An evidence based discussion, illustrated with a made up case history, of a method for approaching patients with low back pain in general practice.
Aims & Objectives The aim of this essay is to discuss the diagnosis and management of low back pain (LBP) in general practice. The aim will be achieved by addressing the following objectives: The epidemiology & aetiology of LBP The economic implications of LBP for the individual and society. The LBP consultation Triaxial (biopsychosocial) diagnosis Patient-centred Prognostic factors for poor outcomes Examining what is considered best practice for management of LBP The GP as a Gatekeeper Dealing with uncertainty Individual management based on population guidelines.
computer networks. He is unmarried and does not have any children but lives with his brother in a 4th floor flat in a tower block with a lift. He is an ex-heavy smoker (but gave up 1 year ago after attending the smoking cessation clinic) and he drinks approximately 30 units of alcohol per week. The Clinical Case Mr Golding walked stiffly into the GPs office and sat down slowly complaining of back pain. The pain had started suddenly 2 days ago when he felt a twinge in his back as he tried to lift a computer out from under a desk. He was in an awkward position which he described as lifting with his legs straight and back bent over the desk with his arms at full stretch. The initial pain had eased but his back had stiffened up whilst driving around in his van for the rest of the day. His back felt best when he was lying down and was worse after periods of driving or lifting. On direct questioning he had rated the pains severity as 7/10, it was constant, did not radiate to his lower limbs and he had no other symptoms that might suggest serious or related problems. He had hurt his back a few times when he was younger working as a labourer and he was worried that he may have done some damage to his back which might get worse and force him to stop work early. He had not been able to work due to the discomfort. He didnt enjoy his current job because it involved a lot of driving, lifting and crawling under desks (all of which exacerbated his back pain). But he needed the money and he was worried that lifting the computer he may have slipped a disc. On examination Mr Golding was overweight and moved reluctantly with some discomfort. A back examination revealed reduced active range of movement and the left paraspinal muscles felt tense and contracted, but there was no tenderness on palpation or any neurological deficit.
with cLBP include depression, disability, and loss of employment.12 It is estimated that LBP costs the UK economy in excess of 12 billion per annum.13 This estimate includes both the direct costs of treatment and incapacity benefits as well as the indirect costs incurred by businesses through the loss of human resources.14 In general it costs more to train someone to do a job, than to rehabilitate an employee with LBP15 which emphasises the important role that a GP can have in helping people, businesses, and the economy.
LINK 2. Anatomical borders and landmarks used to differentiate between different sites of pain.
Aetiology The aetiology of LBP is complex and poorly understood. Pain may arise from one or more of the backs components and the aetiology of LBP is seldom found because clinical assessment lacks the specificity to make a precise diagnosis.9 This complexity has been recognised along with the duration of pain in the classification of low back pain (fig 1). The majority of patients (~95%) who present to primary care have non-specific low back pain, or mechanical back pain (where a specific cause can not be diagnosed). Less than 5% have a diagnosable condition and serious conditions are rare (less than 1%).10 Thus, providing serious pathology is competently screened for GPs should be able to manage the majority of patients presenting with low back pain.
FIGURE 1. Diagnostic triage and classification f LBP.
FIGURE 2. Red Flag Symptoms.
implications for the rehabilitation of the patient and should be considered by the doctor. If the patients experience of the illness is not adequately explored the patient is unlikely to be satisfied with the consultation.6 This has been shown to reduce concordance with management plans6 which in the case of LBP may lead to unnecessary prolongation of the pain, and possibly disability. The identification of the important association between yellow flags and cLBP has led to the development of screening instruments to help identify patients at risk of progressing to cLBP.17,21-23 However, a GPs assessment of a patients risk is as accurate as the instruments currently available, and is probably the best available predictive option.17 Work related risk factors or blue flags (fig 4) are also important in determining the risk of progression to cLBP24 and further screening tools are being developed.24 But research to identify and improve the validity and reliability of these screening tools is needed before they can be reliably implemented.25 This could result in a better understanding of the pathways involved in developing cLBP and the formulation of better more targeted interventions. However, the feasibility of multiple screening interventions within the time constraints of a consultation is questionable. A simple, uniform framework for identifying people who may benefit from further in-depth evaluation is probably of greater use and more acceptable to most GPs and patients.
in their recovery will be most beneficial for the patient.32 Fears and misconceptions about LBP should be addressed explicitly and explanation should be clear to allow informed decisions by the patient about their treatment options. The self-limiting nature of LBP and that further investigations are not indicated should be explained to the patient (perhaps with an analogy to an ankle sprain which also would not show up on an x-ray). Activity and continuing to work should be encouraged as pain allows and bed rest discouraged. If they are unable to work, encouragement should be given to return to usual activity and work as soon as possible (this may be before all of the pain has stopped). To help patients to keep active, trials of local cold or heat packs can be tried for short-term relief. Propping the legs up with pillows when in bed may also help in the shortterm.10 Adequate analgesia should also be offered after careful consideration of the severity of pain as well as any contraindications. Paracetamol (preferred) or NSAIDs are recommended first-line treatments. The WHO analgesic ladder should then be followed if additional pain relief is required. If strong opioids are required, referral to a specialist should be considered. Follow-up & safety netting Recommendations for follow-up (based on expert opinion) suggest that clinical judgement should be used to decide if and when patients should be followed up.10 Cases where yellow flags have been identified and are therefore at increased risk of developing cLBP may benefit from regular follow-up. In other cases with good prognosis, follow-up may be deemed unnecessary but safety netting should be used to help GPs to deal with uncertainty. After explaining the natural history of LBP, it should be made clear to all patients that if their symptoms worsen or do not improve then they should come back to the GP.
1. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J. 1975;2(5969):486-9. 2. Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India. 2000;48(8):771-5. 3. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992;156(2):163-5. 4. Mead N, Bower P, Hann M. The impact of general practitioners patient-centredness on patients post-consultation satisfaction and enablement. Soc Sci Med. 2002;55(2):283-99. 5. Taylor K. Paternalism, participation and partnership - the evolution of patient centeredness in the consultation. Patient Educ Couns. 2009;74(2):150-5. 6. Tate P. The Doctors Communication Handbook: Fifth Edition. 5th ed. Radcliffe Publishing Ltd; 2006. 7. Walker A. Working with people: introduction to consultation models. 2008. Available at: https://studentcentral.brighton. ac.uk/webapps/portal/frameset.jsp?tab= courses&url=/bin/ common/course.pl%3Fcourse_id%3D_48878_1 [Accessed April 30, 2009]. 8. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-91. 9. The Royal Australian College of General Practitioners. Back pain clinical assessment. Available at: http://www.racgp.org.au/ afp/200406/14757 [Accessed March 20, 2009]. 10. Clinical topic Back pain (low) and sciatica. 2008. Available at: http://cks.library.nhs.uk/back_pain_low_and_sciatica [Accessed April 30, 2009]. 11. Chew-Graham C, May C. Chronic low back pain in general practice: the challenge of the consultation. Fam Pract. 1999;16(1):46-9. 12. Hepple P, Robertson ARR. Back pain-- reducing long-term problems. Br J Gen Pract. 2006;56(526):324-6. 13. Jones GT, Johnson RE, Wiles NJ, et al. Predicting persistent disabling low back pain in general practice: a prospective cohort study. Br J Gen Pract. 2006;56(526):334-41.
14. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84(1):95-103. 15. Tackling the 17 billion scourge of back pain. 2007 Available at: http://new.wales.gov.uk/news/archivepress/healthpress/ healthpress2005/708847/?lang=en [Accessed April 5, 2009]. 16. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. 17. Jellema P, van der Windt DAWM, van der Horst HE, Stalman WAB, Bouter LM. Prediction of an unfavourable course of low back pain in general practice: comparison of four instruments. Br J Gen Pract. 2007;57(534):15-22. 18. Magliano L, Fiorillo A, De Rosa C, Malangone C, Maj M. Family burden in long-term diseases: a comparative study in schizophrenia vs. physical disorders. Soc Sci Med. 2005;61(2):313322. 19. Holmes AM, Deb P. The effect of chronic illness on the psychological health of family members. J Ment Health Policy Econ. 2003;6(1):13-22. 20. van der Meer JB, Mackenbach JP. Low education, high GP consultation rates: the effect of psychosocial factors. J Psychosom Res. 1998;44(5):587-97. 21. Crawford C, Ryan K, Shipton E. Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. N Z Med J. 2007;120(1254):U2536. 22. Melloh M, Aebli N, Elfering A, et al. Development of a screening tool predicting the transition from acute to chronic low back pain for patients in a GP setting: protocol of a multinational prospective cohort study. BMC Musculoskelet Disord. 2008;9:167. 23. Neubauer E, Junge A, Pirron P, Seemann H, Schiltenwolf M. HKF-R 10 - screening for predicting chronicity in acute low back pain (LBP): a prospective clinical trial. Eur J Pain. 2006;10(6):55966. 24. Shaw WS, van der Windt DA, Main CJ, Loisel P, Linton SJ. Early patient screening and intervention to address individual-level occupational factors (blue flags) in back disability. J Occup Rehabil. 2009;19(1):64-80.
25. Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: the key to better outcomes for patients? Pain. 2007;129(1-2):8-11. 26. Gilbert FJ, Grant AM, Gillan MGC, et al. Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial. Health Technol Assess. 2004;8(17):iii, 1-131. 27. Rubinstein SM, van Tulder M. A best-evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol. 2008;22(3):471-82. 28. Hughes P, Kerr I. Transference and countertransference in communication between doctor and patient. Adv Psychiatr Treat. 2000;6(1):57-64. 29. Hodgkin P. Commentary: The principle of referral; the gatekeeping role of the GP. Br J Gen Pract. 2008;58(547):130. 30. Mathers N, Hodgkin P. The Gatekeeper and the Wizard: a fairy tale. BMJ. 1989;298(6667):172-4. 31. Chenot J, Leonhardt C, Keller S, et al. The impact of specialist care for low back pain on health service utilization in primary care patients: a prospective cohort study. Eur J Pain. 2008;12(3):275-83. 32. Kikuchi S. New concept for backache: biopsychosocial pain syndrome. Eur Spine J. 2008;17 Suppl 4:421-7. 33. SHOW team SC. Working Backs Scotland. Available at: http:// www.workingbacksscotland.scot.nhs.uk/ [Accessed April 14, 2009]. 34. Kaner EFS, Beyer F, Dickinson HO, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev. 2007;(2):CD004148.


Remember the summer of 2016 when the cap spiked and some very questionable contracts were handed out? If so, you might shudder when you read that history seems poised to repeat itself in the summer of 2019. The NBA's salary cap is projected to jump from just under $102 million for the 2018-19 season to $109 million for the 2019-20 season. This means multiple teams will be flush with cap space in July of 2019.
A jump of $7 million itself is pretty big, but that alone won't cause the cap space to grow around the NBA by such big margins. Several of those questionable (read: bad) contracts are now coming off the books. Combine the jump and expiring money and you have a situation where 14 teams are expected to have between $13.5 and $54 million in cap space.
The Indiana Pacers project to have the most space, by virtue of conservative roster building following the Paul George trade. Indiana has several expiring contracts and is locked into only Victor Oladipo for more than $7 million. This gives the Pacers the flexibility to go in any number of directions, which could include re-signing some of their own free agents, adding new talent to their burgeoning core, or a mixture of both.
While it's unusual for a playoff team to have so much cap space, a handful of perennial postseason teams project to join the Pacers. The Los Angeles Clippers, Utah Jazz and New Orleans Pelicans should each have between $23.6 and $52.5 million in space. In an always tough Western Conference, those four teams have a shot to set themselves up for years to come with smart summers.
In the Eastern Conference, the Philadelphia 76ers are looking at their last offseason with cap room for some time. The Sixers project to have over $28 million in space come July. After the 19-20 season, extensions will kick in for Ben Simmons and Dario Saric, to go along with the max extension Joel Embiid already signed. If Philadelphia is ever going to add a big-time free agent, this coming summer is probably their last chance for several years.
And then you have the rebuilding teams: the Dallas Mavericks, Brooklyn Nets, Chicago Bulls, Sacramento Kings, Atlanta Hawks, New York Knicks, Cleveland Cavaliers and Orlando Magic. Each are at different points in their rebuilds. Some could be looking for the player or two that will put them over the top and back in the playoffs. Others will be prime candidates to eat bad contracts for future assets, as they continue to turn things around.
Finally, looming over everyone are the Los Angeles Lakers. After signing LeBron James this summer, the Lakers only signed palyers to one-year contracts for the rest of the summer to keep long term flexibility. With the game's best player already in the fold, some exciting young talent and the ability to add another max free agent, the Lakers will set the market this coming July.
Every four to five years, the NBA goes through a major reset in the offseason. With the cap spiking again, and nearly half the league positioned to have cap space, the summer of 2019 feels like it will be the start of a season of change across the league.
The NBA's most recent cap projection of $109 million is used.
Rookie Scale, Minimum Scale and Exceptions all bump up accordingly by the percentage of the cap increase.
Projections are made on which options will be picked up (both player and team), and which partial/non-guaranteed players will be waived or kept.
No extension projections are made.
Luol Deng (LAL) and Joakim Noah (NYK) are projected to be waived and stretched.
Starting Cap Space = the amount of space each team will have without renouncing or waiving any players/picks. Projected 2019 draft picks not included.
Maximum Cap Space = the amount of space each team could have if they waived or renounced all players/picks who are not fully guaranteed.
Projected Cap Space = the amount of space each team is projected to have after roster decisions are made.


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The Bates Motel gang has been putting in overtime getting ready for the 2012 season. Our website has been updated and we will now open in late September and will be open the first weekend in November. Our castle sculpt is complete and has been distressed and ready for paint! Chris sculpting the stone lines on the west tower
New Arches for the entrance to our Hayride
We are adding to the grand entrance of the Haunted Hayride with two huge arches towering above the wagons as they enter the trail. Watch for special effects as you pass them!
Bates Motel is Rocking this October
The Bates Motel and Haunted Hayride is blowing the doors off all the other attractions in the Philadelphia area this year. With a brand new trail in the Haunted Hayride, and massive new sets, this ride is better than ever. Customers are loving the new scenes and scares. The haunted trail features more actors and new props that will blow you away. With giant mechanical spiders, and a life-size alligator and new pond scene, guests have been raving about our corn field trail. The infamous Bates Motel has also added new rooms and more actors than ever to give you the best Halloween family fun. Don't forget to check out our sponsor, Paranormal Activity 3, that will premier in theatres October 21st. here's a shot from the movie
Opening in theatres next week
Don't forget to visit Pennhurst Asylum, America's Scariest Haunted Attraction.
Bates Motel gets rave reviews
The Bates Motel and Haunted Hayride has been getting incredible reviews from magazines and blogs all over the country. The resounding fact is that this place is really SCARY! Check out some of them from the links below. The Bates crew are working hard on new sets for the Haunted Hayride that will put this attraction over the top. New scenes in our haunted trail are also coming together. The corn maze has been planted and will take shape soon.
Here's a link to the Fangoria Magazine review: http://www.fangoria.com/index.php?option=com_content&view=article&id=2447:halloween-haunts-the-bates-motel-and-pennhurst-asylum&catid=36:demo-articles&Itemid=56
Here's a link from scariesthauntedhouses: http://scariesthauntedhouses.net/scariest-haunted-houses/bates-motel-philadelphia-haunted-house.html
Look for more reviews in our next blog.
Amazingly Scary Pyro
Last year the Bates Motel and Haunted Hayride added some new toys to our inventory of terrifying monsters, props and sets. Jeff Cox, who owns a film special effects company, built two flame explosion units for our show. One is located in our haunted hayride, and the other was mounted on the roof of the Bates Motel. Here's a shot of the one on our haunted house. Keep an eye out for more updates about America's favorite haunted attraction!
20' ball of fire highlights the Bates Motel
Behind the scenes at the Bates Motel and Haunted Hayride
Welcome to the official blog for the The Bates Motel and Haunted Hayride. Last year we had one of our best seasons ever. In fact, NBC's Mike Tiberi called it "the most elaborate Halloween Haunted Attraction in America" during his interview with us last October. Clearly if you are looking for sheer fear, this is the place to go! And we are looking forward to another great season in 2011, with new scary props, huge sets and monsters. Our Haunted Hayride is getting a makeover with a new trail section and three new sets that will be sure to strike fear in the hearts and souls of our customers! Stay tuned for a sneak preview of these new sets. But to make the season jam packed with things that make our customers scream and come back for more…a lot goes into our haunt all year round.
With just over 6 months left to opening night, the Bates Motel and Haunted Hayride construction is going full speed ahead! We have a crew of 12 construction experts working full time upgrading the infrastructure in the hayride trail, and adding new scary scenes to the haunted corn maze. Along with a new pond filled with monsters, this scary maze will also resurrect the infamous "clown show" that is guaranteed to strike fear in the bravest of people. We try hard to make this the top Halloween event on the east coast. Let us know what you think is scary; post a comment below with ideas and maybe you will see it come to life in October!
So if you want to get a behind the scenes peak at what makes us the Number One Haunt in America check this blog often or look for posts on our Facebook page.
Here's a featured video from the Travel Channel.
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redpajama_set_name: RedPajamaCommonCrawl


Suzanne is also co-author of "Media Ownership and Control: Law, Economics and Policy in an Indian and International Context" (Hart Studies in Competition Law, 2014) and "Hong Kong Competition Law" (Hart/Bloomsbury, 2016). Suzanne is a contributor to "Cross-Border Copyright Licensing, Law and Practice (Elgar Intellectual Property Law and Practice series, 2018).
Advising and supporting the FCA on consultations and engagement with WP29 including most recently in relation to draft guidance on transfers of personal data outside the EEA pursuant to Articles 45-49 GDPR.
Suzanne has wide experience of advising on supervision, investigations and enforcement under the Financial Services and Markets Act 2000.
on complaints under the 2012 Complaints Scheme including cases at stage 1 and before the Complaints Commissioner.
Wide experience of EU and international human rights law. Suzanne has particular experience on human rights issues in regulatory investigations and enforcement by public authorities.
"GDPR: Implications for Trustees and Personal Representatives." Practical Law Private Client - 11 April 2018.
"Running on In" - Competition Law Insight - Volume 17, Issue 3, March 2018.
Regular contributor to Lexis PSL Practice Notes on a range of competition law and regulatory topics. Author of Lexis PSL EU court monthly update.