Watchful Waiting in Chronic Lower Back Pain

Posted February 21st, 2008 by Matt

Spine Lumbar

Amid the many treatments available for the management of chronic lower back pain (CLBP), watchful waiting remains an approach for patients who do not have acute back pain nor injuries or disabilities that would deteriorate and cause more harm if left untreated.

Watchful waiting must be explained to the patients it is not the same thing as doing nothing. The author of this article defines watchful waiting as "minimal care through rest, activity modification, education, or avoidance of inciting or aggravating factors. Watchful waiting is a passive intervention and does not include any active interventions."

The patient, unknowingly, may be undertaking watchful waiting on his or her own by not seeking medical attention. Of course, watchful waiting depends on the cause of back pain. In the early 1990s. the US Department of Health and Human Services developed and published clinical practice guidelines on the management of acute lower back pain, divided into these three categories:

1- potentially serious spinal conditions, such as fractures, infections, tumors and cauda equina syndrome
2- sciatica
3- non-specific back symptoms

Many people live with and are able to cope with low-level nagging back pain by ignoring it or adapting their lifestyle to accommodate the pain. Some will self-treat with some success. Often, these patients will seek medical help if the pain becomes more insistent, frequent, or intense.

The author of this study described the steps to watchful waiting. In the Watchfulness stage, the healthcare professional must perform a thorough medical exam to rule out any condition that may require urgent or aggressive treatment. The Waiting stage involves seeing if the pain will resolve with time. The Reassurance part of watchful waiting involves reassuring the patients to reduce anxiety levels and to assure them that they are being monitored and not ignored. The article author writes, "Reassurance usually consists of educating the patient about the basic facts, that this is a common problem, an that 90 percent of patients recover spontaneously in four to six weeks."

Another part of this approach includes activity modification, whereby the patient may have to rest, although no more than two days of bedrest are recommended, and gradual reintroduction of previous activities. Education, another important aspect in watchful waiting, teaches patients who to be responsible for their back, the steps they must take for good back care, promotion of physical activity, weight loss, and smoking cessation, if these are appropriate.

Red flags for watchful waiting, whereby watchful waiting is not recommended include: age over 70 years, duration of pain of more than six weeks, neurological or progressing neurological deficit, history of cancer, immunosuppression, intravenous drug use, prolonged use of steroids, osteoporosis, recent significant or milder trauma if over the age of 50 years, unexplained fever, and unexplained weight loss.

The only harms noted by the author is that CLBP may worsen and intrude on quality of life and ability to work.

Ben B. Pradhan, MD, MSE. Evidence-informed management of chronic low back pain with watchful waiting. In The Spine Journal. January/February 2008. Vol. 8. Issue 1. Pp. 253-257.

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