If you are reading this because you are experiencing or have experienced low back pain then you may take some comfort in the fact that you are in the majority – not the minority. It is estimated that 70-90% of people will experience low back pain at some point in their life. The 2011/12 Australian Bureau of Statistics National Health Survey reported that 3 million Australians (13.6% 0f the population) were experiencing back problems. While there may be some comfort in this information it does not take your back pain away - so what should you do to manage your low back pain? There are many different health professionals/ therapists/ drugs that claim to treat low-back pain so how do you decide what path to take. Or should you just try everything? An important consideration is the financial costs associated with treatment and this can be quite substantial. For any treatment, particularly one that may hit your wallet/purse quite hard, it would be nice to know before committing to it whether it is likely to be effective in treating your back condition. There has been a lot of research in to the effectiveness of different treatments for low back pain, and guidelines established for the best management. The summary below will hopefully help you make an informed decision on how you are going to manage your condition.

On review of different International Guidelines for the management of back pain there are some consistent features that all seem to agree on1:
Acute back pain (within 4-6 weeks) sufferers should be encouraged in to early and gradual activation/movement; bed-rest is discouraged and any individual factors that may lead to the injury becoming chronic should be identified.
Chronic back pain (3+ months) responds to supervised exercises, education and behavioural changes to help the condition and a multi-disciplinary treatment approach to address the contributing factors. Despite wide variations in treatment patients seem to experience broadly similar outcomes although the cost of treatment can vary substantially2. So costs associated with treatment should be an important factor when deciding your treatment provider. Beyond cost, here is what the research suggests your care provider should employ in your management:
Acute Back Pain

  • Patients should be reassured of a favourable prognosis, advised to stay active, use of medication if needed, bed-rest is discouraged and there is no need for a supervised exercise program1.

  • Imaging or other diagnostic tests should not be routinely performed unless a more serious injury is suspected2.

  • You should be provided with information on your injury, the expected course it will run and be provided with effective self-care options2.

  • If medication is required then for most patients first line medications are simple paracetamol or Non-Steroidal Anti-Inflammatories2.

  • Manual therapy/ mobilisations can provide small to moderate short-term benefits2.

  • Exercise therapy is as effective as other conservative treatments and there appears to be no additional benefit to spinal manipulative therapy than other recommended therapies2.

 In summary, if your treatment provider can provide you with good information and advice regarding self-management strategies and prescribes exercises you can easily perform yourself then you should make a good recovery without having to fork out lots of money. If you find manual therapy helps your pain levels you may decide to receive this treatment as your pain settles.

Chronic Back Pain

  • The use of modalities (therapeutic ultrasound, electrotherapy) should be discouraged and short-term use of medication may be beneficial1.

  • You should be performing a supervised exercise therapy1.

  • All contributing factors (physical and non-physical) should be identified and appropriately addressed through multi-disciplinary treatment1.

  • Self-care is important, including advice on staying active and education about your condition2,3.

  • Medications may be required and non-pharmacological treatments that have shown effectiveness in treating chronic back pain include manipulative therapy (manipulations/mobilisations); exercise therapy; massage; acupuncture; yoga; cognitive behavioural therapy; progressive relaxation or multi-disciplinary approach involving a selection of the above2.

  • Exercise therapy has an effect in reducing pain and improving function4. Programs incorporating individual tailoring, supervision and a combination of stretching and strengthening are associated with the best outcomes1.

  • Massage is more likely to be beneficial when combined with exercises and education and pressure point massage appears to offer more relief than traditional Swedish7.

  • Spinal manipulative therapy (manipulation or mobilisation) appears as effective (no better or worse) than other existing therapies6.

Again an active approach is important when managing chronic low back pain. It appears some form of appropriate supervised exercise program that has been tailored to your presentation is important and may be complimented by appropriate manual treatment such as massage, mobilisation and/or manipulation or acupuncture. Again cost-effectiveness is important when deciding upon your treatment provider/providers so you should consider whether a provider offers a suitable combination of the above treatments.

There are many options available for treating your back pain. Hopefully the summary above helps you make a more informed choice when deciding your treatment approach.

Stuart McKay
APA Physiotherapist

1. Koes BW, van Tulder M, Lin CC, Macedo, LG, McAuley J, & Maher, C (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 19: 2075-2094
2. Chou R, Qaseem A, Snow V, Casey D, Cross Jr T, Shekelle P & Owens DK (2007) Diagnosis and Treatment of Low Back Pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 147: 478-491
3. National Institute for Health and Care Excellence (NICE) Clinical guideline 88 (2009). Low Back Pain: Early management of persistent non-specific low back pain (guidance.nice.org.uk/cg88).
4. Hayden J, van Tulder MW, Malmivaara A & Koes, BW (2005) Exercise therapy for treatment of non-specific low back pain (Review). The Cochrane Library 2005, Issue 3
5. Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW (2012) Spinal manipulative therapy for acute low-back pain (Review). The Cochrane Library 2012, Issue 9
6. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR & van Tulder MW (2011) Spinal manipulative therapy for chronic low-back pain (Review). The Cochrane Library 2011, Issue 2
7. Furlan AD, Imamura M, Dryden T & Irvin E (2008) Massage for low-back pain (Review). The Cochrane Library 2008, Issue 4

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