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Managing back pain in primary care

Louise Letley
RN
Senior Research Nurse
MRC General Practice Research Framework
London
E:l.letley@gprf.mrc.ac.uk
 
In a 1998 Office of National Statistics (ONS) survey,(1) 40% of adults reported back pain lasting for more than 1 day in the previous year. Of these, 15% reported that they were in pain throughout the year and 40% had consulted their GP, placing a considerable burden on general practice. In 1998 the cost of general practice consultations was estimated at £141m and the overall cost of back pain, including time away from work and incapacity benefits, was more than the costs for many other conditions including coronary heart disease, stroke, lower respiratory tract infections and depression.(2)
Back pain is a complex condition and although most episodes resolve spontaneously recurrences are common and a proportion of patients will go on to suffer from chronic back pain. A number of treatments are used for back pain but the evidence of effectiveness for many is weak. It is difficult for the primary care practitioner to know which patient is going to benefit from what treatment. The evidence review that underpins the RCGP clinical guidelines for the management of acute low back pain summarises the available evidence, indicating the strength of the evidence, and makes recommendations for the assessment and treatment of acute low back pain.(3)

Diagnosis and assessment
Low back pain is diagnosed by clinical history and examination. Lumbar spine X-rays are not indicated in the management of simple back pain but are occasionally useful when a serious underlying cause such as malignancy is suspected. However, keep in mind that lumbar spine X-rays result in 150 times as much exposure to radiation as chest X-rays.
Most back pain can be managed effectively in primary care. Specialist referral is only required when there are signs of serious spinal pathology (also known as "red flags" - see Table 1) or where the back pain is not resolving. Low back pain can be defined as:

  • Acute - lasting less than 6 weeks.
  • Subacute - lasting between 6 and 12 weeks.
  • Chronic - lasting more than 12 weeks.

[[NIP12_table1_20]]

The RCGP guidelines categorise low back pain and include recommendations for referral as follows.(3)

Simple backache

  • Presentation between 20 and 55 years of age.
  • Pain in the lumbosacral region, buttocks and thighs.
  • Pain varies with time and physical activity.
  • Patient is otherwise well.

These patients can be managed in general practice.

Nerve root pain

  • Unilateral leg pain worse than the back pain.
  • Pain radiating to foot or toes.
  • Numbness and paraesthesia in affected foot or toes.
  • Signs of nerve irritation.
  • Motor, sensory or reflex change (limited to one nerve root).

In the absence of any signs of possible serious spinal pathology these patients can be managed within general practice. Specialist referral should be considered if symptoms of nerve root pain are not resolving. Fifty per cent will recover within 6 weeks.

Cauda equina syndrome

  • Difficulty with micturition.
  • Loss of anal sphincter tone/faecal incontinence.
  • Saddle anaesthesia, loss of sensation to the ­buttocks, perineum and inner surfaces of the thighs.

Emergency specialist referral required

Treatment
The management of simple back pain is relatively straightforward with 90% of patients recovering within 6 weeks. As the primary care nurse is increasingly involved in triage and treating minor ailments s(he) will come into contact with patients with low back pain on a regular basis. The advice in Table 2 is based on the best evidence currently available.

[[NIP12_table2_21]]

Drug therapy
In practices where nurses are qualified to undertake supplementary prescribing it is now possible to consider management of back pain via a clinical management plan (CMP) agreed with the GP independent prescriber. As part of their CMP patients can also receive support from the nurse in relation to health education advice and concordance.
Present guidance states that:(3)

  • Analgesics should be prescribed to be taken ­regularly, not as required.
  • Simple analgesics such as paracetamol or aspirin should be used as firstline treatment.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at alleviating back pain but can have serious side-effects, particularly at high doses or in the elderly.
  • Ibuprofen has the lowest risk of gastrointestinal side-effects, followed by diclofenac.
  • If simple analgesia or NSAIDs are ineffective, a paracetamol/weak opioid compound such as ­ co-dydramol may be effective.
  • If pain is still uncontrolled muscle relaxants such as diazepam may be used. Due to adverse effects and risk of addiction, these should only be used in courses of less than one week.

For patients with back pain that is not resolving and whose daily activities continue to be limited, there are other treatments that they may find helpful. However, as the evidence base for the effectiveness of these therapies is limited it is difficult to know which patients are most likely to benefit.

Symptomatic relief
Ice, heat, massage, transcutaneous electrical nerve stimulation (TENS), and ultrasound may be useful for symptom control but they do not appear to have any beneficial effect on disease progression or outcome.

Manipulation
This is generally carried out by an osteopath, chiropractor or manipulating physiotherapist. The principles used by each professional are similar but the techniques are different. The risk of complications from manipulation by qualified therapists is very small. There is some evidence that manipulation is effective in improving pain relief and activity level in the short term in acute and subacute back pain.

Exercise
There is no evidence that specific back exercises are helpful in acute back pain. There is weak evidence that exercise programmes based on cognitive behavioural principles may improve levels of pain and increase activity in patients with chronic back pain.

Acupuncture
There is no evidence available to enable acupuncture to be recommended as a treatment for back pain.

Risk factors for chronicity
There are a number of factors known to increase the risk of developing chronic back pain.(3) These include both physical factors, such as a previous history of back pain, radiating leg pain, reduced straight leg raising and signs of nerve root involvement, and psychosocial factors (also known as yellow flags - see Table 3). Although yellow flags are important predictors for chronicity there is no data to advise on the best way of managing these patients.

[[NIP12_table3_22]]

The role of the practice nurse in the diagnosis and treatment of back pain
Familiarity with diagnostic triage for back pain will enable the practice nurse to:

  1. Provide appropriate advice and reassurance to patients with simple back pain.
  2. Identify any patients who consult them about back pain who have "red flags" for possible serious spinal pathology for whom further investigation should be considered.
  3. Identify the warning signs for cauda equina ­compression requiring emergency referral.

Advising patients with back pain to remain as active as possible may help to reduce the burden of back pain disability. As well as giving this advice when consulted about back pain it can be integrated into routine consultations, such as new patient checks.
The Back Book, available from The Stationery Office, is a patient information leaflet based on the RCGP guidelines and is available to order online (see Resources section).

Future research
As back pain is such a complex condition and the available evidence for effectiveness of treatments is generally weak, there is a need for additional, high-quality primary care research in this area.
Recently the UK Backpain, Exercise And Manipulation (UK BEAM) trial, a multicentre randomised trial, investigated the effectiveness and cost-effectiveness of physical treatments for back pain in primary care. A total of 1,334 patients throughout the UK were recruited from 181 general practices from the MRC General Practice Research Framework. This is the largest ever back pain study and data, which are currently being analysed, will provide valuable information for the primary care professional involved in the management of patients with back pain.
Further details on this and other musculoskeletal research studies undertaken within the MRC General Practice Research Framework can be found at www.mrc-gprf.ac.uk

References

  1. Office of National Statistics. The prevalence of back pain in Great Britain in 1998. London: HMSO; 1999.
  2. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95-103.
  3. Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M. Low back pain - evidence review. London: RCGP; 1999.

Resources
RCGP low back pain evidence review
W:www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/index.asp

Arthritis Research Campaign
Back pain section
W:www.arc.org.uk/about_arth/booklets/6002/ 6002.htm

Patient UK
Back pain section
W:www.patient.org.uk/showdoc.asp?doc=139

The Back Book Available from
W:www.tso.co.uk/bookshop

MRC General Practice Research Framework
W:www.mrc-gprf.ac.uk