Clinical Guidelines for (LBP)

Royal College of General Practitioners Report: On Management of Acute Low Back Pain:

The report on "Clinical Guidelines for the Management of Acute Low Back Pain" was published by the Royal College of General Practitioners in 1996.

It was designed to help doctors and other health professionals with the multi-disciplinary approach to the initial assessment, triage, and evidence-based management of acute low back pain (LBP).

Medical assessment (diagnostic triage) should occur to exclude treatable causes (sciatica, red flags such as carcinoma, HIV, spinal abscess, spinal cord compression). X-rays are not routinely indicated for simple back pain. Biopsychosocial assessment should occur early.

Pain killers (relievers, analgesics) should be prescribed regularly and not "as required" to be more effective. Start with paracetamol, adding in anti-inflammatory drugs (ibuprofen, diclofenac), and weak opioids (codeine) as necessary. Consider a short course of a muscle relaxant (diazepam max. 7 days).

Avoid strong opioids if possible (morphine max. 7 days).
Bed rest is not a treatment for simple low back pain. Bed rest may need to be taken early on in the episode, but this should not be considered a treatment. Bed rest for longer than 3 days has been shown to be harmful by delaying the speed of recovery.

Stay as active as possible and continue with normal daily activities. Gently increase activity levels after an acute episode of back pain over a period of days to weeks. If you are in work, then either stay at work or return to work as soon as possible.

Prolonged periods off work will reduce your overall chance of working again (e.g. only 2% of people can return to work after 1 year off sick).

Spinal manipulation treatment within the first 6 weeks has been shown to be beneficial for pain relief and rehabilitation in those where the back pain does not resolve spontaneously.

Active rehabilitation (exercise programme OR physical re-conditioning) should be started at 6 weeks if there has not been return to work or resumption of normal activities.

The Challenge of Back Pain

In our body, no area presents more of a challenge to doctors than the back.

Second only to that of head pain, debilitating low back pain strikes 80 per cent of us during our lifetimes; it causes millions of lost work days and accounts for a steady stream of patients to general practitioners.

In spite of endless research into its diagnosis, causes and treatment, medical practitioners seem no nearer to understanding back pain. The facts are that misdiagnosis or unproven and aggressive treatment with drugs and surgery contributes more to the problems of back pain sufferers than they do to the solutions.

Conventional methods of diagnosis are still very ineffective. For instance, routine x-rays to determine whether low back pain is caused by a serious condition are virtually useless. By treating back pain as a disease rather than a symptom, we have gone down many one way streets of diagnosis and treatment, with many patients only suffering increased pain from inappropriate treatment.

Some doctors have suggested that conventional medicine should increase its understanding of the back and its problems by adopting an osteopathic / chiropractic understanding of back pain.

The back then becomes part of a whole, complex structure that includes the spine, ribs, pelvis, hips and their surrounding muscles and ligaments and other supporting tissues, as well as the organs contained within those bony structures. Dysfunction or displacement of any of these parts of the structure can eventually lead to back pain.

The vast majority of medical practitioners need to be able to both evaluate and assess the whole impact of the back pain on an individual whilst the individual needs to be able to understand their back pain so that they can work more effectively with their chosen health practitioner.

Ouch! My Back Hurts.

Acute low back pain

It happens to most of us at some stage in our lives, so how we manage it is vital.

There is good scientific evidence on how we should deal with this.

Back pain is extremely common and nothing to worry about. It may recur but this does not mean re-injury and there will usually be no permanent problems.

Managing episodes of back pain successfully can make a difference to your abilities in the long term.

What to do when you have an episode of back pain:

Do not rest unless you have to, and then 2 to 3 days maximum. Rest is not a treatment for low back pain and can lead to stiffness, weakness, loss of fitness, and disability.

Do seek professional advice early on if you are concerned in any way about your back pain.

Keep up normal activities by giving yourself small goals to keep to, eg to walk around for a few minutes every so often, sit for a certain time etc.

Pace your activities - do normal daily activities but cut them up into small blocks of time that you can easily manage. Increase activities by fixed increments and stick to what you plan, not to how you feel.

Take adequate pain-killing medication. Medication should be taken in fixed doses at fixed times, and not when you feel like it or the pain gets too bad. Drugs used need to be discussed with your doctor or pharmacist.

Recognise negative beliefs and deal with them. Look upon the episode as a relapse, not a disaster.

Manipulation can be useful to provide short-term improvement in pain and abilities. As long as you choose a skilled therapist the risks of manipulation are very low.

Use relaxation techniques, either from classes, books or tapes.

Go back to work/normal activities as soon as possible. Don’t wait.

Do not expect to be completely pain free before resuming normal activities.

You should have returned to normal activities and work by six weeks after the start of your episode. If not you may need to join an exercise programme under supervision or at the gym to prevent long term problems.

Acupuncture For Neck Pain

A study by a team of researchers at the University of Southampton has revealed that Western style acupuncture can be effective in treating chronic neck pain.

Moreover its beneficial effects may be as much to do with the non-specific but powerful effects of the treatment process as the specific effect of the needles.

The results of the study are set out in a paper that appeared in the Annals of Internal Medicine on 21 December 2004.

Chronic neck pain presents a substantial problem and may be responsible for as many days' absenteeism as low back pain. It is usually associated with unspecific degenerative changes such as osteoarthritis.

Acupuncture is the most frequently used complementary and alternative medicine (CAM) therapy for the treatment of osteoarthritis, with approximately one million people in the USA seeking CAM treatment each year. However, despite this huge increase in popularity and use, there has been little sound evidence to date that acupuncture helps patients with chronic neck pain.

Led by Dr Peter White and Dr George Lewith of the University's Complementary Medicine Research Unit, this new study aimed to evaluate whether 'Western style' acupuncture is an effective treatment for chronic neck pain. 'Western style' acupuncture involves a conventional diagnosis followed by the use of an individualised acupuncture treatment using a combination of prescriptive points. In contrast, a traditional Chinese approach formulates an individualised diagnosis based on Chinese theories of meridians and energy.

A total of 124 patients with chronic neck pain aged between 18 and 80 years took part in the study. Patients received eight treatments over four weeks having been randomly assigned either acupuncture or mock stimulation to acupuncture points by the same therapist.

Patients were only allowed to use paracetamol for pain relief and were not allowed to undertake any other forms of treatment - even exercises or stretches - during the study or for two months afterwards. During the treatment all patients kept a diary to record pain and also completed questionnaires before, during and after their treatment to assess ease of movement and quality of life.

The results show acupuncture was effective at reducing neck pain and produced a statistically but not a clinically significant effect when compared to the mock treatment or placebo.
Over the 12 weeks of assessment, patients from both groups reported a similar and significant decrease in pain levels of over 60 per cent. The number of patients taking paracetamol also fell, as did the average number of tablets taken by patients. Interestingly, the study also showed that female patients tended to respond better than males and further research is required to establish whether there is a real difference in response in the sexes.

The results of the study cannot be generalised because only one therapist treated all the patients; more information would be gained by using several therapists. It is also impossible to identify whether treating patients with a traditional Chinese medicine-based approach might produce a different outcome so the research team cannot comment on the 'best' type of acupuncture.

Dr Lewith comments: 'Our rigorous and methodologically sound study clearly shows that there was significant and long lasting improvement for both treatment groups. The implications for this are two-fold. First, acupuncture was clearly very effective at reducing pain, with patients experiencing large decreases over a prolonged period which would recommend its clinical use. Second, our study also implies that most of the improvement gained from acupuncture was not due to the needling process itself but due predominantly to the non-specific yet powerful effects which are probably part of the treatment process.

Pregnancy Back Pain

Osteopathy is well recognised as a treatment for back trouble in pregnancy but most people are unaware of its full potential. Many of the conditions suffered in pregnancy are symptoms of an overall pattern of imbalance in the body. By finding and correcting these imbalances, osteopathy can alleviate many of the adverse side effects of pregnancy in the body. This helps ensure an easier more comfortable pregnancy and improves the chances of a straightforward birth, and a mother that can recover quicker.

The aches and pains that are common in pregnancy, result from the body changing shape to accommodate the increasing size and weight of the uterus. The ligaments of the whole body also soften during pregnancy, due to the action of hormones.
This allows the bones of the pelvis to separate slightly during delivery to facilitate the passage of the baby’s head through the pelvis.

Unfortunately this softening affects the whole body and makes it more vulnerable to strain. Postural imbalances may cause backache, sciatica, neckache, headaches, aching legs, and fatigue. If prior to pregnancy a woman’s body is already under stress from previous strains, trauma or lifestyle factors these changes are likely to impose a physical strain on all the organs and tissues.

Osteopathic treatment aims to assist the body in making postural changes more easily, making the pregnancy more comfortable.

Active Rehabilitation:

Latest thinking on managing back pain - the leading cause of sickness absence in the UK - is unusual.

It encourages a speedy return to work, rather than the traditional prescription of complete rest.

Back Trouble UK believes that employees should not take long periods of time off work to recover from low back injuries, even if they are still suffering from the symptoms.

The most effective route to recovery is for employers to establish a program of active rehabilitation that encourages employees to get back to work as soon as possible.

Occupational health practitioners and managers are being encouraged to tackle the problem, by working closely together, with a common, consistent approach to agreed goals.

Improving Health

As well as affecting injured employees and their families, back pain has a major effect on industry through absenteeism and avoidable costs.

The Confederation of British Industries estimates that back pain costs £208 for every employee each year, while, at any one time, 430,000 people in the UK are receiving various social security benefits primarily for back pain.

There is strong evidence that physical activities at work, such as manual handling, account for only a small number of low back injuries among employees. Workers in heavy manual jobs report more low back pain symptoms, but people in lighter jobs have similar problems, related to normal everyday activities such as bending and lifting.

As a first step, health practitioners should raise awareness among employers and employees that work-related activities are not the only cause of lower back pain. But it should also be made clear that work activities can make the symptoms worse.

The next step is to carry out a pre-placement assessment to identify employees who may be more likely to develop lower back pain while carrying out particular work activities. This should include finding out whether employees have a previous history of pain. Care should also be taken when placing individuals with a strong history of lower back pain in physically demanding jobs.

The longer a worker is off work, the lower their chances are of ever returning to work. In fact, evidence shows that, whereas half those injured return to work after six months, only five per cent return after a year off work.

Employers are being encouraged to establish an active program of rehabilitation to help employees stay active and return to ordinary work activities as early as possible. This can lead to a faster recovery than traditional medical treatment, while the business benefits can include shorter periods of work loss and reduced sickness absence.

Occupational Issues

One way of promoting a quick return to work is for organisations to establish joint employer-worker initiatives to facilitate and support workers remaining at work or returning as soon as possible.

Back Trouble UK recommends that health practitioners should:

Initiate communication with the primary health care professional early in treatment and rehabilitation;
Advise the employee to continue as normally as possible and to provide support to achieve this;
Advise employers on the actions required, which may include sympathetic contact with the absent worker;
Consider how an employee's work tasks can be temporarily modified or how they can be given lighter work until they are fully recovered.

Guidelines suggest implementing rest pauses, work rotation, or using mechanical handling aids to carry out lifting operations to achieve this aim.

Other practical steps that can be taken to tackle the problem of low back pain include advising employees on current good working practices - for example, good lifting techniques - and issuing them with user-friendly information, such as HSE guidance publications.

Employers are also encouraged to:Consider joint employer-worker initiatives to identify and control occupational risks;

Monitor back problems and sickness absence due to Lower Back Pain;
Recognise that high job satisfaction can help to reduce disability and sickness absence rates attributed to Lower Back Pain.

Conventional tests such as X-rays and clinical examinations are of limited value when it comes to assessing and preventing lower back pain.

It is important to identify work-related factors. For example, dissatisfaction with work may get in the way of an employee's recovery and may cause symptoms to persist.

Please join us, we welcome your comments.

You can email us at: consultants@backtrouble.co.uk

My Brain Hurts?

CHRONIC BACK PAIN EATS AWAY AT BRAIN

Scientists in Chicago have discovered new clues into what role the brain plays in chronic back pain (CBP).

The investigators used magnetic resonance imaging brain scans to compare the morphology of 26 individuals with CBP with 26 pain-free control subjects.

According to the report "patients with CBP showed 5-11% less neocortical gray matter volume than control subjects. The magnitude of this decrease is equivalent to the gray matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm(3) loss of gray matter for every year of chronic pain."

The study also showed that CBP patients had decreased gray matter density.

"Our results imply that CBP is accompanied by brain atrophy and suggest that the pathophysiology of chronic pain includes thalamocortical processes," conclude the authors.

Decisions, Decisions!

CHRONIC BACK PAIN IMPAIRS DECISION MAKING

Scientific evidence supports the hypothesis that chronic pain impairs an individual`s decision-making capability.

As part of one study, investigators compared 26 healthy people with 26 patients with chronic back pain (CBP) and 12 patients with a condition called chronic complex regional pain syndrome (CRPS).

CRPS is a chronic nerve disorder typically afflicting the arms or legs, which usually onsets following an injury.

The study participants were asked to perform a test researchers use to assess emotional decision-making. The test, called the Iowa Gambling Task, is a gambling card game.
Subjects with CBP performed 41% worse than did pain-free individuals. Those with CRPS performed even poorer.

The study`s authors conclude that "our evidence indicates that chronic pain is associated with a specific cognitive deficit, which may impact everyday behaviour especially in risky, emotionally laden, situations."

"Other cognitive abilities, such as attention, short-term memory, and general intelligence tested normal in the chronic pain patients."

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