Non-specific low back pain

1. Non-specific low back pain = low back pain, which is not attributed to a recognisable pathology Acute = <12 weeks duration Chronic = >12 weeks duration Van Tulder M, et al. Low back pain (acute). Clinical Evidence 2006

2. There’s 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 thirdof 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: 1430–4European 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. < 20 years of age Acute onset in older people (> 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 Exclude serious pathology by using “Red flags”Speed C. BMJ 2004; 328: 1119–21Koes BW, et al. BMJ 2006; 332: 1430–4

5. 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

6. Treatment of chronic back painEuropean 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 recommendationsVan Tulder M and Koes B. Low back pain (acute & chronic). Clinical Evidence 2006