Non-Surgical Management of Non-Specific Low Back Pain Evidence Based Medicine

Dr. Yusef Sarhan,FACRM

Definition of Pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

Epidemiology

Life time prevalence is up to 84% Relapses of pain 44-78% Relapses of work absenteeism 23-37% Prevalence of chronic non-specific LBP of 23% (best estimate) Disability by LBP 11-12% population Population at any given time 4-33%

WHO and EU guidelines

Classifications (Diagnostic Triage)

Specific pathology Radiculopathy Non-specific (85%)

Duration

Acute up to (4)6 weeks Sub-acute (4)6-12 weeks Chronic >12 weeks

Acute <6 wk

Subacute 6wk to 3 mo

Chronic >3 mo

90% resolves within six weeks

Imagined Course
8 7 6 5 4 3 2 1 0

Real Course
7 6 5 4 3 2 1 0

Natural Course
On average 62% (range 42-75%) of the patients still experienced pain after 12 months, and 16% (range 3-40%) were sick listed 6 months after inclusion.
The mean prevalence of low back pain reported in cases with previous episodes was 56% (range 14-93%), which compared with 22% (range 7-39%) for those with no prior history of low back pain.

Hestbaek L,et, al. Low Back Pain: what is the long-term course? A review of studies of general patient population. Eur Spine J 2003; 12)2): 149-65

Evidenced Based Review and Guidelines

The Cochrane Database of Systematic Review. Philadelphia Panel. SUB-The Swedish Council on Technology Assessment in Health Care. European Guidelines. Annals of Internal Medicine (American Pain Society and American College of physician) Clinical Practice Guidelines. New Zealand Guidelines. NICE clinical guidelines. CLIP clinical guidelines.

Diagnostic Triage

Non-Surgical Management of Chronic Non-Specific Low Back Pain Evidence Based Medicine

Concept of Diagnosis

Use of Diagnosis triage No radiographic imaging is recommended unless a specific cause is suspected EMG, NCS can not be recommended Assessment of prognostic factors

Assessment of prognostic factors

Work related factors Psychosocial distress Depressive mood Severity of pain Functional impact Prior episode of LBP Extreme symptom reporting Unrealistic patient expectation

Management of CLBP according to (Flags Approach)

Red Flags Orange Flags Yellow Flags Blue Flags Black Flags

Red Flags (serious spinal pathology)

Sphincter disturbances Gait disturbances Saddle anaesthesia Age <20 or >50 Non-mechanical pain

Thoracic pain PH of Ca, steroids, HIV Unwell, weight loss Widespread neurology Structural deformity

Yellow Flags (person)

Thoughts: Catastrophising (focusing on the worst possible outcome) Inaccurate beliefs about the condition, pain and harm Negative expectations about the future Feelings: Worry, distress, low mood Fear of movement Uncertainty for the future

Behaviour: Extreme symptom reporting Passive coping strategies Repeated ineffective therapy

Blue flags (workplace)

Fear of re-injury High physical job demand Low expectation of return to work Low job satisfaction Low support Lack of adjustments Poor communication

Black Flags (context)

Misunderstanding between key players (patient, employer, doctor) Financial/ compensation problems Process delays (waiting lists) Sensationalist media reporting Spouse/ family beliefs Social isolation Unhelpful company policies

Not Recommended

Complete Bed Rest Firm Mattresses. TENS. Biofeedback. Traction (?can not) Lumbar Support (?can not)

Can Not Be Recommended

Ultrasound Interferential Low-level laser therapy Thermotherapy Shortwave diathermy Massage Acupuncture

Recommended

Stay active Exercise therapy (Individualized, supervised, Stretching and strengthening) Multidisciplinary Treatments (Bio-psycho-social) Cognitive Behavioral Therapy Functional Restoration Manual Therapy Back Schools Yoga

Successful Rehabilitation Program

Exercise Therapy
- Individually designed - Supervised - Including Stretching and Strengthening

Cognitive-Behavioral Approach (with progressive relaxation) Mechanisms of adherence Aerobic Component

Documentation Based Care (DBC)

DBC Treatment Concept
Treatment Device

Patient

Assessment

Individualized Treatment Plan

Outcome Monitoring

Support Function

Baseline Assessment (Standardized)

1. Questionnaires

Medical background Pain intensity, duration and drawing Psychological questionnaires

- Fear-Avoidance - Rimon Brief Depression Scale - Recovery Locus of Control

Physical Impairment Index Job description and working status Physical activity Stress VAS Personal Goals

2. Examination Range of motion Fatigue and EMG activity in Low back muscles Isometric strengthening Balance

Individualized Treatment Program

Pattern of the disorder Duration of treatment Exercises - Setting ROM - Setting load and progression Cognitive and Behavioral support Supporting elements - Relaxation and functional exercises - Psychological and work place intervention Maintaining Results

Monitoring Outcome

Progress check and outcome evaluation Follow up Reports

It is more important to add life to years, rather than add years to life

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