All you wanted to know about that nagging back pain!

Chronic back pain is a common problem with a large health and social cost. Around a quarter of adults have had back pain in the last month, with one in 40 reporting disabling back or neck pain. Each year around 5% of patients consult their primary care practitioner with back pain, resulting in 137 consultations per 1000 patients. This means a practitioner with 1750 patients will typically see at least one patient with back pain each day.

Facts about back pain:
It's common to see minor abnormalities on x ray films of the lumbar spine. Two randomised studies did not show any benefit in outcome from performing lumbar spine x rays. One found that they have an adverse effect on outcome. They also expose patients to large amounts of radiation.

It's common to see minor abnormalities on magnetic resonance imaging (MRI) scans of the lumbar spine. This is an expensive investigation that's unlikely to improve the patient's outcome. One randomised controlled trial showed that patients who had an x ray had a similar outcome to patients who had a magnetic resonance imaging scan.

Abnormalities are commonly found on magnetic resonance imaging scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found:

* Bulging discs in 20% to 79%
* Herniated discs in 9% to 76%
* Degenerative discs in 46% to 91%.

Measuring the ESR or plasma viscosity is the best test for excluding malignancy or ankylosing spondylitis. This costs hardly 20rupees!

Evidence suggests that investigating simple back pain is unnecessary. A careful history and examination, if indicated, should exclude any serious cause.

Few treatments have been shown to benefit people with back pain.

Spinal manipulation has not been shown to be effective for chronic low back pain when compared with no treatment. Massage is likely to benefit people with chronic low back pain. But the evidence is weak and based on studies that might have had methodological flaws. There is better evidence for the benefits of exercise classes.

Acupuncture has not been shown to be effective for treating chronic low back pain.

Facet joint injections are likely to be ineffective or harmful.

We also don't know whether the following treatments are effective: electromyographic feedback, epidural steroid injections, lumbar supports, muscle relaxants, physical conditioning programmes, specific exercise regimens such as the McKenzie approach, and transcutaneous electrical nerve stimulation.

Weight loss surprisingly does not reduce back pain but weight gain can aggravate a back ache.

General exercise appears to benefit people with chronic low back pain. There are some data, including cost analysis, supporting the use of an exercise class using cognitive behavioural principles.


Multidisciplinary treatment consisting of intensive physical and psychosocial training by a team often using a group approach, and avoiding passive physiotherapy, reduces pain and improves the day-to-day activity of patients with chronic back pain.

Few people who have been off work with back pain for more than six months ever return to work. Usually patients are worried about returning to work. Returning immediately after an acute back pain episode to full duties might cause their condition to deteriorate in the short term, reducing chances of returning fully to work. A supportive employer can help many people return to work.

Few therapies offered by outpatient physiotherapy departments as a uni-disciplinary treatment are likely to be effective for people with chronic back pain. But it might be worth considering a graded exercise programme, if your local physiotherapy department offers one.

In one study, 32% of patients who presented with back pain reconsulted within three months.21 The same study found that only 21% of those interviewed three months after seeing their GP with back pain were free from symptoms. The authors concluded: "Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences."

Surgical intervention is rarely indicated for chronic simple back pain. Understandably, few orthopaedic surgeons are interested in non-surgical management. Their time is probably better spent delivering treatments proved to be effective.

A systematic review found tricyclic antidepressants, but not SSRIs, to be moderately effective in the treatment of chronic low back pain in patients without depression.

Surprisingly paracetamol eight times a day is very effective in back ache!