJ 2002;325:534-537 No Caption Found

8. Red Flags Red flags for the cauda equina syndrome include: – Saddle anaesthesia. – Recent onset of bladder dysfunction or faecal incontinence. – Major motor weakness. Red flags that suggest spinal fracture include: – Sudden onset of severe central pain in the spine which is relieved by lying down. – Major trauma such as a road accident or fall from a height. – Minor trauma, or even just strenuous lifting, in people with osteoporosis. – Structural deformity of the spine. Red flags that suggest cancer or infection include: – Onset in a person over 50 years, or under 20 years, of age. – History of cancer. – Constitutional symptoms, such as fever, chills, or unexplained weight loss. – Intravenous drug abuse. – Immune suppression. – Pain that remains when supine; aching night-time pain disturbing sleep; and thoracic pain (which also suggests aortic aneurysm).

9. Yellow Flags Yellow flags are psychosocial barriers to recovery. They include: The belief that pain and activity are harmful. Sickness behaviours, such as extended rest. Social withdrawal, lack of support. Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress. Problems or dissatisfaction at work. Problems with claims for compensation or applications for social benefits. Prolonged time off work (e.g. more than 6 weeks). Overprotective family. Inappropriate expectations of treatment, such as low expectations of active participation in treatment.

10. Examination Observation + Tip Toe Palpation – muscle spasm/deformity/masses (Range of motion) Neurological tests Provocation tests : –SLR & Crossed SLR –(SLUMP) –(Femoral Nerve ST) Abdomen /Hip/Lower Limb Circulation

11. Investigation Do not offer X-ray of the lumbar spine for the management of non-specific low back pain. MRI for non-specific low back pain should only be performed within the context of a referral for an opinion on spinal fusion. Consider referral for MRI if sciatica persists > 6 weeks ESR/CRP if suspect cancer, infection, Ank Spond HLA B27 if suspect Ank Spond

12. Mangement Education Remain active Analgesia/ ? Heat Therapies: –Exercise –Manual therapy –Acupuncture –Psychological

13. Pharmacological Mnx Regular paracetamol Consider offering NSAIDs for short-term use when paracetamol is ineffective. Consider offering strong opioids for short-term use to people in severe pain. Consider referral to Pain Clinic for people who may require prolonged use of strong opioids. Consider offering a trial of tricyclic antidepressants. Not SSRIs for treating pain. Benzodiazepines & muscle relaxants Gadbapentin

14. Exercise Maintain a physically active lifestyle. Consider offering a structured exercise programme - stretching, low impact aerobic, and strengthening exercises aimed at all main muscle groups Offer supervised group exercise programmes in preference to one-to-one supervised exercise programmes.

15. Manual Therapy End range High velocity Small amplitude Physiotherapist Osteopath Chiropracter

16. Acupuncture/Injection Therapy Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks10. Do not offer injections of therapeutic substances into the back e.g. Nerve blocks, caudal epidural, prolotherapy

17. LBP - Referral for Surgery Completed a comprehensive package of care including a combined physical and psychological treatment programme and who have persistent severe non-specific low back pain for which the patient would consider surgery. People who have psychological distress should receive appropriate treatment for this before referral for spinal fusion. If spinal fusion is being considered, refer the patient to a specialist surgical service. Do not refer people for intradiscal electrothermal therapy (IDET), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) or radiofrequency facet joint denervation.

18. Specific Conditions Disc prolapse Spinal Stenosis Ankylosing spondylitis Spondylolysis

19. Disc Prolapse - Symptoms Neurological pain Back pain Sensory disturbances Muscle weakness Loss of reflexes Cramps

20. Disc prolapse - Management Bed Rest – max 48 hours Analgesia Remain active Referral Therapies: –Physiotherapy –? Caudal epidural –Surgery : Red Flags Failure to respond to conservative treatment

21. Sciatica - When to Refer Remember that motor deficits and bowel or bladder disturbances are more reliable than sensory signs. If red flags suggest a serious condition refer with appropriate urgency. If there is progressive, persistent, or severe neurological deficit: – Refer for neurosurgical or orthopaedic assessment (preferably to be seen within 1 week). If pain or disability remain problematic for more than a week or two: – Consider early referral for physiotherapy or other physical therapy. If, after 6 weeks, sciatica is still disabling and distressing: – Refer for neurosurgical or orthopaedic assessment (preferably to be seen within 3 weeks). If pain or disability continue to be a problem despite appropriate pharmacotherapy and physical therapy: – Consider referral to a multidisciplinary back pain service or a chronic pain clinic.

22. Red Flags There is difficulty with micturition. There is loss of anal sphincter tone and faecal incontinence. Saddle anaesthesia by the anus perineum or genitals. Widespread or progressive motor weakness in the legs or gait disturbance. Pain is constant, progressive and non-mechanical in nature. Sciatic symptoms are not resolving after four to six weeks of conservative treatment. The patient is systemically unwell. There is widespread neurology. There is structural deformity. ESR is abnormal.

23. Spinal Stenosis Leg pain on walking, eased by leaning forward or sitting, but not by standing still (unlike vascular claudication, where pain does improve after standing still). Normal peripheral circulation; normal straight leg raising (nerve root signs appear late). More likely in over-60s or ankylosing spondylitis.

24. Ankylosing Spondylitis Suspect in anyone with chronic or recurrent low back pain, fatigue and stiffness, especially if: They are a teenager or young adult. The back pain and stiffness is inflammatory (rather than mechanical). They have current or previous: – Buttock pain – Arthritis - predominately asymmetric and in the lower limbs. – Enthesitis, costochonditis or epicondylitis. – Anterior uveitis (iritis) – Psoriasis or inflammatory bowel disease, or recent infective diarrhoea or sexually transmitted disease

25. Spondylolysis and - listhesis Defect and subluxation between vertebrae Commonest level – L5/S1 Defect may be uni or bilateral.

26. Risk Sports Occurs in sports which involve repetitive stresses across Pars Gymnastics Cricket Throwing Tennis Rowing

27. Clinical Presentation Asymptomatic Active young individuals Back pain Leg pain Stiffness Deformity Gait

28. Grades of Spondylolisthesis Grade 1 Grade 2 Grade 3 Grade 4

29. “Core Stability” TA activated before movements of limbs delayed in back pain Multifidis activation = good postural control ? Quadratus lumborum Rehab more effective if re-education of postural muscles incorporated Recurrence rate of LBP reduced if postural control incorporated in rehab