Monday, August 10, 2009

low back pain - general information

low back pain - general information

how common is low back pain and how long does it last? Low back pain is very common and it's becoming commoner. In the USA the number of people disabled by back pain has grown 14x faster than the general population1, a greater growth of medical disability than with any other disease. 21% of UK adults suffer backache in any fortnight2 and about 2% lose time from work annually with an average duration of nearly 26 days per episode. Happily most back pain gets better fairly quickly - for example one study3 found that of 100 patients consulting their GP, 44% were better within a week, 86% within a month and 92% within two months. It's encouraging too to know that back pain may well become less common4 when one reaches one's 60's and older. Even long term "failed backs" may well ease with time5 - typically with the pain becoming less constant. Despite the body's self-healing abilities, back pain can be hell. How can one get better quicker and reduce the chances of getting further attacks? If one is unlucky enough to have persistent pain, what can be done to help?

what causes back pain and how can it be helped? Factors associated with increased risk6 of low back pain and sciatica include physical fitness, body weight, car driving, smoking, height, psychological distress, and age group 30 to 50. Several different structures may be involved in mechanical back pain - for example muscles, ligaments, nerves, joints, discs and bones. Precise diagnosis is typically more a matter of opinion than hard fact7. Happily just as we don't have to know what virus we have and the kind of immune response that it has caused in order to recover from a common cold, so too a diagnosis of non-specific mechanical low back pain is usually quite good enough as a basis for developing effective treatment. When considering how to help back trouble, it is often useful to think in terms of three general areas: the treatment of back pain of recent onset, how to prevent back pain recurring, and how to help persistent long term pain.

recent onset back pain: Remember that the great majority of back pain episodes are likely to get better within days or a few weeks3 even with no specific treatment. Pain can often be eased with medication, massage, and local heat or cold. These measures may well make the back more comfortable, though they probably won't affect the actual speed of recovery itself. Bed rest does have a part to play in back pain treatment, but it should be used sparingly8. For bad back pain with no leg involvement, 2 days rest appears to yield as good results as 7 days. When there is pain radiation to the lower leg, one can try rest for up to 2 weeks. It is probably OK to get up to go to the toilet and possibly for eating too. Resting too much may well prolong the time it takes to get better. If they don't flare the pain too badly or for too long, walking and swimming are likely to help. Take it slowly and build up what you can do. The McKenzie exercises are also worth considering9. Physiotherapy, osteopathy, chiropractic and acupuncture can all at times speed recovery, but acute recent onset back pain usually gets better quite quickly on its own. Unless the pain is particularly bad, it's worth waiting at least a week or two before seeking help.

how to prevent back pain recurring: As a therapist, one of the first questions I would ask here is whether the back is really absolutely fine between attacks. If there are some minor symptoms even between flare ups, then it may reduce future attacks to treat the areas that are still giving trouble. For example one can use physiotherapy, exercises, manipulation, acupuncture or injections. If there are really no symptoms between attacks then treatment by a therapist doing something actively to you is unlikely to be useful. Self-help has much more chance of being effective. Becoming physically fitter10, losing weight, stopping smoking and doing something about stress may all be of use6. So too may modifying working conditions or reducing the amount of time spent driving. Some people find using a lumbar roll11 or changing their sitting position in other ways can be helpful. It clearly makes sense as well to learn correct ways to lift and carry. Increasing physical fitness seems particularly worthwhile as, like stopping smoking, [PTO] increased fitness can be helpful in so many ways (see the companion sheet on How important is physical exercise?). Improved heart-lung stamina is important - as a bonus this also improves one's psychological state and reduces death rates from heart disease and cancer. Strength and flexibility also need to be considered. Unfortunately 80% of adults don't take enough exercise.

coping with persistent pain: Surprisingly pain, distress and disability don't all necessarily worsen and improve together. It's usually more helpful to think in terms of overall quality of life rather than just concentrating on the pain by itself. Surgery has a limited place. It may be useful for well-defined nerve root symptoms. Physiotherapy, acupuncture, manipulation and injections all also have a part to play - so too may transcutaneous nerve stimulation (TENS)12. Gradually increasing strength and fitness is extremely important10. Informed advice about exercise may well be helpful, as too is reducing unnecessary medication. Connie Peck's book13 discusses these and other issues. The Back Pain Association14 is a good source of support and there are local group activities, including hydrotherapy. James Hawkins's tape15 gives useful general advice as well as introducing the use of relaxation. Long term persistent pain is immensely hard to live with. With determination and help it is certainly possible to make the situation considerably better.

books, references & other resources:

1. National Center of Health Statistics. (1981) Prevalence of selected impairment. United States 1977. Hyattsville, Maryland: Dept. Health and Hum. Services. 1981. Nat. Center of Health Statisitics. Series 10, Number 134.
2. Wood,P.H.N. & Baddeley,E.M. (1980) Epidemiology of back pain,in M.I.V.Jayson (ed) The lumbar spine and back pain, 2nd ed., Tunbridge Wells, Pitman.
3. Dillane,J.B.,Fry,J. & Kalton,E. (1966) Acute back syndrome - a study from General Practice, Br.Med.J. 2: 82-4.
4. Hay,M.C. (1974) The incidence of low back pain in Busselton,in Twomey,L.T. (ed) Symposium: low back pain, Western Aust. Inst. Tech., Perth.
5. Crook,J.,Weir,R. & Tunks,E. (1989) An epidemiological follow-up survey of persistent pain sufferers in a group family practice and speciality pain clinic, Pain 36: 49-61.
6. Ernst,E. (1991) Primary prevention of back trouble: what can we tell our patients? Phys Med & Rehabil 2(2): editorial.
7. Jayson,M.I.V. (1984) Difficult diagnoses in back pain, Br.Med.J. 288: 740-1.
8. Spitzer,W.O.,LeBlanc,F.E.,Dupuis,M.,Abenhaim,L.,Belanger,A.Y. et al. (1987) Scientific approach to the assessment and management of activity-related spinal disorders, Spine 12: Number 7S.
9. McKenzie,R. (1985) Treat your own back, 4th ed., Waikanae, N.Z., Spinal Publications. McKenzie has also written a book on self-help neck treatment. Both books should be available at £7.99 each from Ferrier's Ltd, 8 Teviot Place, Edinburgh EH1 2RB. Tel: 031-225 5325. They can no doubt be ordered through other bookshops as well.
10. Rodriquez,A.A.,Bilkey,W.J. & Agre,J.C. (1992) Therapeutic exercise in chronic neck and back pain. Arch Phys Med Rehabil 73: 870-5.
11. Lumbar rolls can be ordered from PO Box 275, West Byfleet, Surrey KT14 6ET. An alternative deluxe lumbar support - the Backfriend - can be bought from MEDesign Ltd, Clock Tower Works, Railway St., Southport PR8 5BB. Tel: 0704-542373. MEDesign also stock a variety of other equipment which can help those with low back pain - ask for their catalogue.
12. Ottoson,D. & Lundeberg,T. (1988) Pain treatment by TENS: a practical manual, Berlin, Springer-Verlag. There are many suppliers of TENS machines. One possibility is the Pulsar range made by Spembly Medical Ltd., Newbury Road, Andover, Hampshire SP10 4DR. Tel: 0264-365741. You may be able to borrow one from a physiotherapy or pain clinic.
13. Peck,C. (1985) Controlling chronic pain, London, Fontana. Out of print, so order a copy through your library.
14. Back Pain Association, 31-33 Park Road, Teddington, Middlesex TW11 0AB. Tel: 081-977 5474. Send SAE for their leaflets. The Lothian Branch of the BPA can be contacted through Mary Taggart, 36 Rosemount Buildings, Edinburgh. Tel: 031-229 8832. They run various activities including a weekly hydrotherapy session at the Astlie Ainslie.
15. Hawkins,J. (1992) Coping with persistent pain, self-help tape available from BHMA, Royal Shrewsbury Hospital South, Shrewsbury, SY3 8XF. Tel: 01743-261155. All proceeds go to help the work of the BHMA, a medical charity.

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