31 Jul Back pain causes and exercises

Back pain discussed by local specialists Damian Clark (knee surgeon, NBT), Neil Upadhyay (spinal surgeon, NBT) and Paul Maries (GP, Montpelier).

We see a lot of people in GP with simple lower back pain, often a recurrent spasmodic type pain. How is it best managed?

A genetic predisposition for back pain exists. Additional risk factors include obesity, smoking and job dissatisfaction. Spasmodic back pain is rarely due to a specific pathology. Patients need to accept it’s a condition needing lifelong self-management.

Patients must take ownership of their condition by reversing lifestyle risk factors. They should start activities that strengthen core and gluteus muscles. Also, they need to stretch hamstring and psoas tendons. They should avoid inactivity or unfamiliar activities and maintain employment.

The goal is for less frequent exacerbations and a return to function. Patients should develop individual strategies that self-manage intermittent exacerbations.

There is often a long wait for physiotherapy. What pearls of wisdom do you have in managing these patients?

Weekly physiotherapy over 6-12 weeks achieves little in isolation. Physiotherapy should support a patient’s own long-term activity programme. If they won’t accept that concept, all treatments will waste both the patient’s time and NHS resources.

Patients should find activities and exercises they enjoy and reverse lifestyle risk factors. They could join an exercise, pilates and/or yoga class. There is much talk of specific back exercises but these can reinforce the condition. Patients should do the activities they enjoy. They should understand back pain does not equal harm. Most regular activities will recruit key muscle groups and benefit gained.

See the long wait as an opportunity for patients to develop their own self-directed exercise programme. At the appointment, they can discuss their experiences and receive further advice. Refer patients to www.tamethebeast.org for more information.

GPs often wonder about the right time to request an MRI?

There are 3 “time-dependent” groups.

1. Very urgent MRI. This includes suspected spinal cord/cauda equina compression, acute radicular weakness (such as foot drop) and suspected spondylodiscitis/epidural abscess. Performed via hospital discussion/admission.
2. Urgent MRI. Such as suspected cancer.
3. Routine imaging. No improvement of radicular pain after 6-week onset.*
   Residual intrusive radicular pain after 3 months onset.**
   * Earlier scans may aid return to work.
   ** Consider MATS referral before MRI in complex or elderly patients. (complex being patients who have more diffuse symptoms)

What are the surgical options for treating acute radicular pain? Are there particular groups of patients requiring an early referral?

Consider early routine imaging if Paracetamol, NSAIDs, mild opiates and Pregabalin/Gabapentin or Amitriptyline are completely ineffective.

If imaging demonstrates acute concordant pathology a spinal root block may alleviate the pain and allow earlier graduated return to activities/employment.

Acute symptoms that become bilateral or objective motor weakness develops (such as foot drop) discuss the case with hospital on-call.

Patients should attend their local emergency department if symptoms of Cauda Equina Syndrome develop.

I rarely advise surgery within 3 months of symptom onset unless simple measures such as analgesia, lifestyle changes (in particular smoking cessation) and root block have failed. 90% of acute radicular symptoms improve by 3 months of onset.

Does every red flag require urgent investigation?

Red flags aim to highlight potential concerning pathologies such as cancer, infection or significant neurological compression. Back pain in the elderly is mostly not due to cancer or spondylodiscitis. Intermittent night pain in my experience is benign.

Next up will be hip arthritis.