From the Guidelines
Low back pain is a complex condition that requires a multifaceted approach to diagnosis and treatment, with a focus on remaining active, using over-the-counter analgesics, and applying heat for acute non-specific cases, as recommended by the most recent guidelines 1.
Definition and Etiology
Low back pain is discomfort occurring in the lumbar spine region, between the lower ribs and gluteal folds, affecting approximately 80% of adults at some point in their lives and is a leading cause of disability worldwide. The etiology is diverse, with most cases being mechanical or non-specific (about 90%), caused by strain on muscles, ligaments, or intervertebral discs. Other causes include degenerative disc disease, facet joint arthropathy, spinal stenosis, herniated discs, vertebral compression fractures, and less commonly, inflammatory conditions (ankylosing spondylitis), infections (discitis, osteomyelitis), or malignancy.
Clinical Features and Diagnosis
Clinical features typically include localized pain that may radiate to the buttocks or legs, muscle spasms, and limited range of motion. Red flags suggesting serious pathology include fever, unexplained weight loss, history of cancer, trauma, age over 50, neurological deficits, or bowel/bladder dysfunction. Diagnosis primarily relies on a thorough history and physical examination, with imaging reserved for cases with red flags or persistent symptoms, as outlined in the updated guidelines from the American College of Radiology 1.
Treatment
Initial treatment for acute non-specific low back pain should include remaining active within pain limits, over-the-counter analgesics like acetaminophen (500-1000mg every 6 hours) or NSAIDs such as ibuprofen (400-800mg three times daily with food) for 1-2 weeks, and application of heat, as supported by the American College of Physicians and the American Pain Society 2. Muscle relaxants like cyclobenzaprine (5-10mg three times daily) may help with spasms. Physical therapy focusing on core strengthening and flexibility is beneficial for subacute and chronic pain. For persistent pain, consider referral to specialists for interventional procedures like epidural steroid injections or, in select cases, surgical evaluation.
Prevention
Prevention strategies include maintaining proper posture, regular exercise, weight management, and ergonomic workplace modifications. It is essential to assess psychosocial risk factors when obtaining patient history, as they are strong predictors of patients who are predisposed to developing chronic disabling LBP problems, as noted in the updated guidelines 1.
From the Research
Definition of Low Back Pain
- Low back pain is defined as pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain 3
- It can be classified into non-specific low back pain, which is not attributed to recognizable, known specific pathology, and specific low back pain, which has a known pathomorphological cause 3
Etiology of Low Back Pain
- The etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery 4
- Chronic low back pain can be influenced by psychological factors, such as stress, depression, and/or anxiety 5
- In most cases, low back pain can be attributed to a specific pain generator, with its own characteristics and different therapeutic opportunities 5
Clinical Features of Low Back Pain
- Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain 4
- The prevalence of low back pain in the general US adult population is 10-30% annually, and the lifetime prevalence of US adults is as high as 65-80% 4
- Chronic low back pain occurs in about 13% of U.S. adults and can have a significant impact on functional capacity and occupational activities 6
Diagnosis of Low Back Pain
- Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology 4
- A thorough history taking and clinical examination are sufficient for most patients with low back pain 3
- Extended diagnostic analysis is needed in cases of nerve root pain/radicular pain and serious spinal pathology, respectively, after identification of red flags 3
Treatment of Low Back Pain
- A multidisciplinary, logical approach to treatment is most effective for chronic back pain patients and can include multimodal medical, psychological, physical, and interventional approaches 4
- Nonpharmacologic treatment is first-line management and may include therapies such as counseling, exercise therapy, spinal manipulation, massage, heat, dry needling, acupuncture, transcutaneous electrical nerve stimulation, and physical therapy 6
- Pharmacologic interventions are second-line treatment, with nonsteroidal anti-inflammatory drugs being the initial medication of choice 6
- Adding acetaminophen to ibuprofen does not improve outcomes within 1 week for patients with acute, nontraumatic, nonradicular low back pain 7