Management of
mechanical back pain- Manipulation: acute pain relief. No evidence for long term help.
- Physiotherapy: little evidence of useful effect.
- Exercise: no evidence to support benefit (yet) but there is some evidence that reest makes worse.
Fear-avoidance
- Confronter
- Avoider
Some evidence that (50% of) patients who are likely to develop chronic back pain can be spotted at the start, and remedial action may be taken. Markers are:
- Stressful life events
- Personality
- Somatisation
- Coping strategy
- Previous pain
Pain
50% of patients with LBP will be back to work within 6 months. Less than 20% will get back to work after being off for a year. We have inappropriate attitudes to pain:
- No time for pain - get rid of pain.
- The right person with the right power to sort it out.
- Loss of a sense of proportion, of what is normal.
- Put life on hold to wait for a cure
This leads to anger, fear, a feeling of not being taken seriously, nothing can be done. So the best way to prevent chronic back pain is to address the issues early
- Hopes: "back to normal".
- Fears: "that it gets worse".
- Wishes
"Its not fair"
"Someone has to be blamed"
We need to change the impact of pain on the patients life:
- Anxiety/depression.
- Unhelpful patterns of thinking.
- Pain behaviour.
- Goal setting.
- Problem solving.
- Cognitive coping strategies.
- Lack of control.
Strategies
- "I cant improve your pain" avoids setting up false expectations.
- Need to be allowed to go back to work.
- Pain is normal (ie having chronic pain isnt abnormal).
- Exercise early.
- Consider manipulation.
- Believe in the pain.
- Develop trust.
- Address issues eg relationships, financial.
- Avoid abandonment and perpetuating "sickness".
- Self-protection.
Cognitive-behavioural pain management
- To increase activity and exercise levels.
- To improve function by working towards realistic goals.
- To reduce intake of analgesic and psychotropic drugs.
- To reduce patients pain behaviour and incrrease well behaviours.
- To teach skills of monitoring negative thought and feelings.
Risk factors for chronicity
- Previous history of low back pain
- Total work loss (due to low back pain) in past twelve months
- Radiating leg pain
- Reduced straight leg raising
- Signs of nerve root involvement
- Reduced trunk muscle strength and endurance
- Poor physical fitness
- Self-rated health poor
- Heavy smoking
- Psychological distress and depressive symptoms
- Disproportionate illness behaviour
- Low job satisfaction
- Personal problems - alcohol, marital, financial
- Adversarial medico-legal proceedings