The Schneider Back Pain Clinic Retreat - Braidwood NSW

     Treat your back while you treat yourself...
               back care combined with a luxury holiday break.

CHRONIC LOW BACK PAIN - RECENT TRENDS IN TREATMENT

Low back pain is a major health problem in Society and a major use of medical expenses26. 70 to 85% of the population will experience low back pain at some time in their lives2. Over 70% of patients with acute low back recover quite rapidly simply by following management guidelines which include explanation and reassurance18. The remaining 30% are at risk of having pain persisting for longer than three months and developing chronic low back pain and disability5.

Seven damaging myths about back pain were published by Richard Deyo10. The myths include:

• If you have a slipped disc, you must have surgery.
• X-rays and newer imaging tests can always identify the cause of your pain.
• If your back hurts , you should take it easy until the pain goes away.
• Most back pain is caused by injuries or heavy lifting.
• Back pain is usually disabling.
• Bed rest is the mainstay of therapy.

Research evidence has discounted these beliefs and attitudes. With respect to surgery the outcomes are modest. Surgery can help some patients to various degrees but nearly half will not benefit12, and surgery is not curative in all cases7. An initial drop in mean pain scores is not always maintained33. Furthermore, the disc is often not the source of symptoms, with the zygapophyseal joints21 or sacroiliac joints17 being alternative pain generators. A recent trail has shown that patients with long term chronic back pain and disc degeneration experienced similar levels of improvement with exercise and cognitive therapy as those who underwent spinal fusion7. Low back pain is usually a self limiting and benign disease31 and successful alternative treatments are producing beneficial outcomes.

The causes for chronic low back pain cannot be found using conventional investigations such as X-rays or imaging, with fewer than 10% of cases diagnosed by these means6. A diagnosis becomes possible if diagnostic blocks and discography are used but these investigations are not indicated for every patient with chronic low back pain. One justification for pursuing a diagnosis is the beneficial psychological effect when patients wish to have an explanation for their pain, and are protected from accusations such as imagining their symptoms5.

Studies in the eighties found that lifting, frequent bending, physically heavy work and static work postures were associated with low back pain19. Lifting or bending episodes accounted for 1/3 of all work related causes of back pain9. The search for a safe lifting technique has attracted considerable research attention because of the high risk of injury, but the findings on safer lifting techniques remains controversial. A recent study compared the knee bent and straight back lift with the stoop lift with knees straight and back bent3. Accounting for both internal spinal loads and active passive muscle forces, the results advocated the freestyle posture, or the posture with moderate flexion as the posture of choice during static lifting tasks. The number of times the back is loaded was emphasised in another study as an important factor in developing back disorders20. The study found that the number of repetitions of static load on the lumbar spine is a risk factor in the development of trauma. Excessive repetitions significantly increase the severity of the low back disorder. The authors stated that controlling the number of repetitions and allowing appropriate rest duration between loading might be helpful in preventing the occurrence of chronic low back disorders. Notwithstanding, the past decade has seen a dramatic shift in the understanding of the origin of disc degeneration in the lumbar spine. Heavy physical loading has remained the main suspected risk factor for disc degeneration but more recent research has suggested that sciatica, disc herniation and disc degeneration may be explained to a large degree by genetic factors1. Recent research indicates that heredity has a dominant role in disc degeneration, explaining 74% of the variance in adult populations4. The study emphasised that nearly all signs associated with disc degeneration, such as disc narrowing, osteophytes, bulging and end plate irregularities are common in adults but heredity has a dominant role in explaining the variability in disc degeneration, and several gene forms have been identified associated with disc degeneration.

The myths of back pain being disabling, and taking it easy and bed rest as therapy, are being challenged by two campaigns to deliver simple messages about the management of back pain. The health initiative "Working Backs Scotland" followed an Australian campaign entitled "Back pain - Don't Take It Lying Down" 23,32,8 . These campaigns stress that back pain is not a serious medical condition: it typically does not require elaborate evaluation and treatment; Back pain sufferers should be encouraged to stay active and stay at work. In the traditional injury model back pain was regarded as an injury that needed to be rested. Patients were often advised to restrict normal activity and cease work until their injury healed23. Britain's Health and Safety Commission contend that chronic low back pain problems are compounded by inappropriate pain beliefs, fear avoidance behaviour and inactivity levels, and that the inappropriate beliefs must be tackled. The Scottish website emphasises "it is important to stay active and continue as normally as possible". Norwegian Physician Aage Indahl encourages his patients to forget the cautious approach to low back pain, to stop worrying about hurting their backs, and were advised that returning to normal activity would not harm their spines in any way. They were encouraged to use their backs freely - bending them, loading them and moving naturally7. Reducing fear and promoting activity had beneficial effects on middle aged patients with chronic or recurring low back pain who were reporting moderate to severe interference with normal activities due to their pain. The benefits of activity resumption were reflected in a reduction in disability and pain scores. It was emphasised that flare-ups were common but manageable30.

Many varied therapeutic interventions are available for the treatment of low back pain and offer a cure for this problem22,27. However, the effectiveness associated with most of these interventions has not yet been demonstrated beyond doubt and, consequently, the therapeutic management of low back pain varies widely26. van Tulder reviewed 16 trials on chronic low back pain and concluded that strong evidence exists that exercise therapy is effective for chronic low back pain. There is growing opinion that the conflicting results among exercise trials may be due to every low back pain patient being given the same exercises, instead of specific exercises being matched against an individuals assessment findings and clinical signs. For example success has been reported by prescribing exercises tailored to a patient's "directional preference" which is identified when certain postures or movements decrease pain16. Further to specific exercise prescription there is strong evidence that strengthening exercises are not more effective than other types of exercises26. A recent randomised controlled trial tested a postural and exercise program on patients with back and leg pain which employed principles derived from Yoga and Pilates to attempt to lower intradiscal pressures and thereby relieve sciatica25. Three-quarters of group reported greater than 50% pain reduction. Other programs with postural components are also under investigation with two trials finding that the Alexander technique was effective in reducing disability in patients with back pain11.

Another approach to the management of chronic low back pain is multidisciplinary therapy which comprises various combinations of exercises, education and behavioural therapy. A distinguishing characteristic of all programs is that they address physical disabilities and patients beliefs about their pain and resulting behaviour. Pain relief is not an overt objective. Nor are a diagnosis and specific anatomical treatment pursued5. Bogduk emphasises that multidisciplinary therapy cannot be regarded as curative. For some patients, it offers the possibility of better pain control and improved function, but overall it amounts only to palliative therapy6.

Patient expectations of treatment for back pain were studied by Jos Verbeek et al28 who concluded "patients have explicit expectations on diagnosis, instructions, and interpersonal management. New strategies need to be developed in order to meet patient's expectations better. Practice guidelines should pay more attention to the best way of discussing the causes and diagnosis with the patient and should involve them in the decision making progress" 28. Patients satisfaction in their contacts with health care providers was considered a relevant outcome measure. Satisfaction with health care has been defined as a positive feeling of the patient toward an aspect of the process or outcome of health care. The strongest dimension of satisfaction is usually to be treated with respect or in an humane way by the provider of care15. There is a close link between patient expectations and satisfaction. Patients may be dissatisfied because the treatment did not meet their expectations29, 24. Patient expectations may include a diagnostic explanation, pain relief, and instructions on how to deal with their pain and disability. They expect the physicians to be good listeners and effective and confident communicators. With respect to provider patient interactions a new trial has found that advice from a physiotherapist to patients with mild and moderate pain and disability was just as effective as physical therapy13. A new study investigating cost savings both for the patient and for society found that for the majority of patients with non specific low back pain, information, advice, and personal communication served adequately as the treatment of choice19. The studied showed that the combined treatments of manipulation, exercise and consultation was only slight more effective for reducing pain, but leading clearly to increased patient satisfaction as compared to the physician consultation alone.

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