Management of Non-specific LBP Flashcards
What is the management for low risk LBP
Reassurance + advice
Direct to GP for oral analgesics
Encourage normal activities and return to work
Avoid bed rest
What is the management for medium risk LBP
Focuses on the secondary prevention for future LBP-related disability and address current symptoms:
- Education + advice
- Reassurance
- Offer group exercise programmes
- Consider manual therapy
- Promote return to normal activity and return to work
- Consider for CBT/pain management
What is the management of high risk LBP
Aims to reduce disability, reduce pain (where possible), improve psychological functioning and enable self management:
Likely to have 4 or more out the 5 psychological risk factors
Advice- return to normal
Education- understand nature of the pain, clarification of the roles of investigations
Focus of psychological factors- CBT, pain management
CBT research
Peter O’Sullivan advocates a recent approach for CBT as well as a graded exposure to exercise, movement and activity
Research for contextual factors
Contextual factors have shown to have placebo or nocebo effects in MSK.
Rossettini et al
What are contextual factors
Are factors that directly impact the quality of the therapeutic outcome.
They include: physio characteristics, patient characteristics, patient-physio relationship, treatment and healthcare setting.
What can you reassure patients about if they have common myths about LBP? (research)
Peter O’sullivan et al:
- Not a serious medical condition
- Getting older is not a cause of back pain
- Scans rarely show the cause of back pain
- Pain when exercising and moving doesn’t mean harm
- Pain flare-ups do not mean you are damaging yourself
- Injections, surgery and strong drugs arent a cure
What are the main factors consistently associated with poor outcome for LBP? (research)
Chris Maher et al
Higher disability
Presence of sciatica
Older age
Poor general health
Increased psychological distress
Negative cognitive characteristics
Heavy physical work demands
Research for pharmacological therapies
Prescribe oral NSAIDs for LBP at the lowest effective does for the shortest time possible- NICE guidelines (2016)
NSAIDs and muscle relaxants - evidence to say these are effective
American college of physicians and American pain society
Do not offer paracetamol alone for the management- NICE (2016)
Manual therapies and Modalities research evidence
Consider manual therapy (manipulation, mobs, massage) for managing LBP but only as part of a treatment package including exercise- NICE guidelines (2016)
Patients believe manual therapies to be effective which could be as a result of contextual factors as treatment beliefs could be seen in the patient characteristic subcategory and therefore have a placebo effect- Thomas et al
What are the guidelines for sending someone for a scan?
Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica- NICE 2016
Send straight to A+E for a scan if suspected Cauda Equina Syndrome or Stenosis with claudication
What is an annular fissure/annular tear? And how would you explain this to a patient?
Is a crack in the outer layer of a disc.
Usually asymptomatic and not a cause for concern. It is a normal change to the discs in your spine as life goes on.
What is a disc bulge or herniation? And how would you explain this to a patient?
The outer layer of a spinal disc weakens and protrudes out. Protrusion is when the nucleus tries to push through the annulus an an extrusion is when the nucleus has broken otu of the annulus layer.
‘Happens when a spinal disc weakens and something within the disc tries to push through the layers and protrude out of the disc’
What is Facet joint arthropathy? And how would you explain it to a patient?
Degenerative changes to the facet joints. For example arthritis.
‘The joints, called facet joints, which enable you to do movements like rotation and side flexion have become inflamed which is a common degenerative change that people go through as we all get older’
Research about exercise for LBP
Consider a group exercise programme- NICE guidelines (2016)
Global benefits of group exercise programmes with education include: decreased catastrophic thinking and fear of movement as well as reduced pain intensity and functional disability- Martins et al
Person centred care for LBP (guideline)
NICE guidelines (2016)
Treat patient with person-centred car when they present with chronic LBP. Including:
- Knowing the patient as an individual
- Enabling patients to actively participate in their care, including.
- Foster a collaborative and supportive relationship with the person with chronic pain.
How to talk to patients/family about chronic LBP and what to reassure them (guidelines)
NICE guidelines (2016)
- The likelihood that symptoms will fluctuate over time and that they may have flare-ups.
- The possibility that a reason for the pain (or flare-up) may not be identified
- The possibility that the pain may not improve or may get worse and may need ongoing management
- There can be improvements in quality of life even if the pain remains unchanged.
What is the research about having a scan for uncomplicated LBP? And how do you say this to a patient?
5-10% of pain is caused by a specific spinal pathology.
90-95% has no indication of a serious cause and can be managed conservatively.
Scanning unecessarily can have a negative effect on patient recovery and can uncover changes in the spine that are normal and may not even be causing the pain- Maher et al
I would say we don’t routinely offer scans because 90-95% of LBP has not indication of a serious cause
Nocebic language research
Keeffe et al
Found that using phrases such as ‘episode of back pain’ and ‘non-specific lower back pain’ reduced the need for imaging, surgery and a second opinion compared to diagnostic labelling.
