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Non-specific low back pan which persists for some time is a common presentation for various health care practitioners to deal with, representing a major reason for absence from work due to sickness. Research has moved ahead quickly over the last decade, making a scientific view of assessment and treatment recommendations possible which could lead to predictable benefits for patients with persistent low back pain. The National Institute for Clinical Excellence (NICE) has just released a new set of guidelines in May 2009.

The first requirement in the assessment of back pain is to establish a diagnosis. By definition the source is not clear in non-specific low back pain but many potential diagnoses have been ruled out such as ankylosing spondylitis, arthritic diseases, fractures, infections or tumours. Diagnosis is not a one time thing with periodic reassessment important if things change, and investigations should be requested if a specific diagnosis is suspected. Radicular symptoms in the leg, typically called sciatica, and cauda equina syndrome are neurological syndromes which cause severe and very specific symptoms and need consultation with a spinal surgeon.

Low back pain has been typically classified as acute, sub-acute and chronic. Acute back pain is said to be back pain of a duration of less than six weeks, while sub-acute back pain is said to continue between six and twelve weeks. Over twelve weeks the back pain is said to be chronic although this classification may be too rigid to reflect the reality of the incidence patterns of low back pain. Many people’s symptoms vary significantly with more and less acute episodes over a long period of time.

In the UK adult population around a third are thought to suffer from an episode of low back pain every year. Of this number around a fifth of sufferers will attend their GP to seek help for their back pain. Research has shown that it persists for a long period with 62% of sufferers still having pain at one year after the onset. Patients who are unable to work due to their back pain episode have a 16% probability of still being off work due to back pain after a year. The disability and pain improves rapidly over the first month but with little more after three months.

The costs of back pain are very large although up to date figures are difficult to come by. Costs not borne by the NHS are high in the UK with patients consulting private physiotherapists, osteopaths, chiropractors and acupuncturists. Exclusion of important causes for low back pain is vital when someone presents with a new episode or a worsening. Malignant changes are more likely in older people and in anyone with a history of tumours which can spread to bones. Infections may be more likely in anyone with a compromised immune system such as suffering from HIV. Older people are more likely to suffer osteoporotic fractures, particularly women after menopause or anyone who has been on oral steroids.

The early management of non-specific low back pain which persists for any time from six weeks to a year is to ensure the episode does not turn into long term disability, loss of normal activities and loss of work. Distress, disability and pain are the important factors which must be addressed to improve the outcome, as high levels of pain, high disability and psychological distress are predictive of a poorer outcome.  A very large number of treatments exist and are claimed to be helpful but the scientific basis for most treatments is not good. The NICE group decided to look at an overall package of care, potentially deliverable by many professional groups, rather than individual therapies.

Typical interventions for the management of low back pain include:

Psychological therapies such as a form of cognitive behavioural therapy, mindfulness and self-management.

Non-invasive physical therapies such as transcutaneous electrical nerve stimulation, traction, spinal corsets, interferential, laser and ultrasound.

Manual therapy which covers massage, mobilisations and manipulation.

Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.

Psychological interventions to improve self management, either mindfulness or a form of cognitive behavioural therapy.

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