Non Specific Low Back Pain: Difference between revisions

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== Physical therapy management<br>  ==
== Physical therapy management<br>  ==


The conservative treatment in the initial phase is ice massage followed by passive knee-to-chest stretch (one leg at a time then both legs together). Also daily walks followed by stretching, electrical stimulation and iontophoresis are recommended in this phase.<ref name="two" /> It’s important to identify possible causes and to correct harmful activities and attitudes, to avoid further back pain problems.<ref name="three" /><br>
Stratified care&nbsp;has been suggested as an appropriate approach to manage non-specific low back pain<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:


In the second phase it’s necessary to continue the pain management and to be alert for ‘red flags’. The rehabilitation program exists out of stretching of the hamstrings and back (knee-chest), strengthening of back flexors and extensors and core strengthening.<ref name="two" />  
#Patient prognosis- matching treatment to patients prognosis such as the likelihood of persistnet pain and disability (e.g. [[STarT Back Screening Tool]]<ref>Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. [http://onlinelibrary.wiley.com/doi/10.1002/art.23563/full A primary care back pain screening tool: identifying patient subgroups for initial treatment]. Arthritis Care and Research 2008;59:632-41.</ref><ref>Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. [http://www.ncbi.nlm.nih.gov/pubmed/21963002  Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial]. Lancet 2011;378:1560-71.</ref>).
#Responsiveness to treatment - matching treatments to individuals who would benefit from that treatment (e.g. [[Treatment Based Classification Approach to Low Back Pain]], STOPS Trials). &nbsp;
#Underlying mechanisms -&nbsp;matching treatment to mechanisms that drive pain and disability such as pathology, pain mechanisms, negative thoughts and behaviours (e.g. Cognitive Functional Approach<ref>K Vibe Fersum, P O’Sullivan,2 JS Skouen, A Smith, and A Kvåle1. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul; 17(6): 916–928.</ref>, McKenzie appraoch<ref>Helen Clare, Roger Adams, Chris G Maher. [https://www.researchgate.net/publication/8153747_A_systematic_review_of_efficacy_of_McKenzie_therapy_for_spinal_pain A systematic review of efficacy of McKenzie therapy for spinal pain]. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 50(4):209-16 · FEBRUARY 2004</ref><ref>Tom Petersen. [http://fysio.dk/Upload/Graphics/PDF-filer/Afhandlinger/phd_afhandling/Phd_Petersen_Non-specific_low_back_pain.pdf Non-specific Low Back Pain: Classification and treatment]. Lund University, 2003</ref>).<br>


Patients should be taught several correct and comfortable positions and postures (during sleeping, sitting, lying, standing, walking and lifting techniques) that are safe for the spinal structures.<ref name="three" /><br>  
The use of these different stratification appraoches vary around the world and there are overlaps between these three different approaches. A perfect subgrouping approach would include all there of these approaches.&nbsp;These models don’t replace clinical reasoning or experience but they do warrant judicious exploration in clinical practice in appropriate settings.<br>


== Resources  ==
== Resources  ==

Revision as of 17:41, 10 October 2015


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Definition[edit | edit source]

Non-specific (or Simple or Mechanical) low back pain is the general term that refers to any type of back pain in the lumbar region that is not related to serious pathology and/or does not have a specific cause. 

Non-specific 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]

Epidemiology/etiology
[edit | edit source]

Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime[2][1]. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by low back pain[3].  In the 2010 Global Burden of Disease study the global age-standardised point prevalence of LBP (from 0 to 100 years of age) was estimated to be 9.4%[4]. The same study showed that prevalence in 2010 was highest in western Europe followed by North Africa/Middle East, and lowest in the Caribbean followed by central Latin America.

Economically LBP is a huge burden, LBP causes more global disability than any other condition[4].  The cost of care for LBP has been reported (in the USA) to be over $50 billion annually[5]. Despite the intense focus and formal research on the care of non-specific LBP Pransky et al[6] reported a five fold increase in the prevelance of LBP over a 15 year period. It should be noted that most of the epidemiology/economic studies have been done in the western industrialised higher resourced countries and these figures will differ globally.

Low back pain is a self limiting condition[7]:

  • 90% of people with LBP will recover in 3-4 months with no treatment.
  • 70% of people with LBP will recover in 1 month with no treatment.
  • 50% of people with LBP will recover in 2 weeks with no treatment.
  • 5% of the remaining 10% will not respond to conservative care (such as physiotherapy)
  • The final 5% are the more challenging cases that don't naturally improve that we as physiotherapists commonly see.

However these figures may be deceptive because although the pain may go away the the reoccurrence rate of LBP is extremely high  and these individuals are likely to experience another episode of LBP within 3-6 months.  Reoccurrence is a major problem with the reoccurrence rate being approximately 60%.

Non-specific low back pain accounts for over 90% of patients presenting to primary care[8] and these are the majority of the individuals with low back pain that present to physiotherapy.

Non-specific low back pain can caused by:

  • Traumatic injury
  • Lumbar sprain or strain
  • Postural strain

Or can be secondary to condiions such as:[9]

Cook et al (study ongoing 2015) studied risk factors for LBP pain: 

First occurrence Recurrent episode
Community setting
  • standing or walking >2hrs per day
  • frequent moving or lifting >25 lbs
  • widespread pain
  • limping
  • higher general health scores
  • other musculoskeletal compliants
  • sitting, standing or walking >2hrs per day
  • frequent moving or lifting >25 lbs
  • strength <50%
  • depression
  • perceived inadequacy i.e. income, job
Occupational setting
  • female
  • obesity
  • increased driving time
  • perceived heavy lifting requirements
  • slower velocity doing activities
  • poor MCS SF-12 score (i.e. higher anxiety, depression etc)
  • obesity
  • poor health
  • prior LBP
  • poor back endurance
  • frequent moving or lifting >25 lbs
  • manual jobs
  • awkward posture
  • mental distress
  • poor relationships at work

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.  Some specific causes of leg pain need to be managed in a different way to simple non-specific low back pain.

Possible Mechanisms[edit | edit source]

Any innervated structure in the lumbar spine can cause symptoms of low back and referred pain into the extremity or extremities. This long list of potential structures includes the muscles, ligaments, dura mater and nerve roots, zygapophyseal joints, annulus fibrosis, thoracolumbar fascia, and vertebrae.  One might expect that improvement in the resolution of imaging technology has increased the likelihood of detecting a link between pathology and pain in the lumbar spine. However, the determination of a pathoanatomic origin of low back pain is made difficult by the rate of false-positive findings on imaging studies, that is, individuals without low back pain showing abnormal findings. For example, evidence of herniated disc material is shown on computerized tomography (CT) scans, MRI, and myelography in 20% to 76% of persons with no sciatica[10]. Furthermore, Savage et al[11] reported that 32% of their asymptomatic subjects had “abnormal” lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression) and only 47% of their subjects who were experiencing low back pain had an abnormality identified. In longitudinal studies, low back pain can develop in the absence of any associated change in radiographic appearance of the spine[12]. Boos et al[13] followed asymptomatic patients with a herniated disc for 5 years and determined that physical job characteristics and psychological aspects of work were more powerful than MRI-identified disc abnormalities in predicting the need for low back pain–related medical consultation. Thus, the association between clinical complaints and concurrent pathological examination with radiological findings must be considered cautiously. Further, even when abnormalities are present, establishing a direct cause and effect between the pathological finding and the patient condition has proven to be elusive and most often does not assist greatly in patient management[10].

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)[14]. 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[14]. 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[15][16][14].

Diagnostic procedures
[edit | edit source]

Once serious spinal pathology and specific causes of back pain have been ruled out the patient is classified as having non-specific low back pain. As mentioned above it is not necessary to determine the specific pain causing structure to effectively manage this patient group.

Differential diagnoses
[edit | edit source]

  • Discogenic back pain 
  • Cauda Equina Syndrome
  • Fracture (compression, spinosus process, stress fractures of pars)
  • SI dysfunction
  • Non-back pain infection (AAA, Pancreatitis, posterior penetrating ulcer and pyelonephritis)
  • Metastatic disease (prostate, renal cell, thyroid, breast)

Examination[edit | edit source]

SeeLumbar Examination

Medical management[edit | edit source]

Mechanical low back pain (LBP) is not a life-threatening illness. Unfortunately, it does have a far-reaching impact on medical care expenditures for injured workers.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Pharmacological interventions for the relief of low back pain (LBP) include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), topical analgesics, muscle relaxants, opioids, corticosteroids, antidepressants, and anticonvulsants.

Acetaminophen remains one of the best first-line treatments of acute LBP.

Physical therapy management
[edit | edit source]

Stratified care has been suggested as an appropriate approach to manage non-specific low back pain[17]. Stratified care is the targeting of treatment to subgroups of patients based on characteristics.  Foster et al[17] suggest that there are 3 different approaches to stratification that have good evidence:

  1. Patient prognosis- matching treatment to patients prognosis such as the likelihood of persistnet pain and disability (e.g. STarT Back Screening Tool[18][19]).
  2. Responsiveness to treatment - matching treatments to individuals who would benefit from that treatment (e.g. Treatment Based Classification Approach to Low Back Pain, STOPS Trials).  
  3. Underlying mechanisms - matching treatment to mechanisms that drive pain and disability such as pathology, pain mechanisms, negative thoughts and behaviours (e.g. Cognitive Functional Approach[20], McKenzie appraoch[21][22]).

The use of these different stratification appraoches vary around the world and there are overlaps between these three different approaches. A perfect subgrouping approach would include all there of these approaches. These models don’t replace clinical reasoning or experience but they do warrant judicious exploration in clinical practice in appropriate settings.

Resources[edit | edit source]


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


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References[edit | edit source]

  1. ↑ 1.0 1.1 Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine (Phila Pa 1976). 1995 Mar 15;20(6):722-8.
  2. ↑ Truchon M. Determinants of chronic disability related to low back pain: towards an integrative biopsychosocial model. Disabil Rehabil. 2001 Nov 20;23(17):758-67.
  3. ↑ Balagué F1, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.
  4. ↑ 4.0 4.1 Damian Hoy, Lyn March, Peter Brooks, Fiona Blyth, Anthony Woolf, Christopher Bain, Gail Williams, Emma Smith, Theo Vos, Jan Barendregt, Chris Murray11, Roy Burstein11, Rachelle Buchbinder. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968-974
  5. ↑ Liliedahl RL1, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):640-3.
  6. ↑ Pransky G, Borkan JM, Young AE, Cherkin DC. Are we making progress?: the tenth international forum for primary care research on low back pain. Spine (Phila Pa 1976). 2011 Sep 1;36(19):1608-14.
  7. ↑ Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine (Phila Pa 1976). 1995 Dec 15;20(24):2702-9.
  8. ↑ Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
  9. ↑ Atlas S.J. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120-131
  10. ↑ 10.0 10.1 Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy, 2012, 42(4)
  11. ↑ Savage, R.A., G.H. Whitehouse, and N. Roberts, The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J, 1997. 6(106-114).
  12. ↑ Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106–114.
  13. ↑ Boos N, Semmer N, Elfering A, et al. Natural history of individuals with asymptomatic disc abnormalities in magnetic resonance imaging: predictors of low back pain-related medical consultation and work incapacity. Spine (Phila Pa 1976). 2000;25:1484–1492.
  14. ↑ 14.0 14.1 14.2 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. ↑ 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
  16. ↑ 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
  17. ↑ 17.0 17.1 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
  18. ↑ Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Care and Research 2008;59:632-41.
  19. ↑ Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71.
  20. ↑ K Vibe Fersum, P O’Sullivan,2 JS Skouen, A Smith, and A Kvåle1. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul; 17(6): 916–928.
  21. ↑ Helen Clare, Roger Adams, Chris G Maher. A systematic review of efficacy of McKenzie therapy for spinal pain. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 50(4):209-16 · FEBRUARY 2004
  22. ↑ Tom Petersen. Non-specific Low Back Pain: Classification and treatment. Lund University, 2003


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