FEATURE ARTICLE: Low Back Pain: Focus On Self-Management - DEVDEEP AHUJA

Low Back Pain: Focus on Self Management:  Low back pain is a major health problem around the world which accounts for considerable socioeconomic and healthcare burden. The life time incidence of LBP has been reported between 60-80% (Twomey 2000; O’Sullivan 2005) and out of these incidents in about 80-90% cases pain subsides within first 2-3 months and rest of the patients (around 10-20%) develop chronic pain syndromes (Carey et al 2000). Chronic low back pain (CLBP) patients comprises 73-77% of all the patients with lower back pain disorders. In about 85% of these patients the exact cause and diagnosis is still elusive (Main and Watson 1999) and classified as non specific chronic lower back pain (NSCLBP) (Waddell 2004).

A considerable amount of research has been conducted to explore the biomechanical aspects of back pain and a vast number of manifestations has been reported in CLBP patients such as altered muscle recruitment with sudden loading and unloading ( Richardson et al 2004), poor balance (Radebold et al 2001), poor proprioception(O'Sullivan et al 2003), inability to initiate muscle contraction (O’Sullivan 2000) and associated structural spinal tissue anomalies (radiological instability, Disc herniation, facet joint degeneration) (O'Sullivan et al 2003). Numerous modalities of therapeutic interventions are available for treatment of low back pain: surgery, drugs, manipulation, physical therapy, behaviour therapy, massage, and neural blockade. But there is wide reported discrepancy between the effectiveness of these modalities in achieving long lasting pain relief for patients with low back pain, even though most modalities may provide short term pain relief. Having so many treatment options may mean that none of these have any strong impact on improving outcomes in low back pain. This persistence of pain shows the existence of non-structural and psychological factors in addition to physical pathology which might be contributing towards nociception even after resolution of the physical pathology.

Over the years, there has been a shift in terms of patient involvement from being a passive recipient to active self-management to achieve long term pain relief. Most low back pain guidelines like NICE, Australian Acute Musculoskeletal Pain Guidelines etc. now recommend self-management as an important strategy for managing patients with low back pain. So instead of daily regular application of electro therapeutic modalities like ultrasound, short wave diathermy, etc., along with heat packs and exercises and traction, physiotherapists should be encouraging patients to understand their symptoms, aggravating factors, easing factors and then use exercises, activities and strategies to manage these symptoms on their own while the therapist can play a monitoring role in modifying and enhancing the program as needed.

This would need a paradigm shift from both the patient and therapist in terms of moving the locus of control from therapist (external) to patient (internal), where patient feels responsible for their own pain and that they have to make an effort to get rid of the pain instead of depending upon the therapist to 'crack and fix' their spine to ease low back pain. I remember working as a physiotherapist in India about 5 years ago, we would see our low back pain patients every day, apply all the modalities possible, use fancy manual therapy and taping techniques. It would help us get results, our patients were happy and went home satisfied with their treatment. But the disconcerting thing was that patients had recurrence of pain after a period of time and had to go through the same rigamorale of treatment again, which then served to over medicalize their conditions. Even today, I have come across patients who get a few sessions of physiotherapy, do not get better, then are referred to an Orthopedic Consultant, who undertakes evaluation and then requests MRI scan and other expensive investigations and then when nothing can be found, simply refer the patient back to physiotherapist confirming that it is a soft tissue injury to undergo the same treatment once again. So unless patients are given the tools and knowledge to be able to take charge of their own pain and self manage, this downward spiral of patients returning with recurring low back pain will not be resolved.

So what does self management of low back pain include?- Providing self management strategies means giving patients the tools to take control of their symptoms and be able to use preventive and management strategies to minimise impact on work and function. This needs to start at the outset, during assessment/ evaluation, with clear explanation of findings or lack thereof and its meaning. Patients need to be given clear information about the nature of non specific low back pain. It is imperative that any red flags/ systemic conditions which can cause low back pain are ruled out. Self management also involves encouraging patients to stay active and continue with their normal activities of daily living as much as possible instead of taking rest, which has been shown to have no beneficial effect and indeed can be a deterrent to recovery. 

The next aspect of self management is providing patients with advice on posture and preventative strategies, so that they are able to use these to avoid aggravating their pain while trying to maintain their normal activities of daily living. Examples include advice about correct lifting, bending, and turning, sitting, standing, walking and driving positions / postures. Next the focus of self management advise needs to be exercises. Patients should be made aware of the general health benefits of exercises and specific exercises to alleviate low back pain. These exercises can be incorporate a combination of general fitness routine like walking, swimming and back specific exercises woven into a bespoke program tailored as per the ability and needs of the patients. Self management programs also need to incorporate advice about the warning signs, such as numbness/ pins and needles in legs or difficulty passing urine. Patients must be stressed the importance of seeing a doctor straight away if they experience any of these symptoms along with their low back pain.

It is also important to understand that self management will not work for everyone. It is important to be able to identify patients who will adhere to self management strategies against those who have an external locus of control and will depend on their doctor or physiotherapist for management of their condition. General criteria which can be used to define patient groups who will benefit from self management include patients who are active, have low severity, their condition is long standing and either has stayed the same or improved very gradually. It is important to consider other management options like mobilization/ manipulation, acupuncture, injections etc. in patients who need present with high severity of low back pain before they can be considered suitable for self management program.In summary, self management presents a useful option for low back pain patients with low severity or chronic ongoing condition. Its success can be dependent on selecting appropriate patients and providing bespoke tailored advice and exercise programs to suit their needs. But physiotherapist need patients to move away from the ‘crack and fix’ mindset to allow long lasting successful rehabilitation. 

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