Low Back Pain: Difference between revisions

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There has been a recent move away from a pathoanatomical approach to managing individuals with back pain. &nbsp;No longer do we aim to diagnose a structure at fault and aim our treatment at that particular structure. &nbsp;Research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain<ref name="Koes" /><ref name="van Tulder" /><ref>Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.</ref>. &nbsp;Instead a stratified approach to managing low back pain has become popular.  
There has been a recent move away from a pathoanatomical approach to managing individuals with back pain. &nbsp;No longer do we aim to diagnose a structure at fault and aim our treatment at that particular structure. &nbsp;Research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain<ref name="Koes" /><ref name="van Tulder" /><ref>Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.</ref>. &nbsp;Instead a stratified approach to managing low back pain has become popular.  


<span style="font-size: 13.28px; line-height: 19.92px;">International guidelines recomend advice and analgesia<ref name="NICE">Low back pain: Early management of persistent non-specific low back pain.  NICE guidelines [CG88], May 2009</ref> plus physiotherapy interventions such as exercise, manual therapy and acupuncture as appropriate treatment techniques to use in the management of individuals with back pain. &nbsp;To direct these treatment plans s</span>tratified care&nbsp;has been suggested as an appropriate approach<ref name="Foster">Foster N.E, Hill J.C, O'Sullivan P, Childs J.D, Hancock M.J. Stratified models of care for low back pain. WCPT Congress, Singapore, 2015</ref>. &nbsp;Stratified care is the targeting of treatment to subgroups of patients based on characteristics. &nbsp;Foster et al<ref name="Foster" />&nbsp;suggest that there are 3 different approaches to stratification:<br><br>
International guidelines recommend advice and analgesia<ref name="NICE">Low back pain: Early management of persistent non-specific low back pain.  NICE guidelines [CG88], May 2009</ref> plus physiotherapy interventions such as exercise, manual therapy and acupuncture as appropriate treatment techniques to use in the management of individuals with back pain. &nbsp;To direct these treatment plans stratified care&nbsp;has been suggested as an appropriate approach<ref name="Foster">Foster N.E, Hill J.C, O'Sullivan P, Childs J.D, Hancock M.J. Stratified models of care for low back pain. WCPT Congress, Singapore, 2015</ref>. Stratified care is the targeting of treatment to subgroups of patients based on characteristics. &nbsp;Foster et al<ref name="Foster" />&nbsp;suggest that there are 3 different approaches to stratification that have good evidence:  


===  ===
#Patient prognosis - matching treatment to patients prognosis (i.e. the likelihood of persistnet pain and disability)
 
#Responsiveness to treatment - matching treatments to individuals who would benefit from that treatment. &nbsp;
=== Immediate  ===
#Underlying mechanisms -&nbsp;matching treatment to mechanisms that drive pain and disability ( e.g. pathology, pain mechanisms, negative thoughts and behaviours)<br>
 
There is strong evidence that most people with simple back pain improve rapidly with limited intervention<ref>Hancock MJ, Maher CG, Latimer J, et al. Can rate of recovery be predicted in patients with acute low back pain? Development of a clinical prediction rule. Eur J Pain 2009;13:51–55</ref><ref>Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008;337:a171</ref>. The initial treatment should include emphasis on the benign nature of the problem, advice to remain as active as possible, avoid bed rest, and reassurance that the pain is likely to settle quickly.1,2 Patients are advised to take simple analgesics if required.1,2 Physiotherapists commonly add manual therapy and/or exercise interventions if the assessment reveals that these are likely to help an individual patient. In patients with severe pain and muscle spasm, modalities such as heat and massage may be used to provide short-term pain relief. In patients with mechanical low back pain imaging is not ordered, as per international guidelines.1,2
 
=== Short term (days to weeks) ===
 
If the patient is progressing well the physiotherapist may see the patient once or twice more over the following weeks to monitor progress, extend the exercise program (either general activity or specific exercises as needed) and provide manual therapy if indicated. The aim of treatment is to address the patient’s individual goals, with emphasis on self-management<ref name="Hancock" />.  
 
=== Medium term (up to 6 months)  ===
 
The expectation is that most patients will recover well before this time and be discharged from physiotherapy. Physiotherapists do not typically continue to see patients in a preventative or maintenance manner. However, if the examination revealed impairments such as poor strength or muscle coordination, which research has shown to be associated with recurrent low back pain,10,11 physiotherapists will often teach patients appropriate exercises to work on these impairments. This is a decision made with a patient, as after the episode has settled some patients are motivated to work on prevention strategies while others are not.
 
If patients do not improve well within the first few weeks a more detailed examination is required. Management of patients who develop chronic back pain is more complex and beyond the scope of this article but often involves a multidisciplinary approach and may require further investigation such as imaging.
 
=== Long term (years, including prevention and maintenance strategies) ===
 
Physiotherapists do not commonly see patients in the long term for prevention or maintenance. Group exercise classes for prevention have become increasingly common and there is some evidence for the effectiveness of these measures.12


== Contraindications  ==
== Contraindications  ==

Revision as of 11:36, 1 October 2015

Original Editors - Fauve simoens

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Introduction[edit | edit source]

File:Interactive Spine - Lumbar Vertebral Spine - L7F19.jpg
© Primal Pictures

Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. 

There are different definitions of low back pain depending on the source. According to the European Guidelines for prevention of low back pain, low back pain is defined as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain"[1]  Another definition, according to S.Kinkade, which resembles the European guidelines is that low back pain is “pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs”.[2]  The most common form of low back pain is the one that is called “non-specific low back pain” and is defined as “low back pain not attributed to recognizable, known specific pathology”.[1]

Low back pain is usually categorized in 3 subtypes: acute, sub-acute and chronic low back pain. This subdivision is based on the duration of the back pain. Acute low back pain is an episode of low back pain for less than 6 weeks, sub-acute low back pain between 6 and 12 weeks and chronic low back pain for 12 weeks or more.[1]

Low back pain that has been present for longer than three months is considered chronic. More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode[3][4][5]. It is estimated that seven million adults in the United States have activity limitations as a result of chronic low back pain[6].

Low Back Pain Examination[7][edit | edit source]

The first aim of the physiotherapy examination for a patient presenting with back pain is to classify the patient according to the diagnostic triage recommended in international back pain guidelines[8]. Serious (such as fracture, cancer, infection and ankylosing spondylitis) and specific (such as radiculopathy, caudal equina syndrome) causes of back pain are very rare[9] but it is important to screen for these conditions[8][10]. When serious and specific causes of low back pain have been ruled out individuals are said to have non-specific (or simple or mechanical) back pain.

Leg pain is a frequent accompaniment to low back pain, arising from disorders of neural or musculoskeletal structures of the lumbar spine. Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology. Schäfer et al[11] proposed that low back-related leg pain be divided into four subgroups according to the predominating pathomechanisms involved. Each group presents with a distinct pattern of symptoms and signs although there may be considerable overlap between the classifications. The importance of distinguishing low back-related leg pain into these four groups is to facilitate diagnosis and provide a more effective, appropriate treatment:

  1. Central sensitization with mainly positive symptoms such as hyperalgesia
  2. Denervation with significant axonal damage showing predominantly negative sensory symptoms and possibly motor loss
  3. Peripheral nerve sensitization with enhanced nerve trunk mechanosensitization
  4. Somatic referred pain from musculoskeletal structures, such as the intervertebral disc or facet joints.

Mechanical low back pain accounts for over 90% of patients presenting to primary care[12] and these are the majority of the individuals with low back pain that present to physiotherapy.  Physiotherapy assessment aims to identify impairments that may have contributed to the onset of the pain, or increase the likelihood of developing persistent pain. These include biological factors (eg. weakness, stiffness), psychological factors (eg. depression, fear of movement and catastrophisation) and social factors (eg. work environment)[7]. The assessment does not focus on identifying anatomical structures (eg. the intervertebral disc) as the source of pain, as might be the case in peripheral joints such as the knee[7]. Previous research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain[8][10][13].

Management strategies[edit | edit source]

There has been a recent move away from a pathoanatomical approach to managing individuals with back pain.  No longer do we aim to diagnose a structure at fault and aim our treatment at that particular structure.  Research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain[8][10][14].  Instead a stratified approach to managing low back pain has become popular.

International guidelines recommend advice and analgesia[15] plus physiotherapy interventions such as exercise, manual therapy and acupuncture as appropriate treatment techniques to use in the management of individuals with back pain.  To direct these treatment plans stratified care has been suggested as an appropriate approach[16]. Stratified care is the targeting of treatment to subgroups of patients based on characteristics.  Foster et al[16] suggest that there are 3 different approaches to stratification that have good evidence:

  1. Patient prognosis - matching treatment to patients prognosis (i.e. the likelihood of persistnet pain and disability)
  2. Responsiveness to treatment - matching treatments to individuals who would benefit from that treatment.  
  3. Underlying mechanisms - matching treatment to mechanisms that drive pain and disability ( e.g. pathology, pain mechanisms, negative thoughts and behaviours)

Contraindications[edit | edit source]

There are few contraindications to physiotherapy interventions for mechanical back pain as long as the diagnostic triage has been applied to identify people with serious causes of back pain. Osteoporosis is a contraindication to most manual therapy. Importantly, physiotherapists work in a model where effects of treatments are closely reassessed to minimise the likelihood of increasing symptoms or adverse events[7].

Prevention of Low Back Pain[edit | edit source]

Prevention is also categorized in 3 types of prevention.

  1. Primary prevention is defined as “specific practices for the prevention of disease or mental disorders in susceptible individuals or populations. These include health promotion, including mental health; protective procedures, such as communicable disease control; and monitoring and regulation of environmental pollutants. Primary prevention is to be distinguished from secondary prevention and tertiary prevention.”[17]  
  2. Secondary prevention is defined as “the prevention of recurrences or exacerbations of a disease that already has been diagnosed. This also includes prevention of complications or after-effects of a drug or surgical procedure”[17] 
  3. Tertiary prevention as “measures aimed at providing appropriate supportive and rehabilitative services to minimize morbidity and maximize quality of life after a long-term disease or injury is present”.[17]


The guidelines discuss different possibilities to prevent low back pain, and most of them are supported by other articles. Physical exercise is recommended to prevent consequences of low back pain, such as absence of work and occurrence of further episodes. With physical exercises is especially mend training of back extensors and trunk flexors in conjunction with regular aerobic training. There is no specific recommendation of exercise frequency or intensity.[1][2][18] With regard the back school programs, a high intensity program is advised in patients with recurrent and lasting low back pain but not in preventing low back pain. The program consists of exercises and an educational skills program. Education and information alone or based on biomechanical model has only a small effect. Education and information in combination with other interventions, in a treatment setting based on biopsychosocial model has a better effect. Information based on biopsychosocial model is focused on beliefs in low back pain and reducing work loss caused by low back pain. This attitude of giving information has a positive effect on back pain beliefs.[1]  It is important to know that individually tailored programs and intervention may have more results in comparison to group interventions.[18] Lumbar supports, back belts and shoe insoles are not recommended in the prevention of low back pain. Lumbar supports and back belts have also been shown to have a negative effect on back pain beliefs and are therefore not recommended in preventing low back pain.[1][2] Specific mattresses and chairs for prevention have no evidence in favor or against. Medium mattresses may decrease existing persistent symptoms of low back pain.[1] Ergonomic adjustments regarding work environment can be necessary and useful to achieve earlier return to work.[1][19]

In the prevention of acute low back pain becoming chronic low back pain Kinkade refers to the European guidelines and suggests exercise and to not use back belts or lumbar supports. Important in preventing acute low back pain of becoming chronic is to mention the interest of psychosocial factors that correlate with the development of chronic low back pain.[2]
- Disputed compensation claims
- Fear avoidance (exaggerated pain or fear that activity will cause permanent damage)
- Job dissatisfaction
- Pending or past litigation related to back pain
- Psychological distress and depression
- Reliance on passive treatments rather than active patient participation
- Somatization

Further on, there is still more research needed.[18]  

Guidelines[edit | edit source]

See Low Back Pain Guidlines

Related Pages[edit | edit source]

Presentations[edit | edit source]

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 Exercise and Low Back Pain: Where do we Stand

This presentation, created by Jason Steere as part of the Evidence In Motion OMPT Fellowship in 2011, discusses the basis and evidence for specific stabilisation exercises for low back pain.

View the presentation

http://ptcoop.org/fellow-lecture-specificity-of-thrust-and-non-thrust-techniques/Thrust techniques in LBP ppt.PNG
 Evidence for the Specificity of Thrust and Non-Thrust Techniques for the Management of Low Back Pain

This presentation, created by Ernest Gamble, PT, DPT, OCS, Evidence in Motion OMPT Fellowship 2013

View the presentation

https://http://www.youtube.com/watch?v=F3eDmSYBEaQOccupational related LBP ppt.PNG
 Occupational Related LBP: Prevention and Management

This presentation, created by Matt Gieringer, Brittany Holmes, Caleb Melde, Maiela Martinez; Texas State Class of 2014, Evidence-based Practice projects for PT7539 Ortho Spine course.

Occupational Related LBP: Prevention and Management/ View the presentation

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group. 2004: 1-53. (Level 1A)
  2. ↑ 2.0 2.1 2.2 2.3 Kinkade S. Evaluation and treatment of acute low back pain. Am Ac of Family Phys. 2007: 1182-1188.
  3. ↑ Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.
  4. ↑ Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.
  5. ↑ Chou R, Qaseem A, Snow V, Casey D, Cross TJ, Shekelle P, Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
  6. ↑ Chou R. Pharmacological Management of Low Back Pain. Drugs [online]. 2010;70 (4):387-402. Available from MEDLINE with FULL TEXT. Accessed April 30, 2011.
  7. ↑ 7.0 7.1 7.2 7.3 M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118
  8. ↑ 8.0 8.1 8.2 8.3 Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94
  9. ↑ Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072–80.
  10. ↑ 10.0 10.1 10.2 van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15(Suppl 2):S169–91
  11. ↑ Axel Schäfer, Toby Hall and Kathy Briffa. Classification of low back-related leg pain—A proposed patho-mechanism-based approach. fckLRManual Therapy, 2009;14(2):222-230
  12. ↑ Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
  13. ↑ Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
  14. ↑ Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
  15. ↑ Low back pain: Early management of persistent non-specific low back pain. NICE guidelines [CG88], May 2009
  16. ↑ 16.0 16.1 Foster N.E, Hill J.C, O'Sullivan P, Childs J.D, Hancock M.J. Stratified models of care for low back pain. WCPT Congress, Singapore, 2015
  17. ↑ 17.0 17.1 17.2 National Center of Biotechnology Information [www.ncbi.nlm.nih.gov]. Brussels [cited 2011 Apr 17]. Available from: http://www.ncbi.nlm.nih.gov/mesh/.
  18. ↑ 18.0 18.1 18.2 van Poppel MNM , WE. An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace. Occupational Medicine. 2004: 345-352. (Level 1A)
  19. ↑ Van Nieuwenhuyse, P. G. The role of physical workload and pain related fear in the development of low back pain in young workers: evidence from the BelCoBack Study; results after one year of follow up. Occup Environ Med. 2006: 45-52. (Level 2B)


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