Management of Non-specific Back Pain

Physiotherapy in the treatment of nonspecific back pain and neck pain This document provides an overview of best practices for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. Further up the relevant primary research is also highlighted. A tiered approach in which the physiotherapist initially recommended has a history and perform a physical examination to exclude any potentially serious pathology and identify any particular functional impairment. Initially, the advice simple messages of explanation and tranquility will be the basis of a patient education package. Self-management emphasizes everywhere. A return to normal activities is encouraged. For the patient who is recovering after a couple of weeks, a short course of physiotherapy may be offered. This should be based on an asset management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if necessary to relieve pain and assist in helping patients move. Obstacles to recovery must be explored. The few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, but is not widely available. Liaison with the workplace and / or social services may be important. Getting all players on side is crucial, especially at this time. Introduction Back pain and neck pain are responsible for an enormous personal and social cost, and are the leading cause of work disability [1-3]. Unlike traditional thinking, or back pain or neck pain is a problem that always resolves. Recurrences are common, and its course is highly variable [4-8]. Many researchers have tried to classify back pain and neck and many different methods have been proposed [9, 10]. The best and most widely accepted method of classification for low back pain is diagnostic triage, where patients are classified as belonging to one of three groups [11]: serious spinal pathology, neurological involvement, and no low back pain. Similar categories could be applied to patients with neck pain. This paper focuses on the role of exercise therapy for nonspecific low back pain and neck pain, which represent the majority of patients with back pain and neck. It is based on evidence-based guidelines, systematic reviews of literature and the complementary results of recent trials of high quality. A phased approach may be the most rational approach [12], offering simpler and less intensive interventions from the beginning. (i) In the first case, the classification of diagnosis, patient education and counseling are likely to be the best approaches. (ii) If this fails and the problem does not improve after a few weeks, a short course of physiotherapy may be offered. In a few weeks, it is expected that the condition of most patients improve enough so they can return to normal activities, including work. The more patients with back pain are out of work, the more likely that will never work [13]. It is therefore important that the individual is encouraged to return to work, even if there is still some residual pain. (iii) For a small number of patients, more extensive and intensive rehabilitation programs may be indicated. The latter are not widely available on the NHS in the UK. The literature review in this paper is mainly based on systematic reviews, including Cochrane reviews in which they were available, and also obtains information from the various randomized clinical trials where appropriate, as in the University of Milan, School of Medine (37). The European guidelines for the treatment of acute low back pain and chronic forms an important basis for the recommendations in this document [14, 15]. For the development of these guidelines, searches through November 2002 were performed in Cochrane, Medline, Health Star, Embase, Pascal, PsychoInfo, Biosis, Lilacs and IME (Spanish Medical Index). Keywords include 'back pain', 'back pain "and" systematic. "Additional Documents published more recently known for the 11-member international task force were also considered for inclusion until the end of 2004. These quality evaluation was performed using the checklists Cochrane Library [16]. The remainder of this paper is divided into three sections based on the tiered approach outlined above. A diagnostic classification was carried out by the doctor, usually the general practitioner (GP) prior to referral to the physiotherapist. Potentially serious pathology (red flags) therefore have been controlled by the physician. But more often now, clinicians can expect to be the first line of contact. It is therefore imperative that the therapist is familiar with the red flags. If any are found, a quick referral to a specialist for further investigation needs to be fixed. A close working relationship between the practitioner and the physician or surgeon is important. Some physical therapists may refer patients for imaging, including plain radiography and magnetic resonance imaging. There is some evidence for the use of magnetic resonance imaging (even in the absence of red flags) in the development of orthopedics, slightly improving treatment outcomes. However, the false positives, such as bulging discs are common and can cause unnecessary worry. The routine use of MRI to non-acute or chronic, nonspecific back pain is not recommended. In the rare case of a patient with back pain to presentation of the physiotherapist with extensive neurological, emergency reference is necessary because it may indicate the signs of cauda equina syndrome. Once you exclude any signs of potentially serious illness, the practitioner can confidently consider the condition of the nonspecific back pain or neck pain. The history and physical examination The therapist performs a subjective evaluation (history), followed by physical examination. Active listening to the patient's concerns not only about their pain and its location, but also on the consequences of pain and how it-is essential for the proper diagnosis and management [1, 18]. A physical examination should be based on the history of the problem, rather than strictly following a proforma. The judicious use of physical evidence should be used to clarify the nature of the mechanical dysfunction of the patient. Understanding the patient's condition Once history has been taken and physical examination is done, the therapist must provide a detailed explanation of reassurance that no disease or injury has been found. This may be the most important and most difficult part of treatment. Physiotherapists need to avoid reinforcing the fears of patients about the processes of the threat that may be happening in your spine. These fears and concerns, can act as a barrier to recovery [19] and should be treated properly. Patients often expect to be given a label to describe their problem [20], but this can be fraught with difficulties. It takes great care to select appropriate, non-threatening words that will not be misinterpreted by the patient [21]. Provide patients with information on the biomechanics of the spine that is not based on evidence can add to their concerns [22]. Psychosocial factors are at least as important and must be addressed both in patients with back pain and neck pain [14, 15, 23, 24]. Encourage a prompt return to normal activities The physiotherapist plays an important role in promoting self-management of assets, and this is an essential component of treatment for all patients with back pain and neck. The main objective is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by the evidence that offers a simple brochure based on education [25-29]. This provides simple messages that can help allay the fears of maladaptation and misconceptions about their back pain or neck pain. Evidence of a brief intervention that provides patient education The short term intervention for the purpose of this document refers to any minimal intervention, usually one or two sessions only (www. backpaineurope. Org). They all provide some educational input and recent studies have considered cognitive-behavioral principles. However, different authors use the term to cover a range of approaches. A review of the literature shows that patient education in the form of a brief intervention can be effective even for chronic back pain [15]. The content and delivery can vary greatly. Can be delivered as a one by one by the practitioner, or in parallel with a medical consultation / educational session. The European Guidelines group concluded that such intervention (no more than two sessions) encouraging a return to normal activity may be as effective as physiotherapy or aerobic exercise habit for chronic back pain [15, 30-33]. More recently, a large, high quality test with subacute low back pain patients (n = 402) compared manual therapy (four sessions) with a hands-off brief intervention for pain treatment (three sessions) and found no difference significant change scores for disability at 12 months [34]. There is less evidence for the effectiveness of brief interventions and strategies for patient education for patients with neck pain [35]. However, a recent study of patients with neck pain (n = 268) showed that if patients have preferred a short speech, they were encouraged to self-management, they did, and patients were randomized to physiotherapy usual [36]. Brief interventions based on evidence available to both back pain and neck pain should be offered, especially when it fits the patient's preference. Back Neck schools and colleges One way to give back and neck care education to patients through a group intervention is sometimes called a "back school" or a "school of the neck, which can be profitable, since theoretically uses fewer resources per patient. This intervention is a program of education and skills, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist [37]. The original of the Swedish back school, introduced in 1980, consisted of four sessions of 45 minutes [38]. Back schools vary widely in their approach. The contents, means and methods of delivery are particularly important. Those that occur in a relevant context , encourage return to usual activities and take account of psychosocial issues may be more effective than focusing on biomechanical factors. According to the most recent Cochrane Systematic Review [39], back schools, especially in the workplace, may be more effective in the short and medium term that the exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls for patients with chronic and recurrent low back pain. For neck pain, hardly There is evidence of the effectiveness of schools in the neck, with only a small low-quality study has found no significant effect [40]. Back schools may be effective at least in the short and medium term and should be available for patients with chronic back pain, particularly in a professional environment. Intuitively, schools in the neck may also be useful, but currently no evidence to support their effectiveness. The history and physical examination The therapist performs a subjective evaluation (history), followed by physical examination. Active listening to the patient's concerns not only about their pain and its location, but also on the consequences of pain and how it-is essential for the proper diagnosis and management [1, 18]. A physical examination should be based on the history of the problem, rather than strictly following a proforma. The judicious use of physical evidence should be used to clarify the nature of the mechanical dysfunction of the patient. Understanding the patient's condition Once history has been taken and physical examination is done, the therapist must provide a detailed explanation of reassurance that no disease or injury has been found. This may be the most important and most difficult part of treatment. Physiotherapists need to avoid reinforcing the fears of patients about the processes of the threat that may be happening in your spine. These fears and concerns, can act as a barrier to recovery [19] and should be treated properly. Patients often expect to be given a label to describe their problem [20], but this can be fraught with difficulties. It takes great care to select appropriate, non-threatening words that will not be misinterpreted by the patient [21]. Provide patients with information on the biomechanics of the spine that is not based on evidence can add to their concerns [22]. Psychosocial factors are at least as important and must be addressed both in patients with back pain and neck pain [14, 15, 23, 24]. Encourage a prompt return to normal activities The physiotherapist plays an important role in promoting self-management of assets, and this is an essential component of treatment for all patients with back pain and neck. The main objective is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by the evidence that offers a simple brochure based on education [25-29]. This provides simple messages that can help allay the fears of maladaptation and misconceptions about their back pain or neck pain. Evidence of a brief intervention that provides patient education The short term intervention for the purpose of this document refers to any minimal intervention, usually one or two sessions only (www. backpaineurope. Org). They all provide some educational input and recent studies have considered cognitive-behavioral principles. However, different authors use the term to cover a range of approaches. A review of the literature shows that patient education in the form of a brief intervention can be effective even for chronic back pain [15]. The content and delivery can vary greatly. Can be delivered as a one by one by the practitioner, or in parallel with a medical consultation / educational session. The European Guidelines group concluded that such intervention (no more than two sessions) encouraging a return to normal activity may be as effective as physiotherapy or aerobic exercise habit for chronic back pain [15, 30-33]. More recently, a large, high quality test with subacute low back pain patients (n = 402) compared manual therapy (four sessions) with a hands-off brief intervention for pain treatment (three sessions) and found no difference significant change scores for disability at 12 months [34]. There is less evidence for the effectiveness of brief interventions and strategies for patient education for patients with neck pain [35]. However, a recent study of patients with neck pain (n = 268) showed that if patients have preferred a short speech, they were encouraged to self-management, they did, and patients were randomized to physiotherapy usual [36]. Brief interventions based on evidence available to both back pain and neck pain should be offered, especially when it fits the patient's preference. Back Neck schools and colleges One way to give back and neck care education to patients through a group intervention is sometimes called a "back school" or a "school of the neck, which can be profitable, since theoretically uses fewer resources per patient. This intervention is a program of education and skills, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist [37]. The original of the Swedish back school, introduced in 1980, consisted of four sessions of 45 minutes [38]. Back schools vary widely in their approach. The contents, means and methods of delivery are particularly important. Those that occur in a relevant context , encourage return to usual activities and take account of psychosocial issues may be more effective than focusing on biomechanical factors. According to the most recent Cochrane Systematic Review [39], back schools, especially in the workplace, may be more effective in the short and medium term that the exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls for patients with chronic and recurrent low back pain. For neck pain, hardly There is evidence of the effectiveness of schools in the neck, with only a small low-quality study has found no significant effect [40]. Back schools may be effective at least in the short and medium term and should be available for patients with chronic back pain, particularly in a professional environment. Intuitively, schools in the neck may also be useful, but currently no evidence to support their effectiveness. Conclusions The physiotherapist plays a powerful role in all stages of back pain and neck pain. At first, it is for the physiotherapist to identify patients with serious spinal pathology and sent to the most appropriate specialist. They are also in an ideal position to identify patients who are developing psychosocial barriers to recovery, reassuring advice, explanation and education and promote an early return to normal activities. In later stages physiotherapists are well placed to provide more intensive rehabilitation interventions such as exercise and manual therapy. Using cognitive behavioral techniques can maximize the benefit. Physical modalities should be used judiciously. The management of the most persistent and disabling back pain and neck pain is difficult and may need to focus on helping the patient to come to terms with their grief. 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