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.
SeminarNon-specific low back pain
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
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