Topic Summary - Low back pain
This case assesses the candidate’s management of a common condition. The candidate must safely assess the patient with a targeted history and examination. The request for an X-Ray should prompt an exploration of the patients’ ideas, concerns and expectations. The candidate should explain the appropriate use of investigations with empathy for the patients concerns. A good candidate will reach a shared understanding of risk and management based on evidence for good practice.
Must be assessed in ALL patients with back pain
· backache in <20 years or > 55 years
· history of cancer or immune suppression
· non mechanical back pain (i.e. not related to movement)
o inflammatory pain is
§ worse in the second half of the night or after waking.
§ associated with morning stiffness lasting more than 30 minutes.
§ is relieved by activity.
· thoracic pain
· systemic features (weight loss, night sweats, fever)
· widespread neurological signs (disturbed micturition/anal tone, saddle anaesthesia, widespread progressive
motor weakness, gait problems)
· progressive neurological signs
· structural deformity or major trauma associated with backache
· steroid use or drug abuse
· severe nocturnal pain that disturbs sleep
A focused history and brief clinical exam are adequate to diagnose simple/‘non specific’ low back pain
· No investigations are required for simple low back pain
· Check that pain originates in the lower back (not hip/pelvis)
· Assess for risk of long term pain/disability (Yellow Flags)
o Misunderstanding of the cause of back pain.
o The belief that pain and activity are harmful.
o Sickness behaviours, such as extended rest.
o Overprotective family
o Social withdrawal, lack of support.
o Emotional problems such as low or negative mood, depression, anxiety, or feeling under stress.
o Problems with claims for compensation or applications for social benefits.
o Inappropriate expectations of treatment, such as low expectations of active participation in treatment.
In addition, for employees, assess for:
o Prolonged time off work.
o Problems or dissatisfaction at work.
o Lack of support from the employer or co-workers.
o Pessimistic expectations of ability to return to work.
· Inspection for bony deformity
· SLR for nerve root irritation
· Sciatic stretch
The natural history
• 50–80% recover completely in 4 weeks without treatment and 90% in 6 weeks.
• in 80% of cases no specific diagnosis is made;
• however, nearly 70% of patients who ever experience an episode will suffer three or more recurrences.
When to refer
Evidence of cauda equina syndrome or widespread neurological disorder (disturbed micturition/anal tone, saddle anaesthesia, widespread progressive motor weakness, gait problems).
‘Red flag’ signs suggestive of serious pathology;
Simple backache and non-progressive nerve root entrapment should normally be managed within general practice, but referred if prolonged (not returned to normal activities in 3 months) and unresolved.
Tell the patient about the cause, treatment and self management – encourage positive thinking and self efficacy & correct any misunderstandings
· Acute non-specific low back pain is a mechanical problem —caused by disturbance of function, not by serious structural damage.
· Back pain is an everyday bodily symptom — it is not a disease in itself.
· Acute non-specific low back pain settles in most people, but back pain does tend to recur at irregular intervals
Understanding the treatment
· Pain control is routinely provided in the expectation that the pain will be temporary.
· Recovery is helped by getting moving again and getting back to work as soon as possible.
· A positive attitude is important in coping with the problem.
· Medication can be taken to relieve the pain.
· Staying physically active is likely to be beneficial.
· Bed rest should not be prolonged any longer than is necessary.
· Normal activities should be resumed as soon as possible. Because many normal postures and movements will stimulate some pain, resuming normal activities should be paced by conducting them at a reduced level or slower rate. The aim is to do a little more each day.
· Keeping as active as possible and exercising regularly is important. Participating in a structured exercise programme should be considered (if available). Suitable exercise includes aerobic activities, movement instruction, muscle strengthening, postural control, and stretching.
· Care should be taken when lifting and twisting.
· A cold pack or local heat can relieve back pain.
· A small firm cushion between the knees when sleeping on the side, or several firm pillows propping the knees up when lying on the back, may ease symptoms.
· Return to work as soon as possible.
o There is no need to wait for complete freedom from pain before returning to work.
o Work adjustments can make an early return to work possible.
o Returning to work helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.
· Simple analgesia
· Diazepam for muscle spasm if indicated
If red flags present or if symptoms fail to improve within 6 weeks of onset
National Collaborating Centre for Primary Care 2009