Back pain is extremely common; 80% of us will experience back pain at some time in our lives. Acute back pain is defined as pain lasting up to six weeks. Any pain lasting longer than that is termed chronic back pain.
Back pain is one of the most common reasons for people taking time off work and consulting their GP. Over the years, there have been many misconceptions about the treatment of back pain. One of these is that activity is bad for back pain and people consequently can become inactive and stay in bed. This has been one of the reasons for an increase in the size of the problem. Subsequently, this belief has been disproved by work in the UK.1
In New Zealand, ten years ago there was an epidemic of people taking time off work with back pain and claiming sick benefit, as it became acceptable to do this in popular culture. The New Zealand government commissioned work to address this problem and there has since been a huge public health campaign to educate the population about back pain and encourage a culture of staying active and not taking time off work. This has been very successful.2
Therefore, it seems the current epidemic of chronic back pain may be partly cultural. Fifty or sixty years ago, the welfare state was not as well established as it is now, and people stayed at work whilst with back pain and largely recovered more quickly. Today, unemployment is more of a problem and people are often not in regular work when they experience their back pain for the first time.
The population of the UK is also becoming more obese and levels of exercise are falling. Children’s activity levels are much lower than 20-30 years ago and this leads to an unfit, deconditioned population which is less able to cope with acute back pain and the risk of chronicity is much higher.
Risk factors for chronicity
Only a relatively small proportion of the population will progress to chronic back pain , but this small percentage are responsible for 80% of back-pain related healthcare use and expenditure.
Individual risk factors will predict how likely it is for a given person to become a chronic back pain patient.
Many of these risk factors are markers of chronicity and are known as yellow flags. We are all familiar with red flags, reasons for urgent treatment, such as infection, trauma or malignancy. Yellow flags are less well known, but are very important psychosocial reasons that prevent prompt recovery. Nearly all human illness can be described in a biopsychosocial way, splitting the disease into three component parts;
- Bio describes the organic dysfunction, such as a fractured femur or prolapsed inter-vertebral disc.
- Psycho describes mood disturbances, such as depression, or abnormal health beliefs, such as that rest is imperative with back pain.
- Social describes the factors in a person’s life, work and family which may have an impact on their recovery, such as an ongoing compensation claim after an injury, a threat of losing their job, or a parent with a chronic back problem.
These yellow flags are the main reasons for someone with acute back pain becoming a patient with a chronic back pain problem.3
Other yellow flags are:
- A belief that back pain and activity are harmful
- Sickness behaviours, such as taking extended rest
- Low or negative mood and social withdrawal
- Treatment which does not follow best-practice guidelines, such as opiate use
- Problems with compensation and claims
- Heavy work and long hours
- Poor job satisfaction
- Lack of support from family or conversely, an over-protective family.
Looking for and addressing any yellow flags reduces the risk of the acute back pain patient developing a chronic health problem. It is imperative for GPs and physiotherapists to familiarise themselves with the biopsychosocial model of illness.
Assessing back pain
Work at Keele University has recently produced a tool to help in the initial assessment of patients with acute back pain.
This tool is called StartBack.4 It is a quick and easy screening tool to stratify patients with back pain into low, medium and high risk. High risk patients can then be referred to a multidisciplinary back pain management service which will be able to address not only the physical problem, but also the psychosocial issues with the use of therapists and CBT techniques.
Low and medium risk patients receive standard care with a physiotherapist.
This approach has been shown to reduce overall costs of back pain management, and improve patient outcomes.
There are many reasons for the increase in chronic back pain in the UK. It is partly due to an increase in levels of poor fitness and obesity, but also due to a failure to recognise the yellow flags, which may indicate a high risk of chronicity when a patient presents to the primary care team. Promptly recognising and addressing these will facilitate a full recovery.
Dr Warburton is a GPSI in rheumatology in Telford, Shropshire
1. Hagen JB, Jamvedt G et al ; The updated Cochrane review of bed rest for low back pain and sciatica. Spine 2005; 30(5); 542-6.
2. Accident compensation corporation and the New Zealand Guidelines Group; New Zealand Back pain guide (incorporating the guide to assessing psychosocial "yellow flags" ); Wellington NZ; ACC/NZGG; 2004 Oct.3. Croft PR, Macfarlane JG et al. Outcome of low back pain in general practice; a prospective study.
BMJ 1998; 316(7141); 1356-9.
4. Comparison of stratified primary care management for low back pain with current best practice(StartBack). Lancet.