Back Pain – Nuffield hospital presentation Dr I. Stuart Miller Sport Physician Chesterfield Hospital and English Institute of Sport Chief Medical Officer British Paralympic Team Clinical Director of Sport and Exercise Medicine at Bath University
How common is back pain What can you do about it The role of exercise in back pain
Just how common is Back Pain
4 33% ¡of ¡people ¡will ¡have ¡ back ¡pain ¡at ¡any ¡point ¡in ¡ 4me ¡ 65% ¡1-‑ ¡year ¡prevalence ¡ i.e. ¡65% ¡of ¡people ¡will ¡ report ¡an ¡episode ¡of ¡back ¡ discomfort ¡in ¡a ¡given ¡ year, ¡ 84% ¡of ¡people ¡get ¡some ¡ back ¡pain ¡in ¡their ¡life4me. ¡ ¡
What is the burden • 2.6 million people, in the UK, seek advice about back pain from their GP each year • 11% have disabling back pain in the previous three months, • 23% have low back pain lasting more than three months and, • 18% have at least moderately troublesome pain in the previous month • Andersson, H. I., Ejlertsson, G., Leden, I. et al, 1993; Cassidy, J. D., Carroll, L. J., and Cote, P ., 1998; Parsons, S., Breen, A., Foster, N. E. et al, 2007). • Macfarlane, G. J., Jones, G. T ., and Hannaford, P . C., 2006). • (Arthritis Research Campaign., 2002).
What is the outcome to the interventions • 62% of people still have pain and 16% of those initially unable to work are not working after one year • Hestbaek, L., Leboeuf-Yde, C., and Manniche, C., 2003).
What is the Cost • In 1998 healthcare costs in UK £1,632M • £565M borne by the NHS i.e. a lot of private physio osteopathy etc. (this is unusual compared to other illnesses and injuries • Lost production costs between £3,440M and £9,090M depending on calculation • (Maniadakis, N. and Gray, A., 2000 ).
8 Why is back pain so difficult to treat?
A general Practice encounter • NB Treating back pain in a 10 minute consultation is a nightmare for both Doctor and Patient! • Can identify major life, limb or nerve threatening issues • Can arrange referrals (but impossible waits on NHS way outside the normal course of the condition i.e. resolution within a short time) • GP’s do not have a great deal of training in this area • Physiotherapists can be a reasonable point of call but Dr is more likely to think diagnostically and pick up a significant problem • Pressure on NHS physio is more likely to result in advice rather than manual therapy (this is not always bad but not the full picture)
Why does conventional treatment fail so often • Access to timely, high quality advice and treatment • Physical therapies not focused on the problem (whatever that might be) • Reluctance to comply with exercise advice • The feeling that if you were caught by your employer exercising you might be reprimanded for not being at work • Boring, repetitive job or very heavy loading at work or poor postures at work • Medico legal reluctance to allow return to work or provide grading reintroduction of work
Common statements and advice to avoid • Rest for a couple of weeks (this can work but needs qualifying!) • Have some bed rest for a week or so • Take some pain killers and have a sick note • Let me just put back your disc for you (non surgical!) • Do more exercise (getting better but What exercise!
Common themes that reinforce the problem • Let me pick that up for you • I have a bad back (forever) • I am always hurting my back – I only have to lean over and it goes • My disc needs putting back into place every month or so • I have been told not to pick things up from the floor • My family rally round me all the time as they know I have a bad back – they help me with all the work that needs to be done around the house!
Back pain is not always a lost cause!
Potential causes of LBP Posture • • Abnormal biomechanics • Poor muscle strength (core or more generally) • Lumbar muscle strain through unaccustomed exercise (>the normal function of your muscles- see above) • An injury to ligaments – Chronic postural – acute injury • Higher velocity injury e.g. in sport or accident • Disc prolapse • Congenital abnormality • Tumour (prostate / Breast) • Infection – discitis • disc, joint disease Pars fracture, and a host of rarer conditions
Intervention Aims • Doctor Diagnosis – identifying and reassuring re serious pathology with investigations if needed. Treat serious problems as needed e.g. surgery, injection, etc. Treat pain to allow exercise Advice regarding suitability to exercise – permission giving Arranging suitable Physical interventions
The key to treating (non- surgical) back pain • EXERCISE • Prescribed • Stepwise increase in activity as soon as pain allows • Accepting pain as a part of getting better • Improving general fitness • Improving back strength • Improving CORE (lumbar, scapulathoracic and Pelvic)
Physiotherapy Physiotherapy Reduce pain through physical interventions e.g. mobilization, massage, acupuncture, Improve core stability Increase mobility Help plan exercise and rehabilitation Encourage exercise both specific targeted back exercises AND Exercise in General
Core Stability a demonstration • Splay back stance • Abdominal control • Hip abductor control
Managing phycology of 19 back pain • Constant reinforcement of the problem – waking up • Giving definitive advice and clear explanation • Avoiding excessive simplification – your disc has slipped • Discourage illness behavior • Reassure that you can improve their symptoms • Manage pain well • Giving permission to exercise • Suggest realistic exercise and goal setting
10 minute consultation advice To stay active To ensure pain does not interfere and take over life To comply with physiotherapy and Medical advice to exercise Get back to normal activity as soon as practical (dependent on risk of activities) Change lifestyle to include more exercise Seek attention if struggling
Personal Trainer/S and C coach/Exercise Therapist To help with compliance To design a sustainable exercise program To encourage a change in exercise behavior To advise regarding safe exercise
What does not work Absolute , non –targeted rest • • X rays do not cure and do not tell us much. MRI often not needed • ‘Having discs put back’ although a good physical therapist can help with hands on manipulation • A poor patient understanding of back pain – explanation goes a long way in getting patients better • Encouraging the patient not to adopt a sick role – stay active • Traction, laser, interferential/ultrasound (physio old style interventions) • Lumbar supports
What should work Good quality opinion regarding why the back is sore • • Timely referral to MSK focused clinician, spinal surgeon or Pain clinic when this is indicated • A good quality explanation and discussion about what is and is not wrong • Good quality pain management – helps with mobility and reduces the ‘drag’ of back pain • Good quality physical intervention including strengthening and balancing of biomechanics and core stability training • Exercise in general • A positive attitude- CBT and other psychology interventions can help when chronic. • If you are not succeeding or need more time, consider referral to a specialist with the time and focus to deal with the problem. It may pay dividends in the end!
And never forget the healing power of Paws!
Dr I Stuart Miller 25 Nuffield Chesterfield Hospital Bristol Tel: 0117 9064884 e mail: info@bristolsportsdoc.co.uk secretary: Jayne hainsworth jayne.hainsworth@nuffieldhealth.com website: www.bristolsportsdoc.co.uk
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