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Back pain made simple: An approach based on principles and evidence

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ABSTRACTIn cases of low back pain, the goal is to detect serious problems and to prevent the pain from becoming chronic by promptly detecting risk factors. The authors lay out a simple, evidence-based approach to low back pain.

KEY POINTS

  • Most back pain has no recognizable cause and is therefore termed “mechanical” or “musculoskeletal.” Underlying systemic disease is rare.
  • Most episodes of back pain are not preventable.
  • Confounding psychosocial issues are common.
  • A careful, informed history and physical examination are invaluable; diagnostic studies, however sophisticated, are never a substitute. Defer them for specific indications.
  • Refer patients only if they have underlying disease or progressive neurologic dysfunction or do not respond to conservative management.
  • Encouragement of activity is benign and perhaps salutary for back pain and is desirable for general physical and mental health. Evidence to support bed rest is scant.
  • Few if any treatments have been proven effective for low back pain.


 

References

Low back pain should be understood as a remittent, intermittent predicament of life. Its cause is indeterminate, but its course is predictable. Its link to work-related injury is tenuous and confounded by psychosocial issues, including workers’ compensation. It challenges function, compromises performance, and calls for empathy and understanding.1

In this brief paper, we offer a simple approach to one of the most common human afflictions, based on principles and evidence.

WHY IS BACK PAIN IMPORTANT?

Low back pain is common and affects people of all ages. It is second only to the common cold as the most common affliction of mankind, and it is among the leading complaints bringing patients to physicians’ offices. Its lifetime prevalence exceeds 70% in most industrialized countries, with an annual incidence of 15% to 20% in the United States.

Its social and economic impact is substantial. It is the most frequent cause of disability for people under age 45. In 2005, the mean age- and sex-adjusted medical expenditure among respondents with spine problems was $6,096 vs $3,516 in those without spine problems, and it had increased by 65% (adjusted for inflation) from 1997 to 2005.2

WHAT ARE THE GOALS AND PRINCIPLES OF MANAGING LOW BACK PAIN?

The goals of management for patients with low back pain are to:

  • Decrease the pain
  • Restore mobility
  • Hasten recovery so the patient can resume normal daily activities as soon as possible
  • Prevent development of a chronic recurrent condition: low back pain is considered acute when it persists for less than 6 weeks, subacute between 6 weeks and 3 months, and chronic when it lasts longer than 3 months
  • Restore and preserve physical and financial independence and comfort.

Principles of management

  • Most back pain has no recognizable cause and is therefore termed “mechanical” or “musculoskeletal.”
  • Underlying systemic disease is rare.
  • Most episodes of back pain are unpreventable.
  • Confounding psychosocial issues are often contributory, important, and relevant.
  • A careful, informed history and physical examination are invaluable; diagnostic studies, however technologically sophisticated, are never a substitute.
  • Defer diagnostic studies for specific indications.
  • Refer patients only if they have underlying disease or progressive neurologic dysfunction, or if they do not respond to conservative management.
  • Encouragement of activity is benign and perhaps salutary for back pain and is desirable for general physical and mental health; there is only scant evidence to support bed rest.3
  • Few if any treatments have been proven effective for low back pain.
  • Talking to the patient and explaining the issues involved are critical to successful management.4

INITIAL CONSIDERATIONS WHEN EVALUATING A PATIENT

When encountering a patient with back pain, the initial consideration is whether the symptoms are regional—ie, local, mechanical, and musculoskeletal—or if they reflect a systemic disease. It is also important to look for evidence of social or psychological distress that may amplify, prolong, or confound the pain or the patient’s perception of it.

What are the clues to a systemic process?

Red flags of a serious, systemic cause of low back pain are presented in Table 1. Other symptoms that may indicate a systemic cause include night pain (also seen with disk disease and neurocompression), pain with recumbency (malignancy), back pain with morning stiffness lasting for more than 1 hour (spondyloarthropathy), cauda equina syndrome (overflow incontinence, saddle anesthesia, and paraparesis), and other systemic and constitutional symptoms.

Does the patient have a regional low back syndrome?

Regional low back syndromes account for 90% of the causes of low back pain. They are usually mechanical in origin.

Regional back pain is due to overuse of a normal mechanical structure (muscle strain, “lumbago”) or is secondary to trauma, deformity, or degeneration of an anatomical structure (herniated nucleus pulposus, fracture, and spondyloarthropathy, including facet joint arthritis). Chronic regional back syndromes include osteoarthritis of the spine (ie, spondylosis), spinal stenosis, and facet joint arthropathy.

Characteristically, mechanical disorders are exacerbated by certain physical activities, such as lifting, and are relieved by others, such as assuming a supine position.

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