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Low back pain (non-specific)

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Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. Most cases are non-specific, but in about 10% of cases a specific cause is identified. Red flags are typical signs or symptoms that are frequently associated with specific LBP. Yellow flags are prognostic factors associated with a more unfavourable and often chronic disabling course of the disease. LBP has a lifetime prevalence of 60–85%. At any one time, about 15% of adults have LBP. LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect costs) and less so by direct treatment costs. A substantial proportion of individuals with chronic LBP has been found to have chronic widespread pain. LBP is often associated with other pain manifestations such as headache, abdominal pain and pain in different locations of the extremities. Widespread pain is associated with a worse prognosis compared to localised LBP.

Treatment targets are reduction of pain and better activity/participation, including prevention of disability as well as maintainance of work capacity. The evidence from selected and appraised guidelines, systematic reviews and major clinical studies was classified into four levels, level Ia being the best level with evidence from meta-analysis of randomised controlled trials.

Key recommendations (level Ia): fitness programmes and advice to stay active can reduce pain, improve function and can prevent LBP becoming chronic. Simple analgesics, NSAIDs and muscle relaxants can reduce pain and can improve and maintain function. Maintaining physical activity, avoiding rest and manual therapy can reduce pain and maintain and restore function in acute LBP. Behavioural treatment can prevent LBP becoming chronic. Aerobic fitness and endurance training, behavioural treatment and multi-disciplinary treatment programmes can reduce pain and can improve/maintain function in chronic LBP.

Introduction

Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. Most cases are non-specific, but in 5–10% of cases a specific cause is identified. Specific causes of back pain are some degenerative conditions, inflammatory conditions, infective and neoplastic causes, metabolic bone disease, referred pain, psychogenic pain, trauma and congenital disorders. Non-specific LBP is defined as back pain with no known underlying pathology. The term ‘specific low back pain’ is restricted by some health care professionals to destructive diseases such as tumour and infection, as well as to diseases associated with a neurological deficit, such as disc herniation and spinal stenosis. Others use this term in the presence of a localised source of pain when a specific structure of the spine is painful and if a specific diagnosis is available to characterise the cause of the pain. Acute LBP occurs suddenly after a period of a minimum of 6 months without LBP and lasts for less than 6 weeks. Subacute LBP occurs suddenly after a period of a minimum of 6 months without LBP and lasts for between 6 weeks and 3 months. Chronic LBP has a duration of more than 3 months, or occurs episodically within a 6-month period.

Considering the high prevalence of non-specific LBP, the normal population (i.e. the whole population at all ages) is the population at risk, because almost everyone has episodes of ‘back pain’. Acute and subacute back pain is an early manifestation of the disease, whereas chronic LBP with high disability characterizes late disease.

Red flags are typical signs or symptoms that are frequently associated with specific LBP (Table 1). Yellow flags are prognostic factors associated with a more unfavourable and often chronically disabling course of the disease (Table 2).

Section snippets

The perspective of the individual

LBP has a lifetime prevalence of 60–85%. At any one time, about 15% (12–30%) of adults have LBP.*1, 2, 3 The prevalence in most studies was determined regardless of the diagnosis or cause, which makes it difficult to make accurate assessments of the incidence of specific or non-specific LBP. One study reported that of all back pain patients in primary care, 4% had a compression fracture, 3% spondylolisthesis, 0.7% a tumour or metastasis, 0.3% spondylitis ankylopoetica and 0.01% an infection.4

Treatment goals

In order to assess the evidence and develop recommendations key outcome measures were defined. These were defined according to the ICF classification11:

  • Symptoms: pain

  • Tissue damage/structure: the definition of non-specific back pain excludes the presence of tissue damage of relevance to the problem.

  • Activity/participation:

    • Disability

      • Instruments specific to back pain: Roland Morris, Oswestry

      • Generic instruments: SF36, NHP, EuroQol

    • Return to work

According to these key outcome measures, targets can be

What can be done: the evidence for interventions to prevent and treat low back pain

The evidence for different interventions is considered below in the context of the agreed targets for the prevention and treatment of LBP and for the populations that the evidence applies to. However, only the effect on symptoms and activity/participation was considered. The effect on tissue damage was not considered because it is excluded, by definition, in non-specific LBP. The evidence is presented in Table 3, Table 4, Table 5, below. The evidence for these recommendations was taken from

Prevention

The prevalence and incidence of LBP appears to be moderately increasing, with a greater increase in the functional consequences, especially work disability. Systems of social support may also affect the chronicity of the problem in some cases. This increase may also be influenced by the ageing of the population along with a high rate of obesity and a sedentary lifestyle. LBP will therefore continue to be a major problem for individuals and society. Prevention is therefore important and there is

Summary

Acute and subacute low back pain are common problems. Treatment includes the advice to stay active and the use of paracetamol or non-steroidal anti-inflammatory drugs. Checks should be made for indicators of severe organic diseases as well as for risk factors of chronification! Recommended treatment for chronic non-specific LBP is exercise therapy, behavioural therapy including pain management, or a combination of these (Table 6).

Practice points

  • Standardise examinations by the use of yellow and

Acknowledgements

This paper is based on the work of The Low Back Pain Group of the Health Strategies for Europe Project, which consisted of:

  • Professor Maurits van Tulder, Institute for Research in Extramural Medicine, University Medical Center & Institute of Health Sciences, Vrije Universiteit, Amsterdam

  • Professor Francis Guillemin, Ecole de Sante Publique, Faculté de Medecin, Vandourve les Nancy, France

  • Professor Karin Harms-Ringdahl, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

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