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ARTICLE #10: PEOPLE WHO GET CLEAR ADVICE ABOUT THEIR BACK PROBLEM DO MUCH BETTER

At a glance:
People who were given advice that empowered them to understand and manage their back problem:

• had 50% less days absent from work
• were twice as likely to return to work
• were half as likely to have a long term disability
• had 50% less disability when followed up five years later.

PERSPECTIVES:

Employee
Understanding how to best manage your back pain will help reduce your suffering, assist you in getting back to your normal life, and speed your recovery.

Back pain can settle over weeks or months, and sometimes takes a year or two to resolve. However, most people are able to return to a good level of function within a short space of time. Most people return to their normal level of home and work activity even with a sore back.

This study shows that patients with a lower back problem who continued normal activities, learnt how to stretch to relieve pain, and understood that lower back pain isn't likely to be serious, recovered better.

Discuss this with your doctor or treating health professional to help decide what the best treatment for your back problem is.

Employer
Back pain can be severe and draining. People with back pain are often worried, and their workplace can make a major contribution to improving their confidence.

Those with back pain often believe that once your back goes it is serious and long term. However, research shows that back pain is not a serious long term problem for most people.

Supporting employees with back pain to get the best advice and encouraging them to return to work as soon as possible is not only good for your organization but will assist them to recover and return to normal health more quickly.

Treater
Low-back pain is one of the most common symptoms causing adult patients to seek medical attention. A number of studies have now looked at the best practice for management of back pain.

Excluding serious pathology is important. Key questions need to be asked about age, history of cancer, trauma, unexplained weight loss, immunosuppression, duration of symptoms, responsiveness to previous therapy, pain that is worse at rest, history of intravenous drug use, and urinary or other infection. After excluding these 'red flags,' the symptom of pain that radiates into the leg, particularly if it goes below the knee, and findings of a positive straight-leg raising test or its equivalent, help to separate patients with radicular back pain from those with other types of back pain.

The prognosis for patients with either mechanical or radicular back pain is very good. About 50% return to normal activities within 4 weeks, and 95% return by 6 months. This favorable prognosis and the fact that history and physical examination indicate nothing serious is wrong needs to be stressed to the concerned patient. For those with back pain, the treatment should focus on an early return to usual activities. Over-medicalizing acute low-back pain through an emphasis on bed rest, continued passive treatments, or restriction of usual activities probably lengthens rather than shortens the time to improvement.

A realistic approach to a patient's fears and expectations, combined with appropriate conservative care, should improve the treatment of low-back pain. Providing advice and explanations to patients often sounds simple but it takes preparation and time. The treating doctors and physiotherapists in this study provided meaningful advice, using analogies to help the person understand the condition. An interview with the clinic specialist provides an explanation.

The essential elements were:

• Reassurance that lower back pain does not usually indicate a serious problem
• Explanation of back pain and muscle spasm
• Demonstration of stretching to relieve pain
• Encouragement to continue normal activities

Only a small number of musculoskeletal specialists focus on providing advice and explanation. This study shows that simple information from the primary care professional can be effective in preventing disability from back pain.

Insurer
This study suggests we should encourage people to be as active as possible in returning to work.

When patients are told to continue with normal activities, they have control over their day to day tasks at home or at work and can be active or rest and stretch when appropriate.

Lower Back Pain is rarely the result of a serious disease, but an assessment by a medical practitioner is needed to exclude the presence of serious conditions before deciding on treatment.

Original Article, Authors & Publication Details:
A. Indahl1, L. Velund1 and O. Reikeraas2 (1995).

Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine; 20(4):473-477.

1Oestfold Central Hospital, Fredrikstad
2National Center for Orthopedics, Oslo, Norway

Background, Study Objectives, How It Was Done:
In the 1980s and 1990s rest was often recommended for back pain. However, there was little evidence rest was helping back pain sufferers, and doctors began to take a more active approach to recovering from their own back pain. The authors of this research study looked at the effects of a more active approach to treating back pain, giving patients the management program that doctors generally undertook themselves.

In this study, patients with back pain who had been off work for 8-12 weeks were divided into a control group and a treatment group. The control group continued with their “normal care', which consisted of seeing their local doctor and continuing any other treatment (e.g. physiotherapy) they were having. The treatment group continued with normal care (as did the control group), but with the addition of attending the specialist clinic.

The patients who attended the specialist clinic all had a CT scan of their back. The results of the CT scan did not alter the advice given. The same advice was given to people with normal scans, disc bulges (“herniated' disc) and disc prolapse (“slipped' disc), as they all had similar symptoms. Those who required surgery, however, were excluded from the study.

Patients attended the clinic on two occasions, and both times were given information about their back pain. They were reassured that the back pain was unlikely to be a serious problem. It was explained to patients that severe back pain was best thought of as inadequate circulation in the muscles and that the resulting muscle spasms and pain did not indicate a serious long term problem.

They were advised to continue doing normal activities. Advice to continue activities encouraged people to return to normal lives. It was strongly emphasized that the worst thing they could do for their back was to be too careful.

They were advised:

• There was probably a small crack in a disc in their spine
• This crack caused reflex spasms and decreased circulation in the muscles of the back
• The decreased circulation caused their pain and stiffness
• This in turn could lead to guarding of the back muscles, increasing muscular tightness, and therefore increasing pain.
• They were assured that light activity would not injure the disc or any other structure, and was more likely to enhance the repair process

Further advice included:

• The link between emotions and low back pain was explained as a muscular response, increasing tension in the muscles which could increase the pain

• The worst thing they could do for their back was to be careful. Great emphasis was put on removing fears about low back pain

• Mobilizing the spine regularly by activity such as walking would help circulation and decrease pain
• They should set their own goals for recovery
• They should avoid sitting or standing still, and awkward postures

• Acute stabling pain as muscle spasm should be treated with stretching and light activity. Each patient was given a demonstration on how to stretch their back.

Each patient was reviewed after 3 months, the advice reinforced and any questions answered.

Study Findings:
There was a highly significant (50%) reduction in sickness absence from work for the treatment group. That is, people who were given advice to help them understand and manage their back problem did significantly better than those who weren't. They were twice as likely to return to work, and half as likely to have a long term disability with a long period off work.

The researchers were able to follow up the study participants five years later. They found that the results were long-lasting: 19% of the treatment group were off work five years after they attended the specialist clinic, while 34% of the control group, who had not been given information and advice, were off work.

In addition, the treatment group had fewer recurrences of sick leave than the control group (who did not receive information and advice).

Conclusions:
This landmark study showed clearly that the usual treatment of rest for low back pain does not work. It also showed that that advice to be active, and return to usual activities, prevented disability and helped people to recover and get back to work.

We are aware that long term disability from a back problem is associated with many other problems, such as depression, isolation, and financial difficulty. This simple intervention gave back pain sufferers advice that they understood and could use, and suggested a positive way to manage their back problem. This treatment approach took time, but was not expensive and did not have the side effects that can accompany medication or surgery. Outcomes were much better for the patients and the community.

The information from this 1993 study is not always followed. Patients with back pain are still often advised to protect their back and to avoid activities that hurt. This study shows that being active will assist recovery.

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