Akuter Rückenschmerz: ein neeus Praradigma im Management

http://www.bmj.com/cgi/content/extract/313/7069/1343

Limited imaging and an early return to normal activities

The new clinical guidelines issued by Britain's Royal College of General Practitioners highlight new principles of back pain management that have emerged in the past decade.¹ The era of routine radiography, strict bed rest, corsets, and traction has passed. It has been replaced by parsimonious imaging, early return to normal activities, and greater emphasis on exercise to prevent recurrences or to treat chronic pain. Physical activity is guided by setting goals (even if there is some discomfort) rather than by the traditional dictum to "let pain be your guide." These newer concepts are based on steadily improving scientific evidence, and represent a major shift from the earlier paradigm of rest and pain contingent treatment.

Many observers would now argue that back pain is a nearly ubiquitous part of human experience, is often the earliest sign of normal age related changes in the body, and has been over medicalised in this century. Back pain has always been with us (arguably even more prevalent in an earlier era of more physically demanding jobs), yet work disability due to back pain is a modern epidemic. Modern medical care has not prevented a steady rise in back related disability in most developed countries, and some fear that medicine may have contributed to the rise.²

In this context, the new clinical guidelines, and their American counterpart from the Agency for Health Care Policy and Research,³ offer a breath of fresh air. The British guidelines explicitly built on the foundation of the earlier American effort, and their authors had the benefit of three additional years of research findings. This new research permitted refinement of earlier recommendations and some entirely new features. For example, a recent study suggests that both exercise and bed rest may slow recovery.⁴ In fact, this study and others⁵ now suggest that nearly immediate return to normal activities may be the optimal recommendation for patients with acute back pain. Though specific exercise does not seem to be useful in acute management,^{4 6 7} it does seem to reduce recurrences after the acute phase has subsided⁸ and improve function for patients with chronic pain.^{9 10}

A novel feature of the British guidelines is an algorithm for simple backache that recommends referring problematic cases to a general practitioner with special interest in back pain or a specialist physiotherapist. In the absence of any surgical indications, such a referral pattern seems highly appropriate, and a similar strategy has proved satisfactory to both patients and physicians in a large American health maintenance organisation.¹¹

With a plethora of emerging clinical guidelines on all aspects of medicine, practitioners may justifiably ask "How were these guidelines developed, and why should I follow them?" Traditionally, many guidelines were the product of expert consensus, which may or may not have been informed by a complete evaluation of available scientific evidence or a critical appraisal of its rigour. Happily, both the American and British guidelines were products of exhaustive literature searches, which began with computerised bibliographic databases and an explicit review of study quality based on sound principles of research design. Because even the best studies leave room for interpretation and debate, and because some important aspects of care have been too rarely studied for evidence based recommendations, the guideline panels sought broad multidisciplinary membership to encourage balanced deliberation. Both panels not only summarised their findings but rated the strength of evidence to support each conclusion.

Successful implementation of new guidelines typically requires more than simply publishing and disseminating them. A local process of review and adaptation, which involves the practitioners of a particular locale or healthcare system, is often more persuasive than the edict of a national panel. Feedback to individual practitioners about their levels of compliance with specific recommendations, or comparison with their peers, may be valuable. One to one educational efforts by an influential peer and redesign of delivery systems to facilitate certain recommendations may be necessary. Finally, the new back pain guidelines represent such a substantial shift from the traditional approach that the public will need to be re-educated. We need to assure that the expectation of x ray films or other imaging is replaced by knowledge of their limited value; the habit of bed rest and "taking it easy" is replaced by rapid return to normal activities; and pain dependent recommendations for treatment and activity are replaced by recommendations based on goals.

Medical knowledge is not static and so every guideline must be regularly updated. The British panel wisely set an explicit review date of April 1998. However, we should all stay alert to the developing online database being compiled by the Cochrane Collaboration, an international effort which seeks to synthesise and continually update the best available literature on efficacy of treatment. There is a large and active group evaluating studies of back pain, and the fruits of this effort should be available within the next few years.

 Managing acute low back pain

 For simple back ache (age 20-55 years, no radiation below the knee,
 "mechanical' pain, patient well):

 * Radiography, imaging, and specialist referral are unnecessary; psy-
 chosocial factors should be considered

 * Bed rest is not recommended; patients are advised to stay as active
 as possible and continue normal daily activities

 * Drugs should be prescribed at regular intervals, not as required,
 and should begin with paracetamol or non-steroidal anti-
 inflammatory drugs, avoiding narcotics if possible

 * Spinal manipulation may be considered for relief of symptoms
 within six weeks of onset

 * Patients who have not returned to ordinary activities and work by
 six weeks should be referred for an exercise programme

Professor Department of Medicine and the Department of Health Services, University of Washington, Seattle, WA 98195 USA

Supported in part by grant #HS-08194 from the United States Agency for Health Care Policy and Research

Richard A Deyo 

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