Clinical Pearls & Morning Reports
Nonspecific low back pain accounts for approximately 80 to 90% of all cases of low back pain. Most patients with an acute episode of nonspecific low back pain will recover in a short period of time. Read the NEJM Clinical Practice Article here.
Q: Is there a way to predict whether acute nonspecific low back pain will become chronic?
A: Screening tools can be used to estimate the risk that acute nonspecific low back pain will become chronic. The Predicting the Inception of Chronic Pain tool is a validated prediction model that estimates the risk of chronic low back pain on the basis of five measures (i.e., disability compensation, presence of leg pain, pain intensity, depressive symptoms, and perceived risk of persistent pain) among patients who have an initial episode of low back pain.
Q: Is routine imaging a component of the diagnosis of nonspecific low back pain?
A: Diagnosis of nonspecific low back pain is made after specific disorders of spinal and nonspinal origin are ruled out. A detailed history taking and physical examination can point to spinal conditions or nonspinal conditions that may lead to specific intervention. The history should include attention to red flags (e.g., history of cancer or trauma, parenteral drug use, long-term glucocorticoid use, immunocompromise, fever, and unexplained weight loss), since their presence warrants consideration of an occult serious diagnosis. Routine imaging is not recommended in patients with nonspecific low back pain.
A: Overall, first-line treatments are currently represented by nonpharmacologic interventions, which should be prioritized before pharmacologic treatment is prescribed. Patient education and advice to remain active should represent routine care for patients with acute low back pain. Education may address the benign, nonspecific nature and favorable course of low back pain, and patients should be encouraged to continue with regular activities. Heat and massage therapy are without risks and are reasonable to try, although the benefit of these therapies is supported only by limited data. Exercise therapy that is prescribed or planned by a health professional has not been shown to be effective in patients with acute low back pain, but may be considered in patients at risk for poor recovery, given evidence from randomized trials of the effectiveness of exercise therapy in alleviating chronic low back pain and in reducing the risk of new episodes of low back pain. Among pharmacologic interventions, acetaminophen was not shown to be effective in a large clinical trial, whereas nonsteroidal antiinflammatory drugs (NSAIDs) have shown benefit. However, caution is advised in the use of NSAIDs in older adults and in patients with coexisting conditions such as renal disease.
A: For chronic low back pain, exercise therapy and behavioral therapy represent first-line options, with medications considered to be second-line options. Other therapies for chronic low back pain include spinal manipulative therapy, massage therapy, yoga, and multidisciplinary rehabilitation. A systematic review with moderate-certainty evidence showed no clinically relevant differences in effects on pain and functioning with spinal manipulative therapy as compared with recommended first-line options. There is at best moderate-certainty evidence to support various pharmacologic options for the management of chronic low back pain. NSAIDs can be considered in patients at low risk, although the effects appear to be modest and are supported by low-certainty evidence. Muscle relaxants and antidepressants (e.g., serotonin and norepinephrine reuptake inhibitors) may be used as adjuvant therapy in some patients, although they have had limited effectiveness (with evidence of moderate to very low certainty) and have potential risks.