Low back pain (LBP) is an extremely common occurance amongst the UK population. Although most LBP episodes are simple and self-limiting, symptoms of LBP can be a major cause of physical and psychological disability, placing huge demands on society through the loss of working days and demands on medical resources.
Facts & Figures
Back pain is one of the most common reasons for primary care visits in the UK. Over a 12 month period, 7% of the adult population consults their GPs with back pain (McCormick, et al., 1995). The lifetime prevalence of LBP in industrialised countries is reported as over 70%, with a peak prevalence between the ages of 35 and 55 years (COST B13 Working Group, 2004a). Back pain is the number one cause of long-term absence among manual workers and a common cause of short-term absence. Individuals with musculoskeletal problems are recognised as the second largest group in the UK to receive incapacity benefits (Maniadaki and Gray, 2000; Department of Health, 2006).
LBP is defined as pain localised to the area below the costal margin and above the inferior gluteal folds, with or without leg pain. In the absence of known specific pathology (such as cauda equina syndrome, an inflammatory process, infection, tumour, osteoporosis, ankylosing spondylitis (AS), fracture or a radicular syndrome), the term non-specific low back pain (NLBP) is used. Fewer than 15% of individuals with back pain have any specific underlying pathology (COST B13 Working Group, 2004b).
Symptoms which persist for 6-12 weeks are defined as acute episodes of LBP, while symptoms that continue beyond 12 weeks are classified as chronic. Acute episodes are usually self-limiting. According to the literature, the recovery rate is 90% in 6 weeks. However, it has been suggested that these figures are falsely optimistic and that individuals often continue to have symptoms in the community but opt not to consult their doctor again (Croft et al., 1998). Chronic back pain develops in 2-7% of people which can lead to severe disability and may be associated with pyschosocial barriers to recovery (COST B13 Working Group, 2004b).
Pyschosocial factors are factors which appear to increase the risk of developing chronic pain and long-term disability. Current guidelines focus on the identification of these potential barriers to rehabilitation, so that behaviour can be challenged in a positive way. These factors have beend identified from a range of evidence-based guidelines (NICE, 2008; NHS CKS, 2009) and include:
- Inappropriate pain behaviours such as:
- A belief that pain and activity are harmful leading to fear of avoidance behaviours (i.e. fear of movement).
- The belief that pain should disappear entirely before attempting to return to work or normal activity.
- A passive attitude to rehabilitation.
- Sickness behaviour, such as extended rest.
- Work-related problems:
- Prolonged periods off work.
- Dissatisfaction at work.
- Pessimistic expectations on ability to return to work.
- Lack of support from co-workers/employer.
- Over-protective family, social withdrawal and lack of support.
- Emotional problems, such as negative mood, depression, anxiety or feeling under stress.
- Problems with claims for compensation or applications for social benefits.
- Inappropriate expectations of treatment, such as low expectations of active participation in treatment.
Screening people with chronic musculoskeletal pain for these factors can identify those with a poor progosis for a return to work and may also help to decide who should be offered low-, moderate- or high-intensity treatment (Haldorsen et al., 2002).
Management of NLBP
An active approach is recommended as the best treatment for LBP. It is suggested that management should be focused on reassuring the individual that LBP is not usually a serious condition and that a full recovery would be expected. Individuals should be encouraged to to keep moving and return to work and normal activities as soon as possible.
Since the 19th century, bed rest was considered to be the standard treatment for back pain. There is now strong evidence to suggest that bed rest is associated with increased pain intensity, increased disability and more days off from work (Wilkes, 2000). During an acute episode of back pain, normal activity should be resumed as soon as possible. Normal movements are likely to precipitate pain so should be reintroduced slowly, with individuals encouraged to do a little more every day. Care should be taken with lifting and twisting activities and a return to work should be encouraged.
For individuals identified to have pyschosocial factors, at risk of developing chronic pain, it may be beneficial to intervene early by offering a structured exercise programme (known as GP exercise referral), with an exercise referral qualified fitness professional, with up to eight sessions over a three month period (Welch, 2013). These sessions can be undetaken as part of a group or on an individual basis and incorporate aerobic activity, muscle strengthening exercises and instructions on movement control, stretching and posture improvement (NCCPC/NICE, 2009).
Prevention of NLBP
Some of the key recommendations in the prevention of back pain are summarised below and are readily accessible to individuals in leaflet form from Patient UK: http://www.patient.co.uk/
- Exercise: regular activity with stretching before and after helps to maintain the strength of the lower back;
- Lifting: correct techniques should be used for lifting. Most manual roles will incorporate an induction to teach/reinforce correct techniques;
- Seating: ensure seating at work, at home or when driving for prolonged periods is comfortable and take regular breaks to stretch;
- Weight: excessive weight puts further strain upon the back. Weight reduction is encouraged to reduce this strain;
- Smoking: has been associated with chronic back pain. As such smoking cessation is encouraged;
- Posture: good posture can prevent back pain; and
- Mattress: sleeping on a mattress that supports the natural curves of the spine can help avoid back pain.
McCormick, A., Fleming, D. & Charlton, J. (1995) Morbidity Statistics from General Practice. Fourth National Study 1991-1992. Office of Population Censuses and Surveys. HMSO Series MB5 N0.3 ISBN 10:0116916109/0-11-691610-9; ISBN 13: 9780116916105.
COST B13 Working Group (2004a) European Guidelines for the Management of Acute Non-specific Low Back Pain in Primary Care. Available from World Wide Web: http://wwwbackpaineurope.org/web/files/WG1_Guidelines.pdf [Accessed: 04 May, 2013].
COST B13 Working Group (2004b) European Guidelines for the Management of Chronic Non-specific Low Back Pain in Primary Care. Available from World Wide Web: http://wwwbackpaineurope.org/web/files/WG3_Guidelines.pdf [Accessed: 04 May, 2013].
Croft, P.R., Macfarlane, G.J., Papgeorgiou, A.C., THomas, E. & Silman, A.J. (1998) Outcome of Low Back Pain in General Practice: A Prospective Study. British Medical Journal. 316, pp.1356-1359.
Department of Health (2006) The Musculoskeletal Services Framework. Available from World Wide Web: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documetns/digitalasset?dh_4138412.pdf [Accessed: 04 May,2013].
Haldorsen, E.M., Grasdal, A.L. & Skouen, J.S. (2002) Is There a Right Treatment for a Particular Patient Group? Comparison of Ordinary Treatment, Light Multidisciplinary Treatment, and Extensive Multidisciplinary Treatment for Long-term Sick-listed Employees with Musculoskeletal Pain. Pain. 95, pp.49-63.
Maniadaki, N. & Gray, A. (2000) The Economic Burden of Back Pain in the UK. Pain. 84, pp.95-103.
NCCPC/NICE (National Collaborating Centre for Primary Care/National Institute for Health and Clinical Exellence) (2009) Low Back Pain: Early Management of Persistent Non-specific Low Back Pain. Available from World Wide Web: http://www.nice.org.uk/nicemedia/live/11887/44343/44343.pdf [Accessed: 04 May, 2013].
NHS CKS (National Health Service Clinical Knowledge Summaries) (2009) Low Back Pain without Radiculopathy. Available from World Wide Web: http://www.cks.nhs.uk/back_pain_low_without_radiculopathy [Accessed: 04 May, 2013].
NICE (National Institute for Health and Clinical Excellence) (2008) Metastatic Spinal Cord Compression – Diagnosis and Management of Adults at Risk of and with Metastatic Spinal Cord Compression. Available from World Wide Web: http://www.nice.org.uk/nicemedia/live/12085/42653/42653.pdf [Accessed: 04 May, 2013].
Welch, E. (2013) Low Back Pain. InnovAiT. 5(1), pp.13-21.
Wilkes, M.S. (2000) Chronic Back Pain: Does Bedrest Help? Western Journal of Medicine. 172, pp.121.