HEALTHY LIVING RESULTS

Non-specific low back pan which persists for some time is a common presentation for various health care practitioners to deal with, representing a major reason for absence from work due to sickness. Research has moved ahead quickly over the last decade, making a scientific view of assessment and treatment recommendations possible which could lead to predictable benefits for patients with persistent low back pain. The National Institute for Clinical Excellence (NICE) has just released a new set of guidelines in May 2009.

The first requirement in the assessment of back pain is to establish a diagnosis. By definition the source is not clear in non-specific low back pain but many potential diagnoses have been ruled out such as ankylosing spondylitis, arthritic diseases, fractures, infections or tumours. Diagnosis is not a one time thing with periodic reassessment important if things change, and investigations should be requested if a specific diagnosis is suspected. Radicular symptoms in the leg, typically called sciatica, and cauda equina syndrome are neurological syndromes which cause severe and very specific symptoms and need consultation with a spinal surgeon.

Low back pain has been typically classified as acute, sub-acute and chronic. Acute back pain is said to be back pain of a duration of less than six weeks, while sub-acute back pain is said to continue between six and twelve weeks. Over twelve weeks the back pain is said to be chronic although this classification may be too rigid to reflect the reality of the incidence patterns of low back pain. Many people’s symptoms vary significantly with more and less acute episodes over a long period of time.

Low back pain is estimated to affect around 30 percent of the population of the UK every year, with about a fifth of this number consulting their general practitioner about their back pain. In the past most back pain was thought to settle by six weeks but more recent research has shown that a year after their back pain episode sixty-two percent of sufferers still have pain. In those who are off work with their back pain sixteen percent are still off work at a year. The first month shows a rapid improvement in pain and disability but this is not much improved by three months.

Contemporary figures for the costs of back pain to society are not available but are known to be very high. Patients spend a lot of money on private therapists in the UK, patronising private physiotherapists, acupuncturists, osteopaths and chiropractors. A new episode or a worsening of low back pain makes the exclusion of non-mechanical causes for the back pain vital. Infection is more common in people with immune system problems such as HIV. The incidence of the types of cancers which spread to bone is higher in older age groups. Fractures due to osteoporosis have a higher incidence in older people and anyone on steroids.

Loss of the ability to work, development of disability related to the back and loss of normal activities are the negative factors which can result from sub-acute to chronic low back pain and are the factors which must be addressed to manage this condition successfully. High pain levels, a high degree of disability and psychological distress are risk factors for a poor result and so must be targeted to improve the patient’s outcome. Back pain treatments are very numerous with many claims for effectiveness but there is little good evidence to back up the use of most therapies. NICE made the decision to look at the overall delivery of a care package for back pain rather than concentrate on particular therapeutic interventions.

The common therapies used for treatment of low back pain include:

Patient education which covers advice and explanations from professionals, written material and education sessions.

Non-invasive physical therapies such as transcutaneous electrical nerve stimulation, traction, spinal corsets, interferential, laser and ultrasound.

Land or water based exercise programmes, again either individually or as part of an exercise group.

Other physical, non-invasive therapies such as ultrasound, interferential, laser, TENS, lumbar traction and lumbar corsets.

Psychological management involves self management, mindfulness and different types of cognitive behavioural therapy.

The early part of the year is the time for the new resolutions we have about many things, including our personal appearance and fitness. Summer will soon be here and we want to look our best. Perhaps we have already signed up for the gym and rather predictably not attended anywhere near as much as initially intended. We want to be fit but are not clear at all what that means or the significance of the typical fitness measures used to track progress. Our lack of knowledge impairs our ability to plan our training and reduces the chances of success. While physiotherapists understand more about these concepts than most people they are still not that knowledgeable in detail.

A major health focus in the community is the management and prevention of coronary heart disease, a very common health condition and responsible for a large annual death toll. We can all work at our risk factors and bring the various parameters closer towards safe limits. Fitness is not one thing but composed of various abilities, parts of each of which may need to be developed to reach an acceptable result. Allowing one of the components to be ignored can limit the potential fitness we might achieve.

To achieve aerobic fitness we need to choose an overall body activity and maintain the performance at a particular level for a particular time. e.g. swim for 30 minutes. The degree of difficulty needs to be such to engage a training effect so we must be able to continue the activity for long enough.

To achieve muscular fitness we need to acquire sufficient strength and endurance in our muscles to achieve the forces and duration needed.

Flexibility is the ability of our bodies to be extensible, for the balance of looseness and tightness in bodily structures to be optimal for functional activity.

Dynamic and functional activities demand considerable balance, maintaining the control over our postural stability as we perform complex motions under load.

To put all the previous aspects together, power, endurance, strength, balance and aerobic capacity we need to develop coordination, a dynamic control of movement.

Typical values for the measurements which are used to indicate fitness and health are a resting blood pressure of less than 140/90 (140 over 90). The higher figure, 140, is the systolic blood pressure, the pressure occurring in the main artery when the heart is in systole (sist-oley) which is the main pumping action. The lower figure, 90, is the diastolic blood pressure, the pressure in the main artery when the heart is in diastole (di-ast-oley), the resting phase when it is refilling before the next pumping action. If the diastolic, lower number is elevated it indicates that the arterial system is stiffer than it should be and so the pressure within it is higher.

High blood pressure has consequences which relate to heart disease, kidney function, peripheral blood supply and the likelihood of stroke. This is connected with total cholesterol levels which should be less than 5.0 mmol/l (five millimoles per litre), which indicates the risk for developing atherosclerosis and heart disease to some degree. Body mass is another indicator of our present and future health, with the Body Mass Index (BMI) a useful but not infallible indicator of our status in the health stakes. The BMI is often indicated on a big colourful poster, charting the relationship between our height and our bodyweight and dividing the results into underweight, healthy, overweight and obese.

From 20 to 24.9 are the recommended limits for a healthy body mass index and the chart allows the indication of a desirable weight for our size so we can plan a realistic bodyweight to aim for if we are overweight. There are some difficulties with the BMI in that some people, perhaps due to their structure or muscular bulk, seem to get unreasonable results for their predicted desirable weight. However, the body weight index does give a good indication of what a desired weight should be and can be used along with the desired body fat content of between 21 and 27%.