The Management of Low Back Pain
Dr J C D Wells, Liverpool, UK
Back pain is very common. About 80% of people report back pain at some time in their life. In various studies, between 15% and 30% of people report some back pain or trouble on the day of interview and up to 40% report having had back pain in the last month. On the other hand, true nerve root pain or sciatica affects only 3% to 5% of people at some time in their life.
Estimates in the past of the rate of recovery were probably over-optimistic. Fifty per cent of attacks settle more or less completely within four weeks, but 15% to 20% of patients continue to have symptoms for at least a year. Seventy per cent of people who ever experience an attack will suffer three or more recurrences, although these may diminish over time. Twenty per cent of people with back pain (i.e. 5% to 10% of the population) will continue to have some degree of back pain symptoms over long periods of their life. Four per cent of the population up to the age of 44, and 5 to 7% of those older, will report back problems as a chronic sickness.
In the United Kingdom, disability is increasing greatly, as can be seen from time off work. Looking at this trend over the last decade, the whole working population of the UK will be off sick by the year 2017! Thus, in spite of all our knowledge, inspite of our health service and in spite of research and evidence-based medicine, we seem to be getting things terribly wrong in low back pain.
New studies in the USA and the UK have delineated best practice in the management of back pain, and yet there is often resistance to accepting the advice given. A plethora of treatments exists, and it is of historical note that Where many remedies exist, one can be sure that there is no cure. Diagnostic triage needs to be carried out early in acute back pain, and serious and remediable pathology needs to be excluded or treated. Treatment of the remainder of patients revolves around relief of pain and early mobilisation. This patient needs to be reassured about the aetiology and not turned into a chronic sufferer by bad advice. The good outcome needs to be stressed. The patient needs to be encouraged to take personal responsibility for the continued management and prevention of further exacerbations and chronicity. It can be explained that the outcome depends more on their behaviour than on medical treatments.
Standard management of back pain is rest and analgesic medication. This may go as far as bringing a patient in for traction for 2 weeks, although happily this practice is now dying out. There is evidence to suggest that this is counter-productive. There is no evidence to support the use of rest for simple backache for more than 3 days, and the ill-effects of prolonged rest are well recognised. Active rehabilitation should be distinguished from specific back exercises. Exercises are often recommended, but the
patient is told to stop if pain is provoked. An active rehabilitation programme (ARP) uses exercises, but the main emphasis needs to be on restoring full function and regaining physical fitness, based on goal-setting and a gradual increase in targets, rather than on taking accord of the pain. This difference can be compared with prescribing quadriceps exercises for an elderly patient after a fractured femur, or actually teaching them to walk again.
Speaking immediately after Hubert Rosomoff, one knows that the pain management and behavioural techniques will have been well covered. What evidence is there to suggest that other techniques are of value?
Simple anti-inflammatories are of course appropriate if effective, and if side-effects can be minimised. Some patients with chronic low back pain have experienced side-effects with non-steroidals, which can limit their compliance. Over 47 per cent of patients in a recent survey were unable to take non-steroidals. The new COX2 inhibitors therefore represent a step forward in the management of both acute and chronic low back pain.
Sadly the majority of patients in Europe are proffered codeine-based drugs in combination with paracetamol. This is an illogical combination and as codeine is a pro-drug for morphine, firstly some patients can get no pain relief because there is no metabolism of the codeine and secondly others, in the long term, are exposed to potential opioid side-effects, often without getting the full opioid analgesic effect.
Tramadol may be an effective drug in some patients, although a significant number cannot take it due to side-effects. As with opioid drugs, and secondary analgesics, start low, go slow is the maxim.
It is now accepted that opioids themselves can be used in patients with chronic nociceptive non-malignant pain. Several studies have shown efficacy and a great deal of attention was devoted to opioid pain management at this conference yesterday. Careful selection of patients is imperative and strict follow-up to ensure compliance, increase in activity and a reduction in pain and distress.
Obviously, we were talking about low back pain but if there is any evidence of neuropathic pain, tricyclic antidepressants or anticonvulsants may play a useful part in drug management.
2) Stimulation techniques
These include TENS, acupuncture and even dorsal column stimulation for the chronic pain sufferer. There is a great deal of controversy about the efficacy of both TENS and acupuncture. Whilst both treatments are relatively safe, scientific evidence as to their efficacy remains somewhat weak. There is, however, scientific and anecdotal evidence that they do help some patients, but as yet we have not determined which groups of patients are likely to derive benefit and which are not.
Further scientific work has to be done in order to justify their continued use, and appropriate patient groups should be chosen. Whilst it is not always possible to show that the outcome is better when TENS is used in acute pain, it does seem to provide a good measure of pain relief with low morbidity and low cost in this group, and certainly seems much more appropriate than in-patient care with traction and corsets! Dorsal column stimulation is expensive, but can be useful for chronic back pain sufferers, especially with referred sciatic pain.
3) Alternative Techniques
I thought I would mention these just briefly, especially as Sigrun Chrubasik is speaking in another theatre on devils claw and willow for low back pain, and reports willow is an historical form of aspirin. Sometimes alternatives become mainstream!
Of the many alternative techniques that have been claimed to be effective, massage appears to be the most useful. There is probably a significant relaxation effect from this combined with aromatherapy, or from reflexology and so on. There is undoubtedly a large placebo element, or a response from the therapeutic process. Again, this type of treatment can be deemed relatively harmless; certainly a great number of patients with chronic pain have muscle spasm. If the spasm is reduced by whatever method, the pain is reduced also. These types of treatment need to be considered in relation to other interventions, to look at efficacy and cost benefit.
4) Nerve Blocks
These can be useful if the patient has a specific condition. For instance, facet joint injection can be used for an acute facet joint pain, if this does not settle rapidly with simpler techniques and time. If the patient has an history of acute exacerbations which do not settle with time, then radiofrequency intervention can be considered.
Epidural injections of local anaesthetic and steroid have been shown to be of some efficacy in patients with simple back pain, but the number needed to treat to find an improvement is 9. They are more effective in patients with a referred pain, or nerve root pain. They are also more effective if done under X-ray control. There is controversy about the use of steroids in the epidural space.
Permanent nerve blocks should only be considered in chronic sufferers, and then only in carefully selected patients. Muscle spasm is an important feature in all patients, and as yet we are uncertain as to how best to treat this. Recently, the use of Botulinum toxin to reduce muscle spasm is attracting scrutiny and trial work is ongoing into its usage.
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