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Back to Backs Trent Occupational Medicine Symposium. Philip Sell UHL and NUH 6 th October 2011. 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


6th October 2011

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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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Time course of back pain

  • 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??



Adams et al 2006

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Epidemiology in low back pain

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


Low back pain is a common complaint among adolescents.

similar pattern to adults

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Health problem does NOT equal a medical problem

  • 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

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

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The overall perspective

Societal burden equal to depression, heart diseases or diabetes

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

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Back Pain EpidemiologyKey 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.

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    A RCT of a novel Educational booklet in Primary Care Spine Vol 24 Number 23 Dec 1999

    • reduced re-attends

    • clinically important improvement in disability

    • Improved beliefs

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    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.

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    Cascade of care

    • Simple to complex

    • Bothersomeness and function

    • Effective therapies

    • NICE CG 88 Non specific low back pain

    • Evidence based


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    UK occupational health guidelines

    • 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:

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    Work caused or work-relevant?

    • 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.

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    Acute Low Back Pain

    • Simple Back ache

    • Nerve root pain

    • Possible serious spine pathology

    • Cauda equina syndrome

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    • Red Physical risk factors Serious Spine Disorders

    • Yellow The personPsychosocial obstacles

    • BlueWork Workplace

    • BlackAdministrative obstaclesContext

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    Red Flags

    • Age above 55 and new onset back pain

    • Widespread neurology

    • Progressive and unremitting pain

    • Previous history of cancer

    • Weight loss

    • Deformity

    • Failure to improve

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    Red Flags


    Sensitivity Specificity

    Age >= 5077 71

    Previous cancer31 98

    Unexplained weight loss15 94

    Failure to improve 1/1231 90

    No relief in bed>90 46

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    Tackling Musculoskeletal Problems

    a guide for clinic and workplace

    identifying obstacles using the psychosocial flags framework

    Kendall, Burton, Main, & Watson: TSO Books, 2009




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    • WORK



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    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

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    • Cconflicting diagnosis or explanations for back pain

    • Dramatisation of back pain by health professionals

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    • Belief that work is harmful or will do damage

    • Work history job dissatisfaction, frequent changes

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    • Use of extended rest

    • Withdrawal from activities of daily living

    • Poor compliance with exercise

    • High intensity pain (VAS 10)

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    • Positive expectation

    • Review progress

    • Keep the individual active and at work

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

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    • Acknowledge difficulties

    • Encourage ‘well behaviors’

    • If complex obstacles to management refer to multidisciplinary team

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    All players onside

    • shared beliefs

    • shared goal

    • flexible approach

    • coordinating their actions……

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    Functional Restoration Programs

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    SPINE Volume 36, Number 21S, pp S1–S9October 2011

    Chronic Low Back Pain

    A Heterogeneous Condition With Challenges for an Evidence-Based Approach

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    Degenerative MRI Changes in Patients WithCLBP

    • 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

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    Key Points

    • 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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