by Jonathan Blood Smyth

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.

To conclude that the diagnosis is non-specific low back pain many conditions have to be excluded. These include infections, cancers, broken bones and arthritic diseases such as ankylosing spondylitis, and diagnosis should be reviewed periodically, with appropriate requesting of investigations, if there is any suspicion of a particular diagnosis. Cauda equina syndrome and sciatica (radicular leg pain) are neurological compression syndromes and should be urgently referred for consultation with a spinal surgical specialist.

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.

The cost to society of back pain problems is high but modern figures are not available, with the UK market having a large expenditure on private therapists as well as NHS costs, including private physiotherapists, acupuncturists, chiropractors and osteopaths. When someone develops an exacerbation of their back pain or a new episode it is crucial to exclude non-mechanical causes. Older people are more susceptible to malignancies as is anyone with a history of cancer types with are known to spread to bone. A compromised immune system should raise the suspicion that infection is a possibility. Osteoporotic fractures are more common in those on oral steroids and in older people.

The risks of having low back pain which continues beyond six weeks and towards a year is that it will develop into significant back-related disability, high pain levels and a loss of the ability to work. These factors should be addressed to increase the chances of a good result. High levels of distress of a psychological nature, significant disability and reported high pain levels all indicate an increased risk of a poor outcome. Therapies for back pain are extremely varied and numerous although little solid evidence to back up any claims is available to guide the choice of one or another. NICE has decided to concentrate on the whole package of caring for this condition, applicable to many professional groups, rather than specific treatments.

Typical interventions for the management of low back pain include:

Patient education which covers advice and explanations from professionals, written material and education sessions.

Non-invasive physical therapies such as transcutaneous electrical nerve stimulation, traction, spinal corsets, interferential, laser and ultrasound.

Land or water based exercise programmes, again either individually or as part of an exercise group.

Manual techniques such as mobilisations, massage and manipulation.

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 Physiotherapists, physiotherapy, Physiotherapists in Exeter, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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