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The GPs Problem. LOW BACK PAIN . 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?. Lots of patients. Back pain reported by 60% people at some time in their life

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The gps problem l.jpg

The GPs Problem

LOW BACK PAIN


The gps problems l.jpg
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?


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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


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Prevention

  • Change the environment - ergonomics

  • Change the individual - morphology

  • Change attitudes - education


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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


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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?


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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


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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


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Diagnosis is difficult (3)

  • Social factors

  • Psychological factors


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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?


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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


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Acute low back pain - Triage

  • Aims to differentiate between :-

    • Simple backache (non specific LBP)

    • Nerve root pain

    • Possible serious spinal pathology


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Simple backache

  • Age 20 - 55 years

  • Lumbosacral, buttocks, thighs

  • “Mechanical” pain

  • Patient well


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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)


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Red flags for possible serious pathology

  • age <20 or >55

  • Non mechanical pain

  • Thoracic pain

  • PMH carcinoma, steroids, HIV

  • Generally unwell, weight loss

  • Widespread neurology

  • Structural deformity


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Cauda Equina Syndrome

  • Sphincter disturbance

  • Gait disturbance

  • Saddle anaesthesia


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Assessment

  • Triage based on history and examination

  • In simple backache XR not routinely indicated

  • Psychosocial factors are important


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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?


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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


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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


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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”


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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”


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Ice and heat

Massage

Ultrasound

TENS

Shoe inserts

Acupuncture

Trigger point injections

Facet joint injections

Corsets

Epidurals

Other treatments


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Evidence against

  • Bed rest with traction

  • MUA

  • Plaster jackets

  • Benzodiazepines >2wks


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The GPs Problems

  • Lots of patients

  • Changing guidelines

    - triage

    - what helps and what doesn’t?

  • Can we help those with chronic pain?


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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


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Aspects of treating chronic pain

  • Psychological

  • Physical

  • Pharmacological

  • Procedural

  • Rehabilitation


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