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The guidelines on low back pain are clear: drugs and surgery should be the last resort

By Insights
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Most people with low back pain aren’t getting the most effective treatment.

Sandra Grace, Southern Cross University; Roger Mark Engel, Macquarie University, and Subramanyam R Vemulpad, Macquarie University

Low back pain is the leading cause of disability worldwide and is becoming more common as our population ages. Most people who have an episode of low back pain recover within six weeks, but two-thirds still have pain after three months. By 12 months, pain may linger but is usually less intense.

Still, recurrence is common and in a small number of people it may become persistent and disabling. Chronic back pain affects well-being, daily functioning and social life.

A series on low back pain by the global medical journal The Lancet outlined that most sufferers aren’t getting the most effective treatment. The articles state that recommended first-line treatments – such as advice to stay active and to exercise – are often overlooked. Instead, many health professionals seem to favour less effective treatments such as rest, opioids, spinal injections and surgery.

So, here’s what evidence shows you need to do to improve your low back pain.

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Risk factors for low back pain

The cause of most people’s low back pain remains unknown. But we do know of a number of risk factors that could increase the chance of developing low back pain. These include a physically demanding job that involves lifting, bending and being in awkward postures. Lifestyle factors such as smoking, obesity and low levels of physical activity are also associated with developing low back pain.

People with low back pain should see a health professional to rule out the more serious causes of pain such as fracture, malignancy (cancer) or infection.

Once patients are cleared of these, the current guidelines from Denmark, the UK and the US advise self-management and psychological therapies as the initial response for persistent low back pain. These include staying active, doing appropriate exercises and undertaking a psychological program to help manage the pain.

Exercises such as Tai Chi, yoga, motor control (to restore strength, co-ordination and control of the deep core stabilising muscles supporting the spine) and aerobic exercises (such as walking, swimming, cycling and general muscle reconditioning exercises) are recommended.

If any of these therapies fail or stop working, the guidelines point to manual and physical therapies such as spinal manipulation (Denmark, UK, US), massage (UK and US) and yoga and acupuncture (US) – particularly for low back pain lasting more than 12 weeks.

Exercise and psychological therapy

The guidelines are based on many studies that have shown the benefits of exercise and psychological therapies. For instance, a 2006 study compared pain levels across two groups of physically active people with chronic low back pain.

Participants who followed a four-week program using Pilates exercise equipment reported a more significant reduction in pain and disability than those in a control group who received usual care (consultations with a health care professional as needed). The benefit for the exercise group was maintained over a 12-month period.

Another, 2011 trial explored the benefits of Tai Chi for those with persistent low back pain. Participants who completed a ten-week course of Tai Chi sessions had less bothersome back symptoms, pain intensity and self‐reported disability, compared with a control group who continued with their normal medical care, fitness or health regimen.

Chronic pain is linked with chemical and structural changes at all levels of the nervous system. These include the level of neurotransmitter changes that alter pain modulation, and sensitisation of the nerves involved in transmitting pain signals. Incoming pain signals can be modified by our response to persistent pain.

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Psychological treatments – such as mindfulness-based stress reduction – focus on increasing awareness and acceptance of physical discomfort, as well as challenging emotions often associated with chronic pain.

In a trial including 342 participants, around 45% of those who had completed eight sessions of cognitive behaviour therapy or mindfulness-based stress reduction had clinically meaningful improvements in bothersome pain at 26 weeks of follow-up. This was compared to only 26.6% of people who had received usual care.

Exercises such as swimming can help strengthen the core.

Manual therapy

In Australia, physiotherapists, chiropractors and osteopaths use manual and physical therapy to treat lower back pain. The treatments often include some form of spinal manipulation and massage, as well as advice to stay active and do exercises. This is consistent with The Lancet’s recommendations, also based on evidence from studies.

A 2013 trial of people with acute low back pain compared the effects of spinal manipulation with those of the non-steroidal anti-inflammatory drug diclofenac (Voltaren) and placebo on their pain. Spinal manipulation was found to be significantly better than diclofenac and clinically superior to placebo in reducing disability, pain and the need for rescue medication. It was also found to improve quality of life.

Similar results came from another study of 192 people with low back pain that lasted around two to six weeks. Participants were randomly allocated to one of three groups: chiropractic manipulation with a placebo medication; muscle relaxants with sham manipulation; or placebo medicine with sham manipulation. All subjects improved over time, but the chiropractic group responded significantly better, with a bigger decrease in pain scores, than the control group.

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Physiotherapists, chiropractors and osteopaths are required by law to be registered with the Australian Health Practitioner Regulation Agency (AHPRA) to practise in Australia. To be registered, a person must complete a minimum of four years’ study at a university in a degree that includes a focus on non-pharmacological (drug-based), non-surgical management of musculoskeletal conditions, including low back pain.

Under the government’s Chronic Disease Management Plan patients with persistent low back pain may be referred to physiotherapists, chiropractors or osteopaths for evidence-based therapies such as spinal manipulation and massage. If patients are unfamiliar with these therapies, they can discuss referral with their GP.

Physiotherapists, chiropractors and osteopaths can also be consulted without referral. Their services are usually covered by private health insurance. The AHPRA website lists registered practitioners in your area.

One thing to look out for when you see a practitioner is the number of treatments they recommend. Patients usually start with a short course of two to six treatments to see if the treatment helps. It shouldn’t take many treatments for a change in symptom pattern to become obvious.

The message to the public and to health professionals is clear. People with non-specific low back pain need to learn how to independently manage their pain while remaining active, staying at work and maintaining their social life as far as possible.The Conversation

Sandra Grace, Associate Professor in Osteopathy, Southern Cross University; Roger Mark Engel, Senior Lecturer, Department of Chiropractic, Macquarie University, and Subramanyam R Vemulpad, Associate Professor, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Physiotherapy students have much to learn from the humanities

By Insights

Michael Rowe, University of the Western Cape

Undergraduate physiotherapy students spend most of their time learning about the basic and clinical sciences. This has a certain pragmatic appeal, but a person is more than an assemblage of body parts. Our students learn anatomy and biomechanics – the idea of bodies as machines – and then explore what can be done to those bodies in order to “fix” them. Universities pay lip service to the idea that patients require holistic management. But not much in the curriculum signals to students that it really matters.

Research has confirmed what seems intuitively true to many: empathy is critical in developing medical students’ professionalism. The humanities, and particularly literature, are considered effective tools for increasing students’ empathy. There is also some evidence that health professionals who are trained in the humanities and liberal arts are better at caring for themselves and their patients.

In addition, a relationship between emotion and learning has been well established, with findings from multiple domains supporting the idea that emotion is intimately intertwined with cognition, serving to guide learning, behaviour and decision making. This suggests that introducing concepts from the humanities when educating health professionals can do two important things: develop students’ emotional responses and their empathy; and simultaneously improve their overall learning.

Examples from other disciplines

The medical disciplines have started to embrace the role that the humanities and the arts can play in developing empathy in their graduates. In the US, Johns Hopkins Medical School has a department of art as applied to medicine and Stanford School of Medicine has a programme for medical humanities and the arts. These are two of the world’s top medical schools. Elsewhere in the world, South Africa’s University of Cape Town’s medical school chose the theme “Medicine and the Arts” for its first ever Massive Open Online Course.

In an editorial explaining Stanford’s stance, the medical school’s dean, Lloyd B Minor, wrote:

The specificity of scientific interventions does not account for the messiness of human life … We as physicians heal best when we listen to and communicate with our patients and seek to understand the challenges they face in their lives. The perspectives on illness, emotions and the human condition we gain from literature, religion and philosophy provide us with important contexts for fulfilling these roles and responsibilities.

Physiotherapy lags behind

There is little evidence that physiotherapy and other health professions are following these medical schools’ innovative approaches in undergraduate education. Some physiotherapy researchers have explored how concepts from the humanities could be integrated into clinical practice. But this has tended to focus on the impact on professional practice among qualified therapists, rather than on students and their learning.

The reasons for this are unclear, though several factors may be at play. Physiotherapy is conservative by its nature and tends to privilege positivist methods in general. It favours quantitative measurements of progress as the standard against which impact is measured. Our students are taught how to address physical impairments in a patient’s anatomy and biomechanics, using joint range of motion, strength and fitness as indicators. This is important but also tends to sideline approaches that are more interpretive in nature. For example, it’s good to know how to treat back pain from a purely physiological point of view – but it’s also important to know how to respond to a patient who believes his or her pain is the result of witchcraft.

These differences in perspective may be what limits the potential for the humanities to have much impact on curriculum change from the point of view of the clinical therapist. My own teaching experience, though, suggests that physiotherapy students benefit hugely from practices and ideas that are influenced by the humanities.

Putting theory to the test

About three years ago, as an experiment, I started applying some of these ideas in the professional ethics module I teach at a South African university. Initially the module’s emphasis was on human rights, but I started foregrounding empathy and the development of empathy instead.

Over the past few years my students have explored the humanities – art, literature, theatre, music and dance – in their assignments for this module. This has helped them to develop a sense of awareness of empathy in the context of clinical education.

Students can interpret the assignment in any way they want as long as they integrate concepts from the ethics module with their own experiences in clinical practice. They must also express their work through “creative” means: they write poems, draw pictures or cartoons, film video diaries or re-interpret popular songs. Two of my students have even filmed themselves using interpretive dance to try and embody what it might be like to live with a disability. Others have completed PhotoVoice assignments (such as the image below). Here, they photograph people in community or clinical contexts, and then reflect on how those experiences and interactions informed their personal and professional development as ethical practitioners.

Students’ response

Many students were initially worried about the assignments, telling me they were “not creative” and would prefer to write an essay. I suspect that they were simply feeding off my own hesitation in the early days. Now that I provide literature to support the assignment design, give examples from previous students and am fully committed to the process, far fewer students express these concerns.

They are also starting to open up in much more interesting ways. They draw from their own very deep emotions and personal experiences, and are more willing to share and discuss their work in class.

Building empathy

Creativity does not naturally decrease over time. Instead, higher education systems place less and less emphasis on creative expression as students move through the system. If universities want to graduate physiotherapists who have an increased awareness of patient suffering, and an associated empathic response, maybe the key is to provide them with learning tasks that encourage their creative expression through humanities and the arts.

This article was adapted from a post that first appeared on the author’s own blog.The Conversation

Michael Rowe, Senior Lecturer in Physiotherapy, University of the Western Cape

This article is republished from The Conversation under a Creative Commons license. Read the original article.