Back pain is the most common condition that we see as an osteo. I can tell you now, my weeks are full of patients coming to see me with back pain.
I get all types of patients that present to the clinic; from patients experiencing back pain for the first time, to others having a reoccurrence or severe flare-up, and then to those who go on to develop chronic disabling pain.
With the diverse types of presentation, it can be confusing to know what is best practice, how to manage the patient's pain levels, and ultimately help the patient get back to doing what they love.
The power of natural history
So here is the thing, the majority of the adult population will have a case of non-specific lower back pain (NSLBP; ie: the absence of specific underlying condition) [1,2,3,4,5]. Most of the time people will get better on their own, however, a small portion will continue to have pain and develop into subacute back pain (4-12 weeks), and chronic back pain (CLBP; lasting >12 weeks) [6].
So don’t freak out when people come in distressed, frustrated, or impatient. It’s normal, they are in pain.
In this blog, we will be discussing the treatment of NSLBP. NSLBP is different from specific ‘acute’ conditions such as a vertebral compression fracture, lumbosacral radiculopathy, lumbar spinal stenosis, occupational back pain, and chronic lower back pain. They all have different treatment and management plans to NSLBP and we endeavor to discuss specific conditions in a separate blog.
So here we go:
Treatment Principles for NSLBP:
Your primary goal is Symptomatic Relief
In general, the primary goal of your patients with acute low back pain (LBP) is short-term symptomatic relief. Of course, patients want that. But don’t forget most NSLBP will self-resolve within four weeks. And that's why it's important to encourage patients to go down the pathway of nonpharmacological treatment before pharmacotherapy [4].
You might be thinking, but what if a patient asks you about medication that should be on?
Well, that's a good question. It's important to remember your scope of practice and follow the guidelines. We'll discuss medications a bit later down the blog.
Our bread and butter is Manual Therapy
Here is what we know you can do to help. Our bread and butter as health practitioners is manual therapy (hands-on osteopathic treatment).
When it comes to nonpharmacological treatment, the evidence suggests that there is no superior intervention over another. Superficial heat, massage, acupuncture, and spinal manipulation have been shown to be equally beneficial and have a lower to moderate effectiveness [7].
With patients who are having a reoccurrence or flare-up, what I find helpful to determine the effectiveness of the what type of manual therapy to do is to ask the patient what has worked in the past. This is where you can get easy wins with the patient and the results that they desire. It's such a simple trick, that can change the outcome in an instant.
Not quite getting the results - should you lean towards medication?
Sometimes manual therapy, reassurance, and natural history aren't enough to help the patient get back on track. Sometimes you need more than the simple tricks. You shouldn't stress about it because there is no magic bullet to the treatment for lower back pain. It's normal to experience setbacks.
Everyone is different so everyone will need different avenues to their back. This is where I find having a discussion with the patient on trialing some medications may be useful.
If non-drug treatment is insufficient or the patient prefers pharmacotherapy, nonsteroidal anti-inflammatory drugs (NSAIDs) may be indicated. For complex cases, there are other medications that are available, however, these are beyond the scope of this blog and would require the patient to obtain a prescription from a medical practitioner.
Motion is lotion – Exercise prescription & Activity Modification
Establishing safe movement is imperative as patients who keep active recover faster [8]. Patients will naturally want to avoid certain activities, however, modifying activities should be kept to a minimum. If the patient experiences pain, then advising them how to gradually increase activity as tolerated is important.
In our experience, short rest periods are appropriate, however, avoid prolonged periods of inactivity as it can hinder the recovery process. This is where we find that individualized treatment is necessary and movement preferences (such as the McKenzie method or an ease-bind concept or pain-free approach) to establish safe-anxiety-free movements can be useful.
Patient Education
Patient education is an important aspect of any care. Patients want to be educated on the cause of their LBP, how long it’s going to take for them to recovery, whether further imaging is required, modification of activity and work, and when they need to follow up with you [9].
A 2015 systematic review found that educating patients on the benign nature, the good prognosis of LBP, and the recommendation to stay active, had a decrease in patients visits to primary care and provided long-term reassurance compared to usual care [10].
In our experience, education is necessary, but not sufficient to result in improved outcomes. You should also encourage delaying further imaging and reassure that prognosis of LBP is excellent in most patients.
Prognosis
LBP prognosis is considered excellent for most patients because only one-third of patients seek medical care [11], and for those who do seek care, 22-90% improve within 7 weeks [12, 13].
Recurrences of pain are common and affect up to 50% of the patient within 6 months and 22% within 12 months [14, 15]. These recurrences have a similar prognosis to their initial experience.
Some patients will, unfortunately, develop CLBP, and the estimate of those who do vary; between 5 -20% [14, 15, 16, 17]. Factors that influence the likelihood of developing CLBP are fear of movement, functional impairment, poor general health, presence of mental health/psychosocial related factors [18,19].
Prevention
Prevention of LBP is still a hot debate. Exercise intervention may reduce recurrence. Using lumbar supports, stopping smoking, and or losing weight has been shown to support the prevention of LBP [20, 21], however, there is minimal to no evidence that suggests spinal manipulation reduced the risk of reoccurrence [22].
Clinical Mentorship
You can become the LBP expert for your patients
Learn to apply an evidence-based approach along your osteopathy skill to better manage acute lower back pain. We help you understand the evidence of LBP, how to communicate and reassure your patients with the confidence to get better patient outcomes and practitioner satisfaction.
Learn to take control of your clinical practice. Discover more about us and share your journey with us. To download a copy of the references, email OsteoCoachAU@gmail.com
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