Are you getting the best treatment

for your low back pain?

Paula Salmon and Carol Doyle
Community Business Unit Physiotherapy Service
East Cheshire NHS Trust
Health Matters
Tuesday 4th February 2014
 Who are we?
Paula Salmon
Extended Scope Practitioner
Lead for Physiotherapy Back Pain Service
Carol Doyle
Clinical Physiotherapist at GP Surgery Physiotherapy
Research Facilitator

Community Adult Physiotherapy Services

East Cheshire NHS Trust
 Why are we here?
• To present to you the latest thinking on low back
pain
• To update you on the best evidence for the
treatments available
• To share with you what our physiotherapy service
can offer
• To give you a better understanding on how to
help yourself
 Have you had low back pain?
1. How many of you have ever
had back pain?

2. How many of you seek help

for your back pain?

3. How many of you have ever

had physiotherapy for your
back pain?

‘George’s story’
 What is back pain?
• Back pain is common
• 8 out of 10 people will suffer
back pain at some time
• Majority of people have
nothing seriously wrong
• Costs to NHS and Society huge
- £10668 million!*
*Maniadakis et al. The economic burden of back pain in
the UK. 2000
 How is the back structured?
• 24 spinal vertebrae
• 5 lumbar vertebrae
Cervical spine
• Joints
• Discs Thoracic spine

• Nerves
Lumbar spine
• Muscles
Sacroiliac joint
• Strong Coccyx

• Natural ageing &

stiffness
Facet joint
Vertebra
Nerve roots from spinal cord to leg
Disc
 What causes back pain?
Most cases, cause is unclear
 poor posture
 lack of exercise
 muscle strains and sprains
Some conditions have specific causes
Spondylosis – ‘wear and tear’
Sciatica – ‘leg pain’
Stenosis – ‘nerve tightness’
 Should I see my doctor about my
back pain?
• Immediately
• If you have problems passing or controlling urine
• Lose control of bowels
• Lose sensation around your genitalia or back passage
• Weakness in your legs/ become unsteady on your feet
• If your pain
• Is very severe or persists for a long time
• Affects your everyday activities
 How can I help myself?

 Painkillers can keep you moving

 Regular exercise e.g. swimming, walking, pilates,
yoga, going to gym
 Check posture frequently
 Lift things correctly
 Watch your weight
 Stay at work if possible
 Keep positive!
 Why do back problems become
chronic?
• Not always a reason
• Common to start avoiding normal movement and
activities……..
• Not exercising / muscles weaker………
• Lose confidence……….
• Affect work, social and personal relationships……..
• Get anxious / depressed……..
Vicious cycle!
 What is the outlook for back pain?
• 75 – 90% recover within in a few weeks
• Relapses are common
• For those with persistent pain, only a 1/3 fully
recover
• Most lead normal life and able to work
• Emotional response to back pain important to
recovery e.g. worried, depressed
How are back problems diagnosed?
• A thorough assessment should be able to provide
a diagnosis.
• Xray – do I need one?
• Only a few people with back pain require further
investigations:
– Magnetic resonance imaging (MRI)
– Computerised tomography scan (CT)
– Blood tests
 What treatments are there for back
pain?
• NICE guideline (National Institute for Health and Care
Excellence)*
• specific exercise
• manual therapy
• Acupuncture
• Combined psychological and physical therapy

• Surgery or injections may be considered

*CG88 Low Back Pain: NICE Guideline 2009

 Myths for treatments!

X Bed rest
X Lumbar supports
X Electrical treatments e.g. Laser therapy,
interferential, therapeutic ultrasound
X Traction
X TENS machines – limited use in low back pain
What if my back pain is affecting my
work?

Work is good for you! – financial and social

Stay at work or get back as soon as possible
Keep in touch with your employer
Discuss what can be done to help you when you
return e.g. light duties, changing hours
Occupational advisor may help e.g. adjustments to
your workplace
 What exercises can I do?
• Stretching
• Strengthening e.g pilates
• Hurt does not always mean harm!
• Remember to gradually build up
• GP’s can give you sheets of exercises
• Physiotherapists provide individualised exercises
which can be supervised and progressed
Research and new developments for
back pain
• NEW model in GP practices*
– Grouping patients for treatment according to
risk factors for persisting back problems
– Targeted treatments for different risk groups
given by physiotherapists
– Clinically and cost effective!

What are these risk factors?

*Hill et al. A randomised controlled trial and economic evaluation of stratified
primary care management for low back pain compared with current best practice:
The STarT Back trial Lancet 2011
 Risk Factors (persisting problem)
Anxiety / distress / Stress
BMI / Obesity
Bothersomeness
Catastrophising beliefs /
Perceived risk of not
recovering
Coping catastrophising score
Coping strategies / styles
Days in pain
Depression
Disability
Dissatisfaction with care
Duration
Duration of sick leave
Educational status
Expectations of treatment
Family history of low back pain
or chronic pain
Fear avoidance behaviour /
beliefs
Fear-avoidance work beliefs
Female gender
Frequent consultation
Gradual onset of pain
Height (lower)
History of low back pain
Job dissatisfaction (lack of
stimulating work tasks)
Manual labour
Number of localisations
Older age
Pain elsewhere
Pain intensity
Pain on coughing
Pain radiating to the leg or sciatica
Pain worse on standing
Pain worse when lying
Physical activity
Restricted spinal movements at
presentation
Self-rated health / Well-being
Smoking
Somatization
Straight-leg raising tests of less
than 60° in either leg
Unemployment
Work absence
Workers compensation status
 Which risk factors?
Anxiety / distress / Stress
BMI / Obesity
Bothersomeness
Catastrophising beliefs /
Perceived risk of not
recovering
Coping catastrophising score
Coping strategies / styles
Days in pain
Depression
Disability
Dissatisfaction with care
Duration
Duration of sick leave
Educational status
Expectations of treatment
Family history of low back pain
or chronic pain
Fear avoidance behaviour /
beliefs
Fear-avoidance work beliefs
Female gender
Frequent consultation
Gradual onset of pain
Height (lower)
History of low back pain
Job dissatisfaction (lack of
stimulating work tasks)
Manual labour
Number of localisations
Older age
Pain elsewhere
Pain intensity
Pain on coughing
Pain radiating to the leg or sciatica
Pain worse on standing
Pain worse when lying
Physical activity
Restricted spinal movements at
presentation
Self-rated health / Well-being
Smoking
Somatization
Straight-leg raising tests of less
than 60° in either leg
Unemployment
Work absence
Workers compensation status
 The STarT Back Screening Tool

Items included:
Referred leg pain
Pain elsewhere
Disability
Fear avoidance
Anxiety
Catastrophising
Depression
Overall impact
Screening for risk factors

• Brief tool
• Takes 2 minutes to complete
• Places patients into low ,
medium or high risk groups
• Designed to help clinicians
target your treatment
 Grouping patients

At first contact with a GP

55% of patients are at low risk of persisting problems

33% of patients are at medium risk of persisting problems

12% of patients are at high risk of persisting problems

 NEW model (STarT Back)

Screening for Risk Matched pathways

Factors into Groups For Targeted Treatment

+
 Matched pathways

Skilled physiotherapists to address emotional factors High

12%

Course of physical therapy by physiotherapists Medium risk

33%

Minimal treatment of advice & medication

Low risk
GPs and Physiotherapists
55% Risk
 Targeted treatment

1. Low risk group – 2. Medium risk - 3. High risk -

Minimal treatment physiotherapy Enhanced
physiotherapy
• Assessment As low risk group As medium risk group
• Discuss any worries + +
or concerns •Tailored individual •A combination of
• Encourage stay fit programme of physical physical treatments and
and active treatment treatments to address
• Use of medication •Promote self the emotional responses
• Flare up management to back pain
management •Minimise disability
 Are we working to best practice?

• NICE guidelines (National Institute for

Health and Care Excellence)
 Audit 2010 and 2013 – 100% success!

• New Model (STarT Back)

 Audit 2013 – 100% success!
 ‘The Truth About Back Pain’

www.youtube.com/watch?v=qh7j1xXriVM
George’s story
Acknowledgements
 Questions ?

www.arthritisresearchuk.org/arthritis-information/conditions/back-pain.aspx