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Low back pain is a common complaint and in recent years new evidence has come to light about what does and doesn't work, as Dr Helen Frost explains
Low back pain is one of the commonest problems for GPs with 7 per cent of the adult population seeking consultation each year. In 1998 the total cost of treating back pain in the UK was estimated to be £1,632 million1 with physiotherapy accounting for £251 million. While classification and diagnosis of low back pain is difficult (in 90 per cent of cases no specific medical diagnosis is made) the prognosis of acute low back pain is favourable with an estimated 90 per cent of back pain sufferers recovering within six weeks. However, low levels of pain and disability often persist and most people will have at least one recurrence within 12 months2.
A more active approach
Bed rest should no longer be advised. International guidelines for the management of low back pain based on best evidence and consensus have been published and the recommendations for diagnosis are presented in box 1. Assessment of red flags to exclude serious pathology is common practice but psychological and social factors are often overlooked. These factors should be thoroughly considered as they are known to predict outcome.
Is physiotherapy effective?
In 1995 the managers of the Oxford physiotherapy services were challenged to come up with evidence that the service they offered for back pain was effective. Physiotherapy clinicians, managers and researchers worked together to develop a trial that would reflect current physiotherapy practice and assess effectiveness.
A pragmatic multi-centre trial was funded by the Arthritis Research Campaign in 1997 and included 286 patients with more than a six-week history of low back pain who were 18 years old or over, with or without leg pain. Patients were allocated to either: a course of physiotherapy treatment or advice to remain active. In addition, both groups were given The Back Book a booklet containing advice on how to manage back pain, stay active and avoid disability (available from: www.tsoonline.co.uk).
The results of our tria · 3 are summarised in box 2. As you can see it did not provide strong evidence for the additional physiotherapy treatment. However, patients treated in this trial had mild to moderate disability and those with more severe low back pain may benefit from additional treatment. The result should encourage physiotherapists to deliver single treatment sessions for patients with similar profiles.
What works for back pain?
International guidelines vary in their advice for therapy but for acute low back pain they agree patients should be reassured that the prognosis is favourable, advised to stay active and prescribed some form of pain-relieving medication if required.
There is strong evidence that patients with chronic pain can benefit from exercise therapy including a general fitness approach aiming to increase aerobic fitness, flexibility and strength. For more severely disabled patients this is preferably delivered in the form of multidisciplinary rehabilitation programmes that include cognitive behavioural principles and focus on psychological factors4,5. Patients are often cautious of exercising with back pain so compliance is a problem, but for motivated patients it can be effective. Advice for patients with back pain and examples of simple exercises are available from the Arthritis Research Campaign.
A recent randomised control trial trial involving 1,334 patients compared trained GPs delivering The Back Book with manipulative therapy (including high-velocity thrust techniques), exercise or both6. Relative to best care provided by the GP, manipulation followed by exercise achieved the best results short- and long-term and was cost-effective.
A recent Cochrane review suggests that massage might be beneficial for patients with sub-acute and chronic non-specific low back pain (Cochrane Library issue 4 2004) but invasive treatment including acupuncture, intra-articular (facet) steroid injections and local facet nerve blocks, cannot be recommended for chronic low back pain13. Guidelines for other types of treatment are presented in box 3.
Despite publication and promotion of the RCGP guidelines in 1996 it is difficult to find hard evidence demonstrating any impact on clinical practice. A study to investigate the impact of an educational strategy to promote the guidelines among GPs demonstrated little change in practice but an increase in referral to physiotherapy and a triage service7.
Referral to physiotherapy is often considered when patients fail to make progress but costs are high and resources scarce so it is essential to make the best use of services. Another study suggests establishment of a prompt and direct service is a feasible and acceptable method of managing patients with new episodes of low back pain8.
Treat now or later?
Wand et a · 9 compared an assess/advise/treat model of care with assess/advise/wait for patients with acute low back pain. They found that in the short-term intervention including manual therapy, bio-psychosocial education and exercise was more effective than advice to be active. In the long-term there was no difference in pain and disability but when the treatment was provided later psychological benefits were not achieved.
Guidelines for the management of low back pain, commissioned by the European Co-operation in the field of Scientific and Technical research (COST), were published last November. There are obvious barriers to implementation but they are not insurmountable. What is required is vision, enthusiasm and the collaboration of all involved.
Helen Frost is a research fellow, division of health in the community, Warwick Medical School
1: Summary of recommendations for diagnosis
·Diagnosis triage (non-specific low back pain, radicular syndrome or specific pathological change)
·Physical examination for neurological screening (straight leg raise)
·X-rays or MRIs are not useful for non-specific low back pain
·Exclusion of red flags for serious pathology
· Cauda equina syndrome
· Presentation under age 20 or onset over 55
· Non-mechanical pain
· Thoracic pain
· Part history of carcinoma, steroids, HIV
· Generally unwell, weight loss
· Widespread neurological symptoms
· Structural deformity
·Consideration of psychological factors (yellow flags)
· A belief that LBP is harmful or potentially severely disabling
· Fear avoidance behaviour and reduced activity levels
· Tendency of low mood and withdrawal from social interaction
· Expectation of passive treatment rather than a belief that active participation will help
Source: Koes et al 200110, Working Backs Scotland 200011
2: Summary of physiotherapy trial (Frost et al 20044)
·The trial was pragmatic. Patients were routinely referred by GPs and consultants.
·Patients were included if they had >6 week history of non-specific low back pain and excluded if they had serious pathology.
·Patients were randomised to either an advice group or additional therapy group including commonly used physiotherapy interventions.
·Patients in the advice group were seen and assessed by a physiotherapist and the trial was therefore a comparison of different treatment strategies.
·No evidence was found that the additional physiotherapy treatment, routinely delivered in the NHS, was more effective than a single session of assessment and advice given by a physiotherapist at 12 months.
·In the short-term (two months) there were trends in favour of the therapy group but benefits were small and statistically insignificant.
·Patients were only mild/moderately disabled by their pain and the results cannot be applied to patients with more severe pain who may benefit from different types of therapy such as manipulation or exercise.
·Patients treated in the additional intervention group reported greater perceived benefit of treatment.
·Trial is limited by the 30 per cent loss to follow-up.
·Patients with mild/moderate disabling back pain can be treated in a one-off advice session to allow scarce physiotherapy resources to be utilised for more severe problems.
·This type of management is much more likely to be effective if advice given is positive, reassuring and reinforced by all involved in the patient's care so a consistent message is given throughout treatment.
3. Summary of recommendations for treatment of non-specific low back pain (following exclusion of red flags)
non-specific low back pain (following exclusion of red flags)
Source: Koes et al 200110, Working Backs Scotland 200011, Bekkering et al 20034, Staal et al 200312
Non-specific acute low back pain (<6>6>
·Reassurance of favourable outcome
·Advise patient to stay as active as possible
·Advise patients to remain at work or encourage an early (gradual) return to work with modified duties if necessary
·Prescribe medication if required
·Discourage bed rest
·Consider spinal manipulation for
pain relief as part of a plan to remain active
·There is no evidence for specific exercise
There is strong evidence that bed rest is ineffective and moderate evidence that traction is ineffective
Evidence of effectiveness is unclear for ultrasound, laser, TNS, interferential therapy, acupuncture and massage; it is unclear whether these treatments offer any more than a placebo effect; they have the additional disadvantage of being passive
Non-specific sub acute (6-12 weeks)
and chronic low back pain (>12 weeks)
·Exercise therapy including general aerobic, flexibility and strengthening
·Multidisciplinary rehabilitation including cognitive behavioural principles
·Address psychological obstacles to return to work
·Consider behavioural treatment for selected patients
(see yellow flags)
There is strong evidence that traction is ineffective
Evidence of effectiveness is unclear for ultrasound, laser, TNS, interferential therapy, acupuncture; massage may be beneficial but it is unclear whether these passive treatments offer more
than a placebo effect
www.tsoonline.co.uk (The Back Book; £1.25 or £12 for 10)
www.workingbacksscotland.com (Advice and evidence for GPs, therapists, pharmacists, surgeons and patients)
www.backpaineurope.org (Information on the COST guidelines)
www.arc.org.uk/about_arth/booklets/6002/6002.htm (Arthritis Research Campaign back pain booklet including exercises)
1 Maniadakis N and Gray A. The economic burden of back pain in the UK. Pain 2000;84:95-103
2 Pengel LH et al. Acute low back pain: Systematic review of its prognosis.
3.Frost HL et al. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ; 2004;329:708-11
4.Bekkering GE et al. Dutch physiotherapy guidelines for low back pain. Physiotherapy, 2003; 82.,2, 82-96
5.Guzman J et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511-16
6.UK Beam trial team. UK back pain exercise and manipulation
(UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ ( published online Nov 19 2004)
7.Simpson D et al. Implementation of RCGP guidelines for acute low back pain: cluster randomised controlled trial. Br J Gen Pract. 2004; Jan: 54 (498): 33-7
8.Pinnington MA et al. An evaluation of prompt access to physiotherapy
in the management of low back pain in primary care.
Family Practice 2004; 21(4) 372-80
9.Wand B et al. Early intervention for the management of acute low back pain. A single blind randomised controlled trial of biopsychosocial education, manual therapy and exercise. Spine; 2004, 29, 21, 2350-6
10. Koes BW et al. Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine 2001; 26,22:2504-14
11. Working Backs Scotland Partnership, Health Education Board for Scotland, 2000
12. Staal J et al. Occupational health guidelines for the management of low back pain: an international comparison. Occupational and environmental Medicine 2003; 60: 618-26