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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



Activity Modification

Activity Modification



Drug therapy

Drug therapy
Physical Treatments Physical Treatments
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:


in Physical Treatments section of Physicians Forum

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