This site is intended for health professionals only

Treatment options for low back pain in primary care

Brian McKenna
BSc(Hons)
Osteopathy
Osteopath
Cardiff
Council Member General Osteopathic Council (GOsC)

Low back pain (LBP) has many causes. It may be due to disease or injury in one or more sites within the spine, or a feature of systemic disease, sepsis or malignancy. Overall, 1% of people presenting with LBP in primary care have a neoplasm, 4% have compression fractures, and 1-3% have a prolapsed disc. Pain may also be referred to the back from the aorta, major viscera, hip and genitourinary system.(2)

Structural causes
The best available evidence implicates the lumbar zygapophysial joints, sacroiliac joints and lumbar vertebral discs as the main sources of chronic LBP .(3)

Lumbar zygapophysial joints
The lumbar zygapophysial joints have been shown to cause up to 40% of symptoms in elderly populations and 15% in younger populations.(4) It is likely that this difference is due to degenerative changes.

Sacroiliac joint
The prevalence of sacroiliac joint pain has been shown to be about 20% in patients with chronic low back pain.(5)

Discogenic pain
Internal derangement of the discs without bulging or displacement of the annulus seems to be the main cause of discogenic pain and can account for 40% of patients with low back pain.(6)

Disc prolapse
This occurs where the nucleus and the annulus are displaced beyond the normal perimeter of the disc. This usually becomes symptomatic by causing mechanical irritation and inflammation of one or more of the lumbar nerve roots, causing radicular pain (sciatica). It may cause low back pain also; however, in most cases it does not. It is present in 24% of asymptomatic patients.(7)

Spondylolysis and spondylolysthesis
Spondylolysis is usually due to a failure of the pars interarticularis of one of the lower lumbar vertebra;  spondylolysthesis occurs when the vertebra slips forward due to a spondylolysis. Both can be a cause of LBP. However, the defect is present in 7% of asymptomatic individuals,(8) thus radiographic evidence is not diagnostic.

Spinal stenosis
This can cause central low back pain, but often mimics intermittent claudication.

Other structural causes
Other structural causes of low back pain can be muscle/ligament sprain and muscle spasm. However, this is rare, and it is almost impossible to differentiate individual structures of this type.(3)

Nonstructural causes

Neoplasm
Either primary, most commonly multiple myeloma, or secondary metastases from the breast, thyroid, lung, kidney, prostate, cervix or colon. However, these account for less than 1% of cases of low back pain.

Infection
Osteomyelitis, discitis and paraspinal abscess are relatively rare and a recent history of infection is common.

Inflammatory
Spondyloarthropathies such as ankylosing spondylitis can give LBP. However, Reiter's syndrome, psoriatic arthritis and rheumatoid arthritis can also affect the low back.

Metabolic
Osteoporotic vertebral collapse, Paget's disease, osteomalacia and hyperparathyroidism can also affect the low back.

Patient evaluation
The aim of the evaluation is to establish the cause of the LBP and identify those few patients who have a serious underlying disorder. It is also a good opportunity to identify the predisposing and maintaining factors that precipitated the onset and are preventing healing.
A careful case history should be taken starting with the site quality and frequency of pain; any referral, neurological symptoms, such as numbness, weakness, pins and needles, and any systemic features affecting the gastrointestinal and genitourinary systems should be recorded. Record any previous history of LBP, trauma or serious illness, such as malignancy, HIV infection, fractures, operations and use of medications, as well as any aggravating and relieving factors.
Generally, mechanical pain is worse on movement and relieved by rest. It normally has an identifiable onset, such as lifting or physical activity. Inflammatory causes are normally worse in the morning and not related to posture or activity. Malignancy usually has a gradual onset; the pain is constant and unremitting and can be worse at night. It is usually accompanied by systemic features, such as feeling generally unwell, fatigue and weight loss.
Psychosocial issues (yellow flags) such as attitudes and beliefs about LBP, illness behaviour, psychological distress and depressive symptoms, along with family and work factors, such as low job satisfaction, should be taken into account. Generally, psychosocial issues such as these do not cause LBP. However, they can be used as prognostic indicators as they can affect the reporting of symptoms and illness behaviour, such as fear avoidance, which can hinder early recovery.

Physical examination
The physical examination should include the active and passive assessment of spinal movement, including quality and quantity of movement, movements that exacerbate the symptoms, the presence of hypertonia, tenderness to palpation, identification of the site of pain, gait analysis, posture, spinal curves and deformities. An assessment of related areas that can refer pain to the low back, such as the hips and thoracic spine, should also be carried out. An examination of other systems, such as the peripheral and central nervous systems, cardiovascular system, genitourinary system, gastrointestinal and ventilatory system, should be undertaken as appropriate.
Further testing or referral to a more appropriate healthcare professional may be needed. Imaging, such as X-ray, MRI (magnetic resonance imaging) and CT (computed tomography), is not routinely necessary for simple LBP but can be useful if nonmechanical pain is suspected.
Prompt investigation should be undertaken if there are any red flags, such as:

  • Violent trauma.
  • Nonmechanical pain.
  • The patient is systemically unwell.
  • There is widespread or progressive neurological deficit.

Immediate admission is needed if there are signs of cauda equina syndrome, which includes sphincter disturbance, saddle anaesthesia, widespread or progressive motor weakness in the legs or gait disturbance.

Treatment and management of mechanical low back pain

Advice
Many patients, especially if it is their first episode of LBP, are worried that there is something seriously wrong with them or that they are going to suffer from LBP for the rest of their lives. In the vast majority of cases this is not true. These fears and anxieties need to be taken into account throughout the consultation and individual concerns addressed.
General advice includes reassurance that their pain is not due to a serious cause and that it should resolve. People with acute LBP should be encouraged to keep active and return to work as quickly as possible. This can help speed recovery and lead to less chronic disability.
Bed rest is not advised and should be recommended only for a couple of days for those individuals who are limited by severe pain.(9)
Advice on seated posture, computer use, driving, exercise, lifting, bending and choosing a mattress can be helpful.(9)
If patients have leg pain associated with back pain (sciatica), they should be advised that it will take longer to resolve.
The Back Book is an evidence-based booklet that gives most of the advice given above in an easy-to-understand format. It is very useful as it can be taken away and read and reread later.

Manipulation
The risks of manipulation are very low if it is undertaken by a skilled practitioner.
Early referral to an osteopath for manipulation should be considered as this can provide improvements in pain and activity levels and therefore result in higher patient satisfaction.(10)
The much-awaited results of the "UK Back Pain Exercise And Manipulation UK (BEAM) Trial" were published recently in the British Medical Journal.(11) They show that manipulation is more effective than best care from a GP and specific exercise programmes for acute LBP, and that manipulation is the most cost-effective treatment as patients used fewer other healthcare resources.

Drug therapy
Drug therapy can provide symptomatic relief. Over-the-counter drugs should be sufficient for most people with low back pain. Many patients believe that by using analgesics they may be doing themselves more harm by masking the pain, thus doing things they should not be doing. In most cases, analgesia will only reduce the pain.
Paracetamol should be given at regular intervals rather than when needed. If this is not effective it should be substituted for nonsteroidal anti-inflammatory drugs (NSAIDs) (in the absence of contraindications),(12) again at regular intervals, then paracetamol-weak opioid compounds. A short course of muscle relaxants may be required for those with significant spasm. However, they can have adverse effects.(13)
There is insufficient evidence to support the use of epidural, zygapophysial joint and local injections with corticosteroids or anaesthetics.(14)

Exercise
It is unlikely that specific exercises for the low back give any significant improvement in acute low back pain, although there seem to be some theoretical arguments for introducing physical reconditioning and exercise programmes for chronic low back pain.(10)

Other therapies
Back schools, behavioural therapy and multidisciplinary programmes may have some effect on chronic LBP compared with no treatment. However, the ­evidence is less clear for acute low back pain.(15,16)
There is limited or insufficient evidence for the efficacy of lumbar supports, massage ultrasound, ice, heat or short-wave diathermy in the treatment of LBP.(9,17)
There is no evidence that acupuncture or traction have any effect on LBP.(9,18)

Conclusion
It is essential that all primary care practitioners working in this field have a thorough grounding in the medical sciences and assessment procedures, not only of the musculoskeletal system but of all systems, as many conditions can present in primary care as LBP.
It is essential that the patient with nonmechanical LBP be referred to the most appropriate healthcare professional with the minimum of delay. Osteopaths, as primary care practitioners who specialise in musculoskeletal medicine, are increasingly fulfilling this role as more patients self-refer without having seen any other healthcare professional.
Research is now showing that manipulation is becoming the evidence-based treatment of choice for acute LBP.

[[NIP20_table1_18]]

References

  1. Clinical Standards Advisory Group. Report on back pain. London: HMSO; 1994. p. 1-89.
  2. Speed C. ABC of rheumatology: low back pain. BMJ 2004;328:1119-21.
  3. Adams M, Bogduk N, Burton K, Dolan P. The biomechanics of back pain. Edinburgh: Churchill Livingstone; 2002.
  4. Schwarzer A, et al. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995;54:100-6.
  5. Maigne J, et al. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889-92.
  6. Schwarzer A, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995;20:1878-83.
  7. Jensen M, et al. Magnetic ­resonance imaging of the lumbar spine in people without low back pain. N Engl J Med 1994;331:69-73.
  8. Moreton D. Spondylolysis. JAMA 1966;195:671-4.
  9. Waddell G, et al. Low back pain evidence review. London: Royal College of General Practitioners; 1999.
  10. Royal College of General Practitioners. Clinical guidelines for the ­management of acute low back pain. London: RCGP; 1999.
  11. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation randomised trial: ­effectiveness of physical treatments for back pain in primary care. BMJ 2004;doi: 10.1136/bmj.38282.669225.AE
  12. Van Tulder M, et al. Non steroidal anti-­inflammatory drugs for low back pain (Cochrane review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.
  13. Tulder M van, et al. Muscle ­relaxants for non-specific low back pain (Cochrane review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.
  14. Van Tulder M, Koes B. Low back pain and sciatica. Clin Evid 2001;5:772-89.
  15. Van Tulder M, et al. Back schools for non-specific low back pain. (Cochrane review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.
  16. Van Tulder M, et al. Behavioural treatment for chronic low back pain (Cochrane review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.
  17. Van Tulder M, et al. Lumbar supports for prevention and treatment of low back pain (Cochrane review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.
  18. Van Tulder M, et al. Acupuncture for low back pain (Cochrane Review). In: The Cochrane Library. Issue 3. Chichester: John Wiley & Sons; 2004.

Resources
General Osteopathic Council
W:www.osteopathy.org.uk
British Osteopathic Association
W:www.osteopathy.org
Back care
W:www.backcare.org.uk
UK BEAM Trial result
W:www.york.ac.uk/depts/hsce/ukbeam.htm