Back pain - old problem, old treatment?

It's one of the most common problems I see in my practice - especially after a bank holiday weekend or when the DIY and gardening bug strikes in the warm weather. Forty-one per cent of the UK population - that's 28 million of us - suffer from low back pain in any given year. Ninety-five per cent of people who get a new episode of back pain have 'non-specific' or 'simple' back pain - that doesn't mean it doesn't hurt (believe me, I know it does!) but it means there's no obvious single cause and it tends to settle with no long-term complications within a few weeks. More serious causes of low back pain, ranging from sciatica to compression of the spinal cord, a fractured spine or cancerous deposits almost always have different symptoms to non-specific low back pain and are much less common.

Above the sacrum and coccyx, often known as the tailbone, the spine is made up of 24 bones (vertebrae) connected by dozens of tough connective bands called ligaments and small muscles. There are several joints connecting one vertebra to the next - as well as the joint between the main body of two vertebrae, buffered by a spongy disc, small 'facet joints' connect the spiny outcroppings of bone at the back of each vertebra. Non-specific back pain can be caused by a sprain to any of the ligaments or muscles, or minor misalignment of the facet joints.

Recommendations for treating low back pain have changed a lot over the years. Doctors used to give instructions for strict bed rest, lying flat on your back on a firm mattress or even a board. Now we know that being immobile actually slows down recovery, and always recommend keeping as active as possible. You're going to have to accept feeling some discomfort when you move (while avoiding activities that cause severe pain) and should build up your activities gradually.

But we've been remarkably consistent as far as medicines are concerned. For years, simple painkillers like paracetamol have been a mainstay of treatment, recommended daily in GP surgeries across the country. At present, paracetamol is the first line treatment in the National Institute for Health and Care Excellence (NICE) guideline and every pharmacy, supermarket and petrol station shop keeps copious supplies. Now a new study of over 1,600 people newly diagnosed with non-specific back pain may be about to turn our thinking on its head. Published in The Lancet, it found that in people given advice and reassurance, giving paracetamol either on a regular or an 'as needed' basis was no better than placebo at speeding recovery. The fact that some of the patients in the study used other treatments may have watered down the impact of the trial, and the study didn't look in detail at day-to-day pain in the early stages. Even so, it does call into question our love affair with paracetamol for one of the most common pains suffered in the UK.

But if not paracetamol, what else? Doctors are likely to focus yet more on advice about keeping active and specific exercises. Heat packs may become more the norm. Other pain relieving medications such as ibuprofen, either as tablets or as a topical gel, can cause side effects in some people but for short courses is usually well tolerated by most healthy people and has been found to be effective. As for other options, NICE is working on new guidelines, which should be out in the next few months. Watch this space.

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