Low Back Pain | Mysite

Lower Back Pain Myths Busted:
What You Need to Know

Low back pain is usually nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, intervertebral discs, or surrounding soft tissues. Clinical clues, or red flags, may help identify cases of nonmechanical low back pain and prompt further evaluation or imaging.

Red flags include progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age [1].

Imaging on initial presentation should be reserved for when there is suspicion for cauda equina syndrome, malignancy, fracture, or infection. Plain radiography of the lumbar spine is appropriate to assess for fracture and bony abnormality, whereas magnetic resonance imaging is better for identifying the source of neurologic or soft tissue abnormalities [2].

Diagnosis:

The diagnostic process primarily involves triaging patients into specific or non-specific low back pain. Specific low back pain is attributed to a distinct pathophysiological mechanism (e.g., hernia nuclei pulposi, infection, osteoporosis, rheumatoid arthritis, fracture, or tumor). Non-specific low back pain lacks a clear cause and is diagnosed by exclusion. About 90% of cases fall into this category [11].

Most acute low back pain episodes have a favorable prognosis, but recurrences within a year are common. Imaging should be reserved for cases with specific pathology or nerve root pain.

Medication:

Moderate evidence supports the use of nonsteroidal anti-inflammatory drugs, opioids, and topiramate in the short-term treatment of mechanical low back pain. There is little or no evidence of benefit for acetaminophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain [3].

Physical Therapy:

Physical therapists play an integral role in the diagnosis and treatment of low back pain; however, variable evidence exists for specific physical modalities. Manipulation and mobilization are no more effective than inert interventions for acute low back pain. However, a systematic review and meta-analysis concluded that osteopathic manipulative treatment is effective in reducing acute and chronic mechanical low back pain [5]. There is strong evidence that spinal stabilization exercises have no long-term advantages over other exercises. Exercise therapy is as effective as other therapies for the treatment of acute low back pain and is slightly effective at reducing pain and improving function in chronic low back pain. However, early guideline-directed physical therapy has substantial reductions in use of healthcare and overall costs [6].

Physical therapy modalities such as the McKenzie method may decrease the recurrence of low back pain and use of healthcare [4].

Exercise-Based Interventions:

Trunk Coordination, Strengthening, and Endurance Exercises

Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post-lumbar microdiscectomy.

Centralization and Directional Preference Exercises and Procedures

Clinicians should consider utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute or subacute low back pain with mobility deficits.

Flexion Exercises

Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking for reducing pain and disability in older patients with chronic low back pain with radiating pain [9].

Progressive Endurance Exercise and Fitness Activities

Clinicians should consider:

Moderate- to high-intensity exercise for patients with chronic low back pain without generalized pain.
Incorporating progressive, low-intensity, sub-maximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain [10].

Injection and Surgery:

A Cochrane review concluded that there is no strong evidence for or against the use of injection therapy (i.e., corticosteroids, anesthetics, and other drugs administered at epidural sites, facet joints, or local sites) in the treatment of low back pain. Relatively few patients with mechanical low back pain will benefit from surgery. Other than indications for urgent surgical referral, such as progressive motor weakness or cauda equina syndrome, the American Pain Society recommends offering surgery only to patients who have had disabling low back pain impacting quality of life for more than one year [7]. Spinal fusion and lumbar disk replacement are the most common procedures for mechanical low back pain. However, evidence of superiority over nonsurgical modalities is limited, and a randomized trial found no clear benefit of spinal fusion after nearly 13 years of follow-up [8].

References

Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-70. PMID: 11172169.
Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline. Ann Intern Med. 2007;147(7):478-91. PMID: 17909209.
Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-47. PMID: 27745712.
National Institute for Health and Care Excellence (NICE). Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]; 2016.
Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back pain. Spine. 2005;30(8):966-71. PMID: 15834337.
Fritz JM, Cleland JA, Brennan GP. Does early physical therapy decrease health care utilization for acute low back pain? Spine. 2008;33(5):457-62. PMID: 18317192.
Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1094-109. PMID: 19363455.
Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in chronic low back pain. Spine. 2003;28(17):1913-21. PMID: 12973133.
Slade SC, Keating JL. Exercise prescription for low back pain. Spine J. 2010;10(7):601-13. PMID: 20494814.
Oesch P, Kool J, Bachmann S, et al. Effectiveness of exercise-based interventions for low back pain. Am J Phys Med Rehabil. 2010;89(11):1075-92. PMID: 20467321.
Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates. Spine. 2006;31(23):2724-7. PMID: 17077742.

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