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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. NWH Community Pain Clinic. How can we support people with spinal pain?. Mags Wigram , ESP, Pain Management 6 th September 2013, N Spine, Nottingham. The Clinical Team.

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September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

www.nspine.co.uk

nwh community pain clinic

NWH Community Pain Clinic

How can we support people with spinal pain?

MagsWigram, ESP, Pain Management

6th September 2013, N Spine, Nottingham

the clinical team

The Clinical Team

Pain Consultant Dr Greg Hobbs

Advanced Physiotherapy Practitioner MagsWigram

Nursing Team:

Advanced Nurse Practitioner Paula Banbury

Advanced Nurse Practitioner and

Cognitive Behavioural Psychotherapist Kate Feenan

Clinical Nurse Specialist Julie Conners

the admin team

The Admin Team

Heidi Lewis

NWH Primary Care Patient Services Co-ordinator

Jo Faulkner and Alicia Shaw

NWH Administrators

David Hale

NWH Information and

Governance Co-ordinator

face to face triage

Face to face triage

  • 30 or 40 minute assessments,
  • History taking and physical examination,
  • Triage decision in agreement with patient.

Pain Consultant or Advanced Physiotherapist Practitioner,

face to face triage options

Face to face triage options

Urgent imaging or urgent referral direct to appropriate specialist,

Routine imaging (MRI, nerve conduction studies, x-ray),

Physiotherapy (Community or NUH),

Nottingham Back and Pain Team (via Advanced Nurse Practitioners),

Analgesia review, recommendations to GP,

Spinal injections (Dr Greg Hobbs),

Acupuncture (direct referral) or TENS (clinical nurse specialist),

Non urgent referrals to Spinal Surgeons,

Other e.g. Orthotics, NUH falls team.

recommendations for gp to instigate

Recommendations for GP to instigate

from analgesia review,

regarding blood screening,

regarding urgent or routine referrals on to other specialists (non-spinal) e.g. rheumatology, orthopaedics, vascular or medical specialties, oncology, mental health team,

Any other recommendations e.g. referral to dietician/nutritionist, local exercise schemes, community falls team.

neil history

Neil - History

47 year old police officer.

6/12 history of LBP with right buttock to calf pain.

GP ordered bloods (NAD) and x-ray (L5/S1 changes).

Able to remain at work but duties limited.

Avoids prolonged sitting and driving due to pain.

Affecting sleep, although amitriptyline helps.

Paracetamol ineffective, previous gastric ulcer (avoids NSAIDs), and didn’t like side effects of codeine.

Temporary relief only with chiropractor (massage) and physiotherapy (exercise advice).

neil physical examination

Neil - Physical examination

Lumbar flexion increases buttock and leg pain.

Unable to fully straighten right hip/knee in standing or lying due to buttock and leg pain.

Slight reduction in right calf bulk.

Right hamstrings relatively weaker.

Right achilles reflex slightly dull, but present.

Reduced sensation great toe and sole of foot.

neil triage discussion

Neil - Triage discussion

Lumbar MRI: Possible L5/S1 disc bulge with right S1 nerve root impingement.

Neil would consider nerve root block, but wants to avoid surgery and prefers not to use strong medication because he needs to concentrate at work.

Discussed possible diagnosis and prognosis, and agreed following MRI, options could be nerve root block if indicated and/or further physiotherapy.

For telephone review with results of MRI scan.

neil key considerations

Neil - Key considerations

Relatively acute – manage fears and expectations, explain diagnosis and reassure re prognosis.

Keep him out of secondary care, whilst this can still be managed conservatively.

Acknowledge and discuss concerns

Work demands and worries

Issues re analgesia use, side effects and work demands.

Support with advice, physiotherapy and nerve root block if indicated.

Longer term telephone follow-up via Clinical Nurse Specialist if required.

kathryn history

Kathryn - History

62 year old lady with long history of low back and right leg pain.

2004 L4/5 discectomy.

2008 developed right foot drop.

MRI showed L3/4 disc impinging right L4 nerve root.

Nerve conduction studies showed degeneration in the right peroneal nerve suggestive of proximal (spinal roots or plexus) lesion.

Under spinal clinic, had injections and eventually an L3/4 microdiscectomy 2010, with no improvement.

kathryn symptoms

Kathryn - Symptoms

No new symptoms since discharge from the spinal clinic in 2011.

Describes aching LBP radiating to thighs and knees in a generalised distribution.

Also has constant right dorsal ankle/foot pain, with episodes of numb spasm.

Pain worse with walking and walking distance limited to ¼ mile.

Owns a foot drop splint but never wears it because it is very uncomfortable with a poor fit.

Sleep disturbed by back, leg and foot pains.

kathryn treatment

Kathryn – Treatment

Physiotherapy: Since discharge from the spinal clinic two full courses, including manual therapy, exercises, TENS and acupuncture. At the end of her last course 10 months ago, was told there wasn’t any more that physiotherapy could offer.

Analgesia:

Codeine based medication caused constipation.

Still takes paracetamol and ibuprofen prn, but doesn’t think it helps.

Currently weaning off gabapentin to change to pregabalin. She has had previous M.I. so has not been prescribed amitriptyline.

kathryn social and emotional impact

Kathryn – Social and emotional impact

Kathryn owned a greengrocers, but had to give this up due to her back pain, and has not worked since.

She lives alone and her social contacts have reduced considerably in the last few years.

She keeps occupied by visiting her elderly father, and manages small spurts of housework resting between activities. She enjoys reading.

Her levels of pain concern her, because of how they limit her mobility and activity levels and her ability to care for her father.

She feels lonely and has been feeling very low recently.

kathryn physical examination

Kathryn – Physical examination

Limited lumbar range of movement all directions.

0/5 power in right EHL and dorsiflexors.

All other right lower limb muscle groups 4/5.

Right achilles reflex dull but present.

Reduced sensation in her right great toe and lateral calf.

Loss of passive dorsiflexion in her right ankle.

Borderline allodynia dorsal right foot.

kathryn triage discussion

Kathryn - Triage discussion

Discussion of mood, and whether she would like to access counselling or antidepressants via her GP.

Referral to Advanced Pain Nurse Specialist for assessment for CBT or ACT input including possible attendance at Nottingham Pain Management Programme.

Discussion with Pain Consultant regarding any further changes to analgesia, to be recommended to her GP.

Referral to Orthotics, NUH, for refitting of foot drop splint. Advice today re dorsiflexion stretches.

TENS was previously helpful but lost it. Book with Clinical Nurse Specialist for TENS issue and advice.

kathryn key considerations

Kathryn – Key considerations

Is just about coping but mood deteriorating.

Is despondent because thinks all treatment options have been exhausted, and because she feels people have given up on her.

Recognises there is no cure, but is hoping for improvements in her pain.

Has not fully explored CBT/ACT approaches.

Via community pain clinic, can access a wide range of services tailored to her particular needs.