Musculoskeletal conditions are cited as a common reason for repeat consultations, making up 30 per cent of primary care consultations.1
Presentation of pain
Pain is the primary symptom reported by patients and the main area of pain is the back.2 Many patients who report low back pain do not come for another consultation but still have pain more than three months later.3
When pain occurs for a reason, such as trauma, a reasonable diagnosis and prognosis of recovery can usually be made. Persistent pain of a more gradual onset may be due to a host of differential diagnoses and a prognosis is more difficult to define.
For some patients, the lack of definitive explanation can itself become a source of great distress.
In all cases, it is important in the assessment phase to exclude red flags, such as cauda equina syndrome, violent trauma, unexplained weight loss, systemic infection, and sudden loss of bladder or bowel function.4
Careful explanation
It is crucial that the correct advice and reassurance is provided at the patient's first visit.
Labels such as 'wear and tear', or 'degenerative disc disease', may be unhelpful and prone to misinterpretation by patients. There is some evidence that it is not uncommon for spinal abnormalities such as disc degenerative changes to be found in the asymptomatic general population.
Alternative helpful explanations for the patient who is trying to interpret their normal scans or investigations might include reassurance that they have a normal spine or are experiencing normal age-related changes, just like greying hair.
Flags system
There are several methods available to recognise the distressed back patient, including the flags system. This system can be used to help recognise barriers to recovery and rehabilitation.
Other than red flags, psychosocial factors or 'yellow flags' can be assessed and are shown to be effective in predicting chronicity.5
There may be signs of fear or avoidance of certain activities, poor sense of self-efficacy or catastrophising about the pain by both the patient and their social group.6
If continuance of work or return to work is important, identification or referral for assessment of blue and black flags are indicated.
Blue flags are concerned with perceptions related to work; for example, a patient may be concerned that their employer will be unsupportive of their back pain.
Black flags are related to objective work characteristics, for example, the employer's absence management policy or ill-health retirement policy.
The flags system should not be used to label the patient as 'difficult to treat' but to identify where further treatment approaches or appropriate referrals may assist the patient towards recovery or management of the condition.
Treatment
Early management of low back pain should include encouragement and advice on a gradual return to normal activities, short-term use of analgesics or manual therapies, such as manipulation or physiotherapy.
There is limited evidence for prolonged and multiple interventional techniques at present.7
Low back pain can resolve quickly. However, it is important to recognise psychosocial factors in patients where the pain might persist or where their own coping strategies are currently inadequate.
- Ms Wang is a clinical specialist physiotherapist at INPUT, Pain Management, St Thomas' Hospital, London
- Back pain awareness week is 4-10th October 2008 (www.backpain.org)
Managing back pain4
- Perform a thorough physical examination.
- Exclude red flags.
- Give a clear explanation of the symptoms.
- Reassure the patient.
- Refer for assessment if necessary.
- Advise the patient to be gradually active.
- Give pain relief in a timely but time-limited manner.
- Advocate restraint in prescribing prolonged sick leave.
References
1. Musculoskeletal Services Framework (2006) www.dh.gov.uk/en/
2. Breivik H, Collet, B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10: 287-333.
3. Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316: 1,356-9.
4. Overmeers T, Linton S, Holmquist L, Eriksson M, Engfeldt P. Do evidence-based guidelines have an impact in primary care? A cross-sectional study of Swedish physicians and physiotherapists. Spine 2004; 30: 146-51.
5. Kendall NAS. Psychosocial approaches to the prevention of chronic pain: the low back paradigm. Best Pract Res Clin Rheumatol 1999; 13: 545-54.
6. Woby S R, Roach N K, Urmston M and Watson P. The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. Eur J Pain 2007; 11: 869-77.
7. European Commission Research Directorate General. Cost action B13. Low back pain guidelines for its management. www.backpaineurope.org
