Low Back Pain

Original Editors - Fauve simoens

Lead Editors Bo Hellinckx - 

Introduction

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© Primal Pictures

There are different definitions of low back pain depending on the choice of the source. According to the European Guidelines for prevention of low back pain, low back pain is defined as “pain and discomfort , localized below de costal margin and above the inferior gluteal folds, with or without leg pain"  Another definition, according to S.Kinkade - resembles a lot on the one above of the European guidelines – is that low back pain is “ pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs”.
The most common form of low back pain is the one that is called “non-specific low back pain” and is defined as “ low back pain not attributed to recognizable, known specific pathology”.

After decades of research, the relationship of low back pain to disc degeneration is poorly understood. Most cases of low back pain can’t be clearly attributed to the disc. And the treatment of “discogenic pain” hasn’t proven to be a panacea for chronic low back pain.

However, in its narrow focus on the disc, the spine field may have overlooked other potential keys to the understanding of low back pain, including one immediately adjacent to the disc.

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.

Low back related leg pain

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. Schäfer et al proposed that low back-related leg pain be divided into four subgroups according to the predominating pathomechanisms involved:

1. central sensitization with mainly positive symptoms such as hyperalgesia
2. denervation with significant axonal damage showing predominantly negative sensory symptoms and possibly motor loss
3. peripheral nerve sensitization with enhanced nerve trunk mechanosensitization
4. somatic referred pain from musculoskeletal structures, such as the intervertebral disc or facet joints.

Each group presents with a distinct pattern of symptoms and signs although there may be considerable overlap between the classifications. The importance of distinguishing low back-related leg pain into these four groups is to facilitate diagnosis and provide a more effective, appropriate treatment.

Diagnostic procedures

The diagnostic process is mainly focused on the triage of patients with specific or non-specific low back pain.This triage is focused on identification of “red flags” as indicators of possible underlying pathology, including nerve root problems.

"Red Flags":

Onset age < 20 or > 55 years,(Level of evidence: 1B) Non-mechanical pain (unrelated to time or activity)(Level of evidence: 2B) Thoracic pain Previous history of carcinoma, steroids, HIV  Feeling unwell ,(Level of evidence: 2B) Weight loss  Widespread neurological symptoms  Structural spinal deformity  Saddle anesthesia (Cauda equina syndrome)  Recent onset of bladder dysfunction (Cauda equina syndrome)

Prevention of low back pain

Prevention is also categorized in 3 types of prevention. Primary prevention is defined as “specific practices for the prevention of disease or mental disorders in susceptible individuals or populations. These include health promotion, including mental health; protective procedures, such as communicable disease control; and monitoring and regulation of environmental pollutants. Primary prevention is to be distinguished from secondary prevention and tertiary prevention.”  Secondary prevention is defined as “the prevention of recurrences or exacerbations of a disease that already has been diagnosed. This also includes prevention of complications or after-effects of a drug or surgical procedure”  and tertiary prevention as “measures aimed at providing appropriate supportive and rehabilitative services to minimize morbidity and maximize quality of life after a long-term disease or injury is present”.

The guidelines discuss different possibilities to prevent low back pain, and most of them are supported by other articles. Physical exercise is recommended to prevent consequences of low back pain, such as absence of work and occurrence of further episodes. With physical exercises is especially mend training of back extensors en trunk flexors beside regular en aerobe training. There is no specific recommendation of exercise frequency or intensity. Regard the back school programs, a high intensity program is advised in patients with recurrent and lasting low back pain but not in preventing low back pain. The program consists of exercises and an educational and skills program. Education and information alone or based on biomechanical model has only a small effect. Education and information in combination with other interventions, in a treatment setting an based on biopsychosocial model effect has a better effect. Information based on biopsychosocial model is focused on beliefs in low back pain and reducing work loss caused by low back pain. This attitude of giving information has a positive effect on back beliefs.  It is important to know that individually tailored programs and intervention may have more results as to group interventions. Lumbar supports, back belts and shoe insoles are not recommended in the prevention of low back pain. Lumbar supports and back belts have also a negative effect on back pain beliefs and are therefore not recommended in preventing low back pain. Specific mattresses and chairs for prevention have no evidence in favor or against. Medium mattresses may decrease existing persistent symptoms of low back pain. Ergonomic adjustments regarding work environment can be necessary and useful to achieve earlier return to work.

In the prevention of acute low back pain becoming chronic low back pain Kinkade refers to the European guidelines and suggest to exercise and to not use back belts or lumbar supports. Important in preventing acute low back pain of becoming chronic is to mention the interest of psychosocial factors that correlate with the development of chronic low back pain.
- disputed compensation claims
- fear avoidance (exaggerated pain or fear that activity will cause permanent damage)
- job dissatisfaction
- pending or past litigation related to back pain
- psychological distress and depression
- reliance on passive treatments rather than active patient participation
- somatization

Further on, there is still more research needed.  

Guidelines

See Low Back Pain Guidlines

Related Pages

• Low Back Pain in Pregnancy
• Low Back Pain in Pregnancy
• Telehealth for Low Back Pain
• Low Back Pain and Breathing Pattern Disorders
  
• Low Back Pain Related to Hyperlordosis

Presentations

Exercise and Low Back Pain: Where do we Stand This presentation, created by Jason Steere as part of the Evidence In Motion OMPT Fellowship in 2011, discusses the basis and evidence for specific stabilisation exercises for low back pain. View the presentation

Recent Related Research (from Pubmed)

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 References

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