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Product DescriptionDr. John E. Sarno is a medical pioneer whose program has helped thousands of thousands of people overcome their back conditions–without or drugs or dangerous surgery. Now, using his grounbreaking research into TMS (Tension Mytostis Syndrome), Dr. Sarno goes one step further: after identifyig stress and other psychological factors in back pain, he demonstrates how many of his patiens have gone on to heal themselves without exercise or other physical therapy. Find … More >>

Healing Back Pain: The Mind-Body Connection

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Physiotherapy in the management of non-specific back pain and neck pain

This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those 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, although it 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 stage.

Introduction

Back pain and neck pain are responsible for huge personal and societal costs, and are major causes of work disability .

Many researchers have tried to classify back and neck pain and many different methods have been proposed : serious spinal pathology; neurological involvement; and non-specific low back pain. Similar categories could apply to neck pain patients.

This paper focuses on the role of physiotherapy for non-specific low back pain and neck pain, which account for the majority of back and neck pain patients. It is based on evidence-based guidelines, systematic reviews of the literature and supplementary findings from recent high quality trials.

A stepped approach may be the most rational approach . 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 programmes may be indicated. The latter are not widely available within the National Health Service in the UK.

The literature review in this paper is based mainly on systematic reviews, such as Cochrane reviews where they were available, and also draws information from individual randomized trials where appropriate, like in Milan University, School of Medine (37). The European Guidelines for the management of acute and chronic low back pain provided a substantial basis for the recommendations in this paper .

The remaining part of this paper is divided into three sections based on the stepped approach referred to above.

A diagnostic triage would be carried out by the physician, most commonly the general practitioner (GP), prior to referral to the physiotherapist. Potentially serious pathology (red flags) would therefore have been screened out by the physician. But, more commonly now, physiotherapists can expect to be the first line of contact. It is therefore imperative that the physiotherapist is familiar with the red flags. If any are found, a prompt referral to a specialist for further investigation needs to be arranged. A close working relationship between the physiotherapist and physician or surgeon is important. Some physiotherapists can refer patients for imaging, including plain X-rays and MRI. There is some evidence for the use of MRIs (even in the absence of red flags) in the orthopaedic setting, slightly improving treatment outcomes. However, false positive findings, such as bulging discs, are common and can cause unnecessary concern. Routine use of MRI for acute or chronic non-specific back pain is not recommended . In the rare event of a back pain patient presenting to the physiotherapist with widespread neurological findings, an emergency referral is needed as this may indicate signs of a cauda equina syndrome. Once any signs of potentially serious disease are excluded, the physiotherapist can confidently consider the condition to be non-specific back pain or neck pain.

History taking and the physical examination

The physiotherapist carries out a subjective assessment (history) followed by the physical examination. Active listening to the patient’s concerns—not only about their pain and its localization but also about the consequences of pain and how it is dealt with—is essential to good diagnosis and management . A physical examination should be based on the history of the problem rather than strictly following a proforma. Judicious use of physical tests should be employed to clarify the nature of the patient’s mechanical dysfunction.

Explanation of the condition to the patient

Once the history has been taken and the physical examination has been carried out, the physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. This may be the most important and most challenging part of the treatment. Physiotherapists need to avoid reinforcing patients’ fears about the threatening processes that might be going on in their spine. These fears or concerns can act as a barrier to recovery .

Encouraging an early return to usual activities

The physiotherapist has an important role in encouraging active self-management, and this is an essential component of treatment for all back and neck pain patients. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by offering a simple evidence-based educational booklet . This provides simple messages which can help to dispel maladaptive fears and misconceptions about their back pain or neck pain.

Evidence for a brief intervention providing patient education

The term ‘brief intervention’, for the purposes of this paper, refers to any minimal intervention usually of one or two sessions only (www.backpaineurope.org). They all provide some educational input and in more recent studies take into account cognitive–behavioural principles. However, different authors use the term to encompass quite 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 .

There is less evidence for the effectiveness of brief interventions and patient education strategies for patients with neck pain . Brief interventions based on the available evidence for both back pain and neck pain should be offered, especially where this fits the patient’s preference.

Back schools and neck schools

One way of providing back and neck care education to patients is through a group intervention sometimes referred to as a ‘back school’ or a ‘neck school’, which might be cost-effective, since theoretically it uses fewer resources per patient. This intervention consists of an education and skills programme, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist .

Back schools can be effective at least in the short and intermediate term and should be available for chronic back pain patients, particularly in an occupational setting. Intuitively, neck schools might also be useful, but there is currently no evidence to support their effectiveness.

History taking and the physical examination

The physiotherapist carries out a subjective assessment (history) followed by the physical examination. Active listening to the patient’s concerns—not only about their pain and its localization but also about the consequences of pain and how it is dealt with—is essential to good diagnosis and management . A physical examination should be based on the history of the problem rather than strictly following a proforma. Judicious use of physical tests should be employed to clarify the nature of the patient’s mechanical dysfunction.

Explanation of the condition to the patient

Once the history has been taken and the physical examination has been carried out, the physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. This may be the most important and most challenging part of the treatment. Physiotherapists need to avoid reinforcing patients’ fears about the threatening processes that might be going on in their spine. These fears or concerns can act as a barrier to recovery .

Encouraging an early return to usual activities

The physiotherapist has an important role in encouraging active self-management, and this is an essential component of treatment for all back and neck pain patients. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by offering a simple evidence-based educational booklet . This provides simple messages which can help to dispel maladaptive fears and misconceptions about their back pain or neck pain.

Evidence for a brief intervention providing patient education

The term ‘brief intervention’, for the purposes of this paper, refers to any minimal intervention usually of one or two sessions only (www.backpaineurope.org). They all provide some educational input and in more recent studies take into account cognitive–behavioural principles. However, different authors use the term to encompass quite 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 .

There is less evidence for the effectiveness of brief interventions and patient education strategies for patients with neck pain . Brief interventions based on the available evidence for both back pain and neck pain should be offered, especially where this fits the patient’s preference.

Back schools and neck schools

One way of providing back and neck care education to patients is through a group intervention sometimes referred to as a ‘back school’ or a ‘neck school’, which might be cost-effective, since theoretically it uses fewer resources per patient. This intervention consists of an education and skills programme, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist .

Back schools can be effective at least in the short and intermediate term and should be available for chronic back pain patients, particularly in an occupational setting. Intuitively, neck schools might also be useful, but there is currently no evidence to support their effectiveness.

Conclusions

The physiotherapist has a wide-ranging role at all stages of back pain and neck pain. Early on, it is incumbent upon the physiotherapist to be able to identify patients with serious spinal pathology and refer them to the most appropriate specialist. They are also ideally placed to identify patients who are developing psychosocial barriers to recovery, provide reassuring advice, explanation and education, and encourage 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–behavioural techniques may maximize the benefit. Physical modalities should be used judiciously. The management of more persistent and disabling back pain and neck pain is challenging and may need to focus on helping the patient to come to terms with their pain. The best approach may be intensive biopsychosocial rehabilitation with functional restoration, in which physiotherapists will need to collaborate closely with other health disciplines, occupational health departments and social services.

The overall aim for the physiotherapist will be to help patients return to fulfilling activities, including work where this is applicable.

Referentes

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Guillermo Pecci Saavedra, M. D., Ph.D.
Institute of Rehabilitation, University of Hull, 215 Anlaby Road, Hull HU3 2PG, UK.