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Lower back pain

Back pain and Primary Care roles

[00:00:06] Munir Adam: Hi guys, welcome back. It's Munir Adam here, and this episode is about lower back pain. Now, lower back pain is a very common condition, or presentation, perhaps I should say. And depending on who you are in primary care, it may be something that you're very familiar with. So, for example, if you're a GP or a first contact physiotherapist, and perhaps those in other roles as well, it may be something that you deal with every day and you're already very familiar with it.

[00:00:33] Or, you may be somebody whose role doesn't involve dealing with lower back pain at all. Perhaps you're a clinical pharmacist who deals mainly with medication reviews and certain conditions, but not back pain. So if you're somebody who's either already familiar or somebody who doesn't really have to deal with it, you might wonder why we're covering this topic.

[00:00:50] Well, the thing is, although we're very familiar with it, I think you'd agree with me that management of this and control of lower back pain is far from perfect. Yes, there are many patients who come along, get the right treatment and get better. There is no shortage of of experiences that each of us have where we really feel we've tried everything and we're just not solving the problem.

[00:01:11] We may even feel that we've let the patient down or that it's a patient who looks like they just don't want to get better or don't want to follow with all the treatment recommendations that we've made. And what do we do? So two things to say about that. The first is, have we properly done all the basics right?

[00:01:27] And the second is, if we have tried everything and things are not getting better, well, where can we send them and what more can be done? So both of those are going to be addressed later. 

[00:01:36] Now how about you're somebody who doesn't normally deal with back pain at all, if it's not your remit? Why would you want to listen to this? And I'll tell you why. It's such a common condition that regardless of your role, you're likely to come across it. And also it links in with other conditions. Now, if you're somebody providing counseling services, did you know the interplay and connection between lower back pain and psychological state?

[00:01:58] Some people will know about yellow flags. Some of us will be very familiar with this, and they're quite challenging patients. And if you stay till the end, you will be hearing some advice. And besides, regardless of who you are, I bet every single one of you listening knows somebody in their life suffering with lower back pain. And, you know, if we know a bit more about what this is all about and how to deal with it, all the better. 

[00:02:25] So, what are we providing in this episode? Well, it's a conversation that I've had with Dr.

[00:02:30] Adnan El Kaysi, who is a consultant specialist working for Guy's and St. Thomas Trust, and Guy's and St. Thomas department is a tertiary center, so they specialize in these conditions. In fact, they receive referrals from throughout the country. It was initially difficult to get hold of Adnan, as he was busy in conferences in other parts of the world. But when I did, he was only too delighted to remind us about the basics of lower back pain, some of the important things to bear in mind, and some of the innovative, or at least from my point of view, innovative technologies and approaches to lower back pain as well.

[00:03:06] So, in partnership with Integrated Care Support Services, let's continue season two of Primary Care UK.

[00:03:12] 

Introduction and Guest Background

[00:03:25] Munir Adam: Thank you, Adnan for joining us today. Perhaps you'd like to start by introducing yourself, your role and maybe your department as well

[00:03:34] Adnan: Thank you, Muneer, for this opportunity. It's a pleasure and joy to join you today. My name is Adnan El Kaysi. I'm a consultant in pain medicine. I work at the Pain Management Center at Guy's and St. Thomas Hospital. The center actually is located at St. Thomas Hospital. And this is one of the oldest centers, and probably the biggest in the world.

[00:03:59] We are 90 people working in the department, 12 consultants, psychologists, physiotherapists, occupational health, nurses. And all the admin team required. Is a tertiary referral center and it is recognized by NHS England as one of the top specialized centers. So the fund coming from NHS England, not from CCGs.

[00:04:25] So, the group of patients that we are dealing is, um, usually complex, and as I said, coming from different parts of the country, including Channel Islands.

Understanding the Magnitude of Lower Back Pain

[00:04:35] Munir Adam: Okay Back pain and lower back pain specifically isn't a topic that needs introduction really to anybody. We're very aware in primary care It's such a common problem. And so hearing about departments like yourself that specialize in this, that being part of the remit is very welcome news But how big a problem is lower back pain from your experience?

[00:04:56] I mean, what are we actually dealing with here in terms of, say, numbers? And how important is the problem? Why does it matter so much? 

[00:05:02] Adnan: Oh the reality is that lower back pain is one of the most commonly encountered chronic pain conditions in the clinical practice. As well as in our center, we see about 50 to 60 percent of the patient with a chronic lower back pain. And it is estimated globally, there's nearly, 500 million people, uh, suffering from this condition.

[00:05:24] Oh, yeah. And, and it is complex condition influenced by biopsychosocial, uh, psychological factors, as well as comorbidities. So a truly complex. 

[00:05:36] Although a large number of patients with lower back pain get treated. But we have 10 to 20 percent actually proceed to become chronic. 

[00:05:43] Munir Adam: Right. 

[00:05:44] Adnan: Yeah.

[00:05:45] The pain persists for more than one year. Um, they are unlikely. to return back to work. 

[00:05:51] Munir Adam: Wow. No, what you mean ever? 

[00:05:53] Adnan: That patient, it becomes severely disabled because of the pain. And they will never be able to go back to work if they are off work for more than one to two years. And that has implications in terms of the cost. The cost, you know, on health care nearly about 3 billion. And loss of productivity about 3. 5 billion. So we're talking about substantial amount of financial implication, and it is dilemma for two reasons. Number one is the tissue source of low back pain could not be identified most of the time Because the spine is so complex and there is number of structure could be the target of the pain.

[00:06:38] There is no logical and effective intervention. So we manage, and when it comes to chronic back pain, we manage the pain and make people better. But we are not curing It. 

[00:06:52] Munir Adam: So what I'm hearing is that as well as being a very significant medical consequence in terms of the pain that they're experiencing, there are those psychosocial elements to it, and the economic impacts of that, and it makes one wonder first of all, why is it so common? And perhaps related to that question, is that the case in other areas? And I know that a couple of times when I've tried to secure an appointment with you to do this recording, you've been into various parts of the world and conferences and things like that. So it'd be useful to hear from you about whether this is specifically a problem mainly in, in a few countries like the UK or how this varies in other regions as well.

[00:07:32] Adnan: It is worldwide. A problem is a modern life issue, and this is resulting from a number of factors; because we are not taking care of our back very well. You know a lot of time we, uh, sit on our bum for long period of times. We are not doing regular exercise; carrying heavy objects without paying attention to our back.

[00:07:58] Smoking, diet has all implication. While we think that is restricted to the Western world, no it is not. Because I travel the world and I see people from even third world countries having this issue.

[00:08:11] Munir Adam: Right. And as a result of this, you've mentioned some of the important consequences of that. Now, let's just start with some of the basics because our focus is on, as you mentioned, not being able to identify the cause and essentially focusing then on managing the symptoms rather than being able to cure the problem.

Initial Approach to Lower Back Pain in Primary Care

[00:08:29] Munir Adam: But that we, we might not reach that conclusion straight away when a patient presents to us for the first time, isn't it? How should we be approaching this in terms of somebody coming with and saying, well, look, my, my back's hurting. What might be the important things to cover in the history and on examination? 

[00:08:43] Adnan: I think it, it is back to basic history. and thorough physical examination. From the history, we have to establish whether this is an acute pain and whether the patient has history of a trauma and of elderly having malignancy and if the symptoms happened all of a sudden. There is some of the symptoms, maybe a mild pain in the lower back but there is other symptoms which one has to exclude and ask for.

[00:09:12] And, uh, to exclude this horrible condition called the cauda-equina syndrome. So we have a number, uh, while it is low number, but it can cause severe morbidity. So the issue is, number one, we have to exclude any fractures if there is in a patient and their, you know, had sustained a trauma. And number two, if the patient has a history of malignancy, we have to exclude any metastasis.

[00:09:37] And for cauda-equina syndrome, one has to be careful about this, to ask simple questions regarding whether the patient has urinary retention, um, and it could progress to urinary or fecal incontinence. SADDLE anesthesia, where the patient lose sensation in the anal genitalia, as well as the butock region. there's associated weakness in advanced cases. We need to pick up these very quickly. And best thing is the patient to be referred to a and e. So this is one of the most important things I want every single GP to, to be well aware about this. 

[00:10:18] However, as I said, these are a small number. You are talking about 1% if that. Majority of the patients are presenting with simple lower back pain, a majority being precipitated by carrying heavy weight or bending, over exhaustion, overload. And the patient presents usually with back pain, muscle spasm, and some sensation down in their buttock. 

[00:10:44] Uh, management of this patient is simple. Uh, we started with simple analgesia like your NSAIDs uh, codeine and simple also measurement like, uh, heat apply on the back pain like a wheat bag. They can get it from any, uh, health center like booths or pharmacy. And one I highly recommend, highly recommend is TENS machine. Trans Cutaneous Electrical Nerve Stimulation for muscle spasm.

[00:11:11] Very cheap. You can get it for 20 pounds from Boots. For muscle spasm, it work with the back pain. With muscle spasm, it work wonder. And I use it myself when I have acute back pain. So it is, uh, because I travel a lot and sometimes I don't do my exercise. And you can get this horrible lower back pain. In the past we call it lumbago now it's called lower back pain.

Challenges in Medication Management for Lower Back Pain

[00:11:37] Adnan: Now, I would like to touch base on one thing just for a few seconds about the practice of using diazepam. Diazepam is an anxiolytic. It is not really muscle relaxant. In order to be muscle relaxant, you get 50 milligrams. 

[00:11:54] Munir Adam: Ah... 

[00:11:55] Adnan: so, I have no issue if you use it for 3 days to relax the patient 2 milligrams 3 times daily. That's not a problem. But we don't want it to be a common practice because this is very addictive medication. Alternative to this is other muscle relaxants like Baclofen. So, um, and that you can use it, uh, for a small amount of, you know, 10mg three times daily; Tizanidine , which we use for severe muscle spasm from a spinal nerve injury, but it can be used for acute pain condition. Again, small dose, two milligrams, and it can be increased slowly to, divided doses two milligram, three times daily, let's say for example, 12 milligrams. Be cautioned with the drug interaction and side effects. So I really, I wanted to emphasize this, but majority of the pain really recovered very well. And I cannot emphasize enough to use the TENS machine for this group of patients.

[00:12:56] Munir Adam: Okay. Well, that's really useful to know. Number one, the TENS machine, because although we hear that quite a lot in primary care, we don't often get the feedback of how beneficial it can be. But the other point you make as well about diazepam, because I have to say, I think it's more common to end up prescribing that compared to say, Baclofen, as you mentioned.

[00:13:12] Even though the latter probably doesn't have those risks of addictiveness and tolerance and things that diazepam and abuse that diazepam can lead to as well if, if we're prescribing it on a relaxed way. And as you say, it's not even a relaxant. Well, it's not, it's not a muscle relaxant as such. 

[00:13:28] Adnan: It is anxiolytic. And I have to say, you know, I've seen some patients which used it and the patients respond. And we explained to the patient that you cannot use more than like three days or so. And this is, this is the maximum you can give. 

Importance of Lifestyle Changes and Exercise

[00:13:45] Adnan: The second thing after this acute attack of back pain, the rest is only three days. We need to encourage patients to, become more active, gradually going back to the normal activities, you know, walking, going upstairs, down stairs. We need to activate this muscles, which is getting into, into the spasm. And walking, the muscle eventually will relax. And we need to identify this group of patients who are coming with this condition. And we're trying to encourage them to take care of, for themselves, you know. We have to empower them to manage their pain by doing regular back exercise. I cannot emphasize this. If they do 10 minutes in the morning, 10 minutes in the evening, trust me, their condition will be settled nicely for years to come.

[00:14:40] Munir Adam: Can you say a little bit more about, because I know that we find in primary care quite a lot of the time patients come along. Now medical certificates can also be prescribed by a range of other healthcare professionals working in primary care as well. So that burden is being spread across, not just with doctors, but nurses and clinical pharmacists and so on.

[00:14:58] And patients come along and they want to have one month off work because their back is hurting and they will inevitably blame it on work. And they're going to say, well, how, how on earth could being at work be good for me when my back is so painful? Well, how should we respond to that? Sure 

[00:15:11] Adnan: I discourage this, and if it's true, if they want to have some help, we help them by managing their condition rather than encourage them to stay away from work. And that's where it comes with the education of the patients. And of course, for acute attack they're entitled to have three days and maybe maximum one week. After that, they should go back to work.

[00:15:36] Munir Adam: And is it something to do with keeping the muscles going or from from wasting away or or is it a psychological thing? 

[00:15:42] Adnan: Number one is the activity of the muscle to come back to some form of normality. 

[00:15:47] Munir Adam: Okay. 

[00:15:48] Adnan: And number two is self confidence, to bring them back to work. They feel that they're actually going to achieve something. 

[00:15:56] Munir Adam: Hmm. 

[00:15:57] Adnan: Number three, get them out of the house rather than sitting there feeling sorry for themselves. 

[00:16:02] Munir Adam: Hmm. 

[00:16:03] Adnan: And and prevent chronicity.

[00:16:06] Of course, there is a number of patients who come with, um, some, what we call it, yellow flags, as there is uh, social risk factors with the low back pain and we need to address this. And if they have a family member with them, always encourage them to support them and help them to get out of this vicious circle of back pain, depression, isolation.

[00:16:31] We need to get them out of this hole. 

[00:16:32] Munir Adam: Yeah. 

[00:16:33] Adnan: And that's coming back with the education. And then we move on, you know, for group management if we have something locally within the GP surgery.

[00:16:44] Munir Adam: Yeah.

[00:16:44] So let's stick on this point for an extra minute or two. So our focus on, look, try and get back to work sooner rather than later. Yes, some of the pharmacological treatments that you mentioned a few minutes ago. Is there anything else we can say to them in terms of what they should be doing?

[00:17:01] Lifestyle factors? Is there anything else that will help them in this situation before we go on to more advanced treatments? 

[00:17:08] Adnan: Oh, absolutely. And this is one of the things that uh, within the group from your side, those people who have sort of repetitive issues with their condition, exercise sessions and physiotherapy, group sessions and with physiotherapy, uh, manual therapy, if it is available by train personnel; and then if it those people who are with the severe depression, we need to get them some form of cognitive behavioral therapy, either in one to one basis. or in a group, We're trying to do that where we work in Lombard, you know, it's around St. Thomas's Hospital. And this primary support from secondary care, it seems working and working well 

[00:17:52] Because we don't want the acute pain to progress to chronic condition and because it will be then difficult to treat and it is very expensive on the health care, most importantly on the patients themselves.

[00:18:07] Uh, so I would say the cornerstone is the patient education and we need to empower them to take care of themselves and, uh, do on don't list. And there is number of booklets around about how they sit, how they stand what kind of exercise they have to do. It's been published by NHS England for a number of years. And it's available, and I think in every single GP this booklet for back pain or neck pain should be available. 

[00:18:39] Most importantly also, keeping repeating myself, we have to empower the patient and the compliance. Sadly, even from our side, we advise the patients to do these exercises, and when they come back, how much you've done, and things like that, some of them are honest, they said, I've done it for a few weeks, but, um, I'm busy, and so it needs to be routine. No negotiation. On a regular basis. 10 minutes in the morning, 10 minutes in the evening, and it can do wonder for them. I'm not going to go about swimming and go to the gym. It is in house, simple set of exercise they do.

[00:19:17] Just like all of us, we are all, I'm doing regular exercise. And I'm trying to go to do my back. exercise, go to the gym on regular basis, the diet control, loss of weight, stop smoking. So all of this play a major factor in not only improving the back pain, but preventing it and make it uh, from progress to getting chronic.

[00:19:42] Munir Adam: Indeed. Yes. And I would say to people listening in primary care that there's a very real risk of becoming despondent with this and believing that other than medication and investigations, patients are not going to follow your advice in terms of what they can do in terms of their lifestyle.

[00:19:57] But actually there are those who are in that category. There are those patients who seem to reject a lot of that advice but suggesting for them, but there are many others who are willing to follow it as long as we explain it clearly. Because sometimes we're a bit wishy washy about it, you know Yeah, do some exercise eat healthy do a bit of cycling or whatever And we're not really explaining clearly in a way that they can manage this. 

[00:20:19] And in addition to that in primary care In some areas now we have lifestyle coaches, you know, lifestyle medicine is a growing area and also some practices have in house physiotherapists as well that can help. So all of that going on as well. 

[00:20:34] But that reminds me, there will be those who come back and say, look, I just need to have an MRI scan. What would you say? Should all of them be having a scan before we refer them onwards to secondary care or, or not?

[00:20:46] Adnan: Yeah, MRI scan does not talk to pain. It is not specific and sensitive. So for chronic lower back pain, it has no value whatsoever. 

[00:20:57] Munir Adam: All right. 

[00:20:58] Adnan: Uh, however, if patient develop radiculitis, where having shooting, burning, pain going down to the foot, and this pain associated with numbness or tingling sensation and occasionally weakness, this patient be worthwhile to undergo MRI scan. But some back pain can have a referred, simply referred from the facet joints going to the back of the thigh. And this is referred pain don't fall into this. So, MRI scan restricted only on. radiculitis, shooting pain down to the leg.

[00:21:35] Munir Adam: Okay. All right. That's that. Uh, we'll have to be a bit more strict on ourselves in that sense. 

Referral to Secondary Care and Advanced Treatments

[00:21:40] Munir Adam: So who should then be referred onwards to secondary care and what can be done in secondary care? 

[00:21:46] Adnan: Well, when the condition become chronic, and definition is pain more than 12 weeks... 

[00:21:53] Munir Adam: right. 

[00:21:54] Adnan: Despite all the measures that being taken, that we talked about. And even for this group of patients, we must, you know, with the chronic pain patients, we don't want to see all of them, obviously. But I'm hoping that the patient will undergo some education session, as I say, a group exercise session specifically with a charted physiotherapist.

[00:22:18] We not talk about, uh, movement exercise by trained therapists, uh, like manual therapies. And CBT, as with the group of people, and if those people are still having significant back and leg pain, then after this management and all these measures being taken, we're quite happy to see them. 

[00:22:38] Um, just I would like to take you one more step back because there is a common practice in the GPs who start people on gabapentin, or pregabalin, and please don't do that.

[00:22:51] Munir Adam: Ah, 

[00:22:52] Adnan: It's a waste of time and money and has a serious side effect. 

[00:22:56] Munir Adam: really? 

[00:22:58] Adnan: And they said it is a neuropathic pain because gabapentin and pregabalin is used for neuropathic pain. Like, injury or complex regional pain syndrome, trigeminal neuralgia. And they try to fit it in, obviously, for the cell, you know, they're saying, oh, this is a neuropathic pain, so you can give them gabapentin and pregabalin.

[00:23:16] We've done all the studies, meta analysis, and systematic review, gabapentin and pregabalin has no place in the management of back pain. Period. 

[00:23:24] And 

[00:23:25] Munir Adam: Right. 

[00:23:26] Adnan: It can cause a lot of water retention uh, memory loss, lack of concentration, and depression. So, don't use this medication, please.

[00:23:35] Munir Adam: What about, um, I don't know, Amitriptyline is quite commonly used as well, isn't it? 

[00:23:40] Adnan: Triptyline is tricyclic antidepressant, and we've used it for over 30 years, it's a long safety record, and it can work very well. Uh, start those 10 milligrams and you can escalate 25 milligrams Nocti at night. It enhance the endorphin, uh, and it can be relaxing and it enhance sympathetic activities.

[00:24:07] It work and it work well in some of these group of patients. We have no problem with this. The side effects like dryness in the mouth and drowsiness will be tolerated with time, with the use of the medication.

[00:24:21] Munir Adam: It's quite difficult with lower back pain in primary care when we find that more and more guidance is telling us not to put people on a whole range of painkillers. Like first, anti inflammatories were often contraindicated for various reasons with the side effect profile and risk. And then the MHRA publication, I think about a year ago, to try and avoid opiates and even co codamol and co didromal now before we prescribe it, we have to think about the risks of toxicity and so on. 

[00:24:44] Adnan: That's correct. And because, uh, what happened regarding the opioid, the major issues is the addiction and the biggest scandal happened in U. S. and including U. K. and western part of Europe, that accidental death with the overdose of opioid. In 2014 alone, 30 million people in U. S. alone died because of opioid overdose 

[00:25:11] Munir Adam: That's quite a bit. 

[00:25:13] Adnan: Yeah, it's more than road traffic accident. Imagine. So, and these companies being sued and et cetera, and we don't want to get into this stage of throwing medication on people. We need to be a smart enough and apply modern medicine way of encouraging people to be part of their management and, um, simple measures that they can take to, to take them. 

[00:25:39] I have no problem people having imitriptyline 10, 15 milligrams, uh, on a regular basis. And I have no issues to taking paracetamol, codeine, when they need. We don't want them on a regular basis. But opioids, strong opioids, we don't, we don't advise it. Not only they're useful for acute pain conditions, like after surgery, opioids can work very well. But after three months, it has no role whatsoever. If anything, it starts to cause side effects, and people will start to escalate the dose of the opioid and and they develop tolerance and habituation. With that, we find that actually, when in high doses, it can result in a condition called hyperalgesia.

[00:26:21] It can generate pain, causing more pain, because nerve ending, it becomes very sensitized. 

[00:26:28] Munir Adam: Ah. Hyperalgesia. Gosh. Yeah. How about that for first do no harm? 

[00:26:37] Adnan: So, these, these things is all systematically reviewed and studied. And when we advise people to reduce it , and eliminate it from them, he said how do you feel? I said, I feel much better; and although, you know, the pain, maybe not, the intensity of pain doesn't change, but they say, at least I have something not make me drowsy or, lack of concentration and side effects.

[00:26:57] Munir Adam: Okay. So we've got to be more careful with what we're using in terms of prescriptions for patients. There's definitely more that we can be doing in primary care in terms of providing that holistic and lifestyle approach. But let's suppose we've done all of that and we're still stuck in a position where we're just not managing and we feel we've got to pass this on and refer this onwards and they've tried physio and all of those things. We would normally refer to secondary care, or would we be referring directly to your services, because you're a tertiary center?

[00:27:27] Adnan: We are tertiary centered and always there is a different algorithm and different pathways in different part of England. Uh, SMK, for example, lower back pain, they take the big part of this group of patients. And then they decided where the patient goes, but we are very happy if these patients went through all these hoops and they cannot manage their pain, we're happy to see these complex cases. 

[00:27:55] And once they get to us, we do all necessary investigation for these patients. And just like we are police, you know, we need all the previous correspondence. We need the summary history from the patient themselves about all their conditions, comorbidities, the medication they've taken previously for managing their pain, what measures they've taken.

[00:28:21] So we will have the whole foundation about the patient before we start their management. Some patients require further assessment. For example, they may require a MRI scan, PET scan, or CT scan uh, nerve conduction studies. So, we, we provide package on investigation, so we do full history and physical examination.

[00:28:43] A lot of patients coming with problem called facet joint syndrome, uh, that's the backside of the joints become very inflamed and you touch their back and they jump. This patient can be treated with simple facet joint injection. And this is middle branch. This is NICE guidelines approved. If the patient reduce more than 50 percent we'll consider procedure called radiofrequency denervation.

[00:29:09] So that we hit the middle branch of this, so we obliterate it. And the pain will get better. It's not magic. The pain will get better, but in order to enhance the outcome from this procedure the patient must do these exercises that we provide to them. And also avoiding it from getting any worse. And it work well for properly selected group of patients.

[00:29:37] Other group of patients, they come in with radiculitis that we talked about, that an inflamed nerve resulting either from a disc prolapse or an inflammation and scarring from previous operation in the lower back. And we do a procedure called epiduralysis. This is um, people do nerve block. But we are, we do this epiduralysis is advanced technique where we insert a specialized catheter from the tail of the spine reaching out to the affected nerve. So pinpoint accuracy. We inject contrast so we can color where the nerves is. And then we inject normal saline and hyalase, hyalase is a substance to dissolve if there's any adhesions of fibrosis. So in many way called hydrodistention. If the nervous is scarred, strangulated, will become swollen, red, and angry.

[00:30:30] And we're trying to open this strangulation by doing this procedure. And we inject local anesthetic/ steroid. And again, we advise the patients to do a neuroflossing exercise. We're trying to pull this sciatic nerve from getting stuck down within the spine area. So, we do all these measures for this group of patients.

[00:30:53] And then we have very advanced therapies for refractory group of patients.

[00:30:59] Munir Adam: So what I'm hearing from you is that regardless of the intervention or surgical intervention or any other measure such as joint injections, the role of exercises and lifestyle modification is always going to be central And this is something in which we can encourage patients in between appointments that they might have with yourselves. We can be making sure that they're doing that part of it. 

[00:31:18] Adnan: Absolutely. It is essential. I cannot emphasize it, you know, enough, because it will enhance outcome, you know, this is a give the patient an opportunity to reduce the pain from, let's say, 7/ 8 out of 10 to 3 or 4. So the pain is manageable, but we need to get the rest of the muscles, the joint to come back to normality and the stiffness go away.

[00:31:44] So that's what it's all about in this exercise.

[00:31:48] Munir Adam: Now it does sound a little bit gloomy when we Think about and discuss lower back pain as being something that can't be cured and how it's such a major problem. Do you sometimes come across success stories? Patients who you've been able to treat in a way that they actually feel pretty much pain free or they feel that they're, you know, their life is much, much better and they're happy.

[00:32:06] Do they have a smile on their face? 

[00:32:08] Adnan: A lot. Otherwise we stop working. No, it is, it is very important. Uh, and, and we have, we have, we have a lot, a lot of successful story. It is, um, and those patients would like to get better. They want to get better. They work with us. We work with you guys. And and they, they listen to us and they follow the instructions and they empower themselves and they will get better.

[00:32:36] I would just like to touch one base, if I may, regarding the guidelines for chronic lower back pain in 2016 by NICE guidelines. So NICE made it crystal clear, there is no spine surgery. Spine surgery has no place for management of chronic lower back pain. Period.

[00:32:55] Munir Adam: Really? Wow. Okay. 

[00:32:57] Adnan: No spine surgery or disc replacement for chronic lower back pain.

[00:33:03] Please, I cannot, you know, I appeal to you. Don't send the patient for chronic lower back pain to unnecessary surgery. 

[00:33:11] Munir Adam: Okay. 

[00:33:12] Adnan: Of course, the surgery for certain conditions can be useful. For example, trauma or infection to the spine. These rare conditions or malignancy, uh, surgery, it will be great, but for chronic lower back pain with, you know, a couple of black discs or degeneration, uh, surgery has no place there. 

[00:33:35] Munir Adam: That's really, that's the first time I'm hearing this, and that's really useful for me to know. I have to say that even when surgery is being discussed, I've always said to patients that there's no guarantee this is going to help you, and there are the risks of complications and side effects. And some people after surgery don't feel any better necessarily.

[00:33:49] So yeah, there must be those patients who have to have surgery, maybe because, well, I mean, cauda equina being an example. 

[00:33:55] Adnan: That's absolutely, and it can be, you know, a safe patient from going to be paralyzed like that. That's perfect. That's a very good indication, but chronic lower back pain is, is, is not. And not only that, when the spine gets diffused, or even disc removed partially like microdiscectomy, the spine will never be the same at all.

[00:34:18] Tomography of the spine will change. And then, and within two years for a spinal diffusion condition called adjacent segment syndrome, the other two parts of the spine above where they done the diffusion get worse. So they do further effusion, and then after another two years, the one above that, so the patient will be ended and multiple spinal effusion, and then they try to do anterior.

[00:34:43] So, in my overview that this is a NICE guidelines, it's showing that morbidity can get worse. And now we're looking into a completely fresh way of doing this, uh, by implant technology.

Innovative Treatments: Spinal Cord Stimulation

[00:34:58] Munir Adam: This is exactly what I was going to come on to then. If surgery is not the answer... 

[00:35:01] Adnan: Well, yeah, , so the department, uh, very well known in implant technology called spinal cord stimulation. And the program been running since 1980. So the therapy for spinal cord stimulation is nothing new. It's been available since 1967. But the technology for the last 10 -15 years advanced so much, so we start to use a special waveform, can manage to control the back pain much better than conventional spinal cord stimulation.

[00:35:31] The therapy is simple. It is just delivering a small voltage of electricity where the pain is and on the spinal cord. So to create electromagnetic field and stopping the pain impulses from traveling to the brain It is consists of inserting specialized wire via needle and it can be tunneled under the skin, so you don't see anything and connected the small pulse generator similar to the pacemaker.

[00:36:00] So this is the pacemaker of pain. Unlike pacemaker for the heart, the pacemaker for pain, you can use a remote control. The patient has a remote control. They can adjust the signal to their like to control their pain. And the more advanced therapies now we can set one single program, and that will last for years.

[00:36:24] The beauty about this therapy is the patient will undergo a trial with external power battery for two weeks to see and assess whether this therapy can help their original pain. So the procedure can be done under x ray control within 20 minutes and the patient will go home. And we encourage them to walk and do things, and do the things that they are not able to do, and see how much that is helping them.

[00:36:48] And, and if the intensity of pain drop more than 50%, if there is improvement in the function, ability to sleep better, and they don't require a breakthrough medication, we call it success and bring them back to fit them with a permanent implant. 

[00:37:05] And also it is reversible. Let's say after ten, uh, five years, ten years, they say, look doctor, I'm using it less and less, my pins get better, we can remove it, reversible, and there is no impact on the spine whatsoever.

[00:37:21] Munir Adam: Is this available on the NHS? 

[00:37:24] Adnan: It is available on the NHS, yes. And back in 2006, NICE approved. So that's we call it implant technology, and in our center, really, we filter through those patients who could benefit from it, because it's not suitable for every single back pain patient. We evaluate the patient, and and some of the patients, they undergo rehabilitation for one week, two weeks, in our pain management program to prepare them for the therapy. Some of them are straightforward cases, and we set them up for the therapy.

[00:38:00] Munir Adam: Okay, well, there will be some people that it's suitable for and I'm sure people across the country are going to be thinking, uh, yeah, this might be something to refer for, especially for the really severe or impactful cases of lower back pain, which is really significantly affecting patients where other things perhaps haven't worked.

[00:38:15] You do take referrals from throughout the UK, don't you? 

[00:38:18] Adnan: That's correct. Simply, you just write to us , and you put it for consideration of a spinal cord stimulation. And it will be filtered to us very quickly. We give rapid access for this group of patients to be covered by Guy's and St. Thomas Hospital referral center.

[00:38:36] Munir Adam: It's fantastic to know that it's available. And just for listeners, that's clearly not suggesting that every single person with back pain needs to be referred over to the specialist service. And there are many that will be managed successfully in primary and in secondary care, but lower back pain is so common that even if it's only a very small proportion that we're really stuck with, despite secondary care referrals and despite pain clinic referrals, then this is another place.

[00:39:00] Is there anything else that you can enlighten us with in terms of the future of managing lower back pain? 

[00:39:06] Adnan: Well, there is, there is a lot of, a number of interventional therapy coming in the horizons. Uh, minimal invasive techniques can be done. But number one, this, it will going to take years to come and we need to investigate them. All these therapies that we apply with advanced technology, some of them are pioneered by ourself at, uh, pain management center.

[00:39:28] And we work with NHS England to provide evidence based medicine. We investigate it in our center before we give it to people or, you know, suggest it to our patients. 

Cognitive Behavioral Therapy and Pain Management Programs

[00:39:40] Adnan: One of the things I'd just like to touch base on, uh, cognitive behavioral therapy for people with severe psychosocial issues called the Onput Pain Management Program. So, number of patients with different chronic pain condition, they have severe psychosocial issues, and they cannot manage their pain very well. And we have this pain management program. It's a three week program. It's a residential program. 

[00:40:10] Munir Adam: Okay 

[00:40:10] Adnan: Monday to Friday. Friday, Saturday, Sunday, they go home. And they stay with us in a specialized place in St. Thomas Hospital. Yeah, breakfast, lunch. It looks at the Big Ben and the House of Commons. Uh so we're dealing with this group of patients whom have severe psychosocial issues and, uh, psychology physiotherapy, occupational health, nursing. We reset their mind about their pain. Again, this is, very intensive care, and we keep looking after them. We follow them up. We give them a lot of instructions. And the pain management program, not necessarily take the pain away, but we arm them with tips to manage their pain in a better way. And coping strategies.

[00:41:00] Munir Adam: Wow, that is a really dedicated way of wanting to help these very difficult patients who unfortunately were so familiar with and often feel completely helpless and you know what, at this point, I was just going to ask you that we're going to be including useful resources in the show notes. And if you wanted to say anything about any of those resources right now, but you know what, how to actually access the service, we can include that as well in the show notes.

[00:41:26] Adnan: Yeah, we're quite happy to provide the link. It could be online. Everything online, electronically to be sent for us. There is a special email for referral too, but we have a website at GSTT, Guy's and St. Thomas Hospital and the Pain Management Center, and you got the referral there; referral pathway.

[00:41:49] Munir Adam: So in less than 60 seconds, then take home messages. 

Conclusion: Key Takeaways in Managing Lower Back Pain

[00:41:53] Munir Adam: What do you want everybody listening to know about managing lower back pain? 

[00:41:57] Adnan: I think education, education, education. Patients need to be empowered to take care of themselves and, to listen to the instruction of their medical doctors, to their specialist. 

[00:42:10] Um, I would say avoid giving uh, strong analgesia to the patients. 

[00:42:16] I would advise people to avoid major spine surgery. That's unnecessary. It might cause a lot of trouble to people. 

[00:42:25] If you have refractory patients with chronic pain condition, not necessarily back pain uh, please don't sit on them. Um, reach out at these specialised Center, and there's a number of specialized centers, not necessarily us, but reach out and ask for help for this group of patients. 

[00:42:42] Munir Adam: Brilliant. Thank you very much Well, I hope that we don't um overload your service now after this. Thanks so much for joining It's been fantastic talking to you about this and learning about this really common condition. Thank you Adnan

[00:42:54] Adnan: Thank you very much, Munir, for this opportunity.

[00:42:56] Munir Adam: And there we are. So that was lower back pain. Now I don't know about you, but I certainly learned a few things. I have to admit, I had started patients on pre gablin for lower back pain before. And I have referred patients who I'm really stuck with for surgery, even though they didn't really have any actual indication as per what we've heard today.

[00:43:19] You may or may not agree with making those mistakes yourself, but I bet one you will not be able to deny and that is, I bet that you have also requested an MRI scan for patients when you knew it wasn't really indicated. So perhaps this is an important reminder for us to do the right thing. But the thing that I'm really keen to try out is that service that they provide where you can send patients who are in that sort of yellow flag category and where they'll keep them there and work with them to get them to a better place. And I'm looking forward to trying that out. 

[00:43:50] Now you may have noticed that in this episode we took a break from the theme that we were following for dealing with patients who belong to categories where the inverse care law applies, where they're not able to access care.

[00:44:01] And, uh, next month we resume this as we talk about patients with mental health problems. But that's it for today. Do leave your feedback on Apple Podcasts or wherever you listen to your podcasts. Let your colleagues know about this so that they too can benefit from it. And if you want to sponsor this, or you know others who may be able to sponsor episodes, then please do ask them to get in touch with us using the email address provided in the show notes.

[00:44:28] Have a pleasant rest of the day or night, wherever you may be. And until next time, keep well and keep safe.

Disclaimer

[00:44:34] Munir Adam: Primary Care UK was developed by Therapeutic Reflections Limited to inform, educate, support, and unite the primary care workforce. Specifically, it is not for the general public or patients. All information and advice contained therein is time, location, and context dependent and is general advice only.

[00:45:15] No guarantees are provided with respect to the accuracy of the content. The hosts, contributors, and the organizations they represent do not accept liability for any actions, consequences, or effects that result directly or indirectly from the content provided. Please refer to the episode description.

[00:45:31] Thank you for listening.