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Acute low back pain: Beyond drug therapies

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Abstract
An approach to low back pain should involve an initial triage to screen for serious pathology, assessment for psychosocial risk, clear explanations to reduce the sense of threat, active rehabilitation and discouragement of unwarranted radiological investigation.
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L
ow back pain (LBP) is rated as one of the most disabling
health disorders in the western world, resulting in an
enormous personal, social and economic burden.1 During
adolescence there is a n exponential increa se in the reporti ng
of LBP, almost reaching the adult rate at the age of 17 years, with a
concurrent increa se in disabilit y, care seek ing and activit y avoidance
associated with the disorder.2 LBP is rarely reported before the age
of 10 years. At any point in time, a quarter of all adults in Australia
h av e L BP.
3
For a signific ant group, estimated bet ween 10% and 40%,
LBP becomes persistent and profoundly disabling.
4
LBP is also
commonly comorbid wit h other pain disorders, such a s other mus-
culoskelet al pains, head ache, migraine, pe lvic girdle pai n and irritable
PAIN MANAGEMENT TODAY 2014; 1(1): 8-13
Profess or O’Sulliva n is a Professor at the S chool of P hysiotherapy, Cur tin
University and S pecialist Musculoskeletal Physiot herapist at Body Logic
Physiotherapy, Perth, WA.
Dr Lin is Adjunct Senior Teaching Fellow at the Schoo l of Physiotherapy, Curtin
University, Assistant Professor at the Combined Universities Centr e for Rural
Health, Universi ty of Western Aust ralia, Perth, an d Physiotherapist at Geraldton
Regional Aboriginal Med ical Ser vice, Gerald ton, WA.
Acute low
back pain
Beyond drug
therapies
PETER O’SULLIVAN DipPhysio, PGradDipMTh, PhD, FACP
IVAN LIN BSc(Physio), MManipTher, PhD
An approach to low back pain should involve an initial
triage to screen for serious pathology, assessment
for psychosocial risk, clear explanations to reduce
the sense of threat, active rehabilitation and
discouragement of unwarranted radiological
investigation.
FEATURE
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bowel syndrome, as wel l as other health di sorders such as depression
and an xiety, highlight ing its complex and multi dimensional natu re.
e biomedical approaches to managing LBP over the past
15years have led to an exponential increase in physical therapies,
MRI imaging, spinal injections, surgical interventions and phar-
macologica l treatments, with a ma ssive increase in healt h care costs.5
is is despite ev idence that only 8 to 15% of patients with LBP have
an identified pathoanatomical diagnosis, leaving most patients
diagnosed as having ‘nonspecific’ LBP, resulting in a management
vacuum. Ironically, this has also been associated with a concurrent
increase in disability and chronicity relating to LBP, highlighting
the failure of the current approaches to management.5
It has been proposed that the reason for the failure of current
clinic al practice to effect ively manage LBP is in part a ssociated with
a lack of adherence to cu rrent evidence. is is related to a dom inant
biomedical approach to m anaging LBP and t he failure to adequately
consider and mana ge LBP from a biopsychosocial perspec tive. ere
is also a lack of patient-centred targeted management based on this
knowledge. Best practice for the management of acute LBP
incorporates:
initial diagnosis based on a triage process
interpreti ng an LBP disorder from a biopsychosocia l perspective
(including screening patients according to the risk of ongoing
disabli ng LBP)
tailoring management according to the presentation and in a
way that empowers patients as active participants in their
recovery.6
Diagnosis and assessment
Triage process
In most people, LBP is benign and represents a simple back sprain
associated with a mecha nical loading incident or a ‘pain flare’ asso-
ciated with psychosocial or lifestyle stresses. On the initial visit,
triage is required to eliminate the small possibility of serious or
specific pathology.7
Only 1 to 2% of people presenting with LBP will have a serious
or systemic disorder, such as systemic inflammatory disorders,
infections, spinal malignancy or spinal fracture. Features such as
an insidious onset of pain, constant and nonmechanical nature of
pain (not clearly provoked by postu res and movement), night pain,
morning stiffness, past history of malignancy, age over 65 years
and/or declining general health warrant further investigation.
Recent evidence su ggests that the best pred ictors of fracture are t he
presence or ‘cluster’ of a history of severe traumatic injury, the
presence of abrasions or contusion, prior corticosteroid use and
being a woman over 74 years of age.8 e factor that best predicts
malignancy is a previous history of malignancy. It should also be
noted that a number of sy stemic, abdominal a nd pelvic patholog ies
Key points
The burden of low back pain can be reduced if
management is more aligned with evidence.
The evidence supports a patient-centred approach to
low back pain care that addresses the biopsychosocial
influences on the disorder and empowers patients to
actively self -manage.
Radiological imaging should only be undertaken when
there are clear indications for its use.
Short, easy-to-use, evidence -based tools are available
to assist clinicians in managing patients with low
back pain.
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may also cause people to present with spinal pain.7
In approximately 5 to 10% of people with LBP, the pain may be
associated with radicular features with or without neurological
deficit. is is associated with compression of the nerve root spinal
cord or cauda equina syndrome, which is linked to an underlying
pathology, such as disc prolapse, lateral recess and canal stenosis or
advanced grade spondylolisthesis (see the flowchart on this page).
A presentation of progressive neu rological deficits or signs of caud a
equina sy ndrome (new urine retent ion, faecal i ncontinence or saddle
anaesthesia) warrants further investigation.7
Nonspecific low back pa in in which a definit ive pathoanatomical
diagnosi s cannot be made accounts for 90 % of people who experience
LBP.7
The role of imaging
Radiologica l imaging for LBP, in the absence of red flags , progressive
neurologica l deficits and traumat ic injury, is not warr anted and may
in fact be detrimental. However, over-imaging for LBP is endemic
in prima ry care.
9
Alth ough advance d disc degenerat ion, spondylolis -
thesis and modic changes of the vertebral end plate (changes to the
bone structure of the vertebral body that may be seen on MRI) are
associated with an increased risk of LBP, they do not predict future
LBP.10 ,11 Further confounding the problem of diagnosis is the high
prevalence of ‘abnormal’ findings on MRI i n pain-free populations
(disc degeneration [91%], disc bulges [56%], disc protrusion [32%],
annula r tears [38%]).
12
Furt hermore, thes e findings cor relate poorly
with pain and disability levels.5 Critically, there is strong evidence
Web evidence -ba sed resources on pain for patients and healthcare practitioners are available
at: http://painhealth.csse.uwa.edu.au/pain-management.html and www.pain-ed.com
* Manage ment sho uld be und erpin ned by a str ong the rapeu tic allia nce, whic h empha sises per son -cen tred ca re and
utilise s a motiva tional c ommuni catio n style, a ctive m anagem ent pla nning and c onside ratio n of the pa tients’ he alth,
comor biditi es, ‘life’ co ntext, g oals and h ealth lit eracy.
High risk
Explain biopsychosocial nature of LBP
Pain management as indicated
Advice to remain active
Referral for targeted cognitive
functional approach with emphasis
on reducing levels of distress,
vigilance, fear avoidance and pain
behaviours, combined with targeted
functional restoration
Psychological management will be
required, if psychological comorbidities
dominate
Medium risk
Explain biopsychosocial nature of LBP
Pain management as indicated
Advice to remain active
Referral for targeted cognitive
functional approach with an emphasis
on physical restoration, fear reduction
and lifestyle change
Low risk
Explain biopsychosocial nature of
LBP
Pain management as indicated
Advice to remain active
Lifestyle advice
Undertake the triage pr ocess
A patient presents with acute low back pain
Framework for assessment and targeted management of patients with low back pain (LBP)*
Assess for psychosocial risk factors
STarT Back Screening Tool or Orebro Screening Tool
ACUTE LOW BACK PAIN CONTINUED
Refer for imaging in the presence of
progressive neurological deficit and/or
cauda equina symptoms
Medical management as appropriate
Serious or systemic pathology (1 to 2 %)
Malignancy
Systemic inflammatory disorders
Infections
Fractures
Diagnosis based on clinical examination
and investigations
LBP with significant neurologic al
deficits (5 to 10% )
Cauda equina syndrome
Sciatica due to symptomatic disc
prolapse or lateral canal stenosis
Central stenosis
Symptomatic spondylolisthesis
Nonspecific LBP (90%)
No clear pathoanatomical diagnosis
Absence of red flags
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that unwarranted imaging makes patients worse; MRI scans for
nontraumatic LBP lead to p oorer health outcomes, greater d isability
and work absenteeism due to the pathologising of the problem.10
It’s not just about the back
ere is growing evidence that factors such as sleep disturbance,
sustained high stress levels, depressed mood and anxiety are strong
predic tors of LBP.13 is highl ights growing ev idence for the role that
lifestyle and negative emotional factors play in sensitising spinal
structures via the central nervous system and dysregulation of the
hypotha lamic–pituitar y–adrenal axi s. is may reflect clinically as a
patient present ing with ac ute LBP, reporti ng high levels of pa in, distre ss
and muscle guarding associated with a ‘minor’ mechanical trigger.
It is also important to note that negative beliefs about LBP are
predictive of pain intensity, disability levels and work absenteeism
as well as chronicity.14 Beliefs that independently increase disability
and impair recovery in an episode of LBP are having a negative
future out look (e.g. ‘I know it will just get worse’) and bel ieving t hat
‘hur t equals harm’ and t hat ‘movements that hurt shou ld be avoided’
because of fear of pain and/or harm.
14
Many of these beliefs gain
their origins from healthcare practitioners,
15,16
highlighting the
critica l role of communication in the acute ca re of people with LBP
(see Boxes 1 and 2).
ere is also evidence that, in the absence of a clear traumatic
injury, pain be haviours, such as limpi ng, protective muscle gua rding
and gri macing, are more reflective of cat astrophic thin king (e.g. ‘my
back is damaged’, ‘I am never going to get bet ter’ and ‘I am going to
end up in a wheel chair’), fear and distress.17 ese behaviours can
result in abnorma l loading of sensitised spinal structures, feeding a
vicious cycle of pa in. ey are also li nked to poor coping styles , such
as avoidance and exc essive rest, and leave the person feel ing helpless
and disabled. In contrast, people who have positive beliefs about
LBP and its future consequences are less disabled.14
In contrast to popular belief, there is little evidence that LBP is
associated w ith a loss of ‘core’ or trunk st ability. Rather, there is growi ng
evidence t hat altered movement patterns and i ncreased trun k muscle
co-contraction are associated with the recurrence and persistence
of LBP, providing opportunities for targeted management.6
Screening patients with nonspecific LBP
ere is evidence su ggesting that hea lthcare practitioners a re poor
at identifying psychological risk factors (depression, anxiety, cat-
astrophising and fear) associated with LBP.18 is highlights the
need to screen patients with LBP for psychological risk factors in
primar y care. Simple screening tools such as the STarT BackScreen-
ing Tool (see http://painhealth.csse.uwa.edu.au/pain-self-checks.
1. Messages that can harm in patients with
nonspecific low back pain
Promote beliefs about structural damage/dysfunction
‘You have degeneration/arthritis/disc bulge/disc disease/
a slipped disc
‘Your back is damaged’
‘You have the back of a 70-year-old’
‘It’s wear and tear
Promote fear beyond acute phase
‘You have to be careful/take it easy from now on’
‘Your back is weak’
‘You should avoid bending/lifting’
Promote a negative future outlook
‘Your back wears out as you get older’
‘This will be here for the rest of your life’
‘I wouldn’t be surprised if you end up in a wheelchair
Hurt equals harm
‘Stop if you feel any pain’
‘Let pain guide you’
2. Messages that can heal in patients with
nonspecific low back pain
Promote a biopsychosocial appr oach to pain
‘Back pain does not mean your back is damaged – it means it is
sensitised’
‘Your back can be sensitised by awkward movements and
postures, muscle tension, inactivity, lack of sleep,
stress, worry and low mood’
‘Most back pain is linked to minor sprains that can be very painful’
‘Sleeping well, exercise, a healthy diet and cutting down on your
smoking will help your back as well’
‘The brain acts as an amplifier – the more you worry and think
about your pain the worse it gets’
Promote resilience
‘Your back is one of the strongest structures of the body
‘It’s very rare to do permanent damage to your back’
Encourage normal activity and movement
‘Relaxed movement will help your back pain settle’
‘Your back gets stronger with movement’
‘Motion is lotion’
‘Protecting your back and avoiding movement can make you worse’
Address concern s about imag ing results and pain
‘Your scan changes are normal, like grey hair
‘The pain does not mean you are doing damage – your back is
sensitive’
‘Movements will be painful at first – like an ankle sprain – but they
will get better as you get active’
Encourage self-management
‘Let’s work out a plan to help you help yourself
‘Getting back to work as you’re able, even part time at first, will
help you recover’
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html) and the Shor t Form Orebro Musculoskeletal Pai n Screening
Questionnaire (www.mnbml.com.au/icms_docs/168340_Ore-
bro_Questionna ire.pdf) have been developed to ident ify risk statu s
based on a short questionnaire.
e STarT Back Screening Tool is designed for use in a primary
care setting and is a validated tool that stratifies patients into risk
groups: low risk (LBP with little distress), medium risk (moderate
levels of pain, disability and distress) and high risk patients (high
levels of pain, d isability and d istress). ese risk groups are predic tive
of chronicity, disabi lity and work absenteeism, providing a basis for
targeted stratified care.19
e Short For m Orebro Muscu loskele tal Pa in Scre ening Ques -
tionn aire als o identifies pe ople with hi gh psychosocial risk s tatus.20
As this questionnaire includes occupational risk factors it may be
more suited to use for work-related LBP.
Management
Specific pathology
For the smal l group of patients (5%) who present with L BP due to disc
herniation a nd associated radicu lar pain wit h or without neurologica l
deficit, the nat ural histor y is very good. Prospec tive studies demonst rate
high recover y rates (over 80%) and reduction of the hern iation in most
of these patients at 12 months of follow up.
21
Only in people with
progressive neurolog y and cauda equina sy mptoms is a surgical opi nion
immed iately warranted. Pa in management in the ac ute stage of radic-
ulopathy is important when pain levels are distressing. Reinforcing
the excellent natural h istory for the disorder is crucial to reassure the
patient. As pain settles, a graduated rehabilitation program can be
instituted to normalise movement and retur n the patient to activitie s
of daily living. In the case of lateral recess and central canal stenosis
when pain is disabling, review for decompression surgery may be
indicated if conservative rehabilitation, targeting hip and spinal flex-
ibility, exercises to re duce extension spinal load ing and lifesty le factors
(obesity and acti vity levels), has failed . Low-grade (1 to 2) spondylolis-
thesis can be managed well conservatively with targeted exercise
programs.22
Nonspecific LBP
Best pract ice management for LBP, once the triage proce ss has been
conducted, is g uided by screening for psychosocia l risk factors and
addressing m aladaptive beliefs a nd behaviours to be tter target care.
In the acute phase of LBP, short-term pain management is indi-
cated if the pain is distressing. ere is also growing evidence that
targeting the beliefs and behaviours that drive disability is more
effective t han simply treating t he symptoms of LBP. Acute LBP may
be associated with high levels of fear and distress, and providing a
clear and effe ctive explanation to the patient with a n effective man-
agement plan is crucial.19
Explain and empower patients about their LBP
Patients are oen worried about why they are in pain and their
expected prognosis. Sensitive, patient-centred communication is
needed to:23
understand patient concerns
identify and address negative beliefs about LBP
reassure patients regarding the benign nature of LBP
discuss the limitations of radiological examinations
carefu lly explain t he biopsychosocia l pain mechanisms relev ant
to the patient
advise patients to keep active and normalise movement.
If radiology has been performed, emphasis should be placed on
the fact t hat common findings (disc degenerat ion, disc bulges, an nular
tears and fac et joint arthrosis) are norma l in the pain-free popu lation,
3. Activities and exercises to recommend to
patients with acute low back pain
Advice for patients
‘Pain with movement does not mean you are doing harm’
‘Gradually increase your activity levels based on time rather than
the levels of pain’
‘It is safe to exercise and work with back pain – you may just have
to modify what you do in the first few days’
The guidelines below may a ssist this process
Relaxation
Encourage breathing to the lower chest wall and stomach –
diaphragm breathing
Facilitate awareness of tension in the muscles of the trunk
and encourage mindful relaxation
Mobility exercises
Encourage gentle flexibility -based exercises for spine and hips
progressing from nonweight bearing to weight bearing (e.g. hip
and back stretches lying down, progress to sitting and standing)
Functional movement training
Encourage relaxed movements and avoidance of guarded
movements, and discourage breath holding and propping off the
hands with load transfer
Encourage patients to incorporate movement tr aining into their
usual daily activities (e.g. walking, bending, twisting) and
streng thening and conditioning if relevant to the patient
(e.g. squatting for someone who is involved in manual work)
Physical activity
Aim for patients to undertake aerobic exercise for 20 to 30 minutes
each day that does not excessively exacerbate pain (e.g. walking,
cycling [leg or arm cycling] or swimming based on comfort and
preference)
Explain to patients that they may need to exercise for a shorter
duration initially, or exercise for shor t periods throughout the
day to build exercise tolerance
Advise patients to increase activity gradually (e.g. 10 % per week)
Refer patient to a physiotherapist if pain and functional impairments
persis t and/or if the patient is at moderate to high ri sk of chronicity
ACUTE LOW BACK PAIN CONTINUED
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are not a sign of damage or injury and do not predict outcome.24
Sensitive, mot ivational communicat ion builds hea lth literacy about
LBP and empowers patients to take an active role in their rehabili-
tation rather than rely on passive treatments (see Boxes 1 and 2).
Excellent online resources for consumers with information about
LBP and other t ypes of pain are now ava ilable (see: http://pain health .
csse.uwa.edu.au/ and http://ww w.pain-ed.com/).
Movement, exercise, manual therapy and work
participation
A primary aim for the management of acute LBP is the restoration
of normal, confident spinal movement and functional capacity (e.g.
part icipation in work, family a nd recreationa l activities). is is cruc ial
to facilit ate a return to the whole healt h (physical, menta l and social)
of the patient. Activity modification should only be recommended
in the acute phase if there is evidence of tissue strain. Otherwise,
advice to keep active in a graded manner contingent on time rather
than ba sed on pain is import ant to reduce the pain avoidance v icious
cycle. Pain behaviours and guarded movement patterns should be
discouraged in the absence of a traumatic injury mechanism and in
the case of trauma as tissue healing occurs.23 is can be facilitated
via clear exercise advice (see Box 3) that consists of:
relaxat ion exercises to reduce trun k muscle guardi ng – diaphragm
breathing
gentle mobility exercises for the spine and hips to normalise
movement impairments
f unctionally t argeted movement traini ng linked to streng thening
and conditioning where indicated
general aerobic exercise guided by levels of comfort and patient
preference.
People with nonspecific LBP more commonly increase trunk
muscle guarding and have stiffness, which paradoxically increases
spinal loading and pain.6 erefore, practising relaxation of trunk
muscles incorp orated wit h graded movement training i s important
to unload sen sitised spi nal structu res and allow normal movements
to occur. Manua l therapies may be more suitable in t he acute/subacute
phase when movement limitat ions are present to help facilitate retur n
to normal movement patter ns and functiona l restoration. Addressing
lifestyle factors (e.g. sedentary behaviours, inactivity, stress, poor
sleep hygiene, smoking and obesity) may also be important.
e importance of work should be emphasised and patients
should be encouraged not to enga ge in avoidance behav iours related
to work.25 Short-term modification of work environments may be
indicated initially in the acute phase.
Targeted care for nonspecific LBP
Targeted care can be facilitated by a careful patient assessment in
conjunction with screening tools.
For the low-risk group in which L BP is associ ated with low levels
of distres s, best practice ma nagement consists of suitable pain ma n-
agement if needed, advice regarding the benign nature of LBP,
guida nce to keep active and norma lise movements, and modificat ion
of lifestyle factors. is group should need minimal intervention
and has a good prognosi s. Over-investigating and t reating this g roup
may result in worse outcomes.19
For the medium-risk group in which LBP is associated with
moderate dist ress levels, best pract ice management consists of suitable
pain ma nagement if pain is dist ressing, advice regard ing the benign
nature of LBP and reinforcing the importance of keeping active.
Physiotherapy intervent ions that include dea ling with the cog nitive
aspects of LBP, targeted functional restoration and lifestyle advice
are shown to be more effective than traditional therapies, such as
manipulat ion, stabilising and /or general exercises to reduce d isability,
work absenteeism and the need for ongoing healthcare.19, 23
e high-risk g roup in which LBP is associ ated with high di stress
levels requires special attention, directing management to reduce
high levels of fear, anxiety, depressed mood, catastrophising and
distress. Interventions that incorporate motivational interviewing
techniques, careful explanations regarding biopsychosocial pain
mechani sms pertaini ng to the individua l, exposure tra ining for feared
movements and restoration of normal movement base d on the patient’s
presentation require a higher level of training.19,23 Allocat ing greater
healthcare resources (in terms of time and clinicians with greater
expertise) has long-term clinical and healthcare cost benefits.19
If LBP is lin ked to panic attack s, post-traumatic stres s and depres-
sion, consideration for psychological referral of the patient may be
indicated. In the case of severe and distressing pain that persists,
pain management that addresses central pain mechanisms may be
required. In this case, it is impor tant that all interventions are used
in an integrated way to change behaviour linked to functional res-
toration, rather than as treatments in isolation.
Conclusion
An approach to mana ging patients with LBP to reduce t he burden in
the communit y involves: an initia l triage to screen for ser ious pathology;
assessment of psychosocial risk; provison of clear explanations to
reduce the sense of threat; encouragement of active rehabilitation;
and discouragement of unwarranted radiological investigation.
Screening and targeting management for more complex cases
when psychosocial risk factors and pain behaviours dominate, and
using interventions that target the cognitive and functional impair-
ments associated with the disorder, reduces the burden of disabilit y,
work absenteeism and associated health and societal costs. Pain
management and psycholog ical interventions should be i ncorporated
if pain levels and psychological distress dominate the disorder. PMT
Acknowledgements
We acknowledge Dr Roger Goucke and Dr Mick Gibberd for reviewing earlier
drafts of this manuscript.
References
A list of references is included in the website version (www.medicinetoday.
com.au) of this article.
COMPE TING IN TERESTS : None.
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PAIN MANAGEMENT TODAY 2014; 1(1): 8-13
Acute low back pain
Beyond drug therapies
PETER O’SULLIVAN DipPhysio, PGradDipMTh, PhD, FACP; IVAN LIN BSc(Physio), MManipTher, PhD
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Comments

Independent Researcher
> Read your article on non-specific low back pain and thought you might be interested in some specifics.
> In 1965 I found that non-specific back pain was caused by a reversible biomechanical lesion in anterior innominate rotation and symptoms could be relieved immediately by a manual posterior innominate rotation on each side. In 2007 I discovered the sacral x axes deep under the ilial tuberosity and recently was able to complete my research on the pelvis. The sacral x axes are critical to…
February 20, 2017
University of Utah
Thanks to Professor O'Sullivan and his team for the phenomenal work they continue to do in advancing the appropriate management of patients with LBP. This article is a beautiful summary that could be shared with physicians and fellow physios, clearly summarizing the current best evidence and emphasizing the importance of managing the Person, not the Pain.
PT's have been trained to do an exam and arrive at an appropriate intervention, leading to a very bio-medical, tissue based approach. The…
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