Low back pain which persists and does not have a specific origin is a frequent source of consultation for professionals in the healthcare professions, consisting of a high percentage of sickness absence from work. The last ten years have seen a great improvement in the quality and quantity of research work on this subject, finally leading to the ability to give scientific advice about the management of low back pain of a persistent nature. NICE, the National Institute for Clinical Excellence, has just published its latest guidelines in May 2009.
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.
Clinicians and researchers have classified low back pain into three categories, acute back pain, sub-acute back pain and chronic back pain. If the back pain has lasted for less than six weeks it is said to be acute, if it lasts from six to twelve weeks it is sub-acute and if it continues after the twelve week point it is said to be chronic. This system of back pain classification is only partly useful as its rigid boundaries often do not correspond to the persistence and variability of back pain as people typically experience it.
About one third of the UK population are estimated to be affected by low back pain each year and of these people about twenty percent consult their general practitioner about their pain. Back pain was initially viewed as mostly getting better in six weeks but studies now show than 62% of people still have some back pain one year after their episode started. And importantly, 16% of those who were unable to work with their back pain initially are still unable to do so by one year later. Disability and pain reduce quickly during the first month after back pain incidence but little more improvement occurs by the third month.
The costs of back pain are very large although up to date figures are difficult to come by. Costs not borne by the NHS are high in the UK with patients consulting private physiotherapists, osteopaths, chiropractors and acupuncturists. Exclusion of important causes for low back pain is vital when someone presents with a new episode or a worsening. Malignant changes are more likely in older people and in anyone with a history of tumours which can spread to bones. Infections may be more likely in anyone with a compromised immune system such as suffering from HIV. Older people are more likely to suffer osteoporotic fractures, particularly women after menopause or anyone who has been on oral steroids.
The early management of non-specific low back pain which persists for any time from six weeks to a year is to ensure the episode does not turn into long term disability, loss of normal activities and loss of work. Distress, disability and pain are the important factors which must be addressed to improve the outcome, as high levels of pain, high disability and psychological distress are predictive of a poorer outcome. A very large number of treatments exist and are claimed to be helpful but the scientific basis for most treatments is not good. The NICE group decided to look at an overall package of care, potentially deliverable by many professional groups, rather than individual therapies.
The common therapies used for treatment of low back pain include:
External physical interventions such as transcutaneous electrical nerve stimulation (TENS), laser, ultrasound, interferential, spinal traction and lumbar supports.
Patient education via information either from a professional individually or in a formal group session, including written materials.
Manual therapy which covers massage, mobilisations and manipulation.
Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.
Exercise programmes, either in water or on land, either individually or in groups. - 14130
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.
Clinicians and researchers have classified low back pain into three categories, acute back pain, sub-acute back pain and chronic back pain. If the back pain has lasted for less than six weeks it is said to be acute, if it lasts from six to twelve weeks it is sub-acute and if it continues after the twelve week point it is said to be chronic. This system of back pain classification is only partly useful as its rigid boundaries often do not correspond to the persistence and variability of back pain as people typically experience it.
About one third of the UK population are estimated to be affected by low back pain each year and of these people about twenty percent consult their general practitioner about their pain. Back pain was initially viewed as mostly getting better in six weeks but studies now show than 62% of people still have some back pain one year after their episode started. And importantly, 16% of those who were unable to work with their back pain initially are still unable to do so by one year later. Disability and pain reduce quickly during the first month after back pain incidence but little more improvement occurs by the third month.
The costs of back pain are very large although up to date figures are difficult to come by. Costs not borne by the NHS are high in the UK with patients consulting private physiotherapists, osteopaths, chiropractors and acupuncturists. Exclusion of important causes for low back pain is vital when someone presents with a new episode or a worsening. Malignant changes are more likely in older people and in anyone with a history of tumours which can spread to bones. Infections may be more likely in anyone with a compromised immune system such as suffering from HIV. Older people are more likely to suffer osteoporotic fractures, particularly women after menopause or anyone who has been on oral steroids.
The early management of non-specific low back pain which persists for any time from six weeks to a year is to ensure the episode does not turn into long term disability, loss of normal activities and loss of work. Distress, disability and pain are the important factors which must be addressed to improve the outcome, as high levels of pain, high disability and psychological distress are predictive of a poorer outcome. A very large number of treatments exist and are claimed to be helpful but the scientific basis for most treatments is not good. The NICE group decided to look at an overall package of care, potentially deliverable by many professional groups, rather than individual therapies.
The common therapies used for treatment of low back pain include:
External physical interventions such as transcutaneous electrical nerve stimulation (TENS), laser, ultrasound, interferential, spinal traction and lumbar supports.
Patient education via information either from a professional individually or in a formal group session, including written materials.
Manual therapy which covers massage, mobilisations and manipulation.
Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.
Exercise programmes, either in water or on land, either individually or in groups. - 14130
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 Hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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