Physician's Forum

Low back musculoskeletal disorders have become one of the most significant medical and socioeconomic problems in the world.  Diagnosing and treating the patient with low back pain or neck pain can often be challenging, and decisions regarding optimal management are not clear-cut.

In the majority of patients and injured workers with low back problems, recovery occurs within the first four weeks of symptoms (the acute phase). Those who have not improved at the end of that period may need further diagnostic evaluation and consideration of other treatment options.

One of the new trends in medicine is to promote and utilize evidence-based health care. When considering the available options for the treatment of low back pain, current medical practices should be based more firmly on the results of reproducible outcome research, and less on common familiar theories and methods.  

Standardizing the evaluation and care of low back pain patients is critical because of the growing magnitude of the problem.  Inappropriate and expensive evaluations and ineffective treatments have been historically commonplace.

The natural history of recovery from low back pain is favorable and is commonly used as the standard by which to evaluate and compare other treatments. In the absence of serious underlying medical conditions, many patients can expect to recover from the initial acute episode in the first three to four weeks. The evaluation and management during this period can generally proceed without special studies.  The patient’s normal activities are limited by their low back condition, and they modify these activities to minimize their pain which allows the tissue to rest and recover spontaneously.  When possible, patients learn to self-treat and manage their condition in the early stages. Patients with sciatica may recover more slowly on average because of more severe underlying problems such as herniation or spinal stenosis.

Although a high percentage of patients with acute low back pain recover within 4-6 weeks, a significant number of patients suffer from recurrences. Von Korff has studied the natural history and found that approximately 60% will have a recurrence.

In a study of back pain in primary care, Von Korff and Saunders found that 60% to 75% improve in the first month, 33% report intermittent or persistent pain at year one, and 20% of patients describe substantial limitations at this time.

Klenerman et al demonstrated that 7.3% of individuals with acute low back pain who had not recovered by two months still reported high levels of pain and disability at twelve months after onset.  

Chronic low back pain is increasing faster than any other disability, and 5 to 7% of the population will report their back problems as being a chronic illness.  Fifty percent of work loss caused by back pain is accounted for by duration of disability for longer than 4 weeks.                        

Many patients remain untreated in the early phases of their low back pain, or are simply treated with medications and palliative therapies. With this method of management, if the patient does not experience recovery within the first eight weeks, the initial benign problem becomes a chronic situation. A common element in many of the current back pain programs is that many of the treatments employed do not exert a direct beneficial effect on the basic pathophysiological processes taking place in the disc itself. 

Since chronicity and recurrence are common with the low back pain patient, we must shift the emphasis of care away from the focus on management of pain, and employ specific treatment that affects the pathology in the disc.