Physician's
Forum
Low back
musculoskeletal disorders have become one of the most
significant medical and socioeconomic problems in the
world.
Diagnosing and treating the patient with low back
pain (LBP) can often be challenging, and decisions
regarding optimal management are not always clear-cut.
In
the majority of patients and injured workers with low
back problems, recovery occurs within the first four
weeks of symptoms (the acute phase). Those who have not
improved at the end of that period may need further
diagnostic evaluation and consideration of other
treatment options (subacute phase = 1 to 3 months).
Standardizing the evaluation
and care of LBP patients is critical because of the
growing magnitude of the problem. Inappropriate and
expensive evaluations and ineffective treatments have
been historically commonplace in the care of patients
with low back pain.
The natural history of recovery
from low back pain is favorable and is commonly used as
the standard by which to evaluate and compare other
treatments. In the absence of serious underlying medical
conditions, many patients can expect to recover from the
initial acute episode in the first three to four weeks.
The evaluation and management during this period can
generally proceed without special studies. The patient’s
normal activities are limited by their low back
condition, and they modify these activities to minimize
their pain which allows the tissue to rest and recover
spontaneously. When possible, patients learn to
self-treat and manage their condition in the early
stages. Patients with sciatica may recover more slowly
on average because of more severe underlying problems
such as herniation or spinal stenosis. Approximately
fifty percent of patients with disc/hernia induced
sciatica will recover in the first four to six weeks.
Although a high percentage of
patients with acute low back pain recover within 4-6
weeks, a significant number of patients suffer from
recurrences. Von Korff has studied the natural history
and found that approximately 60% will have a recurrence1.
In a study of back pain in
primary care, Von Korff and Saunders found that 60% to
75% improve in the first month, 33% report intermittent
or persistent pain at year one, and 20% of patients
describe substantial limitations at this time2.
Klenerman et al demonstrated
that 7.3% of individuals with acute low back pain who
had not recovered by two months still reported high
levels of pain and disability at twelve months after
onset3.
Chronic low back pain is
increasing faster than any other disability, and 5 to 7%
of the population will report their back problems as
being a chronic illness. Fifty percent of work loss
caused by back pain is accounted for by duration of
disability for longer than 4 weeks.
Many patients remain untreated
in the early phases of their low back pain, or are
simply treated with medications and palliative
therapies. With this method of management, if the
patient does not experience spontaneous recovery within
about two months, the initial benign problem may become
a chronic situation. Many non-interventional treatment
programs are delivered in an episodic manner and are
simply aimed at providing temporary reduction of the
patient’s symptoms without altering the underlying
disease process.
Pain control should be instituted at the outset for
patient comfort, but a definitive management program
must be instituted as soon as possible to avoid the
merry-go–round of medicating the pain.
Considerable controversy exists
with regards to the effectiveness of the various
palliative modalities and procedures currently employed
in the initial (acute) treatment phase of low back pain
and the redundancy of many of those prescribed in the
secondary (sub-acute) phases. These include the
following
Table 1 (Medical Services Department; Work. Compensation
Board):
Table 1:
Treatments for LBP employed in acute phase and secondary
phase:
Initial (Acute)
Phase Treatments |
Secondary (Sub
acute) Phase Treatments |
Education |
Education |
Activity Modification |
Activity Modification |
Exercise |
Exercise |
Drug therapy |
Drug therapy |
Physical Treatments |
Physical Treatments |
TENS |
TENS |
Acupuncture |
Acupuncture |
Epidural Injections |
Epidural Injections
|
Myofacial Trigger point
Injections |
Myofacial Trigger point
Injections |
Lumbar Supports |
Discectomy / Laminectomy
/ Spinal Fusion |
Patients who fail therapy at
the acute phase of care are routinely referred to the
orthopedic surgeon or neurosurgeon, especially if
abnormalities are noticed on CT scan or MRI. The
majority of these patients are not ideal surgical
candidates.
A common element in many of the current back pain
programs is that many of the treatments employed do not
exert a direct beneficial effect on the basic
pathophysiological processes taking place in the disc
itself.
Since chronicity and recurrence
are relatively common with the low back pain patient, we
must shift the emphasis of care away from the focus on
management of pain, to a disease management program that
focuses on improvement of outcomes, the patient's
functioning (Activities of Daily Living), the patient’s
work ability during and after treatment, issues that
delay recovery, cost effectiveness and long term
management of the patient's condition.
The examination of low back
pain statistics and evidence regarding current
treatments indicates that a shift in practice paradigms
is necessary. There is
now a need for early,
effective, treatments for spinal pain4.
In the absence of a cauda equina syndrome, rapidly
progressing neurological deficit or spinal instability,
virtually all patients should be treated conservatively5.
The U.S. Agency for Health Care
Policy and Research and other evidence based medical
research groups have updated the review carried out by
the AHCPR in 19946 and
have undertaken a systematic review of further evidence
published between 1993 and 1996. These groups also
undertook four new systematic exercise, searching
evidence from 1964 to 1996.
This website presentation has also drawn on the Clinical
Guidelines for the Management of Acute Low Back Pain,
Royal College of General Practitioners September, 19967,
published by the Royal College of General Practitioners
in Great Britain. In addition, material was obtained
from a number of sources including the Cochrane
Collaboration back pain review group and from other UK
guidelines.
An examination of the Initial Phase Treatments suggested
under the current guidelines (CA IMC, Medicare and
others) for Mechanical Low Back Problems reveals the
following:
::Continued::
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