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Trent Occupational Medicine Trent Occupational Medicine SymposiumSymposium

Philip SellPhilip Sell

UHL and NUHUHL and NUH66thth October 2011 October 2011

www.spinesurgeons.ac.uk

Population based intervention to change Population based intervention to change back pain beliefs and disability:three part back pain beliefs and disability:three part

evaluationevaluation

Rachelle Buchbinder et alRachelle Buchbinder et al

BMJ no 7301 23 June 2001BMJ no 7301 23 June 2001

Time course of back painTime course of back pain

TIME

SE

VE

RIT

Y

TIME

SE

VE

RIT

Y

LBP is a recurrent LBP is a recurrent phenomenonphenomenon at all agesat all ages

Untidy pattern across the life Untidy pattern across the life course with variable course with variable periodicity and severity.periodicity and severity.

Coexisting symptoms Coexisting symptoms (physical and mental) (physical and mental) commoncommon

Are chronic cases such from Are chronic cases such from beginning or are they result beginning or are they result of failed early treatment??of failed early treatment??

Adams et al 2006

Episode

Lifetime

Epidemiology in low back painEpidemiology in low back pain

Symptom not a diseaseSymptom not a disease

• cause unexplained in 85%cause unexplained in 85% data are self-reported - questionnaires:data are self-reported - questionnaires:

• tell us about how people experience LBPtell us about how people experience LBP• different questions give different numbersdifferent questions give different numbers

Consequences more of a problem than symptomsConsequences more of a problem than symptoms• care seekingcare seeking• sick leavesick leave• disabilitydisability

Low back pain is a common complaint among adolescents. Low back pain is a common complaint among adolescents. similar pattern to adultssimilar pattern to adults

Health problem does NOT equal Health problem does NOT equal a medical problema medical problem

Reasons for care seeking are Reasons for care seeking are complexcomplex

Person not always seeking a fixPerson not always seeking a fix Reassurance may be enoughReassurance may be enough

• ''My back hurts, but the reason I'm My back hurts, but the reason I'm here is that I can't cope on my here is that I can't cope on my own any longerown any longer ' ' (Hadler 1999)(Hadler 1999)

Genetics / IndividualGenetics / Individual

Twins studies, controlling for environmental Twins studies, controlling for environmental (occupational) factors:(occupational) factors: 70% of disc degeneration associated with genetic 70% of disc degeneration associated with genetic

factorsfactors Heritability of back pain possibly >50% Heritability of back pain possibly >50%

Muscle strength and level of fitness have little Muscle strength and level of fitness have little influenceinfluence

The overall perspectiveThe overall perspective

Societal burden equal Societal burden equal to depression, heart to depression, heart diseases or diabetesdiseases or diabetes

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

Back Pain EpidemiologyBack Pain EpidemiologyKey MessagesKey Messages

• LBP- LBP- Data demonstrate substantial nonbiologic Data demonstrate substantial nonbiologic influencesinfluences

Heritability of back pain possibly higher than 50%Heritability of back pain possibly higher than 50%• 70% of disc degeneration associated with genetic 70% of disc degeneration associated with genetic

factorsfactors• Production loss (due to absenteeism and disability) Production loss (due to absenteeism and disability)

has the greatest impact on the ecmonic burden of has the greatest impact on the ecmonic burden of back painback pain

• An early investment in correct evidence based care An early investment in correct evidence based care can generate long term cost saving.can generate long term cost saving.

A RCT of a novel Educational booklet in Primary A RCT of a novel Educational booklet in Primary Care Care

Spine Vol 24 Number 23 Dec 1999Spine Vol 24 Number 23 Dec 1999

reduced re-attendsreduced re-attends

clinically important improvement in disabilityclinically important improvement in disability

Improved beliefsImproved beliefs

Is there a right treatment for a particular patient Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light group? Comparison of ordinary treatment, light

multidisciplinary treatment, and extensive multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed multidisciplinary treatment for long-term sick-listed

employees with musculoskeletal pain. employees with musculoskeletal pain.

Pain 2002 95: 49-63. Pain 2002 95: 49-63. EM Haland Haldorsen et al. EM Haland Haldorsen et al.

Cascade of careCascade of care

Simple to complexSimple to complex Bothersomeness and functionBothersomeness and function Effective therapiesEffective therapies NICE CG 88 Non specific low back painNICE CG 88 Non specific low back pain Evidence basedEvidence based FUNCTIONAL RESTORATION FUNCTIONAL RESTORATION

PROGRAMSPROGRAMS

UK occupational health guidelinesUK occupational health guidelines

Individual psychosocial findings are a risk factor for Individual psychosocial findings are a risk factor for the incidence (onset) of LBP, but overall the size of the incidence (onset) of LBP, but overall the size of the effect is small.the effect is small.

Unsatisfactory psychosocial aspects of work are risk Unsatisfactory psychosocial aspects of work are risk factors for reported LBP, health care use, and work factors for reported LBP, health care use, and work loss, but the effect size is modest.loss, but the effect size is modest.

Individual and psychosocial aspects of work play an Individual and psychosocial aspects of work play an important role in persisting symptoms and disability, important role in persisting symptoms and disability, and also influence response to treatment.and also influence response to treatment.

Carter & Birrell 2000: www.facoccmed.ac.uk

Work caused or work-relevant?Work caused or work-relevant?

• Whilst some (episodes of) low back pain may Whilst some (episodes of) low back pain may be caused by work, most are not.be caused by work, most are not.

• Yet, symptoms may affect workabilityYet, symptoms may affect workability work can be difficult/painful because of work can be difficult/painful because of

symptomssymptoms• consequences are driven more by consequences are driven more by

psychosocial than physical factors.psychosocial than physical factors.• LBP may be highly work-relevant, irrespective LBP may be highly work-relevant, irrespective

of cause.of cause.

Acute Low Back PainAcute Low Back Pain

Simple Back acheSimple Back ache Nerve root painNerve root pain Possible Possible seriousserious spine pathology spine pathology Cauda equina syndromeCauda equina syndrome

FlagsFlags

Red Red Physical risk factors Physical risk factors Serious Spine DisordersSerious Spine Disorders

Yellow Yellow The personThe personPsychosocial obstaclesPsychosocial obstacles

BlueBlue Work Work WorkplaceWorkplace

BlackBlack Administrative obstaclesAdministrative obstaclesContextContext

Red FlagsRed Flags Age above 55 and new onset back painAge above 55 and new onset back pain Widespread neurologyWidespread neurology Progressive and unremitting painProgressive and unremitting pain Previous history of cancerPrevious history of cancer Weight lossWeight loss DeformityDeformity Failure to improve Failure to improve

Red FlagsRed FlagsCancerCancer

Sensitivity SpecificitySensitivity Specificity

Age >= 50Age >= 50 7777 71 71

Previous cancerPrevious cancer 3131 98 98

Unexplained weight lossUnexplained weight loss 1515 94 94

Failure to improve 1/12Failure to improve 1/12 3131 90 90

No relief in bedNo relief in bed >90>90 46 46

Tackling Musculoskeletal Problemsa 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 FLAGSYELLOW FLAGS

ATTITUDES AND BELIEFSATTITUDES AND BELIEFS EMOTIONSEMOTIONS DIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENT FEAR AND BELIEFSFEAR AND BELIEFS WORKWORK FAMILY AND CARERSFAMILY AND CARERS COMPENSATION ISSUESCOMPENSATION ISSUES

www.tsoshop.co.uk/flags www.tsoshop.co.uk/flags

CatastrophisingCatastrophising

EvaluationEvaluation Identify interpretations of Identify interpretations of

symptoms bodily symptoms bodily sensations or persons sensations or persons situation that are out of situation that are out of proportionproportion

This leads the patient to a This leads the patient to a sense of uneasesense of unease

A lack of feeling of controlA lack of feeling of control

Questions to askQuestions to ask When you are in pain do When you are in pain do

you think it is terrible and you think it is terrible and will never get better?will never get better?

Does pain feel Does pain feel overwhelming to you?overwhelming to you?

MIXED MESSAGESMIXED MESSAGES

Cconflicting diagnosis or explanations Cconflicting diagnosis or explanations for back painfor back pain

Dramatisation of back pain by health Dramatisation of back pain by health professionalsprofessionals

WorkWorkBelief that work is harmful or will do Belief that work is harmful or will do

damagedamage

Work history job dissatisfaction, frequent Work history job dissatisfaction, frequent changeschanges

BehaviorsBehaviors

Use of extended restUse of extended rest

Withdrawal from activities of daily livingWithdrawal from activities of daily living

Poor compliance with exercisePoor compliance with exercise

High intensity pain (VAS 10)High intensity pain (VAS 10)

ActionActionPositive expectationPositive expectationReview progressReview progressKeep the individual active and at workKeep the individual active and at workCommunicate that time off work reduces Communicate that time off work reduces

probability of successful return to workprobability of successful return to work

ActionActionAcknowledge difficultiesAcknowledge difficultiesEncourage ‘well behaviors’Encourage ‘well behaviors’If complex obstacles to management If complex obstacles to management

refer to multidisciplinary teamrefer to multidisciplinary team

All players onsideAll players onside

shared beliefsshared beliefs shared goalshared goal flexible approachflexible approach coordinating their coordinating their

actions……actions……

Functional Restoration Functional Restoration ProgramsPrograms

SPINE Volume 36, Number 21S, pp S1–SPINE Volume 36, Number 21S, pp S1–S9S9

October 2011October 2011

Chronic Low Back PainChronic Low Back Pain

A Heterogeneous Condition With A Heterogeneous Condition With Challenges for an Evidence-Challenges for an Evidence-

Based ApproachBased Approach

Degenerative MRI Changes in Patients WithDegenerative MRI Changes in Patients WithCLBPCLBP

There is insufficient evidence to support the There is insufficient evidence to support the routine use of MRI routine use of MRI Strength of recommendation: StrongStrength of recommendation: Strong

Surgical treatment of CLBP based exclusively on Surgical treatment of CLBP based exclusively on MRI findings of degenerative changes is not MRI findings of degenerative changes is not recommended. recommended. Strength of recommendation: StrongStrength of recommendation: Strong

Key PointsKey Points

Current low back pain management is fragmented into Current low back pain management is fragmented into five major management spheres, which have little or no five major management spheres, which have little or no interactions with one another.interactions with one another.

Chronic LBP is a heterogeneous condition and this affects Chronic LBP is a heterogeneous condition and this affects the way it is diagnosed, classified, treated,and studied.the way it is diagnosed, classified, treated,and studied.

While nonoperative approaches are the mainstay of While nonoperative approaches are the mainstay of management of LBP, surgery offers improved outcomes in management of LBP, surgery offers improved outcomes in carefully selected patients.carefully selected patients.

There is an urgent need for large national registries to There is an urgent need for large national registries to track the natural history and outcomes of treatments for track the natural history and outcomes of treatments for chronic LBP.chronic LBP.