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There are different definitions of low back pain (LBP). According to the European Guidelines for prevention of low back pain, low back pain is defined as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain.”[1] Another definition, according to S.Kinkade, which resembles the European guidelines is that low back pain is “pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs”.[2] Simply put, LBP is a common disorder involving the muscles, nerves, and bones of the back.[3] Pain can vary from a dull constant ache to a sudden sharp feeling.[3]

Low back pain is usually categorized in 3 subtypes: acute, sub-acute and chronic low back pain. This subdivision is based on the duration of the back pain. Acute low back pain is an episode of low back pain for less than 6 weeks, sub-acute low back pain between 6 and 12 weeks and chronic low back pain for 12 weeks or more.[2]

In most episodes of low back pain, a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as muscle or joint strain.[4] If the pain does not go away with conservative treatment or if it is accompanied by “red flags” such as unexplained weight loss, fever, or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem

Causes

LBP is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness.[5] The majority of LBP does not have a clear cause[1] but is believed to be the result of non-serious muscle or skeletal issues such as sprains or strains.[6] Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture and poor sleeping position may also contribute to low back pain.[5] A full list of possible causes includes many less common conditions.[5] Physical causes may include osteoarthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an infection or tumor of the spine.[5]

Women may have acute low back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids.[5] Nearly half of all pregnant women report pain in the lower back or sacral area during pregnancy, due to changes in their posture and centre of gravity causing muscle and ligament strain.[5]

Low back pain can be broadly classified into four main categories:

  • Musculoskeletal – mechanical (including muscle strain, muscle spasm, or osteoarthritis); herniated nucleus pulposus, herniated disk; spinal stenosis; or compression fracture
  • Inflammatory – HLA-B27 associated arthritis including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease
  • Malignancy – bone metastasis from lung, breast, prostate, thyroid, among others
  • Infectious – osteomyelitis; abscess

Signs and symptoms

In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as sciatica) may be present. The first experience of acute low back pain is typically between the ages of 20 and 40. This is often a person’s first reason to see a medical professional as an adult.[1] Recurrent episodes occur in more than half of people[5] with the repeated episodes being generally more painful than the first.[1]

Other problems may occur along with low back pain. Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep.[5] In addition, a majority of those with chronic low back pain show symptoms of depression [5] or anxiety.[5]

Classification

There are a number of ways to classify low back pain with no consensus that any one method is best.[5] There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, herniated discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebra), non-mechanical back pain (tumours, inflammatory conditions such as spondyloarthritis, and infections), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others).[5] Mechanical or musculoskeletal problems underlie most cases (around 90% or more),[5][6] and of those, most (around 75%) do not have a specific cause identified, but are thought to be due to muscle strain or injury to ligaments.[5][6] Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders.[6]

Low back pain may be classified based on the signs and symptoms. Diffuse pain that does not change in response to particular movements, and is localized to the lower back without radiating beyond the buttocks, is classified as nonspecific, the most common classification.[5] Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation), or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers is radicular, making up 7% of cases.[5] Pain that is accompanied by red flags such as trauma, fever, a history of cancer or significant muscle weakness may indicate a more serious underlying problem and is classified as needing urgent or specialized attention.[5]

The symptoms can also be classified by duration as acute, sub-chronic (also known as sub-acute), or chronic. The specific duration required to meet each of these is not universally agreed upon, but generally pain lasting less than six weeks is classified as acute, pain lasting six to twelve weeks is sub-chronic, and more than twelve weeks is chronic.[3]Management and prognosis may change based on the duration of symptoms.

Prevention

Exercise is very useful for preventing low back pain.[6] Exercise is also probably effective in preventing recurrences in those with pain that has lasted more than six weeks.[1][7] Medium-firm mattresses are more beneficial for chronic pain than firm mattresses.[8] There is little to no evidence that back belts are any more helpful in preventing low back pain than education about proper lifting techniques.[6][10] Shoe insoles do not help prevent low back pain.[6][5]

Management

Management of low back pain depends on which of the three general categories is the cause: mechanical problems, non-mechanical problems, or referred pain.[9] For acute pain that is causing only mild to moderate problems, the goals are to restore normal function, return the individual to work, and minimize pain. The condition is normally not serious, resolves without much being done, and recovery is helped by attempting to return to normal activities as soon as possible within the limits of pain.[3] Providing individuals with coping skills through reassurance of these facts is useful in speeding recovery.[1] For those with sub-chronic or chronic low back pain, multidisciplinary treatment programs may help.[52]Initial management with non–medication based treatments is recommended, with NSAIDs used if these are not sufficiently effective.[6]

Physiotherapy management

Exercise therapy is effective in decreasing pain and improving function for those with chronic low back pain.[9] It also reduces recurrence rates for as long as six months after the completion of program[12] and improves long-term function.[11]

Medications

The management of low back pain often includes medications for the duration that they are beneficial. With the first episode of low back pain the hope is a complete cure; however, if the problem becomes chronic, the goals may change to pain management and the recovery of as much function as possible. As pain medications are only somewhat effective, expectations regarding their benefit may differ from reality, and this can lead to decreased satisfaction.[13]

Surgery

Surgery may be useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control.[14] It may also be useful in those with spinal stenosis.[15] In the absence of these issues, there is no clear evidence of a benefit from surgery.[14]

References

  1. Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group. 2004: 1-53.
  2. Kinkade S. Evaluation and treatment of acute low back pain. Am Ac of Family Phys. 2007: 1182-1188.
  3. “Low Back Pain Fact Sheet”. National Institute of Neurological Disorders and Stroke. 3 November 2015. Archived from the original on 4 March 2016. Retrieved 3/7/2018.
  4. Low Back Pain Fact Sheet”. National Institute of Neurological Disorders and Stroke. 3 November 2015. Archived from the original on 4 March 2016. Retrieved 3/7/2018.
  5. https://en.wikipedia.org/wiki/Low_back_pain. Retrieved 3/7/2018.
  6.  Cohen SP, Argoff CE, Carragee EJ (2008). “Management of low back pain”. BMJ. 337: a2718. doi:10.1136/bmj.a2718. PMID 19103627.
  7. Borczuk, Pierre (July 2013). “An Evidence-Based Approach to the Evaluation and Treatment of Low Back Pin in the Emergency Department”. Emergency Medicine Practice. 15 (7). Archived from the original on 14 August 2013.
  8. Low Back Pain Fact Sheet”. National Institute of Neurological Disorders and Stroke. National Institute of Health. Archived from the original on 19 July 2013. Retrieved 3/7/2018.
  9. “Fast Facts About Back Pain”. National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institute of Health. September 2009. Archived from the original on 5 June 2013. Retrieved 3/7/2018.
  10. U.S. Department of Health and Human Services – National Institutes of Health. Archived from the original on 1 April 2013. Retrieved 3/7/2018.
  11. Majchrzycki M, Mrozikiewicz PM, Kocur P, et al. (November 2010). “[Low back pain in pregnant women]”. Ginekol. Pol. (in Polish). 81 (11): 851–5.
  12. van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW (2011). “A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain”. Eur Spine J. 20 (1): 19-39.
  13. Smith C, Grimmer-Somers K (2010). “The treatment effect of exercise programmes for chronic low back pain”. J Eval Clin Pract. 16 (3): 484–91.
  14. Miller SM (September 2012). “Low back pain: pharmacologic management”. Prim. Care. 39 (3): 499–510.
  15. Manusov, EG (September 2012). “Surgical treatment of low back pain”. Primary care. 39 (3): 525– 530.
  16. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD (May 2009). “Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline”. Spine. 34 (10):1094109.

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