Low Back Pain: At A Glance

Key Points

1. Low back pain is the leading cause of disability worldwide.

2. Most people with acute non specific low back pain recover after 4-6 weeks with conventional treatments and physical exercise.

3. Risk stratification approach can reduce the risk of patient developing chronic pain and disability.

4. The mechanism of lower back pain is likely multifactorial. A biopsychosocial framework improves the understanding and manage of low back pain.

The International Association Studies of Pain (IASP) has named 2021 as the Global Year About Back Pain. Low back pain is very common. Some general practitioners see at least one patient with lower back pain per week. Most acute non specific low back pain are self-limiting. Some have spinal pathology and can experience subsequent episode or develop chronic pain.

Acute non specific low back pain practice points

1. Emphasise that it is safe and helpful to move. Consider ‘hurt does not mean harm’ and ‘sore but safe’.

2. Consider functionally-oriented stretching, strengthening and aerobic exercises, such as pilates, yoga and swimming.

3. Grade exercise by exercise duration rather than pain level. (Pacing techniques)

4. Reassuring patients about the likelihood of a positive prognosis

5. Encouraging self-management strategies such as heat packs

Rule out RED FLAGS

Age older than 50 years old, trauma, neurological deficit, bladder/bowel incontinence, symptomatology suggestive of infection, malignancy or cauda equina syndrome

What are the causes of Low Back Pain?

Lower back pain is complex. Lower back pain could be due to:

1. Myofascial pain – muscle (especially psoas, quadrates lumborum, erector spinae muscles, paravertebral muscles), ligaments, tendons strain and sprain or tight knots, which is called trigger point

2. Facet joints – also known as zygapophyseal joints, that guide and limit movement of each spinal motion segment.

3. Spondylosis – including osteoarthritis and spondylolisthesis (with slippage of vertebral bodies), that could cause nerve compression or inflammatory signals

4. Disc disease – could be disc bulge, desiccation or degeneration

5. Nerve pain – nerve irritation could be from spinal canal stenosis, foraminal narrowing, osteoarthritis, post-infection

6. Central sensitisation – when there is increased responsiveness of signalling from nervous system

7. Post surgical/trauma pain – the complex interaction between nerve, muscle and tissue inflammation, adhesion, weakness and sensitisation.

It is likely that many of these mechanisms interplay or reflect overlapping processes that combine with genetic, epigenetic, individual and lifestyle factors to eventually lead to chronic back pain. There are scientific evidence that Inflammation, sensitization, changes in innervation of spinal structures and altered cortical response have been observed in people with back pain and animal models of back pain. 

Poor sleep quality, work-related stress, poor interpersonal relationships, stressful life events, alcohol and tobacco consumption are associated with the chronic back pain prevalence. Regular leisure time physical activity and positional variation may  be more important in preventing or managing back pain. 

What’s next?

Lower back pain is complex. If pain persisted despite the use of simple analgesia and physical rehabilitation, a referral to pain specialist for comprehensive biopsychosocial assessment is recommended. Management options varies between patients, but it could include pharmacotherapy, spinal physiotherapist, pain psychologist, pain procedures and/or referral to spinal specialist.

Check out the IASP 2021 Global Year about Back Pain Fact Sheet: PATHOPHYSIOLOGICAL ASSESSMENT OF NON-SPECIFIC BACK PAIN

Reference:

1. NPS MEDICINEWISE. Low back pain: Providing reassurance, encouraging activity and reducing reliance on imaging. 16 October 2018 (accessed 15 Feb 2021) – https://www.nps.org.au/professionals/low-back-pain

2. Traeger AC, Lee H, Hubscher M, et al. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial. JAMA Neurol 2018.

3. Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009;79(12):1067-1074.