Wednesday, October 15, 2014

Low back pain

Low back pain is one of the most frequently encountered conditions in clinical practice. Up to 84 percent of adults have low back pain at some time in their lives, and over one quarter of U.S. adults report recent (in the last three months) low back pain.1,2

Low back pain can have major adverse impacts on quality of life and function; it is frequently associated with depression or anxiety.


Low back pain is also costly—in 1998, total U.S. health care expenditures for low back pain were estimated at $90 billion.3 Since that time, costs of low back pain care have risen at a rate higher than observed for overall health expenditures.4 Low back pain is one of the most common reasons for missed work or reduced productivity while at work, resulting in high indirect costs.5

The prognosis for acute low back pain (generally defined as an episode lasting less than 4 weeks) is generally favorable. Most patients experience a rapid improvement in (and often a complete resolution of) pain and disability and are able to return to work.6 In those with persistent symptoms, continued improvement is often seen in the subacute phase between 4–12 weeks, though at a slower rate than observed at first. In a minority of patients, low back pain lasts longer than 12 weeks, at which point it is considered chronic; levels of pain and disability often remain relatively constant thereafter.7

Recently, a National Institutes of Health Research Task Force defined chronic low back pain as a back pain problem that has persisted at least 3 months and has resulted in pain on at least half the days in the past 6 months.8 Patients with chronic back pain account for the bulk of the burdens and costs of low back pain.9,10 Predictors of chronicity are primarily related to psychosocial factors such as presence of psychological comorbidities, maladaptive coping strategies (such as fear avoidance [avoiding activities because of fears that they will further damage the back] or catastrophizing [anticipating the worst possible outcomes from low back pain]), presence of nonorganic signs (symptoms without a distinct anatomical or physiological basis),11 high baseline functional impairment, low general health status, and others.7

In the majority (>85%) of patients with low back pain, symptoms cannot be attributed to a specific disease or spinal pathology.12 Spinal imaging abnormalities such as degenerative disc disease, facet joint arthropathy, and bulging or herniated intervertebral discs are extremely common in patients with low back pain, particularly in older adults, and such findings are poor predictors for the presence or severity of low back pain.13 Radiculopathy from nerve root impingement (often due to a herniated intervertebral disc) and radiculopathy from spinal stenosis (narrowing of the spinal canal) are each present in about 4–5 percent of patients with low back pain and can cause neurological symptoms such as lower extremity pain, paresthesias, and weakness; the natural history and response to treatment for these conditions may differ from back pain without neurologic involvement.14

Treatments

Multiple treatment options for acute and chronic low back pain are available. Broadly, these can be classified as pharmacological treatments,15 noninvasive nonpharmacological treatments,16 injection therapies,17 and surgical treatments.18 The report focuses on the comparative benefits and harms of pharmacological and noninvasive nonpharmacological treatments; each of these categories encompasses a number of different therapies. Pharmacological treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, muscle relaxants, antiseizure medications, antidepressants, and corticosteroids; nonpharmacological treatments include exercise and related interventions (e.g., yoga), complementary and alternative therapies (e.g., spinal manipulation, acupuncture, and massage), psychological therapies (e.g., cognitive-behavioral therapy, relaxation techniques, and interdisciplinary rehabilitation), and physical modalities (e.g., traction, ultrasound, transcutaneous electrical nerve stimulation [TENS], low level laser therapy, interferential therapy, superficial heat or cold, back supports, and magnets). Important challenges in conducting a review of this topic include the large number of treatment options, potential variability in response to treatment depending on patient characteristics, difficulty in effectively blinding many of the nonpharmacological therapies (e.g., exercise or psychological therapies), the need to consider multiple outcomes related to both pain and function, and the relative paucity of evidence for specific low back conditions such as radiculopathy and spinal stenosis.

  1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates. Spine (Phila Pa 1976). 2006 Nov 1;31(23):2724-7. PMID: 17077742.
  2. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000;13(3):205-17. PMID: 10872758.
  3. Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine (Phila Pa 1976). 2004;29(1):79-86. PMID: 14699281.
  4. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008 Feb 13;299(6):656-64. PMID: 18270354.
  5. Stewart WF, Ricci JA, Chee E, et al. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003;290(18):2443-54. PMID: 14612481.
  6. Pengel LHM, Herbert RD, Maher CG, et al. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323-7. PMID: 12907487.
  7. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7;303(13):1295-302. PMID: 20371789.
  8. Deyo RA, Dworkin SF, Amtmann D, et al. Report of the NIH Task Force on Research Standards for Chronic Low Back Pain. Spine (Phila Pa 1976). 2014 Jun 15;39(14):1128-43. PMID: 24887571.
  9. Frymoyer JW. Predictors of low back pain disability. J Clinical Orthop Relat Res. 1987 August;22:89-98. PMID: 2955993.
  10. Engel CC, Von Korff M, Katon WJ. Back pain in primary care: predictors of high health-care costs. Pain. 1996;65:197-204. PMID: 8826507.
  11. Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976). 1980 Mar-Apr;5(2):117-25. PMID: 6446157.
  12. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-97. PMID: 12353946.
  13. van Tulder MW, Assendelft WJ, Koes BW, et al. Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies. Spine. 1997;22(4):427-34. PMID: 9055372.
  14. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-91. PMID: 17909209.
  15. Chou R, Huffman LH. Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):505-14. PMID: 17909211.
  16. Chou R, Huffman LH. Non-pharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2007;147:492-504. PMID: 17909210.
  17. Chou R, Atlas S, Stanos S, et al. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34:1078-93. PMID: 19363456.
  18. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: A review of the evidence for an American pain society clinical practice guideline. Spine (Phila Pa 1976). 2009;34(10):1094-109. PMID: 19363455.

Source: Agency for Healthcare Research and Quality
Published by à
Labels , ,