Elsevier

The Lancet

Volume 389, Issue 10070, 18–24 February 2017, Pages 736-747
The Lancet

Seminar
Non-specific low back pain

https://doi.org/10.1016/S0140-6736(16)30970-9Get rights and content

Summary

Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Management guidelines endorse triage to identify the rare cases of low back pain that are caused by medically serious pathology, and so require diagnostic work-up or specialist referral, or both. Because non-specific low back pain does not have a known pathoanatomical cause, treatment focuses on reducing pain and its consequences. Management consists of education and reassurance, analgesic medicines, non-pharmacological therapies, and timely review. The clinical course of low back pain is often favourable, thus many patients require little if any formal medical care. Two treatment strategies are currently used, a stepped approach beginning with more simple care that is progressed if the patient does not respond, and the use of simple risk prediction methods to individualise the amount and type of care provided. The overuse of imaging, opioids, and surgery remains a widespread problem.

Introduction

Low back pain is a symptom rather than a disease. Like other symptoms, such as headache and dizziness, it can have many causes. The most common form of low back pain is non-specific low back pain. This term is used when the pathoanatomical cause of the pain cannot be determined.

Section snippets

Epidemiology, risk factors, and costs

In a 2008 review of the worldwide prevalence of low back pain, which included 165 studies from 54 countries, the mean point prevalence was estimated to be 18·3%, and 1-month prevalence 30·8%.1 Low back pain was more common in female than male individuals and in those aged 40–69 years than in other age groups. Prevalence was greater in high-income countries (median 30·3% [IQR 16·9–46·6]) than middle-income (21·4% [10·6–38·6]) or low-income (18·2% [0·8–21·7]) countries, but there was no

Clinical presentation, signs, and symptoms

In a study of 1172 consecutive patients with acute low back pain attending Australian primary care (family doctor, physiotherapist, or chiropractor), most (76%) reported having a previous episode.20 Most patients had moderate to very severe pain intensity (80%) that caused moderate to extreme interference with daily function (76%). Patients reported problems being able to cope with their pain and were worried about the risk of persistence. A third (36%) were already taking medication for the

Differential diagnosis

Low back pain is a symptom that accompanies several diseases. The diagnosis of non-specific low back pain implies no known pathoanatomical cause. Triage aims to exclude those cases in which the pain arises from either problems beyond the lumbar spine (eg, leaking aortic aneurysm); specific disorders affecting the lumbar spine (eg, epidural abscess, compression fracture, spondyloarthropathy, malignancy, cauda equina syndrome); or radicular pain, radiculopathy, or spinal canal stenosis. Remaining

Diagnostic investigations

Diagnostic investigations have no role in the management of non-specific low back pain. Although diagnoses based on lumbar structures (discogenic low back pain, facet joint pain, sacroiliac joint pain) remain popular in some settings, the available clinical tests for these conditions have insufficient accuracy.28

Diagnostic investigations have a role when the clinician suspects a specific disease process that would be managed differently from non-specific low back pain. The threshold for

Prevention

There are popular interventions to prevent low back pain that are based around limiting exposure to risk factors. Examples of interventions that aim to reduce excessive loading of the spine include use of lifting devices in workplaces, braces to support the spine, and ergonomic office furniture. Few trials have investigated such strategies; most prevention interventions have only face validity.

A 2016 review (21 studies, 30 850 patients) concluded that exercise alone or in combination with

Clinical course

The clinical courses of acute and persistent low back pain are typically presented as being completely different. A common view is that most cases of acute low back pain recover completely within 4–6 weeks but persistent low back pain has a very poor prognosis with recovery unlikely. This simple portrayal of the course of low back pain needs reconsideration.

A systematic review (24 studies, 4994 patients) summarised the clinical course of low back pain with pooled mean pain scores expressed on a

Acute management

Table 2 summarises the evidence from systematic reviews about the effects of treatments for acute low back pain on short-term pain outcomes. When possible, we relied on Cochrane reviews. By definition, non-specific low back pain does not have a known pathoanatomical cause. There are, therefore, no specific treatments that can be provided for non-specific low back pain. Instead, management focuses on reducing pain and its consequences, including any associated disability. Although there are some

Long-term management

No treatments can cure persistent low back pain, but interventions are available that reduce pain and disability, and address the consequences of long-term pain (table 3). Many patients and clinicians find this position hard to accept, which provides a fertile ground for people with vested interests to market non-evidence-based treatments that purport to cure persistent back pain. Part of the challenge of managing persistent low back pain is to guide patients away from the wide array of centres

Controversies and uncertainties

Although low back pain occurs in both children and older people, we have a limited understanding of how to manage the problem in these groups because they are usually excluded from studies of interventions. A systematic review of the management of low back pain in children and adolescents identified only 15 trials,128 but a search of CENTRAL on March 18, 2016, across all age groups, identified 5354 trials. Many trials exclude workers, people with comorbidities, individuals on compensation, or

Outstanding research questions

A major issue is how best to close the large gaps between evidence and practice that persist in the management of low back pain. The many attempts worldwide to influence clinical practice and improve uptake of evidence into routine management have yielded disappointing results. A systematic review of 17 qualitative studies investigating barriers to clinician adherence to low back pain guidelines reported that clinicians believe that guidelines constrain professional practice, popular clinical

Search strategy and selection criteria

We searched the Cochrane Library and PubMed for reports published in English from database inception until Feb 13, 2016, with the term “low back pain” and each heading in our Seminar (eg, “differential diagnosis”). Additionally, we identified current clinical guidelines, searched our existing records for relevant publications, and examined the reference lists of studies retrieved by the searches. We gave particular emphasis to clinical guidelines and systematic reviews over primary studies.

References (141)

  • JC Hill et al.

    Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial

    Lancet

    (2011)
  • D Hoy et al.

    A systematic review of the global prevalence of low back pain

    Arthritis Rheum

    (2012)
  • D Hoy et al.

    The global burden of low back pain: estimates from the Global Burden of Disease 2010 study

    Ann Rheum Dis

    (2014)
  • Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

    Lancet

    (2015)
  • MS Swain et al.

    An international survey of pain in adolescents

    BMC Public Health

    (2014)
  • L Hestbaek et al.

    Is comorbidity in adolescence a predictor for adult low back pain? A prospective study of a young population

    BMC Musculoskelet Disord

    (2006)
  • P Coenen et al.

    The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis

    Occup Environ Med

    (2014)
  • R Shiri et al.

    The association between obesity and low back pain: a meta-analysis

    Am J Epidemiol

    (2010)
  • MB Pinheiro et al.

    Symptoms of depression and risk of new episodes of low back pain: a systematic review and meta-analysis

    Arthritis Care Res (Hoboken)

    (2015)
  • BF Walker et al.

    Low back pain in Australian adults: the economic burden

    Asia Pac J Public Health

    (2003)
  • DJ Schofield et al.

    Chronic disease and labour force participation among older Australians

    Med J Aust

    (2008)
  • DJ Schofield et al.

    Early retirement and the financial assets of individuals with back problems

    Eur Spine J

    (2011)
  • R Froud et al.

    A systematic review and meta-synthesis of the impact of low back pain on people's lives

    BMC Musculoskelet Disord

    (2014)
  • P MacNeela et al.

    Experiences of chronic low back pain: a meta-ethnography of qualitative research

    Health Psychol Rev

    (2015)
  • S Bunzli et al.

    Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain

    Clin J Pain

    (2013)
  • S Snelgrove et al.

    Living with chronic low back pain: a metasynthesis of qualitative research

    Chronic Illn

    (2013)
  • N Henschke et al.

    Characteristics of patients with acute low back pain presenting to primary care in Australia

    Clin J Pain

    (2009)
  • D Steffens et al.

    What triggers an episode of acute low back pain? A case-crossover study

    Arthritis Care Res (Hoboken)

    (2015)
  • C Parreira Pdo et al.

    Can patients identify what triggers their back pain? Secondary analysis of a case-crossover study

    Pain

    (2015)
  • D Steffens et al.

    Effect of weather on back pain: results from a case-crossover study

    Arthritis Care Res (Hoboken)

    (2014)
  • V Duong et al.

    Does weather affect daily pain intensity levels in patients with acute low back pain? A prospective cohort study

    Rheumatol Int

    (2016)
  • Back pain

  • JG Jarvik et al.

    Back pain in seniors: the Back pain Outcomes using Longitudinal Data (BOLD) cohort baseline data

    BMC Musculoskelet Disord

    (2014)
  • MJ Hancock et al.

    Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain

    Eur Spine J

    (2007)
  • BW Koes et al.

    Diagnosis and treatment of low back pain

    BMJ

    (2006)
  • RA Deyo et al.

    Low back pain

    N Engl J Med

    (2001)
  • N Henschke et al.

    Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain

    Arthritis Rheum

    (2009)
  • WT Enthoven et al.

    Prevalence and “red flags” regarding specified causes of back pain in older adults presenting in general practice

    Phys Ther

    (2016)
  • A Downie et al.

    Red flags to screen for malignancy and fracture in patients with low back pain: systematic review

    BMJ

    (2013)
  • AS Downie et al.

    Trajectories of acute low back pain: a latent class growth analysis

    Pain

    (2016)
  • M Underwood et al.

    Red flags for back pain

    BMJ

    (2013)
  • R Chou et al.

    Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians

    Ann Intern Med

    (2011)
  • Primary care management of low back pain

  • R Chou

    In the clinic. Low back pain

    Ann Intern Med

    (2014)
  • R Chou et al.

    Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society

    Ann Intern Med

    (2007)
  • Suspected cancer: recognition and referral. NICE guidelines [NG12]

  • S Li et al.

    Estimated number of prevalent cases of metastatic bone disease in the US adult population

    Clin Epidemiol

    (2012)
  • S Goergen et al.

    Acute low back pain. Education modules for appropriate imaging referrals: Royal Australian and New Zealand College of Radiologists

  • DA van der Windt et al.

    Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain

    Cochrane Database Syst Rev

    (2010)
  • D Poddubnyy et al.

    Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis

    Ann Rheum Dis

    (2015)
  • Cited by (0)

    View full text