Simple back pain is identified as an adult patient between 25 – 55 years with the pain restricted to the back, buttocks and thighs and aggravated by exercise and varying in severity from time to time. The patient is otherwise fit.
In contrast, with nerve root pain or sciatica, there is pain radiating down the thigh and leg to the foot often with numbness and tingling. In these patients there may well be a prolapsed intervertebral disc.
The final group are those in whom there is some possible serious disease and in whom detailed investigations are required. Causes of suspicion includes a patient less than 20 or more than 55 years; a history of injury to the back; the pain is constant and gradually progressive and may spread up the spine into the back of the chest; some serious illness in the past or be on drugs like steroids; the patient may feel ill or lose weight; evidence of damage to more than one nerve. Examination of the back may show some alteration in the shape of the spine. In these patients there may be important underlying problems and detailed tests may be necessary.
Q. Most doctors now encourage patients with back pain to remain active. What evidence is there that this is more effective than rest and what are the exceptions?
A. There has been a radical change in our approach to management of patients with acute simple back pain. In the past we advised patients to rest until the pain resolved. Indeed we often told patients that they should go to bed, lie flat and await resolution of the problem and following this they should very carefully mobilise.
Research in recent years has shown that this advice was wrong. The first study was by a physician Richard Deyo. He compared the results from patients whose bed rest was limited to two days compared with those for seven days. Those in only whom two days bed rest was prescribed recovered more rapidly and got back to work sooner.
There have been several subsequent studies showing similar results. In particular a study comparing bed rest, traditional physiotherapy treatments and encouraging patients to remains at work if possible showed that those remaining at work provided the best results.
So the current advice now is that patients should remain at work if at all possible. If they are off work it should be for the shortest period of time. If the pain is extremely severe, they may need to rest in bed but again this should be for a minimal period. Return to exercise and activity as soon as possible provides the best results.
Q. Is there any evidence that a particular type of painkiller works better than others?
A. For the vast majority of patients simple painkillers such as paracetamol are sufficient. In severe pain paracetamol may be mixed with stronger analgesics in combined tablets such as Co-Codamol, Co-Proxamol or Co-Dydramol. Very rarely opiod analgesics are necessary. They are very much stronger but generally are not required for patients with back problems.
An alternative to pure painkillers are the anti-inflammatory dugs like Ibuprofen, Diclofenac and Naproxen etc. They combine an anti-inflammatory effect with a pain relieving effect and for some patients they may be much more likely to produce indigestion and abdominal upsets and many patients experience difficulties with them. Recent developments in these drugs has been directed at trying to separate the painkilling effects from the indigestion producing effect. In some patients there is a lot of muscle spasm and under those circumstances we sometimes use a muscle relaxant.
In chronic back pain we now know that secondary changes in the brain and spinal cord play an important part in making back symptoms much more painful. For these patients drugs such as Amitriptyline work well whereas simple analgesics do not help.
Finally some patients experience a neuralgic type of pain with shooting electric shock type pains spreading down the leg. The anti-epileptic drugs are used because they quieten down the nerve cells in the spinal cord in the same way as they quieten down the nerve cells in the brain to prevent epileptic fits.
Q. Do you support the use of manipulative therapies such as physiotherapy, osteopathy and chiropractic?
A. Manipulation has been used as a form of treatment for back pain since the time of Hippocrates. The ancient medical literature contains illustrations of forms of manipulation often combined with traction and sometimes other forms of physical treatment.
In the nineteenth century osteopathic manipulation was developed by Andrew Taylor Still and chiropractic D.G.Palmer. Although they helped many back pain patients, unrealistic claims were made for treating numerous other diseases with the result that the medical establishment looked upon osteopathy and chiropractic with suspicion.
Things have changed dramatically and today osteopathic and chiropractic manipulation together, with manipulation practiced by physiotherapists, manipulative physicians and orthopaedic surgeons have become commonly used forms of treatment.
Scientific trials have been undertaken of manipulation including two by my own group. The overall results suggest that manipulation is effective in helping people recover from acute episodes of back pain more quickly than conventional treatment alone. There is debate about whether these treatments have long lasting benefits. One study has suggested that following manipulation many cases of back pain have less problems in subsequent years but this is not proven.
The various practitioners all manipulate in different ways. There is no good evidence that one form of manipulation is better or worse than any other. Whether any benefit is specifically due to the manipulation or alternatively general mobilisation of the back and encouragement remains to be determined.
Q. When should patients with back pain be X rayed?
A. When we look at X-rays we examine shadows of bones. The X-rays do not show the soft tissues. In the back they may show the space occupied by the disc and if a disc is very worn then this becomes obvious. However subtle soft tissue changes in the disc will not be apparent.
X-rays involve exposure to radiation. Because the X-ray taken of the back has to go through a lot of tissue the radiation exposure will be high and in consequence best avoided if at all possible.
In acute simple backache there is not need for an X-ray. By use of the assessment method described in the first answer, it is possible to identify the patients in whom it is extremely unlikely that there is any serious pathology and for these people X-rays do not help in the management and are harmful in exposing them to unnecessary radiation. If simple backache fails to get better over say 6 to 8 weeks, then investigations including an X-ray may be required.
In nerve root pain with sciatica the X-rays are usually uninformative and if the problem does not remit, more detailed investigations such as MRI scan may be required because this enables us to see the detail of the disc and what may be happening.
The primary requirement for X-rays is the patient with possible serious spinal pathology. The clinical features will suggest there may be some important underlying problem and in those cases X-rays are necessary.
Q. Why do you think that back pain is becoming more common?
A. Over the last twenty years there has been an exponential rise in the number of working days lost to back pain. Surprisingly however the actual number of incidents of back pain remain virtually unchanged. Back pain is not becoming more common. What has changed is that the disability associated with back pain has increased dramatically.
There appears to be a number of reasons for this change. There has been the belief that the patient suffering from back pain should protect the back and for this reason many people rest until the back recovers. We now know that advice has been harmful rather than beneficial and has aggravated disability with back pain and prolonged the period off work. General practitioners have been only too willing to sign off certificates for the back pain patient, whereas we now know they should have been encouraging the person to stay at work if at all possible. Employers have been extremely cautious and have encouraged the disabled worker to rest at home and protect the back fearing that the job may aggravate the problem.
All this has led to the present problem. The current advice is aimed at reversing this approach. There is a glimmer on the horizon that back disability will be reduced by these means but there is much ground to be retrieved.
Q. When do you think a referral to a specialist is appropriate?
A. Specialist referral is not required for simple back pain. These patients can be managed very easily by the general practitioner, physiotherapist, osteopath or chiropractor. A specialist referral is only necessary if the problem persists and fails to resolve. If the patient is no better by six to eight weeks then he or she should be referred to a rheumatologist or a pain specialist.
In the patient with sciatica with acute pain running down a lower limb there is probably nerve root damage by a herniated intervertebral disc. Careful examination will indicate whether or not this is likely to be the case. Patients such as this may well need surgery. If the pain does not resolve within six weeks then the patient should be referred to an orthopaedic surgeon or a neurosurgeon.
The concern is the patient with possible serious spinal pathology. These are the patients who may well be unwell or show evidence suggesting some underlying problem. Careful investigation is required to determine the underlying diagnosis before any treatment can be contemplated. Patients such as this should be referred to see the rheumatologist who has the important diagnostic skills.
Emergency referral may be required for the patient who has evidence of severe nerve root damage. The patient may complain of pain, numbness or tingling spreading into both lower limbs. There may be numbness in the perineum (saddle region) and loss of bladder control and bowel function. Such patients may have a large disc prolapse and an emergency referral to a neurosurgeon or possible an orthopaedic surgeon may be necessary to prevent permanent nerve damage.
