Back Pain

Dawn Carnes and Professor Martin Underwood sift through the evidence on the common problem of back pain, in response to questions from GP Dr Graham Archard

1. How effective is chiropractic/osteopathy in comparison with physiotherapy for the treatment of backache?

Randomised controlled trials comparing chiropractic, osteopathy and physiotherapy are the subject of much debate due to the number of complex factors that may influence outcome. Findings also vary between the disciplines, depending on what they were compared with, for example exercise, sham therapy and massage.

Spinal manipulation/mobilisation is common to all three disciplines. The UK BEAM trial (BMJ 2004) compared the effectiveness of manipulation and exercise with best practice GP care. They found a small but statistically significant difference in outcome with manipulation followed by exercise at three and 12 months. Manipulation alone, compared with best practice GP care, fared similarly. This indicates some effectiveness of manipulation for low back pain.

There are few research studies that support the use of passive physiotherapeutic approaches for the management of low back pain. Because evidence is limited and conflicting, the European guidelines (www.backpaineurope.org) do not recommend the use of interferential therapy, laser therapy, massage or therapeutic ultrasound. The guideline authors found no evidence to support shortwave diathermy, transcutaneous electrical nerve stimulation, heat/cold therapy and corsets. They found evidence against the use of traction.

2. What simple exercise measures can be taught in the surgery, rather than asking for physiotherapy advice?

Activity/exercise is better than passive treatment, but there is insufficient evidence to recommend any particular type. A recent systematic review investigated the effectiveness of different exercise regimes: the overall conclusions were that any exercise of almost any sort (except the extreme sort which increases your risk of injury in all areas) has a positive effect on low back pain.

Exercise advice should be pitched at a level appropriate to a patient's capabilities. At the easiest end of the spectrum there is gentle stretching and walking, to yoga, core stability exercise and more strenuous cardiovascular sport.

Gentle stretching to the lumbar paravertebral, gluteal, hamstring and leg abductor muscles, with the spine supported (patient supine), are unlikely to be contraindicated in those with non-specific low back pain.

3. Is there a place for the use of NSAIDs in the treatment of spinal osteoarthritis?

NSAIDs are likely to help those with spinal OA. But they should be avoided in patients at risk of upper gastrointestinal bleeding. Paracetamol may be as effective as NSAIDs, and over a long period the risk of gastrointestinal complications is less.

Patient preference may be an important consideration. If their perception of one drug is superior to others and there are no other contraindications, then this may have a positive benefit for the overall effectiveness of the drug. Clinically, paracetamol would be the treatment of choice for long-term use, which is more probable with spinal OA. Regular use of painkillers is often more effective than taking them when pain is at its worst.

4. I had a patient whose backache never improved until he started playing squash again. Was he mad, lucky or enlightened?

If a person presents with non-specific low back pain, that is, back pain with no red flags indicating pathology – such as referred pain, altered sensation, disturbance in bladder and bowel movement, and being systemically unwell – there is no reason why they should not continue with normal activities.

Squash may seem extreme for most, but it was normal for this patient. Movement generally is known to benefit low back pain. Exercise can also promote general well-being, strength, mobility, weight loss and cardiovascular fitness.

5. Just how efficacious are epidural and caudal injections?

Facet joint injections are unlikely to be effective in patients with non-specific low back pain. Systematic reviews have shown there is no significant difference in pain relief after six weeks and six months with epidural steroid injections or facet joint injections (Van Tulder and Koes, Clinical Evidence).

Surgical intervention is rarely indicated for chronic non-specific low back pain. The European guidelines only suggest surgical intervention in exceptional circumstances, such as those with severe pain for whom two years of conservative treatments have failed.

6. Is there a role for acupuncture and other complementary therapies in backache?

A recent primary care study showed that when osteopathy, chiropractic and acupuncture were offered to patients there was a clinically significant improvement in outcome, GP consultations fell and fewer prescriptions were issued. The European guidelines recommend manipulation for both acute and chronic non-specific low back pain and there is RCT evidence that acupuncture can reduce pain intensity and increase overall improvement in backache.

Patients who consult osteopaths or chiropractors now get the same protection as when they see a doctor. Legal statutory regulations are now enforced by the professional bodies. The statutory titles mean practitioners calling themselves osteopaths or chiropractors have to be trained to standards recognised by their regulatory body, and they have to adhere to the principles of professional practice defined by these bodies.

The regulatory authorities for each profession can investigate professional conduct in the same way as the GMC, with the same consequences, ensuring acceptable standards of practice and suitable patient care.

7. What is the single most important thing to do to prevent back pain becoming chronic?

Patients with non-specific low back pain are unlikely to do any serious harm by moving when it is painful. If a patient rests every time their back is sore recovery is less likely. There is an increased chance of developing chronic disability with continued rest.

Encouraging return to normal activity as soon as possible is paramount. Reassuring patients with non-specific low back pain that it has no obvious pathology, and that normal activity and exercise will not harm them, is crucial to their recovery and reducing the risk of chronic pain later.

8. Depression screening has become a QOF requirement for some chronic conditions. Should we screen those with chronic back pain as well?

Psychosocial risk factors are negative attitudes towards low back pain with a belief that it is harmful and disabling, causing avoidant behaviour. Other factors indicative of long-term chronicity and disability are: a desire for passive treatment rather than active engagement, low mood and possible social and financial problems.

Changing thoughts, attitudes and behaviour is likely to help patients. Cognitive behaviour therapy is recommended for those with psychosocial risk factors.

9. I know we should not X-ray spines routinely, but if backache has continued for more than six weeks is there a particular view to ask for?

No. Unless there is reason to suspect a serious cause, exposing the patient to X-rays should be avoided. Minor abnormalities are common on X-rays of the lumbar spine even on those with no pain. If an X-ray shows minor abnormalities, the treatment approaches available remain the same. In the meantime you have exposed them to additional radiation.

The dose of radiation is 120 times that of a chest X-ray. The incidence of cancers induced by radiation following X-rays of the lumbar spine is around one in 25,000.

10. GPs have been asked to try to reduce their referral rate. What would be the single thing you would suggest to prevent that extra referral?

Give good advice. Reassure patients that 90 per cent of low back pain sufferers have recovered by 12 weeks; advise them to keep active, avoid bed rest and resume ordinary activities as soon as possible, and manage the pain pharmacologically if necessary.

It is worth backing your advice up with printed information such as The Back Book by Roland et al (2002). Recommending manipulative therapy is also an option. Unfortunately there are few NHS services available.

Dawn Carnes is a registered osteopath in Kent; she is also part of the locomotor research team at Barts and The London Queen Mary School of Medicine and Dentistry – she is just completing a PhD about chronic musculoskeletal pain. Competing interests: none declared

Martin Underwood is a professor of general practice and heads the research centre for health sciences at Barts and The London Queen Mary School of Medicine and Dentistry; his recent research has focused on low back and chronic musculoskeletal pain conditions – he is a part-time GP in east London and was one of the main investigators in the UK BEAM trial. Competing interests: Martin Underwood has received speaker fees from Pfizer, the manufacturer of valdecoxib and celecoxib, and from the General Osteopathic Council

What I will do now

Dr Archard responds to the answers

• While I had previously thought taking X-rays after six weeks of chronic back pain was indicated, I shall no longer be doing this. This will reduce unnecessary expense to the NHS and unnecessary risk to patients.
• I shall be encouraging manipulative therapies to patients if they can afford them.
• I will also encourage the PCT to consider funding these procedures in the future – these therapies seem to have positive evidence-based outcomes and I am, apparently, within good medical practice guidelines to refer on to these.
• Changing patient attitudes towards back pain appears to be important to improve outcome and I shall be stressing positive attitudes in the future, particularly in getting back to normal activity as soon as possible.

Graham Archard is a GP in Christchurch, Dorset