Non Specific Low Back Pain


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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. 

Epidemiology/etiology
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At some point during our adult lives, most people experience bouts of back pain. Chronic back pain is pain that persists after an injury or surgery where the source is hard to determine. Acute pain can develop into Chronic Pain for a number of reasons.[1]

Non-specific low back pain accounts for over 90% of patients presenting to primary care[2] 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:[3]

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[4]. Furthermore, Savage et al[5] 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[6]. Boos et al[7] 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[4].

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)[8]. 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[8]. 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[9][10][8].

Characteristics/clinical presentation
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This low back pain is usually aggravated by: [11]

  • Long levered activities
  • Lifting heavy objects
  • Levered postures (bending forward)
  • Static loading of the spine (prolonged sitting or standing)

Testing:[edit | edit source]

The following tests are used when evaluating low back pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

  • Observe the patient walking into the office or examining room
  • Observe the patient during the history-gathering portion of the visit for development, nutrition, deformities, and attention to grooming
  • Measure blood pressure, pulse, respirations, temperature, height, and weight
  • Inspect the back for signs of asymmetry, lesions, scars, trauma, or previous surgery
  • Measure lumbar range of motion (ROM) in forward bending while standing (Schober test)
  • Palpate the entire spine to identify vertebral tenderness that may be a nonspecific finding of fracture or other cause of low back pain
  • Test for manual muscle strength in both lower extremities.
  • Test for sensation and reflexes
  • Imaging studies: Persistent pain may require CT scanning, diskography, and 3-phase bone scanning; electromyography and nerve conduction studies can help in the evaluation of neurologic symptoms or deficits

Diagnostic procedures
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It’s difficult to reliably identify by diagnostic testing. These typically involve processes in the muscles and/or ligaments.[3]

Differential diagnoses
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  • 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]

  • Paraspinal muscle tenderness[12]
  • No bony tenderness[12]
  • Back pain with passive knee-to-chest stretch [13] [12]
  • Limited ability to forward bending as a resullt of limited ROM [13] [12]
  • Muscle spasm[13]
  • Negative discogenic exam[12]

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
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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.[12] It’s important to identify possible causes and to correct harmful activities and attitudes, to avoid further back pain problems.[11]

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.[12]

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.[11]

Resources[edit | edit source]

http://www.allaboutbackandneckpain.com/recognizingsymptoms/causesoflowbackpain.asp

http://www.fmcpaware.org/m-n/mechanical-low-back-pain

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


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References[edit | edit source]

  1. ↑ http://my.clevelandclinic.org/health/diseases_conditions/hic_your_back_and_neck/chronic-back-pain-overview
  2. ↑ Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
  3. ↑ 3.0 3.1 Atlas S.J. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120-131
  4. ↑ 4.0 4.1 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; Sports Physical Therapy, 2012, 42(4)
  5. ↑ 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).
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 8.0 8.1 8.2 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.
  9. ↑ 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
  10. ↑ 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. ↑ 11.0 11.1 11.2 Cite error: Invalid <ref> tag; no text was provided for refs named three
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Cite error: Invalid <ref> tag; no text was provided for refs named two
  13. ↑ 13.0 13.1 13.2 Cite error: Invalid <ref> tag; no text was provided for refs named one


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