Back Pain Management

We currently do not offer the option to download the slides for offline teaching. However, CSS will discuss the suggestion you posted as it may fit into our future plans for dissemination of the Back Health CMEs in the primary care field.

Sacroiliac pain has a pattern all its own. It is buttock dominant, centered in the mid to lower section. It is constant, although the amount of pain varies much more than the typical back pattern and can go from almost absent to severe in the course of the day. The pain is least in the morning and increases during the day. It is aggravated by twisting (rolling over in bed is a common cause of pain), by walking or prolonged standing. When severe, the pain can radiate down the back of the thigh to the knee. SI pain is more common in women and is frequent during pregnancy. It can be relieved by the use of a pelvic belt. A positive response is a good diagnostic test. The physical examination includes tests that stress the SI joint. I suggest that the examiner select four (anterior gapping of the iliac crests, lateral compression, posterior pressure on the sacrum and the FABER manoeuver are fairly standard) and three of the should reproduce the patient’s typical buttock dominant pain. The diagnosis of ankylosing spondylitis is the diagnosis of Pattern 1 PEN or more commonly Pattern 2 in a young person in their 20s or 30s (the sex difference with males more likely to have the disease is no longer widely accepted) with a history of prolonged morning back stiffness. The diagnosis is made on the lack of sustained improvement with mechanical therapy and a significant temporary improvement with NSAIDs. Early in the course of the disease the diagnosis can be difficult and relates more to the recurrent clinical course and lack of anticipated response than to any single presenting symptom. I have added the question, “If you are under 45 do you have morning back stiffness lasting more than 30 minutes?” to my standard eight questions. Now there are nine.

Dear Dr. Lockner,
The reason there is no literature support is because there has never been a study to demonstrate that Low Level Laser Therapy has an effect. There is, however, good evidence both from laser physics and human physiology that the laser beam (which incidentally is about the intensity of the standard laser pointer) does not penetrate the skin surface more than a few millimeters before it loses the coherence, columnation and energy that make it a laser. All that is left is the colour of the light. It is actually for this reason that many low intensity laser proponents suggest that different conditions require different colour lasers.

Laser is far from the only “unproven” technique that helps back pain. Any online search will uncover dozens of approaches that purport to eliminate back pain and all come with sincere testimonials as to their effectiveness. Back pain is a transient, recurring condition and can be influenced by a number of factors. The most powerful of these is a beneficial placebo effect. Functional MRI studies have demonstrated amazing levels of observable change in brain activity and pain reduction with nothing more than powerful suggestion.

It is highly unlikely that you will find support for your use of the laser in any controlled study. But that doesn’t mean that it won’t work. If you are having success with Low Level Laser and your patients are returning to normal function in a consistent and sustained fashion, I see no harm. There are many facets to the Art of Medicine and evidence base is only one.

Hamilton Hall

Instructing the physiotherapist requires a sense of balance. Too much instruction may be poorly received and limits the therapist’s initiative. Too little instruction allows the all-too-common passive approach of modalities and manipulation. The communications should state the mechanical pattern or syndrome and ask for patient education, specific pain control strategies based upon the presenting mechanical pattern and an estimate of treatment frequency and duration.

Mechanical back pain changes quickly. A response can be seen almost immediately and typically, within 24 hours. The change may not be sustained but it will be apparent and serves to direct further interventions. Because of this, the re-evaluation should take place within 24 to 48 hours if at all possible. Clearly sooner is better than later.