There are many studies describing the way treatment providers fail to follow clinical guidelines for managing acute low back pain – and because there are inconsistencies between various guidelines for chronic low back pain, it’s not surprising that people with back pain (whether acute or chronic) get a little confused about what to do. Of course, if you use a popular search engine or two you’ll be able to find loads of sites on the internet that put forward their ideas of how to manage, and the quality of these sites is pretty variable. So when a group of Australians carried out an online survey asking what people did when they had back pain, you can guess there was a pretty wide range of strategies used.
In February 2009, 1001 participants who met the inclusion criteria for this study (>18 y and having experience back pain in the previous 6 months) were asked 29 questions about their experience: specifically, they were asked 5 screening questions, 8 demographic questions, and 16 questions about their back pain and its management. Participants were recruited from a national Australian online consumer panel comprised of 70,000 individuals. About 5640 people were randomly selected from the larger pool and invited to be part of this survey – and from this group, 1220 people agreed to participate. After screening, 1001 people were left, and 570 of these reported only having lower back pain.
It’s interesting to note, just as an aside, that over 30% of the 1001 people reported having both upper back pain and lower back pain, and only 10% reported having upper back pain only. We can be under no illusions that low back pain is rare! And we can’t imagine, either, that back pain is only ‘mild’ – the average pain intensity (n=570) on 0 – 10 point scale was 5.17±2.03 and these people reported being in pain for 13.6±11.1 days in the last month. It’s also interesting to find that there is a relationship (strong and positive) between pain intensity and the mean number of days people had experienced their pain, and there was a difference in both intensity and duration between those who were describing their first ever bout of back pain, (8.66 days and mean pain score of 4.77) and those who had a recurrent back problem (14.34 days and mean pain score of 5.23). And only a teeny tiny number of people (77) said this was their first bout – that’s a whole lot of people with a whole lot of pain IMHO.
So, let’s take a look at what they did about their pain.
- Ask for health care – 58% reported that they looked for health care, and the most commonly asked professional was the GP. There was quite a difference between the first timers and the ‘old hands’ in the proportion asking for help – nearly 30% of people with back pain for the first time went to their GP, while over 40% of those with recurrent back pain went back to their GP. Curious – it would have been really interesting to see whether this proportion changed over time for those with recurrent back pain – one would hope that after having back pain once or twice people would be asking ‘how can I look after this myself without having to seek treatment?’ but I wonder whether this does happen.
- Receive advice on exercise – well that’s a relief! Something is getting through to health care providers at least. Roughly half, or slightly more, of the GP’s and ‘other health care providers’ gave this advice, but it is also really interesting to see that although GP’s initially recommend exercise to 60% people with their first episode of back pain, for people with recurrent back pain, this drops to 40%. Yet it’s highly likely that as the back pain recurs, exercise is going to be far more useful than most other treatment modalities. And I say this while not being a total fan of ‘exercise’ (though I hasten to add I love walking the dog and bellydancing!) Note I said ‘receive advice’ – what is really interesting is how few people getting this advice actually followed through with it.
- Discuss or recommend pain relief – around 30% of people, whether first timers or old hands, were prescribed or at least discussed pain relief. Again, there is a bit of difference between those with recurrent back pain and those with new back pain in terms of what the GP’s recommend – more of those with recurrent back pain were offered pain relief by their GP. I’m not sure why, but it is definitely interesting and worth thinking about.
- Remember I said that people were offered the advice to exercise? How many actually did this? Only 19 (24.7%) people with first-time back pain and 87 (17.8%) people with recurrent pain said that their first response was to do additional stretching or exercise. I guess the ‘don’t take your back pain lying down’ hasn’t really reached the people who need to do it the most.
- Keeping active doesn’t only mean doing exercise, it also means maintaining daily activity. How many did this? “Among those with first-time back pain, 39.0% maintained their usual level of daily activity, whereas 32.5% were less active than normal. Among those with recurrent back pain, 31.8% maintained usual activities and 34.7% were less active than usual.” Once again, people with recurrent back pain described less positive responses to their pain than those with the first onset. The guidelines all recommend maintaining or returning to normal activity as far as possible, so it’s a real challenge to find that as people’s experience with back pain goes on over time, they are more likely to restrict their activities. But before you tell me off, remember that there was an association between pain intensity and pain duration, so it could be an artifact of this, we’re not told.
- Bed rest was not common, with the majority of those reporting that if they did take bed rest it was for less than 1 day. Oh joy!! That’s something I am really glad to hear!
What can we take away from this?
It seems to me that despite all the work that has gone into helping health professionals understand the relatively benign nature of back pain, it’s GP’s who may find it more difficult to continue to recommend maintaining activity and exercise to people who have recurrences of their pain. GP’s are still the gatekeeper and ‘authority’ on what to do with a health problem especially when it becomes more bothersome or recurs. So what a GP says and does has major impact.
We can also learn that giving advice to someone to ‘go away and exercise’ may well fall on deaf ears. Information or advice alone doesn’t seem to cut it when people are feeling sore and uncomfortable. Actually, that holds true even when people are not sore and uncomfortable – telling people doesn’t take in account their readiness to step out of their comfort zone and do something unfamiliar. We need to learn how to help people feel that exercising is important for their health and especially for their recovery from back pain, and that they can feel confident about what to do and how to do it. I happen to think it’s the latter (confidence) that is most likely to prevent someone from starting to do exercise when they’re sore. While this study didn’t look at anxiety about low back pain, there are enough studies that suggest if someone is anxious about moving because it ‘might’ either increase their pain, or they worry it might ‘harm’ them (do more damage), they’re very unlikely to ‘just do it’ on the advice of someone who is not in their shoes. We need to do more to help people feel OK about doing activities while they’re sore AND we need to learn how to help them become committed to doing it.
The final bit that really, really bothers me is this: although I accept that in this study people with longer bouts of back pain also reported higher pain intensity, I‘d have hoped that people who had recovered once would have had some input from someone (GP, physiotherapist, chiropracter, even occupational therapist or psychologist or practice nurse) to help them know what to do when/if they have it again. (Sorry about the length of that sentence!)
Perhaps that’s something that we really need to start getting out there in the community – moving is not only good for short term pain, it’s also good if that pain comes around again. A ‘setback’ plan or ‘flare-up’ plan that lists in a step-by-step way what the person can do to get through an episode of pain. What do you think?
Wilk V, Palmer HD, Stosic RG, & McLachlan AJ (2010). Evidence and practice in the self-management of low back pain: findings from an Australian internet-based survey. The Clinical journal of pain, 26 (6), 533-40 PMID: 20551729