Investigating and Managing Low Back Pain
Published: 12 February 2024
Published: 12 February 2024
About 16% of Australians (4 million) are currently affected by back problems, and about 70 to 90% of people are expected to experience low back pain at some point during their lifetime (AIHW 2023; ACSQHC 2021).
Back pain is a leading cause of disability that may adversely affect all aspects of daily functioning (Mayo Clinic 2023; Better Health Channel 2019). Between 10 and 40% of adults with low back pain are estimated to experience persistent and disabling symptoms (Wheeler et al. 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 et al. 2018).
Effectively managing low back pain is therefore essential in ensuring patients are able to enjoy a high quality of life.
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 significant 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).
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:
(Better Health Channel 2019; Healthdirect 2023)
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 et al. 2018).
The most common causes of low back pain are ‘triggers’ such as:
(Healthdirect 2023; Better Health Channel 2019)
Risk factors for low back pain include:
(Healthdirect 2023)
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:
(Peloza 2017; Better Health Channel 2019)
The following symptoms may indicate a serious underlying problem:
(SA Health 2022)
Anyone experiencing any of the above symptoms is encouraged to seek medical advice immediately (SA Health 2022).
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 et al. 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 behaviors, in turn, may increase the patient’s disability (Wheeler et al. 2018).
Furthermore, unless ‘red flag’ signs or symptoms are present, a serious medical problem is unlikely. In many cases, patients are referred for spinal imaging when there is no evidence it will benefit them (Wheeler et al. 2018).
Patients who receive high-quality education without unnecessary imaging are more likely to have a positive outcome (Wheeler et al. 2018).
International guidelines for the clinical care of low back pain are generally consistent (Wheeler et al. 2018). The general consensus regarding care is that:
(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:
The Low Back Pain Clinical Care Standard was released by the Australian Commission on Safety and Quality in Health Care in 2022.
This standard aims to enhance the early assessment, management, review, and referral of low back pain and reduce the use of unnecessary, ineffective, and harmful treatments (ACSQHC 2022).
The standard comprises the following eight Quality Statements:
Quality Statement | Description |
---|---|
1: Initial clinical assessment | Assessment for patients presenting with new low back pain should centre on potential underlying conditions and take into account psychological and social factors. The assessment should include a thorough history and physical assessment, along with a neurological examination if indicated. |
2: Psychosocial assessment | Patients presenting with new low back pain should undergo an assessment of psychosocial factors that may affect their recovery. This assessment will be repeated during future visits in order to monitor their progress. |
3: Reserve imaging for suspected serious pathology | In order to reduce unnecessary patient distress and radiation exposure, imaging should only be performed when a serious underlying cause for low back pain is suspected. |
4: Patient education and advice | Patients should be appropriately informed about their condition and the benefits, risks and costs of their treatment options. |
5: Encourage self-management and physical activity | Patients should be supported to remain active and return to their usual daily activities as soon as they can. Clinicians should work with patients to develop a self-management plan for increasing function and reducing the impact of pain. |
6: Physical and/or psychological interventions | Patients should be offered physical and/or psychological interventions when indicated. Treatments should focus on removing barriers to recovery. |
7: Judicious use of pain medicines | Medicines should be prescribed with the goal of enabling physical activity rather than preventing pain. They must be prescribed according to the Therapeutic Guidelines and regularly reviewed. Anticonvulsants, benzodiazepines and antidepressants should not be prescribed for low back pain, while opioid analgesics should only be prescribed for carefully chosen patients, at the lowest dose for the shortest possible length of time. |
8: Review and referral | Patients who are experiencing persisting or worsening symptoms should be reassessed early so that any barriers to improvement can be identified. These patients may require referral for an interprofessional approach and, in certain cases, a specialist medical or surgical review. |
(ACSQHC 2022)
Question 1 of 3
True or false: Most low back pain requires spinal imaging to rule out the possibility of a serious medical issue.