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  • Writer's picturePaul Monaro

Lumbar - Low Back Pain Management update 2019

Management of a patient with ALBP, or more importantly how they self-manage, will have a large bearing on the duration of their symptoms and degree of disability. I regularly see patients who do all the wrong things in the early stages after injury. Examples include engaging in bedrest, sitting when it is harmful, doing inappropriate stretches, and continuing to perform movements that aggravate the condition.

When a patient presents with a first episode of LBP, or with recurrent episodes occurring frequently, they will often have very little idea about the injury and how to manage it. The right advice and guidance is crucial for them.

This will include:

1. Education about the nature of the injury. Research shows that patients have a strong desire to be given a diagnosis. It is also helpful for their recovery if they can understand the nature of injury, and why the proposed management will assist their recovery.

2. Reassurance. Most episodes of ALBP, even when initially severe, are benign and will recover quickly. Patients will be less anxious, and their pain will appear less threatening when reassured of this.

3. Advice to remain active. It is natural for a patient to feel the need to rest when they are in pain and movements are not comfortable. However, too much sitting aggravates most forms of ALBP. And lying down for more than the standard eight hours per night leads to increased stiffness, greater disability and rapid deconditioning. On the flip-side, movement is therapeutic. Healing tissues require a degree of regular loading to stimulate healthy rebuilding, and to maintain physiological metabolism. This is particularly important for the intervertebral discs, the largest avascular structures in the body, that need movement for healing and homeostasis.

Just as importantly, resuming normal activities as quickly as possible assists psychological as well as physical recovery.

4. Guidance about how to minimize further injury. This will include discussion of the patients daily work and home tasks, and recommending specific modifications where appropriate.

5. Education regarding pain relief. I do not give my patients instructions regarding pain relief. I leave this to their medical practitioner. However, for dealing with those patients who seek this intervention, it is useful knowledge that clinical practice guidelines from various countries now recommend against any form of analgesia in the early stages of ALBP. For patients not improving as expected, NSAID’s are recommended ahead of stronger forms of analgesia. When a patient needs encouragement to remain active, strong analgesics can be counter-productive. Prescription of opioid medications is not recommended. For clarification, a link to recent guidelines published in the MJA is provided:

6. Education regarding imaging. If a patient with ALBP requests imaging, they need to be strongly advised that it will not be helpful, and will not influence management. I find the explanation that ‘they have suffered a strain which cannot be detected by imaging’ will satisfy most patients. Some studies have found early imaging negatively impacts recovery.

Benefits of early physiotherapy referral

A physiotherapist who specialises in treating the spine will have treated ALBP patients virtually every day over many years. They will recognise patterns in patient presentation that determine what approaches to management will be most effective. Certain patients will benefit greatly from a McKenzie approach, others from early mobilisation or massage, and some will simply need the correct advice and guidance on how to manage the condition. Physiotherapy should commence within one to two days after pain onset to get the patient on the right track early. Then with recovery, appropriate progression of therapy, home exercises and activity levels will assist them to recover in the shortest possible timeframe. For those who require longer-term prevention strategies, the experienced physiotherapist has the greatest expertise in this area as well. Such strategies might include core strengthening, postural advice, lifestyle modification, or education about healthy movement patterns when performing work or exercise. A degree of expertise is required for knowing what is appropriate for each patient, and at what stage of recovery these interventions should be introduced.

An experienced physiotherapist will also be able to identify patients who are at risk of having a prolonged recovery. These will include patients with greater physical impairment, or with ‘yellow flag’ characteristics, such as negative attitudes to recovery and fear-avoidance behaviours. Appropriate interventions for these individuals can then be considered before the condition becomes chronic.

For information for doctors on physiotherapy management of all types of injuries visit:

Information for patients is at:

Ph (02) 9736 1092

Copyright © 2014 Paul Monaro. All Rights Reserved

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