Early behavioural management of lumbar disorders

Suggested steps to better early behavioural management of low back pain include:

Be positive and realistic

  • Provide a positive expectation that the individual will return to work and normal activity. If the problem persists beyond two to four weeks, provide a reality-based warning of what is going to be the likely outcome (for example loss of job, the need to begin reactivation from a point of reduced fitness)
  • Be directive in scheduling regular reviews of progress. When conducting these reviews shift the focus from the symptom (pain) to function (level of activity). Instead of asking ‘How much do you hurt?’ ask ‘What have you been doing?’.

Provide expectations of continued activity

  • Keep the individual active and at work if at all possible, even for a small part of the day.
  • Acknowledge difficulties with activities of daily living, but avoid making the assumption that these indicate all activity or any work must be avoided.
  • Help to maintain positive cooperation between the individual, employer, compensation system and health professionals.
  • Make a concerted effort to communicate that having more time off work will reduce the likelihood of a successful return to work.
  • Be alert for the presence of individual beliefs that he or she should stay off work until treatment has provided a ‘total cure’.

Promote self-management and self-responsibility

  • Encourage people to recognise, from the earliest point, that pain can be controlled and managed so that a normal, active or working life can be maintained. Provide encouragement for all ‘well’ behaviours – including alternative ways of performing tasks, and focusing on transferable skills.
  • Encourage the development of self-efficacy to return to work.

Involve multidisciplinary services if required

  • Be prepared to ask for a second opinion, provided it does not result in a long and disabling delay, especially if it may help clarify that further diagnostic work up is unnecessary. Be prepared to say ‘I don’t know’ rather than provide elaborate explanations based on speculation.
  • Avoid confusing the report of symptoms with the presence of emotional distress. Distressed people seek more help, and have been shown to be more likely to receive ongoing medical intervention. Exclusive focus on symptom control is not likely to be successful if emotional distress is not dealt with.
  • If barriers to return to work or accustomed activity are identified and the problem is too complex to manage, referral to a multidisciplinary team is recommended.