Issue 8 March 2004
General points
- Explanation and reassurance are simple measures that are shown to improve outcomes
- The evidence has strengthened for advising activity i.e. staying or becoming physically active and resuming usual activities, including work where possible
- Analgesia (paracetamol or non-steroidal anti-inflammatory drugs) and manipulation of the spine often provide short-term symptom control and improve outcomes
- Extended bed rest and the use of narcotics or diazepam has proven to be harmful
- Follow-up and identification of barriers to recovery should be planned
Background
In 1994 a major change to the clinical management of acute low back pain was recommended by the USAgency for Health Care Policy and Research. Subsequent research and systematic reviews have provided additional support for the clinical effectiveness of those measures. The recommendations for clinical management of acute low back pain from ACC’s recently published guide1 are summarised below.
Approach to Management
Following an assessment to exclude any serious underlying problem (Red Flags), the patient’s progress should be clinically managed and reassessed for pain and function weekly, until the patient has resumed usual activities and is self-managing any symptoms. Clinical management options for acute low back pain range from those that are effective through to those that cause harm.
The evidence for these options is summarised as follows:
- Evidence of improved clinical outcomes: advice to stay active (including work);A analgesia, using paracetamol and nonsteroidal anti-inflammatory drugs;A manipulation of the spine in the first 4-6weeks;A and a multi-disciplinary approach to management.B
- Evidence shows no improvement in clinical outcomes: TENS (transcutaneous electrical nerve stimulation),A traction,A specific back exercises,A education pamphlets about symptoms,A massage,A acupuncture,A and surgery (unless disc compression is indicated).A
- Evidence of harm: use of narcotics or diazepam;A bed rest for more than 2 days;A bed rest, with or without traction;A manipulation under general anaesthesia;A and a plaster jacket.A
- Insufficient evidence to comment: aerobic and muscle conditioning, epidural steroid injections, shoe lifts or corsets, biofeedback, and physical agents and passive modalities (including ice, heat, short wave diathermy, and ultrasound).
Interventions where there is insufficient evidence or which may cause harm, such as opioids, diazepam and prolonged bed rest, should be avoided – although they are still advised by some clinicians. Priority should be given to treatment that improves clinical outcomes.
Give Patients the Green Light
Green Light strategies of activity advice, explanation and reassurance, and symptom control improve outcomes for people with acute low back pain.
Activity advice and reassurance
Advise patients to progressively increase their physical activity according to an agreed plan rather than being guided by their pain level. Bed rest should be avoided, particularly prolonged bed rest, which is harmful. Staying active and continuing usual activities such as walking, swimming, non-contact sports, and work (with modifications if required), usually results in a faster recovery from symptoms, less chronic disability and less time off work.
There is benefit in reassuring patients that full recovery is likely and that the activity that triggered the episode (often a common action like a bend or twist) will not cause further injury. Surgery is not indicated for non-specific acute low back pain. The long-term outcome for surgery for back-related leg pain is no better than for conservative management. However, if there is no improvement at 6 weeks, some patients with back-related leg pain and a defined disc lesion may recover more rapidly with surgery.
Symptom control
Paracetamol and non-steroidal anti-inflammatory drugs have proven effective if taken in regular doses rather than ‘as required’. Avoid potentially addictive medications such as narcotics or diazepam. It is important to combine symptom control with advice to remain active to prevent patients developing a fear of moving or using their back. Manipulation of the spine by trained practitioners using appropriate techniques is safe and effective in the first 4-6 weeks. If there are neurological signs, approach manipulation with caution.
Ongoing Management
Ongoing review helps the patient to work through their recovery plan and addresses barriers to recovery promptly. At each followup:
- give advice to stay or become active and resume usual activities
- provide specific advice on activities that may cause problems
- support return to activity with optimal pain control
Identify and address any barriers to recovery such as:
- excessively heavy or prolonged work; problems with treatment, rehabilitation or compensation; and psychosocial factors, known as Yellow Flags.
4-6 Week Follow-up
After 4weeks, if the patient has not resumed normal activities, a formal reassessment should be conducted for both Red and Yellow Flags. If progress is still delayed, reassess again at 6weeks. A full blood count, ESR and plain X-rays of the lumbar spine need to be considered even where Red Flags are absent and neurological function is normal. To help prevent long-term problems and chronic back pain, it may be necessary to refer the patient to a specialist between 4-8weeks after onset of pain.
Reference & Grades of Recommendations
- The full guideline “New Zealand Acute Low Back Pain Guide, Incorporating the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain” June2003 can be obtained at www.nzgg.org.nz. The evidence on which the recommendations are made was graded using the Scottish Intercollegiate Guidelines Network (SIGN) criteria: