Jovi Stuart
Good evening and welcome to this evening's webinar - Low Back Pain Model of Care. We are joined by our presenters, Dr Steve Petersen, Professor Ian Harris and Professor Michael Nicholas. My name is Jovi and I am your RACGP representative for this evening. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. For me, I am joined on Cammeraygal Land on Sydney's North shore.
I would like to now formally introduce to you our speakers for this evening. Dr Steve Peterson is a fellow of the RACGP and combines a mix of emergency telehealth, addiction medicine and education, as well as corporate and local government responsibilities on the background of high cervical quadriplegia. Prior to practicing in Orange as a GP at the local Aboriginal Medical Service and as a VMO at the emergency department in March 2018, Steve was hit by a car sustaining complete C4 quadriplegia amongst many other injuries. Currently, Steve conducts regular rural emergency telehealth work through the VRGS and RaRMS. Steve is a non-executive director on the board of LiveBetter, a rural focused disability service organisation, and is also an Orange City Councillor. Welcome to Steve. Professor Ian Harris is a professor orthopaedic surgeon at UNSW and a clinical academic at Liverpool Hospital. Ian's research is focused on the effectiveness of surgery and overtreatment in medicine. Ian has published two publications critical of modern medicine and the lack of science in medicine. Welcome to Ian. Lastly, we have got Professor Michael Nicholas. Michael is a clinical psychologist in pain medicine. He has held a conjoint position at the University of Sydney, Sydney Medical School, Northern Clinical School and Kolling Institute, Pain Management Research Institute (PMRI) and the Pain Management Research Centre (PMRC) at the Royal North Shore Hospital since 1994. Externally, he has been a member of the Pain Management Network Executive since its inception in 2013, including six years as co-chair. In this role, he has contributed to the implementation of New South Wales Health Pain Management Plan and the development of broader community level services and support for people living with pain in New South Wales. Welcome to all our speakers this evening.
I would like to move on to our learning objectives for tonight. By the end of this CPD activity, you should be able to discuss the role and responsibilities of SIRA and the rationale of the value-based healthcare; explain the model of care for the management of low back pain and the ten principles in treating patients with low back pain. List screening tools to assess patients. List relevant referrals or treatment to patients with low back pain, and explain common misconceptions about low back pain among patients and provide psychoeducation to patients. I will now pass over to Michael to start off the session. Now over to you, Michael.
Professor Michael Nicholas
Thanks Jovi, and good evening, everyone. Thank you for joining us. I am sure you know what SIRA is, but just to make sure it is the State Insurance Regulatory Authority for New South Wales that covers those three schemes, Workers Comp, CTP and Home Building. Tonight we are really focusing mainly on CTP and Workers Compensation. Clearly a lot of people are covered by one of these schemes at any one time, but the aim of these schemes is for promoting recovery and return to activity and work and better quality of life.
Why is it a problem? Well, it is not the only injury, but it is quite sizeable, as you can see, about 18% of all injuries in the Workers Comp schemes and similar for the motor accident scheme. The one of the problems is the way it gets treated. You could see a summary of that research that Professor Ian Harris is talking tonight reported a few years ago that clearly suboptimal outcomes for people with low back pain under Workers Comp who receive surgery. As you can see there, ongoing care, poor return to work rates, high costs of treatment and so on. In CTP, again, people with back pain getting back to their lives slower than people with other conditions particularly if they have got a concurrent psychological injury and that is the same actually in the Workers Comp scheme. If you get both then that is a problem.
Next slide. Just to summarise then, I think you will have a copy of this document. Just to draw your attention to y key changes from the previous models of care. The first is there is less emphasis on the use of imaging, pain medicines, particularly opioids, but others as well, and also less or reduced encouragement to refer for surgery given those results. There is a greater emphasis on self-management by the patient, active physical and psychological management and regular reviews of progress towards patient specified goals rather than just chasing pain relief.
Next slide. There are ten of these principles. I do not have time to go through all of them in great detail. The first ones are fairly self-explanatory. What I am sure you would do now, which is a formal examination and getting a history, but the second is actually something that really is not done very much and it is often delayed, ad what we are trying to do is get people to recognise psychosocial factors that can be present right from the start that will influence outcomes if they are not attended to. There are two measures that are recommended. One is called STarTBack and the other one is the Orebro questionnaire. They are just very brief questionnaires that the patients can answer in the waiting room and then go through with you in your consultation. It gives you immediately a quick summary of risk factors for delayed recovery and it gives you somewhere to start with this group of people rather than having to guess. The third principle is Only imaging, as I said, with those with suspected serious pathology.
Education of patients is important using a cognitive behavioural approach, which is really about trying to encourage the patients and their self-management of their symptoms and working towards particular goals of returning to activities, returning to work, understanding their role in this process that you can assist with, helping them see the relationship between their beliefs about what is wrong and what they do and addressing any that are getting in the way. Encouraging them to not just focus on relieving pain, but rather on improving function because that in the end will lead to less pain as well. Then active physiotherapy rather than passive. Getting people to exercise, do things that is incredibly important.
Next slide. Again, we will talk about analgesics a bit later, but basically avoiding getting into the opioids. Just simple analgesics if any to start with. Then reviewing people regularly two, six and 12 weeks rather than a wait-and-see approach. It is just trying to get on top of the case rather than let things drift, which is easy to do, and then finally referral if things are not getting better at least by six weeks, musculoskeletal specialists, and if by 12 weeks then if they are not improving or getting worse, then we would recommend referral to a multidisciplinary pain management program which can take a more comprehensive approach to these problems.
Next slide. The risk stratification, I mentioned, based on the concept of yellow flags or psychosocial risk factors, and this can be done within a few days of the injury. I have certainly done research like this. Then it can be repeated at six weeks, 12 weeks to see if there is any progress. If it is not progressing, then that is telling you something. They help in identifying those at risk of delayed recovery for those reasons, and then allows you to tailor your care to the identified risk factors. What are they worried about, what is the source of their distress and so on. You can address that directly rather than having to conduct extensive psychological interviews.
The cognitive behavioural approach really emphasises these points. It is working with the patient collaboratively and other healthcare providers may be involved. You do not do this to people, you do it with them. It is like working together with the patient on their goals. The patient must understand they have got to play an active role, not just wait passively for you to make them better. They have got to play a role. The GP should be active in identifying risk factors identified from the screening, supporting the patient to develop functional goals versus pain relief that is return to activities, things that are important to them. This ideally would be done in a graded or gradual approach rather than straight back to work. The GP should recommend specific strategies where they can or use other healthcare providers who have got the appropriate expertise and they might be physiotherapists or clinical psychologists. Pacing activities or doing things bit by bit is an excellent way of getting people to gradually upgrade their activity level. Finally, rather than wait-and-see, we think you should be actively involved in reviewing progress and helping them to deal with problems that emerge before they take control. We believe if you do all this within the first two or three months, then we will be a long way ahead. I will leave it there and I will pass on to Ian.
Jovi Stuart
Perfect. Thanks, Michael. We will just go to Ian's slides now. Over to you, Ian. Thank you.
Professor Ian Harris
Thanks for the great introduction and overview. My talk is more focused. What I am going to be talking about is who to refer to and when to refer because as you know this varies a lot. I used to think, "Oh, just refer everything to surgeons" because I am a surgeon and we can sort everything out, but I have since realised with experience and with some of the research I have done that that is not always the best first step. Just getting an MRI on everybody and if it shows something, sending it to the surgeon is not the best answer. Firstly, because an MRI in anybody aged over 30 or 40 is going to show something, it just will not necessarily relate to their back pain and surgeons do tend to rely on what they know, which is surgery, and they often do not have a good handle on the non-operative alternatives. I think a more sensible stepped approach is better. I am going to stick to the guidelines themselves. Hopefully, you have got a copy of the guidelines, but I am going to take little snippets out of it anyway.
The next slide. There are three pathways in this slide. I am going to deal with pathway B first because it is really separate to to the others. The others are more people with pain and is it getting better, is it not getting better. Pathway B is a different pathway. These are the people with acute low back pain and neurological involvement. By neurological involvement, I do not just mean sensory changes or loss of reflexes. These people actually have documented neurological loss. This is normally weakness, which is much more objective. If you have got a patient who has got clear signs of neurological loss then they probably need a more urgent referral, particularly if it is associated with acute onset. These are the patients that get referred and and whether you want to refer them to an emergency department or whether you can get them into see a surgeon quickly depending on your local factors is up to you, but these patients probably need emergency referral. That is probably all I am going to say about pathway B. People worry a lot about pathway B and they worry about the red flags, but these are rare. These make up such a small proportion of people with low back pain.
Just quickly on the next slide, I will just cover the red flags. Most of you probably know them better than me, but these are people who are possibly unwell. They may have a spinal infection, in which case they may be quite significantly systemically unwell, but they might also have signs of inflammatory disease or they may have a severe neurological deficit like bladder or bowel dysfunction. Cauda equina is an interesting thing. It gets overdiagnosed and I know pockets in Australia where it gets diagnosed all the time and there are pockets where you never see it. I honestly, in 30 years of surgical practice, have never seen a patient with cauda equina syndrome. It is not very common. A lot of people have bladder symptoms, but that does not mean they have cauda equina syndrome. They need to have significant preferably muscle loss, loss of anal tone and things like that. If they have got a history of malignancy as well, that is another red flag and obviously a significant trauma patient from an industrial accident, that kind of thing who may have a fracture or dislocation. Unexpected weight loss goes with malignancy. In the elderly, they can get minimal trauma fractures as well. They can get osteoporotic fractures. They are the red flags.
I am going to move on now to the other two pathways and the other two pathways talk about yellow flags and they talk about failure to improve. That is when you need to consider referral. Some of it depends on your own ability and comfort level on managing these patients as to exactly when you want to refer, but certainly within the first six weeks there is no urgency if there is no neurological loss. This is with or without leg pain. Look for yellow flags because yellow flags are the patients that are going to be difficult. They are more likely to be chronic. We will probably have a quick look at the yellow flags on the next slide. I will not go through each one except to say that these are the patients who are in general unhappy and possibly have unhelpful behaviours. They are fearful of activity. They are pessimistic. They think that everything is…they will come out with statements like, "My life is ruined, my life is over." These patients can catastrophise a bit, and it is often associated with people treated in the compensation system, unfortunately. Even within that system, it is often people have poor job satisfaction who are more likely to fall into this area. There are various tools you can use.
I will just go to the next slide, it just has a photo of the STarT Back. There are two questionnaires that we recommend, but if you just look through them, you will see how it picks up these people. These people are more likely to have things like worrying thoughts to really sort of slow down their activity. They feel that things are terrible and never going to get better. They do not really have a very positive outlook as well. Unfortunately, this becomes a self-fulfilling prophecy for many of them.
Just go to the next slide. We will talk about the pathway. Pathway B in the middle there. That is the people who have got progressive neurological loss, significant function. They are separate. You just get them off to see someone quickly. If you can get them in to see a surgeon quickly, that is great. Otherwise, send them to the emergency department. Pathways A and C are the ones where you need to screen them for yellow flags. If they have got no yellow flags, that is great. They have probably got a better prognosis. You see how they go over the first six weeks. The difference between pathways A and C is that one is acute low back pain. The other one is acute low back pain and leg pain. Sometimes it is difficult to tell. Sometimes they have a bit of pain in the buttock. Sometimes it goes down the back of the thigh a little bit. I do not worry too much about it unless they have a really clear dermatomal pattern like they have got numbness and loss of sensation on the outer border of the foot. That is S1, but when they have got pain down the back of their leg, that is just very commonly associated with back pain. Anyway without neurological loss, I do not pay that much attention to it. That is pathways A and C. Let us look at what the recommendations are in the next slide.
It is the 6-week and 12-week mark that you need to consider things and there is some flexibility here, but the guide says at six weeks consider referral to a musculoskeletal specialist. We will talk about what that actually means. You may be a musculoskeletal specialist if you have a special interest in back pain in managing such patients, that is fine as well. By 12 weeks, though, you have got a patient who does not have neurological signs, but they have got yellow flags are coming up and they are not getting better at 12 weeks. These are the patients you need to consider referral to a multidisciplinary pain management team. Unfortunately, pain management varies a bit. The type of pain management team that Michael, who was just speaking, it works in is probably the ideal and that is a true multidisciplinary pain management team. Not somebody that is just going to give them scripts for opioids and not somebody who is just going to use one intervention after another, and spinal cord stimulators and whatever. I do not necessarily think that that is more helpful and sometimes more interventions can be worse for these people, particularly if they are not effective.
The next slide please. This talks about what they mean by a musculoskeletal specialist. This could be you, it could be a GP but it could also be a specialist physiotherapist or rheumatologist or a spinal surgeon or a spine team that can have a mixture of of practitioners interested in spine. There are various units that work around town that have these multidisciplinary teams. That is who we are thinking about, but it is the higher risk patients. When you are thinking more about pain management, that is when you are thinking more about people who have specific cognitive behaviour therapy training or a pain clinic. As I said before, there is a lot of variation between these specialists and between these clinics. Try and get to know the good ones and refer them there.
Next slide please. There are resources that you can refer patients to. This is just a still image of a YouTube video, but there are lots of these around by good practitioners that are really about educating patients about back pain, dispelling myths about back pain and often giving patients a little bit more education and a bit more reassurance about their back pain. Certainly look up some of these and you can refer patients to these. Your decision on referring them to an MSK specialist or pain management team or managing them yourself depends on your resources and depends on the patient as well.
Last slide. In summary, if they have got red flags, this is so-called pathway B and neurological loss. These are the people that need to be seen urgently. The other patients do not need to be seen urgently, but it is these patients who have the yellow flags. These really high risk patients for chronicity that are really behind the eight ball. You need to get those patients to high quality multidisciplinary pain management. For the other patients, failure to improve at six weeks, consider MSK specialists. Failure to improve at 12 weeks, then it is getting a little bit too long. Then we are going to pain management team. Thanks.
Jovi Stuart
Perfect. Thank you, Ian. We will just move on to Steve's presentation.
Dr Steve Peterson
Thank you. My name is Steve and thank you for joining with us tonight. General practice involvement for lower back pain. Well, this is definitely right in our lane. Back pain is one of the 10 most common presentations for Australian general practice. According to the BEACH data, I have seen that listed once as the most common presentation for Australian general practice. It is something we should all be familiar with and able to approach. Like most GP presentations, an individual's presentation to the GP has multiple potential outcomes. A back injury within a Workers Compensation context, the outcome could range from returning to work with normal life to never working again with all the implications of that and we have influence on that outcome. It is not all up to us, but it cannot be said that that we do not have influence with our patient. Why GPs again? We are more accessible. We are easier to get into, although that is not always the case, but certainly easier to get into than most specialists, often more affordable. We are the gatekeepers, the first line of contact, and we have the longitudinal care capacity. My colleague earlier was talking about six week reviews and 12 week reviews. The take home point from that is this is often not something that it is a stitch up the wound and never see it again. This is something that does need that longer term approach and we are best suited to manage that.
If I can go to the next slide, please. I am not telling you anything you would not already know. Like almost every consultation, a good history and an examination is going to be the foundation of figuring out what is going on, making a good plan, getting the patient by and getting a good outcome. We all would know that a good workup improves the efficacy of whatever management we decide to do, and the vice versa also applies. A rushed or poorly done plan, we will have a higher risk of negative outcomes. What would be specific? History and examination is nothing new. I will be specific about the low back pain consultation in the context of Workers Compensation. First of all, as mentioned earlier, to exclude the red flags to work out the tiny number of the patients that will see with this that should not be managed by the GP but instead should be off to to hospital quite quickly. The next bit would be identifying the yellow flags. I will go over some in the next slide and some have been mentioned earlier. Please go back to the previous slide. In the next slide, I will talk about them. We will try to preemptively identify and manage some of these yellow flags to give education about patients of what could possibly go wrong and what they need to avoid and what their attitude and focus should be, give the patient some credit. The majority of them can well benefit from taking ownership of their care and being aware of the risks and how to avoid them. We are developing an individual plan, individual exercise and treatment to the patient. We have not been replaced by robots yet because we are supposed to be integrating what we learn from the patient with history and examination. Hopefully, with what we know about the patient anyway, from the other contact we might have had with them in the past, then make a plan that is suited for them and being prepared to change it. The longitudinal care is useful because then we have the chance to see what is progressing and then to change it accordingly, which is again our bread and butter.
If I can go to the next slide, please. We mentioned imaging earlier, and I would like to expand upon that a little bit now. One of the questions that I had earlier from one of the participants. Most lower back pain will spontaneously or improve with appropriate treatment and does not need imaging. Many of the abnormalities you might find on particularly lumbar spine x-ray imaging are physiological. They would be present in a high proportion of patients randomly selected off the street and may well not correlate with pain. Identifying them has potential harms. Giving a diagnostic label based on some sort of radiological finding that does not actually contribute to the patient's pain can cause harms of being some sort of untreatable, unfixable reason that that the patient can latch on to for a variety of pathology that might occur down the line. If we are going to image, we would only do so for suspected serious pathology. Those red flags we mentioned and being, good, helpful, collaborative GP's. If we are therefore imaging looking for that suspected serious pathology, then we need to say that on the imaging form, guide our radiologist colleagues about what we are actually looking for and what needs to be ruled out. It is worth mentioning as well that some sort of precise anatomical diagnosis of exactly what particular structure in the back is contributing to the pain is often not necessary, and it is often not even possible. The back like many parts of the body is quite a complex structure and there may not be the ability to pinpoint one particular problem and say that is where everything comes from. Not all the other adaptions that might happen for the body to minimise the pain in that particular spot.
We have talked about a bit about yellow flags, and their relationship to our consult. One thing I think that is important when we are seeing any patient, but particularly a patient with the potential for a chronic disease or chronic process that could be managed well, could be managed otherwise is we should take a little bit of ownership of this and set the course of treatment and manage the misconceptions early. Do not let them find out or do their research on the internet or some sort of Facebook focus group or what they heard from their second aunts and their relatively unusual background. We should be giving them the first and the accurate information. We can fire that that first shot, give them the right resources and try to lance the yellow flags before they even happen. Some of the more common ones that I wanted to mention. Pain does not necessarily correlate well with the severity of the pathology, I should say, as well that pain is definitely something that is very unique to each individual patient, so just because it hurts or it is 10/10 times, does not necessarily mean that that is a much more severe pathology than the person with 3/10 back pain that is getting on fine. Spinal issue is a cause dear to my heart. Back pain in all itself is quite highly unlikely to be harmful to the spine. There are other red flags that might make you suspicious for back pain by itself, not so. Radicular pain alone does also not represent serious pathology just because the pain is pain radiating down a leg in a context of back injury itself does not necessarily mean that this is some sort of a more serious pathology than otherwise. Physical activity is beneficial even if it hurts, and is probably worth saying that before you encourage people to go and do that lest they fail to engage in the exercise program because there is pain and pain, they may believe that that pain might mean that there might be new harm being caused, but I think we need to lance that boil early. That pain does not always equal harm, and that active participation has been mentioned by one of my colleagues is going to be more helpful than passive treatment. You want to avoid you know this slide just being a list of feel good information that you could probably well figure out anyway. It can become useful if we actually take when we see lots of back pain. It is one of the most common reasons to see for a doctor to be consulted in Australia, and before we start Mr Smith, I just want to say a few things that I know have caught up some of my patients in the past and do not want affect you again, that is why the first shot.
I can go to the next slide please. So I have gone on about trying to get useful resources to the patient. Well, what are they given we have probably only got 15 minutes to see the patient and we are still going to do that quick history and examination that I was talking about before. Accurate, easy to digest information is often available in practice software, Best Practice and Medical Director, if you do not know, you should ask your colleagues and get that little picture of the patient wearing a university hat and find some good handouts of lower back pain there. What we have been talking about tonight, the SIRA patient fact sheet, managing lower back pain and the model of care, I think are also quite useful resources to give to the right patient, maybe even to attach to a referral letter if you are going to send somebody for referral, so they know that the overview of the plan of what you are trying to do. Therapeutic guidelines should probably always be open on your desktop when you are consulting a patient, also has a good write-up, a good article about back pain. You will need to pick your patient, but there would be many patients where printing that that 2 or 3 pages and giving it to them is useful information they can take home and read and show their family as opposed to what they might find on the internet. Also, in most consultation rooms you might well find the textbook Murtagh general practice. I find it quite interesting that back pain it was quite an interest of the original author. In fact, his thesis was the management of back pain in general practice. It is something obviously of a particular interest to him, and I think those few pages are quite good resources for you and for the patient as well.
I can go to the next slide, please. Analgesia. What can we do to help and hopefully not harm our patients? Therapeutic Guidelines has a good write up on this, and again, that is something that I would be encouraging doctors to consult if they were not very, very sure they knew what to do otherwise going through the various options. According to therapeutic guidelines, the anti-inflammatories have good evidence as being short-term pain relief BEARING in mind it needs to be the appropriate patient. Obviously, we would be well aware of the potential risks with the patient with renal impairment or stomach issues or the like. Having said that, this patient population you may well find to be younger, fitter patients who might have some of them anyway less of the comorbidities and NSAIDs could be appropriate. Paracetamol actually has got pretty weak evidence of its effectiveness, but fortunately it is got quite a positive safety profile, and certainly therapeutic guidelines recommendation is give it a try, we are unlikely to make things worse. Oral corticosteroids and muscle relaxants have some evidence of improvement in the initial days. Talking about the first three or four days, all of you so unlikely are there going to be the sort of patient that you will see and as you are able to see someone maybe the very day of their injury, if they come to see you a week later, the evidence is not there, but then there is plenty of evidence for harm, so we are not for long term use. Opiates again not selling anything that people do not already know, but there is quite a minimal evidence of benefit for the chronic musculoskeletal pain and low back pain and plenty of evidence for harm. They are really not for use. You do not really have a good medicolegal defence to stand on if they cause problems down the line. Neuropathic pain agents, so we are talking about gabapentins and pregabalins, they may have some use for the patient with radicular pain, maybe the patient with some diabetic nephropathy, but there really are not any good quality randomised controlled trials yet. The evidence is not there. It is probably not as useful a pain medication as we would hope, but for the selected patients, maybe. One other point about pain medications is our responsibility to prescribe them, our responsibility is to de-prescribe them as well. For some of these patients that might not be going well with their pain, if we give them a medication and they are still in pain a couple of weeks later, we should cease that medication if we do not believe it is having an effect. A lot of these medications here that I mentioned with evidence of harm, that harm is particularly with the prolonged use. If for whatever reason a medication is trailed in good faith, we have two possible outcomes. One is that the pain gets better and therefore we can start tapering the medication down, encouraging them back into normal activities and eventually stop. The other outcome is that the pain is not improving so we can stop the medication, which is clearly not being that helpful and try other approaches or potentially refer elsewhere.
Can I go to the next slide please. I have been trying to answer questions as I go. Just stop while I was giving my section of the talk, I will hand back to IMC and we will go from there.
Jovi Stuart
Perfect. Thanks, Steve. Just sharing with everybody just the learning objectives for tonight. We will now move on to some questions. Let me just put that up there. What I will do, I will read out some of the questions that have come through to the chat and speakers can respond to them. I will go just by most recent ones. First question is where are we up to with chiropractors as part of the MSK specialist team? Anyone? Michael? Ian like to, open your cameras and your mics.
Professor Ian Harris
I do not know if Michael wants to comment on that, I know what Chris Myers answer would be, is that they vary a lot, and so in chiropractors there is different. The schools of chiropractic and some more evidence based than others, and so I think just with any referral, you just have to be careful that you are referring to one that is acting a little more evidence based, but I do not normally refer to them. Michael.
Professor Michael Nicholas
I would agree there is variation as in any professional discipline, but I think the key things are because I have taught chiropractors in my courses, is to select ones who are going to really do what physios should do as well, which is promoting activities of daily life exercises and a gradual upgrading of those despite the pain, rather than trying to get someone pain free through manipulations and things. I think that is the wrong focus. You are much better off focusing on assisting someone to become more functional through exercises they do at home rather than have to come to a clinic once a week or once a fortnight for some movement. There are chiropractors like that, so that would be the question I would be asking.
Jovi Stuart
Let us move on to the next question. So Rakitha asked sciatica with early focal neurological signs is not a red flag, is not it, until non-resolution at six weeks.
Professor Ian Harris
The term neurological signs, yes, no, always appears to be such a cut and dried thing. They are either there or they are not, and that is actually not the case, so there will be a lot of patients with neurological signs that means they might have pain down the leg. They might have paraesthesia down the leg. They might say that they have some urgency and micturition and things like that, but I would distinguish people from having neurological symptoms or so-called flags or signs to patients who actually have documented neurological loss, and they are the people have a foot drop or they are the people that have weakness in toe flexion that would indicate an S1 lesion or they have anaesthesia and no anal tone, S2, S3, so these are people with neurological loss rather than neurological symptoms, and it is the ones with neurological loss is the red flag, the ones with neurological symptoms, you can certainly because these are people just who have leg pain, and you can certainly manage them without referral, at least initially.
Dr Steve Peterson
The radicular pain just down the leg, itself, is not a red flag.
Professor Ian Harris
The next question talks about a person with MRI findings of moderate nerve impingement and radicular pain. Is that considered a yellow flag? The yellow flag is the patient behaviour and the patient who is more likely in need of pain management, psychological input. It is red flags that are neurological loss, but no, so many MRI findings have moderate nerve impingement or there is some contact with the nerve root, or there is a suggestion of something pushing the nerve. I largely ignore those signs unless there is significant neurological compression or flattening of the nerve root, then it is something that is either not causing the problem or it is going to get better anyway.
Jovi Stuart
Thank you. So, Wafa asked how effective is back manipulation therapy?
Dr Steve Peterson
I was suggesting a couple of questions ago, it is probably very much going to depend on the person involved with it and their attitude whether it is going to push something into place that is going to fix the pain that probably does not have the evidence or if it is part of a return to exercise and work and good back care and I suppose if you are a general practitioner in your area for a long period of time, hopefully you will work out which of the local resources are good and which maybe not so much.
Professor Ian Harris
Manipulation itself does not really have the evidence, unfortunately. It is like a lot of things we do in the back. It sounds good. It is like nerve root injections, which is another one of the questions up there. The evidence for them is woeful. The cost of them is much higher than it should be, and there is real risk. I saw an old patient of mine just coming home tonight is in hospital with IV antibiotics for two weeks because he got an infection from a spinal injection, but the role for them is vastly overplayed.
Jovi Stuart
There are a few votes for that one, what is the role of CT guided nerve root corticosteroid injection for low back pain.
Professor Ian Harris
I do not use them at all because the best evidence of comparing them to placebo is that they do not work. In fact, the NICE guidelines came out a few years ago saying that they should not be used at all, but I think that is changed since then, possibly with pressure from people that do it. The number that we do in Australia is absolutely massive, but that does not mean it works because the number of spinal cord stimulators we do in Australia is absolutely massive and they do not work at all.
Jovi Stuart
Thank you and Dr Tso asked what is the different role of physio and exercise physio and low back pain? Do we need to start at the same time for those allied health service, and is there any role of steroid injections on low back pain?
Professor Ian Harris
The steroids injections, the only time Rheumatologists sometimes use them, but steroid injections are sometimes used for people who have nerve impingement, so these are the ones that actually have a prolapsed disc which is causing inflammation and pressure on the nerve, so for good going sciatica, some people use it. Surgeons tend not to, it is something that some people do like to use and there is some evidence that it will reduce the inflammation a little quicker, but not a whole lot of evidence. What was the other part of it? There was steroids injections and physio and exercise. Physiologists looked at those and it does not matter which one they are, but if it is somebody with an interest and knowledge in back pain and pain management, then they are going to be better than the other one.
Professor Michael Nicholas
I think there are sort of demarcation disputes, but basically the physios would argue they are better trained in doing diagnosis, but in terms of actual intervention, they both use exercises and encourage people to become more functional, as can GP's, so I could not say one or the other on the basis of their title, I think it is important to get a sense of is this person and do they know much about pain management. They are just focusing on pain relief, it is a warning sign. Whereas they should be both focusing on functional gain, which is referred in the SIRA guidelines to the high value care, that is really where we need to be pointing and getting away from symptom relief as the focus because people say to get the pain under control, then they will become active. Well, actually, that has not got a very good track record, and it just can lead to just endless brief treatments which work for 5 minutes and then wear off. It is much better to be getting the patient engaged in their own care and both the physios and exercise physiologists can do that. Just going on to the physio for a massage and some acupuncture I think is hopeless, but if they are going along to have their review exercises and encourage them to be doing these things at home or going to a gym or whatever is available, then that is a better use of their time.
Jovi Stuart
Got a question from Dr Cotter. Please comment on the role of diazepam and amitriptyline as muscle relaxants and for anxiety related to pain.
Dr Steve Peterson
Studying therapeutic guidelines would say that if muscle relaxant like diazepam would have potentially some use in the immediate couple of days, two, three and after that, then I would certainly avoid it. In terms of amitriptyline or particularly mirtazapine, absolutely amitriptyline one that does seem to have some sort of analgesic side effect. If you had someone who needs a medication for their depression anyway and you are trying to pick which one of the 15 odd choices, then amitriptyline might be good for somebody who has some chronic pain, and maybe mirtazapine might be better for somebody who has problem sleeping and the like. I probably would not start it by itself as a treatment for pain in its own entity without any other good reason for being on an antidepressant. Any other thoughts?
Professor Michael Nicholas
Just the way we would use them, and certainly amitriptyline low dose mainly to assist with sleep, that is something really important, but it is important for people to get sleep, so that might have a have a role there, and they are not being used in what a psychiatrist would call therapeutic doses for depression. I guess mirtazapine has become more popular. I do not know how they stack up against each other.
Dr Steve Peterson
I never had some people tell me the mirtazapine has helped with their pain, but sleep most certainly.
Professor Michael Nicholas
Also anxiety. I do not think you necessarily have to take a drug for anxiety. I think it is more useful to find out what are they anxious about, what is their concern, what are their worries, and that is what you do when you are dealing with the yellow flags because anxiety is a yellow flag and they might be worried one wrong move and they are going to end up in a wheelchair or something. That is often driven by beliefs that are understandable but unhelpful and promote avoidance of activity, so I would be reassuring them about this pain is not a danger signal. They will be okay with some pain and it is important to get moving. Those I guess would be better than prescribing something because even if you do prescribe an anxiolytic, the patient still has to do something. They cannot just sit around waiting for the drug to work, so I think it is better just to work on getting the patient to do things in the first instance, and understanding why you are promoting that.
Jovi Stuart
Dr Rankin asks, is there any way that we can assess whether a pain service is going to assess and treat patients appropriately? The pain service at my local tertiary hospital has a wait of 6 to 12 months minimum.
Dr Steve Peterson
That will depend on your own geographical area, but it is certainly a common complaint. I am not entirely sure what the one is here in orange, but liaising with the service and finding out what capacity they have is probably a good idea.
Professor Michael Nicholas
Yes, that is what I would ask. That is right. The other thing that they probably have a priority order, so we have one at North Shore where I am on this triage committee, so we look at the referrals from the GPs and try to work out according to various criteria, their order of priority, and, if we think it is a recent injury, there is a possibility of CRPS developing or there is there is a Worker's Comp claim, then we would prioritise that person or if they have got cancer or something, we would prioritise that, but if they have had it for 20 years and you get the idea, you just another port of call, well then that would go lower priority. We are trying to get towards the people who are more acute at the end of the spectrum, but it depends on the case, and writing a good letter is very helpful in these priorities, and it is getting into a dialogue with the pain service because as Ian said, they do vary a lot and there are some that certainly in the private sector they do far more blocks and radiofrequency lesions than in the public sector and it is clearly a financial thing. I was in Switzerland just before Christmas talking to their pain society and they said they do not do any radiofrequency lesions, but they do a lot of medial branch blocks and asked about why and they said, well the medial branch blocks are funded by the health fund but radiofrequency lesions are not, so they do not do them. If that was the case here, I am sure it would be very similar, but I would get into a dialogue with your local pain service and I am sure they would be very pleased to hear from you, because again, they should not be taking over care. They should just be providing some assistance to you and for ongoing management, and that would be important in getting away from procedures, I think is critical.
Jovi Stuart
Thank you. So I have got a question here to Dr Steve. What does Steve recommend to his non-specific lower back pain patients to do the first three to seven days?
Dr Steve Peterson
I think taking a starting with a good history and examination and getting your idea of how this is going to go, what is the person's risk and red flags and particularly what is the person's risk of yellow flags. Is that a swell idea? If you do not have particular concerns that that come up then there I suppose from the non-drug management, we want them to stay active doing what they can do. We do not want them to be doing bed rest. If there are things like heat packs or hot baths that sort of helped, that would be a good idea. If they smoke, they should stop or certainly cut down. If they have got a garbage mattress that is 20 years old and garbage footwear, they might want to think about not having those. If they want to have a look for analgesia options, and initially you would start with simple analgesia like paracetamol and ibuprofen, but you are going to have to do all this in context to the patient to take a good history and examination and decide what if that is relevant.
Jovi Stuart
Thanks Steve. We will just go through a couple of more questions as we are running out of time.
Professor Michael Nicholas
There was one by Andrew Lie about sleeping problems. They are very common. The OMPQ does actually ask about that. It is one we can pick up just from the questionnaire, but it is a question of what are their sleep habits? How do they go about trying to get sleep and what and so a referral to a psychologist could be warranted providing that you check they know something about sleep management. There is a very good app an American one called CBT-i, the I stands for insomnia, and I think that is a good place to start and that uses basically approach we use at our centre with our patients, and it is just getting people to look at their own their own habits, preparing to go to bed, what stimulants and so on they are taking at night and what to do if they if they cannot sleep or they wake up in the night. They can put on their iPhone. There are those sort of aids I think are quite useful if you want to speed it up.
Jovi Stuart
There are a couple of more questions. Dr Samit says can we use baclofen or Norflex?
Professor Ian Harris
Okay. Muscle relaxants. Yeah, I never use it.
Dr Steve Peterson
I mean in theory you can use anything for anything, but I guess you would have to decide what is the chance of these things actually assisting the patient, and is it better than the harms? I certainly have not used either. If you were to use them, therapeutic guidelines would suggest only in the first few days for the acute sort of patient, but I would not think there is a lot of evidence there.
Professor Ian Harris
I think they are just another thing that does not have the evidence behind them, but it sounds good, but it is probably less harmful than a lot of other things like injections, and if I were to ever use them, I would only ever use them on a short time basis, I think.
Jovi Stuart
One more question to fit in. Is the GP allowed to do some manipulation to patient regarding the low back pain other than referral or prescribing analgesics?
Professor Ian Harris
I guess the GP can do what they want, but there is just no evidence that that is actually going to help them at all.
Dr Steve Peterson
I think it would be a pretty unusual GP and that they had the training and skills to do that effectively, and as we said this earlier, there is no real good evidence for it.
Jovi Stuart
Thank you. I think that is all we have got time for this evening. I would like to thank all of our speakers Michael, Ian and Steve and everyone that has joined us online tonight. We do hope you enjoyed tonight's presentation. If you have missed any part of tonight's recording, it will be uploaded on the RACGP website and within the next week. Just a kind reminder that as this is a CPD accredited activity, your CPD hour will be allocated once you have completed the survey following this webinar. Again if you have any questions that have not been answered, please email them through to us at the webinar email that is on the screen now, that is nswact.webinar@racgp.org.au. We do also have the upcoming webinar on personal injury schemes upcoming on 13th of May. You can register via our website.