Mechanical back pain disorders can prove difficult to treat and providing evidence for one type of treatment being superior to another is difficult. Typically effect sizes from randomised controlled trials using conservative care for mechanical LBP are small. Recently a randomised controlled trial using a classification based CFT (an approach we have been using at Central Bassendean Physiotherapy for a few years now) was compared with traditional manual therapy and exercise (Fersum, European J of Pain 2013). CFT provides a targeted approach to management of LBP based on a thorough examination. The classification based management considers movement and postural behaviours, psychological factors, neurophysiological factors and lifestyle behaviours (sedentary vs. excessive activity). CFT challenges thoughts and behaviours in a functionally specific and graduated manner. The CFT approach showed clinically and statistically significant large effect sizes for primary and secondary outcomes across multiple dimensions. Outcomes included disability measures and pain outcomes. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment.
Recently the CFT approach was discussed by Peter O’Sullivan on the ABC health report. This should be compulsory listening to anyone with back pain or managing back pain. To listen
The CFT approach considers much more than just the structure of the back. X-rays, CT scans and MRI scans are frequently used to investigate spinal pain. Spinal imaging plays an essential role in diagnosing and planning surgery in a limited number of LBP presentations. Localised low back pain rarely should require imaging. A thorough clinical examination should indicate if there is a need for imaging. Modern imaging technology, with ever improving resolution uncover structural findings that appear alarming to many but distract attention from the real issues.
Adults without back pain routinely show findings that could frighten patients. Jensen (N Eng Med J 1994) studied adults without pain and reported only 36% had normal discs. A bulging disc was shown in greater than 50% investigated and this prevalence increased with age. Findings of doubtful relevance have been shown to have an adverse effect on patient’s beliefs and behaviours. Richard Deyo (New Eng J Med, 2013) suggests that discussing the prevalence of various findings in normal subjects could provide useful additional information to MRI reports. (e.g. findings: degenerative L5/S1 disc – high prevalence in those without back pain) Ash (Am J Neuroradil 2008) randomly assigned patients who had an MRI scan to receive their imaging results or not. Patients who received their imaging results reported less improvement in their health over the following year. Webster (2010) showed those who had early MRI in an episode of LBP who didn’t require scanning, received care that cost three times of those who didn’t receive an MRI scan. They also took significantly longer to recover and were more likely to have surgery. To hear more about imaging and LBP listen to Richard Deyo. This should be compulsory listening if you have had a scan of your lower back.
To help health consumers access reliable, practical and usable evidence informed information to assist in management of musculoskeletal pain, the Western Australian Health Department launched a new website on April 11, 2012 called painHEALTH, the website offers many resources and information to help assist musculoskeletal pain. There is information on common pain conditions such as low back pain, neck pain, osteoarthritis, rheumatoid arthritis, osteoporosis and fibromyalgia.