Low back pain. It’s a story told and re-told by generations of scholars, clinicians, students, and skeptics, yet the most perplexing and widely misunderstood. Maybe because we often try to understand it all at once with absolute certainty. Without realizing that not even experts have understood it any better than the average ‘updated’ clinician (in a broader sense).
In this blog, we’ll attempt to simplify the introduction to low back pain.
Firstly by discussing (only) acute low back pain and its meanings.
Then, some of the relevant information about acute LBP and its management and clinical context.
But before we move ahead, let’s establish a few things.
Acute low back pain, Acute LPB, ALBP, and LBP might be used interchangeably within this article.
When we mention ‘management’, we mean treatment modalities, clinical interaction, and decision-making within the scope of physiotherapy (or Non-surgical management). (Only a select few times getting into pharmacological management)
When we mention ‘clinical context’, we mean any and everything related to a person’s clinical environment, clinical interaction, decision-making, beliefs, actions, etc. (see figure below)
Let’s dive into Low back pain.
What is Acute Low Back Pain? If we were to break down, Low back pain would be from anywhere below the 12th rib or 12th thoracic vertebrae to the sacrum.
It could be because of any other structure that is contained or relates to this region,
The vertebrae (spine),
The spinal nerves or roots (or cord),
The ligaments of the spine (structures that join bones to bone),
The joints of the spine (Zygapophyseal joints or the facts)
The sacrum and pelvis (sacroiliac joints and pubic symphysis)
The muscles attached to this region (paraspinal muscles, abdominal muscles)
The organs (abdominal organs, retroperitoneal organs, pelvic organs)
Cancer, Infection, Arthritis, Inflammation, Metabolic Syndrome, Autoimmunity or maybe pain referred from distant structures.
And if the pain in this region is present for 4-6 weeks because of any of the above reasons it is called ‘ACUTE’ Low Back Pain (probably 12 if we stretch into the subacute category as well)
Simple enough? So we think.
An especially common flavor (≥90% cases of LBP) of LBP comes in the form of ‘Non-specific LBP’. LBP is said to be ‘Non-Specific’ when after careful initial deliberation and due diligence we fail to recognize a specific causal factor or when there is an absence of a recognizable specific and worrisome pathology (red-flag: infection, tumor, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome). (Ref, Ref)
Still, one might wonder why with all these advancements in medical technology and diagnostic modalities, are we not able to ascertain the cause of LBP.
The answer is simple, it is precisely because of ‘all these advancements in medical technology and diagnostic modalities’ that we can conduct good quality studies that show us that many of the factors we once considered ‘causative’ are just ‘correlated well’ with the condition and does not explain its presence or clinical picture.
Let’s take disc pathology (and MRI findings of which) for an example, once believed to be ‘the’ cause (and predictor) of low back pain; is a moderate correlate at best as seen in research done over the past few decades. ( Ref, Ref, Ref, Ref, Ref, Ref)
This doesn’t mean that we discount all the known causes of LBP and just stick with Non-specific labels and a very ‘shot-in-the-dark’ approach to diagnosis and treatment.
Clinical inquiry before using non-specific labels is and needs to be thorough.
With the ‘WHATs’ clear let's keep it concise and move on straight to the tidbits.
1- LBP might not seem that troublesome, but it is.
On a global scale, LBP is consistently one of the top 10 reasons for average time lived with disability and lost working hours, not only among the expected elderly and old age groups but the young and adult age groups too. '
And it has only risen in the ranks in the last couple of decades, indicating the serious and prolonged impact this seemingly non-threatening condition can have. (Ref)
2- Natural History of Acute LBP is confusing, to say the least.
Natural history is the natural course a condition takes over time regardless of intervention and treatments.
The same for acute LBP is quite jumbled, it is often said that acute low back pain symptoms and disability in 60-80% (sometimes ~90%) rapidly decrease in the first few weeks and months, and only a handful (~10-15%) of people develop chronic pain. Often it is episodic and recurring regardless of treatment. However, in patients with NSLBP, it is quite difficult to say why the pain becomes chronic in some and why not in others. Experts have been studying and debating various explanations but none is conclusive enough to explain such a complex and multifactorial process.
Secondly, the role of any treatment (conservative or otherwise) is questionable when it comes to LBP (considering some people develop chronic pain regardless). That is regardless of the treatment chosen in the primary care the course of LBP remains relatively unchanged.
The prognosis, in the end, is quite favorable for most (besides those who develop chronic pain), symptoms often decline readily in the first 6 weeks to a couple of months with a few having some pain or disability at 1 year.
3- Expectations play a huge role in the outcome of LBP.
The most common expectation a patient has besides the hope that a clinician will listen to them without interruption is the usual imaging referral (often an X-ray), rarely do patients expect actual clinical examination or clinical diagnosis to be on par with the ol’ XtremeRay (X-ray of course), and it’s not their fault. Through the years biomedical approach has conditioned the masses to expect a definite structural cause identified by a clinician and if not question the credibility of their clinical skills, but we have established that this isn’t the case for LBP which is often non-specific, it creates a divide between expectations, informed clinical choices and outcomes.
Often there’s an obvious conundrum a person faces in the presence of pain and disability, it’s the weight of different opinions, for example, A person experiencing pain would get a few examples from their family where a missed MRI led to debilitating outcomes for someone’s pain, leading to expectations of imaging, further a few examples by friends where they have been advised total bed rest and no physical activity (contradictory to any sensible guideline-based advice), creating a distrusting divide between clinician’s advice to remain active with some additional physical activity when the discomfort subsides and their personal belief ‘rest is best’.Such differences are not only fueled by patient beliefs and expectations but also by a clinician's willingness to stay updated with current practice and evolve with evidence. (Ref)
4- NSAIDS can be used for initial symptomatic management, but Muscle relaxants…
Talking about immediate symptomatic management, i.e. pain relief, we often consider the most commonly prescribed classes of drugs the NSAIDS (Disprin, Nurofen, Voltaren, Celebrex, etc.) or the Muscle Relaxants (Skelebenz, Myosone, Flexabenz, Myotop, etc.). As far as immediate-term(≤ 1 week) management is concerned, “the most efficacious interventions … were heat wrap, manual therapy, exercise, NSAIDS and opioids” (Ref.)
Considering opioids and the whole scientific debate around their non-judicious usage it is safe to assume NSAIDS best pharmacological choice for short-term management.
Muscle relaxants on the other hand are quite puzzling, several guidelines recommend using them, and other few don’t recommend their use, some don’t even consider them as first-line symptomatic management. So, to be on the safer side muscle relaxants must be considered as a secondary option with caution, as: “non-benzodiazepine antispasmodics(muscle relaxant) might reduce pain intensity at two weeks or less for acute low back pain, the effect is unlikely to be considered clinically important. In addition, non-benzodiazepine antispasmodics could increase the risk of an adverse event being reported (commonly, dizziness, drowsiness, headache, and nausea)” (Ref.)
5- What physical activity can worsen back pain?
Consider this, you have back pain(unfortunately but surely once) and you don’t know what will make it better or worse because everything hurts, moving anywhere, anyhow is problematic and relief is a thing of dreams. Suddenly pain starts getting better gradually and now you are even more confused about how it’ll recur and what would that unfateful position be.
Will it be heavy lifting? Lifting repeatedly? Running? Your morning jogs? Weekend tennis or football sessions? Physical therapy? Standing at work?... Nope, it’s likely going to be Sitting (for >6 hours) uninterrupted, “But sitting is safe! considerably safer than lifting amirite?”, turns out it’s not safer and it’s not the danger you expect either if you smartly rest and move within a long period of sitting time you can avoid discomfort. It could be especially problematic if you have experienced a stressful event (it could just be the back pain itself) or have some depressive symptoms because of the pain (or otherwise) because these could add to the chances of you having a flare-up. (Ref.)
Bonus for clinicians- Overdiagnosis and Overtreatment.
Understandably, clinicians have to meet certain expectations of patients to establish a relationship with
them. But it is also imperative that clinicians uphold a sense of responsibility in guiding patients towards what’s best for them and away from all the dogma and misinformation that is already present in society.
The two most important bulls (metaphorical) we have to tame in this context are overdiagnosis and overtreatment.
Firstly Overdiagnosis, it is easy to assume advanced imaging means more certainty, but in the case of LBP it's quite the opposite, although specific pathologies are quite serious and warrant urgent imaging to rule out, they are also very uncommon.
Thus, using MRIs and such aren’t often recommended in primary care (for acute LBP and NS Chronic LBP as well) and surprisingly early MRI in people with acute LBP without any red flags (suspected serious pathology) can contribute to increased length of disability experienced by the patient.
So, if you are a clinician try to educate your patients about it and if they already have an advanced imaging report with them, try to explain the extent and nature of the findings and how they relate to (or not) the cause of back pain.
Secondly, Overtreatment. Although it involves the more ‘interventional’ experts’ opinions to rationalize, evidence suggests that higher rates of prescription of opioid analgesics, and suggestions of interventions like spinal anesthesia or spinal surgery even likely aren’t improving the outcomes for acute or chronic low back pain (especially for acute low back pain, it’s like using a cannon to subdue a naughty child.).
Not just demeaning self-efficacy and self-management of back pain, it fuels and keeps alive the misinformation around such a prevalent healthcare problem. Overtreatment also contributes to a lot of unnecessary medical expenditure, something that can be easily prevented by judicious advisory and prescription.
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Disclaimer: This blog is for educational purposes only.
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