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Trent Occupational Medicine
        Symposium

         Philip Sell
        UHL and NUH
       6th 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
                 Time course of back pain
                                 LBP is a recurrent
                                  phenomenon
                                     at all ages
SEVERITY




                                 Untidy pattern across the life
                                  course with variable
                       TIME
                                  periodicity and severity.
      Episode                    Coexisting symptoms
                                  (physical and mental)
                                  common
                                 Are chronic cases such from
SEVERITY




                                  beginning or are they result
                       TIME
                                  of failed early treatment??
      Lifetime
    Adams et al 2006
                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
    •   disability
   Low back pain is a common complaint among adolescents.
      similar pattern to adults
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)
          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
        The overall perspective


 Societal  burden equal to depression, heart
  diseases or diabetes
 Production loss (due to absenteeism and
  disability) far greatest impact
        Back Pain Epidemiology
            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

 reduced      re-attends

 clinically   important improvement in disability

   Improved beliefs
 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
 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

   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?
• 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
 Simple Back ache
 Nerve root pain
 Possible serious spine pathology
 Cauda equina syndrome
              Flags
 Red      Physical risk factors
           Serious Spine Disorders

 Yellow   The person
           Psychosocial obstacles
 Blue     Work
           Workplace
 Black    Administrative obstacles
           Context
              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
                 Red Flags
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
Tackling Musculoskeletal Problems
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
   ATTITUDES AND BELIEFS
   EMOTIONS
   DIAGNOSIS AND TREATMENT
   FEAR AND BELIEFS
   WORK
   FAMILY AND CARERS
   COMPENSATION ISSUES
www.tsoshop.co.uk/flags
                Catastrophising
Evaluation                       Questions to ask
 Identify interpretations of     When you are in pain do
  symptoms bodily                  you think it is terrible and
  sensations or persons            will never get better?
  situation that are out of
  proportion                        Does pain feel
 This leads the patient to a        overwhelming to you?
  sense of unease
 A lack of feeling of control
       MIXED MESSAGES
Cconflicting diagnosis or explanations
 for back pain

Dramatisation   of back pain by health
 professionals
                 Work
      that work is harmful or will do
Belief
 damage



Work history job dissatisfaction, frequent
 changes
               Behaviors
Use   of extended rest

Withdrawal   from activities of daily living

Poor   compliance with exercise

High   intensity pain (VAS 10)
               Action
Positive expectation
Review progress
Keep the individual active and at work
Communicate that time off work reduces
 probability of successful return to work
               Action
Acknowledge     difficulties
Encourage ‘well behaviors’
If complex obstacles to management
 refer to multidisciplinary team
All players onside


           shared   beliefs
           shared goal
           flexible approach
           coordinating their
            actions……
Functional Restoration
      Programs
SPINE Volume 36, Number 21S, pp S1–
                S9
           October 2011

       Chronic Low Back Pain
   A Heterogeneous Condition With
     Challenges for an Evidence-
           Based Approach
     Degenerative MRI Changes in Patients With
                      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

   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,and
    studied.
   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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posted:11/25/2011
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