Download What about patients with Radicular Pain?

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Regional Back Pain and Radicular Pain Pathway
Frequently asked Questions and Answers
Moving BACK to health
Don’t let your back pain get the better of you!
The Regional Back Pain and Radicular Pain Pathway covers all aspects of the management of
acute episodes of non-specific mechanical back pain and radicular pain
A key focus of the Pathway is that patients are encouraged to manage their back pain
themselves by being given appropriate advice and literature from the outset, but with clear
guidance on when further consultation and interventions may be required. NICE says that
effective management is essential for relieving the disability and economic burden that back pain
can have and also preventing it from becoming chronic, which can lead to considerable social
and personal effects and loss of work. As such, it’s important to enable people to manage the
condition themselves so they can continue with normal everyday life, but the pathway allows
early identification of those individuals who have characteristics that could result in their condition
becoming chronic and prioritising professional input into this group.
The pathway itself will deliver quality improvements by the introduction of a single point of contact
for patient management early in the pathway by a trained practitioner providing an improved
patient experience by replacing the current “pinball” management pathway. It will eliminate the
delays between therapy options, thus reducing the development of chronicity. It will eliminate
ineffective but costly therapies which are still widely offered. It will achieve cost savings derived
from discontinuation of ineffective investigations/therapies, from reduction in referral for fusion
surgery by mandating participation in Combined Physical and Psychological Programme (CPPP)
as recommended by NICE prior to any consideration for surgical referral for non-specific back
pain and by improving waiting times for interventions for non-resolving radiculopathy
We have put together below some questions and answers that may be of help for now. Please
do not hesitate to contact us if you have any further questions or queries. These can be sent to
Helen Ridley by email [email protected] or Dr Khapra by email [email protected]
As a GP/Clinician what is your role within the Pathway?
The role of the GP is essential to the success of the pathway as the initial clinical assessment will
dictate the progression of the patient through the pathway.
First/Initial Attendance
The GP/first contact clinician should be skilled in screening for cauda equina and red flags and be
able to identify: Neuropathic pain, nerve root pain, vascular pain, and inflammatory disorders.
If the clinician feels that the patient on initial presentation has features suggestive of nonmechanical back pain (Cauda Equina, Red flags, Inflammatory arthropathy) then appropriate
© STHNFT v.8 – updated October 2015, minor modification 31 march 2016
pathways are available including: urgent referral to specialist services (cauda equina, spinal
infection, fracture); referral to specialist services (Rheumatology - inflammatory disorders, 2 week
rule - suspected metastases) and referral to Triage and Treat Practitioner (nerve root pain or red
flags)
The clinician will have telephone access to advice from Triage and Treat Practitioner (T&TP) if
required to help clinician access the appropriate pathway.
For mechanical or non-specific back pain what is said to the patient early on in their presentation
can significantly affect their on-going perceptions and health seeking behaviours. For patients
where mechanical back pain is suspected, it essential for the success of the pathway that
everybody ‘sticks to the same script”, giving standard literature and advice with a positive outlook
– for example: “Many people have back pain from time to time but it is rare for this to be caused
by a specific problem. Mostly all that is needed is to get your back moving again and things will
settle down”. Review after two weeks may be offered if patient is no better but make it clear from
the outset that most episodes will get better within a 6 week timeframe.
Also the vast majority of radiculopathy episodes resolve with conservative interventions and only
the minority will require either imaging or surgical interventions
A brief template will be used to capture data on the episode and advice/treatment given.
Second Attendance - at 2weeks
If the patient returns for a 2nd attendance after 2 weeks use of the StarT Back questionnaire is
required. The StarT Back questionnaire is a simple and very short prognostic tool to match
patients to treatment packages appropriate for them. Using nine simple questions it stratifies
patients into high/ medium/ low risk categories of developing chronic problems related to the back
pain. The questionnaire can be completed either before or during the appointment - it will be
available digitally.
Low risk - Patients who are deemed to be low risk of developing chronicity should again have
the standard advice concerning activity and appropriate medication, be encouraged to keep
moving and be discharged; but with advice on when it would be appropriate to return
Medium/High Risk Patients deemed to medium or high risk on the StarT Back should be
referred to the local Triage and Treat Practitioner (T&TP) for further assessment and onward
referral to appropriate therapy. The emphasis of the pathway is on self-management and
demedicalisation, most patients recover within 6 weeks and so for both of these reasons
immediate referral to manual therapy is not suggested. First contact clinicians should not suggest
that the referral is for further investigations e.g. MRI, as this may not be appropriate and could be
harmful to the patient’s recovery. The onward case management for the patients back care will
now be the responsibility of the T&TP who will advise the GP of the patient’s progress through
the pathway.
Again the attendance will be captured for data purposes on a specific template that will have the
StarT Back tool and referral form embedded in it.
GPs refer for MRIs and X-Rays at present, what will happen once the Pathway is
implemented?
Plain X-Rays of the lumbar spine are rarely indicated and expose the patient to high levels of
radiation (lumbar X-Ray radiation 150x that experienced during a CXR). The information provided
is limited.
MRIs are frequently requested but often the reported findings have little or no relevance to the
patient’s current symptoms and can be the potential cause of much anxiety if not explained in the
full context of the patient’s clinical picture. Recent research indicates that early scanning actually
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increases the risk of chronicity and significantly increases the use of unnecessary injections or
surgery
To limit unnecessary investigations, GPs or other professionals will not need to request spinal
imaging, unless sinister features (red flags) are present. NICE Guidance (CG88) provides a
comprehensive evidence review outlining effective and ineffective investigations and treatments.
The Triage and Treat Practitioners will determine if the patient requires further investigations and
treatments for non-resolving simple back pain or radiculopathy.
I have a patient who has been suffering bouts of Back Pain for over 10 years;
would I refer them to the Triage and Treat Practitioner (T&TP)?
This care map is intended for acute/persistent spinal pain, including radicular pain. Most people
who complain of back pain normally manage their symptoms effectively, but if they have an acute
episode of severe pain which is not settling with typical measures then they may be considered
for the pathway and be referred to see the T&TP if appropriate. If patients have longstanding,
continuous intractable back pain they may not be suitable for pathway care but require a more
individual management plan.
I have a patient who has had chronic back pain for a number of years and has now
become dependent on opioid drugs, would I refer them into the Triage and Treat
Practitioner?
This patient cohort would be more appropriately managed by pain services.
Who are the Triage and Treat Practitioners and what service will they provide?
Triage and Treat Practitioners (T&TP) are the key professional in the patient’s pathway and will
provide safe, consistent advice to the patient, requesting appropriate investigations (MRIs, bloods
etc) if required, referring for approved therapies as indicated and providing continuity of care
throughout the pathway. The Triage and Treat practitioner will usually be an Extended Scope
Physiotherapist or Specialist Nurse. They may be already working in primary care in group
practice surgeries, MSKS services and other facilities of the CCGs, but the pathway will bring
them into a key worker role earlier and throughout the patients journey, bringing expertise and
continuity of care closer to patients. The most consistent message from patients is that the want
to feel there is somebody in overall charge of their care pathway.
What are approved Therapies?
The T&TP may refer for appropriate therapy which will be functionally based, goal driven and
delivered by a physical practitioner (physiotherapist, osteopath, chiropractor). Again it is
essential for the success of the pathway that all professionals involved ‘sticks to the same script”,
giving standard literature and advice, using a biopsychosocial approach and avoiding
medicalising the patient. All therapy will be overseen by the T&TP.
Physical practitioners will provide an individualised package of education and care tailored to the
patient. Low back pain related distress, anxiety, fears, beliefs and expectations should be
addressed as an integral part of the package of care. An exercise based approach to therapy
provision using current best evidence will be followed. Patients may be referred to a formal
exercise group, if patients are unsuitable for this, individualised exercise therapy with /or without
a course of manual therapy or acupuncture may be considered.
It is anticipated that the number of treatment consultations will vary between patients with many
only needing short periods of care. Core treatments, if effective, may be used up to the maximum
limit indicated below. In practice however, if manual therapy or acupuncture are not
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demonstrating improvements after 3-4 treatments, then a re-evaluation of approach should be
considered.
A structured Exercise programme may be delivered by an appropriate physical practitioner as a
group exercise programme (up to 10 people) or a one-to-one tailored exercise programme over
12 weeks for up to 8 sessions using a CBT approach promoting self- efficacy. If appropriate, up
to 10 sessions Acupuncture and 9 sessions of Manual therapy (including mobilisation, massage
and spinal manipulation) over a period of up to 12 weeks may be considered.
Patients with a good response may be discharged by the physical practitioner; otherwise a review
by the T&TP should take place after treatment to evaluate patient’s progress to discuss if a
change in approach is required. Formal review will be made at 12/52. Following this review a
number of options are available. In some cases a further 6/52 of core therapy may be provided.
Referral to Combined Physical and Psychological Treatment Programme (CPPTP) or other
specific services as indicated in the pathway may be discussed in consultation with the patient.
What about more intensive treatments?
Patients should only be referred for combined physical and psychological treatment (100 hours of
therapy over a maximum of eight weeks is recommended) when they have had at least one of the
less intensive treatments and it has not been effective, or if they have significant disability or
psychological distress.
Surgery (spinal fusion) should only be considered if a patient has completed an optimal course of
care, including a combined physical and psychological treatment programme, and if their back
pain is still so severe that they would consider surgery.
Are there treatments that should not be used?
In addition to advising that therapeutic substances should not be injected into the back, NICE
recommends that several other non-medical therapies should not be carried out. These therapies
include transcutaneous electrical nerve stimulation (TENS), lumbar supports, traction, laser,
therapeutic ultrasound or interferential therapy.
What are Red Flags?
The red flags were introduced in 1994 in the CSAG report. They comprise a number of symptoms
and signs which have been associated with increased risk of underlying serious conditions.
Recently some doubt has been cast on the sensitivity and specificity of the flags but they remain
useful shorthand for clinicians to maintain awareness of possible serious pathology. These red
flags will require either urgent further investigations or direct referral to Secondary Care.
If cauda equina signs, significant new neurological deficit, spinal infection or unstable
fracture are suspected, immediate/ same day referral to appropriate secondary care specialist is
required.
If spinal metastases, osteoporotic fracture is suspected on examination then refer to
secondary care under the two week rule, or T&TP within 5 days.
Inflammatory and vascular disorders should be referred to secondary care specialists as
appropriate.
If nerve root pain is suspected refer to T&TP, urgently if appropriate.
© STHNFT v.8 – updated October 2015, minor modification 31 march 2016
Suspected
Red Flag:
Spinal
metastases:
Spinal infection:
Suspected
unstable
fracture:
Neurological
Deficit:
• Age <16, 50>
with new onset
back pain
• Hx CA
• fever
• wt loss
• IV drug use
• urinary
incontinence
/retention
• unrelieved
pain
• progressive
non mechanical
pain
• recent infection
• severe low
back pain
following
significant
trauma
• thoracic pain
• previous
Cancer
• thoracic spine
pain
• weight loss
• immunecompromised pt
(steroids, diabetes,
transplant)
• faecal
incontinence
• altered perianal
sensation
• limb weakness
• steroid use
Osteoporotic
fracture:
• infection
• sudden onset
• fevers/rigors
• minor trauma
• urinary
incontinence
/retention
faecal
incontinence
• age
• hyper-reflexia
• clonus
• new /progressive
spinal deformity
• Babinski
• osteoporosis
• recent
deformity
• altered
perianal
sensation
• limb
weakness
What is Radicular Pain?
Radicular pain is a type of pain that radiates into the lower extremity directly along the course of a
spinal nerve root, caused by compression, inflammation and/or injury to a spinal nerve root.
Common causes include herniated disc, foraminal stenosis and peridural fibrosis. Because it is
caused by neurological compression or dysfunction, radicular pain is accompanied by numbness
and tingling, muscle weakness or loss of reflexes - radiculopathy. Radicular pain in the leg is
usually called sciatica and frequently radiates along the sciatic nerve down the back of the thigh
and sometimes into the calf and foot. Radicular pain can be effectively treated conservatively
(non-surgically) with physical therapy, medications and epidural injections. If conservative
treatments fail, decompressive surgery, such as a laminectomy or discectomy, may alleviate
radicular pain.
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What about patients with Radicular Pain?
Patients with radicular pain should be referred to the Triage and Treat Practitioner who after their
assessment will have access to fast track surgical appointments for therapeutic nerve root block
or epidural which will be undertaken in secondary care, for example by a nurse practitioner at
South Tees. These will be directly bookable by the T&TP. The T&TP will also have access to
booked slots in the surgical clinics for appropriate patients.
© STHNFT v.8 – updated October 2015, minor modification 31 march 2016