Nonspecific low back pain

1
Non-specific low back pain
low back pain, which is not attributed to a
recognisable pathology Acute lt12 weeks
duration Chronic gt12 weeks duration Van Tulder
M, et al. Low back pain (acute). Clinical
Evidence 2006
2
Theres a lot of it about

• 40 of adults had back pain lasting more than 1
  day, in the previous 12 months
• 15 of back pain sufferers said that they were in
  pain throughout the year
• A third of sufferers said that back pain had
  restricted their activity in the previous 4 weeks
• and it causes lots of lost work days
• 5 of sufferers in employment had taken time off
  in the previous month because of back pain
• 13 of sufferers aged 16 64 years, who were
  unemployed in the previous month, mentioned back
  pain as a reason why they were not in work
• Less than half of those who have been off work
  with low back pain for 6 months will return to
  work
• Department of Health. The prevalence
  of back pain in Great Britain in 1998. Van Tulder
  M, et al. Low back pain (acute). Clinical
  Evidence 2006

3
Key points in diagnosing back pain Koes BW, et
al. BMJ 2006 332 14304 European guidelines
2004 www.backpaineurope.org

• Diagnostic triage to exclude specific spinal
  pathology and nerve root pain
• Assessment of prognostic factors (yellow flags)
  such as, work related factors, psychosocial
  distress, depressive mood, severity of pain and
  functional impact, prior episodes of low back
  pain, extreme symptom reporting, and patient's
  expectations
• Imaging is not recommended, unless a specific
  cause is strongly suspected
• Magnetic resonance imaging is the best option for
  radicular symptoms, discitis, or neoplasm
• Plain radiography is the best option for
  structural deformities
• Reassess if acute pain worsens, or does not
  resolve within several weeks

4
Exclude serious pathology by using Red
flagsSpeed C. BMJ 2004 328 111921Koes BW,
et al. BMJ 2006 332 14304

• lt 20 years of age
• Acute onset in older people (gt 55 years)
• Constant, or progressive non-mechanical pain
• Thoracic pain
• Nocturnal pain
• Fever, night sweats, feeling unwell
• Unexplained weight loss
• Morning stiffness
• Bilateral, or alternating symptoms
• Structural spinal deformity

• Widespread neurological disturbance
• Sphincter disturbance
• Immunosuppression, HIV
• Current, or recent infection, e.g. UTI
• History of malignancy
• Claudicant symptoms, signs of peripheral
  ischaemia, or abdominal mass
• Pain that is not improved with lying in the
  foetal position or prone with the stomach
  supported
• Recent trauma

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Primary care treatment aims of acute back pain
European guidelines 2004 www.backpaineurope.org

• Provide adequate information to reassure the
  patient that low back pain is usually not a
  serious disease and that rapid recovery is
  expected in most patients
• Provide adequate symptom control, if necessary
• Recommend that the patient remains as active as
  possible and returns to normal activities,
  including work, as soon as possible

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Treatment of chronic back pain European
guidelines www.backpaineurope.org

• Few guidelines exist for the management of
  chronic low back pain
• It is not a diagnosis, but a symptom
• Patients have different stages of impairment,
  disability and chronicity
• Overall, there is limited positive evidence for
  therapies in patients with non-specific chronic
  low back pain
• For most therapeutic procedures, the effect sizes
  are rather modest
• In cases of low impairment and disability, simple
  evidence-based therapies encouraging activity/
  exercise, brief cognitive-behavioural
  interventions, and medication may be sufficient
• No single intervention is likely to be effective
  in treating the overall problem of chronic low
  back pain of longer duration and more substantial
  disability, owing to its multi-dimensional nature

7
Summary of treatment recommendations Van Tulder
M and Koes B. Low back pain (acute chronic).
Clinical Evidence 2006