Evidence based treatment approach for back pain

Initial consultation:

¨  In the vast majority of people (<90%)  LBP is benign and represents a simple muscle spasm associated with a mechanical loading incident or a muscle spasm with “central mediation” associated with psychosocial or lifestyle stresses.

¨  Only 1 to 2% of people presenting with LBP will have a serious or systemic disorder, such as systemic inflammatory disorders, infections, spinal malignancy or spinal fracture.

¨  Less than 5% present with significant neurological deficits such as cauda equine syndrome.

Demystify scan results:

¨  Over-imaging for LBP is endemic in primary care (Runciman et al 2012)

¨  Radiological imaging for LBP, in the absence of red flags, progressive neurological deficits and traumatic injury, is not warranted and detrimental (Deyo 2013).

¨  Advanced disc degeneration, spondylolisthesis and modic changes of the vertebral end plate do not predict future LBP (Deyo 2013; Jarvic et al 2005).

¨  High prevalence of ‘abnormal’ findings on MRI in pain-free populations (disc degeneration [91%], disc bulges [56%], disc protrusion [32%], annular tears [38%]) (McCullough et al 2012)

¨  Findings correlate poorly with pain and disability levels (Deyo 2005).

¨  There is strong evidence that unwarranted imaging makes patients worse;  MRI scans for nontraumatic LBP lead to poorer health outcomes, greater disability and work absenteeism due to the pathologising of the problem (Deyo 2013).

 

Demystifying common beliefs about pain:

¨  Negative beliefs about LBP are predictive of pain intensity, disability levels and work absenteeism as well as chronicity (Main et al 2010)

¨  Beliefs can independently increase disability and impair recovery (Main et al 2010):

¡  Having a negative future outlook (e.g. ‘I know it will just get worse’)

¡  ‘Hurt equals harm’

¡  ‘Movement should be avoided’

¨  Many of these beliefs gain their origins from healthcare practitioners (Darlow 2013; Lin 2013) highlighting the critical role of communication in the acute care of people with LBP.

¨  Catastrophic thinking increases pain behaviours by increasing fear and distress (Sullivan et al 2001)

¡   ‘my back is damaged’

¡  ‘I am never going to get better’

¡  ‘I am going to end up in a wheel chair’

¨  Pain behaviours (limping, and protective muscle guarding) then lead to:

¡  Abnormal loading of sensitised spinal structures

¡  Feeding a vicious cycle of pain

¡  Poor coping styles, such as avoidance and excessive rest.


                    Leaves the person feeling helpless and disabled.

¨  In contrast, people who have positive beliefs about LBP and its future consequences are less disabled (Main et al 2010)

 

¨  “Whether young or old, very old, sick or feeble, one can attain perfection in yoga by practising.” (Hatha Pradipika 1:64, 15th century)

 

Empathetic, patient centred communication:

Current evidence supports sensitive, patient-centred communication (Vibe Fersum 2013)

¨  This helps therapists to:

¡  Understand patient concerns

¡  Identify and address negative beliefs about LBP

¡  Reassure patients regarding the benign nature of LBP

¡  Discuss the limitations of radiological examinations: emphasise that disc degeneration, disc bulges, annular tears and facet joint arthrosis are normal in the pain-free population, are not a sign of damage or injury and do not predict outcome (Chou et al 2012)

¡  Carefully explain the biopsychosocial pain mechanisms relevant to the patient

¡  Advise patients to keep active and normalise movement.

¨  This sensitive, motivational communication:

¡  Builds health literacy about LBP

¡  Empowers patients to take an active role in their rehabilitation rather than rely on passive treatments

Divert attention away from the back, focus on yoga practice

¨  Evidence indicates that factors such as sleep disturbance, sustained high stress levels, depressed mood and anxiety are strong predictors of LBP (Gatchel 2007).

¨  Lifestyle and negative emotional factors sensitise spinal structures via the central nervous system and dysregulation of the hypothalamic–pituitary–adrenal axis.

¡  Common patient presentation:

ú  Acute LBP

ú  Report high levels of pain, distress and muscle guarding associated with a ‘minor’ mechanical trigger

¨  In patients with fibromyalgia (Verbunt et al 2000) and Chronic Lower Back Pain, (Mason et al 2008) the degree of pain, perceived disability and Quality of Life were influenced more by their mental health status than the degree of physical impairment.

¨  The evidence suggests that an integrated approach to exercise rehabilitation that includes practices at the biomechanical, respiratory, and cognitive levels, applied individually and in a graded manner is supported by the current evidence for improving Quality of Life in several chronic conditions such as fibromyalgia (Da Silva et al 2007) and rheumatoid arthritis (Haslock et al 1994)

¨  Current evidence indicates that therapists should be shifting the patient’s focus away from their back. (I.e. the focus becomes the positive yoga practice, rather than the back pain.)

¨  Do yoga not ‘core exercises”:

¡  In contrast to popular belief, there is little evidence that LBP is associated with a loss of ‘core’ or trunk stability.

¡  There is growing evidence that “core stability exercises” result in altered movement patterns, increased trunk muscle co-contraction, are associated with the recurrence and persistence of LBP.

Movement, breathing and relaxation as primary means of treatment

Evidence:

¨  People with nonspecific LBP more commonly increase trunk muscle guarding and have stiffness, which paradoxically increases spinal loading and pain (O’Sullivan 2012).  Therefore, practising relaxation of trunk muscles incorporated with graded movement training is important to unload sensitised spinal structures and allow normal movements to occur.

¨  Activity modification should only be recommended in the acute phase if there is evidence of tissue strain.

¨  Otherwise, advice to keep active in a graded manner is important to reduce the pain avoidance vicious cycle.

¨  Pain behaviours and guarded movement patterns should be discouraged in the absence of a traumatic injury mechanism and in the case of trauma as tissue healing occurs (Vibe Fersum 2013).

 

Advice for patients

‘Pain with movement does not mean you are doing harm’

‘Gradually increase your activity levels based on time rather than

the levels of pain’ (Graduated activity)

‘It is safe to exercise and work with back pain – you may just have

to modify what you do in the first few days’

 

Yoga programs include:

Relaxation

Encourage diaphragmatic breathing

Facilitate awareness of tension in the muscles of the trunk and encourage mindful relaxation

Mobility exercises

Encouragement gentle flexibility-based exercises for hips  and spine progressing from non-weight bearing to weight bearing (e.g. hip and back stretches lying down, progressing  to kneeling, then standing).

Functional movement training

Encourage relaxed movements and avoidance of guarded movements, and discourage breath holding and propping off the hands with load transfer

Encourage patients to incorporate movement training into their usual daily activities (e.g. walking, bending, twisting).

Tailor postures to meet the strength and conditioning needs of the patient (e.g. squatting postures for someone who is involved in manual work)

Explain the functional connection between postures and activities of daily living to clarify relevance of the exercises.

Graduated exercise

Slowly building the exercise tolerance of the patient is synonymous with yoga therapy principles. Patients are guided to increase their program gradually.

Encouragement to be active in society and work

A primary aim for the management of acute LBP is the restoration of normal participation in work, family life and recreational activities, which indirectly promote confident spinal movement and functional capacity. This is crucial to facilitate a return to the whole health (physical, mental and social) of the patient.

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Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA.

Three-year incidence of low back pain in an initially asymptomatic cohort.

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