Non Specific Low Back Pain




Original Editor­ - Sam Verhelpen

Top Contributors - Admin, Anouk Van den Bossche, Pieter Verbeirens, Lien Hennebel, Andeela Hafeez, Arne De Cort, Kim Jackson, Vidya Acharya, Michelle Lee, Evan Thomas, Debontridder Jordy, Tarina van der Stockt, Benjamin Desmedt, Simisola Ajeyalemi, Samuel Adedigba, Isa, 127.0.0.1, Sam Verhelpen, Laura Ritchie, Wanda van Niekerk, Lucinda hampton, Vanessa Rhule and George Prudden


Search Strategy

We searched with the following keywords. "Non Specific Low Back Pain" And "Physical Therapy" Not "Sergury". 

Definition

Non-specific low back pain is defined as low back pain not attributable to a recognizable, known specific pathology (eg, infection, tumour, osteoporosis, Lumbar Spine Fracture, structural deformity,inflammatory disorder, radicular syndrome, or  Cauda Equina Syndrome).

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.

Epidemiology/Etiology

Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. 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.  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%. 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. The cost of care for LBP has been reported (in the USA) to be over $50 billion annually. Despite the intense focus and formal research on the care of non-specific LBP Pransky et al reported a five fold increase in the prevalence 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:

• 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 re-occurrence rate of LBP is extremely high and these individuals are likely to experience another episode of LBP within 3-6 months. Re-occurrence is a major problem with the re-occurrence rate being approximately 60%.

Non-specific low back pain accounts for over 90% of patients presenting to primary care 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 conditions such as:

• Spondylolysis and Spondylolisthesis
• Disc Herniaton
• Spinal Stenosis
• Osteoporosis with Compression fracture (Lumbar compression fracture)
• Congenital disease such as Kyphosis and Scoliosis

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 complaints 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

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. Furthermore, Savage et al 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. Boos et al 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.

Diagnostic procedures

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.

Differential diagnoses

• 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

As mentioned above it is not necessary to determine the specific pain causing structure to effectively manage this patient group. 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). 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. 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.

SeeLumbar Examination

Medical management

The NICE guidelines for low back pain recommend advice, analgesia and imaging only in specific circumstances.

Information, education and patient preferences

Provide people with advice and information to promote self-management of their low back pain.

1. Offer educational advice that:
   • includes information on the nature of non-specific low back pain
   • encourages the person to be physically active and continue with normal activities as far as possible.
2. Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
3. Take into account the person's expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments.

Pharmacology

No opioids, cyclooxygenase 2 (COX-2) inhibitors or tricyclic antidepressants and only some non-steroidal anti-inflammatory drugs (NSAIDs) have a UK marketing authorisation for treating low back pain. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtained and documented. Take into account the individual risk of side effects and patient preference.

First medication option should be regular paracetamol. When paracetamol alone provides insufficient pain relief, offer non-steroidal anti-inflammatory drugs (NSAIDs) and/or weak opioids (codeine and dihydrocodeine). Give due consideration to the risk of side effects from NSAIDs, especially in older people and other people at increased risk of experiencing side effects.

Tricyclic antidepressants may be considered if other medications provide insufficient pain relief. Strong opioids should only be considered for short-term use to people in severe pain. Consider referral for specialist assessment for people who may require prolonged use of strong opioids.

Imaging

1. Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
2. Consider MRI when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected.
3. Only offer an MRI scan for non-specific low back pain within the context of a referral for an opinion on spinal fusion.

If these treatments do not result in satisfactory improvement consider offering physiotherapy interventions such as exercise, manual therapy and acupuncture as appropriate treatment techniques.

Surgery

Consider referral for an opinion on spinal fusion for people who have completed an optimal package of care, including a combined physical and psychological treatment programme (see below) and still have severe non-specific low back pain for which they would consider surgery.

It is important to offer anyone with psychological distress appropriate treatment for this before referral for an opinion on spinal fusion.

NICE guidelines state to not refer people for any of the following procedures:

1. intradiscal electrothermal therapy (IDET)
2. percutaneous intradiscal radiofrequency thermocoagulation (PIRFT)
3. radiofrequency facet joint denervation.

Physical therapy management

The following physical therapy management strategies are from the NICE guidelines.  Also see Interventions for LBP.

If first line medical management of analgaesia and advice fail offer one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.

Physical activity and exercise

1. Advise people with low back pain that staying physically active is likely to be beneficial.
2. Advise people with low back pain to exercise.
3. Consider offering a structured exercise programme tailored to the person. This should comprise up to a maximum of eight sessions over a period of up to 12 weeks. Offer a group supervised exercise programme, in a group of up to 10 people. A one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
   • Exercise programmes may include the following elements:
   • aerobic activity
   • movement instruction
   • muscle strengthening
   • postural control
   • stretching.

Manual therapy

The manual therapies reviewed for the NICE Guidelines were spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues). Consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.

Other non-pharmacological therapies

1. Electrotherapy modalities
   • Do not offer laser therapy.
   • Do not offer interferential therapy.
   • Do not offer therapeutic ultrasound.

Transcutaneous nerve stimulation

Do not offer transcutaneous electrical nerve simulation (TENS).

Lumbar supports

Do not offer lumbar supports.

Traction

Do not offer traction (this may be indicated in specific causes of low back pain such as radiculopathy).

Invasive procedures

1. Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of up to 12 weeks.
2. Do not offer injections of therapeutic substances into the back for non-specific low back pain.

Combined physical and psychological treatment programme

1. Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who have received at least one less intensive treatment and have high disability and/or significant psychological distress.
2. Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise.

Stratified Care

Stratified care has been suggested as an appropriate approach to manage non-specific low back pain. Stratified care is the targeting of treatment to subgroups of patients based on characteristics. Foster et al 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).
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, McKenzie appraoch).
   

The use of these different stratification approaches 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.

Clinical Bottom Line

Non-specific low back pain is defined as low back pain not attributable to a recognizable, known specific pathology. The place for surgery in chronic non-specific low back pain is very limited and its overuse has been criticized. Level of evidence 1A 

For acute low back pain, most clinical practice guidelines agree on the use of reassurance, recommendations to stay active, brief education, paracetamol, non-steroidal anti-inflammatory drugs, spinal manipulation therapy, muscle relaxants (as second line drugs only, because of side-effects), and weak opioids (in selected cases). Level of evidence 1A [1]

For chronic low back pain, the use of brief education about the problem, advice to stay active, non-steroidal anti-inflammatory drugs, weak opioids (short-term use), exercise therapy (of any sort), spinal manipulation are recommended and Self-management strategies. Level of evidence 1A [1]

Recent Related Research (from Pubmed)


Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=18WX1aNNAKMlvla5ZEpGIXwHbj-hotir6ce8Bh9Et3F66D8os5|charset=UTF­8|short|max=10: Error parsing XML for RSS