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Chapter 11 - part 2
Illustrative patient pathway
to self care: back pain
How would you demonstrate that you have achieved your outcomes?
| Consider Tools 9 or 12 for reviewing outcomes |
- Feedback (informal and formal) from patients and carers about their self care of
back pain.
- Practice manager records absences for back pain among staff before and after the
back care classes, and examines any episodes sustained at work for avoidable
factors.
- Comparison of the rates of re-attendance with further episodes of back pain among
those patients who attended with a first attack before and after the introduction of
the information about prevention, management and self care.
- Comparison of consultation rates for back pain before and after the project.
- Self-rating and peer discussion of the care of acute, sub-acute and chronic back
pain by GPs.
- Comparison of referrals rated as inappropriate by the physiotherapy service before
and after the project.
- Comparison of the number and types of referrals to secondary care orthopaedic or
pain services before and after the project.
- Significant event audit of any failures to identify and refer those few patients requiring medical input for acute back pain.
Table 11.1: Role and responsibilities checklist
For each task tick the box for each team member who has a role or responsibility - then note
your role and responsibilities for the task.
Section 2 Self care for back pain
How big is the problem?
Around 4%of consultations with GPs are for low back pain. More than seven out of ten people in developed countries will have back pain at some time in their lives and between 15% and 45% of adults suffer low back pain each year.5 Around 4.9 million working days are lost due to back pain every year, costing British industry billions of pounds.7 Around 70% of people who are on sickness absence due to back pain will return to work within one week, and 90% return within two months. The longer the period of sickness absence with back pain, the less likely it is that someone will return to work.
Symptoms
Pain and muscle tightness or stiffness in the back between the lower ribs and the top of the legs is the commonest complaint. Pain going down the leg (sciatica) may be present. Back pain is classified into:
- acute: lasting under six weeks
- sub-acute: lasting between 6 and 12 weeks
- chronic: lasting more than 12 weeks.
Symptoms, pathology and X-ray appearances are poorly correlated and most people have non-specific mechanical pain that cannot be accurately categorised. About4%of people with low back pain have compression fractures and around 1% have tumours. A prolapsed intervertebral disc is only present in 1-3%. Ankylosing spondylitis and infections are rare.5
Risk factors
Back pain is more likely in those people who do heavy physical work, frequent bending, twisting and lifting, suffer whole body vibration, or remain in one position for a long time. Psychosocial factors (often known as ‘yellow flags’) include anxiety, depression and mental stress at work. Most people developing low back pain are adults aged 20–55 years and are otherwise well.7
Self care advice and guidance: take PART
Think of the range of advice and guidance about self care you might give to patients who consult you with back pain (see Box 11.1).
Box 11.1: Range of self care advice and guidance for back pain to give to patients or their carers P Programmes for the general public for the prevention of back pain are mainly run by public health, governmental organisations, voluntary agencies and employers. PCTs, general practice teams, pharmacies, and other health care departments may want to run their own prevention programmes. Workplace initiatives can help to prevent back pain, the commonest form of ill health at work.7 Education projects in schools can help children to be more aware of their posture, how they use their backs and what causes back pain.8 Midwives,9 district nurses and health visitors can educate individuals or groups. GPs, physiotherapists and other physical therapists who see people who have already had an episode of back pain, can help people to avoid recurrences.10,11 Avoiding manual lifting by using machines and aids, learning to lift properly and how to stand and sit with proper support, as well as flexibility and strengthening exercises should be included in the programmes. A Await resolution: most people with acute back pain have sufficient improvements in pain and disability to return to work within one month. Further improvements occur up to three months, after which pain and disability remain almost constant. Low levels of pain and disability may persist from three to at least 12 months. Most people will have at least one recurrence within 12 months.12 A safety net of advice on warning signs of more serious conditions is needed.13 You could use the algorithmon self care for backache in adults produced by NHS Direct.4 R Advice on self care for relief of symptoms (see Box 11.2). T Many of the activities suggested above are also applicable to tolerating symptoms from long term back pain: Clinical Evidence provides evidence for various strategies to care for chronic back pain.5 |
Box 11.2: Advice on relief of symptoms by self care of back pain to give to patients or their carers
|
Alarm symptoms or signs (red flags)
- Age outside the usual range should prompt a medical review for causes other than
simple mechanical pain. Mechanical back pain in children is more common than
previously thought; around 13% of teenagers experience recurrent mechanical
low back pain.14
- Associated pain in the abdomen with a pulsating sensation; or pain in the chest and
upper back made worse by a severe cough or wheeze (may be a dissecting
aneurysm – especially in someone over 60 years old).
- Presence of fever or rigors (shivering attacks), being generally unwell, loss of
weight or severe unrelenting pain, including at night, suggests infection or
cancer.
- Pain that worsens with walking, that goes into both legs, with or without leg
weakness, and is associated with relief by bending forward, may be due to spinal
stenosis and should be referred urgently to secondary care.
- Radiation of pain into both legs may be due to a central disc herniation, cancer or
an inflammatory condition, and requires further investigation.
- Numbness in the genital area and around the back passage, incontinence or
difficulty with bladder or bowel emptying, ormuscle weakness may be due to spinal
cord compression, and requires immediate referral.
- A history of recent injury, HIV infection or other immunosuppression or a past
history of cancer requires further investigation.
- Persistent pain and stiffness in a person under 40 years old suggests spondylitis.
Other diagnoses
If other symptoms accompany the back pain, for example, burning when passing urine, a pain that moves from one side of the back to the groin, upper back pain with a cough and fever, assessment by a health practitioner is required. A long list of differential diagnoses for back pain accompanied by other symptoms appears in the Prodigy guidelines.14
Investigations
Taking an X-ray of the lumbar spine is not useful in mechanical low back pain. X-rays expose the patient to harmful radiation and increase the workload and costs for the NHS with no improvement in clinical outcomes. Magnetic resonance imaging is the best procedure if symptoms and signs suggest nerve root compression or a tumour. Blood tests may be indicated if an inflammatory or neoplastic condition is suspected.
Treatments
- Advice to remain active has been shown to be the most effective treatment. Bed rest
is worse than no treatment.5
- Paracetamol is the first choice for pain relief because the risk of adverse effects is low, it is inexpensive and effective for mild pain. Codeine-containing pain relief is the next step up the pain control ladder.5
- NSAIDs have been shown to increase overall improvement after one week and
reduce the need for additional analgesia.5
- Cognitive behavioural therapy reduces acute low back pain and disability by
addressing psychosocial factors.5
- Muscle relaxants can be helpful for short term use, but there are dangers of
dependence, dizziness and drowsiness, especially with benzodiazepines.5
- Chronic back pain is usually treated with analgesics including opioids, antidepressants (most trials have used amitriptyline) and NSAIDs. Non-drug treatments such as spinal manipulation, back schools, exercise or physical conditioning treatment are likely to help. A summary of the evidence for other treatments appears in Clinical Evidence.13
References
1 Burton K. The Back Book. London: The Stationery Office; 2002.
2 Chambers R. Beat Back Pain (52 brilliant ideas series). Oxford: The Infinite Ideas Company
Ltd; 2005.
3 McKenzie R. Treat Your Own Back. New Zealand: Spinal Publications Ltd; 1997.
4 www.nhsdirect.nhs.uk
5 Tovey D (ed). Clinical Evidence Concise (13). London: BMJ Publishing Group; 2005.
www.clinicalevidence.com/ceweb/conditions/msd/1102/1102.jsp
6 McIntosh A and Shaw C. Barriers to patient information provision in primary care:
patients’ and general practitioners’ experiences and expectations of information for low
back pain. Health Expectations. 2003; 6: 19–29.
7 www.hse.gov.uk/msd/backpain
8 Airedale Physiotherapy Clinic. The Airedale Backcare for Children programme. In: Chartered
Society of Physiotherapists. Making Physiotherapy Count. London: Chartered Society of
Physiotherapists; 2004. www.csp.org.uk/sepp
9 www.pregnancy.com.au/back_pain_in_pregnancy.htm
10 www.positivehealth.com/permit/Articles/Back%20Pain/ablett24.htm
11 www.nhsdirect.nhs.uk/en.aspx?ArticleID=234
12 Pengel LHM, Herbert RD, Maher CG and Refshauge KM. Acute low back pain: systematic
review of its prognosis. British Medical Journal. 2003; 327: 323–5.
13 www.clinicalevidence.com/ceweb/conditions/msd/1116/1116.jsp?searchTerm=
chronic+back+pain
14 www.prodigy.nhs.uk/pk.uk/back_pain_lower
Illustrative patient pathway to self care: back pain 145