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Effective services for the care of patients with back pain

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David Pinnock, MSc, RN, DipHE, Clinical Nurse Specialist

Nottingham Back Team, Mobility Centre, City Hospital, Nottingham

Back pain is an extremely common symptom experienced by between 60 and 80% of people at some time in their lives (Papageorgiou et al, 1995). In most cases it is self-limiting, with approximately 46% of cases resolving within four weeks of onset (Mason, 1994). Most commonly it causes minimal interference with daily activities (Croft et al, 1996). However, for others, it is severely disabling (Croft et al, 1996) and impacts dramatically on their quality of life (Ruta et al, 1999).

Back pain is an extremely common symptom experienced by between 60 and 80% of people at some time in their lives (Papageorgiou et al, 1995). In most cases it is self-limiting, with approximately 46% of cases resolving within four weeks of onset (Mason, 1994). Most commonly it causes minimal interference with daily activities (Croft et al, 1996). However, for others, it is severely disabling (Croft et al, 1996) and impacts dramatically on their quality of life (Ruta et al, 1999).



When it comes to helping people whose back pain does not resolve there has, historically, been a considerable degree of debate about the most effective treatment. Many changes that can be seen on scan or X-ray, such as disc degeneration, that are the focus of medical interventions to reduce pain, frequently occur without causing back problems (Savage et al, 1997).



Treating people who very frequently have no unequivocal cause for their pain, has long been a challenge to health-care services (Waddell, 1998) and a source of lengthy debate in the professional literature. This debate led to a large-scale formal examination of the back-pain phenomenon in the UK in the form of the Clinical Standards Advisory Group (CSAG) Report on Back Pain (CSAG, 1994).



The findings of this landmark report (CSAG, 1994) represents the defining principles of most contemporary services for people with back pain in the UK. The report demonstrated that the resources being used to treat back pain had increased considerably but that, contrary to expectations, disability had risen. Indeed, back pain-related disability was shown to be increasing at an alarming rate. Between 1978 and 1992 the number of days of benefit paid for back pain disability had increased by 208% (CSAG, 1994), and numbers were shown to be continuing to rise.



The authors of the report concluded by suggesting that: ‘Traditional medical treatment has certainly not solved our present epidemic of low back pain disability’ (CSAG, 1994). They also noted that: ‘There is a clear need to reconsider our whole approach to the management of low back pain and disability’ (CSAG, 1994).



The report produced guidelines for the treatment of acute back pain (Table 1), with the aim of preventing disability and reducing symptoms. The guidelines began with an assessment to exclude serious underlying pathology, through prompt triage to provide medical intervention to those who are most likely to benefit from it. These clear reasons for specialist referral, such as progressive neurological disease, tumour, infection or unremitting nerve root pain were named ‘red flags’.



This aspect of the report also removed those who had no potentially dangerous cause for their symptoms from the traditional medical model of care. The guidelines concentrate on people who have what the report describes as ‘simple back pain’ although back pain is rarely simple. The report also emphasised the need for back pain to be viewed as more than a physiological anomaly. The authors suggested it is a biopsychosocial phenomenon made up of independent elements (Table 2).



The New Zealand low back pain project (Kendall et al, 1997) further emphasised the importance of psychosocial factors in the course of an individual’s back pain, identifying key factors in the development of chronic problems that they called ‘yellow flags’ (Table 3).



The Nottingham Back Team approach
In Nottingham a team was assembled to organise and deliver care to people referred to see a spinal surgeon who were very unlikely to be offered medical treatment for their back problem. The team comprises nurses, occupational therapists, physiotherapists, clinical psychologists, a project manager and team secretary.



The team is committed to viewing chronic back pain as a biopsychosocial phenomenon that, because of its complex nature, requires multidisciplinary management. The first stage of this management is assessment and triage.



AssessmentIn accordance with the CSAG guidelines we offer our patients an holistic assessment of their back pain. This assessment aims to exclude any ‘red flags’ and, through liaison with local spinal surgeons, we can facilitate urgent referral to medical specialists. We also consider the relative influence of psychosocial factors, including yellow flags. It has been demonstrated, for example, that patients with chronic back pain often experience psychological distress (Croft et al, 1996).



The success of future treatment is dependent on an assessment that identifies the key effects the back pain is having not only on individuals’ functional activities (what they are doing) but also their attitudes and beliefs (why they do what they do), their psychological health, and their behaviour. The team assessment also has a therapeutic element. It is our first opportunity to address and adjust our patients’ negative thoughts and beliefs about their back pain.



To address these ‘yellow flag’ psychosocial issues we offer three levels of treatment for patients to match the range of psychosocial problems that their back pain represents and the assessment identifies the most appropriate group for the individual. As a result of the thorough assessment process, treatment is applied using principles of cognitive behavioural therapy and incorporates: education, exercise, relaxation and advice about the rational use of analgesics.



To emphasise the biopsychosocial approach to back pain, treatment is offered away from places that may be associated with the medical model of care, such as leisure centres. It is hoped that some patients will continue to use these facilities when their treatment has finished.



EducationThe team sees education as a vital part of treatment that shifts people’s understanding and views on their back pain. However, education alone has been demonstrated to have a very variable level of effect in back-pain sufferers. Cherkin et al (1996) found that, although some patients found the information they were given helpful, it made no difference to their symptoms or the course of their back pain. Conversely, Little et al (2001) demonstrated the usefulness of primary care physicians giving literature and advice.



The mixed effectiveness of providing information for patients suggests that perhaps a key point is the manner and framework in which the information is given.The Nottingham team uses interactive teaching strategies supplemented by printed information sheets. During the education session we discuss issues and challenge people’s misconceptions about their back problems. A good example is the relative lack of importance of X-ray and scan findings. These are frequently a source of anxiety for patients but can often be clinically insignificant. Indeed, education becomes a part of the overall cognitive behavioural approach that we use in virtually all aspects of the treatment we offer.



There is some evidence that a cognitive behavioural approach to treat chronic (van Tulder et al, 2000) and sub-acute back pain (Karjalainen, 2001) can be effective. These approaches to treatment involve identifying and modifying patients’ cognitions towards their pain and adjusting their behaviour.



RelaxationRelaxation is an accepted component of the vast majority of chronic pain management treatment packages and the team practices and encourages patients to use several techniques. The underlying principle of its use is that it can lead to a reduction in pain and engender a feeling of control over the pain in patients (Buckelew et al, 1998). The many techniques that can be used all attempt to counteract the effects of the stress response such as muscle tension, hyperventilation, and heightened mental arousal. There is little actual evidence to support the effectiveness of relaxation as an individual strategy. McQuay and Moore (1997) identified only a few studies of low quality in their review on this subject. However, relaxation is an element of many cognitive behavioural treatment packages and therefore it could be argued that it is effective. The team finds that patients frequently find relaxation helpful and pleasant.



When examining the effectiveness of various elements of a treatment package it is difficult to separate the effects of one element from another - a problem affecting all cognitive behavioural treatment programmes (Guzman et al, 2001).



ExerciseExercise is recognised as an essential element in the treatment of lower back pain in both the acute and chronic states. Logically, a key part of treating a problem that causes dysfunction is to return to activity and function, which may be achieved through exercise.



Mannion et al (1999) found that those following active therapies for chronic low back pain experienced reductions in disability and pain intensity and in fear of movement and use of negative strategies for coping with their back pain. However, while there is agreement regarding the benefits of exercise, there is a debate about how exercise works for people with back pain and what type is most effective. van Tulder et al’s review of randomised controlled trials for the Cochrane Collaboration Back Review Group (2001) report could draw no conclusions about what type of exercise was most effective in chronic back pain.



As a team we address this issue pragmatically by giving people exercises that are most likely to help them achieve their goals and help them in their daily lives. So a patient who is having difficulty putting on his socks and shoes will be given an exercise to improve his range of movement into forward flexion to make that task easier.



AnalgesiaThe principles of using medications to manage back pain are to tailor analgesia to the elements of pain the patient reports. This means treating the nociceptive, neuropathic and inflammatory dimensions of the back pain.



Paracetamol and mild opiates have both been shown to be reasonably effective in treating back pain, particularly in combination (De Craen et al, 1996) and would tackle the nociceptive element of the pain. The Nottingham team advocates the use of ibuprofen and diclofenac as the best tolerated (Henry et al, 1996) and most effective non-steroidal anti-inflammatory drugs (Cherkin et al, 1998) to address the inflammatory element of the pain. Routine use of antidepressants to treat low back pain is inappropriate; however, in cases of nerve root entrapment amitriptyline may be helpful; some studies have shown positive results from the use of antidepressants (van Tulder et al, 1997).



The guiding principles in advising about medication use are twofold. First, only those medications that have demonstrable efficacy in the treatment of chronic back pain are advocated. Second, it is made clear to patients that analgesia alone will not help them much with their back pain; they need to combine it with active rehabilitation, emphasising the importance of a rounded biopsychosocial approach.



This paper has discussed back pain and charted the growth of multidisciplinary teams using a biopsychosocial model to manage this condition.



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