Back Pain Booklet - BackCare · 1 Back pain: the size of the problem Back pain is a major health problem, affecting approximately 17.3 million people in the UK – over one-third

Standards of Care for people with

Back Pain

Contents

The background 1

About these Standards 3

The Standards of Care:

Standards to improve access to information, support and knowledge 5

Standards to improve access to the right services that enable early assessment and management 7

Standards to improve access to ongoing and responsive treatment and support 10

Glossary 13

Appendix 1: Evidence-based interventions 14

Appendix 2: Developing the Standards 14

Acknowledgements 14

Bibliography 17

Photographs on front cover reproduced by kind permission of BackCare

© Nov 2004 Arthritis and Musculoskeletal AllianceAny part of this publication may be freely reproduced for non-commercial purposes and with the appropriate acknowledgement.

The contents of this document and further resources including contact details for our member organisations, further informationabout our work and this project, including additional examples of good practice and resources to support implementation areavailable on the ARMA website at www.arma.uk.net

The Standards of Care project has been managed by ARMA. The project has been funded from a range of sources, includingunrestricted educational grants from a number of pharmaceutical companies. A wide range of individuals and organisations havegiven time, expertise and other support in kind. For details of contributors, please see Acknowledgements on page 14

• Arthritis Care• Arthritis Research Campaign• BackCare• British Chiropractic Association• British Coalition of Heritable Disorders of Connective Tissue• British Health Professionals in Rheumatology• British Institute of Musculoskeletal Medicine• British Orthopaedic Association• British Scoliosis Society• British Sjögren's Syndrome Association• British Society for Paediatric and Adolescent Rheumatology• British Society for Rheumatology• British Society of Rehabilitation Medicine• Chartered Society of Physiotherapy• Children’s Chronic Arthritis Association• CHOICES for Families of Children with Arthritis• Early Rheumatoid Arthritis Network• Lupus UK

• Manipulation Association of Chartered Physiotherapists (UK)• Marfan Association (UK)• National Ankylosing Spondylitis Society• National Association for the Relief of Paget's Disease• National Association of Rheumatology Occupational

Therapists (NAROT)• National Osteoporosis Society• National Rheumatoid Arthritis Society• Podiatry Rheumatic Care Association • Primary Care Rheumatology Society• Psoriatic Arthropathy Alliance• Raynaud's and Scleroderma Association• Rheumatoid Arthritis Surgical Society• Royal College of Nursing Rheumatology Nursing

Policy and Practice Group• Scleroderma Society• Society for Back Pain Research

ARMA is the umbrella organisation for the UK musculoskeletal community. ARMA is a registered charity No 1108851.Our member organisations are:

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Back pain: the size of the problem

Back pain is a major health problem, affecting approximately 17.3 million people in the UK –over one-third of the adult population. Over the course of a year, around 3.5 million peopleexperience back pain for the first time, and for 3.1 million people their pain lasts throughout thewhole year. It affects men and women equally, and more people experience back pain as theygrow older.[1]

What is the impact of back pain?

Persistent back pain (ie pain which has lasted for more than three months or has been presenton more than half the days of the previous year), in particular, has a serious impact on people’slives. It frequently reduces people’s quality of life and adversely affects their family and socialrelationships.[2] Back pain can also impact on a person’s ability to work, and compromise theirearning capacity. Moreover, the longer someone is absent from work with back pain, the poorertheir chances are of returning.[3]

The direct healthcare costs of back pain are huge, including £141 million each year for GPconsultations and £512 million for hospital care (inpatient, outpatient and emergency). Overall,back pain costs the NHS and community care services more than £1 billion each year – andwith £565 million also spent on private services, the direct annual healthcare costs are over £1.6billion.[4]

Unsurprisingly, back pain has a massive economic impact. It is the second commonest cause oflong-term sickness absence for much of the UK[5], and the commonest for people in manualoccupations.[6] Up to 180 million working days were lost in 1997/8 due to back pain, including119 million that were lost due to registered disability caused by back problems.[7] Reports haveestimated that the total cost of back pain corresponds to between 1% and 2% of gross nationalproduct (GNP).[8]

Types of back pain

There are many different causes of back pain but in most cases the cause is uncertain and thecondition is referred to as 'simple' or 'mechanical' back pain. In the remaining cases, it isimportant to make a specific diagnosis as the underlying pathology may be serious, even life-threatening, or require a specific type of treatment. Examples of serious spinal pathologyinclude tumour and infection, fracture due to trauma or osteoporosis, inflammatory disease as inankylosing spondylitis, structural deformity such as scoliosis and extensive neurologicalcomplications. Between the ‘simple’ and serious cases are individuals with nerve root pain (alsoknown as sciatica), which is commonly due to a disc prolapse (‘slipped disc’). The majority ofpeople with back pain will not require anything more than conservative management, includingadvice, pain control and exercises.

These Standards of Care focus on ‘simple’ or ‘mechanical’ back pain.

Why we need Standards of Care

The care of people with back pain involves many different professions and disciplines, and untilnow there has been no standardised approach. Despite the publication of Clinical Standards

The background

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Advisory Group (CSAG) Guidelines in 1994, people’s experiences and the quality of the carewhich they receive vary enormously depending on the approach and configuration of serviceswhere they live. Current provision is often poorly co-ordinated and may not fully incorporateevidence-based practice. Worryingly, many people continue to believe that bed rest is the bestway to manage an episode of back pain. Indeed, some healthcare providers continue topromulgate the message.

Given the huge costs of back pain to the NHS and to national productivity, it is a majordrawback that there is no National Service Framework either for back pain or for othermusculoskeletal conditions. This lack of focus is reflected in the fact that back pain does notfeature in the Quality and Outcomes Framework of the current General Medical Services (GMS)contract in England.

Yet there is good evidence for the effectiveness of many approaches and treatments. Moreover,despite the lack of priority and resources attached to back pain services, health services insome parts of the UK have identified innovative ways of improving the care that they provide.

These Standards aim to bring together existing evidence and good practice to create aframework for services which really meet the needs of the many people with back pain.Implementation of these Standards should:• improve quality of life for the millions of people who are affected by back pain each year• identify for people with back pain the care and treatment which they can expect• enable the NHS to make more effective use of resources by helping to prevent avoidable

disability and by reducing the number of return GP consultations and hospital appointmentsdue to back pain

• promote consistent advice and treatment• reduce levels of disability due to back pain• improve productivity and reduce the benefits bill, by supporting people to stay active and

remain in work.

1 Maniadakis A, Gray A (2000).2 Pain in Europe (2003)3 Clinical Standards Advisory Group (1994)4 Maniadakis A, Gray A (2000)5 Department for Work and Pensions (2002)6 Chartered Institute of Personnel and Development (2004)7 Department of Health (2000)8 Norlund AI, Waddell G (2000)

About these Standards

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ARMA’s Standards of Care for people with back pain are intended to support people of all ageswith back pain to lead independent lives and reach their full health potential through:• access to information, support and knowledge that optimise musculoskeletal health for

everyone and enable self-management• access to the right services that enable early diagnosis and treatment• access to ongoing and responsive treatment and support.

The Standards define what services are appropriate under these three themes and suggestways of providing them effectively, and in a measurable way, in the form of key interventions. Adetailed rationale for the Standards draws on available evidence and examples of good practicedrawn from ARMA’s ongoing call for good practice: a database giving details of these and otherexamples is available at www.arma.uk.net.

The Standards are not guidelines, or algorithms of care, though they refer to these where available.

The Standards of Care for people with back pain form part of a suite of Standards; otherStandards published to date are for inflammatory arthritis and osteoarthritis. Further Standards,for bone disease, soft tissue rheumatism and connective tissue disorders, are planned for 2005.

The Standards acknowledge the fact that those planning and delivering services around the UKface differing demographic, geographic and economic factors, which will affect how theStandards are implemented in each locality. We hope the Standards will act as a tool for allstakeholders - service users, providers, commissioners and policy-makers - to work together toreview and improve their local musculoskeletal services.

Key principles – the user-centred approach

The project has been driven by the needs of people living with musculoskeletal conditions. Itbegan with the establishment of a set of key principles for care, developed by a group of peopleliving with musculoskeletal conditions and consulted upon widely. These principles haveunderpinned the development of each set of condition-specific Standards.

The key principles, which can be found on ARMA’s website www.arma.uk.net, affirm that‘patients’ are individuals who need different types of advice and support at different times; andwho need integrated services providing advice and support that cover all aspects of managingand living with the condition – clinical, personal, social and employment/education.

In particular, the Standards recognise that health services play a key role in supporting peopleto maintain or return to employment or education.

Nevertheless, while these standards focus on health services, it must be recognised that peoplewith back pain and other musculoskeletal conditions have wide-ranging needs. Social careoften plays a key role in ensuring people can remain as active and independent as possible.Factors such as access to transport and the built environment may have a major impact onquality of life. More work is needed to understand and meet these needs.

Musculoskeletal conditions affect families and carers as well as individuals. Indeed, manypeople with these conditions may be carers themselves. The Standards do not make specificrecommendations on issues relating to carers: this also needs to be the subject of further workto ensure that carers’ needs are understood and addressed.

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How the Standards were developed

The Standards of Care for people with back pain were developed by an expert working group,facilitated by ARMA. The group included people with back pain, representatives of userorganisations, experienced service providers and experts from many professions, from aroundthe UK. Starting with a review of the needs of people with back pain, the group met 4 timesbetween December 2003 and June 2004 to determine evidence-based Standards to meet thoseneeds, consulting widely and publicly on the drafts. The Acknowledgements on page 14 givedetails of the working group membership.

Clinical experts have identified the evidence base, including relevant guidelines for themanagement of back pain. References are shown as footnotes in the Standards. Evidence hasnot been graded for the purposes of this document. For further details on the evidence base,please refer to the references quoted in the document.

The resulting Standards are therefore based firmly on the experiences and preferences ofpeople with back pain, and on evidence and good practice where this is available.The working group plans to review these Standards in 2007, or sooner if there are significantdevelopments in care for people with back pain.

Next steps

The publication of these Standards is the beginning of an ongoing programme involving thewhole community to improve musculoskeletal services.

We are circulating the Standards widely to people with musculoskeletal conditions, doctors,allied health practitioners, providers and commissioners of health services, voluntaryorganisations and policy makers. We will publish audit tools to support the Standards’implementation. We are also collecting and sharing examples of good practice, which areaccessible to everyone through our online database.

We invite all stakeholders to make a commitment to implementing the Standards. First stepsmight be to:• audit existing services• identify champions for change in musculoskeletal services, and set up a working group to

develop your local strategy and priorities• work in partnership with all stakeholders, including national and local voluntary organisations,

to involve service users in designing and developing services.

Above all share your success! Tell us about your initiatives; send us examples of good practice;help to build a national resource for high-quality musculoskeletal services.

Standards to improve access to information,support and knowledge

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The rationale

• People are not always aware of how to reduce the risk of developing back pain. Informationshould be widely available which is evidence-based and which emphasises physical fitness,smoking cessation, weight reduction and avoidance of sedentary lifestyles.[9]

• Many people will experience back pain during their lives and for most this will be short-lived.Most individuals should be able to manage their pain without needing medical advice.

• Health promotion campaigns have been shown to be effective in promoting messages aboutmaintaining healthy backs, and in particular the message that ‘hurt’ does not necessarilymean ‘harm’.[10] However campaigns should inform people how to identify warning signswhich they should report to appropriate health care professionals.

• Myths persist about the need to limit physicalactivities during an episode of back pain, forexample about the need for bed rest and forabsence from work. Health promotionprogrammes should also therefore educatepeople to avoid unnecessary bed rest and tomaintain normal activities. Healthcareprofessionals, including pharmacists, play avaluable role in directing individuals toappropriate sources of support and advice.

• These messages are likely to have the greatestimpact when they are positively promoted byeveryone involved or interested in the problemof back pain, including employers, educationand health service providers, leisure servicesand voluntary organisations.

• Much of the long-term disability that resultsfrom back pain is avoidable. Health promotion

Standards of Care forpeople with back pain

Risk reduction

Standard 1Information should be widely available on howto reduce the risk of developing back pain.

Self-management

Standard 2Health services, the voluntary sector and otheragencies should provide information, adviceand facilities to enable people to manage

episodes of back pain in the community, andprovide guidance on whether and when toseek medical advice.

Involvement of people with back pain inservice development

Standard 3Healthcare organisations should involvepeople with back pain in the development oftheir services for musculoskeletal conditions.

Good Practice Example - A

A pain clinic within a hospital trust hasdeveloped and implemented, incollaboration with the local districtcouncils, evidence-based active exerciseclasses at local leisure centres.The programme employs a back pain co-ordinator to organise healthy backclasses. Fitness instructors take thelessons. The programme provides aconsistent approach and information onback pain by using The Back Book (TSO)which is given to all attendees. Surveysshowed that 70% of attendees self-referto the class and satisfaction with theclasses is high with 93% continuing toexercise at six months.

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can play a key role in helping people maintain musculoskeletal health and function,particularly in the workplace and in educational establishments.

• People with back pain should be involved in helping to plan and develop services at bothlocal and national level. Their perspective on service delivery can lead to imaginative solutionsand improvements to healthcare services, ensuring that services meet people’s real needs.

Putting the Standards into practice: key interventions

There should be public health strategies to promote healthy backs.

Health promotion strategies should educate people about how to self-manage episodes of backpain. The Back Book[11] and other information on exercise and activities should be freelyavailable.

Schools, workplaces and other facilities (such as pharmacies and leisure centres) shouldprovide information on how to manage episodes of back pain.

Developmental: Information should be clear, accessible, and available in a variety of formats.Professionals involved in caring for people with back pain should take into account theirlanguage, culture and educational level.

Developmental: There should be a range of facilities available for physical activity and exercisein the community.

Employers should have access to information about managing back pain in the work place inorder to promote good working practice.

Health service providers should involve people with back pain in helping to plan and developservices at both local and national level.

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9 Burton AK et al (1999)10 Buchbinder R (2001)11 Roland M, et al (2002)

For further information and resources, including details of ARMA’s member organisations andother examples of good practice and information on implementation, visit www.arma.net.uk

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The rationale

• Back pain, particularly when persistent, leads to lossof productivity and diminishes quality of life.[13] It is vitalto try to prevent an episode of back pain fromdeveloping into a persistent health problem. It istherefore crucial that people whose back pain is notresponding to self-management are able to get timelyand reliable advice and management to restore themto optimal health as quickly as possible.

• Most back pain can and should be managed‘conservatively’ in the community.

• Most active physical interventions are carried out bystate-registered therapists, including physiotherapists,chiropractors, osteopaths and musculoskeletalphysicians.

• A very small percentage of people will have warningsigns which need to be investigated. Healthprofessionals should screen people for these warningsigns, or ‘red flags’, which may indicate seriousdisease. People in whom serious disease is suspectedshould be referred without delay to specialist servicesfor investigation and treatment in accordance withnational guidelines, such as NICE referral protocols.[14]

Standards to improve access to the right servicesthat enable early assessment and management


standard

s 4-7Early assessment and identification of

warning signs

Standard 4People with back pain should have promptaccess to practitioners who are able toidentify warning signs of serious disease.Where these warning signs are present,practitioners should refer without delay forspecialist assessment.

Pain relief

Standard 5People with back pain should have access toskilled practitioners who can provide paincontrol. This should follow the Royal Collegeof General Practitioners’ current guidelinesfor the treatment of back pain.[12]

Standard 6People with back pain should have access toinformation and facilities to enable them tomake informed choices about managementoptions, including self-management of theirpain.

Remaining active

Standard 7People with back pain should be encouragedand supported to remain in work or educationwherever possible, and the professionalsinvolved in their care should avoid‘medicalising’ the condition. Vocationalrehabilitation should be available to supportpeople in staying in existing employment orfinding new employment.

Red Flags

The person:• is younger than 20 or older than 55

when they get back pain for the firsttime

• has had cancer in the past or atpresent

• is on steroids• is a drug user, or has HIV• is feeling generally unwell• has lost significant weight• continues to have great difficulty

bending forwards• has developed a number of

problems in their nervous system(e.g. numbness, loss of power, etc)

• has developed an obvious structuraldeformity of the spine.

The pain:• is continuing for more than 4-6

weeks• follows a violent injury, such as a

road traffic accident• is constant and getting worse• is in the upper part of the spine.

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There need to be skilled practitioners in the community who can:• determine whether people have non-specific back pain, nerve root pain, or suspected serious

disease (pathology) that requires specialist opinion and investigation• refer people directly to specialist services, to be seen within one week or according to clinical

urgency, if they identify warning signs of serious disease, or 'red flags'• offer effective pain management in accordance with national guidelines• prescribe or recommend appropriate analgesia.

Clinical governance teams should ensure that there is access to training on the needs and careof people with back pain for all professionals involved in their care and support.

There should be timely interventions for back pain that is not resolving in the first four weeksafter onset. These should be provided by a competent practitioner, and be available within oneweek of request. This should be in line with the evidence for effective interventions (seeAppendix 1).

Developmental: In a primary care setting, if X-rays are desirable, they should be performed andreported within one week of request. Other imaging should be performed and reported withinone month of request, depending on clinical urgency.

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Good Practice Example - B

A hospital trust has established alow back pain triage servicemanaged by the physiotherapyservice. The service was plannedin consultation with thephysiotherapy, rheumatology,orthopaedics and pain services,together with local GPrepresentatives. A referral protocolwas agreed, including direct MRIrequests by physiotherapists. Thephysiotherapists assess and eitherdecide on treatment or triage torheumatology or pain clinics.Introduction of the service hasseen a reduction in waiting timesfor all clinics, almost completeeradication of inappropriatereferrals to orthopaedics, andsignificant reduction of back painreferrals to rheumatology. Allpatients referred are assessed bythe triage team within 4 weeks.

• A small minority of people may need investigations,such as X-rays or other imaging, to help determinewhether they need to be referred to specialist services.If so, these should be performed promptly.

• The vast majority of people with back pain do notneed investigations, including X-rays,[15] or hospitaltreatment. It is important to avoid ‘medicalising’ backpain unnecessarily.

• All people with back pain require information to enablethem to make informed choices about the range ofmanagement options available, including self-management. All professionals involved in the care ofpeople with back pain should encourage and supportthem to remain active, to continue at work or ineducation wherever possible and to maintain othernormal activities.

• Good pain control is needed to enable people tomaintain or regain function. Under-treated pain islinked to the development of persistent back pain.[16]

• Some people require analgesics to control their pain.These should be appropriate and adequate and mayinitially include opioids if the pain is severe.[17]

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Advice should be available on modifying working practices and on adapting workplaces andeducational establishments. People should have access to information on the steps that can betaken to support them. Employers should seek advice from various sources, for example fromhealth professionals and government agencies, including the Health and Safety Executive (HSE),Access to Work and Disability Employment Advisors.[18] For children and adolescents attendingeducational establishments, support and advice should be provided by special needs advisorsand through the annual statementing process if this applies to the child/adolescent.

Developmental: Occupational health services, where available, should provide advice toemployers.

People who have experienced episodes of back pain, and voluntary organisations concernedwith their care, should be involved in and consulted about the development of health care policyand practice, at both local and national level.

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12 Royal College of General Practitioners (1996 and 1999)13 Maniadakis A, Gray A (2000)14 National Institute for Clinical Excellence (2001)15 Royal College of Radiologists (1998)16 Frank JW, el al (1996)17 Pain Society (2004)18 Health and Safety Executive (2004)


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The rationale

• The right intervention at the right time is key to preventing an episode of back pain frombecoming a persistent health problem. Where an episode of back pain has not settledsufficiently within six weeks for a person to be able to resume work or other normal activities,they should have access to back pain triage and management services.

• These services will often be provided by an extended scope physiotherapist, nurse specialist, orother competent professional. To minimise delay in assessment and management, thisprofessional should be able to refer people directly for investigations, further opinion or othersupport.

Standards to improve access to ongoingand responsive treatment and support


Triaging persistent pain

Standard 8Where a person’s back pain is not respondingto conservative management, they should beoffered effective, evidence-based managementin accordance with national guidance. Thisshould ideally be provided through a triageservice which has the authority to refer forfurther specialist assessment or investigation,including surgical opinion if indicated.

Managing persistent pain

Standard 9People with persistent back pain should begiven information on self-management and beoffered access to self-managementprogrammes such as the Expert PatientProgramme. Information on othermanagement strategies should be provided toenable them to make informed choices.Information should be available about localand national support groups.

Standard 10People with persistent back pain should haveaccess to a full range of pain andrehabilitation services.

Surgery

Standard 11For the small minority of people who mightbenefit from surgery, there should be a

convenient and responsive specialist spinalsurgery service, including comprehensive post-operative rehabilitation. People should besupported in preparing for and recovering fromsurgery. This should include a pre-operativeassessment and planning for dischargeinvolving relevant healthcare professionals,social workers, family and carers.

Remaining in or returning to work and education

Standard 12People should be helped to remain in or returnto work or education, through effectiverehabilitation services working in liaison withemployers or educational establishments.Developmental: Where it is not possible forpeople to return to work, they should bereferred to the Disability Employment Advisorand given the opportunity to participate inwork assessments and retraining and toreceive financial and practical support throughbenefits and other support services. Ideallythis should be individualised through personalcase management by a competentprofessional.

Supporting those unable to work

Standard 13Where a person is assessed as unable towork, they should have access to adviceabout benefits and support services.

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• Self-management programmes are beneficial for people with long-term conditions such asback pain.[19]

• A small percentage of people with back pain may benefit from surgery, especially those withpersistent nerve root symptoms.

• People who initially have non-specific back pain that is not responding to explanation andreassurance, pain control and strategies to remain active, may benefit from other types ofmanagement, including psychosocial support, cognitive behavioural therapy[20] and other painmanagement strategies. Treatments should be evidence-based[21] (see Appendix 1).

• The longer a person is off work with back pain, the less likely they are to return.[22] People with backpain should be encouraged to remain at work or in education, or to return as soon as possible, asthis has been shown to improve recovery. Whatever the treatment provided, there should be astrong focus on rehabilitation and returning to everyday activities and to work in particular.

• If a person is unable to return to work, they may need advice and support to enable them toaccess benefits and other services.


If serious disease (red flags) becomes apparent,immediate referral should be made to appropriatespecialist services.

There should be prompt access to a triaging servicefor people with back pain where conservativemanagement has not been successful. Triagearrangements should have been agreed with therelevant stakeholders including:• provider services (pain, orthopaedic, rheumatology,

therapy)• commissioners of services• user groups.

A comprehensive chronic pain service should beavailable to include psychosocial support,counselling, psychology, cognitive behaviouraltherapy, pain clinics and full Pain ManagementProgrammes (PMPs).

People should have access to self-management andeducation programmes, including the Expert PatientProgramme.

Clear and consistent information should be availableabout evidence-based treatment options, providersand services, including local and national support

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Good Practice Example - C

Several NHS trusts working togetherhave funded a back pain co-ordinatorto develop and implement a backrehabilitation programme for low backpain patients. The initiative providespatients with a four-week backrehabilitation programme (of eightsessions) held at a local leisure centrewhich is run jointly by fitnessinstructors and physiotherapists.Participants are assessed andcomplete questionnaires before andafter the programme and are alsosent a one-year follow-upquestionnaire. Assessment showed81% improvement in function, 47%reduction in disability, 61% reductionin fear of movement. 90% ofparticipants reported that they werevery happy with the programme. 70%of participants continued to havereduced disability after one year.

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groups. This should be available in a variety of formats, in accessible and understandableterms, and in different languages where appropriate.

People with surgically treatable back pain should have prompt access to a specialist surgicalspinal service. They should be offered an opinion from a specialist spinal surgeon within threemonths of referral or sooner if clinically indicated.

People who need surgery should be given information to support them in preparing for andrecovering from surgery. Pre-operative assessment and discharge planning should involve allprofessionals involved in their care.

People should have access to services tosupport them in returning to work oreducation. These could include post-operative physical rehabilitation services,vocational rehabilitation and/oroccupational health services, DisabilityEmployment Advisors and EmploymentMedical Advisory Services, who are ableto work in liaison with employers andindividuals.

Developmental: People should haveaccess to a case manager with expertisein employment issues, who can help to‘bridge the gap’ between people’s healthand employment needs.[23]

People should have ongoing access tocareers advice, employment advice andjob retraining which addresses theirindividual case.

Children and young people should be supported by all people responsible for their care(including doctors, allied health professionals, teachers, social workers, youth workers andothers) in achieving their normal social, educational and physical milestones.

People should have access to advisory services for benefits and other appropriate support ifthey are unable to work.

Good Practice Example - DA rheumatology centre within a hospitaltrust has established two chronic painmanagement clinics per week. These areled by nurse consultants and provide amulti-disciplinary pain managementprogramme as an integral part of clinicalservices within the department. Referralsare from medical clinics following adiagnosis of a chronic pain disorder wheremedical or surgical intervention isinappropriate. Each patient undergoes anindividual assessment to determine amanagement plan. An audit of the serviceshowed improvement in function andreduced fatigue. All stakeholders,including service users, were involved inthe planning and ongoing evaluation ofthe service.

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19 Lorig KR et al. (1999)20 Van Tulder MW et al (2000)21 Waddell G, et al (1999); Van Tulder MW et al (2000 and 2004); Carroll D et al (2004)22 Clinical Standards Advisory Group (1994)23 British Society of Rehabilitation Medicine (2003)


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Allied Health Practitioner (AHP)a member of the care team who is not amedical doctor. For example a nurse,physiotherapist, occupational therapist,podiatrist, dietician, pharmacist.

Nurses are registered with the Nursing &Midwifery Council.

Health professionals are registered with theHPC (Health Professions Council) whoregulate arts therapists, orthoptists,biomedical scientists, prosthetists, orthotists,chiropodists/podiatrists, paramedics, clinicalscientists, physiotherapists, dietitians,radiographers, occupational therapists,speech and language therapists.

Pharmacists are registered and regulated bythe Royal Pharmaceutical Society

analgesiapain relief

conservative managementmanagement to reduce the impact of illnesswithout using invasive or high-risk measures

episodea period of time during which someoneexperiences back pain

extended scope physiotherapista physiotherapist with additional skills andclinical responsibilities

Expert Patient Programmeis the name given to an initiative to helppeople with long-term conditions maintaintheir health and improve their quality of life; akey element of this initiative is lay-led self-management training whose primary aim is tofacilitate the development of self-managementskills rather than to provide medicalinformation.

interventionsa general term covering treatments, advice,education and other care that a practitionermay give

medicalisingidentifying or categorising a condition orbehaviour as being a disorder requiringmedical treatment or intervention

multi-disciplinary teama healthcare team that includes professionalsfrom different disciplines working together toprovide a comprehensive service for peoplewith back pain; the team may include GP,consultant rheumatologist, consultantorthopaedic surgeon, consultants in otherdisciplines, doctors in training (both hospitaland GPs), nurse specialist, physiotherapist,occupational therapist, dietician, podiatrist,orthotist, psychologist, pharmacist and socialworker

opioidsa group of medications that can be prescribedfor strong pain control

persistent painpain that has lasted for more than threemonths or has been present in episodes onmore than half the days of the previous year;sometimes alternatively referred to as chronicpain

psychosocial support professional care which addresses a person’spsychological and social health needs; thismay include support to reduce a person’sdistress, fear or ability to cope, support forsocial and family relationships, andsupport/advice about employment or benefits

red flagsa group of symptoms or signs (clinicalindicators), any one or more of which maysuggest a possibility of serious disease

triagethe categorisation of a person’s back pain intoone of the following: non-specific back pain,nerve root pain or serious pathology; also theprocess to decide the preferred treatmentoption and/or referral pathways

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Appendix 1: Evidence-based interventions

The following evidence-based[26] interventionsshould be available for people with low backpain in the absence of serious disease orneurological complications (red flags).

In the first four weeks from onset:• adequate information and reassurance• advice to avoid bed rest• advice to stay active• adequate pain control.

For people whose back pain is not resolvingby four weeks from onset, add:• access to physical reconditioning exercises• access to spinal manipulation.

For people whose pain is becoming persistent(six to 12 weeks from onset) or have been offwork for four weeks, add:• multi-disciplinary biopsychosocial

intervention including:• educational programme• exercise programme for functional

restoration• cognitive interventions• work based intervention• involvement of Disability Employment

Advisor.

for people whose pain has become persistent(more than 12 weeks without improvement):• specialist pain service• biopsychosocial assessment• group cognitive behavioural therapy

sessions• vocational intervention• special investigations if indicated

Appendix 2: Developing the Standards

The working group met four times betweenDecember 2003 and June 2004 and consultedwidely and publicly on these Standards duringMay and June 2004.

Acknowledgements

The Standards of Care project has beenmanaged by the Arthritis and MusculoskeletalAlliance (ARMA). A wide range of individualsand organisations, including ARMA memberorganisations, have generously given time,expertise and other support in kind.

ARMA would like to acknowledge thecontributions of all those involved in thisproject. ARMA thanks all those who havebeen involved in project working groups andwho have taken time to comment on theconsultation drafts of these documents; alsothose who have contributed examples of goodpractice. We welcome further contributionsand feedback.

ARMA would like to thank its memberorganisations for their ongoing support for itswork, and to thank Arthritis Care, ArthritisResearch Campaign and the British Societyfor Rheumatology for their core funding whichhas enabled ARMA to carry out this project onbehalf of the musculoskeletal community.

ARMA would like to thank the followingcompanies for supporting this project throughunrestricted educational grants: AbbottLaboratories Limited, Merck Sharp & DohmeLimited, Pfizer Limited, Schering PloughHoldings Limited, Wyeth Pharmaceuticals.

ARMA is a registered charity (no 1054784).

Appendices andAcknowledgements

26 Waddell G et al (1999)

15

ARMA Standards of CareSteering GroupAilsa BosworthNational Rheumatoid ArthritisSocietyMaureen CoxRoyal College of NursingRheumatology Nursing Policy andPractice Group Dr Mark DevlinPrimary Care RheumatologySocietyHywel EvansArthritis Care, WalesMartin JonesArthritis CareCaroline RattrayExternal Relations Manager, British Society for RheumatologyDr Jane ReebackHonorary Secretary, Scientific Section, ARMAProfessor David G I ScottPresident, British Society forRheumatology, 2002-2004Dr Nicholas J SheehanHonorary Treasurer, ARMA, 1999-2004Dr Mike WebleyChairman, ARMA

Back Pain Working GroupWorking Group Co-ordinatorsDr Nicholas J SheehanHonorary Treasurer, ARMA, 1999-2004Dr Jane ReebackHonorary Secretary, Scientific Section, ARMAWorking Group MembersProfessor Alan BreenThe Institute for MusculoskeletalResearch & ClinicalImplementationProfessor Kim BurtonSpinal Research Unit,University of HuddersfieldSue ClaytonLay member of Patient LiaisonCommittee of the British PainSocietyCathy CookNHS Modernisation Agency

Dr Nadine FosterPrimary Care Sciences Research Centre, Keele UniversityDr Andrew FrankBritish Society of RehabilitationMedicineProfessor Elaine HayConsultant, CommunityRheumatologyDr Philip HelliwellSociety for Back Pain ResearchJeanette HuceyAssociate Director, OrthopaedicServices Improvement,NHS Modernisation AgencyDr Richard HullBritish Society for Paediatric andAdolescent RheumatologyDr Jumbo JennerLewin Rehabilitation Centre,CambridgeMr Jonathan JohnsonBritish Orthopaedic AssociationDr Tom KennedyBritish Society for RheumatologyPetra KlompenhouwerNational Association ofRheumatological OccupationalTherapistsDr Charles PitherSociety for Back Pain ResearchJulia RowleyIndependentTeresa SawickaBackCareDr Cathy A SpeedUniversity of CambridgeNia TaylorChief Executive, BackCareSue WilliamsClinical Nurse SpecialistDr Michael WrightBritish Institute ofMusculoskeletal Medicine

ARMA Standards of CareReference GroupMr Robin AllumHonorary Secretary, BritishOrthopaedic AssociationAilsa BosworthNational Rheumatoid ArthritisSociety

Sam BrinnProgramme Manager,Orthopaedic ServiceImprovement,NHS Modernisation AgencyMargaret BruceNorth Central London StrategicHealth AuthorityMaureen CoxRoyal College of NursingRheumatology Nursing Policy andPractice Group Lynne DargieRoyal College of NursingRheumatology Nursing Policy andPractice GroupDr Mark DevlinPrimary Care RheumatologySocietyDr Krysia DziedzicPrimary Care Sciences ResearchCentre, Keele University; BritishHealth Professionals inRheumatologyProfessor Edzard ErnstPeninsula Medical School,Universities of Exeter andPlymouthHywel EvansArthritis Care, WalesKim FligelstoneScleroderma SocietyDr Andrew FrankBritish Society of RehabilitationMedicineJeanette HuceyAssociate Director, OrthopaedicServices Improvement,NHS Modernisation AgencyDr Richard HullBritish Society for Paediatric andAdolescent RheumatologyDr Mike HurleyRehabilitation Research Unit, King's College LondonPetra KlompenhouwerNational Association ofRheumatological OccupationalTherapistsDarryl McGheeScottish Society forRheumatology

16

Caroline MountainNational Association ofRheumatological OccupationalTherapistsSusan OliverIndependent RheumatologySpecialist Nurse,Royal College of NursingRheumatology Nursing Policy andPractice GroupDr Max PittlerPeninsula Medical School,Universities of Exeter andPlymouthCaroline RattrayExternal Relations Manager,British Society for RheumatologyAnthony RedmondPodiatry Rheumatic CareAssociationDr Jane ReebackHonorary Secretary, ScientificSection, ARMAProfessor David G I ScottPresident, British Society forRheumatology, 2002-2004Dr Nicholas J SheehanHonorary Treasurer, ARMA, 1999-2004Nia TaylorChief Executive, BackCareJane TadmanArthritis Research CampaignMr Andrew ThomasBritish Orthopaedic AssociationDr Mike WebleyChairman, ARMAElaine WylieARMA Northern Ireland

Good Practice Working GroupWorking Group Co-ordinatorDr John HalseyConsultant Rheumatologist,Morecambe Bay Hospitals NHSTrustWorking Group MembersSam BrinnProgramme Manager,Orthopaedic ServiceImprovement,NHS Modernisation Agency

Robert CarterSheffield West Primary Care TrustMaureen CoxRoyal College of NursingRheumatology Nursing Policy andPractice Group Dr Peter T DawesUniversity Hospital of NorthStaffordshireAngela DonaldsonArthritis Care, ScotlandDr Jim GardnerMorecambe Bay Primary CareTrustMr Roger GundleBritish Orthopaedic AssociationJeanette HuceyAssociate Director, OrthopaedicServices Improvement,NHS Modernisation AgencyPetra KlompenhouwerNational Association ofRheumatological OccupationalTherapistsProfessor Peter MaddisonLupus UKStephen McBrideArthritis Care, Northern IrelandSusan OliverIndependent RheumatologySpecialist Nurse,Royal College of NursingRheumatology Nursing Policy andPractice GroupElaine WylieARMA Northern Ireland

Consultation Planning GroupLizzie BloomBritish Society for RheumatologyAilsa BosworthNational Rheumatoid ArthritisSocietySusan OliverIndependent RheumatologySpecialist Nurse,Royal College of NursingRheumatology Nursing Policy andPractice GroupProfessor David G I ScottPresident, British Society forRheumatology, 2002-2004

Other ContributorsWe are also grateful to thefollowing for their valuablesuggestions and advice Dr Andrew BamjiConsultant Rheumatologist,Queen Mary’s Hospital SidcupDr Jeffrey GrahamDepartment of HealthRab HarkinsDepartment of HealthMartin MachrayDr Philip SawneyDepartment for Work andPensionsJane TaptiklisDepartment of HealthProfessor Gordon WaddellCentre for Psychosocial andDisability ResearchUniversity of CardiffARMA Trustees and CouncilMembers

Project TeamSophie EdwardsChief Executive, ARMARosemary ChapmanARMA Standards of Care ProjectOfficerAbigail PagePolicy and Campaigns Officer,ARMA

ProductionKate WilkinsonDocument Editor/WriterArtichoke Graphic DesignDocument Design and ProductionCatfish Web DesignWeb Design and Production

17

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Back Pain Booklet - BackCare · 1 Back pain: the size of the problem Back pain is a major health problem, affecting approximately 17.3 million people in the UK – over one-third