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Back to Backs Trent Occupational Medicine Symposium. Philip Sell UHL and NUH 6 th October 2011. www.spinesurgeons.ac.uk. Population based intervention to change back pain beliefs and disability:three part evaluation. Rachelle Buchbinder et al BMJ no 7301 23 June 2001.

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Back to backs trent occupational medicine symposium l.jpg

Back to BacksTrent Occupational Medicine Symposium

Philip Sell

UHL and NUH

6th October 2011



Population based intervention to change back pain beliefs and disability three part evaluation l.jpg

Population based intervention to change back pain beliefs and disability:three part evaluation

Rachelle Buchbinder et al

BMJ no 7301 23 June 2001


Time course of back pain l.jpg
Time course of back pain and

  • LBP is a recurrent phenomenon

    • at all ages

  • Untidy pattern across the life course with variable periodicity and severity.

  • Coexisting symptoms (physical and mental) common

  • Are chronic cases such from beginning or are they result of failed early treatment??

Episode

Lifetime

Adams et al 2006


Epidemiology in low back pain l.jpg
Epidemiology in low back pain and

Symptom not a disease

cause unexplained in 85%

data are self-reported - questionnaires:

tell us about how people experience LBP

different questions give different numbers

Consequences more of a problem than symptoms

care seeking

sick leave

disability

Low back pain is a common complaint among adolescents.

similar pattern to adults


Health problem does not equal a medical problem l.jpg
Health problem does NOT equal a medical problem and

  • Reasons for care seeking are complex

  • Person not always seeking a fix

  • Reassurance may be enough

    • 'My back hurts, but the reason I'm here is that I can't cope on my own any longer' (Hadler 1999)


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Genetics / Individual and

Twins studies, controlling for environmental (occupational) factors:

70% of disc degeneration associated with genetic factors

Heritability of back pain possibly >50%

Muscle strength and level of fitness have little influence


The overall perspective l.jpg
The overall perspective and

Societal burden equal to depression, heart diseases or diabetes

Production loss (due to absenteeism and disability) far greatest impact


Back pain epidemiology key messages l.jpg
Back Pain Epidemiology and Key Messages

  • LBP- Data demonstrate substantial nonbiologic influences

  • Heritability of back pain possibly higher than 50%

    • 70% of disc degeneration associated with genetic factors

    • Production loss (due to absenteeism and disability) has the greatest impact on the ecmonic burden of back pain

    • An early investment in correct evidence based care can generate long term cost saving.


  • A rct of a novel educational booklet in primary care spine vol 24 number 23 dec 1999 l.jpg
    A RCT of a novel Educational booklet in Primary Care and Spine Vol 24 Number 23 Dec 1999

    • reduced re-attends

    • clinically important improvement in disability

    • Improved beliefs


    Slide11 l.jpg

    Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 2002 95: 49-63. EM Haland Haldorsen et al.


    Cascade of care l.jpg
    Cascade of care Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Simple to complex

    • Bothersomeness and function

    • Effective therapies

    • NICE CG 88 Non specific low back pain

    • Evidence based

    • FUNCTIONAL RESTORATION PROGRAMS


    Uk occupational health guidelines l.jpg
    UK occupational health guidelines Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Individual psychosocial findings are a risk factor for the incidence (onset) of LBP, but overall the size of the effect is small.

    • Unsatisfactory psychosocial aspects of work are risk factors for reported LBP, health care use, and work loss, but the effect size is modest.

    • Individual and psychosocial aspects of work play an important role in persisting symptoms and disability, and also influence response to treatment.

    Carter & Birrell 2000: www.facoccmed.ac.uk


    Work caused or work relevant l.jpg
    Work caused or work-relevant? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Whilst some (episodes of) low back pain may be caused by work, most are not.

    • Yet, symptoms may affect workability

      • work can be difficult/painful because of symptoms

        • consequences are driven more by psychosocial than physical factors.

    • LBP may be highly work-relevant, irrespective of cause.


    Acute low back pain l.jpg
    Acute Low Back Pain Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Simple Back ache

    • Nerve root pain

    • Possible serious spine pathology

    • Cauda equina syndrome


    Flags l.jpg
    Flags Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Red Physical risk factors Serious Spine Disorders

    • Yellow The person Psychosocial obstacles

    • Blue Work Workplace

    • Black Administrative obstacles Context


    Red flags l.jpg
    Red Flags Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Age above 55 and new onset back pain

    • Widespread neurology

    • Progressive and unremitting pain

    • Previous history of cancer

    • Weight loss

    • Deformity

    • Failure to improve


    Red flags18 l.jpg
    Red Flags Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    Cancer

    Sensitivity Specificity

    Age >= 50 77 71

    Previous cancer 31 98

    Unexplained weight loss 15 94

    Failure to improve 1/12 31 90

    No relief in bed >90 46


    Slide19 l.jpg

    Tackling Musculoskeletal Problems Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    a guide for clinic and workplace

    identifying obstacles using the psychosocial flags framework

    Kendall, Burton, Main, & Watson: TSO Books, 2009 www.tsoshop.co.uk/flags

    PERSON

    WORKPLACE

    CONTEXT


    Yellow flags l.jpg
    YELLOW FLAGS Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • ATTITUDES AND BELIEFS

    • EMOTIONS

    • DIAGNOSIS AND TREATMENT

    • FEAR AND BELIEFS

    • WORK

    • FAMILY AND CARERS

    • COMPENSATION ISSUES


    Www tsoshop co uk flags l.jpg
    www.tsoshop.co.uk/flags Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.


    Catastrophising l.jpg
    Catastrophising Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    Evaluation

    Questions to ask

    When you are in pain do you think it is terrible and will never get better?

    Does pain feel overwhelming to you?

    • Identify interpretations of symptoms bodily sensations or persons situation that are out of proportion

    • This leads the patient to a sense of unease

    • A lack of feeling of control


    Mixed messages l.jpg
    MIXED MESSAGES Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Cconflicting diagnosis or explanations for back pain

    • Dramatisation of back pain by health professionals


    Slide24 l.jpg
    Work Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Belief that work is harmful or will do damage

    • Work history job dissatisfaction, frequent changes


    Behaviors l.jpg
    Behaviors Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Use of extended rest

    • Withdrawal from activities of daily living

    • Poor compliance with exercise

    • High intensity pain (VAS 10)


    Action l.jpg
    Action Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Positive expectation

    • Review progress

    • Keep the individual active and at work

    • Communicate that time off work reduces probability of successful return to work


    Action27 l.jpg
    Action Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Acknowledge difficulties

    • Encourage ‘well behaviors’

    • If complex obstacles to management refer to multidisciplinary team


    All players onside l.jpg
    All players onside Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • shared beliefs

    • shared goal

    • flexible approach

    • coordinating their actions……


    Functional restoration programs l.jpg
    Functional Restoration Programs Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.


    Spine volume 36 number 21s pp s1 s9 october 2011 l.jpg

    SPINE Volume 36, Number 21S, Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. pp S1–S9October 2011

    Chronic Low Back Pain

    A Heterogeneous Condition With Challenges for an Evidence-Based Approach


    Degenerative mri changes in patients with clbp l.jpg
    Degenerative MRI Changes in Patients With Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. CLBP

    • There is insufficient evidence to support the routine use of MRI

      • Strength of recommendation: Strong

    • Surgical treatment of CLBP based exclusively on MRI findings of degenerative changes is not recommended.

      • Strength of recommendation: Strong


    Key points l.jpg
    Key Points Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain.

    • Current low back pain management is fragmented into five major management spheres, which have little or no interactions with one another.

    • Chronic LBP is a heterogeneous condition and this affects the way it is diagnosed, classified, treated,andstudied.

    • While nonoperative approaches are the mainstay of management of LBP, surgery offers improved outcomes in carefully selected patients.

    • There is an urgent need for large national registries to track the natural history and outcomes of treatments for chronic LBP.


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