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Principle Recommendations

• The report on "Clinical Guidelines for the Management of Acute Low Back Pain" was published by the Royal College of General Practitioners in 1996. It was designed to help doctors and other health professionals with the multi-disciplinary approach to the initial assessment, triage, and evidence-based management of acute low back pain (LBP).
• Medical assessment (diagnostic triage) should occur to exclude treatable causes (sciatica, red flags such as carcinoma, HIV, spinal abscess, spinal cord compression). X-rays are not routinely indicated for simple back pain. Biopsychosocial assessment should occur early.
• Pain killers (relievers, analgesics) should be prescribed regularly and not "as required" to be more effective. Start with paracetamol, adding in anti-inflammatory drugs (ibuprofen, diclofenac), and weak opioids (codeine) as necessary. Consider a short course of a muscle relaxant (diazepam max. 7 days). Avoid strong opioids if possible (morphine max. 7 days).
• Bed rest is not a treatment for simple low back pain. Bed rest may need to be taken early on in the episode, but this should not be considered a treatment. Bed rest for longer than 3 days has been shown to be harmful by delaying the speed of recovery.
• Stay as active as possible and continue with normal daily activities. Gently increase activity levels after an acute episode of back pain over a period of days to weeks. If you are in work, then either stay at work or return to work as soon as possible. Prolonged periods off work will reduce your overall chance of working again (e.g. only 2% of people can return to work after 1 year off sick).
• Spinal manipulation treatment within the first 6 weeks has been shown to beneficial for pain relief and rehabilitation in those where the back pain does not resolve spontaneously.
• Active rehabilitation (exercise programme OR physical re-conditioning) should be started at 6 weeks if there has not been return to work or resumption of normal activities.
• Advising Patients about work - Advice for patients and GP's

Evidence Review

Evidence exists to support the following statements

1. Most severe LBP and severe activity limitation improves considerably in a few days or at most a few weeks, but milder symptoms may persist longer, often for a few months.
2. Most people will have some recurrences of back pain from time to time. Recurrences are normal and do not mean that you have re-injured your back or that your condition is getting worse.
3. About 10% of people will have some persisting symptoms a year later, but most of them can manage to continue with most normal activities. People who return to normal activities feel healthier, use fewer analgesics, and are less distressed than those who limit their activities.
4. The longer someone is off work with LBP, the lower their chance of ever returning to work.
5. LBP does not usually increase with age, but becomes (slightly) less common after age 50-60. However, older people who do continue to have back pain may have more persistent symptoms and more activity limitation.
6. Appropriate information and advice about acute LBP can reduce anxiety and improve patient satisfaction with care.

• Diagnostic Triage of acute LBP should occur to be able to classify people into one of three groups - simple backache OR nerve root pain OR possible serious pathology (tumour, infection, inflammatory disorders, spinal cord compression). This last group requires an urgent specialist referral.
• X-rays are not indicated for acute LBP within the first month unless there are red flags. X-rays are suggested in the following circumstances - recent significant trauma to the spine (any age), mild trauma (over 50 years), history of prolonged steroid use, osteoporosis, age >70years. X-rays plus simple blood tests may help rule out tumours or infection in people with previous history of cancer, persistent fever, IV drug abuse, prolonged steroid use, LBP worse with rest, unexplained weight loss. MRI, CT or Bone scans may be indicated in those with red flags and a normal X-ray.
• Psychological, Social and Economic factors play an important role in people with chronic LBP and disability, and at an earlier stage than previously believed. Psychosocial factors influence the patient's response to treatment and rehabilitation.
• Evidence exists for the following treatments for acute LBP  - pain killer combinations such as paracetamol with codeine plus an anti-inflammatory drug for acute LBP (but not for sciatica), short term muscle relaxants, staying active within the limits of your pain, return to work as soon as practicable, spinal manipulation treatments within the first 6 weeks, back exercises (weaker evidence), epidural steroid injections for good short term relief of sciatic pain.
• There is inconclusive evidence for the following treatments for acute LBP - ice, heat, short wave diathermy, massage, ultrasound, traction, TENS, insoles, corsets, trigger point injections, ligament sclerosants, acupuncture, facet joint injections, and biofeedback.
• Evidence exists against the following treatments for acute LBP - strong opioids (morphine) for longer than 2 weeks, muscle relaxants (diazepam) for longer than 2 weeks, oral steroids, bed rest with traction, manipulation under anaesthesia, and plaster jackets.

Diagnostic Triage

The following descriptions are a simple guide to diagnosing types of back problems in the pain clinic:-

• Simple Backache is defined as presentation between ages 20 -55 years, perceived in the lumbo-sacral region, buttocks and thighs, which seems mechanical in nature (varies with physical activity and with time), and where the patient is well. 90% of people recover within 6 weeks.
• Nerve Root Pain (Sciatica) is likely to be the diagnosis when leg pain is worse than lower back pain, where the pain radiates to the foot or toes, where there is numbness and tingling in the same distribution as the leg pain, where there are nerve root irritation signs (positive straight leg raising test or slump test), and where examination suggests changes in leg strength, sensation, and reflexes specific to one spinal nerve root. 50% of people recover within 6 weeks.
• Red Flags for possible serious pathology include age of onset less than 20 or greater than 55 years, violent trauma (e.g. fall from a height or road traffic accident), constant progressive non-mechanical pain, thoracic pain, previous history of cancer, long term oral steroid use, history of drug abuse or HIV, patient systemically unwell, recent unexplained weight loss, persisting severe restriction of forward trunk flexion, widespread neurological changes, and structural deformity.
• Cauda Equina Syndrome / Widespread Neurological Disorder is likely to be the diagnosis where there is recent onset of incontinence of urine, loss of anal tone with incontinence of faeces, numbness affecting the anus, perineum and genitals, widespread (more than one nerve root) or progressive loss of strength in the legs or walking disturbance, and the appearance of a sensory level on pinprick testing. Urgent referral to a spinal surgeon is recommended to prevent paralysis and permanent loss of bladder and bowel control.
• Spinal Inflammatory Disease e.g. ankylosing spondylitis and related disorders is likely to be the diagnosis where there is gradual onset before the age of 40 years, marked morning stiffness, persisting limitation of spinal movements in all directions, peripheral joint involvement, eye inflammation, psoriasis, colitis, urethral discharge, and a strong family history of similar problems.

Biopsychosocial Assessment

Biopsychosocial assessment consists of the following three parts:-

• Biomedical Assessment should include a history and examination to exclude nerve root problems and serious spinal pathology. Blood tests (ESR) and X-rays are the initial investigations to aid diagnosis.
• Psychological Assessment should occur to record the patient's attitudes and beliefs about back pain (e.g. fear avoidance beliefs about activity and work, and where the responsibility lies for chronic pain management and rehabilitation). Signs of psychological distress, depressive symptoms, and illness behaviour should be sought.
• Social Assessment should occur to examine the family attitudes and beliefs about LBP, and whether they are reinforcing disability behaviour in the patient. A work history should be taken to look at the physical demands of the job, job satisfaction, other health problems causing time off work, and non-health problems causing time off work.

Chronic LBP Risk factors

The following 14 items have been shown to increase the risk of developing chronic LBP:-

• Previous history of LBP
• Total absence from work over the last 12 months
• Radiating leg pain (sciatica)
• Reduced straight leg raising (positive sciatic nerve irritation test)
• Signs of nerve root involvement
• Reduced trunk strength and endurance
• Poor physical fitness
• Poor self-rated health
• Heavy smoking
• Psychological distress and depressive symptoms
• Disproportionate illness behaviour
• Low job satisfaction
• Personal problems (alcohol, marital , financial)
• Adversarial medico-legal proceedings