Persistent low back pain of non-specific origin is commonly assessed and managed by healthcare practitioners, making up a major proportion of all those people off work due to sickness absence. During the last ten years there have been significant increases in valid research work on this subject, allowing for the first time an evidence based set of recommendations for the assessment and management of longer term back pain. In May 2009 the National Institute for Clinical Excellence (NICE) has published updated guidelines.
The first requirement in the assessment of back pain is to establish a diagnosis. By definition the source is not clear in non-specific low back pain but many potential diagnoses have been ruled out such as ankylosing spondylitis, arthritic diseases, fractures, infections or tumours. Diagnosis is not a one time thing with periodic reassessment important if things change, and investigations should be requested if a specific diagnosis is suspected. Radicular symptoms in the leg, typically called sciatica, and cauda equina syndrome are neurological syndromes which cause severe and very specific symptoms and need consultation with a spinal surgeon.
The classification of low back pain has been traditionally divided into chronic back pain, sub-acute back pain and acute back pain. Chronic back pain refers to pain persisting longer than 12 weeks with sub-acute back pain lasting between 6 and 12 weeks. Under six weeks duration is referred to as acute low back pain. However, due to the variability of symptoms and the long term nature of many back pain syndromes this classification system is too rigid to be useful in the assessment and management of back pain.
In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after three months.
Contemporary figures for the costs of back pain to society are not available but are known to be very high. Patients spend a lot of money on private therapists in the UK, patronising private physiotherapists, acupuncturists, osteopaths and chiropractors. A new episode or a worsening of low back pain makes the exclusion of non-mechanical causes for the back pain vital. Infection is more common in people with immune system problems such as HIV. The incidence of the types of cancers which spread to bone is higher in older age groups. Fractures due to osteoporosis have a higher incidence in older people and anyone on steroids.
Loss of the ability to work, development of disability related to the back and loss of normal activities are the negative factors which can result from sub-acute to chronic low back pain and are the factors which must be addressed to manage this condition successfully. High pain levels, a high degree of disability and psychological distress are risk factors for a poor result and so must be targeted to improve the patient's outcome. Back pain treatments are very numerous with many claims for effectiveness but there is little good evidence to back up the use of most therapies. NICE made the decision to look at the overall delivery of a care package for back pain rather than concentrate on particular therapeutic interventions.
The large number of potential interventions for low back pain includes:
Patient education which covers advice and explanations from professionals, written material and education sessions.
Exercises which cover individual programmes to group based exercise classes, both on land and in water.
Land or water based exercise programmes, again either individually or as part of an exercise group.
Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.
Psychological interventions to improve self management, either mindfulness or a form of cognitive behavioural therapy.
The first requirement in the assessment of back pain is to establish a diagnosis. By definition the source is not clear in non-specific low back pain but many potential diagnoses have been ruled out such as ankylosing spondylitis, arthritic diseases, fractures, infections or tumours. Diagnosis is not a one time thing with periodic reassessment important if things change, and investigations should be requested if a specific diagnosis is suspected. Radicular symptoms in the leg, typically called sciatica, and cauda equina syndrome are neurological syndromes which cause severe and very specific symptoms and need consultation with a spinal surgeon.
The classification of low back pain has been traditionally divided into chronic back pain, sub-acute back pain and acute back pain. Chronic back pain refers to pain persisting longer than 12 weeks with sub-acute back pain lasting between 6 and 12 weeks. Under six weeks duration is referred to as acute low back pain. However, due to the variability of symptoms and the long term nature of many back pain syndromes this classification system is too rigid to be useful in the assessment and management of back pain.
In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after three months.
Contemporary figures for the costs of back pain to society are not available but are known to be very high. Patients spend a lot of money on private therapists in the UK, patronising private physiotherapists, acupuncturists, osteopaths and chiropractors. A new episode or a worsening of low back pain makes the exclusion of non-mechanical causes for the back pain vital. Infection is more common in people with immune system problems such as HIV. The incidence of the types of cancers which spread to bone is higher in older age groups. Fractures due to osteoporosis have a higher incidence in older people and anyone on steroids.
Loss of the ability to work, development of disability related to the back and loss of normal activities are the negative factors which can result from sub-acute to chronic low back pain and are the factors which must be addressed to manage this condition successfully. High pain levels, a high degree of disability and psychological distress are risk factors for a poor result and so must be targeted to improve the patient's outcome. Back pain treatments are very numerous with many claims for effectiveness but there is little good evidence to back up the use of most therapies. NICE made the decision to look at the overall delivery of a care package for back pain rather than concentrate on particular therapeutic interventions.
The large number of potential interventions for low back pain includes:
Patient education which covers advice and explanations from professionals, written material and education sessions.
Exercises which cover individual programmes to group based exercise classes, both on land and in water.
Land or water based exercise programmes, again either individually or as part of an exercise group.
Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.
Psychological interventions to improve self management, either mindfulness or a form of cognitive behavioural therapy.
About the Author:
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Newcastle. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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