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Low Back Pain

Pain in lumbosacral area of the back between the bottom of the
 ribs and the top of legs.

How common –One of the most common health problems among all populations of the world Most people would experience back pain at some point of their lives – 70 to 85 % of adults will experience LBP at some point on their life Most cases are managed in primary care ( up to 65 % ) and subsequently they become the sole provider for these patients Estimated point prevalence is 18 % ( ie 18 % experience LBP at any given time ) Incidence is highest in 3 rd decade and overall prevalence increases with age until 60-65 yrs and then declines gradually Men and women are affected equally but in the age group > 60 yrs women report LBP more often than men About 2-7 % of patients will develop chronic LBP In France chronic LBP affects 8-10 % of patients with LBP Prevalence of chronic low back pain is increasing – risk of disabling pain rises in older age It is thought that chronic LBP affects an estimated 15-45 % of the population
and is the most common cause of disability in individuals between ages 45-65 yrs.

Types- Non-specific low back pain-Low back pain not attributable to a known cause . Responsible for 90-95 % of all cases of LBP

Radiculopathy / sciatica , specific LBP , acute , subacute and chronic LBP-Guidelines differ in duration Acute ranges from 4-6 weeks
Subacute up to 12 weeks Chronic is generally considered 
as > 12 weeks ( 3 months )

Risk factors –poor general health low educational status ( more common among people with low socioeconomic status – Freburger et al ) , lack of physical exercise stress , anxiety and depression job dissatisfaction low levels of social support whole body vibration BMI – association is not clear but obesity is known to promote overloading of the articular stuctures of the lumbar spine , thus predisposing to degeneration hours spend watching TV / physical inactivity occupational hazards ( e.g activities involving repetitive bending 
and / or lifting , prolonged sitting ) joint trauma and injuries e.g sports , heavy physical activity positive family history

Disease burden –high economic and social costs estimated annual direct cost of treating LBP in France is 2.7 billion euros or 1.5 % of the overall health care costs cost in some other nations -
○ annual cost is 100 billion $s in the USA ,○ 3.5 billion euros in Netherlands
○ 6.6 billions in Switzerland and 17.4 billions in Germany in 2013 back pain was responsible for 11 % of the total disability in the UK in 2015 LBP and neck pain were ranked the 4th leading cause of disfe ability-adjusted life yrs ( DALYS ) globally -just after IHD , CVD and LRTI GBD also reports that in 2015 more than 1/2 a billion people worldwide had LBP and more than 3rd of a billion people had neck pain of more than 3 months duration.

Onset , severity , location , quality. duration circumstances associated with onset of pain radiation intensity of pain ( consider using VAS scoring ) aggravating and relieving factors any associated symptoms any h/o ? trauma / injury psychological impact- sleep , mood occupational history impact of the condition ? limitations any medications / treatments tried

Examination –Palpation Posture assessment Range of spinal movements Straight leg raise ( L4-S1 ) Strength , reflexes and sensation
○ sensation Toes- lateral (S1) and medial (L5) Ankle and great toe dorsiflexion
○ extentsion big toe ( L5)
○ stand on tip toes ( S1) Knee (L3/4) and ankle ( S1 ) reflexes

The intensity of LBP can be evaluated using
tools like
• visual analogue scale ( VAS )
• numerical rating scale 
• Oswerty Disabling Index
• Roland Morris Disability Questionnaire


Red/ Yellow flags –older age H/o malignancy ( e.g cancer , neoplasm ) Systemically unwell / weight loss prologed corticosteroid usage Structural deformity Cauda equina syndrome Inflammatory pain → night pain , morning stiffness Fracture – significant trauma Infection – fever

Yellow flags –beliefs that pain and activity are harmful treatment preferences that do not fit with the best practice – for e.g passive over active treatments lack of social support

Investigations –Most guideline for LBP recommend against the use of routine imaging for patients with non-specific LBP Imaging should be considered in presence of red-flags or if the results are likely to change management Current NICE guidance states using MRI scan in specialists clinics only – if it will change outcome Inform patients that the decision about imaging would be taken by the specialist – incidental findings as disc degeneration and appropriate clinical co-relation is needed when explaining the MRI result is necessary An X-Ray of the spine may be considered if a spinal fracture is suspected for e.g
○ sudden onset new back pain in a women > 60
○ h/o osteoporosis / steroid use / risk Fxs OP
○ h/o ankylosing spondylitis Laboratory investigations – if any red flags suspected for e.g infection / cancer

Specific spinal pathology –vertebral fracture malignancy spinal infection axial spondyloarthritis ( often missed ) cauda equina syndrome.

Radiculopathy / sciatica – radicular pain ( also known as sciatica ) radiculopathy – N root dysfunction presents as sensory disturbances , weakness of muscles innervated by that N root and hypoactive muscle stretch reflex of the same N root spinal stenosis – neurogenic claudication relieved in forward flexion or sitting

These are group of conditions where the source of the presentation lies in the lumbosacral nerve root pathology associated with 
○ disc herniations
○ osteophytes
○ spondylolisthesis
○ acquired or degenerative canal stenosis.

Non-specific lower back pain –Use history and clinical examination to r/o red-flags Neurological examination to identify radicular syndrome Assess psychosocial issues Imaging – only if a serious pathology is suspected For most patients with acute LBP simple first line care ( advice , reassurance and self-management ) with a plan for review in 1-2 weeks is sufficient Non-pharmacological interventions should be encouraged over pharmacolgical treatment Pharmacological therapy- use the lowest cost effective dose and for the shortest period of time possible

Risk stratification tools –Use of risk stratification tools is supported by several guidelines Orebro tool – this is a yellow flag screening tool that predicts long -term disability and failure to return to work when completed 4 to 12 weeks following a soft-tissue injury For e.g use of STarT back screening tool is recommended by NICE and UKSSB

Kele Start Back tool –These tools have evolved to help in early identification of patients at risk of developing persistent LBP STarT back tool is a brief questionnaire for screening indicators ( both physical and psychosocial risk factors ) for persistent disabling back pain Use of STarT back tool has been vaildated in clinical trials- its reliability and screening ability have been proven
○ SBST tool predicts outcomes of physical therapy in a cohort of patients receving outpatient physical therapy for LBP
 ( Katzan et al 2019 )
○ SBT may be an applicable and useful tool in physiotherapy practice ( Robinson et al 2017 ) The tool is available online- see links Based on SBT the patients are divided into 3 subroups -for developing persistent LBP.

Low risk –Reassurance good prognosis self management pain management for e.g NSAIDs / weak opioids advice on returning to normal activity avoiding bed rest referral is not required.

Medium and high risk –refer physiotherapy MSK / CATS manage pain follow local / national protocols for e,g the National back pain pathway

Consider referral

presence of red flags symptoms have recurred following previous successful treatment STarT back group medim or high Low risk STarT back with no improvement after 4-6 weeks of management in primary care Primary care conservative management fails Specific spinal pathology Consider referral for for patients with radicular syndrome if primary care managament fails to control symptoms Spinal stenosis Significant functional impairment Patients with chronic low back pain with significant psychological component and failed previous conservative management Patients with disabling levels of distress , depression or anxiety

References

  1. Aoki, Yasuchika et al. “Evaluation of nonspecific low back pain using a new detailed visual analogue scale for patients in motion, standing, and sitting: characterizing nonspecific low back pain in elderly patients.” Pain research and treatment vol. 2012 (2012): 680496. doi:10.1155/2012/680496 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505659/
  2. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791‐2803. doi:10.1007/s00586-018-5673-2 ( Abstract ) https://pubmed.ncbi.nlm.nih.gov/29971708/
  3. Diagnostic triage for low back pain : a practical approach for  primary care :ynn D Bardin , Peter King , Chris G Maher Narrative review via https://www.mja.com.au/system/files/issues/206_06/10.5694mja16.00828.pdf
  4. Back pain-clinical assessment Australian Family Physician Steve Jensen Vol 33 , No 6, June 2004 via https://www.racgp.org.au/afpbackissues/2004/200406/20040601jensen.pdf
  5. Hurwitz EL, Randhawa K, Yu H, Côté P, Haldeman S. The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. Eur Spine J. 2018;27(Suppl 6):796‐801. doi:10.1007/s00586-017-5432-9 ( Abstract ) via https://pubmed.ncbi.nlm.nih.gov/29480409/
  6. Katzan IL, Thompson NR, George SZ, Passek S, Frost F, Stilphen M. The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain. Spine J. 2019;19(4):645‐654. doi:10.1016/j.spinee.2018.10.002
  7. Robinson, Hilde Stendal, and Hanne Dagfinrud. “Reliability and screening ability of the StarT Back screening tool in patients with low back pain in physiotherapy practice, a cohort study.” BMC musculoskeletal disorders vol. 18,1 232. 31 May. 2017, doi:10.1186/s12891-017-1553-x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452390/
  8. Scott, N Ann et al. “Managing low back pain in the primary care setting: the know-do gap.” Pain research & management vol. 15,6 (2010): 392-400. doi:10.1155/2010/252695 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008665/
  9. Alain Lorenzo, Pauline Schildt, Mathieu Lorenzo, Hector Falcoff, Fréderique Noel, Acute low back pain management in primary care: a simulated patient approach, Family Practice, Volume 32, Issue 4, August 2015, Pages 436–441, https://doi.org/10.1093/fampra/cmv030
  10. Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24(6):769‐781. doi:10.1016/j.berh.2010.10.002 https://pubmed.ncbi.nlm.nih.gov/21665125/ ( Abstract)
  11. Rachael E. Docking, Jane Fleming, Carol Brayne, Jun Zhao, Gary J. Macfarlane, Gareth T. Jones, on behalf of the Cambridge City over-75s Cohort Study collaboration, Epidemiology of back pain in older adults: prevalence and risk factors for back pain onset, Rheumatology, Volume 50, Issue 9, September 2011, Pages 1645–1653, https://doi.org/10.1093/rheumatology/ker175
  12. The Epidemiology of low back pain D.HoyaP.BrooksbF.BlythcR.Buchbinder

    Best Practice & Research Clinical Rheumatology Volume 24, Issue 6, December 2010, Pages 769-781

  13. Wong, A.Y., Karppinen, J. & Samartzis, D. Low back pain in older adults: risk factors, management options and future directions. Scoliosis 12, 14 (2017). https://doi.org/10.1186/s13013-017-0121-3
  14. What are the risk factors for low back pain (LBP) and sciatica? Updated: Aug 22, 2018 Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA https://www.medscape.com/answers/1144130-118909/what-are-the-risk-factors-for-low-back-pain-lbp-and-sciatica
  15. Risk Factors Forchronic Low Back Pain Karunanayake Aranjan Lionel Associate Professor Department of Health Sciences, College of Medicine, Nursing and Health Sciences Fiji National University, Fiji https://www.omicsonline.org/risk-factors-forchronic-low-back-pain-2161-0711.1000271.php?aid=22679

  16. Non-specific low back pain and sciatica: 1
    management NICE guideline: short version 4 Draft for consultation, March 2016 https://www.nice.org.uk/guidance/ng59/documents/short-version-of-draft-guideline
  17. Primary care management of non‐specific low back pain: key messages from recent clinical guidelines Matheus Almeida Bruno Saragiotto Bethan Richards Chris G Maher ( Abstract )First published: 02 April 2018 https://doi.org/10.5694/mja17.01152

  18. Clinical practice guidelines for the management of non‑specific low back pain in primary care: an updated overview
    Crystian B. Oliveira1  · Chris G. Maher2,3  · Rafael Z. Pinto4  · Adrian C. Traeger2,3  · Chung‑Wei Christine Lin2,3  · Jean‑François Chenot5  · Maurits van Tulder6 · Bart W. Koes7,8 European Spine Journal (2018) 27:2791–2803 https://doi.org/10.1007/s00586-018-5673-2
  19. North and East Devon Formulary and Referral Non-specific / mechanical low back pain via https://northeast.devonformularyguidance.nhs.uk/referral-guidance/eastern-locality/musculosketal/non-specific-mechanical-low-back-pain
  20. Keele Start Back via https://startback.hfac.keele.ac.uk/
  21. Orebo Musculoskeletal Pain Questionnaire ( OMPQ ) https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/212908/Orebro_musculoskeletal_pain_questionnaire_Final.pdf
  22. Prevalence and risk factors for low back pain Jella Ramdas , Vasantha Jella International Journal of Advances Medicine Ramdas J et al Int J Adv Med . 2018 Oct;5 (5) : 1120-1123

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