In 1994 the Clinical Standards Advisory Group published a report that altered the way that GPs dealt with the management of uncomplicated low back pain.
Patients were advised to be as mobile as possible, with rest being the exception rather than the rule.
The focus now is on keeping people at work or encouraging them to return to work as soon as possible.
Uncomplicated back pain is a common symptom that can be distressing. It occurs both in men and women and it is increasing in office workers. It mostly affects people between 30 and 60 years of age. Onset of back pain outside this age range raises the possibility of a more serious cause.
According to the charity Backcare, the number of working days lost in 2003/4 was five million and is rising. The condition costs £512 million in hospital care, £141 million in GP consultations and £150 million in physiotherapy. Adding in private care, the total cost is £16 billion a year.
Significant factors predisposing to back pain include psychological factors, obesity and smoking and job dissatisfaction.
|Red Flag Symptoms|
About 95 per cent of back pain cases will be simple back pain that will resolve quickly. One problem for the GP is to identify those cases that may have a potentially serious cause, and this means looking out for red flag symptoms (see box above).
The patient should be asked key questions about whether the pain has occurred before, how and when it started, whether the pain radiates and whether anything makes it worse or better.
Work and other activities may be relevant, and it is always worth asking the patient what they think caused their pain. Ask them what steps they have been taking to control their pain, and check the medical history for possible relevant factors such as steroid use and osteoporosis.
Examining the patient
In most cases this will take less than five minutes. The presence of any suspicious findings will dictate whether a more detailed examination is necessary.
It is a good idea to develop a fixed routine rather than adapting your strategy each time because you will carry out such assessments many times during your professional life.
A quick look at the bare back will show if there is any muscle spasm, scoliosis or loss of lumbar lordosis. The patient should be asked to bend to the left and right, and then to bend forward as far as they can. This will reveal any limitation of movement, rotation on bending, or aggravation of pain.
Ask the patient to lie on the couch. Simply observing how the patient does this can be useful. Raising a straight leg (lifting the heel and ensuring the knee is kept straight) will determine how limited this movement is.
Feel for resistance and watch the patient's face to avoid causing too much pain. Ask the patient to indicate the site of any pain, and make sure that limitation of movement is not just due to tight hamstrings.
It is useful to include a femoral nerve stretch. Ask the patient to roll over, bend the knee and raise the thigh to see if there is any pain or limitation of movement. While the patient is in this position, press firmly on the lumbar spine and over the sacroiliac joints to see if any pain is elicited.
In the absence of any red flag symptoms or signs, a diagnosis of uncomplicated or simple back pain is most likely. Other terms used are non-specific low back pain and mechanical back pain.
It is important to explain to the patient that you have found no significant problem. Be positive and reassuring, and tell them that rest is not recommended. Emphasise it is important to keep mobile, and return to normal activity as soon as possible.
As in all consultations, the GP should look out for complicating factors such as underlying anxiety or depression, and aggravating features such as problems at work or a lack of support at home.
If the work environment is clearly having an impact on the patient's back pain, offer advice concerning desks, chairs and computers, and correct lifting techniques and driving positions for long-distance drivers.
Occasionally it may be necessary to dispel beliefs that continued activity will be harmful, or it may be that there are compensation issues colouring the patient's attitude.
Analgesia will help the patient to work through the pain. Many will have already tried paracetamol or OTC ibuprofen, but ensure the dosage is adequate.
A prescription for a higher dosage NSAID may help, if not contraindicated. Evidence of benefit from manipulation and acupuncture in simple back pain is weak, and in most cases even physiotherapy is unlikely to be of much value in speeding a return to normal.
It is important to ensure that acute back pain does not become chronic. If a patient seems predisposed to avoid activity, they should be strongly persuaded to undertake active rehabilitation, perhaps by attending a back school or exercise therapy.
Routine X-rays for simple back pain are discouraged because the information gleaned is limited and does not influence outcome. If a serious cause is suspected, urgent referral for MRI will be required.
Prognosis and prevention
About three-quarters of those off work with uncomplicated back pain are back at work within four weeks, but there is a significant risk of recurrence. Persistent or recurrent pain probably justifies further investigation.
Today, prevention measures are often a feature of the work-place, with programmes to teach safe lifting, for example. There is little evidence that the incidence of back pain is reducing, and it is not known if this is due to increasing pathology or higher expectations.
- Dr Barnard is a retired GP in Fareham, Hampshire
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Item Code: MINT/PPR-12008
Date of Preparation: May 2012