Investigating and Managing Low Back Pain

More patients consult general practitioners about low back pain than any other musculoskeletal condition (ACSQHC 2019).

About 16% of Australians (4 million) are currently affected by low back pain, and about 70 to 90% of people are expected to experience it at some point during their lifetime (AIHW 2020; ACSQHC 2019).

Back pain is a leading cause of disability that may adversely affect all aspects of daily functioning (Mayo Clinic 2020; Better Health Channel 2019). Between 10 and 40% of adults with low back pain are estimated to experience persistent and disabling symptoms (Wheeler, Karran & Harvie 2018).

Despite the prevalence of low back pain in the community, research suggests that 28% of healthcare for low back pain in Australia does not follow clinical guidelines. Often, the mismanagement of low back pain involves unnecessary treatments that do more harm than good (Wheeler, Karran & Harvie 2018).

Effectively managing low back pain is therefore essential in ensuring patients are able to enjoy a high quality of life.

What is Low Back Pain?

The spine is comprised of bones known as vertebrae, which stack on top of one another to form a column in the shape of an ‘S’ (Better Health Channel 2019).

Low back pain affects the lumbar spine, which comprises the vertebrae L1, L2, L3, L4 and L5. The lumbar spine carries a significant amount of weight from the upper body (NINDS 2020).

Most low back pain is acute, lasting between a few days to a few weeks. However, in some cases it may become chronic, persisting for 12 weeks or more even after the initial cause has been treated (NINDS 2020).

Causes of Low Back Pain

While there are many potential causes of low back pain, it usually originates from the muscles, ligaments and joints rather than being caused by damage to the spine itself (Better Health Channel 2019).

Occasionally, low back pain is caused by:

• Medical conditions such as sciatica, a slipped disc, ankylosing spondylitis, spondylolisthesis, arthritis, whiplash, osteoporosis or a muscle or ligament strain
• Serious conditions such as a broken bone in the spine, an infection or cancer.

(Healthdirect 2019)

However, only about 8 to 15% of low back pain has a particular pathoanatomical cause. Most low back pain is instead classified as ‘non-specific’ (Wheeler, Karran & Harvie 2018).

The most common causes of low back pain are ‘triggers’ such as:

• Manual handling
• Bending awkwardly
• Lifting, carrying, pushing or pulling objects incorrectly
• Repetitive actions (bending, lifting or sitting)
• Bad posture (slouching or being hunched over)
• Standing or bending down for a prolonged period of time
• Twisting
• Overstretching
• Driving for a prolonged period of time
• Overusing muscles (e.g. due to sport or repetitive movements)
• Exposure to a whole body vibration
• Muscle tension from stress
• Lack of physical activity.

(Healthdirect 2019; Better Health Channel 2019)

Risk Factors for Low Back Pain

• Being overweight (as this puts more pressure on the spine)
• Lack of exercise
• Smoking (which may damage tissues in the back or indicate an unhealthy lifestyle overall)
• Pregnancy (as this puts more pressure on the spine)
• Prolonged use of medicines that weaken bones, such as corticosteroids
• Stress (which may cause muscle tension in the back)
• Depression (this may cause a cycle wherein back pain causes feelings of depression, leading the patient to gain weight, which then further exacerbates pain and continues the cycle).

(Healthdirect 2019)

Symptoms of Low Back Pain

Low back pain varies depending on the cause. Onset may be sudden or gradual, and symptoms may range from mild to debilitating. Furthermore, the pain may be dull or sharp in intensity (Peloza 2017; NINDS 2020).

Symptoms may include:

• Dull, achy pain in the low back
• Stinging, burning pain that travels from the low back to the thighs, lower legs or feet and may include numbness or tingling (sciatica)
• Tightness and muscle spasms in the low back, pelvis or hips
• Pain that is exacerbated by standing or sitting
• Difficulty standing up straight, walking, or getting up from a seated position
• Psychological symptoms such as distress, anxiety and mood issues if the pain is prolonged.

(Peloza 2017; Better Health Channel 2019)

The following symptoms may indicate a serious underlying problem:

• Incontinence
• Numbness near the rectum or genitals
• Numbness, pins and needles or weakness in the legs
• Unsteadiness
• Unexplained weight loss
• Night sweats
• Chills
• Fever
• Nausea and vomiting
• Unrelenting pain at night.

(SA Health 2020)

Anyone experiencing any of the above symptoms is encouraged to seek medical advice immediately (SA Health 2020).

Investigating Low Back Pain

A major issue regarding the care of patients with low back pain is the unnecessary use of spinal imaging to assist in diagnosis or rule out a serious medical condition (Wheeler, Karran & Harvie 2018).

While routine spinal imaging might seem like an effective way to reassure patients, it has actually been found to decrease patients’ sense of wellbeing and cause unnecessary anxiety. Patients may become concerned about age-related degenerative changes that are found through imaging, causing them to be fearful or avoidant. These behaviours, in turn, may increase the patient’s disability (Wheeler, Karran & Harvie 2018).

Furthermore, unless ‘red flag’ signs or symptoms are present, a serious medical problem is unlikely to be present. In many cases, patients are referred for spinal imaging when there is no evidence it will benefit them (Wheeler, Karran & Harvie 2018).

Patients who receive high-quality education without unnecessary imaging are more likely to have a positive outcome (Wheeler, Karran & Harvie 2018).

Managing Low Back Pain

International guidelines for the clinical care of low back pain are generally consistent (Wheeler, Karran & Harvie 2018). The general consensus regarding care is that:

• First-step care should comprise encouraging the patient to stay active, providing high-quality education and reassuring the patient that there is no serious disease present.
• Second-step care for acute low back pain should comprise at least one of the following: physical therapy, psychological therapy and complementary therapy.
• Second-step care for chronic low back pain should comprise physical therapy, psychological therapy and/or complementary therapy.
• Third-step care for chronic low back pain should comprise interprofessional pain management.
• Low back pain should preferably be treated without the use of medicines. If pain medicine is required, however, first-line treatment should be a nonsteroidal anti-inflammatory medicine at the lowest effective dose for the shortest time possible. Note: This should only be discussed with the patient if you are a healthcare professional who is qualified to do so.
• Opioids should be avoided as a treatment option where possible.
• Patients with chronic, non-specific low back pain should not be offered injectable steroid medicines.
• Routine spinal imaging should be avoided unless ‘red flag’ signs or symptoms are present.

(Traeger et al. 2019)

Overall, evidence suggests that unnecessary care (spinal imaging, spinal injections, hospitalisation and surgery) adversely affects patients in most cases (Traeger et al. 2019).

Therefore, when investigating and managing low back pain, it is important to:

• Communicate with the patient in a positive way
• Encourage the patient to return to normal activity as soon as possible, as most low back pain improves after four to six weeks
• If imaging is required, refer to evidence-based guidelines when educating the patient
• Remember that radiological abnormalities are common and are not necessarily related to the pain
• If imaging finds age-related changes, explain these to the patient using reassuring, non-threatening language, and provide epidemiological context
• Refer to other healthcare professionals if needed.

The Low Back Pain Clinical Care Standard

The Australia Commission on Safety and Quality in Health Care is currently in the process of developing a new Low Back Pain Clinical Care Standard. This standard will aim to support evidence-based management and reduce the use of unnecessary, ineffective and harmful treatments (ACSQHC 2019).

This section will be updated when more information about the new standard becomes available.

Additional Resources

• ACSQHC, Low Back Pain Clinical Care Standard

References

• Australian Commission on Safety and Quality in Healthcare 2019, Low Back Pain Clinical Care Standard, ACSQHC, viewed 8 February 2021, https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standard
• Australian Institute of Health and Welfare 2020, Back Problems, AIHW, viewed 8 February 2021, https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/what-are-back-problems
• Better Health Channel 2019, Back Pain, Better Health Channel, viewed 8 February 2021, https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/Back-pain
• Healthdirect 2019, What Causes Back Pain?, Healthdirect, viewed 8 February 2021, https://www.healthdirect.gov.au/what-causes-back-pain
• Mayo Clinic 2020, Back Pain, Mayo Clinic, viewed 8 February 2021, https://www.mayoclinic.org/diseases-conditions/back-pain/symptoms-causes/syc-20369906
• National Institute of Neurological Disorders and Stroke 2020, Low Back Pain Fact Sheet, National Institutes of Health, viewed 8 February 2021, https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
• Peloza, J 2017, Lower Back Pain Symptoms, Diagnosis, and Treatment, Spine-Health, viewed 8 February 2021, https://www.spine-health.com/conditions/lower-back-pain/lower-back-pain-symptoms-diagnosis-and-treatment
• SA Health 2020, Low Back Pain, SA Health, viewed 8 February 2021, https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/conditions/pain/low+back+pain/low+back+pain
• Traeger, A C, Buchbinder, R, Elshaug, A G, Croft, P R & Maher, C G 2019, ‘Care for Low Back Pain: Can Health Systems Deliver?’, Bulletin of the World Health Organization, vol. 97, no. 423-433, viewed 8 February 2021, https://www.who.int/bulletin/volumes/97/6/18-226050.pdf
• Wheeler, L P, Karran, E L & Harvie, D S 2018, ‘Low Back Pain: Can we Mitigate the Inadvertent Psycho-behavioural Harms of Spinal Imaging?’, Australian Journal of General Practice, vol. 47, no. 9, viewed 8 February 2021, https://www1.racgp.org.au/ajgp/2018/september/low-back-pain