acute low back pain

What to do about acute low back pain


I should add another line to that heading: in one easy step! And I’d be inundated with hits and if I could cash in on them I’d be rich! And wrong.

If there was a simple recipe for success, I’d expect that by now we’d have it. The very fact that SO MANY options for managing a bout of low back pain exist is a good reason for skepticism should you ever get tempted to take a headline like mine as a cause for celebration. However I do want to talk about acute low back pain because I think clinicians are often probably doing it wrong.

First of all, low back pain doesn’t include pain that also goes down the leg. Let’s get the definitions clear before we talk! In 2008 a Delphi study by Dione, Dunn, Croft, Nachemson, Buchbinder, Walker and colleagues (2008) developed two definitions: a minimal definition, and an optimal definition. These definitions were developed for epidemiological studies and the minimal definition is very simple – “In the past 4 weeks, have you had pain in your low back?” and “If yes, was this pain bad enough to limit your usual activities of change your daily routine for more than one day?”

from Dionne, Dunn, Croft, Nachemson, Buchbinder, Walker et al, (2008)

Now when it comes to defining a first bout of acute low back pain, Ardakani, Leboeuf-Yde & Walker (2019) raise some very interesting points: researchers investigating acute low back pain don’t clearly distinguish between the factors associated with the disease of low back pain (as they put it, the onset of the very first episode) from its recurring episodes – as they put it, “the continued manifestations of the “disease”.” In fact, in their systematic review for identifying risk factors from “triggers” (their term for subsequent episodes), they could find only one study dealing with the true incidence of first time low back pain – and this was low back pain caused by sports injury. All the remaining studies either explored new episodes, or recurring episodes. The major problem with these studies? They didn’t define how long a person should have had no low back pain at baseline. And given many of us develop back pain in adolescence (see Franz, Wedderkopp, Jespersen, Texen and Leboeuf-Yde, 2014, or Jones & MacFarlane, 2005) for example) it’s probable that studies investigating those over 18 years old will include a lot of people who have had that first bout already.

The trajectories for those of us who do develop low back pain are also reasonably murky because of the challenges around definitions, and there are several studies with slightly different results as you’d expect. Essentially, though, most researchers find that there are three or four patterns that emerge from longitudinal studies: lucky ones who have one bout and no or low levels of pain thereafter; those who have persisting mild pain, those who have fluctuating bouts over time, and those who develop persistent and severe pain. Chen and colleagues (2018) found that “lower social class”, higher pain intensity at the beginning, the person’s perceptions of more challenging consequences and longer pain duration, and greater “passive” behavioural coping were most significantly associated with the more severe trajectory over five years.

So, what does this mean for clinicians – and how well are we doing?

Acute low back pain can really frightening for people, especially if the pain is severe. As clinicians generally choose this work because we care about people, we get hooked into wanting to reduce pain and help. There’s nothing wrong about this – unless it means we also get hooked into trying to offer something we cannot. We’re inclined to believe that people seek help for their back pain because of the pain – but as Mannion, Wieser & Elfering (2013) found from a study of over 1,000 people with back pain at the time of the survey, 72% hadn’t sought care over the previous four weeks; 28% had sought care – and most from more than one provider. Women were more likely to seek care, those who had experienced more previous bouts, those who had trouble with activities of daily living and more trouble with work activities. While pain intensity did feature, it wasn’t as much of a predictor as many clinicians would expect. Indeed, an earlier meta-analysis by Ferreira and colleagues (2010) found that disability was a stronger predictor for seeking treatment than pain intensity.

So what do clinicians focus on? I suspect, though I aim to be proven incorrect, that almost every clinician will ask “what is your pain intensity on a scale from 0 – 10?” Frankly, this question is one that irritates me no end because how on earth do you rate pain? Seriously. Yes, there are a lot of clinicians who then ask about activities a person wants to be able to do (yay!) though when we look at the treatments offered, I wonder how many follow through with practical goal-setting for daily activities like getting shoes and socks on, carrying the groceries, sitting while driving the car or at work… And treatments? the arguments on social media between clinicians would be fun to watch if only they weren’t accompanied by such vehemence!

What I don’t see are conversations about how we help people recognise that they’re likely to follow one of those four trajectories, and what we do to help people self manage a life alongside low back pain.

I don’t see much attention paid to helping people sleep well.

Lots of conversations about pain neurobiology – in an attempt to use this explanation to bring someone on board to engage in treatments.

I don’t see a lot of discussion about how to ask about the person’s main concern – perhaps it’s nothing to do with pain, but more about “my niece is coming to visit and I’m not sure I can cope with entertaining her and managing my back pain”, or “we’re coming up to the busy time at work and I can’t not go in, but when I get home I’m trashed, how can I manage that?”, or “Monday’s are our busiest day, and I have to keep going because the team needs me, what do I do?”

I wonder whether clinicians could be persuaded to get out of the way and stop confusing people with recipes or algorithms or “special exercises” that “must be done this way” – I wonder if we could offer some very simple steps: specific answers to the person’s main concerns (best form of reassurance there is!); goal setting around the things the person needs and wants to do over the first six to eight weeks; sleep strategies including some mindfulness because that’s likely to help long-term; and lots of encouragement as the person returns to activity. Developing a relationship with the person doesn’t need lots of prescriptive steps or cookie cutter programmes, it does mean listening, showing trust in the person’s own capabilities, and willingness to let go of a few sticky thoughts we’ve acquired during our training. Maybe 2021 could be the year clinicians get back to basics and begin to support resilience in the people we see – firstly by showing them that we trust they have the capabilities.

Ardakani, E. M., Leboeuf-Yde, C., & Walker, B. F. (2019). Can We Trust the Literature on Risk Factors and Triggers for Low Back Pain? A Systematic Review of a Sample of Contemporary Literature. Pain Res Manag, 2019, 6959631. doi: 10.1155/2019/6959631

Dionne, C. E., Dunn, K. M., Croft, P. R., Nachemson, A. L., Buchbinder, R., Walker, B. F., . . . Von Korff, M. (2008). A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine, 33(1), 95-103.

Franz, C., Wedderkopp, N., Jespersen, E., Rexen, C. T., & Leboeuf-Yde, C. (2014). Back pain in children surveyed with weekly text messages-a 2.5 year prospective school cohort study. Chiropractic & Manual Therapies, 22(1), 35.

Jones, G. T., & MacFarlane, G. J. (2005). Epidemiology of low back pain in children and adolescents. Archives of disease in childhood, 90(3), 312-316.

Mannion, A. F., Wieser, S., & Elfering, A. (2013). Association between beliefs and care-seeking behavior for low back pain. Spine, 38(12), 1016–1025

Work conditioning, work hardening and functional restoration for workers with back and neck pain


In New Zealand most people who have been off work with chronic pain, and receive compensation from ACC, will have been a participant in some sort of fitness programme.  It’s almost a rite of passage for people to have a programme of functional restoration before or during an attempted return to work once the person has been off work for around 3 – 6 months.

There are a lot of different types of programme available:

  • two of the Prof Mick Sullivan’Goal attainment’ programmes for sub-acute pain,
  • Functional restoration programme – for sub-acute pain, involving activity with some ‘education’
  • Pain management psychological services – for psychological strategies for pain management
  • Activity focus programme – for chronic pain, involving activity and cognitive behavioural therapy approach for self management
  • Multidisciplinary programme – a three-week intensive interdisciplinary programme with a cognitive behavioural approach, including reactivation

(more…)

Managing low back pain: knowledge and attitudes of hospital managers


Now this is a really useful, although unsurprising, study of hospital line manager’s knowledge of the management of low back pain. Sad to say, Caitriona Cunningham, Catherine Doody, and Catherine Blake of UCD School of Physiotherapy and Performance Science, Dublin, Ireland, found that 54% (N=32) of the managers who responded to their survey believed that “a staff member needs to be pain free prior to return to work (RTW)”. The managers were employed in Irish University Hospital, and reflect the views of 64% of the managers approached.

Unsurprising? Yes, because this news is old news – to people researching acute low back pain. But somehow the message just hasn’t got through – especially sad in a hospital setting. In addition, managers reported “difficulties in dealing with colleagues of workers with LBP and in knowing the work capacity of the worker with LBP. Managers demonstrated poor awareness of the importance of the manager–worker relationship in influencing RTW.”

Hospitals should be one of first places to actively and appropriately managing acute low back pain. Why? Well, the nature of the work itself, which is high stress, high demand, with low control and high responsibility suggests that people working in hospitals may find it difficult to return to work (ACC, 2002), and the long duration of work disability among nurses (Tate, Yassi & Cooper, 1999).

Despite this, the literature is replete with studies of biomechanical demands in nursing (e.g.Morlock et al., 2000; Skotte, 2001; Videman, Ojajarvi, Riihimaki, & Troup, 2005) – and patient handling guidelines barely mention psychosocial factors or strategies for reducing work disability amongst nursing staff.

This study by Cunningham, Doody & Blake also found that “managers believed more information, easier access to health services, more ergonomic training and better staff resources were necessary supports in facilitating the management of workers with LBP”. Surely, if these things were effective, placed like the UK, Australia and New Zealand, who have thrown vast amounts of money at providing patient handling equipment, training and so on, would have by now demonstrated some reduction in time lost from low back pain.

At least in two hospitals that I have worked in, patient handling strategies seem to have increased the reporting of low back pain, while approaches to reduce disability have remained firmly focused on returning individuals to ‘suitably selected work’. Now this isn’t a bad thing, suitable work and early, managed return to work is a great component of effective rehabilitation from acute low back pain.

BUT, and it’s a big but, it also requires support from line managers. And at least from this study, it seems they haven’t got that particular message – and are not yet even aware of the need to ask for support to learn how. Instead, they seem to have problems managing individuals who are experiencing ongoing disability, and are unaware of the influence of at-work interpersonal and psychosocial factors.

The methodology and generalisability of this study is relatively weak – but for a moment, if you’re working in a hospital, think of the line managers in your workplace. What exposure do they have to recent research in low back pain and return to work? And how good is the research into workplace rehabilitation? So, although this study is telling us perhaps what we already know, it is incredibly relevant – we just need to take it to the next step and answer questions like ‘how can managers learn more?’, ‘what do they need to do?’, ‘what happens when rehabilitation takes longer than expected?’, ‘how can hospitals provide suitable support while under budget squeeze?’.

It’s nice to see a simple study like this carried out in the ‘real world’ – because this is where you and I live. no-pain.jpg

Do managers feel our pain?

doi:10.1093/occmed/kqn015

Managing low back pain: knowledge and attitudes of hospital managers
     Caitriona Cunningham, Catherine Doody, and Catherine Blake
     Occup Med (Lond) published 15 March 2008

Morlock, M. M., Bonin, V., Deuretzbacher, G., Muller, G., Honl, M., & Schneider, E. (2000). Determination of the in vivo loading of the lumbar spine with a new approach directly at the workplace–first results for nurses. Clinical Biomechanics, 15(8), 549-558.

Skotte, J. H. (2001). Estimation of low back loading on nurses during patient handling tasks: the importance of bedside reaction force measurement. Journal of Biomechanics, 34(2), 273-276.

Tate, R B., Yassi, A; Cooper, J. (1999), Predictors of Time Loss After Back Injury in Nurses, Spine, Volume 24(18), p 1930

Videman, T., Ojajarvi, A., Riihimaki, H., & Troup, J. D. G. (2005). Low back pain among nurses: a follow-up beginning at entry to the nursing school. Spine, 30(20), 2334-2341.

ResearchBlogging.org
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Stabilisation exercises for low back pain: a systematic review


I was recently in a forum for dancers where I suggested that there were no specific exercises that were particularly helpful for low back pain – horrors! Someone said ‘You mean the doctor might as well have said to go home and pick your nose as do even Pilates’, to which I sighed…not exactly what I meant.

So I was really pleased to see this systematic review of stabilization exercises for low back pain by Stephen May and Ros Johnson.

Pilates

I think I mentioned a few posts ago that I’ve seen fads come and fads go, and one of the most recent ones is ‘core stability’, along with using a swiss ball, and doing loads of abdominal exercises. This review summarises 18 trials that met the selection criteria:

  • randomized clinical trials,
  • in English,
  • full publications,
  • adults with low back pain,
  • one group with specific stabilization exercises as the primary intervention, and
  • outcome measures included pain/function.

Studies were scored using PEDro, and because of heterogeneity of interventions, control groups, follow-up duration, outcome measures and study population, meta-analysis was not carried out. A large number of possible studies were excluded because they did not meet the PEDro criteria.

 

And the results? Overall, there was little evidence to support the use of stabilization exercises for acute low back pain, some evidence for their use in chronic low back pain, but mainly when the control condition was no treatment rather than any other active treatment.

What this means is that with the evidence in its current state, it’s not possible to recommend using stabilization exercises over any other form of active intervention such as maintaining activity levels, general strengthening, manual therapy and ‘general exercise’.

This is particularly the case for acute low back pain, with some suggestion that in some cases (possibly identified through clinical examination of ‘instability’) chronic low back pain may respond to stabilization. The problem is that clinical assessment of ‘instability’ is subject to poor interrater reliability, apart from the prone instability test, and the authors of this paper state ‘there are no completely valid and reliable methods for detecting at baseline those who might respond to stabilization exercises’.

I keep hearing from physiotherapists, occupational therapists, oh and even medical practitioners ‘if we were only to use evidence-based treatments, we wouldn’t be able to use anything’. It is a problem – except, if we take the example of acute low back pain, we know that the majority of people recover all by themselves in around 6 weeks to 3 months.

We also know that the majority of people having trouble recovering are those with psychosocial yellow flags – particularly fear of moving. My thoughts are that

  • if we can provide effective support to help people to move again despite pain,
  • reduce the talk of ‘instability’ or ‘pathology’ in order to demedicalise this very common but incredibly painful condition, and
  • teach all health care providers just what ‘reassurance’ consists of,

we might reduce the amount of unnecessary suffering and long-term disability that I see when working in chronic pain management.

The problem is, there is very little training for health care providers in this thing called ‘reassurance’, and while the theory of ‘supporting people to move again’ seems simple, it is actually quite hard to do because it means thinking psychologically. For physiotherapists and indeed anyone who likes ‘hands-on’ therapy, it’s incredibly difficult to sit firmly on those hands and watch as someone starts moving on their own.

Where do we need more research?

Yes, loads more research on treatments that follow quality guidelines as outlined in this article – double blind, randomized, good control groups, clear specification of the treatment components so that replication can occur, long term follow up (oh yeah, that means funding…), and publication of negative results…

 

But we also need to know more about the things that people with acute conditions find reassuring (or not). What something thinks when they have a physical examination and hear ‘instability’, what they believe is going on when the health practitioner prods and taps and says ‘hmmmmm’. We need to know this, so we can train health care providers in the practicalities of ‘reassurance’, so that people with acute low back pain don’t feel like they’ve been given a brush-off.

This is qualitative, exploratory, observational, clinically-relevant research. It’s also within the grasp of clinicians in everyday practice.

How about it?

 

May S, Johnson R. Stabilisation exercises for low back pain: a systematic review, Physiotherapy (2008), doi:10.1016/j.physio.2007.08.010

Update on Acute Low Back Pain Management


Well, by update, I really mean a new study assessing the effect of diclofenac and/or spinal manipulation therapy, or neither.

240 patients with acute low back pain who had seen their general practitioner and had been given advice and paracetamol were randomly allocated to one of four groups in our community-based study: diclofenac 50 mg twice daily and placebo manipulative therapy (n=60); spinal manipulative therapy and placebo drug (n=60); diclofenac 50 mg twice daily and spinal manipulative therapy (n=60); or double placebo (n=60). The primary outcome was days to recovery from pain assessed by survival curves (log-rank test) in an intention-to-treat analysis.

Neither diclofenac nor spinal manipulative therapy appreciably reduced the number of days until recovery compared with placebo drug or placebo manipulative therapy (diclofenac hazard ratio 1.09, 95% CI 0.84-1.42, p=0.516; spinal manipulative therapy hazard ratio 1.01, 95% CI 0.77-1.31, p=0.955). 237 patients (99%) either recovered or were censored 12 weeks after randomisation. 22 patients had possible adverse reactions including gastrointestinal disturbances, dizziness, and heart palpitations. Half of these patients were in the active diclofenac group, the other half were taking placebo. One patient taking active diclofenac had a suspected hypersensitivity reaction and ceased treatment.

The key interpretation of this result is that there is limited benefit for people recovering from acute low back pain to receive either diclofenac or ‘spinal manipulative therapy’.  We don’t exactly know what this latter therapy is (it’s not entirely standardised, although a protocol was previously published – and the therapy included high velocity thrusts, but was tailored to suit the individual), but it seems from this study at least, there were no benefits even up to 12 weeks after initial presentation.

It should be noted that one common treatment for all was ‘advice and regular paracetamol’.  The advice is unfortunately not detailed in this study – a shame as it appears that this is the one part of the intervention protocol that was not standardised, and may have been one of the most potent treatment components.

The benefits to patients of not having to either attend treatments, or take a medication with known side-effects is useful.  It may help patients to remain at work (rather than needing to take time off to attend treatment), and reduces the risk of medicalising what seems to be a relatively short-term condition.

What this study does not address is how people with sub-acute or chronic low back pain respond – it is likely that people in these categories require more intensive input.  The input required may well be advice that is tailored to their specific concerns (and more often than not, about psychosocial issues).

I would dearly love to see GP’s and community health care providers develop skills to provide advice to people in the acute and sub-acute phases of low back pain.  It is a complex area, much more challenging to study than whether a medication or a manipulation has any effect!  And of course, because it doesn’t sell medications, may be rather difficult to fund.

HANCOCK MJ, Maher CG, Latimer J, McLachlan AJ, et al.
Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. 
Lancet. 2007;370:1638-43.