Pain Management Tips for GPs
Management of Acute Back Pain – Health professionals
(Adapted from the Workcover publication Work-related acute low back pain clinical guidelines: Information for general Practitioners. Version 2, November 2004)
There are two basic guidelines for the management of non-specific low back pain
1. Encourage the patient to continue or resume ordinary activities of daily living as normally as possible, despite the pain of doing so
Specific analgesia and the resumption of normal activities can result in equivalent or faster symptomatic recovery from acute symptoms of non-specific lower back pain than the traditional management approaches (i.e. ‘rest’ and ‘let pain be your guide’). This approach has been shown to result in shorter periods of work-loss with fewer recurrences (Waddell, G. (1998). The Back Pain Revolution.
2. Take into account all psycho-social factors as well as the bio-medical ones.
There is strong evidence that psycho-social factors play an important role in persisting symptoms and disability. These can be related to the individual or the work place and need not bear a direct relationship to the original injury. In addition, they will strongly influence the individual’s response to treatment and rehabilitation (Bigos, S.J., Battie, M.C., Spengler, D.M., et al (1991). A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine, 16, 1-6; Pincus, T.,
The following suggestions, which are based on the above guidelines, should assist in the prevention of long-term disability through early intervention of low back pain problems:
- Provide realistic and confident reassurance that the patient will return to normal activities. If the problem lasts beyond 2-4 weeks provide a warning (based in reality rather than the ‘worst possible’ case) of what will be their likely outcome.
- Provide regular reviews of the patient’s progress and focus on assessing their level of activity as a guide of how well they are doing rather than focusing on their level of pain.
- Encourage maintenance of regular daily activities, including work, even if only for part of the day. Consider reasonable requests for selected duties. If no improvement after 4-6 weeks identify barriers for return to work and manage appropriately. These may consist of psycho-social factors, which cannot be addressed within a physical modality.
- Acknowledge that the patient may be having difficulties with some activities of daily living but avoid the assumption that this is an indication that all activity or work must be avoided.
- Be aware of the relationship between the patient, the employer, the compensation system and health professionals and assist to keep this co-operative. A break down in these relationships will lead to difficulties in the return to work process.
- Ensure that you clearly communicate that having more time off work will reduce the likelihood of a successful return to work. If there are still no improvements by the 6 week mark, start to suggest vocational redirection or job change.
- Be aware of any beliefs that the individual should remain off work until a ‘total cure’ has been achieved.
- Be aware of expectations of a simple fix.
- Encourage and promote self management of the condition to cultivate self efficacy. Reinforce attempts to overcome aversive stimuli (e.g. kinesophobia).
- Be prepared to say “I don’t know” rather than provide elaborate explanations based on speculation. Be prepared to ask for a second opinion, provided it doesn’t lead to long delays.
- Do not focus exclusively on symptom control. If emotional distress is not dealt with, symptom control is unlikely. Avoid confusing symptoms with emotional distress.
- Avoid any suggestions that the person should start to work from home, rather than in their usual work environment. It is more difficult to self motivate when in pain and therefore it is likely that their activity will become pain contingent and lead to a deactivation syndrome with all the negative physical and emotional consequences of this.
- Encourage the idea from early on that pain can be brought under control and managed and that normal activities can be maintained. Encourage all forms of ‘well’ behaviours.
- If the problem is too complex to manage or barriers to return to work are identified then referral to a Multidisciplinary Pain team is recommended.
Please check these websites
NSW Therapeutic Assessment Group – Prescribing guidelines for Primary Care Clinicians – Low Back Pain:
Workcover Corporation South