J.R. Gilbert

Management of Low-Back Painin Family Practice:A Critical Review

SUMMARYThere is a profusion of both orthodox andunorthodox treatments for low-back pain,many of which have been inadequatelyevaluated. Conflicting claims exist for nearlyall of these treatments. To assess the evidencesupporting these commonly usedconservative therapies in family practice, a setof methodological criteria for evaluating thevalidity and usefulness of the results wasapplied to original artides which describedtrials of bed rest, exercises, manipulation,drug therapy, advice/education, and othertherapies such as traction, corsets andtranscutaneous nerve stimulation (TNS).Guidelines for managing acute back pain andacute back pain with sciatica are indicated.Key questions and certain physical signswhich suggest a functional overlay in a patientwith chronic back pain are also outlined. (CanFam Physician 1986; 32:1855-1861.)

SOMMAIREParmi les tres nombreux traitements plus ou moinsorthodoxes appliques a la lombalgie, beaucoup n'ontpas franchi l'etape d'une evaluation adequate.Pratiquement toutes ces modalit6s therapeutiquesfont l'objet de reclamations conflictuelles. Afind'apprecier la valeur des affirmations faites enfaveur des traitements conservateurs utilisescouramment en pratique familiale, nous avonssoumis certains articles originaux a une serie decriteres methodologiques permettant de mesurer lavalidite et l'utilite des resultats concernant le reposau lit, les exercises, la manipulation, lesmedicaments, les conseils, l'education du patient etles autres formes de traitement comme les tractions,les corsets et la stimulation nerveuse transcutanee(SNT). L'article propose un guide therapeutique de lalombalgie aigue et de la lombalgie aigues'accompagnant de sciatalgie; il traite egalement desprincipaux elements et de certains signes physiquessuggerant une composante fonctionnelle chez unpatient souffrant de lombalgie chronique.

Key words: low-back pain, rehabilitation, chronic back pain

Dr. Gilbert is a professor in theDepartment of Family Medicineand Clinical Epidemiology andBiostatistics at McMasterUniversity, Hamilton, Ontario.Reprint requests to: Dr. J.R.Gilbert, Department of FamilyMedicine, McMaster University,Hamilton, Ont. L8N 3Z5.

A LMOST 80% OF ADULTS will. experience low-back pain at some

point in their lives. Svensson demon-strated that almost 70% of 40- to 47-year-old men in Goteborg, Sweden,had experienced low-back pain, andthat 50% of these men had missedwork at least once because of backpain.' Although the prognosis for

acute low-back pain is excellent, pa-tients whose condition degeneratesinto the chronic phase become a majorsocial and economic problem. InNorth America, backache rates as thenumber-one cause of disability in peo-ple younger than 45 years of age; it isthe third major cause of disability forpeople over 45, coming after arthritisand heart disease.2 Twenty per cent ofpatients who experience back pain ofmore than three- to six-months dura-tion are responsible for 80% of thetotal cost of back pain to society.3Of the profusion of orthodox and

unorthodox treatments for low-backpain, many have been inadequatelyevaluated. Conflicting claims exist fornearly all of the conservative therapieswhich are commonly used in family

practice. To assess the evidence sup-porting the use of these therapies, Ihave applied to original articles de-scribing trials of various therapeuticmethods a set of methodological cri-teria4 for establishing the validity andusefulness of the results. Thesemethods include bed rest, exercises,manipulation, drug therapy, ad-vice/education, traction, corsets andtranscutaneous nerve stimulation(TNS).

After reviewing the literature in theareas just mentioned, I shall suggestsome guidelines for managing acuteback pain and acute back pain withsciatica, and I shall pose key questionsand outline certain physical signswhich may help to identify functional

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overlay in patients with chronic backpain.

Criteria for Therapy TrialsIt is beyond the scope of this paper

to review the guidelines for assessingthe validity and applicability of inter-vention studies. Readers are referredto the in-depth discussion published bySackett.4 Certain criteria, however,we shall examine briefly:

1. Was assignment ofpatients totreatment really randomized?

Random allocation eliminates manyof the biases that produce false resultsin non-randomized trials. Every pa-tient who enters the study should havethe same known probability of receiv-ing one or the other of the treatmentsbeing compared. Because of the meth-odological importance of random allo-cation, this review reports mainly onrandomized studies.

2. Were participating patientsproperly categorized?

It is important to know which pa-tients were included and which wereexcluded from the trial, whether thepatients were drawn from primary ortertiary care, and as much detail aspossible about their case-history dataand physical examinations. In general,in the trials reviewed, this particularcriterion was handled reasonablywell.

3. Was the type of interventiondetermnined?

The intervention, especially if it in-cludes manipulation or exercise,should be described in a manner thatcan be easily understood and repeated.This point often constituted a weak-ness in the trials reviewed in this arti-cle.

I was not convinced that in many ofthe trials I reviewed, the placebo effecton some patients of receiving attentionhad been minimized or eliminated.This effect was especially apparent intrials which used exercises and/or ma-nipulation. It is generally recognizedthat for many patients involved in suchtrials, the "laying on of hands" has astrong placebo effect.

4. Was a 'blind' outcome assessmentensured?

Every effort should be made to en-

sure that the investigator who assessesthe outcome of a trial is unaware of thetreatment assignments. The studyshould specifically mention at whatpoint the observer was 'blinded' to theassignment of treatment.

5. Were outcomes properlymeasured?

It is important to establish reliableand valid measures of outcomes, suchas range of motion, straight-leg rais-ing, activities of daily living, workstatus and pain.

6. Was an adequate sample sizeprovided?

In a properly conducted randomizedtrial, the sample size should be deter-mined before the study begins. Mostof the studies reported here did not jus-tify the sample size. When a study re-ports no differences distinguishing thetreatment groups, it is difficult for thereader to judge whether a clinicallyimportant difference was missed be-cause the trial number of patients wassmall.

7. Did adequate follow-up occur?By trial end, the authors should be

able to account for a minimum of 80%of the patients who began the trial. Asmost of the trials I reviewed were ofshort duration, this point did not con-stitute a methodological problem.

Follow-up of the trial also involvescontinuing to monitor the patients formany months or even for as long as ayear. If back-education programs orphysiotherapy exercises are to be as-sessed properly, the relapse rate of pa-tients over a relatively long period oftime must be known. In only a few ofthe randomized trials reviewed did re-searchers follow their patients for anentire year.

Natural HistoryThe prognosis of an episode of

acute low-back pain is favourable.This is perhaps one of the most im-portant points that we can tell our pa-tients. Choler et al. showed, in acommunity-based study of over 7,000patients, that 60% had returned towork within one week, 67% withintwo weeks, and 88% within sixweeks.5 In an Australian study of ageneral practice sample, 91% of allsubjects recovered from their symp-

toms within four weeks.6 These fig-ures compared favourably with the re-sults of Dixon's study, whichrecorded that 86% of all patients withlow-back pain became symptom freewithin four weeks, irrespective oftreatment.7The information on recurrence rates

is less encouraging, although the dataare not as accurate as they might bebecause many studies do not followthe patients beyond a few weeks.Bergquist-Ullman and Larsson studied217 manual and clerical workers atthe Volvo plant in Sweden. Theseworkers were followed for one year aspart of a randomized trial.8 Just over60% of the patients had a recurrenceof low-back pain within that year; themean number of recurrences totalled1.3 per patient. The recurrences,however, generally involved less se-vere pain than the initial episode. Inour study of family-practice patientsin Ontario, follow-up one year aftertherapy found that about 14% of thepatients had sought help from theirphysician after therapy.9

Specific TherapiesBed rest

Physicians and patients generallyagree that bed rest offers symptomaticrelief for low-back pain. Nachemsonhas measured the intra-discal pressurein volunteer subjects and has demon-strated that the load on the disc is at aminimum when patients are supine.'°Bed rest is a well-established therapyfor patients with typical herniateddiscs.11' 12 I reviewed five studies inwhich patients were randomly as-signed to bed rest as a treatmentmode. Only three of these studies,however, compared the outcome ofbed rest with that of ambula-tion.9' 13, 14 In the first study, 200basic-combat trainees in the U.S.Army who had non-radiating low-back pain were randomly assignedeither to bed rest in hospital or to am-bulation.14 (That all patients were re-ported as totally compliant with theirtreatment suggests conditions thatwould apply only in the military!) Thebed-rest group returned to full activityin 6.6 days as compared to 11.8 daysfor the ambulatory group. Outcomemeasures of pain, range of motionand paravertebral muscle spasm werenot assessed blindly. Moreover it isdifficult to assess the effect of 6.6days in a hospital bed on 23-year-old

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males. It may be that they preferred toreturn to combat training rather thanto remain any longer in bed.Another recent randomized trial as-

signed 203 patients with mechanicallow-back pain who attended a walk-inclinic, to either two or seven days ofbed rest.'3 After three weeks the re-sults were measured by a 'blind' ob-server. While patients' compliancevaried, the group that was randomlyassigned two days of rest lost fewerdays of work than the group that restedfor seven days: 3. 1 days as comparedto 5.6 days.The third trial,9 based on a 2 x 2

factorial design, studied the outcomeof bed rest combined with isometricflexion exercises and a back-educationprogram. One-quarter of the patientswas treated with three days of bed rest;one-quarter exercised and received ed-ucation about their back; one-quarterreceived bed rest, exercise and educa-tion; the remaining quarter received nospecific treatment. Though severaltypes of clinical measures were used toassess the outcome of these treat-ments, including straight-leg raising,lumbar flexion, activities of daily liv-ing, and pain, neither bed rest nor ex-ercises was observed to produce anybeneficial effect. The results, in fact,favoured early mobilization.

ft appears that for the time being wemust await the results of additionalprospective trials in order to determinewhether any, or how much, bed rest isappropriate for patients suffering fromsimple mechanical low-back pain. Atpresent, it seems reasonable to suggestthat patients lie in bed in a semi-Fowler position, or in any comfortableposition, for no more than a day ortwo; then they should begin gradualambulation.

ExercisesAlthough no firm statistics are avail-

able about the percentage of patientsreferred for physiotherapy, it has beenestimated that 25%-50% of all pa-tients treated in physiotherapy clinicssuffer from low-back pain.15 Treat-ments may include such passive mea-sures as heat, massage, ultrasound orexercises. While exercises varywidely, three general types are com-monly recommended:. isometric flexion exercises designedto strengthen both abdominal and lum-bar muscles;. general mobilizing exercises to im-prove overall spinal range of motion;

. hyperextension exercises tostrengthen paravertebral muscles.

I reviewed eight articles describingrandomized exercise trials.6, 9, 15 - 20Methodological problems occurredeven in some of these randomizedstudies: observers were not 'blind'; ex-ercises were inadequately described;and some exercises were coupled withother forms of therapy, making it im-possible to determine the value of theexercise component.

Three of the most rigorously de-signed studies produced conflicting re-sults. Zylbergold's well-designed proj-ect compared three groups of patients.Members of the first group weretreated with moist heat and lumbarflexion exercises; members of the sec-ond group with heat, rotational mobili-zation and manual traction; andmembers of the third group with aback-care advice program and pelvictilt exercises."5 After one month oftreatment there was no significant dif-ference observable among the groupsin any of the five outcomes measured.My main criticism of this study is itssmall sample size, which may havecaused researchers to miss significantdifferences among the three groups.'The second study claimed to show

the advantage of flexion isometric ex-ercises over either general mobiliza-tion or extension exercises. 17, 21 How-ever, because no control group wasused, it is difficult to assess the pla-cebo effect of the program.

In two other randomized trialswhich used subjects from general prac-tice, isometric exercises formed part ofthe main manoeuvre, but were notbeneficial. 6 9 In fact, the results of oneof these trials suggested that the phy-siotherapy was actually doing moreharm than good.9

Although exercises are widely pre-scribed in North America, their superi-ority to placebo effect has not been de-monstrated convincingly.

ManipulationIt is somewhat artificial to separate

trials of manipulation from physioth-erapy (exercise), as the same trialsoften compare the two therapies. In re-viewing 11 randomized trials of ma-nipulation, I was struck by one impor-tant point: the placebo effect. Thiseffect occurs because manipulation/exercises involve considerable physi-cal contact between the patient and thetherapist. Thus any therapeutic effectobserved may be attributed largely to

CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986

the placebo effect associated withphysical contact.

Earlier studies conducted by Gloveret al., who used a single rotational ma-nipulation of the trunk, produced sig-nificantly more subjective improve-ment than the placebo treatment ofsimulated diathermy.22 Another earlytrial reported by Doran and Newell*compared manipulation, physio-therapy, corset and analgesic thera-pies.23 Although both of these studiesare widely quoted in the literature, nei-ther described adequately the manipu-lation that was performed. In Doranand Newell's trial, the therapist wasallowed to exclude any patient whowas unlikely to benefit from manipula-tion, thereby biasing the study.

Other studies which I revieweddemonstrate several methodologicaldifficulties: inadequate description ofmanipulation; no measure of compli-ance; 'unblind' outcome assessments;and the prescription of other therapiesfor the patients who were undergoingspinal manipulation, while the controlsubjects were not prescribed the addi-tional therapies.'6 - 20 Lumbosacralmanipulation is considered quite safe,although there have been occasionalreports of injury.24

In New Zealand, 112 general prac-tice patients were randomly assignedto three groups which received a non-steroidal anti-inflammatory drug(NSAID), or conservative physio-therapy or manipulation.25 Althoughthe assessments that followed were not'blind', more patients treated with ma-nipulation were off work during treat-ment of the illness (NSAID: 50%; phy-siotherapy: 47%; and manipulation:63%).The two best studies suggested

some immediate benefit-a few hoursof relief-from manipulation therapy,but no long-term benefits.6' 26 In theHoehler trial, some patients were ran-domly prescribed lumbosacral manip-ulation, while a control group receivedsoft-tissue massage of the lumbosacralarea without the rotational thrust. Thenumber of treatments varied at the dis-cretion of the treating physicians.After the first manipulation, the exper-imental group reported less pain andshowed improvement in four of the sixsubjective measures of spinal flexion,but at discharge from the therapy andalso after a further three weeks, therewere no differences between thegroups. Twenty-seven per cent of pa-tients were lost to follow-up after three

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weeks, which makes long-term resultsuninterpretable. The authors con-cluded that they were in agreementwith the results of the Sims-Williamstrial.27 While manipulation may facili-tate recovery, there is no evidence toshow that it affects long-term prog-nosis.

Farrell and Twomey studied 48 sub-jects in an Australian general practicewho were randomly assigned to twogroups receiving either conservativetherapy with microwave diathermy,Kendall's isometric abdominal exer-cises and back education, or else pas-sive mobilization and manipulation.6The outcomes, assessed blindly,showed a significant difference be-tween the two groups in the length oftime it took for patients to becomesymptom-free. The group receivingmanipulation required 3.5 treatments,while the group receiving conservativetreatment needed 5.8 treatments. Atthe end of three weeks, however, therewas no significant difference betweenthe pain ratings of the two treatmentgroups.

In Britain, a well-designed trial ran-domly allocated 109 hospital outpa-tients to receive short-wave diathermyor placebo (detuned) short-wave dia-thermy or spinal manipulation.28 Sig-nificant efforts were made to ensurethat all patients received equal atten-tion. One doctor, who was unaware ofthe treatment allocations, made serialassessments of each patient. Immedi-ate improvement was apparent in 59%of the patients who received therapeu-tic short-wave diathermy, in 62% ofthose who received the manipulation,and in 67% of those who were giventhe placebo diathermy.

It is difficult to improve on the au-thor's conclusions that, "our resultsalmost certainly attest to the magni-tude of the placebo response whichmay be achieved when harmless thera-pies are applied with conviction.' '29That statement is appropriate for thewhole area of manipulation therapy atthe present time.

Advice on Back EducationIn their hallmark study, Bergquist-

Ullman and Larsson conducted a ran-domized trial on employees of theVolvo plant in Sweden.8 Patients wererandomly assigned to a back-schoolprogram or a group which combinededucation with physiotherapy, or a

placebo group where treatment con-sisted of short-wave diathermy at thelowest possible intensity.The back-school program is de-

scribed in a paper by Zachrisson-For-sell.29 Over a period of two weeks, pa-tients attend four 45-minute sessionssupervised by a physiotherapist. In-struction includes a sound/slide pre-sentation and other visual aids. Pa-tients learn about relevant, anatomicaldetail, the best resting positions, iso-metric abdominal exercises, unfavour-able working postures, and correct lift-ing techniques. They are encouragedto increase their level of physical ac-tivity during leisure hours despite theirback pain.

All patients were thoroughly fol-lowed up for one year. The outcomeassessments were not done blindly, al-though the authors attempted to mini-mize this methodological problem.

Patients attending the back schoolwere observed to take a shorter sickleave during the initial episode of backpain than the other two treatmentgroups. Members of the back-schoolgroup averaged 20.5 days of sickleave; members of the physiotherapygroup and of the control groupaveraged 26.5 days. The change inpain experienced during the initial epi-sode was equal in all groups, as werethe number of recurrences.

The back-school concept is popularin Europe and in a number of NorthAmerican centres, but Zachrisson-For-sell cautions her readers about the pla-cebo effect:The magnitude of the placebo effect

is difficult to measure with the presentmethods. The personality of the pa-tient and the therapist and the timespent with the therapist are probablyimportant factors when one is trying toassess the placebo effect.29

In our multicentred, randomly as-signed trial of general practice patientsin Ontario, one treatment included iso-metrix flexion exercises and a 20-min-ute slide/tape show of back-educationadvice.9 The patients assigned to thisintervention fared no better than thosewho received no treatment, althoughour tape show may have been toobrief.

Because the placebo effect couldhave been present in the Bergquist-Ullman trial, back-education advicerequires further study in further rando-mized trials. In the meantime, it seemsreasonable for physicians to refer pa-

tients to back schools or be prepared togive advice similar to that set out inTable 1.

DrugsPhysicians use many different drugs

to relieve back pain: analgesics,NSAIDS, anti-depressants and musclerelaxants. Many randomized trialshave used drugs as one type of treat-ment. Deyo reviewed this subject inhis paper on conservative therapy forlow-back pain.30 Methodologicalproblems in drug trials have included:lack of compliance; unblind assess-ments; unreported statistical power;excessive patient drop-out rates affect-ing final outcome measures; and inad-equate clinical descriptions of the pa-tients.

Drugs for which at least one trial hasapparently demonstrated benefit in-clude carisoprodol (SoMA),3 ' difluni-sal (Dolobid)32 and naproxen sodium(Naprosyn).3 One randomized trialclaimed that imipramine hydrochlorideoffered symptomatic improvement andan advantage over placebo, but this re-sult is suspect because of the study'shigh attrition rate (18%).34

There is no overwhelming evidenceof one clearly superior drug for man-agement of low-back pain. Until fur-ther well-designed trials are com-pleted, it appears best to use simple,low-cost drugs with few side-effects.

Other TherapiesAlthough corsets are widely pre-

scribed and frequently used by pa-tients, only three randomized trialshave examined their use.1'6 35, 36 Eventhough it is important to know whetherpatients were compliant in wearingcorsets, the compliance rate for thesetrials was not measured. A second

Table 1Advice/Back Educationfor Patients3 8

* Do not lift heavy objects.* Stand close to the work site.* Avoid bending the back.* Avoid twisting the body.* Change positions frequently.* Avoid sitting in low chairs.* Use a lumbar support and arm restswhen sitting or driving.

* When resting, lie either in the supineposition or on the side with the hipsand knees flexed. When getting up,roll over on the side and use arms toraise the body.

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methodological failure was the lack ofunblind assessment. In Larsson' sstudy the corset was found to be lesseffective than auto-traction.35

I was able to find only one rando-mized trial that investigated transcu-taneous nerve stimulation (TNS). Thisstudy did not adequately describe thesource or the type of patients, nor didit provide enough details about thetreatment itself. A high placebo re-sponse of 32% occurred in patientstreated with the non-functioning sti-mulator.37

Back Pain with SciaticaIn the study mounted by Weber et

al. ,38 patients were randomly assignedto one of two types of passive tractionor to auto-traction, or to manual trac-tion or to a control. All patients wereevaluated blindly. Of the patients whowere treated with manual or autotrac-tion, 25%-30% either responded im-mediately or not at all. Thus, if the ini-tial use of traction relieves pain, thereseems to be evidence to support itscontinuing use.How should patients with positive

myelogram findings be treated?Studies have indicated that epiduralsteroid injections have no effect on pa-tients who have positive myelo-grams. 39 40 Weber et al. have helpedconsiderably to elucidate this area ofresearch.38' 4143 Perhaps their mostrelevant study involved 126 patientswho were admitted to hospital withsymptoms of low-back pain and scia-tica.43 Ninety per cent had myelo-grams that were clearly positive, and10% had myelograms that suggestedpositive finding-s. Initially, all thesepatients were prescribed a two-weekcourse of bed rest, moderate isometricexercises, and back education. At theend of this period, patients were ran-domly assigned either to six weeks ofconservative physiotherapy or to im-mediate small laminotomy. Althoughthe outcomes were not determinedblindly, results at the end of one yearclearly favoured surgery. After fouryears, although the results were nolonger statistically significant, theyagain favoured surgery. After 10 yearsthe outcome measures between the twogroups showed no differences.Two additional factors were noted

in this remarkably long-term follow-up. First, at the assessment made afterfour years, patients who had beenoperated on within three months of the

appearance of symptoms were stilldoing considerably better than patientswho had not been operated on withinthat initial period. Secondly, both thesurgical and non-surgical patients hadgenerally experienced some relieffrom their chronic annoying pain,which had become milder and wasprovoked only by certain body move-ments. No patients in either groupwere rated "'bad" at the 10-year mark;all the patients could perform at leastsome tasks in their homes or on theirfarms, and none suffered severe painin the back or legs.

Chymopapain has been used to treatdisc herniation in Canada and otherparts of the world. In two randomizedtrials,44 45 however, which comparedthe effects of this proteolyitic enzymewith surgery, the latter treatment wasfound to produce superior results.Chymopapain had a 50% failure rate,while the failure rate for surgery wasonly 11%. Chymopapain therapy isfurther complicated by the fact that itis impossible for the physician eitherto predict potentially fatal allergic re-actions in patients, or to identify, inadvance of treatment, patients whomay be suffering from a rare trans-verse myelitis. Chymopapain, there-fore, should be reserved for patientswho do not wish to undergo surgery.

Chronic Baclk Painwith or without SciaticaNo prospective studies exist in the

literature to demonstrate that onemethod of treating chronic back pain issuperior to another.46 Variousmethods have been tried: facet injec-tions, denervations, epidural steroidinjections, traction, transcutaneousnerve stimulation, plastic braces andlaminectomy with fusion, but for pa-tients suffering from this condition formore than six months, there is only a40% chance of rehabilitation,46 whichis further reduced to 15% if the condi-tion has been present for more than ayear. 46

In spite of this depressing assess-ment, some recent studies point to abetter future. Waddell et al. investi-gated which physical and patient-his-tory factors are good predictors ofthose who will react poorly to such in-vasive procedures as chemonucleosisor surgery. These procedures may, infact, reinforce and aggravate patients'illness behaviour.47-51 After studying

CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986

groups of North American and Scot-tish patients, they produced sevenquestions relating to patient historyand five physical signs which are reli-able and valid for identifying patientswho will have a large functional over-lay. Waddell claims that patients withserious spinal pathology, such ascancer or infection, or patients withnon-spinal disease such as hip diseasewill rarely produce these symp-toms. 49 50 The five physical signs sug-gesting non-organic disease are shownin Table 2.49 50 The first is pain result-ing from a minor pinch of the patient'sskin in the lumbar-thoracic area. Thesecond sign is identified by a "stimu-lation test". The examiner pushesdown gently on the patient's skull, andthe result is positive if the patient com-plains of low-back pain. In another testfor stimulated pain the examinerstands in front of the patient, placesher or his hands on the patient's hipsand slowly rotates them, while keep-ing the patient's spine relativelystable. Complaints of back pain pro-duced by this manoeuvre indicate apositive result.

The patient whose back pain is non-organic is much more successful thanthe patient with organic pain in per-forming straight-leg raising. The bestmethod of testing for this is to have thepatient sit on a table and extend theknee joint while the physician tests theplantar reflex.The final two signs of non-organic

back pain are over-reaction to exam-ination and non-anatomical sensory re-sponses to light touch, pin-prick orother forms of tactile stimulation. Ifthree out of five of the above testsprove positive, Waddell's evidence in-dicates a pattern of abnormal illnessbehaviour. Such patients do not pro-gress or rehabilitate well and should begiven invasive treatment only with ex-treme caution.Two notes of caution should be

sounded. First, some patients willhave one or two positive tests of noprognostic significance. Secondly, thetests do not seem to work well for el-derly patients who often have diffi-culty standing because of acute pain,and who may give false positive re-sults in this position.Mayer and his group2 have also re-

ported some interesting results in theirstudy of patients who had been offwork for more than four months be-cause of back injury. With the co-

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operation of a third party (the payer ofa disability pension to the patient),Mayer paid a fee ranging from $5,000to $8,000 to patients, who were thenenrolled for several weeks in a com-prehensive program combining psy-chological counselling, occupationaltherapy and physiotherapy. Of the pa-tients who completed the program,86% were able to return to work, com-pared to 45% of patients in controlcomparison groups.2

ConclusionsReview of the trials of various thera-

pies for low-back pain leaves us withlittle "hard evidence", and so, untilmore and better evidence is availableeach clinician must decide for him- orherself how best to treat this condition.From my review of the literature, Iwould summarize what I consider thebest evidence for the management oflow-back pain as follows:

Managing low-back painwithout sciatica

* Inform the patient of the excellentprognosis, telling him/her that 60% ofpatients recover after one week, and90% within six weeks.5-7* Give simple education as outlined inTable 1 .8, 29 Prescribe rest at home for

Table 2Symptoms and Signs of Appropriate Illness Behaviourin Chronic Backache Patients49-51*

Pain of Pain ofOrganic Origin Non-Organic OriginPatient Patient

Symptoms Responses Responses1) Pain Localized Tailbone, or whole leg2) Numbness Dermatomal Whole leg3) Weakness Myotomal Whole leg gives away4) Time pattern Pain free periods No pain-free intervals5) Response to Variable benefit Intolerance,

therapies Emergency admissions

Physical PhysicalSigns Findings Findings1) Tenderness Localized Non-anatomical2) Head pressure test No back pain Back pain3) SLR No change on Improves with

distraction distraction4) Sensory/ Motor Dermatomal/ Myotomal Stocking pattern/giving

away off muscle groups5) General reaction Appropriate Over-reaction* Reprinted with permission of the British Medical Journal and modifiedfrom an article by Dr. G. Waddell.

two to three days9' 13, 14 and the use ofsimple analgesics.* Encourage the patient to return towork when the symptoms begin to im-prove. Suggest the modification ofworking conditions if possible and/ornecessary.

Managing low-back pain with sciatica* Give advice and back education to-gether with bed rest for three to fivedays, and simple analgesics.* Traction (either autotraction or man-ual) may be useful, but only for thosepatients who respond immediately.38* Warn the patient to report changes inbowel or bladder functions, and referto a specialist at the onset of neurologi-cal signs, or if back pain and sciaticapersist.

Managing chronic back pain* There is no good evidence in favourof any particular therapy, and after 12months of persistent pain only 15% ofpatients-will be rehabilitated.46* As most patients will have only sub-jective symptoms of pain, they shouldbe given educational advice and en-couraged to resume work gradually.3* Referral to a comprehensiverehabilitation program may beconsidered.2

AcknowledgementsI wish to thank Drs. C.E. Evans,

B.G. Hutchison and D.M.C. Wilsonfor reviewing this article and IreneGoodman for her assistance in typingit.

References1. Svensson HO. Low back pain infort\ to

forty-sev,en veair old mnen: ai retrospectiecross-sectional study (thesis). Universityof Goteborg, Sweden 1981.2. Mayer TG, Gatchel RJ, Kishino N, etal. Objective assessment of spine functionfollowing industrial injury: A prospectivestudy with comparison group and one-yearfollow-up. Spine 1985; 10:482-93.3. Nachemson A. Work for all: For thosewith low back pain as well. Clini Orthop1983; 179:77-85.4. Sackett DL. How to read clinical jour-nals: V: To distinguish useful from uselessor even harmful therapy. Department ofClinical Epidemiology and Biostatistics,McMaster University Health SciencesCentre. Cain Med Assoc J 198 1;124:1156-62.5. Choler U, Larsson R, Nachemson A, etal. Ont i ryggen-Forsok med vardpro-gram for patienter med lumbala smarttill-stand. SPRI Rapport 188/85. Stockholm,Socialstyrelsens Planerings och Rationali-serings Institut 1985.6. Farrell JP, Twomey LT. Acute low backpain: Comparison of two conservativetreatment approaches. Med J Aust 1982;1:160-4.7. Dixon AJ. Progress of problems on backpain research. Rheuinatol Rehaibil 1973;12:165-75.8. Bergquist-Ullman M, Larsson U. Acutelow back pain in industry. Acta OrthopScantid 1977; 170 (suppl): 1- 1 17.

9. Gilbert JR, Taylor DW, Hildebrand A,et al. Clinical trial of common treatmentsfor low back pain in family practice. BrMedJ 1985; 291:791-4.10. Nachemson A. The load on lumbardiscs in different positions of the body.Clin Orthop 1966; 45:107-22.11. Hanraets PR. The degenerativ,e backand its differential diagnosis. Elsevier Am-sterdam; Publishing Co., 1959.12. Hakelius A. Prognosis in sciatica. Aclinical follow-up of surgical and non-sur-gical treatment. Acta Orthop Scand 1970;129 (suppl): I +.

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