The non-pharmacological treatment of back pain

Summary
Back pain is a common condition which often settles spontaneously, thus justifying a conservative approach to management by both practitioner and patient. Patients benefit from a confident and knowledgeable practitioner who can dispel doubts and myths, provide appropriate back education and reassurance, outline a logical management plan and refer to other therapists if necessary. The great variety of treatments available indicates the lack of a `quick fix' cure. All treatments have some, albeit limited, benefit. The most beneficial treatments are rest for 2-3 days, exercises and appropriate physical therapy.

Introduction
Back pain is a very common presenting problem in general practice. Approximately 85% of the Australian population will experience back pain at some stage of their lives, while 70% of the world's population will have at least one disabling episode. At least 50% of these people will recover within two weeks and 75% within the month, but recurrences are frequent and have been reported in 40-70% of patients.¹ In the U.S.A., back pain is the most common cause of limitation of activity in people under 45 years of age.¹

The most common cause of back pain presenting to the doctor is dysfunction of the spinal intervertebral joints (mechanical back pain) due to injury. This problem accounts for about 72% of cases of back pain, while lumbar spondylosis (degenerative osteoarthritis) is responsible for about 10% of painful backs presenting to the general practitioner.² Lumbar spondylosis, which is typically encountered in the older patient, causes marked stiffness and deep aching pain present after strenuous activity or rest. Mechanical pain is provoked by activity and relieved by rest while inflammatory pain is worse at rest and relieved by moderate activity.

The management of back pain depends on the cause. Since most of the problems are mechanical and there is a tendency to natural resolution, conservative treatment is appropriate. Practitioners should have a clear-cut management plan with a firm, precise, reassuring and conservative clinical approach.

The first consultation
This interaction has important prognostic implications for the therapeutic relationship and pain relief. It is appropriate for the practitioner to have a very positive attitude to the problem, and to show competence in the clinical evaluation of the presenting problem. The patient needs to feel believed and feel confident in the practitioner's ability to manage the problem. The stereotypes that describe migrant workers as accident prone or malingerers cannot be supported.³

A detailed history of the problem, a physical examination which can be performed quite quickly and appropriate investigations can exclude other causes of back pain. Not all patients, e.g. young patients presenting with acute back pain for the first time after a traumatic event, require radiological investigation. Such a decision is based on the clinical findings and medico-legal factors.

It is incumbent on the practitioner to provide competent care from the onset with appropriate referrals where necessary so that the patient remains in mainstream medicine and is not tempted to gravitate to alternate practitioners who may confuse management.

Explanation and reassurance
The symptom of back pain, like arthritis, can have disturbing connotations for many patients, especially those who identify it with chronic, perhaps lifelong, disability. For some, persistent pain may imply cancer — a fact which we tend to forget.

The patient needs and deserves appropriate reassurance and explanation about the nature of the problem, its generally benign nature and good prognosis. In this context, the degree of professionalism of the therapist plays a major role in the therapeutic outcome. A confident, knowledgeable and interested approach gives the patient a feeling of security and confidence in the practitioner.

Rest and back pain
The Hilton concept of rest and pain is applicable to back pain.⁴ Studies have highlighted the importance of strict rest for 2-3 days for patients with acute disabling pain. Bed rest beyond this time does not significantly improve the outcome. This optimal period of bed rest is one of the few scientifically validated therapies for back pain.^5,6

Back education program
Scandinavian studies show that back education and physiotherapy are superior to placebo treatment of acute low back pain.⁷ `Back school' education programs consist of bi-weekly instructions in the proper care and rehabilitation of the back.

The author uses an individualised back education program based on the small patient booklet called `Back pain', published by Pitmans.⁸ In this program, patients are instructed about the cause of their pain, optimal care for daily activities (e.g. advice on lifting, sitting, driving and lying down), the use of a firm mattress, posture techniques, possible aggravating factors and their avoidance, and the value of an exercise program.

Specific areas of advice:

– keep your spine straight at all times, but allow the natural lordosis of your lower back to be maintained e.g. use a lumbar support

– go to bed or lie on a mattress placed on the floor for acute pain (for 2-3 days)

– avoid sitting as much as possible. An alternative is to perch on a high bar stool or bench so that you are only supporting your legs on the floor. If lying down, do not sit up to drink; use a straw or feeding cup

– keep as relaxed as possible. Read or listen to the radio or watch television lying on the couch or floor to keep your mind occupied as well as your back straight

Exercises
An individualised exercise program is an under utilised management strategy which is very effective in the recovery and prevention of back pain. There are many effective programs, including flexion and rotation exercises, extension exercises and isometric exercises. For patients with a tendency to sciatica and very painful and limited forward flexion, the McKenzie extension exercises are beneficial.⁹ Patients with painful spinal extension will benefit from flexion and rotation exercises.

Fordyce has highlighted the psychological function of exercises in his work on operant conditioning and graded exercise programs which involve the patient in attempting to counteract the low back pain.¹⁰ This factor appears to explain partly the reason for the success of the Swedish low back pain school which involves considerable education and encouragement of the patients.

In the author's experience, an exercise prescription as early as comfort will permit is the most effective form of physical therapy in the rehabilitation and subsequent prevention of recurrences. Freestyle swimming, especially in heated pools, is an excellent form of exercise and is to be encouraged.

Physical therapy
Passive physical therapy has a significant benefit for mechanical back pain. Studies show that, for patients presenting with acute back pain, spinal mobilisation and/or manipulation is more effective than placebo in the short term and thus reduces the period of morbidity, allowing an earlier return to work.

The timing of the treatment is important. If the medical practitioner is unskilled with physical therapy, referral is appropriate. Spinal manipulation is contraindicated or ineffective in patients with acute low back pain with spasm, fixed lateral scoliosis or sciatica.

The gentler technique of mobilisation may be effective in providing relief and shortening the period of disability. Once the severe pain and spasm phase subsides (average 3-7 days), then it is usually possible to apply the more vigorous spinal manipulation technique. However, it is possible to perform manipulation safely from the outset in many patients. These are the patients who often feel that something in their back has `jammed' and feel the need for physical therapy. Such patients who have received relief, sometimes instantaneously, in the past for a similar disorder will seek out therapists who provide this treatment.

Manipulation's bad name, particularly among surgeons who have to deal with subsequent disrupted discs, is related to inappropriate spinal manipulation which aggravates the problem or fails to help over a long period of time.

Traction
Treatment with traction dates back to the time of Hippocrates. There is evidence that heavy traction helps the person with acute back pain, especially with sciatica. It does not appear to have any benefit for people with chronic back pain.

The patient can have continuous traction in hospital or even at home, or intermittent traction, either applied by the physiotherapist with a traction machine or manually by the therapist. The author prefers manual traction for the patient with acute sciatica.

The issue of inflammation and non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are used widely in the treatment of back pain. However, in many instances, they are inappropriate as there is no inflammatory component to the pain. The only benefit is from their analgesic properties which are mild.

Therefore, NSAIDs should be prescribed only when there is inflammation as evidenced by pain at rest (such as in bed in the morning) which is relieved by activity. Most cases of back pain do not fit into this category.

In sciatica, there is invariably an inflammatory reaction with oedema around the nerve roots and this problem may be aided by a 10-14 day course of NSAIDs.

Other treatments
There are many other treatments bearing testimony to the difficulty involved in managing the problem of back pain (see box next column).

All of these treatment methods have a place, but not as a major panacea. Their efficacy depends on the skill, understanding and `salesmanship' of the practitioners involved. Some of these treatments appear to be successful because the natural history coincidentally allows resolution with time. Studies by the author on injection techniques and other therapies indicate that, as a general rule, one in 4 patients will respond.

Management guidelines

Summary
The management of back pain is incorrectly portrayed as a difficult problem shrouded in medical ignorance. The physician has to provide optimal circumstances for the dysfunction problem to heal itself. The key to successful management is for the practitioner to be well informed, confident and believable, and be prepared to give or organise safe effective physical therapy for back problems which are slow to respond to conservative methods.