Interventions for LBP

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Education

Most guidelines suggest education and advice as a key intervention strategy.  The common message is that patients should be reassured that they do not have a serious disease, that they should stay as active as possible, progressively increase their activity levels and return to work as soon as possible.

The NICE Guidelines summarise many of the available guidelines and state the following:

• Provide people with advice and information to promote self-management of their low back pain.
• Offer educational advice that includes information on the nature of non-specific low back pain and encourages the person to be physically active and continue with normal activities as far as possible.
• Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
• Take into account the person's expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments.
  
• Advise people with low back pain that staying physically active is likely to be beneficial.
• Advise people with low back pain to exercise.

The STarT Back Approach also has some advice for us when educating individuals with LBP:

Language and labels

• Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many people have back pain from time to time but it is rare for this to be caused by a specific problem. Mostly all that is needed is to get your back moving again and things will settle down.
• ”Avoid “spondylitis, degeneration, crumbling” etc.
• Can be more specific sometimes, for example sciatica, if this leads to specific management.
• Avoid investigating in the first place unless it is specifically indicated. However if you do so be aware that the technical terms used in reports often alarm patients. Translate appropriately, examples: “normal for your age ”, “ the changes seen on your scan are like getting grey hair or wrinkles as you get older”
  

Dealing with distress

• Suspend pre-judgment
• Listen carefully / summarize points
• Plan to address points
• Care with language and labels
• Be honest and realistic
• Do not criticize the opinions of other clinicians who have seen the patient.
• Provide information

Activity promotion

• Activity promotion: beneficial, hurt doesn’t equal harm, minimise bed rest
• Pacing: short, frequent bouts of activity rather than overdoing things and then regretting it the next day, rests between activity, do less than maximal capabilities and increase as tolerated.
• Return to work as soon as possible, prolonged absence likely to lead to loss of employment. Use fit notes to support return to work and communicate suggestions to the employer. Help the patient negotiate an early return to work if at all possible.
  

Exercise Therapy

There is now relatively large consensus across the various guidelines that specific back exercises (as opposed to the advice to stay active, including for example walking, cycling) are not recommended for patients with acute low back pain.  There are now also
more firm recommendations in favour of exercise therapy in patients with subacute and chronic low back pain but there is no evidence that one form of exercise is superior to another.  

NICE Guidelines recommend offering a structured exercise programme tailored to the person. Exercise programmes may include aerobic activity, movement instruction, muscle strengthening, postural control and& stretching.  They should comprise up to a maximum of eight sessions over a period of up to 12 weeks, a group supervised exercise programme in a group of up to 10 people or one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.

Delitto et al suggest that clinicians should consider:

• utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with sub-acute and chronic low back pain with movement coordination impairments and in patients post lumbar microdiscectomy. 
• utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. 
• flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain.
• utilizing lower-quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain.
• moderate- to high-intensity exercise for patients with chronic low back pain without generalized pain
• incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain.
  

Manual Therapy

Manual Therapy refers to spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues).

The recommendations regarding spinal manipulation continue to show some variation and systematic reviews have demonstrated marginal treatment effects across heterogeneous groups of patients with low back pain. In some guidelines manipulation is recommended, or presented as a therapeutic option, usually for short-term benefit, but others do not recommend it.  The reason for these differences is probably that the underlying evidence is not strong enough to result in similar recommendations regarding manipulation across all guidelines, leaving more room for interpretation.  There may also be local and political reasons involved.  Recent research has demonstrated that spinal manipulative therapy is effective for subgroups of patients and as a component of a comprehensive treatment plan, rather than in isolation.

Flynn et al developed a clinical prediction rule for patients most likely to benefit from a general lumbopelvic thrust manipulation. Five variables were determined to be predictors of rapid treatment success, defined as a 50% or greater reduction in Oswestry Disability Index scores within 2 visits. These predictors included: Duration of symptoms of less than 16 days, no symptoms distal to the knee, lumbar hypomobility, at least 1 hip with greater than 35 degrees of internal rotation and FABQ-W score less than 19. The presence of 4 or more predictors increased the probability of success with thrust manipulation from 45% to 95%.  A pragmatic rule has also been published to predict dramatic improvement based on only 2 factors: duration less than 16 days and not having symptoms distal to the knee. If these 2 factors were present, patients had a moderate-tolarge shift in probability of a successful outcome following application of thrust manipulation.

The NICE guidelines recommend offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks in early management of non-specific LBP.  

Delitto et al suggest that clinicians should consider utilising thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain.  Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain.

Traction

There is conflicting evidence for the efficacy of intermittent lumbar traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or patients with chronic low back pain.

Electrotherapy

Guidelines suggest that electrotherapy modalities (laser, interferrential, ultrasound, TENS) are not appropriate for non-specific low back pain

Cognitive Behavioural Therapy

The NICE guidelines suggest referral for a combined physical and psychological treatment programme that includes a cognitive behavioural approach and exercise, comprising around 100 hours over a maximum of 8 weeks, for people who have received at least one less intensive treatment and have high disability and/or significant psychological distress.

Recent Related Research (from Pubmed)

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