Low back pain is prevalent, and both debilitating for the patient and costly for society if it becomes a chronic condition. The initial prognosis at the onset of low back pain is positive, however the rate of recurrence is high and about 20% of patients seeking care develop a chronic problem that may or may not lead to disability. The main message, based on the best evidence, is that keeping active despite low back pain is “healthy”. A large portion of patients seeking care can manage their short term and even longer term incapacity. However, for those who cannot manage their pain, significant relief can be found in a variety of conservative treatments. Passive treatment should be kept to a minimum as evidence shows that active treatments are more effective for improving function and return to work. There is evidence that identifying psychosocial symptoms and barriers, and referral to appropriate interventions improves outcomes. There are currently no clear indications for surgery in nonspecific low back pain.
Introduction
Low back pain is prevalent, and both debilitating for the patient and costly for society if it becomes a chronic condition . In their classic review article published in 2001, Deyo and Weinstein pointed out “there are few large, randomized trials of therapy for non-specific LBP”, however since then several major randomized trials have been published on efficacy of treatments for nonspecific low back pain at various stages. The focus of this article is to present a structured approach based on evidence to prevent disability and chronicity in patients with non-specific low back pain, and approaches to dealing with chronic pain patients, including different modalities.
What is non-specific chronic low back pain?
Non-specific low back pain (NSLBP) is a diagnosis of exclusion, meaning that no causality or structure responsible for the pain can be determined with currently available evaluation and/or diagnostic tools. NSLBP can be described as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain radiating to the knee(s) (but not below the knee[s]); it is defined as chronic when it persists for 12 weeks or more. NSLBP is pain not caused by a clearly recognizable pathology (such as infection, tumor, fracture or inflammation) . There are several possible causes, such as bulging discs, that researchers have tried to associate with low back pain. However, no definitive link has been established between these diagnostic findings and clinical signs and symptoms. As such, these remain at best theories worthy of further research investigation, but do not have the scientific support needed to guide treatment protocols. NSLBP includes common diagnoses such as lumbago, myofascial syndrome, muscle spasm, mechanical low back pain, back strain and sprain and other more esoteric names. The common denominator for all these diagnoses is that they are vague and non-specific.
Less than 15% (5% with disc prolapse or spinal stenosis, 0.1% tumor, <3% rheumatoid arthritis, ∼5% other) of patients seeking care for low back pain have diagnoses that can be directly attributed to a specific pathological condition in the spine while about 85% are designated to NSLBP .
What is non-specific chronic low back pain?
Non-specific low back pain (NSLBP) is a diagnosis of exclusion, meaning that no causality or structure responsible for the pain can be determined with currently available evaluation and/or diagnostic tools. NSLBP can be described as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain radiating to the knee(s) (but not below the knee[s]); it is defined as chronic when it persists for 12 weeks or more. NSLBP is pain not caused by a clearly recognizable pathology (such as infection, tumor, fracture or inflammation) . There are several possible causes, such as bulging discs, that researchers have tried to associate with low back pain. However, no definitive link has been established between these diagnostic findings and clinical signs and symptoms. As such, these remain at best theories worthy of further research investigation, but do not have the scientific support needed to guide treatment protocols. NSLBP includes common diagnoses such as lumbago, myofascial syndrome, muscle spasm, mechanical low back pain, back strain and sprain and other more esoteric names. The common denominator for all these diagnoses is that they are vague and non-specific.
Less than 15% (5% with disc prolapse or spinal stenosis, 0.1% tumor, <3% rheumatoid arthritis, ∼5% other) of patients seeking care for low back pain have diagnoses that can be directly attributed to a specific pathological condition in the spine while about 85% are designated to NSLBP .
Natural history and recurrence of NSLBP
Acute NSLBP (≤ 3 months) has a favorable prognosis for most individuals, however, chronic pain may occur in 1 out of 5 patients seeking care for low back pain. Von Korff et al. (2005) found that 20% of the US population has suffered from chronic LBP in the past year and that approximately 30% of the same population suffered chronic LBP during their lifetime .
If recovery from acute NSLBP has not occurred during the first three months, NSLBP is classified as chronic. Studies focusing on the prognosis and natural history of LBP report that 50% of patients who consult a health care provider for acute NSLBP can expect to resume their normal activities within 4 to 6 weeks. By 12 weeks, the rate of recovery rises to approximately 90%. Six to ten percent of NSLBP patients experience chronic pain and work incapacity compared to approximately 35 to 40% of the patients with a specific spine diagnosis . Patients with lower than average initial pain intensity, shorter duration of symptoms and fewer previous episodes recover more quickly (HR = 3.5, 95% CI, 1.8–7.0) than patients without these characteristics . Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery in a primary care cohort .
The recurrence rate of NSLBP has been described to vary considerably (between 5% and 60% with up to 2 years of follow up) in population studies or specific occupational populations . Recurrence rate or episode rate is difficult to estimate, as the definition of an episode is not standardized across different studies . We use the term recurrent NSLBP when the patient has had a pain-free period and has returned to normal activities, including work, for at least 8 weeks from the last episode .
In summary NSLBP has a mostly favourable prognosis but with a high recurrence rate. About 20% will develop persistent or chronic symptoms. In these patients, the uncertainty of prognosis for both clinician and patient is very similar to other non-specific conditions such as knee pain, headache or stomach ache .
Clinical evaluation to direct treatment and management of NSLBP to prevent chronicity and disability (Triaging)
Clinical evaluation and classification (triaging) is necessary to establish the best treatment course for a patient seeking care for low back pain, ideally to prevent chronicity. One major goal of triaging is to prevent chronic low back pain . In theory, triage based on recognized serious medical, psychological, and workplace risk factors for chronicity can help to direct treatment in a way that maximizes the results. In this way patients would receive exactly the specific treatment they need to recover, based on addressing specific individual barriers to recovery. There is no direct evidence for triage studies in low back pain, however there is general agreement that it does make sense to address these factors early on, and some suggestion that such an approach can improve outcomes .
The goal of triaging is to look for serious conditions (Red Flags), possible psychosocial factors complicating the condition (Yellow Flags) and lastly to understand perceptions about work that may lead to prolonged disability (Blue Flags) . These three axes of evaluation are important for prevention of chronicity. The evidence for triaging for Red Flags is robust and the evidence for triaging Yellow Flags is excellent to better understand perception of disability and disability from work . The evidence for triaging by evaluating Blue Flags is not as clear, however they are worth mentioning in the context of returning the patient to full activity including work. The clinical evaluation approach for excluding “Red Flags“ is well-accepted and is primarily based on a careful history, and a musculoskeletal and neurological evaluation of the spine . The psychosocial evaluation is intended to identify beliefs and expectations about recovery, anxiety, distress and depression as well as other prognostic factors. Finally, work related issues are elucidated by questions about expectations for returning to work, anticipated barriers and problems, support form the workplace, job satisfaction and other issues . Research has shown that these psychosocial factors are more predictive for recovery than clinical findings in NSLBP . Other clinical factors that predict prolonged disability from work include prior episodes of low back pain, high pain levels, poor general health and more diffuse, multi-site pain .
Questions about “Blue Flags” screen for workplace factors influencing work disability, these factors include high physical job demands, inability to modify work demands, high levels of job stress, low workplace social support or dysfunctional workplace relationships, low job satisfaction, low expectations for resuming work, and fear of re-injury . Early multidisciplinary management that includes workplace considerations have been shown to positively impact on lost work time .
Black Flags are popular in Europe but are less known in the rest of the world. The Blacks Flags are system-related, meaning that the insurance system itself may be a hurdle in returning a patient to work. For example, a patient may be ready to return to a different type of duty (job reclassification) than the current job assignment, however if there is no mechanism within the insurance system or self insured company to address this issue, the patient remains disabled. This is a complex area that deserves more attention.
Comorbidities
Comorbidities have been associated with delayed recovery in low back pain, with increasing numbers of comorbid conditions negatively impacting on time to recovery . These may include both emotional and physical conditions, such as depression, systemic illness, such as diabetes, and other musculoskeletal conditions, such as neck pain. Among workers, those with comorbid conditions were 1.31 times more likely to remain work disabled than those with uncomplicated NSLBP, after adjusting for age, gender, lifting demands, and company membership (adjusted hazards ratio [HR] = 1.31; 95% confidence interval [CI] 1.12 to 1.52) . It has also been shown that simultaneous neck and low back pain results in both longer short-term [OR 1.69 (1.14–2.51)] and long-term [2.48 (95% CI = 1.32–4.66)] sickness absence among workers . Obese individuals with low back pain report poorer health and worse pain, with increasing levels of obesity associated with poorer outcomes . Better management of complex patients with chronic low back pain may positively impact overall health including pain as well as the comorbid conditions .
Two Useful Treatment Models: The Medical Model and the Bio-psychosocial Model
Two treatment models are commonly used in treating back pain: the medical model and the bio-psychosocial model. In the medical model the classical scheme of illness implies that an interaction between the patient and a disease leads to an illness complex . This model works well in dealing with specific LBP where causality for the pain can be identified. The model: 1) recognizes patterns of symptoms and signs by history and examination, 2) identifies underlying injury or disease by investigation and diagnosis, 3) treats underlying injury or disease by specific biologically-oriented therapy, and 4) expects the patient to recover as explained by the cure.
In the case of NSLBP, the causality, or lack thereof, is more complex; low back pain is a symptom, where direct causality cannot be determined. The bio-psychosocial model is used for NSLBP to identify factors that are associated with delayed recovery. This model calls for the identification of factors outside the scope of traditional biologically-focused medicine; for example, beliefs, a high perception of disability, kinesiophobia, depression, stress from work or family, job dissatisfaction, anxiety, somatization, lack of control and others . The bio-psychosocial model in clinical care:
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Recognizes the non-specific nature of the back pain,
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Identifies underlying psychosocial factors,
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Treats these factors with interventions to extend beyond the biologic approach such as cognitive behavioral treatment or workplace interventions, and
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Empowers the patient to take responsibility for managing a condition that often features recurrence or chronicity.
Cultural influences modulate the meaning and the expression of pain. In this sense, pain is as much a social and cultural construct as the result of biological and psychological processes . These factors are addressed through intervention such as cognitive behavioral treatment.
Both models are important to recognize when triaging and treating low back pain. The medical model ascertains optimal recognition of serious and/or causal signs and symptoms for immediate diagnostics and appropriate selected treatment. The bio-psychosocial model emphasizes the important of psychosocial factors, directs clinicians toward appropriate treatment such as cognitive behavioral treatments or workplace interventions. A positive association is well documented between poorer outcomes from low back pain and the presence of yellow flags . Clinicians must be able to identify and effectively address simple yellow flags, and refer more complex cases, in the acute stage and especially as the patient progresses toward chronicity .
It is helpful for clinicians to recognize both models to better understand hurdles for recovery with NSLBP. For example, a patient with a specific cause of low back pain such as a benign, undisplaced, acute spinal fracture may later become disabled due to NSLBP that is unrelated to the fracture.
Patient expectations, preferences and outcomes
Recent studies and guidelines emphasize the need to better understand the importance of patients’ expectations and the importance of education for best outcomes . Patients approach the clinician with expectations and pre-conceptions . The patients expect diagnostic explanation, pain relief and instructions on how to deal with their pain and disability, referral for treatment and perhaps help with sickness certification. Some patients expect imaging or special tests and specific medication. For example, in one cross-sectional study (n = 1942), 77% of the responders believed that if one has back pain, a wrong movement could lead to a serious problem. Forty percent of the responders also believed, with respect to diagnosis, that X-rays and imaging could always identify the cause of back pain . It takes time to explain inappropriate concepts and discuss expectations. The first encounter with patients is where these misconceptions are addressed. At subsequent visits, these concepts are reinforced and checked . Patients must be well informed with evidence-based facts in order to effectively partner with the clinician in planning an optimal treatment strategy, and one that the patient will more readily comply with. Over time, some treatments may have a higher risk of harmful effects, and finally in new treatments the effect may be currently unknown. The patient and clinician discuss the treatment proposed, and come to an agreement on the treatment regimen and on compliance . Patient education on the choice of treatment and the expected treatment outcomes seem to be key factors to success. Similarly, clinical negotiation is an essential tool when it comes to discussing pain as an active process involving patients’ expectations and coping strategies . A recent systematic review identified 24 studies for expectations of recovery from NSLBP patients . From these studies there was strong evidence that recovery expectation is more predictive of work outcome compared to depression, job satisfaction and stress/psychological strain. These results still have to be interpreted with caution as the studies included were very heterogeneous and the constructs of patient expectations are not well defined.
Treatment goals
From the patient’s perspective, the most important goals are usually to “get rid” of the pain and to be “the same as before” the pain occurred in the back. From the clinician’s perspective the goal is rapid patient recovery or sufficient information for self-managing the condition and resuming all functional activities, including work.
Studies have shown that when the clinician and the patient agree on common treatment goals and outcomes i.e. shared decision making, compliance increased and success rate of treatment increased . A pilot study by Azoulay and colleagues (2005) showed that patients with NSLBP who disagreed with their physician were less satisfied with their medical management, and catastrophized more about their pain than those who agreed. Disagreement was, however, not associated with chronicity or disability . Shared clinical decision making is still quite novel and further research is needed. Some limitations of shared decision making may be that patients may be ill informed about what participation in decision making actually entails and unaware of the benefits they stand to gain by articulating their preferences to their clinician. Furthermore, clinicians are not good at accurately assessing patients’ preferences, while patients may have unrealistic expectations about their clinician’s ability to “know what is best” for them .
A pragmatic approach to evidence based progressive management of NSLBP to prevent chronicity and disability
Education, reassurance and self-care
Patients with NSLBP are ideally managed with reassurance and self-care in the early phase. The purpose of adding education, reassurance and self care to the management of low back pain is to provide accurate information about the natural history of back pain, to reduce patient distress, to promote compliance with evidence-based treatment recommendations, to promote autonomy in the management of symptoms and to optimize functional outcome. The message that the patient should remain active and perform those activities that are tolerable cannot be emphasized enough . Providing sub-acute NSLBP patients with accurate and meaningful information has been shown to positively impact return to work, pain, medication use, patient satisfaction with care and overall improvement. Self-care techniques include (but are not limited to) applying heat or ice to control symptoms for short-term relief, stretching or/and walking or using relaxation techniques . Self-management techniques have the advantage that they can provide the patient with short-term relief at any time. Written information reinforcing the good prognosis, the bio-psychosocial factors influencing recovery and self-care instructions are helpful at this stage .
For chronic LBP there is strong evidence to support the combined use of advice to remain active in addition to specific advice relating to the most appropriate exercise, and/or functional activities to promote active self-management .
Medication (pain control)
The first line treatment to relieve pain associated with subacute and chronic low back pain includes over-the-counter pain medications, such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs). However, the effect size and duration of symptom relief are limited . There has been much written regarding the use of opioid and other prescription medication for improved pain control, specifically in chronic low back pain . The general recommendation is that prescription medications including opioids, tramadol, muscle relaxants, benzodiazepines and gabapentin have a place in the short term treatment of persistent and unremitting low back pain, however the risks and benefits must be continually reassessed, and patients monitored for adverse reactions . Long term use of opioids is discouraged, as overdose, substance use disorders and prolonged work absence may result, without significant improvements in symptoms or function . Tricyclic antidepressants are recommended specifically in the case of chronic low back pain, but clinicians should be wary of the prevalence of depression in this population and refer for appropriate mental health care when indicated . Systemic corticosteroids are not recommended for these patients . Risk-benefit assessment must be ongoing with regard to all medication recommendations.
Passive treatment; massage or manipulation
Passive treatments for subacute and chronic low back should be minimally used due to lack of proven long term effectiveness, cost, and lack of impact on functional outcomes and return to work. Evidence suggests that manipulation may be beneficial for short-term relief, to facilitate increased activity. Manipulation combined with exercise, and massage combined with both exercise and education have been shown to be somewhat effective treatments for subacute and chronic low back pain to reduce pain, but have not shown significant benefits in terms of return to work; and the contribution of each component is yet to be clarified .
Exercise
Patient activity levels, including work resumption, are a key factor in recovery. At the subacute stage the message to stay active becomes critical as the goal is to prevent the patient from progressing to a chronic stage of disability . Many studies have been done to identify most advantageous exercise protocols, however overall the evidence remains inconclusive. There is some limited evidence for yoga or hydrotherapy for chronic low back pain . Yoga has been shown to improve functional disability, pain intensity, and depression in one study of patients with chronic low back pain . Some of the goals of exercise including improving strength, flexibility and general conditioning may lead to decreased fear of movement and encourage full activity, including work. Increased exercise tolerance may also positively impact a sense of wellness and self-efficacy.
Cognitive behavioral therapy
Cognitive Behavioral Treatment (CBT) interventions include various combinations of creative visualization, imagery, progressive muscle relaxation techniques, problem solving techniques and others. The goal is to have the patient understand, accept, and take control of the “back pain” by helping the patient develop adaptive coping behaviors and strategies, and thus eventually empower him or her . CBT is effective for subacute and chronic low back pain . There is moderate to strong evidence that CBT should be used early if certain bio-psychosocial issues are present, and there is strong evidence that CBT should be used in most chronic patients with NSLBP >12 weeks . In addition, there is evidence of no difference in outcome between fear-avoidance training and spinal fusion in chronic low back pain . Further evidence suggests that CBT is cost effective, adds 20% efficacy to usual rehabilitation and reduces the duration of recurrence . While CBT is an effective treatment for chronic low back pain, clinicians must recognize when pharmacological management is indicated, as this is often underutilized in clinically depressed chronic low back pain patients .
Multidisciplinary care
Various terms are used to describe care that aims to address all barriers to recovery identified through the red, yellow and blue flags. For the purpose of this review, such a program will be referred to as multidisciplinary. While red and yellow flags are addressed from the time of assessment, as care progresses without positive outcomes, the simultaneous additions of a functional restoration component is added, and when work absence is present, the aim of the program is return to work. Multidisciplinary programs have been show to positively influence pain, functional status and work performance when implemented early in the chronic phase and when compared with programs not specifically focused on work . One systematic review recommends the international standardization of multidisciplinary programs for chronic low back pain in order to compare outcomes across settings .
A recent systematic review reported a significant positive impact of multidisciplinary programs on return to work in subacute and chronic low back pain . The articles reviewed compared multidisciplinary care to more conventional physical therapy and less structured unimodal and multimodal treatment programs. One limitation of this review was generalizability as most of the reviewed studies were from Scandinavian countries. As long term outcomes (up to four years) are similar in either multidisciplinary care or surgery for chronic NSLBP, there is strong evidence to favor multidisciplinary care for chronic low back pain patients .
Summary
Many patients manage their low back pain by themselves and do not seek care, but those who do, seek care for a reason. The reasons may vary and the flag system enhances the identification of the underlying reasons – concerns about a serious condition, intolerable pain, fear and anxiety, work issues, or other factors. Once serious medical conditions are ruled out the clinician must focus on reassuring the patient that the condition is benign, resolution will occur over time, pain is not a signal of serious pathology, and that recurrence is common. The message of keeping active and using guided self care techniques has been shown to be effective. Some patients need more help and patients’ preferences for treatment can be used to facilitate progressive activity. Only a subset of patients needs more extensive multidisciplinary goal oriented programs.
Is there a place for surgery in chronic NSLBP?
The theory
It has been proposed that Degenerative Disc Disease (DDD) is the cause of many cases of chronic NSLBP . There are two theories prevalent today about the lumbar disc being a source of pain. The first theory is that the disc (nucleus and annulus) itself is very unlikely to be a source of pain based on basic science. Studies have shown that the nucleus is not innervated and the annulus is poorly innervated . Furthermore, lymphatic vessels were not found in the nucleus pulposus or annulus fibrosus of intact, non-herniated discs but were present in surrounding ligaments . Therefore, a degenerated but intact disc may not be a source of pain. However, in non-intact discs (annual tear) when there is extrusion of disc material into surrounding soft tissue, there is in-growth of reparative fibrous tissue containing lymphatic vessels in the surrounding ligaments in the lumbar and thoracic discs. Nerve endings in degenerated discs have been found in deeper layers of the annulus fibrosus; in some studies, nerve endings have been found extending even into the nucleus pulposus. The nerve fibers have been found both in anterior and, recently, in posterior parts of disc specimens following a vascularized zone of granulation tissue. The in-growth of nerve endings has been suggested to be the pathoanatomic correlate to the dull chronic ache, which is exacerbated by the mechanical loading of the spine that is experienced by patients with chronic low-back pain and which is often referred to as discogenic pain . The degenerative process of the disc can lead to a cascade of events like loss of disc height, osteophytes, facet joint subluxation and arthrosis and others. It is still unclear if any of these processes are the source of low back pain.
A second theory is related to the disc based upon the concept that ‘sub-failure’ of ligaments (spinal ligaments, disc annulus and facet capsules) may cause chronic back pain due to muscle control dysfunction . Single trauma or cumulative micro-trauma causes sub-failure injuries of the ligaments and embedded mechanoreceptors. The injured mechanoreceptors generate corrupted transducer signals, which lead to corrupted muscle response patterns produced by the neuromuscular control unit. Muscle coordination and individual muscle force characteristics, i.e. onset, magnitude, and shut-off, are disrupted. This results in abnormal stresses and strains in the ligaments, mechanoreceptors and muscles, and excessive loading of the facet joints. Due to inherently poor healing of spinal ligaments, accelerated degeneration of disc and facet joints may occur. These abnormal conditions may lead to back pain.
These two theories are not necessarily contradictory and may be complimentary. However, since they fail to explain LBP adequately and these findings are equally present in people without back pain , the indications for surgery based on these theories are uncertain.
Related posts:
What is the prognosis of back pain?
Exercise therapy for chronic nonspecific low-back pain
Treatment-based subgroups of low back pain: A guide to appraisal of research studies and a summary of current evidence
Back pain and work
Lumbar Spinal Stenosis
Contemporary low back pain research – and implications for practice
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