Nonspecific low back pain: Evaluation and treatment tips

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Applied Evidence

Nonspecific low back pain: Evaluation and treatment tips

J Fam Pract. 2010 August;59(8):445-448

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References

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

2. Di Iorio D, Henley E, Doughty A. A survey of primary care physician practice patterns and adherence to acute low back problem guidelines. Arch Fam Med. 2000;9:1015-1021.

3. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463-472.

4. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain. JAMA. 2003;289:2810-2818.

5. Jarvik JG, Hollingworth W, Heagerty P, et al. The longitudinal assessment of imaging and disability of the back (LAIDBack) study. Spine. 2001;26:1158-1166.

6. Abenhaim L, Rossignol M, Gobeille D, et al. The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries. Spine. 1995;20:791-795.

7. Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med. 2001;51:124-135.

8. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists? Med Care. 2007;45:973-980.

9. Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.

10. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

11. Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290-302.

12. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine. 2009;34:1218-1226.

13. Finestone AS, Raveh A, Mirovsky Y, et al. Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine. 2009;34:1600-1603.

14. Kent P, Keating J. Do primary-care clinicians think that nonspecific low back pain is one condition? Spine. 2004;29:1022-1031.

15. Brennan GP, Fritz JM, Hunter SJ, et al. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine. 2006;31:623-631.

FAST TRACK

Labeling nonspecific low back pain with a specific diagnosis can make the pain seem more serious to patients than it is.

It’s time to treat: Tell patients to remain active

Practice guidelines for nonspecific LBP recommend providing patients with evidence-based education that emphasizes the favorable course of this condition and that encourages them to remain active.¹ This recommendation was assessed retrospectively in a study of nearly 1200 patients receiving physical therapy for acute LBP. The authors found that adherence to the recommendation for activity and exercise yielded significant reductions in disability and pain, and resulted in significantly fewer visits and lower charges.⁸

For acute cases of nonspecific LBP, good evidence supports the short-term effectiveness of acetaminophen and nonsteroidal anti-inflammatory drugs, as well as skeletal muscle relaxants.^1,9 For chronic cases, good evidence exists for prescribing tricyclic antidepressants.⁹

Nonpharmacologic interventions include, in acute cases, active care, spinal manipulation, and superficial heat (eg, hot packs). For subacute and chronic cases, think about intensive interdisciplinary rehabilitation interventions—therapeutic exercise, soft-tissue manual techniques, acupuncture, movement re-education techniques, spinal manipulation, cognitive-behavioral therapy, or progressive relaxation.^1,10

Further customize your Tx approach

FAST TRACK

Promising evidence suggests that subgrouping patients with nonspecific low back pain can improve outcomes.

While recent data suggest that some front-line physicians who treat patients with LBP may have insufficient knowledge to do so^11-13 (see “Are we out of step?” ), there are promising developments, as well. Many primary care clinicians and researchers believe that nonspecific LBP resembles a heterogeneous condition and that intervention is more effective when treatment is matched to the patient’s history and examination findings.^14,15 In a survey of more than 600 primary care clinicians from multiple disciplines, including physical therapy, chiropractic, and medicine, 93% of the participants reported that they treat nonspecific LBP cases differently, depending on signs and symptoms, with 74% believing there are recognizable subgroups to guide management.¹⁴

An example of subgrouping patients with nonspecific LBP is the idea of treatment-based classification, which evidence has found to be reliable, effective, and cost-efficient for patients with LBP (TABLE).¹¹ In an RCT, Brennan and colleagues¹⁵ examined 123 patients with acute LBP (ie, back pain lasting <90 days) referred to a physical therapist for treatment. Patients were examined and then classified into 1 of 3 subgroups according to the type of treatment expected to work best for them: manipulation, stabilization, or specific exercise. Each patient was then randomly assigned to receive 1 of the 3 treatments. Post-treatment analysis compared outcomes between patients who received treatment matched to their classification and those whose treatment did not match their classification.

At 4 weeks, the matched-treatment group had significantly greater reductions in disability compared with the unmatched-treatment group; this difference was still evident at 1 year. The authors agreed that LBP should not be thought of as a homogenous condition, and found that outcomes can be improved with subgrouping to guide intervention selection.¹⁵

Are we out of step?

Recent data suggest that frontline clinicians who typically treat patients with low back pain (LBP) may have insufficient knowledge to do so.^11,12 Using an observational design, Buchbinder et al¹² surveyed nearly 4000 general practitioners, with and without special interest in LBP, to assess their knowledge in managing acute LBP and their attitudes toward patients with LBP.

Using a 5-point Likert scale ranging from “strongly agree” to “strongly disagree,” the investigators asked physicians questions related to such topics as bed rest, work, imaging, physical activity, interventions by physicians or other healthcare providers, patient expectations, chronic LBP, patient motivation, and usefulness and utilization of practice guidelines. Interestingly, physicians with a special interest in treating LBP actually had poorer management beliefs (ie, not in accord with best available evidence) than those who did not have such an interest.¹

A similar study found that both family practitioners and orthopedists were deficient in knowledge for treating patients with nonspecific LBP; orthopedists were less informed than family practitioners.¹³

TABLE
Matching physical therapy to low back pain attributes can improve outcomes

Treatment recommendation	History and examination findings
Manipulation	No symptoms distal to the knee Recent onset of symptoms (<16 days) Low fear-avoidance Hypomobility of the lumbar spine Good hip internal rotation ROM (>35° for at least 1 hip)
Stabilization/motor control	Younger age (<40 y) Greater general flexibility (postpartum, excessive hamstring length) Aberrant movements, Gower’s sign during lumbar flexion/ extension ROM Decreased pain during provocation via spinal/core musculature activation (positive prone instability test)
Specific exercise
Extension	Symptoms distal to the buttock Symptoms centralize with lumbar extension Symptoms peripheralize with lumbar flexion Directional preference for extension
Flexion	Older age (>50 y) Directional preference for flexion Imaging evidence of lumbar spinal stenosis
Lateral shift	Visible frontal plane deviation of the shoulders relative to the pelvis Directional preference for lateral translation movements of the pelvis
Traction*	Signs and symptoms of nerve root compression No specific exercise/directional preference centralizes symptoms
ROM, range of motion.
*This fourth category was not included in the original study; patient selection criteria were developed at a later date.
Source: Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007;37:290-302.¹¹ Adapted with permission from the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association and The Journal of Orthopaedic and Sports Physical Therapy.