© GGBPS June 2006 (Review date 2009)

NHS Greater Glasgow

and Clyde Pathway for

the Physiotherapy

Management of Low

Back Pain

1st Edition

June 2006

© GGBPS June 2006

ii

Table of Contents

Forewords Gordon Waddell v Helen Frost vii Mick McMenemy

xi

Acknowledgements

xii

1 Purpose and Aims of Pathway Document 1 2 Executive Summary 3 3 Introduction 5 3.1

Introductory Statement 5

3.2 Make up of the Pathway Group 5

3.3 Main Aims of the Pathway Group 5

4 The need for the Pathway Group for Low Back Pain

6

4.1 Reasons Behind the Pathway Group 6 4.2 Frost Report 6 4.3 A Scoping Exercise to Gather

Thoughts and Opinions of all Physiotherapy Staff

7

5 Overview of Low Back Pain 8 5.1 Definition of Low Back Pain 8 5.2 UK Perspective of Low Back Pain

8

6 Greater Glasgow Back Pain Service (GGBPS) 9 6.1 GGBPS Overview 9 6.2 GGBPS Initiatives

9

© GGBPS June 2006

iii

7 Description of Population Area Represented by GGBPS

10

7.1 Population of Greater Glasgow 10

7.2 Overview of GGBPS patients 10 7.3 Community Health Partnerships

12

8 Clinical Guidelines 13 8.1 Overview of Clinical Guidelines 13 8.2 Clinical Guidelines for Low Back Pain 13 8.3 Red and Yellow Flags 13 8.4 Royal College of General Practitioner

(RCGP) Guidelines 14

8.5 European and Cochrane Guidelines

16

9 Physiotherapy management of low back pain 20 9.1 Low Back Pain Studies Relating to

Physiotherapy Opinion

20

9.2 UK Studies 20

9.3 Glasgow Study 21

24 10 Entry routes for Patients with Low Back Pain 24

10.1 GP/Consultant Referrals 24 10.2 Patient Self Referral 24 10.3 Re-directed Referrals from

Orthopaedics

26

11 Exit routes for Patients with Low Back Pain 27 11.1 Psychology 27 11.2 Surgery 28 11.3 Imaging 28 11.4 DEXA 29 11.5 Physiotherapy-led Back Class 29 11.6 Community-led Class 29 11.7 Self Care 30

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iv

11.8 Pain Association Scotland (PAS) 30 11.9 Pain Clinic 31 11.10 Back to GP 32 11.11 Vertebroplasty 32 11.12 Paediatric cases

33

12 Audit 34 12.1 Baseline Audit 34 12.2 Ongoing Audit

34

13 Summary

35

14 References

37

15 Appendices 42 1 Pathway Group Members 42 2 Delphi Study 44 3 GGBPS Referral Pad 47 4 Acute Low Back Pain Information

Sheet 49

5 Modified Linton Questionnaire 51 6 Enhanced Back Class referral forms

(1) East 57

(2) South 60 7 DEXA Referral Form 63 8 Back to Basics 65 9 Cauda Equina Triage chart 66 10 GGBPS Direct access audit 67 11 (1) Acute Management Treatment

Audit

69

(2) Non Acute Management Audit 70

© GGBPS June 2006

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Forewords

Gordon Waddell (June 2006)

Low back pain is still one of the most common causes of chronic

pain and disability, sickness absence, and long-term incapacity.

Yet most low back pain should be manageable, recovery is

normally to be expected (albeit often with some persistent or

recurrent symptoms) and long-term incapacity is not inevitable.

Clearly, much still needs to be done to provide all patients with

low back pain with the best management they deserve.

There is now a solid evidence-base on which treatments are

effective for low back pain and, equally important, which are

ineffective. There is a growing demand for evidence-based

practice and it is no longer acceptable to provide ineffective

treatments simply because ‘I’ve always done it that way’. Yet

busy health professionals do not have time to keep up with the

latest research, which is why there is a need for evidence

reviews and clinical guidelines like this.

There is also now overwhelming evidence and increasing

agreement that low back pain can only be understood and

managed by a ‘biopsychosocial model’. This is a clumsy,

technical term but unfortunately no one has offered a better

alternative. Put simply, this is an individual-centred model that

takes account of the person, his or her health condition, and the

social context. Biological, psychological and social factors can

aggravate and perpetuate chronic pain and disability; they can

also act as obstacles to recovery: clinical management and

rehabilitation must then address the bio – psycho – social

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vi

obstacles to recovery. All health professionals who treat patients

with low back pain should be interested in and accept

responsibility for rehabilitation and for social/occupational

outcomes.

The Greater Glasgow Back Pain Service is a UK leader in this

approach and this Pathway Document is an important further

step to meeting these challenges. The authors are to be

congratulated and I am delighted to support and recommend it.

© GGBPS June 2006

vii

Helen Frost MSc MCSP (June 2006)

Research Fellow, Department of Public Health, Warwick

Medical School, University of Warwick

Low back pain is a common problem that results in 7% of the

adult population seeking consultation each year incurring high

costs to patients and the NHS. The prognosis of acute low back

pain is favourable with an estimated 90% of back pain sufferers

recovering within 6 weeks, however, low levels of pain and

disability often persist and most people will have at least one

recurrence within 12 months. 1 The challenge for all those

dealing with back pain is not how to cure it but how to manage it

effectively. A clinical model was pioneered by Gordon Waddell

in 1987 2 that rejected the traditional medical approach to back

pain and called for active management based on psychosocial

factors that challenges beliefs about pain, focuses on coping

rather than curing pain and encourages return to normal activity.

This model has been adopted by many health care providers but

there are still numerous different types of treatments available

for back pain sufferers many of which have not been subjected to

scientific scrutiny. Over the last 2 decades there has been a vast

number of randomised controlled trials and reviews of back pain

interventions aiming to evaluate some of these interventions.

The quality of the trials is variable but the recent larger trials

show either no differences between groups or only small

treatment effects for pain, disability and general health.3-6 This

is disappointing but these small treatment effects may well be

important to patients and can be cost effective.7 The trial of

physiotherapy intervention that compared a one off session of

© GGBPS June 2006

viii

advice encouraging return to normal activity with additional

physiotherapy treatment caused considerable controversy when

published in 2004.4 It reported no evidence of a significant short

term or lasting effect of additional physiotherapy treatment in

back pain or health related quality of life measures. The most

novel aspect of the trial was the introduction of a single

physiotherapy session of advice, based on The Back Book8, as the

“control” treatment. The data suggests that this model of

treatment was, in general, well received and the trial was

designed and did reflect everyday physiotherapy provision in the

NHS. 9 The trial cannot tell us which treatments work best for

low back pain, but for patients with similar symptom profiles of

low levels of back pain disability, it suggests that

physiotherapists should consider one session of assessment and

advice rather than prolonged treatment. In a feasibility study

that evaluated prompt access to physiotherapy treatment in

primary care more than 70% of patients were satisfied and

successfully treated with a single visit indicating that this type of

treatment can be a useful approach for selected patients.10

Back pain resources are over stretched in the NHS and it is

essential to look at all the evidence to make the best use of

services available. The European guidelines were compiled by a

group of experts in the back pain field and are based on

systematic evidence and consensus.11 12 The guidelines provide a

sound evidence based platform to work from and build upon. The

simple advice to remain active is universally accepted but some

patients need help to motivate them and overcome fear of

© GGBPS June 2006

ix

activity and exercise. Exercise is recommended for patients with

sub-acute and chronic low back pain and, unlike other passive

forms of treatment, has additional health benefits. Unfortunately

exercise is not always a popular option and it can only be

effective if compliance is high. Physiotherapists are well trained

to address this problem but it is a hurdle that needs to be

overcome in order to optimize any potential benefits.

The publication of guidelines does not automatically result in

clinicians following recommendations because barriers to change

remain across the NHS 13-15 This document presents care pathways

for the management of all back pain that could assist

implementation in other Health Authorities. It has been

developed by researchers and clinicians with an aim to help

physiotherapists adopt an evidence-based approach to the

management of back pain and it provides a consistent clear

message that should help to prevent confusion, frustration and

raised expectations experienced by many patients. It presents a

careful approach to the assessment and identification of those

with serious back problems and offers sensible alternatives for

others taking into account severity, disability and psychosocial

factors. It has the potential to be enormously helpful as a guide

to those managing back pain patients in the NHS and will no

doubt evolve with the publication of ongoing research and

further clinical input.

References

1. Pengel HM, Maher CG, Refshauge KM. Systematic review of conservative interventions for

subacute low back pain. Clin Rehabil 2002; 16(8):811-20.

2. Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment

of low-back pain. Spine 1987; 12(7):632-44.

© GGBPS June 2006

x

3. BEAM. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial:

effectiveness of physical treatments for back pain in primary care. BMJ 2004;

329(7479):1377.

4. Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of

physiotherapy compared with advice for low back pain. BMJ 2004; 329(7468):708.

5. Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, et al. Comparison of physical

treatments versus a brief pain-management programme for back pain in primary

care: a randomised clinical trial in physiotherapy practice. Lancet 2005;

365(9476):2024-30.

6. Wyatt M, Underwood MR, Scheel IB, Cassidy JD, Nagel P. Back pain and health policy

research: the what, why, how, who, and when. Spine 2004; 29(20):E468-75.

7. BEAM. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial:

cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;

329(7479):1381.

8. Roland MWG, Klaber Moffett J, Burton K, main C, and Cantrell T. The Back Book. 1996.

9. Foster NE, Thompson KA, Baxter GD, Allen JM. Management of non-specific low back pain

by physiotherapists in Britain and Ireland. A descriptive questionnaire of current

clinical practice. Spine 1999; 24(13):1332-42.

10. Pinnington MA, Miller J, Stanley I. An evaluation of prompt access to physiotherapy in

the management of low back pain in primary care. Fam Pract 2004; 21(4):372-80.

11. Airaksinen O, Bronx JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al.

Chapter 4 European guidelines for the management of chronic non-specific low

back pain. Eur Spine J 2006; 15(Supplement 2):s192-s300.

12. Van Tulder M, Becker A, Bekkering T, al. E. European guidelines for the management of

acute non-specific low back pain in primary care. European Commission, Research

Directorate General. 2004.

13. Dey P, Simpson CW, Collins SI, Hodgson G, Dowrick CF, Simison AJ, et al.

Implementation of RCGP guidelines for acute low back pain: a cluster randomised

controlled trial. Br J Gen Pract 2004; 54(498):33-7.

14. Bishop A, Foster NE. Do physical therapists in the United Kingdom recognize

psychosocial factors in patients with acute low back pain? Spine 2005; 30(11):1316-

22.

15. Bishop PB, Wing PC. Compliance with clinical practice guidelines in family physicians

managing worker's compensation board patients with acute lower back pain. Spine

J 2003;3(6):442-50.

© GGBPS June 2006

xi

Mick McMenemy (June 2006)

Lead Clinician, Greater Glasgow Back Pain Service

The Greater Glasgow Back Pain Service was launched in

September 2002. Its stated aim was to ‘develop into a city-wide

centre of excellence’.

This document now provides a resource describing ‘best practice’

and will be available in all physiotherapy departments. It

describes current entry and exit routes for patients in the

Greater Glasgow area and should help clinicians make the best

decisions with their patients.

A strength of the document is that it is a consensus statement

from a representative cross-section of physiotherapy clinicians

from Greater Glasgow, enhanced by the input from recognised

external experts, Professor Gordon Waddell and Helen Frost. A

huge thanks goes to the group members who contributed to this

piece of work, especially Fraser Ferguson who both convened the

group and compiled the document.

In Glasgow we now have a guide for best practice to help

individual clinicians in every physiotherapy department and a

model which can be audited to ensure patients are receiving the

best care. Publication of this document is an important step in

developing the highest standards of care for all patients with low

back pain.

© GGBPS June 2006

xii

Acknowledgements

Thanks is given to the feedback was obtained from all Clinical

Specialist Physiotherapists working within the GGBPS and from all

other physiotherapy staff working within Greater Glasgow.

© GGBPS June 2006

1

1 Purpose and Aims of Pathway

Document

The Pathway document contains:

o Reasons for its development;

o Evidence based background of management of LBP;

o Areas of confusion and concern raised by physiotherapy

staff;

o UK and Glasgow perspective of physiotherapy management

of LBP;

o Diagram of entry routes for LBP;

o Clear instructions on exit routes from physiotherapy;

o Clear indication of who should refer patients on to other

services;

o Clear timescale for these referrals;

o Plan for baseline and future audits.

• The information in this document is evidence based,

referencing the most recent clinical guidelines for low back

pain.

• More in depth information in the appendices section

supports the basic information contained in the main body

of the text.

© GGBPS June 2006

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• The aim of the document is designed to optimise the

physiotherapy management of low back pain (LBP) within

NHS Greater Glasgow and Clyde (NHSGGC), and promote an

up to date, clinically effective pathway in this

management.

• The intended audience is for physiotherapists who manage

LBP within NHSGGC. It is hoped this document is relevant to

all professionals.

• The document will be updated regularly and any impact of

the document will be audited on a regular basis.

© GGBPS June 2006

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2 Executive Summary

1. The Chartered Society of Physiotherapy (CSP) demands that

there is a system to ensure that all physiotherapists provide

care that is based on the best available evidence of

effectiveness.’ (CSP, Service Standards 4.1) There should be

links established ‘to identify good practice…through sharing

of information…with national sources of critically appraised

reviews of evidence’ (CSP, Service Standards 4.3). This has

been supported by the Scottish Executive, which has recently

reaffirmed its aim to root out ineffective clinical treatment

and promote equity of care (Scottish Executive, 2005).

2. The Greater Glasgow Back Pain Service (GGBPS) includes ALL

PHYSIOTHERAPY STAFF responsible for the management of

low back pain within NHSGGC.

3. Every physiotherapist, working within NHSGGC, should have a

working knowledge of the contents of this document. This

will help ensure the best use of the available resources of

the GGBPS.

4. Review of clinical evidence and clinical guidelines of the best

available evidence of effectiveness conclude that modalities

such as TENS, ultrasound, interferential, pulsed or non-

pulsed shortwave, laser, traction or acupuncture lack

credible evidence based on rigorous scientific trails.

© GGBPS June 2006

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Therefore their use in the physiotherapy management of low

back pain is not routinely recommended (van Tulder et al

2005; Burton et al 2005; Airaksinen; NHS 2005).

5. If the physiotherapy management of LBP within NHSGGC is to

be seen as a credible, evidence based service then we must

critically review our selection of modalities for the

management of low back pain.

6. A good understanding of the available exit routes for patients

with LBP should result in best practice for more patients.

7. However, production of the Pathway Document alone will

not in itself change clinical practice Ongoing education,

service development, staff training and awareness of the

most up to date literature around LBP is equally vital. These

factors will be driven by the 13 clinical physiotherapy

specialists attached to the GGBPS.

8. Work on this Pathway Document for the physiotherapy

management of low back pain (LBP) was started prior to the

recent reorganisation of health services within Greater

Glasgow, which resulted in the newly merged NHS Greater

Glasgow and Clyde Health Board. This pathway document

therefore refers to the management of LBP only within NHS

Greater Glasgow (NHSGG).

© GGBPS June 2006

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3 Introduction

3.1 Introductory Statement

The Greater Glasgow Back Pain Service aims to provide the

highest standards of care to the healthcare users of Greater

Glasgow. The service is evidence based, and systematically

evaluated and developed to ensure this. Patient centered, we

will respect the individuality of all patients and their carers.

Using a bio psychosocial model of back pain, self-management

and the principles of rehabilitation are central to the service

approach; the aim is to develop the GGBPS as a centre of

excellence for the management of patients with low back pain.

3.2 Make up of the Pathway Group

This document has been a consensus of opinion amongst

representatives of NHSGGC physiotherapy staff, covering both

primary care and acute sites. This was supplemented with the

input of recognised world experts in the management of LBP See

appendix 1.

3.3 Main Aims of the Pathway Group

The main aim of this group was to review and redefine the

pathways for the physiotherapy management of LBP within the

NHSGGC.

© GGBPS June 2006

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4 The Need for the Pathway

Group for Low Back Pain

4.1 Reasons Behind the Pathway Group

The Greater Glasgow Back Pain Service Health Board Steering

Group initiated the concept of reviewing the patient pathway for

LBP across NHSGGC.

This is an opportunity to review the pathway for patients, and

the pathway group has representatives of all key areas of

physiotherapy across Glasgow.

Although there is strong anecdotal evidence that many

physiotherapists working within NHSGGC are following evidence

based practice, there is at present no formal verification of this.

4.2 Frost Report

The need for this review was highlighted further following an

influential articles published by Frost (et al, 2004). The main

findings of this article were:

• A full assessment followed by evidence-based advice is as

effective as traditional physiotherapy treatment.

• There was no evidence of effectiveness of additional

physiotherapy sessions.

© GGBPS June 2006

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4.3 A Scoping Exercise to Gather Thoughts and Opinions

of all Physiotherapy Staff

Widespread consultation amongst outpatient physiotherapy staff

took place. At every stage staff had the opportunity to comment

on, or raise points on the aims of the Pathway Document. The

following points were raised as problematic by the Greater

Glasgow NHS Health Board:

i. Confusion over entry routes to GGBPS and for

physiotherapy in general for patients with LBP

ii. Exit routes from treatment for patients with LBP

iii. Awareness of clinical guidelines and present pathway

(see table 5 below)

iv. Ongoing support for changes in clinical practice as a

result of Pathway recommendations

v. How will changes be monitored?

© GGBPS June 2006

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5 Overview of Low Back Pain

5.1 Definition of Low Back Pain

LBP is defined as pain, muscle tension, or stiffness localized

between the areas covered by the 12th rib and the gluteal folds,

with or without leg pain (Frank et al, 1996; Thomas et al, 1999;

Harkness et al, 2003; Manek and MacGregor, 2005).

5.2 A UK Perspective of Low Back Pain

More than three quarters of the UK population can expect to

experience LBP at some point in their lifetime, but 90% of these

presentations are self-limiting within 6 weeks (Nachemson al,

2000; Pengel et al 2003; Pinnington et al 2004). Rates of

recurrence can be as high as 50% (McKenzie, 2005).

The remaining 10% of patients who do not improve within the 6

weeks require a disproportionate use of health services,

estimated at as much as 80% of the total cost of treating LBP

(Nachemson, 1992; Indahl et al, 1995).

© GGBPS June 2006

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6 Greater Glasgow Back Pain

Service (GGBPS)

6.1 GGBPS Overview

The GGBPS was launched in September 2002. The Service consists

of a team of 13 clinical physiotherapy specialists in low back pain

who lead the management of low back pain in Greater Glasgow.

The team also liaises with 2 dedicated Clinical Psychologists. The

GGBPS though includes all physiotherapy staff within NHSGGC

who manage LBP. The overall aim of the GGBPS is to develop into

a citywide centre of excellence for the management of patients

with low back pain. This management aims to be evidence based.

6.2 GGBPS Initiatives

Since its launch in 2003, the GGBPS has begun to establish itself

as a centre of excellence in the management of low back pain.

(CSP, 2003; NHS Scotland 2004, QIS 2005).

© GGBPS June 2006

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7 Description of Population Area

Represented by GGBPS

7.1 Population of Greater Glasgow

The GGBPS covers the entire population of Greater Glasgow, a

population of 900,000.

7.2 Overview of GGBPS Patients

Table 1 below contains a breakdown of all patients with LBP who

have been assessed by GGBPS specialists from January 2004 to

January 2006. Recent changes have seen parts of Argyll and Clyde

absorbed by Greater Glasgow. It is not clear yet how this will

affect GGBPS.

© GGBPS June 2006

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Table 1 GGBPS LBP patients

Overview

56 % Female 44 % Male

65 % Lumbar 35 % Nerve root

83 % Insidious onset 10 % Occupational 7 % Trauma

65 % Acute symptoms i.e. <6/52 35 % Non-acute symptoms >6/12

Accessing GGBPS

36 % Self refer following GP advice

36 % GP referral

19 % Self referral

5 % Physiotherapy colleague

4 % Other

Using Quebec Task Force definitions

4 % No pain

42 % Lumbar pain

16 % Lumbar pain referred to knee

17 % Lumbar pain referred below the knee

31 % Lumbar pain referred below the knee with neurological symptoms

Outcome of discharge

63 % Self care

3 % Back class

1 % Orthopaedic surgeon

1 % GP

1 % Pain Clinic

21 % Other (Inc DNA/FTA etc)

Average number of GGBPS contacts

35 % <2 visits

52 % <4 visits

© GGBPS June 2006

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7.3 Community Health Partnerships

All Community Health Partnerships (CHPs) have input from the

Clinical Specialists working within the GGBPS. All acute sites

where outpatient physiotherapy is provided also have input from

these Clinical Specialists These sites are the Western Infirmary,

Glasgow Royal Infirmary, Gartnavel General, Stobhill, Southern

General and the Victoria Infirmary. The management of LBP by

the GGBPS is based on the recommendations of the RCGP

guidelines for LBP (Hutchison et al, 1996).

© GGBPS June 2006

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8 Clinical Guidelines

8.1 Overview of Clinical Guidelines

Clinical guidelines for the management and treatment of LBP are

plentiful (see table 2). These clinical guidelines have been

produced following the strictest criteria and all the evidence

reported in them was graded in relation to the strength of the

evidence reviewed. Further information on this grading is clearly

contained in each guideline.

8.2 Clinical Guidelines for Low Back Pain

These clinical guidelines have common themes throughout such

as encouraging patients to avoid bed rest, to stay active and

continue ordinary activities as normally as possible, to receive

active treatments and avoid passive therapies where possible

(Koes et al, 2001; Grimmer et al, 2003; Frost et al, 2004).

8.3 Red and Yellow Flags

The recognition of red flags as a means of raising suspicion of

serious spinal pathology (AHCPR, 1994) and the assessment of

yellow flags, which are psychosocial factors which can increase

the risk of a patient with acute LBP developing prolonged pain

and disability, affecting work and social circumstances (Accident

Compensation Corporation, 2003) were also encouraged.

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8.4 Royal College of General Practitioners (RCGP)

Guidelines

The RCGP guidelines have become the agreed guidelines of all

the health professionals who treat patients with LBP in UK

(Waddell, 1998; Pinnington, 2004). Recently the Prodigy

Guidelines have superseded the RCGP guidelines for the

management of LBP in England; however the GGBPS is

underpinned by the RCGP guidelines.

© GGBPS June 2006

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Table 2 Overview of International guidelines for the management of LBP

* For the purpose of this table the European Guidelines are a combination of Airaksinen et al (2004); Burton et al (2004) van

Tulder et al (2004), which made up these guidelines.

** Prodigy guidelines have now supersede RCGP guidelines in the UK

*** Prodigy guidelines have been submitted to Quality Improvement Scotland for ratification for NHS Scotland

Name Country Patient

Group

Target

Group

Treatment recommendations

Agency for Health Care

Policy and Research

(AHCPR)

United

States

(1994)

Acute <12 weeks

from onset

Primary

care

Low impact aerobics. Manipulation <1/12

Dutch College of General

Practice (NHG),

Netherlands

(1996)

Acute and

chronic

GPs Exercise >6/52 Manipulation < 6/52 no use

National Advisory

Committee on Health

and Disability

New Zealand

(1997, 2003)

<12 weeks from

onset

Primary

care

No specific exercise. Manipulation <6/52 useful

Finnish Medical

Association

Finland

(1999)

Acute, sub acute

and chronic > 12

weeks from

onset

Primary and

secondary

care

Graded exercise>2/52Manipulation useful <6/52

National Health and

Medical Research

Council

Australia

(1999)

<12 weeks from

onset

Primary

care GPs

General exercise useful

Royal College of General

Practitioners (RCGP)

United

Kingdom

(1999)

<12 weeks from

onset

Primary

care GPs

Exercise useful >6/52 Manipulation useful to help non

responders

Danish Institute for

Health Technology

Assessment,

Denmark

(2000)

Acute < 12,

chronic > 12

weeks

Primary

care

Manipulation <1/52. McKenzie diagnosis and treatment

The Swedish Council on

Technology Assessment

in Health Care

Sweden

(2000)

> 12 weeks from

onset

Primary

care

Manual therapy and physical exercise

European Guidelines for

LBP *

Europe

(2004)

Acute <12

weeks, chronic >

12 weeks

Anybody

developing

/updating

guidelines

for LBP,

including

professional

bodies

A bio psychosocial approach by musculoskeletal

physiotherapists or osteopaths, or chiropractors. Exercise

therapy and manipulation for a short course

Traction, Electrotherapy Ultrasound Interferential therapy,

Laser treatments and TENS are specifically and clearly

listed as NOT recommended due to their ineffectiveness

PRODIGY Guidance -

Back pain – lower**

England

***(2005)

Acute < 12

weeks, chronic >

12 weeks.

Health care

professional

s

This guidance takes account of the 2004 European

Guidelines listed above

© GGBPS June 2006

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8.5 European and Cochrane Guidelines

The European Guidelines (Airaksinen et al 2004; Burton et al

2004; Van Tulder et al 2004) have produced wide ranging,

evidence-based recommendation on treatments and interventions

for the management of LBP (See table 3). This again reiterates

the lack of evidence amongst many of the passive interventions

often attributed to physiotherapy management of LBP. Table 3

below gives a brief summary of these guidelines in relation to

acute LBP. Further information is available via the reference list.

Intervention Cochrane

Review

European

Guidelines For

Acute LBP

(Reviewed To Oct

2003)

Comments

Advice to stay

active

Review to July

2001

Small beneficial

effect for

simple acute

LBP

Little or no

effect for

sciatica

Less harmful

than bed rest

Evidence to

recommend staying

active including

work if possible;

avoid bed rest

Note difference between

simple low back pain and

sciatica

Bed rest Review to May

2004

Increased pain

levels and

poorer function

with bed rest

compared to

staying active.

No difference

Evidence suggests

avoiding bed rest

Note difference between

simple low back pain and

sciatica

© GGBPS June 2006

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for sciatica

patients

between bed

rest and staying

active

Information and

re-assurance

Currently being

reviewed

Give information

about good

prognosis for

recovery, no need

for imaging when

full history and

examination suggest

no serious problem

Mentions back book

improves beliefs and

function but not pain

compared to other

information booklet.

Small number of studies

Psychosocial

risk factors

Assess psychosocial

risk factors early

and review if there

is no improvement

in overall condition

Urgent need for validated

instruments to assess

psychosocial risk factors

and to identify sub-groups

of patients with a high

risk of chronicity

Pain medication

and NSAIDs

Use paracetamol

first then NSAIDs as

second choice

Muscle

relaxants

Reviewed to Oct

2002

Strong evidence

effective for

acute LBP

Recommend if no

change with

paracetamol/NSAIDs

Caution due to drowsiness

Surgery for disc

prolapse

Reviewed to

May2000

Strong evidence

that sciatica

patients have

faster relief of

pain than with

conservative

27 randomised and quasi-

randomised studies with

methodological

weaknesses

© GGBPS June 2006

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management

Long term

effect unknown

Multidisciplinary

treatment in

occupational

setting

(sub-acute)

Reviewed to

May 2001

Workplace visit,

occupational

health

intervention

with

multidisciplinary

treatment may

lead to

increased return

to work,

reduced sick

leave and

disability

Consider if sick

leave is greater

than 4-6 weeks

2 low quality RCTs

Manipulation Reviewed to

Sept 2003

Manipulation

superior to

sham treatment

for short term

benefit but no

difference

compared to GP

care, analgesia,

exercises,

education, PT

Consider

manipulation if

patients not

returning to normal

activities.

Need to identify

sub-groups of acute

LBP that this

benefits in future

studies

Contraindicated in

patients with severe or

progressive neurological

deficit

Exercise

therapy

Review to Feb

2000

No difference

between

exercise

therapy,

inactive or

other active

treatments

Current evidence

does not support

exercise therapy in

acute LBP

Only one out of twelve

RCTs found better

outcomes for exercise

therapy compared to

conservative treatment or

information.

© GGBPS June 2006

19

Massage Reviewed to Feb 2002

Massage inferior to

manipulation and TENS;

equal to corsets and

exercises; superior to

relaxation therapy,

acupuncture, self care

education and inert

treatments, Acupuncture

massage superior to

Swedish massage

Not

recommended

for acute LBP

Limited evidence for or

against use in LBP

Acupuncture Reviewed to Feb 2003

No conclusions possible in

acute low back pain

3 RCTs with low

participant numbers and

poor methodology

Traction Current

evidence does

not support the

use of traction

in acute low

back pain

Only 2 RCTs one showing

significant improvement

the other showing no

difference

TENS Not

recommended

for acute LBP

Insufficient evidence as

only 2 RCTs one showing

no significant difference

the other showing TENS

more effective than

paracetamol

Lumbar supports Reviewed to May 2000

No conclusions possible

5 poor quality RCTs

2 non randomized trials

Table 3 Review of evidence based European Guidelines for acute low back pain treatment

© GGBPS June 2006

20

9 Physiotherapy Management of

Low Back Pain

9.1 Low Back Pain Studies Relating to Physiotherapy

Opinion

Five studies have investigated the physiotherapy management of

LBP by directly questioning the physiotherapists’ involved over

their thoughts on the management of LBP (Battie et al 1994;

Foster et al 1999; Li and Bombardier 2001; Gracey et al 2002;

Mikhail et al, 2005).

Although they reported what they thought was a gradual

reduction in the use of interventions with poor evidence base,

many of these treatments were still seen as suitable modalities

to offer patients with LBP.

9.2 UK Studies

With direct reference to the UK, the findings by Foster et al

(1998) and Gracey et al (2001) are the most applicable to the

physiotherapy practice explored in this study (Table 4). Foster et

al (1999) found a preference for manual therapy for the

treatment of LBP. However, 48% of the respondents answered

the question on most commonly used electrotherapy treatment.

Gracey et al (2002) highlight the use of advice as being given in

almost 90% of referrals. This is in line with the most such as

current evidence (Hay et al, 2005), which has reported on the

© GGBPS June 2006

21

benefits of advice being given as part of a pain management

programme.

Table 4 - UK Physiotherapy intervention for LBP

9.3 Glasgow Study

Recently a Delphi study was carried out within NHSGGC to

investigate levels of consensus amongst expert physiotherapy

clinicians responsible for the management of LBP.

These results showed a large consensus amongst expert clinicians

towards an evidence based, bio psychosocial, active management

of LBP (See Appendix 2). These can be seen as supporting the

anecdotal evidence, which already exists that generally the

management of LBP within Greater Glasgow tends to follow an

evidence based pathway.

Author

Recruitment

Country

Response

Rate

Sample

Size

Methodology

Most common treatment

Foster et

al

(1998)

Majority

UK/Ireland

Health Services

UK

58.3%

1548

Questionnaire

o 813 responses to Rx

methods most used

o Maitland Mobilisations

59%

o McKenzie 47%

o Abdominal exercises 17%

750 responses to ETUP most

used

Gracey et

al

(2002)

NHS

Physiotherapists

N.Ireland

Not

stated

157

Questionnaire

o Advice 89%

o McKenzie 71%

o ETUP 66%

Mobilisations 43%

© GGBPS June 2006

22

A recent audit (See Appendices 11(1) and 11(2) show in some

detail the actual physiotherapy management for LBP within

NHSGG. This data will form a baseline that will be re audited to

evaluate any impact of the Pathway Document.

© GGBPS June 2006

23

© GGBPS June 2006

24

10 Entry Routes for Patients

with Low Back Pain

10.1 GP/Consultant Referrals

In some cases a written referral is appropriate e.g. complex

medical history. (See appendix 3 for GP referral form) These

patients should be prioritised on an individual basis.

10.2 Patient Self Referral

This is the most common way of accessing physiotherapy. The

flow chart below has been designed to assist physiotherapy

clinicians in the initial management of LBP after they have

accessed treatment via self referral clinics. The acute LBP

information sheet is in appendix 4.

© GGBPS June 2006

25

If improving

BACK PAIN TRIAGE GUIDELINES

1. COMPLETE PATIENT SELF-REFERRAL TRIAGE CARD

2. EXCLUDE CAUDA EQUINA AND SERIOUS PATHOLOGY & SERIOUS SPINAL PATHOLOGY

SIMPLE LOW BACK PAIN

Less than 2/52

onset

SIMPLE LOW BACK PAIN 2-6/52 NO NERVE ROOT

SYMPTOMS

ACUTE LOW BACK PAIN <6/52 WITH

NERVE ROOT SYMPTOMS

BELOW KNEE

BACK PAIN >6/52

With or without referred symptoms

Self-management for 2/52

Put ‘on-hold’ for 2/52

(or discharge)

Soon appointment

Within 2/52

Urgent appointment

1-2/52

Routine

appointment

Plus: GGBPS advice sheet (if<6 weeks) : Back Book (if appropriate) : Analgesia – has GP prescribed analgesia?

• If YES – ensure patient is taking it as prescribed (i.e. regularly)

• If NO – advise patient to see GP or pharmacist for appropriate analgesia

: Reassurance – 90% of acute back pain settles 4 -6 weeks

If patient phones back within

2/52 give a ‘Soon’ appointment

• Nerve Root Pain = Pain radiating below the knee (as per GGBPS guidelines)

• Longstanding symptoms of pain below the knee => Routine appointment

• Back Book – for 1st episode etc but not for flare up of chronic LBP

• Flare up of chronic pain triage as a new acute episode

© GGBPS June 2006

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10.3 Re-directed Referrals from Orthopaedics

The preferred route for surgical opinion should be through the

back pain specialists. Occasionally however a GP will refer

directly to an orthopaedic surgeon. In such cases these referrals

are usually redirected to local physiotherapy departments for

GGBPS to assess initially.

These patients could be seen by any member of the

physiotherapy staff. On discharge a copy of the discharge letter

should be sent to the GP and orthopaedic consultant.

© GGBPS June 2006

27

11 Exit Routes for Patients with

Low Back Pain

11.1 Psychology (Enhanced Back Class)

Acute (6/52) and sub acute (12/52) patients at risk of developing chronic pain symptoms; especially those with significant Yellow Flags and not responding to physiotherapy management.

The Enhanced Back Class (EBC) was devised by psychology and is run jointly with physiotherapy. The class is designed to help those with back pain who have a presentation that includes psychosocial Yellow Flags. The class helps people to limit the influence of these flags on

their pain, through the development of practical skills.

Patients with symptoms > 6/12 are ineligible for EBC.

These patients can be referred for EARLY intervention by psychologists. If appropriate, these patients will be referred onto the EBC.

Modified Linton questionnaire and EBC referral form. (See Appendices 5 and 6)

Referrals should be discussed first with the

Back Pain Specialist.

© GGBPS June 2006

28

11.2 Surgery

11.3 Imaging

Routine plain film x-rays are not to be routinely

carried out.

Should a GP feel the need for plain film x-ray of the lumbar spine, they should discuss the

case with the radiologist.

MRI requests for acute symptoms should be made in tandem with an orthopaedic referral.

There is a fast tracking system in place for these

patients.

Chronic LBP of ANY duration (including stenotic patients) can be referred onto orthopaedics for opinion.

At present there is existing agreement on imaging for these patients.

Acute and sub acute LBP for which there may be a surgical indication and is not improving with 3/12 conservative treatment can be referred for imaging and an orthopaedic

opinion.

Surgery is usually indicated for nerve root pain, below the knee, which is not resolving with conservative physiotherapy and correct drug management.

ALL referrals should be made by the Back Pain Specialist

ALL referrals should be made by the Back Pain Specialist after review.

© GGBPS June 2006

29

11.4 DEXA

11.5 Physiotherapy-led back class

11.6 Community-led classes

All physiotherapy staff can refer a patient for a DEXA scan if concerned about osteoporosis. (See appendix 7)

Osteoporosis may affect the type of exercises prescribed or if the patients should be referred to an osteoporosis

class.

These exercise classes are designed to help people manage their back pain and return to normal activities. They also aim to prevent recurrence of back problems by helping the person to stay active.

A modified Linton questionnaire should be filled out before referral to these classes; patients scoring >105 (if working) and >80 (if not working) should not generally be

referred.

Back to Basics classes are an easy introduction to exercise and exercise techniques, with non-

medical supervision.

Suitable for those experiencing back pain or those who want to become more active and combine a range of activities at a lower intensity level.

© GGBPS June 2006

30

11.7 Self care

11.8 Pain Association Scotland (PAS)

Patients who are discharged to self care should be told that they can contact their physiotherapist within two months if their pain returns. After the two months, the patient should access physiotherapy through

their local self referral clinic.

This standard should be applied to all LBP patients no matter who is treating them.

Pain Association Scotland (PAS) utilises groups which are participant led, and helps to educate them about the causes of pain, the management and coping with chronic pain. Patients may attend regularly or only when they need support. An information leaflet is available for patient

information and PAS contact details.

© GGBPS June 2006

31

11.9 Pain Clinic

The Pain Clinic involves individual assessment and the intervention by the appropriate clinician (physiotherapist, psychologist or anaesthetist), or group of clinicians to help the patient cope with their pain.

Patients with poor pain management (particularly with chronic pain) may benefit from a multidisciplinary team approach.

Some patients with <6/12 duration of nerve root symptoms may benefit from an early assessment at the Pain Clinic for nerve root

blocks or caudal epidurals.

GGBPS may refer directly to the Pain Clinic. GP are also able to initiate referral.

ALL referrals should be made by the Back Pain Specialist after review.

© GGBPS June 2006

32

11.10 Back to GP

11.11 Vertebroplasty

Patients with suspected serious spinal pathology should be referred immediately back to their GP for review, including screening bloods. Serious spinal pathology would include the presence of significant Red Flags such as weight loss and history of

cancer.

Cauda Equina Syndrome (CES) is a potential surgical emergency. These patients should not be referred back to their GP. They that should be managed in line with the GGBPS CES triage chart (appendix 9).

Patients with suspected LBP from osteoporotic collapse may benefit from

vertebroplasty.

Symptoms should be

present >3/12 - < years.

These referrals should be made via Back Pain Specialist.

© GGBPS June 2006

33

11.12 Paediatric cases

<13 year olds with LBP should be referred to Yorkhill physiotherapy.

Discuss with Back Pain Specialist

>13 year olds should be managed by adult service.

© GGBPS June 2006

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12 Audit

12.1 Baseline Audit

Two baselines audits are being carried out.

The first was to examine the appropriateness of physiotherapy

referrals of patients with LBP (see appendix 10).

The second is assessing treatment preferences amongst all out

patient staff. This builds on the Delphi study mentioned earlier

(see appendix 11).

12.2 Ongoing Audit

These audits will be reviewed regularly.

© GGBPS June 2006

35

13 Summary

This document is the work of the pathway group (see appendix

1), and all staff have had the opportunity to influence and

comment on the document. The GGBPS includes ALL

PHYSIOTHERAPY STAFF responsible for the management of low

back pain within NHSGGC.

Issues around lack of clarity on how to enter and exit LBP

services have been cleary defined, and awareness of these should

improve patient care.

Whilst not prescribing physiotherapy treatment for LBP, the

document clearly lays out professional requirements from the

CSP (CSP, Service Standards 4.1) and the most recent evidence to

manage LBP. This has been supported by the Scottish Executive,

which has recently reaffirmed its aim to root out ineffective

clinical treatment and promote equity of care (Scottish

Executive, 2005).

If the physiotherapy management of low back pain (LBP) within

NHSGGC is to be seen as a credible, evidence based service, then

we must critically review our selection of modalities for the

management of low back pain.

Ongoing education, audit, service development, staff training

and awareness of the most up to date literature around LBP is

© GGBPS June 2006

36

equally vital. These factors will be driven by the 13 clinical

physiotherapy specialists attached to the GGBPS.

© GGBPS June 2006

37

14 References

Accident Compensation Corporation (2003) New Zealand Acute

Low Back Pain Guide, incorporating the guide to assessing

psychological yellow flags in acute low back pain.

www.nzgg.og.nz/guidelines/0072/albp_guide_col.pdf (last

accessed 29/08/05)

Agency for Health Care Policy and Research (1994) Acute Low

Back Problems in Adults, Clinical Practice Guideline Number 14,

AHCPR publ no 94-0642, Public Health Service, US Department of

Health and Human Services Rockville, MD.

Airaksinen, O., Bronx, J.I., Cedraschi, C. et al. (2004) European

guidelines for the management of chronic non-specific low back

pain. European Commission, Research Directorate

General.http://www.backpaineurope.org (last accessed 29/08/05)

Bogduk N. Draft evidence based clinical guidelines for the

management of acute low back pain. National Health and Medical

Research Council, Australia, 2000 (URL: http://www.health.gov.au

:80/nhmrc/media/2000rel/pain.htm) (last accessed 29/08/05)

Burton, A.K., Balagué, F., Cardon, G. et al. (2004) European

guidelines for prevention in low back pain. European Commission,

© GGBPS June 2006

38

Research Directorate General. www.backpaineurope.org (last

accessed 29/08/05)

Chartered Society of Physiotherapy Standards of physiotherapy

practice

http://www.csp.org.uk/uploads/documents/SOPPservice.pdf Last

accessed 25/10/05

Clinical Standards Advisory Back Pain (1994) Report of a clinical

standards advisory group on back pain. HMSO, London.

Danish Health Technology Assessment (1999) Low Back Pain –

frequency, management and prevention from an HTA perspective.

Danish Health Technology Assessment 199 Vol.1 (1).

http://www.sst.dk/Applikationer/cemtv/publikationer/docs/Low-

back%20pain/LowBackPain.pdf (last accessed 29/08/05)

Ferguson. F. (2006) An investigation of referrals for low back pain

to outpatient physiotherapy. Consensus of expert physiotherapy

clinicians using a three round Delphi questionnaire. MPhil project

(unpublished as yet)

Foster, N., Thompson, K., Baxter, J.M., (1999) Management of

non-specific low back pain by therapists in Britain and Ireland

Spine Vol. 24 (13) pp.1332-1342.

Frost, H., Lamb, S., Doll, H., Carver, P., Stewart-Brown, S. (2004)

Randomised controlled trial of physiotherapy compared with advice

for low back pain. BMJ Vol.329 pp.708-714.

© GGBPS June 2006

39

Gracey, J.H., McDonough, S.M., Baxter, G.D (2002) Physiotherapy

management of low back pain: a survey of current practice in

Northern Ireland Spine Vol. 27(4) pp. 406-411

Greater Glasgow NHS Board (2005) Audit of patient satisfaction of

the Greater Glasgow Back Pain Service

Grimmer, K., Milanese, S., Bialocerkowski, A. (2003) Clinical

guidelines for low back pain: a physiotherapy perspective.

Physiotherapy Canada Vol. (55) pp.185-194.

Hutchinson, A., Waddell, G., Feder, G. Clinical Guidelines for the

Management of Acute Low Back Pain. London: Royal College of

General Practitioners; 1996 www.rcgp.org.uk (last accessed

29/08/05)

Johsson E. (2000) The Swedish Council on Technology Assessment

in Health Care. Back Pain Neck Pain, an evidence based review

Report number I-45

http://www.sbu.se/Filer/Content0/publikationer/1/back_neckpain_

2000/backpainslut.pdf (last accessed 29/08/05)

Keeney, S., Hasson, F., McKenna, H.P. (2001) A critical review of

the Delphi technique as a research methodology for nursing.

International Journal of Nursing studies Vol. 38 pp.195-200.

Koes, B.W., van Tulder, M.W., Ostelo, R., Burton, K., Waddell, G

(2001) Clinical guidelines for the management of low back pain in

© GGBPS June 2006

40

primary care: an international comparison. Spine Vol. 26 pp 2504-

2513.

McKenzie R.A. (2005) The myth of acute low back pain The New

Zealand Family Physician Vol.32 (2) pp.125-126

Malmivaara, A., Kotilainen, E., Laasonen, E., Poussa, M.,

Rasmussen, M. (1999) Clinical Practice Guidelines of the Finnish

Medical Association Diseases of the low back. Finnish Medical

Association Diseases of the low back.

Mikhail, C., Korner-Bitensky, N., Rossignol, M., Jean-Pierre Dumas,

J.P. (2005) Physical therapists’ use of interventions with high

evidence of effectiveness in the management of a hypothetical

typical patient with acute low back pain Physical Therapy . Vol. 85

(11) pp.1151-1167

NHS (2005) Prodigy guidelines for low back pain

www.prodigy.nhs.uk/guidance.asp?gt=Back pain - lower (last

accessed 29/08/05)

Pinnington, M. A, Miller, J., Stanley, I. (2004). An evaluation of

prompt access to physiotherapy in the management of low back

pain in primary care. Famil. Pracicet. Vol. 21 pp.372-380

Pope, G., Mockett, S., Wright J. (1995) A survey of electrotherapy

modalities. Physiotherapy Vol.81 pp. 82-91

© GGBPS June 2006

41

Turner, G.H., Weiner, D.K. (2002) Essential components of a

medical student curriculum on chronic pain management in older

adults: results of a modified Delphi process. Pain Medicine Vol. 3

(3) pp. 249-252.

Van der Valk, R.W.A., Dekker, J., Van Baar, M.E. (1995) Physical

therapy for patients with back pain. Physiotherapy; Vol. 81

pp.345–51

van Tulder, M., Becker, A., Bekkering, T. et al. (2004) European

guidelines for the management of acute non-specific low back pain

in primary care. European Commission, Research Directorate

General. www.backpaineurope.org (last accessed 29/08/05)

Waddell, G. (1998) The Back Pain Revolution. 1st edition Churchill

Livingstone. Edinburgh

Whitley Council (1992) Whitley Councils for health services (Great

Britain). Conditions of service. HMSO (Scottish Executive, 2005)

Department of Health (2005) Delivering for Health- A response to

the Kerr Report

www.scotland.gov.uk/Topics/Health/care/communitynursing/delive

ringforhealth

© GGBPS June 2006

42

15 Appendices

Appendix 1 Pathway Group Members

Chair: Mick McMenemy (Lead Clinician, GGBPS)

Helen Frost (Research Fellow and published author)

Professor Gordon Waddell

Janice Miller (Physiotherapy Manager West Glasgow CHCP)

Nicholas Evans (Clinical Specialist Physiotherapist, GGBPS)

Fraser Ferguson (Clinical Specialist Physiotherapist, GGBPS)

Convener/Minute taker

Julie Cuff (Senior Physiotherapist, Milngavie Health Centre)

(Alternate; Marion McLaren Senior Physiotherapist, Drumchapel

Health Centre)

Judith Corcoran (Physiotherapy Team Lead for OP in South

Glasgow)

Judith Reid (Orthopaedic Specialist Physiotherapist, Western

Infirmary, Glasgow) (Alternate; Caroline Hoskins. Orthopaedic

Specialist Physiotherapist, Western Infirmary, Glasgow)

© GGBPS June 2006

43

Fiona Wright (Outpatients Superintendent Physiotherapist,

Western Infirmary, Glasgow)

Dr Mary Newton

Isobel Baxter Clinical Effectiveness Facilitator NHSGGC

Jane Forbes GGBPS team secretary

© GGBPS June 2006

44

Appendix 2 Delphi Study

Breakdown of expert physiotherapy panel

34 physiotherapists – Percentage who replied to round one 84% (N=33)

27 female 6 male

23 senior 1 physiotherapists 10 clinical specialist physiotherapists

Mean of 9.4 years working as an out patient physiotherapist,

Range from 6 to 18 years

Response rates of physiotherapists

Round Number Response Rate

1 97.1% (N=33)

2 76.5% (N=26)

3 73.5% (N=25)

To reach a consensus, a three round sequential questionnaire

called a Delphi Technique took place. The first round asked the

panel to list as many answers to the five questions below (Table

7). Subsequent rounds then asked the panel to rate these options

until the predetermined level of consensus had been reached.

Questions answered by the expert panel

1. CONDITIONS OF LBP YOU CONSIDER SUITABLE FOR

REFERRAL TO PHYSIOTHERAPY

2. FACTORS WHICH YOU FEEL SHOULD INFLUENCE THE

DECISION TO REFER PATIENTS WITH LBP TO

PHYSIOTHERAPY

3. PATIENTS WITH LBP ARE REFERRED TO

PHYSIOTHERAPY TO ACHIEVE WHAT?

© GGBPS June 2006

45

4. APPROACHES THAT YOU FEEL SHOULD BE EMPLOYED

IN THE MANAGEMENT OF LBP ARE?

5. CONDITIONS OF LBP YOU CONSIDER NOT SUITABLE

FOR REFERRAL TO PHYSIOTHERAPY ARE?

Preliminary results of this research are contained above

(Ferguson, Webster et al 2005). Expert physiotherapy clinicians

were asked, via a series of questionnaires, their opinions on

factors associated with the overall management of LBP. Initially

the expert panel were asked to list as many points as they

wished, which they felt were important. Subsequent rounds

asked the panel to rank these options to obtain consensus. The

main findings of this study suggest that in fact expert

physiotherapy clinicians can reach consensus on many aspects

associated with the management of LBP. These points of

consensus do in fact hints at a following of evidence-based care.

And may be seen as differing from the studies previously

published, which have directly asked physiotherapists, which

modalities they employ to manage LBP (Foster et al, 1999;

Gracey et al, 2002). Results suggest an awareness of current best

practice. For example these areas of consensus tended to support

a biopsychosocial approach to physiotherapy management in the

study area reviewed. Active rather than passive treatment

approaches were points of consensus. There were no points of

consensus reached, or even raised as options around many of the

electrotherapy modalities often used by physiotherapists (Pope

et al, 1995; Foster et al, 1999).

© GGBPS June 2006

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Appendix 3 GGBPS referral pad

How long has the patient had THIS episode of low back pain? ................... weeks .............. days

Is the patient OFF work because of this episode of low back pain? Yes No

Does this patient have low back pain only? Yes No

OR

Does this patient have pain radiating below the knee in addition to

low back pain? Yes No

Imaging not recommended at this stage (see back pain guideline)

Other relevant information .....................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

................................................................................................................................................................

GREATER GLASGOW BACK PAIN SERVICE REFERRAL FORM

Cord signs? - TREAT AS EMERGENCY

Systemically unwell? · Previous diagnosis of cancer? · Possible infectious cause? · New/altered back pain <20 or >55 years + raised ESR or abnormal FBC or LFTs?

Do not use this form – refer urgently to relevant OP clinic

Patient details Sex M F Name ………………………………………….. Address………………………………………… ………………………………………………….……………………Post Code……………….. DoB………………….Tel. No. ………………. CHI number……………………………………

Practice stamp Practice code......................... Tel No. ......................Fax No.....................

© GGBPS June 2006

47

Referrer’s signature ...........................................Please print name.......................................................

Date ...............................................

Physiotherapy use only below this line.

Outcome Symptoms resolved Spontaneous resolution Referred to orthopaedic surgeon

Referred to DEXA Referred to psychology Referred to community exercise class

Referred for imaging Referred to enhanced back pain class

Discharge comments ………………………………………………………………………………………………..

………………………………………………………………………………………………………………………….

PLEASE POST OR FAX THIS FORM TO YOUR LOCAL PHYSIOTHERAPY SERVICE

© GGBPS June 2006

48

Appendix 4 Acute LBP info sheet

Greater Glasgow Back Pain Service

ACUTE BACK PAIN ADVICE

Back Pain…

• Many people get back pain at some point in their lives. It can be very distressing and you

may feel it limits your daily activities. It is reassuring to know that back pain is very

rarely due to something serious.

• The first few days, or sometimes weeks, tend to be the most difficult to cope with. This

period of time, however, is the most important time to try to follow the advice given.

Things will then be a lot easier longer term.

• Back Pain is normally due to the muscles, ligaments and joints in this area. They have just

been over stressed for some reason and need to be given a chance to work properly again.

The best thing you can do for them is to try to gradually return to normal activity.

How Active Should I Be…

• The most up to date information on Back Pain tells us that we need to keep as active as

we are able to be. It may be that your pain is so much that you feel you need to stay in

bed for a few days. It is very important that this is only one to two days then really try

hard to gradually build up your activity level again. Staying in bed weakens your body

and makes you feel down - avoid this if you can.

Pain Control…

• Sometimes over the counter medication can help greatly. It is very important that you

take your medication as it says on the side of the packet, and regularly. You will be able

to keep much more active if your pain is kept at a constant lower level, rather that letting

it get out of control. If in doubt, talk to your pharmacist or make an appointment with

your Doctor for a review of your medication.

© GGBPS June 2006

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Scans…

• Up to date medical information tells us that x-rays or other scans are rarely required for

back pain. If an x-ray were to be carried out it would probably show changes in the

surfaces of the joints of the spine. This, thankfully, means nothing other than the fact that

we are continuing to grow a little older.

In General…

• The best person to help your back pain recover quickly is you. Try to balance gradually

returning to your normal activity, including work, with continuing to be aware of not

over stressing your back. General Exercise is also important, if, for example walking

does not aggravate your back pain then gradually try to increase your walking distance

everyday. Your Physiotherapist will be able to give you further advice on this if

required.

GGBPS Jan 2006

© GGBPS June 2006 (Adapted with permission from Linton and Halldén, 1998)

(GGBPS, Updated June 2004)

50

Appendix 5 Modified Linton Questionnaire

THE GLASGOW ACUTE BACK PAIN SCREENING QUESTIONNAIRE

Name____________________________________________________________________________

Address__________________________________________________________________________

________________________________________________________________________________

Date_____________________________________________________________________________

Are you (please tick),

in full-time work in part-time work unemployed retired

a student a full-time carer a home-maker

These questions and statements apply if you have aches or pains, such as back, shoulder or neck

pain. Please read and answer each question carefully. Do not take too long to answer the questions.

However, it is important that you answer every question. There is always a response for your

particularly situation.

1. Where do you have pain? Place a � for all the appropriate sites.

Neck Shoulders Upper back Lower back Leg

2. How long have you had your current pain problem? Tick (�) one.

0-1 weeks [1] 1-2 weeks [2] 3-4 weeks [3] 4-5 weeks [4]

6-8 weeks [5]

9-11 weeks [6] 3-6 months [7] 6-9 months [8] 9-12 months [9]

over 1 year [10]

3. How would you rate the pain that you have had during the past week? Circle one.

0 1 2 3 4 5 6 7 8 9 10

No pain Pain as bad

as it could be

© GGBPS June 2006 (Adapted with permission from Linton and Halldén, 1998)

(GGBPS, Updated June 2004)

51

4. Since the start of this episode of pain, on average, how bad has your pain been? Circle one.

0 1 2 3 4 5 6 7 8 9 10

No pain Pain as bad

as it could be

5. How constant has your pain been since the start of this episode of pain? Circle one.

0 1 2 3 4 5 6 7 8 9 10

No pain Constant pain

6. Based on all the things you do to manage your pain, on an average day, how much are you

able to reduce

it? Circle one.

0 1 2 3 4 5 6 7 8 9 10

Can’t reduce Can reduce

It at all it completely

7. How tense or anxious have you felt in the past week? Circle one.

0 1 2 3 4 5 6 7 8 9 10

Absolutely calm As tense and anxious

and relaxed as I’ve ever felt

8. How much have you been bothered by low mood in the past week? Circle one.

0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely

9. In your view, how likely is it that your current pain may never go away? Circle one.

0 1 2 3 4 5 6 7 8 9 10

No chance Extremely likely

© GGBPS June 2006 (Adapted with permission from Linton and Halldén, 1998)

(GGBPS, Updated June 2004)

52

Here are some of the things that other people have told us about their back pain. For each statement

please circle one number from 0 to 10 to say how much physical activity, such as bending, lifting,

walking or driving would affect your back.

10. Physical activity makes my pain worse.

0 1 2 3 4 5 6 7 8 9 10

Completely Completely

disagree agree

11. An increase in pain is an indication that I should stop what I am doing until the pain

decreases.

0 1 2 3 4 5 6 7 8 9 10

Completely Completely

disagree agree

12. I should not do my normal work / day-to-day activities with my present pain.

0 1 2 3 4 5 6 7 8 9 10

Completely Completely

disagree agree

Here is a list of 4 activities. Please circle the one number which best describes your current ability to

do each of these activities.

13. I can walk for an hour.

0 1 2 3 4 5 6 7 8 9 10

Can’t do it because Can do it without pain

of pain problem being a problem

14. I can do ordinary household chores.

0 1 2 3 4 5 6 7 8 9 10

Can’t do it because Can do it without pain

of pain problem being a problem

© GGBPS June 2006 (Adapted with permission from Linton and Halldén, 1998)

(GGBPS, Updated June 2004)

53

15. I can go shopping.

0 1 2 3 4 5 6 7 8 9 10

Can’t do it because Can do it without pain

of pain problem being a problem

16. I can sleep at night.

0 1 2 3 4 5 6 7 8 9 10

Can’t do it because Can do it without pain

of pain problem being a problem

This section is to be completed ONLY by those who are in work (including being currently on

sick leave). If you are not in work, please return this questionnaire to the person who gave it you

and thank you for completing it.

17. Job Title (occupation) _________________________ Date stopped work for this episode __ / __ / __

18. How many days of work have you missed because of pain during the past 18 months? Tick (�) one.

0 days [1] 1-2 days [2] 3-7 days [3] 8-14 days [4] 15-30

days [5]

1 month [6] 2 months [7] 3-6 months [8] 6-12 months [9] over 1

year [10]

19. Is your work heavy or boring? Circle the best alternative.

0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely

20. What are the chances that you will be working in 6 months? Circle one.

0 1 2 3 4 5 6 7 8 9 10

No chance Very large chance

© GGBPS June 2006 (Adapted with permission from Linton and Halldén, 1998)

(GGBPS, Updated June 2004)

54

21. When you think about your work routines, management, salary, promotion possibilities and work mates,

how satisfied are you with your job? Circle one.

0 1 2 3 4 5 6 7 8 9 10

Not at all Extremely

satisfied satisfied

22. I can do light work for an hour.

0 1 2 3 4 5 6 7 8 9 10

Can’t do it because Can do it without pain

of pain problem being a problem

Thank you for completing this questionnaire

----------------------------------------- Below this line is for office use only --------------------------------------

a) Total score for those who are unemployed, retired, a student,

a full-time carer or a home-maker

b) Score for work items

c) Total score for those who are in full or part-time work (a + b)

© GGBPS June 2006

55

Appendix 6 Enhanced Back Class referral forms

(1) East

GREATER GLASGOW BACK PAIN SERVICE

REFERRAL FOR ENHANCED BACK CLASS

Refer if patient not making expected progress at 3-6 weeks (or longer up to 3 months)

(still limited in activities, failure to return to work or normal activities, unsatisfactory

response to treatment)

Patient details Sex: F ٱ M ٱ

Name

…………………………………………………………………………………………..

Address

…………………………………………………………………………………………

Post Code …………………………………………………..

DoB ………………………… Tel No: ……………………………………..

CHI number ………………………………………………………………….

GP Name

…………………………………………………………………………………………..

Address

…………………………………………………………………………………………

Post Code …………………………………………………..

Tel No ……………………………………………………

How long has patient had this episode of back pain? …………..weeks ……….months

Yellow flags noted at initial presentation? ٱ NO ٱYES

If yes describe…………………………………………………………………………

© GGBPS June 2006

56

………………………………………………………………………………………..

What management has the patient had so far (physiotherapy, analgesia, relaxation,

acupuncture, etc)? ………………………………………………………………………

…………………………………………………………………………………………

Attitudes and beliefs……………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

…………………………………………………………………………………………

Behaviours………………………….…………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Compensation………………………………………………………………………….

…………………………………………………………………………………………

Diagnosis and Treatment Issues..…………………………………………………….

…………………………………………………………………………………………

Emotions…………………………………………………………………………….

…………………………………………………………………………………………

© GGBPS June 2006

57

Family………………………………………………………………………………….

…………………………………………………………………………………………

Work…………………………………………………………………………………….

…………………………………………………………………………………………

………………………………………………………………………………………….

Other relevant

information…………………………………………………………………………….

…………………………………………………………………………………………

Clinical Specialist Name …………………………………………………………….

Date……………………………………………………………………………………

Contact details…………………………

PLEASE ATTACH GLASGOW ACUTE BACK PAIN SCREENING QUESTIONNAIRE

There are unlikely to be negative consequences of over identification of Psychosocial Yellow Flags so

if in doubt, please discuss with the clinical psychologist or refer anyway. Do not delay referral.

Please post this form to: Dr Martin Dunbar, Clinical Psychologist, Anaesthetic

Department, Stobhill Hospital, 133 Balornock Road, Glasgow G21 3UW. Tel :

0141 201 3005. Email: MartinDunbar@northglasgow.scot.nhs.uk

© GGBPS June 2006

58

(2) South

GREATER GLASGOW BACK PAIN SERVICE

REFERRAL FOR ENHANCED BACK CLASS

Refer if patient not making expected progress at 3-6 weeks (or longer up to 3 months)

(still limited in activities, failure to return to work or normal activities, unsatisfactory

response to treatment)

Patient details Sex: F ٱ M ٱ

Name

…………………………………………………………………………………………..

Address

…………………………………………………………………………………………

Post Code …………………………………………………..

DoB ………………………… Tel No: ……………………………………..

CHI number ………………………………………………………………….

GP Name

…………………………………………………………………………………………..

Address

…………………………………………………………………………………………

Post Code …………………………………………………..

Tel No ……………………………………………………

How long has patient had this episode of back pain? …………..weeks……….months

Yellow flags noted at initial presentation? ٱ NO ٱYES

If yes describe…………………………………………………………………………

…………………………………………………………………………………………

© GGBPS June 2006

59

What management has the patient had so far (physiotherapy, analgesia, relaxation,

acupuncture, etc)? ……………………………………………………………………

…………………………………………………………………………………………

Attitudes and beliefs……………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Behaviours…………………………………………………………………………….

…………………………………………………………………………………………

…………………………………………………………………………………………

Compensation..……………………………………………………………………….

…………………………………………………………………………………………

Diagnosis and Treatment Issues …………………………………………………….

…………………………………………………………………………………………

Emotions..…………………………………………………………………………….

…………………………………………………………………………………………

Family………………………………………………………………………………….

© GGBPS June 2006

60

…………………………………………………………………………………………

Work…………………………………………………………………………………….

…………………………………………………………………………………………

…………………………………………………………………………………………

Other relevant information…………………………………………………………….

…………………………………………………………………………………………

Clinical Specialist Name …………………………………………………………….

Date……………………………………………………………………………………

Contact details…………………………

PLEASE ATTACH GLASGOW ACUTE BACK PAIN SCREENING QUESTIONNAIRE

There are unlikely to be negative consequences of over identification of Psychosocial Yellow Flags so

if in doubt, please discuss with the clinical psychologist or refer anyway. Do not delay referral.

Please post or fax this form to: Dr David Craig, Chartered Clinical Psychologist,

Dept of Anaesthetics, Southern General Hospital, 1345 Govan Road, G51 4TF

Tel: 0141-201-1658/2385

© GGBPS June 2006

61

Appendix 7 DEXA referral form

Please return to Local Dexa Service

DIRECT ACCESS DEXA SERVICE (DADS) REFERRAL FORM

Name………………………………………… Name…………………………………………………. Address……………………………………… Address………………………………………………. ………………………………………………. Post Code…………………………….. Hospital No….……… Post Code………… Tel No………………………Fax No………………… D.O.B…………………….Tel No……….. CHI No…………………………………….

PATIENT DETAILS GP DETAILS (or stamp)

Steroids >5mg of prednisolone or equivalent per day for more than 3 months Indication…………………………………………………………………..

Age >60 years + menopause aged less than 45 years

Age >60 years + acquired kyphosis

Age >60 years + significant self-reported height loss

Age patient >60 years + family history of a first-degree relative with fracture (>60 at time of fracture)

Age >60 years + family history of a first-degree relative with acquired kyphosis

Age >60 years + family history of a first-degree relative with DEXA confirmed osteoporosis

Depo Provera for > 5 years if DEXA result will influence use of the drug.........................................

Monitoring as recommend by DADS or Bone Mineral Metabolism Clinic or Fracture Liaison Nurse Service (usually 5 years from previous scan). Date of most recent scan ...................................................................................

Men and women over 50 with a fracture at any site (not attributable to RTA nor a fall from above head height) Site of fracture ...................................Date of fracture........................

INDICATE REASON FOR REFERRAL

© GGBPS June 2006

62

Signature of referring person .....................................Designation …...............................................

Address if not GP .......................................................Date …….......................................................

Other current health problems: Current medication:

© GGBPS June 2006

63

Appendix 8 Back to Basics

These sessions employ a range of low impact exercise techniques suitable for those experiencing back pain or those who want to become more active as an easy introduction to exercise.

Available at:

Bellahouston Leisure Centre Friday 5:15 – 6:00pm Gorbals Leisure Centre Wednesday 10:30 – 11:30am Pollok Leisure Centre Thursday 10:30 –11:30am Scotstoun Leisure Centre Tuesday 2:30 – 3:30pm Springburn Leisure Centre Thursday 1:00 – 2:00pm Tollcross Park Leisure Centre Tuesday 11:30 –12:30pm

For more information Please Phone: 0141 287 5913

www.activeglasgow.com

© GGBPS June 2006

64

Appendix 9 Cauda Equina Triage chart

Complete urinary retentionComplete urinary retention

Lack of awareness of bladder fillingLack of awareness of bladder filling

Saddle anaesthesiaSaddle anaesthesiaOverflow incontinenceOverflow incontinence

Saddle anaesthesia can be tested in a less invasive manner by Saddle anaesthesia can be tested in a less invasive manner by

light touch over sacral/medial gluteal area. Testing sphincter light touch over sacral/medial gluteal area. Testing sphincter

tone is not necessary.tone is not necessary.

Usually bilateral sciatica with neurological signsUsually bilateral sciatica with neurological signs

Increased frequency

Incontinence withoutwithoutwithoutwithout saddle anaesthesia

Whole clinical picture to be considered

Table 2: PATIENTS NEEDING TO BE MONITOREDTable 2: PATIENTS NEEDING TO BE MONITOREDTable 2: PATIENTS NEEDING TO BE MONITOREDTable 2: PATIENTS NEEDING TO BE MONITORED

Table 1 : PATIENTS NEEDING URGENT REFERRALTable 1 : PATIENTS NEEDING URGENT REFERRALTable 1 : PATIENTS NEEDING URGENT REFERRALTable 1 : PATIENTS NEEDING URGENT REFERRAL

A&E/Neurosurgery

GGBPS CAUDA EQUINA TRIAGEGGBPS CAUDA EQUINA TRIAGEGGBPS CAUDA EQUINA TRIAGEGGBPS CAUDA EQUINA TRIAGE30/09/04

Pre-existing urological problemse.g. history of incontinence, history of prostate problems, uterine prolapse, previous urology treatment etc. Incontinence due to lack of mobilityIn general these patients are aware of bladder filling but due to severe pain and fear associated with low back pain can find it difficult to reach the toilet in time.Medication causing altered bladder/bowel function

Discuss case with your local GGBPS member if available.If not available contact another GGBPS member.

If patient is to be sent onto A&E or Neurosurgical unit, please make sure you have a letter prepared explaining the clinical presentation

If final outcome is known, complete CES register form and give to your local GGBPS member

Table 3. PATIENTS UNLIKELY TO BE CESTable 3. PATIENTS UNLIKELY TO BE CESTable 3. PATIENTS UNLIKELY TO BE CESTable 3. PATIENTS UNLIKELY TO BE CES

Table 4. GGBPS PREFERRED PATHWAY FOR SUSPECTED CESTable 4. GGBPS PREFERRED PATHWAY FOR SUSPECTED CESTable 4. GGBPS PREFERRED PATHWAY FOR SUSPECTED CESTable 4. GGBPS PREFERRED PATHWAY FOR SUSPECTED CES

© GGBPS June 2006

65

Appendix 10 GGBPS Direct access audit

Greater Glasgow Back Pain Service

Direct Access Referrals Audit

Instructions

Starting on 1st March, 2006, (or your next working day after 1

st March) please complete a form for the next 10 Direct Access

patients you see. Once all 10 forms have been completed please return in envelope provided. If you do not receive 10

referrals by the 31st March, 2006, please return the forms you have completed along with the remaining blank ones.

Many thanks for you help. Isobel Baxter,

Department Public Health, Greater Glasgow NHS Board, Dalian House.

1. About the patient

a. Was the patient:

Do not

write in

this area

Self referred Other – please detail:

Came at GPs suggestion

b. Was the patient triaged:

At drop in clinic Other – please detail:

By telephone

2. Key dates d d m m y y

a. Date of triage 06

b. Date of onset of

symptoms

06

OR

Duration of symptoms:

c. Date of first

appointment

06

3. Your Opinion

In your judgement, was the length of time the patient waited for their appointment:

Any comments:

Too short

About right

Too long

4. Regarding Page 2 of the triage form

a. Was the section on BACK PAIN filled in?

Yes

Most questions completed If the section was NOT fully completed,

About half completed were all the BACK PAIN RED FLAG

© GGBPS June 2006

66

Less than half completed questions completed?

No Yes

No

b. Was the section on PAST MEDICAL HISTORY filled in?

Yes If the section was NOT fully completed,

Most questions completed were all the RED FLAG HISTORY

About half completed questions for BACK PAIN completed?

Less than half completed Yes

No No

5. Which geographical sector are you based in?

North East South East South West

© GGBPS June 2006

67

Appendix 11 GGBPS Management of low back pain audit

Table 1 Non-acute - All cases N=114 NON Acute Always Sometimes Rarely Never Missing

Count % Count % Count % Count % Count %

Manual Therapy 8 7.0% 60 52.6% 37 32.5% 6 5.3% 3 2.6%

Mobilisation 4 3.5% 70 61.4% 32 28.1% 5 4.4% 3 2.6%

Pain management 60 52.6% 46 40.4% 4 3.5% 4 3.5%

McKenzie 18 15.8% 63 55.3% 25 21.9% 5 4.4% 3 2.6%

Active rehabilitation 96 84.2% 16 14.0% 2 1.8%

Graded return to normal activity

89 78.1% 23 20.2% 2 1.8%

Minimal hands on 47 41.2% 54 47.4% 8 7.0% 2 1.8% 3 2.6%

Hands on 5 4.4% 65 57.0% 36 31.6% 3 2.6% 5 4.4%

Postural education 99 86.8% 14 12.3% 1 .9%

Heat 11 9.6% 33 28.9% 40 35.1% 29 25.4% 1 .9%

Ice 2 1.8% 22 19.3% 39 34.2% 50 43.9% 1 .9%

Biofeedback 2 1.8% 13 11.4% 30 26.3% 68 59.6% 1 .9%

Interferential 2 1.8% 17 14.9% 93 81.6% 2 1.8%

Back classes 7 6.1% 96 84.2% 9 7.9% 1 .9% 1 .9%

TENS 1 .9% 48 42.1% 50 43.9% 13 11.4% 2 1.8%

Acupuncture 36 31.6% 42 36.8% 34 29.8% 2 1.8%

Cognitive behavioural therapy

8 7.0% 42 36.8% 18 15.8% 42 36.8% 4 3.5%

Liaise with employers 24 21.1% 48 42.1% 40 35.1% 2 1.8%

Promotion of self-management

106 93.0% 7 6.1% 1 .9%

Bio-psychosocial model 55 48.2% 38 33.3% 12 10.5% 6 5.3% 3 2.6%

Explanation of correct treatment/prognosis

94 82.5% 15 13.2% 1 .9% 1 .9% 3 2.6%

Negotiated approach 74 64.9% 30 26.3% 4 3.5% 1 .9% 5 4.4%

Listening 108 94.7% 5 4.4% 1 .9%

Integrated approach 60 52.6% 44 38.6% 1 .9% 4 3.5% 5 4.4%

Evidence based 61 53.5% 45 39.5% 5 4.4% 3 2.6%

Ortho referral 11 9.6% 82 71.9% 20 17.5% 1 .9%

Psychology referral 1 .9% 35 30.7% 55 48.2% 22 19.3% 1 .9%

Strapping 10 8.8% 43 37.7% 60 52.6% 1 .9%

Manipulation 14 12.3% 39 34.2% 60 52.6% 1 .9%

Exercise 104 91.2% 10 8.8%

Education 112 98.2% 2 1.8%

Advice 112 98.2% 2 1.8%

© GGBPS June 2006

68

Table 2 Acute - All cases N=114 Table 2 Acute

All cases N=114 Table 2 Acute All cases N=114

Table 2 Acute All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

% Count % Count %

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

27.2 5 4.4% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

27.2 2 1.8% 6 5.3%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

7.0 1 .9% 4 3.5%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

9.6 4 3.5% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

.9 1 .9% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

.9 1 .9% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

12.3 2 1.8% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

26.3 2 1.8% 7 6.1%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

.9 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

20.2 23 20.2% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

26.3 39 34.2% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

23.7 68 59.6% 6 5.3%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

16.7 81 71.1% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

21.9 12 10.5% 6 5.3%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

35.1 21 18.4% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

26.3 33 28.9% 6 5.3%

© GGBPS June 2006

69

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

26.3 40 35.1% 8 7.0%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

33.3 39 34.2% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

.9 4 3.5%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

17.5 9 7.9% 9 7.9%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

7 6.1%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

2.6 1 .9% 9 7.9%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

4 3.5%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

4.4 5 4.4% 10 8.8%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

1.8 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

55.3 22 19.3% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

42.1 45 39.5% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

33.3 56 49.1% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

28.9 59 51.8% 5 4.4%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

4 3.5%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

4 3.5%

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

Table 2 Acute

All cases N=114

4 3.5%