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Back Trouble treated in Primary Care 
An overview of current Evidence-based thinking 
80% of the population will report at least one episode of back pain at some time in their life. Both UK and international research over the last decade into the causes, diagnostic tools and treatment of back pain, suggest a more broad approach for the clinical understanding of how we investigate back pain and treat it in primary care. 
For low back pain the evidence indicates: 
Back pain to be a common condition with a broadly consistent pattern from early teenage years to old age. 
The course of most low back pain is usually a recurrent, intermittent complaint. 
There is a blurring of the distinction between: 
phases of extremely painful (acute) pain, or 
where there are phases of no pain and phases of pain, or 
long- term persistent (chronic) low back pain. 
The idea that work is usually a “toxic” influence on the back has little evidence to support it. 
The bio-mechanical/“injury model” of low back pain is largely inappropriate. It may be relevant for many people and their presenting problem, but for many others, it is unhelpful. This is because it does not take account of important psychological and social influences we all have and experience in our lives. 
The notion that back pain can be easily prevented is seriously unrealistic. 
For working-age people early return to work, even if the back remains troublesome, is an important health-giving goal. 
Long-term persistent (chronic) back pain is not an isolated symptom focussed on the lower back. It quite often reflects an inability to manage the pain itself. Much research evidence for this is becoming a practical reality for developing an education-based support for each patient as an individual. (In years past, doctors frequently said “you must learn to live with your pain”. They never offered thought as to why the patient had the problem or how they were suppose to live with it)! 
Imaging (taking X-rays and MRI scans) as reliable tools for low back pain diagnostics have limited clinical value and for Primary Care are poor value for money and may even be misleading. 
The view that disc degeneration is a product of aging, wear, tear, and injuries in the workplace and elsewhere, are no longer supported. The process of disc aging begins around teenage. The primary determinants of disc degeneration appear to be genetic. Environmental factors play a small and as yet, poorly understood role. 
Most common treatments in primary care show no consistent evidence of therapeutic effect and where there is evidence, as for example manual therapy, the evidence is limited and very dependent on the health provider. For each provider, the quality of their own knowledge, experience and beliefs utilised to clinically assess, create and implement a treatment plan for each individual patient are of critical importance. 
Prolonged courses of physical treatment have no demonstrable effect on the natural history of bio/mechanical back problems. For those with long-term (chronic) pain of many years, there is increasing evidence that when provided with opportunities to receive longer term access for support, this can encourage, develop and help maintain an improved status utilising the patient’s own appropriate self-management strategies. 
Based on D Cherkin at the presentation and summary of the last ten years of research to the Primary Care Research on Low Back Pain Forum IX. Palma de Mallorca 2007. Created by Greg Sharp in consultation with Professor AK Burton Huddersfield Spinal Research Centre 
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