Consider supported self-management (SSM).
Consider flags/other pathology/structures/assessment findings/diagnosis/pain control/natural history/communication/education/patient empowerment/treatment approach.
Exit/redirection and health improvement.
Treatment should take into account individual patient needs, preferences, expectations and functional status.
Clinical reasoning should inform treatment based on subjective and objective findings.
Good communication between therapist and patient is essential if a successful outcome is to be achieved. Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.
Informed consent should be sought before beginning treatment.
Aims
The main treatment objectives in the management of LBP are to:
Any advice given should be appropriate to the patient’s needs and evidence based where possible. It should also involve reassurance, encouragement and positive feedback. The physiotherapist should endeavour to:
Provide a clear explanation of the patient’s presenting complaint tailored to the individuals’ needs and intellect
Explain that radiological investigations are not indicated in the first instance as they provide no clinical benefit (unless Red Flags are suspected)
Reassure the patient with regard to the natural history of LBP and expected recovery times. Episodes of NSLBP generally self limit in approximately 6-12 weeks. Approximately 60 – 80% of patients will experience a reoccurrence in the year following their first episode (Hides et al 1996). 80 – 90% of patients with acute radiculopathies will recover within 8 – 12 weeks. However, in some instances symptoms may take up to 18 months to resolve
Advise that simple painkillers can help alleviate symptoms and that cold and heat packs can afford some pain relief. Regular paracetamol is considered the first medication option. Where this proves ineffective, non-steroidal anti-inflammatory drugs (NSAID’s) may be prescribed by a medical practitioner/pharmacist. Some patients with radicular symptoms may benefit from neuropathic pain medications which are prescribed by a medical practitioner
Provide advice and information to promote the self-management of LBP. Written resources are available from:
Encourage patients to remain physically active despite experiencing discomfort. Explain that pain associated with movement is generally not harmful or damaging
Advise and encourage individuals to engage in exercise as part of a healthy lifestyle. E.g. highlight the benefits of walking
Encourage the individual to remain at work or return to work as soon as possible. Explain that this will promote recovery and decrease the probability of further problems occurring. Where necessary provide guidance on the return to work process e.g. light duties, flexible working hours and a gradual return to tasks. Highlight the importance of workstation assessments and manual handling training when appropriate
Advise on the importance of pacing of activities and exercise where necessary
Provide information on voluntary organisations or community fitness and exercise groups, which encourage a return to normal functional activities e.g. Live Active scheme and vitality
When required, provide information about other Health Improvement agencies as appropriate
There is strong evidence from systematic reviews that exercise and advice to remain active helps restore function and reduce pain (Hayden et al. 2004 and Van Tulder et al. 2001a). There is some evidence that exercise helps improve psychological wellbeing. It is therefore a key clinical recommendation that “people with LBP should be given the opportunity to participate in an exercise programme (in a form that is appropriate and acceptable to each individual), after physiotherapy assessment.” (NICE Guidelines, 2015).
The evidence indicates that aerobic and general exercise provides the most benefits through the restoration of function and reduction in pain. There is otherwise no conclusive evidence as to which exercises are the most effective. The NICE guidelines (2015) state exercises confer some benefits either physical and/ or psychological in varying degrees.
A range of exercises may be used to promote self-management strategies. These may include:
In accordance with the NICE guidelines (2015) a structured exercise programme for patients with persistent LBP may be offered. This should be a maximum of 8 sessions over a 12 week period. Consider a referral to the local Back to Fitness class.
A stand-alone education programme without exercise therapy is not advised.
It is recognised that the therapist’s special interest or training may affect the choice of exercise prescribed e.g. McKenzie or dynamic stability exercises.
For the purpose of these guidelines manual therapy refers to joint mobilisation, manipulation and massage or soft tissue mobilisation (or any other unspecified manual technique). There is strong evidence that combined manipulation and mobilisation facilitate an improvement in function and a reduction in pain (UK BEAM, 2004).
It is recommended that manual therapy should only be implemented in association with or as an adjunct to the key recommendation for exercise. If used it should be part of a package of interventions aimed at promoting and directing patient self- management. This should be made clear to the patient.
The NICE guidelines (2015) suggest offering a course of manual therapy comprising a maximum of 9 sessions over a period of up to 12 weeks for patients with persistent LBP. However, regular patient assessment and review of clinical need and treatment effectiveness should determine when manual therapy is best used.
Valid consent should be sought and documented when manipulation is used as per CSP guidance. A risk of possible adverse events should be understood by the therapist and clearly explained to the patient to allow for an informed decision to be made.
The therapist should ensure that knowledge and skills are updated through their CPD as confidence and expertise in performing manual techniques can greatly affect the outcome.
It is recommended that acupuncture should only be offered in association with or as an adjunct to the key recommendation for exercise. It may be performed alongside a structured exercise programme. The NICE guidelines (2009) suggest offering a course of acupuncture comprising a maximum of 10 sessions over a period of up to 12 weeks for those patients with persistent LBP. As with all interventions, treatment should be based on clinical need. Regular assessment and sound clinical reasoning should determine when acupuncture is best used.
All therapists practising acupuncture should be suitably qualified and practise in accordance with the Greater Glasgow and Clyde acupuncture protocol (2013).
Other Physiotherapeutic Interventions
There are other treatment modalities available however NICE (2009) state that these are not to be offered to a patient routinely. On the basis of individual circumstances (strong patient preferences or expectations) and sound clinical reasoning, or where other treatments are contra-indicated, the following treatment modalities may be employed in the short-term:
Supported self management for individual patients should be considered throughout their physiotherapy journey.
Consideration should be given to:
Standard 6 of the CSP Standards of Professional Practice (2005) states that it is an explicit requirement for members to use published/validated outcome measures in routine clinical practice. The outcomes should be clearly identified and documented at the beginning and end of treatment and at the end of the episode of care. Validated outcomes commonly used in the assessment of LPB include:
It is generally acknowledged that treatment outcomes should be functionally driven and goal-orientated. The Patient-Specific Functional Scale conforms to both of these criteria.
At the end of each treatment episode, a statement or discharge summary should be drawn that clearly states the reasons for concluding treatment, and highlights the outcome of the episode of care. This should reflect on:
Where referral to another professional is indicated, clear reasons for this should be made to the patient, and documented.
For more information about permission and access to outcome measures please visit the NHS Scotland Tools and Measures Catalogue.
CHARTERED SOCIETY OF PHYSIOTHERAPY, 2005. Core Standards of Physiotherapy Practice. CSP.
CHARTERED SOCIETY OF PHYSIOTHERAPY, 2006. Clinical Guidelines for the Physiotherapy Management of Persistent Low Back Pain (LBP). Part 1 Exercise. CSP.
CHARTERED SOCIETY OF PHYSIOTHERAPY, 2006. Clinical Guidelines for the Physiotherapy Management of Persistent Low Back Pain (LBP). Part 2 Manual Therapy. CSP.
Greater Glasgow and Clyde, 2013. Acupuncture Guidelines for Physiotherapists. (link correct as at 15/2/22)
HAYDEN, J.A., CARTWRIGHT, J.L., RILEY, R.D., VANTULDER, M.W. and CHRONIC LOW BACK PAIN IPD META-ANALYSIS GROUP, 2012. Exercise therapy for chronic low back pain: protocol for an individual participant data meta-analysis. Systematic reviews, 1, pp. 64-4053-1-64. (link correct as at 15/2/22)
HIDES, J.A., RICHARDSON, C.A. and JULL, G.A., 1996. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine, 21(23), pp. 2763-2769. (link correct as at 15/2/22)
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE, 2009. Low back pain: early management of persistent non-specific low back pain. CG88. (link correct as at 15/2/22)
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE, Clinical Knowledge Summaries [Homepage of NICE], [Online]. Available: http://cks.nice.org.uk/ [15/2/22].
NHS Inform. (2010-2015) Back in control.
UK BEAM Trial Team, 2004. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ, 329(7479), pp. 1381. (link correct as at 15/2/22)
VAN TULDER, M.W., MALMIVAARA, A., ESMAIL, R. and KOES, B.W., 2000. Exercise therapy for low back pain. The Cochrane database of systematic reviews, (2)(2), pp. CD000335. (link correct as at15/2/22)
GGC - MSK Index