Here in New Zealand, our friendly Accident Rehabilitation, Compensation and Insurance Corporation, colloquially and widely known as the ‘ACC’ is a health-premium-tax funded organisation that provides the funding for treatment and rehabilitation after accidents. The ACC is presently endeavouring to control the fiscal results of previous political decisions that saw an expansion of expenditure to hitherto unimaginable levels, which in turn has led to the most recent political decision to adopt a more economically sustainable business model. The see-saw of the political landscape wreaks its own unintended consequences in health care, exerting a measured pressure on case management broadly consistent with the evidence but definitively consistent with fiscal goals. ‘Managed care’, which may utilise clinical guidelines born out of the highest ethical desire to see best practice,  remains primarily concerned with a financial imperative. It is serendipitous when the goals of ‘managed care’ coincide perfectly with the goals of evidence based practice (EBP).

When considering the evidence based health care management of an episode of acute back pain it has been of longstanding interest to me that the message ACC promulgates as evidence based is to remain active – and most preferably, at work. The financial imperative here is evident. The costs associated with income related compensation are very substantial. In addition, the risk of chronicity associated with disengagement from normal everyday activities including work, escalates. So the Corporation puts out the following EBP advice:

In most cases, the patient can be advised to continue working normally. Communication with the patient must include clear statements like ‘working heals rather than harms the back’. The patient should also be reassured that while there may be some temporary increase in pain, the physical activity is beneficial to their rehabilitation, (Non-specific acute low back pain: Return to work – Issue 10; May 2004. http://www.acc.co.nz/for-providers/clinical-best-practice/acc-review/WCMZ003162)

Staying active and continuing usual activities, even though there may initially be pain and discomfort, usually results in a faster recovery from symptoms, less chronic disability and less time off work. NZ Acute Low Back Pain Guide Oct 2004, p12.

The evidence suggests that in the absence of ‘red flags’ – indicators of potentially significant or serious pathology, most individuals improve quite quickly from an episode of acute low back pain. It should be pointed out here that this does not mean they ‘get better’ or make a ‘full recovery’. The implication also exists that as the condition is not diagnosable (at least without expensive, sophisticated imaging or invasive diagnostic tests – and, so it goes, there’s no point anyway as most patients get better)………then it follows that there’s nothing really wrong, which is another subtle reinforcement of the keep moving, stay at work message. The trouble is that the literature also suggests that there is a 50% chance of recurrence within a year after an acute episode which leaves one in little doubt that for a significant proportion of acute low back pain sufferers, an injury of consequence has been incurred -  MRI studies suggest that 35 – 40% of the population have intervertebral disc bulges.

When an injury occurs it requires a period healing. The healing process takes a period of time but it will permit the progressive resumption of pain free activity in a manner that is physiologically consistent with the degree of injury and the role of the structure involved.  In addition, the neurological recovery from a episode of acute pain may arguably take longer – pain pathways are sensitised and some central expansion of related central somatosensory areas may ensure and importantly, the pain experience will not be forgotten.

Now, there is little doubt if one were to fall over, hands outstretched, in a manner that results in the forcible over extension of a knuckle joint, the joint is likely to swell and become painful. It was sprained. More than likely, one will limit the amount of movement until the pain and swelling subsides. Almost certainly, one will not actively wiggle the joint in order to promote a more rapid recovery. In this instance, such behaviour is both inconsistent with a speedy physiological recovery and a pain free life .

A patient experiencing an acute episode of low back pain will sometimes barely be able to walk, let alone think of working. Usually and fortunately, this period is short – days. In most cases individuals do press on as best they can but they will instinctively limit their activities commensurate with their pain. Moving may not be of therapeutic use. And indeed, this is what the evidence now tells us. The ACC Acute Low Back Pain (2004), which refers to the Cochrane Collaboration as a source of data, does not appear to reflect recent Cochrane Collaboration findings.

The Cochrane Collaboration has quite recently withdrawn advice to stay active as a single treatment for low back pain and sciatica (Hilde et al. Cochrane Collaboration, Issue 4, 2009) and highlights the idea that remaining active and engaged in daily activities as normally as possible is the best EBP advice. This stands in notable contrast to the ACC statement that ‘working heals rather than harms the back’ or  ‘In most cases, the patient can be advised to continue working normally’. Such statements are incorrect generalisations that may inadvertently encourage unintended consequences.  They may inhibit rapid physiological recovery by promoting the notion that activity per se is useful – which it clearly isn’t – and they may result in a prolongation of injury and increased risk of chronic back pain. The new evidence however, is consistent with the physiological requirement for recovery from injury, although the Corporation may view it as a fiscally risky recommendation. We’ll see. I suspect fiscal risk will win out.

So the take away message to patients and practitioners, having clinically excluded ‘red flags’, is to pay attention to the symptoms, listen to your body and move about in a manner consistent with managing your discomfort at a tolerable level. Exercise (remember wiggling the knuckle) and acute back pain do not enjoy some secret inverse relationship. In fact, they are not related at all. However, you will find that if you move about in a manner you can tolerate and you stay engaged with life, friends and work you’ll recover with less struggle and potential complication, and you’ll remain saner. I sometimes frame such advice in the following way; number one rule is to stay comfortable and engaged and number two is to move, but not in a manner that compromises number one rule. Needless to say this advice is not only patient specific but also takes into account other potential risk factors associated with the development of a chronic condition.