Health & Care Guide

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 thing is to make a clear diagnosis of the low back pain. In non-specific low back pain the source may not be found but various diagnoses have to be ruled out, including tumours, infections, fractures, ankylosing spondylitis or other arthritic diseases. Reassessment of the potential diagnosis should be kept in mind as time progresses, and if a specific diagnosis is suspected at any time then investigations should be requested. Nerve root compression, often referred to as sciatica, can cause radicular pain in the leg and cauda equina syndrome can cause very severe pain and important symptoms. These conditions need surgical consultation.

Low back pain has been typically classified as acute, sub-acute and chronic. Acute back pain is said to be back pain of a duration of less than six weeks, while sub-acute back pain is said to continue between six and twelve weeks. Over twelve weeks the back pain is said to be chronic although this classification may be too rigid to reflect the reality of the incidence patterns of low back pain. Many people’s symptoms vary significantly with more and less acute episodes over a long period of time.

Low back pain is estimated to affect around 30 percent of the population of the UK every year, with about a fifth of this number consulting their general practitioner about their back pain. In the past most back pain was thought to settle by six weeks but more recent research has shown that a year after their back pain episode sixty-two percent of sufferers still have pain. In those who are off work with their back pain sixteen percent are still off work at a year. The first month shows a rapid improvement in pain and disability but this is not much improved by 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.

Typical interventions for the management of low back pain include:

Psychological therapies such as a form of cognitive behavioural therapy, mindfulness and self-management.

Exercises which cover individual programmes to group based exercise classes, both on land and in water.

Education for patients such as group sessions, written explanatory material and individual instruction from therapists.

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.

Filed under: Alternative Medicine