Non Specific Low Back Pain
Original Editor - Sam Verhelpen
- 1 Definition
- 2 Clinically Relevant Anatomy
- 3 Epidemiology/Etiology
- 4 Possible Mechanisms
- 5 Characteristics/Clinical Presentation
- 6 Differential diagnoses
- 7 Diagnostic procedures
- 8 Outcome Measures
- 9 Examination
- 10 Medical management
- 11 Physical therapy management
- 12 Clinical Bottom Line
- 13 References
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. 
Clinically Relevant Anatomy
The lumbar spine consists of 5, movable relative to each other, lumbar vertebrae (L1-L5). They are the largest segments of the vertebral column, because it supports greater weight of the body against gravity, as compared to the thoracic or cervical region. Each lumbar vertebra consists of a vertebral body, a vertebral arch and a processus spinosus, a processes transversi and facet joints. The fifth lumbar vertebra has a little bit a different morphology then the other lumbar vertebrae, it is more cuneiform which accords with the prominence of the sacrovertebral articulation. Studies also say that the integrity and the anatomy of the body of the lumbar vertebra is multifactorial. .
Before making a searching strategy for finding a cause of the non-specific low back pain problematic, it’s crucial to understand the functional spinal unit (=motion segment, the smallest physiological unit of the (lumbar) spine). This unit consist of 2 adjacent vertebrae and the intervertebral disc in between and they are strongly connected with all the adjoining ligaments, connecting tissues, facet joint and muscles.
The functional unit is divided in 3 compartments, which each part fulfilled a specific function:
- The front lumbar compartment consist the vertebral body and the discus intervertebralis (and also the ligamentum longitudinale anterius/posterius) --> function: support the biggest part of the body weight against gravity and also as a shock absorber. The ligaments play an important role in resisting heavy movements.
- The middle lumbar compartment consist the vertebral canalis --> function: protection of the spinal cord. Note: the spinal cord ends by the first lumbar vertebrae and then from the second lumbar vertebrae the spinal nerves forms the cauda equina.
- The rear lumbar compartment consist the vertebral arch, the processus spinosus, the processes transversi and the facet joints. --> function: protection against rotation and extreme movements + attachment site for connective tissue and muscles.
In total there are 3 motion direction possible in the lumbar spine: flexion/extension, side bending and rotation.The lumbar spine exhibits a lumbar lordosis, which is a result and a key factor of the evolution to the erect posture. This was an adaptation to the newly acquired function of axial loading. Level of evidence: 2A 
The back (lumbar) muscles play along with the abdominal, the glutea and the leg muscles an important role in the etiology of low back pain. Studies suggests that that multifidus and paraspinal muscle groups are significantly smaller in patients with chronic low back pain than in control patients who are healthy and on the symptomatic side of patients with chronic unilateral low back pain compared with the asymptomatic side. Level of evidence: 2A 
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
Cook et al (study ongoing 2015) studied risk factors for LBP pain:
|First occurrence||Recurrent episode|
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.
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. 
Some characteristics/clinical presentation:
- The cause of the problem can’t be explained by a recognizable, known specific pathology (like infection, fracture, cauda equina syndrome,…)
- All age groups can be affected by non-specific low back pain. but the impact on quality of life is lower in adolescents than in adults
- Evidence for the use of sub-grouping in the diagnosis, classification, or management of non-specific low back pain is limited
- The outcome of acute spells is obscured by frequent relapses 
- Results of large-scale epidemiological studies show that one of the main characteristics of low back pain is recurrence
- Most episodes of low back pain are self-limiting and are not associated with serious diseases, but it’s important for the clinician to distinguish the small proportion of patients with serious underlying diseases, so called red flags! Level of evidence 1A 
- Risk factors for red flags are: age at onset (<20j. or > 55j.), significant trauma, unexplained weight loss and widespread neurologic changes
- Overweight/obese is a strong predictor and is often seen by non specific-low back pain. Overweight and obesity have the strongest association with seeking care for low back pain and chronic low back pain
- Studies suggests that psychosocial factors at the subacute stage are a characteristic/predictor in the development of chronic non-specific low back pain
- Studies suggests that increased lumbar spine mobility is a common clinical characteristic/ presentation in non-specific low back pain and that is a high evidence risk factor for non-specific low back pain
Low back pain is a symptom that accompanies several diseases. The diagnosis of non-specific low back pain implies no known pathoanatomical cause. Triage aims to exclude those cases in which the pain arises from either problems beyond the lumbar spine (eg, leaking aortic aneurysm); specific disorders affecting the lumbar spine (eg, epidural abscess, compression fracture, spondyloarthropathy, malignancy, cauda equina syndrome); or radicular pain, radiculopathy, or spinal canal stenosis. Remaining cases are non-specific low back pain. Several lumbar structures are plausible sources of pain (eg, the intervertebral disc, the facet joints), but clinical tests do not reliably attribute the pain to those structures 
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. If no serious pathology is suspected there is no indication for x-rays or MRI diagnostic imaging unless guidance is need to change the management protocol.
In the study of Van der Roer et al. the main outcome measures were the Minimal Clinically Important Change (MCIC) of the pain intensity numerical rating scale (PI-NRS), the Quebec Back Pain Disability Scale (QBPDS), and the Euroqol (EQ) in patients with low back pain. The MCIC was estimated over a 12-week period, and three different methods were used: 1) mean change scores, 2) minimal detectable change, and 3) optimal cutoff point in receiver operant curves. The global perceived effect scale (GPE) was used as an external criterion. The effect of initial scores on the MCIC was also assessed. The MCIC of the PI-NRS ranged from 3.5 to 4.7 points in (sub)acute patients and 2.5 to 4.5 points in chronic patients with low back pain. The MCIC of the QBPDS was estimated between 17.5 to 32.9 points and 8.5 to 24.6 points for (sub)acute and chronic patients with low back pain. The MCIC for the EQ ranged from 0.07 to 0.58 in (sub)acute patients and 0.09 to 0.28 in patients with chronic low back pain. 
The study of Ferreira et al. investigated the comparison of general exercises, motor control exercises and spinal manipulative therapy for chronic low back pain. The primary outcomes in this study were patient-specific function (PSFS, 3–30) and global perceived effect (GPE, −5 to 5) at 8 weeks. These outcomes were also measured at 6 and 12 months. Follow-up was 93% at 8 weeks and 88% at 6 and 12 months. The motor control exercise group had slightly better outcomes than the general exercise group at 8 weeks (between-group difference: PSFS 2.9, 95% CI: 0.9–4.8; GPE 1.7, 95% CI: 0.9–2.4), as did the spinal manipulative therapy group (PSFS 2.3, 95% CI: 0.4–4.2; GPE 1.2, 95% CI: 0.4–2.0). The groups had similar outcomes at 6 and 12 months. Motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain. 
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 catastrophising) 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. This message has not changed in recent clinical guidelines issued by NICE (UK, 2016), KCE (Belgium 2017) , the Danish Health Authority (2018) or the American College of Physicians (2017).
The diagnosis of non-specific low back pain implies no known pathoanatomical cause. Triage aims to exclude those cases in which the pain arises from either problems beyond the lumbar spine (eg, leaking aortic aneurysm); specific disorders affecting the lumbar spine (eg, epidural abscess, compression fracture, spondyloarthropathy, malignancy, cauda equina syndrome); or radicular pain, radiculopathy, or spinal canal stenosis. Remaining cases are non-specific low back pain. Several lumbar structures are plausible sources of pain (eg, the intervertebral disc, the facet joints), but clinical tests do not reliably attribute the pain to those structures.
Diagnostic investigations have no role in the management of non-specific low back pain. Although diagnoses based on lumbar structures (discogenic low back pain, facet joint pain, sacroiliac joint pain) remain popular in some settings, the available clinical tests for these conditions have insufficient accuracy. Diagnostic investigations have a role when the clinician suspects a specific disease process that would be managed differently from non-specific low back pain. The threshold for triggering investigations should reflect both the consequence of missing or delaying the diagnosis and the clinician’s assessment of the likelihood of a more serious disease being present. 
Summary of Common Recommendations for Diagnosis of Low back pain
- Diagnostic triage (non-specific low back pain, radicular syndrome, serious pathology).
- Screen for serious pathology using red flags.
- Physical examination for neurologic screening (including straight leg raising test).
- Consider psychosocial factors (yellow flags) if there is no improvement.
- Routine imaging not indicated for non-specific low back pain
- Lumbar Examination
Movement control dysfunction [MCD] reduces active control of movements. Patients with MCD might form an important subgroup among patients with non specific low back pain. The diagnosis is based on the observation of active movements.
Tests for examination of motor control:
- waiter's bow:Flexion of the hips in upright standing without movement (50-70° flexion) of the low back
Rating protocol: As patients did not know the tests, only clear movement dysfunction was rated as "not correct". If the movement control improved by instruction and correction, it was considered that it did not infer a relevant movement dysfunction.
- Sitting knee extension test for flexion dysfunction: Upright sitting with corrected lumbar lordosis; extension of the knee without movement (flexion) of low back Rating protocol: As patients did not know the tests, only clear movement dysfunction was rated as "not correct". If the movement control improved by instruction and correction, it was considered that it did not infer a relevant movement dysfunction.
- Pelvic tilt for extension dysfunction
- One leg stance difference for rotational dysfunction: From normal standing to one leg stance: measurement of lateral movement of the belly button. (Position: feet one third of trochanter distance apart). Rating protocol: As patients did not know the tests, only clear movement dysfunction was rated as not correct. If the movement control improved by instruction and correction, it was considered that it did not infer a relevant movement dysfunction. 
The NICE guidelines  for low back pain, published in 2009, recommend advice, analgesia and imaging only in specific
circumstances, however the guidelines have changed. Recent NICE guidelines do not recommend analgesia or imaging, unless changing the management protocol. The message from the latest guidelines is advice and stay active and focuses more on non-pharmacological management with emphases on the high risks and low benefits of pharmacological management of acute and chronic low back pain.
Information, education and patient preferences 
Provide people with advice and information to promote self-management of their low back pain.
- Offer educational advice that includes information on the nature of non-specific low back pain and encourages the person to be physically active and continue with normal activities as far as possible.
- Include an educational component consistent with this guideline as part of other
interventions, but do not offer stand-alone formal education programmes.
- 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.
Acetaminophen (paracetamol) was once the first medication recommendation in the management of low back pain, however, this is now only recommended when used with weak opioids when NSAID are not well tolerated or ineffective. NSAIDs are to be prescribed with care due consideration to the risk of side effects, especially in older people and other people at increased risk of experiencing side effects.
Tricyclic and serotonin reuptake inhibitor antidepressants and anticonvulsants are no longer recommended for pain relief, due to low evidence available. The use of opioids has also changed because of the recognised risk of addiction and accidental overdose but varies between guidelines. All four of the recent guidelines suggest caution and should only be used in the short-term where the benefits to the patient outweigh the risks:
- The UK guideline now only supports the use of weak opioids, in contrast to its previous recommendation of strong opioids. And only for cases of acute LBP where NSAIDs are not tolerated, ineffective or contraindicated. And no longer recommends opioids in the management of chronic LBP.
- The Belgian on the other hand recommends prescribing opioids for managing chronic LBP but not on a regular basis.
- The US guideline only recommends opioids as a last resort for patient’s with chronic LBP who have not responded to other non-pharmacological and pharmacological interventions (moderate evidence)
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.
- Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
- Consider MRI when a diagnosis of spinal malignancy, infection, fracture, cauda equina syndrome or ankylosing spondylitis or another inflammatory disorder is suspected.
- 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.
The place for surgery in chronic non-specific low back pain (if any) is very limited and its overuse has been criticised. Failed back surgery (FBSS) is a nonspecific term that implies that the final outcome of surgery did not meet the expectations of both the patient and the surgeon that were established before surgery.
Physical therapy management
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 or a course of manual therapy. Consider offering another of these options if the chosen treatment does not result in satisfactory improvement.
A. Physical activity and exercise
- Advise people to stay active. Level of evidence 1A
- Advise people with low back pain to exercise. Level of evidence 2B
- 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
- For chronic low back pain, self-management strategies for example health-promoting activities, self-monitoring of status, and decision-making are receiving increasing attention as important components in the management of low back pain. Level of evidence 1A 
- In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes. Level of evidence 1A 
- You can offer the patient stabilizations exercises when there is an indications of lumbar instability. These exercises for lumbar instability have been suggested that they can reduce the pain and disability outcome. However latest studies suggest that there is a strong evidence that stabilisation exercises are not more effective than any other form of active exercise in the long term. Level of evidence 1A 
- You can also offer the patient lumbar motor control exercises:
Motor control training focuses on the activation of the deep trunk muscles and targets the restoration of control and co-ordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. There is strong evidence that MCE is not superior to other forms of exercise for both acute and chronic non-specific low back pain. Level of evidence 1A  For lumbar motor control exercises look at: www.youtube.com/watch
- You can also offer the patient back school programs:
Back school programs are introduced by the Swedish back school in 1969, the goal of such a program is to reduce pain and preventing recurrent episodes of low back pain. Recent studies suggests that is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available. Level of evidence 1A 
- You can also offer the patient the McKenzie Therapy:
The McKenzie therapy is a multidimensional, classification-based treatment for patients with low back pain. The therapy consist of 3 parts: evaluation, treatment and prevention. In the treatment the exercises are based upon the direction (flexion, extension, lateral bending and rotation) and the aim is to reduce pain. Studies suggests that the McKenzie method is more effective than passive therapy for acute low back pain; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic low back pain. The effectiveness of classification-based McKenzie is yet to be established. Level of evidence 1A 
B. Manual therapy
Spinal manipulation therapy Level of evidence 1A :
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.
C. Other non-pharmacological therapies
- Do not offer laser therapy.
- Do not offer interferential therapy.
- Do not offer therapeutic ultrasound.
Level of recommendation A (resource – guideline based on level 1a and level 1b evidence) 
D. Transcutaneous nerve stimulation
Do not offer transcutaneous electrical nerve simulation (TENS).
Level of recommendation A (resource – guideline based on level 1a and level 1b evidence) 
E. Lumbar supports
Do not offer lumbar supports.
Do not offer traction (this may be indicated in specific causes of low back pain such as radiculopathy).
G. Combined physical and psychological treatment programme
Cognitive behavioural interventions yield long-term improvements in pain, disability and quality of life in comparison to no treatment and other guideline-based active treatments for patients with LBP of any duration and of any age. Level of evidence 1A 
H. 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: level of evidence 5
- Patient prognosis- matching treatment to patients prognosis such as the likelihood of persistent pain and disability (e.g. STarT Back Screening Tool ).
- 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).
- 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 approach).
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 
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 
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