LOW BACK PAIN

The GPs Problem

•The GPs Problems

• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
 Lots of patients
• Back pain reported by 60% people at some time in
their life
• 1993 - 14 million GP consultations
• 1993 - Cost to NHS app £480 million
• 1993 - Lost production costs app £3.8 billion
• 1993 - DSS benefits app £1.4 billion
 Prevention

 Change the environment - ergonomics

 Change the individual - morphology

 Change attitudes - education

 Improved management

Improved management of Acute LBP

 less time out of action/off work
 fewer patients with chronic or recurrent LBP

Improved management of Chronic LBP

 less long term disability
•The GPs Problems

• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
 Diagnosis is difficult (1)

Anatomical complexity - vertebrae/discs/ligaments/

muscles/SI joints
“The mobile segment” - discs
- facet joints
- muscles and ligaments
at each level = indissoluble mechanical entity
 Diagnosis is difficult (2)
• Nociceptors in all tissues except disc + synovial
membrane
• Stimulation of any of these may cause muscle
spasm which may or may not be painful
• Referred pain - 2 or more sources may refer to the
same site
• Tenderness - may be produced by local
sensitisation nociceptors but may exist in normal
tissue eg at site of referred pain
Diagnosis is difficult (3)

• Social factors
• Psychological factors
•The GPs Problems

• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
Acute LBP - changing guidelines
• Go to bed
• US Agency for Health Care Policy and
Research (AHCPR) 1994
• UK Clinical Standards Advisory Group
(CSAG) 1994
• RCGP 1996
 Acute low back pain - Triage

Aims to differentiate between :-

Simple backache (non specific LBP)
Nerve root pain
Possible serious spinal pathology
 Simple backache

• Age 20 - 55 years
• Lumbosacral, buttocks, thighs
• “Mechanical” pain
• Patient well
 Nerve root pain

• Unilateral leg pain worse than low back pain

• Radiation to foot or toes
• Numbness and parasthesia in same distribution
• SLR reproduces pain
• Localised neurological signs (eg loss ankle jerk)
Red flags for possible serious pathology

 age <20 or >55

 Non mechanical pain
 Thoracic pain
 PMH carcinoma, steroids, HIV
 Generally unwell, weight loss
 Widespread neurology
 Structural deformity
 Cauda Equina Syndrome

 Sphincter disturbance
 Gait disturbance
 Saddle anaesthesia
 Assessment

• Triage based on history and examination

• In simple backache XR not routinely
indicated
• Psychosocial factors are important
•The GPs Problems

• Lots of patients
• Precise diagnosis is difficult
• Changing guidelines
- triage
- what helps and what doesn’t?
• Can we help those with chronic pain?
 Rest or Activity
• 9 RCTs show bed rest for 2-7 days is worse
than ordinary activity
• 8 RCTs show advice to continue ordinary
activity gives better results than the
traditional “let pain be your guide” advice
• Aim is to use symptomatic measures to
control pain and so allow activity
 Drugs
• Prescribe regularly not prn
• start with paracetamol
• NSAIDs (differing side effect rates)
• NSAIDs less effective for nerve root pain
• paracetamol and weak opioid combination
• Muscle relaxants (diazepam) are effective
 Manipulation

“Within 6 weeks of onset of acute or recurrent low

back pain, manipulation provides better short term
improvement in pain and activity levels and higher
patient satisfaction than the treatments to which it
has been compared”
 Back exercises

• “on the evidence available at present, it is doubtful

that specific back exercises produce clinically
significant improvement in acute LBP” but
• “McKenzie exercises may produce short term
symptomatic improvement in acute LBP”
• “Strong theoretical arguments for commencing
exercise programs by 6 weeks”
 Other treatments

• Ice and heat • Trigger point

• Massage injections
• Ultrasound • Facet joint injections
• TENS • Corsets
• Shoe inserts • Epidurals
• Acupuncture
 Evidence against

• Bed rest with traction

• MUA
• Plaster jackets
• Benzodiazepines >2wks
•The GPs Problems
• Lots of patients

• Changing guidelines
- triage
- what helps and what doesn’t?

• Can we help those with chronic pain?

 Risk factors for chronicity
• Previous history low back pain
• Nerve root involvement
• Poor physical fitness
• Self rated health poor
• Heavy smoking
• Psychological distress and depressive symptoms
• Disproportionate illness behaviour
• Low job satisfaction
• Personal problems eg marital, financial
• Ongoing medicolegal proceedings
 Aspects of treating chronic pain
 Psychological
 Physical
 Pharmacological
 Procedural
 Rehabilitation