Low back pain

This narrative review provides current evidence for diagnostic triage for non-specific low back pain by excluding radicular syndrome and specific spinal pathology.

Less than 1% of people presenting with low back pain have an underlying serious spinal pathology that may require imaging.

Around 10% have radicular syndrome, and around 90% have non-specific low back pain that does not require imaging, unless the patient has rapidly deteriorating neurological status.

The review includes a table of alerting features for specific spinal pathologies and the recommended diagnostic workup.

The traditional approach to management of non-specific low back pain was first to stratify by duration of symptoms and then begin with simple care and progress to more complex care if insufficient progress was made. A more recent approach is to use validated risk stratification tools – such as the STarT Back screening tool or the Örebro Musculoskeletal Pain Screening Questionnaire – to stream patients into different care pathways.

An uncomplicated (low risk) episode of low back pain may only require education and reassurance whereas for patients with high risk scores, additional treatment with more intensive interventions such as physiotherapy or even cognitive behavioural therapy may be required.

This article includes information on global epidemiology of non-specific low back pain.

A differential diagnosis section supports the diagnostic triage of low back pain, noting that non-specific low back pain implies no known pathoanatomical cause.

The article reinforces the idea that clusters of alerting features (red flags) are more predictive of a serious spinal pathology than individual features. Imaging has no role in low back pain except when there are major risk factors for cancer, risk factors for spinal infection or cauda equina syndrome.

Patient education can be effective for outcomes such as return to work and global impression of recovery.

Bed rest should be avoided, and the patient should remain as active as possible, gradually resume their normal activity levels and if possible remain at work.

When considering medicines, the potential benefits should be weighed against the harms.

Non-pharmacological therapies for acute low back pain include treatments such as manual therapy, exercise and massage.

The article includes two tables that summarise the evidence from systematic reviews about the effects of treatments for acute low back pain on short-term pain outcomes.

This article details the differential diagnosis of radicular syndrome and specific pathological causes, and reinforces clusters of alerting features.

80% of people with acute low back pain have at least one alerting feature despite less than 1% having a serious spinal pathology. The very low specificity of of most alerting features contribute to unnecessary imaging. Imaging can be delayed in the presence of weak risk factors for cancer and axial spondylarthritis, pending a trial of conservative therapy.

The review includes a summary of the biopsychosocial understanding of risk factors for developing chronic disabling pain in people with acute non-specific pain.

This includes a table of selected predictors and association with poor outcomes.

This systematic review and meta-analysis analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low back pain.

Results showed no significant differences between immediate lumbar imaging and usual care without immediate imaging on pain and function.

There was also no significant difference in quality of life, mental health and overall patient-reported improvement.

This article encourages primary care clinicians to engage in thoughtful use of imaging procedures, and to consider alternative or adjunct methods for providing reassurance, in order to avoid or mitigate the potential negative impact of ‘anomalous’ findings.

The article recognises that while imaging is frequently requested with the goal of reassuring patients, it can paradoxically have a negative impact on patient attitudes and beliefs and can influence pain behaviours.

This letter to the editor recognises that many alerting features have very high false positive rates. As an example, night pain is present in 50% of back pain patients with no serious disease.

The only Cochrane reviews in this area demonstrate that the evidence is sparse and the evidence available suggests that many endorsed alerting features to screen for serious pathology have likelihood ratios close to 1.0 and so are uninformative.

This article summarises recommendations from recently published UK, Danish, Belgian and US guidelines to identify important changes.

The UK NICE and Belgian guidelines recommend simple risk prediction tools to match patients to treatment packages based on their risk of poor clinical outcomes. These include:

• STarT Back
• Örebro Musculoskeletal Pain Screening Questionnaire and
• PICKUP

These tools are freely available online and currently it is unclear which is most effective.

All guidelines recommend advice, reassurance and encouragement of physical activity as first-line care for all patients with non-specific low back pain.

Guidelines have a greater emphasis on non-pharmacological management, with pharmacological options reserved for those whose pain does not respond.

For patients at medium to high risk, based assessment with the stratification tools, the guidelines endorse more complex and intensive treatments.

The second paper in the Lancet’s series on low back pain discusses evidence, challenges and promising directions for prevention and treatment of low back pain.

All guidelines recommend self-management, physical and psychological therapies in management of low back pain and place less emphasis on pharmacological and surgical treatments. Routine use of imaging is not recommended, and very little prevention research exists.

This study systematically reviews the usefulness of individual risk factors or risk prediction instruments for identifying patients more likely to develop persistent disabling low back pain.

Results showed that presence of non-organic signs, high levels of maladaptive pain coping behaviours, high baseline functional impairment, presence of psychiatric comorbidities and low general health status were the most useful predictors of worse outcomes at 1 year. Low levels of fear avoidance and low baseline functional impairment were the most useful items for predicting recovery at 1 year.

Hill JC et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008:59:632-41

Hill JC et al. Supplementary webappendix. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; published online Sept 29

This is the original validation study for the STarT Back tool.

The 2008 Hill study provides the rationale and findings for the initial development of the tool, the purpose of which was to identify patients at risk of poor prognosis.

The 2011 Hill study provides the actual tool and the Keele University webpage provides information on use and scoring, and treatments matched to risk levels.

STarT Back is considered the primary example of available tools, because:

• it has been investigated in five studies in primary care, has good sensitivity of 80% when comparing low to medium plus high risk groups (therefore a false negative rate of 20%) and is brief enough to be used in general practice.
• it is recommended in two Australian guidelines (Therapeutic Guidelines Low back pain 2017 and NSW Agency for Clinical Innovation 2016 Management of people with acute low back pain: model of care).

This Cochrane review is the key study providing evidence in support of the recommendation for patients to stay active as much as possible.

Patients with acute non-specific low back pain can experience small benefits in pain relief and functional improvement from advice to stay active, compared with advice to rest in bed.

Furthermore, evidence suggests little or no difference between those who received advice to stay active, exercise or physiotherapy, which highlights that any movement is beneficial.

The authors stated that none of the included studies reported significant side effects of bed rest, but adverse physiological effects of bed rest have previously been reported.

These results may be relevant to consider in clinical practice, and further demonstrate that advice to rest in bed should be avoided for patients with acute low back pain.

This guideline from the American College of Physicians presents the evidence and clinical recommendations for non-invasive treatment of low back pain.

It provides a succinct summary of evidence for non-pharmacological therapies.

There is low- to moderate-quality evidence showing mixed results for managing back pain with massage and spinal manipulation.

The guideline clearly recommends superficial heat. In particular it finds that of all the different types of superficial heat, only a heat wrap has evidence of benefit for acute non-specific low back pain. This is moderate evidence from a small number of trials.

It found the evidence for superficial cold insufficient.

• The initial treatment of non-specific low back pain should be non-pharmacological.
• Many pain medicines have little or no benefit over placebo, and potential for harm.
• Medicines are not the mainstay of treatment for non-specific low back pain.
• Paracetamol is no more effective than placebo for non-specific low back pain.
• NSAIDs have some evidence of benefit. The clinical significance of this is small (6-point pain reduction on a 100 point scale compared to placebo).
• No RCTs assess opioids for acute non-specific low back pain, so should be used with caution.
• There is evidence that muscle relaxants may be effective in acute non-specific low back pain. However, many of these are not available in Australia.

The guidelines provide information on assessment of radicular syndrome and alerting features of serious spinal pathologies. They reiterate that a precise anatomical diagnosis is usually not necessary, or possible. However, a physical examination is still important to identify alerting features of serious pathologies and neurological signs, and to understand the patient's spinal movement patterns and limitations.

Radiological findings are poorly correlated with symptoms in patients with low back pain.

Risk factors for poor prognosis include a high level of pain and disability at presentation, leg pain, older age, poor general health, psychosocial factors (eg mental stress, anxiety, depression), and reduced cognition. The guidelines recommend the use of the STarT Back tool or Örebro Musculoskeletal Pain Questionnaire.

Management includes graded exercise and non-pharmacological management, including thermotherapy and massage.

The following passive physical treatments are not recommended for non-specific low back pain because evidence does not support a benefit: acupuncture, spinal manipulative therapy, lumbar supports, transcutaneous electrical nerve stimulation (TENS), laser therapy, traction, electromyographic biofeedback, therapeutic ultrasound or short-wave diathermy.

• History and examination as part of a diagnosis of exclusion
• Using risk stratification tools to determine the amount and type of treatment patients need
• All patients receive education
• Encouraging physical therapy
• Simple analgesic medicines only if required
• Judicious use of complex medicines
• A cognitive behavioural approach
• Only image patients with suspected serious pathology
• Review each patient's progress at 2, 6 and 12 weeks
• Timely referral and access to specialist services.

The 2016 UK National Institute for Health and Care Excellence (NICE) provides evidence-based information on the management of low back pain.

The guideline provides the evidence about the limited role of imaging only if it changes management, as well as the STarT Back Screening tool and the Örebro Musculoskeletal Pain Screening Questionnaire.

The guideline moves away from the traditional analgesic ladder and advises only two options: oral NSAIDs at the lowest effective dose for the shortest time possible and the use of a weak opioid (with or without paracetamol) if the patient does not tolerate or their pain does not respond to an NSAID.

The guideline also provides evidence on exercise and non-pharmacological management like manual therapies.

Belgian guidelines 2017 provide a recent review of risk assessment tools and risk stratification.

These guidelines provide a recent review of the evidence on risk assessment tools, and supports the use of these tools in the management of acute non-specific low back pain.

This guideline by the American College of Physicians presents the evidence and clinical recommendations for non-invasive treatment of low back pain.

It provides a succinct summary of evidence for non-pharmacological therapies.

These RANZCR education modules provide information on appropriate imaging referrals for acute low back pain.

There is a an imaging decision flow chart and detailed information on ruling out serious spinal pathology.

• Focussed history and physical examination for diagnostic triage, including an assessment of psychosocial factors.
• Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific low back pain.
• Perform diagnostic imaging for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected.
• Provide patients with evidence-based information on low back pain, advise patients to remain active, and provide information about effective self-care options.
• Consider the use of medications with proven benefits in conjunction with back care information and self-care.
• Consider the addition of non-pharmacological therapy with proven benefits, eg, for acute low back pain, spinal manipulation.