Back Pain: The Importance of Management Within the Community

Abstract

Rapid triage should exclude serious causes for back pain and make a diagnosis of non-specific mechanical low back pain (LBP). Once the diagnosis is made investigations are unnecessary and only heighten patients’ anxiety. However the diagnosis needs to be reevaluated if the course is not typical.

Despite all efforts a small proportion of LBP patients have ongoing problems with persistent pain and disability. Reasons for hypersensitivity of the nervous system are physical and psychosocial, and the biopsychosocial model provides a framework for understanding and managing the problem. Pain may lead to distress particularly if associated with unhelpful health beliefs and attitudes. These factors, together with an adverse social environment, may conspire to produce illness behaviour. Intense multidisciplinary programmes are then needed to attempt to reverse this chronically disabled state.

The phenomenal rise in disability has stimulated politicians and health professionals to find a solution. Socio-economic factors such as unemployment, the drive for efficiency, and the benefit system have played a part. The solution lies in an active strategy of management and rehabilitation. Confusion and delay must be avoided. The responsibility for this lies in primary care with GPs, physiotherapists, osteopaths, chiropractors, and occupational health services. A flexible and responsive secondary care service is required with a minimal waiting list. There is a place for a community back pain clinic run by an interested GP who has experience and training in musculoskeletal and occupational medicine. The main role for such a clinic would be to take the heat out of the acute situation and give guidance before unhelpful behaviour patterns develop. For LBP the object is to rehabilitate and reduce medical input and Sports Centres can serve this purpose.

Management of occupational LBP may be facilitated by early collaboration between the worker, manager, physical therapist, lawyer, and insurance company to minimise damage in the case of a claim.