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Low back pain
General Practitioner, Astwood Bank, Worcestershire, UK
E-mail: bleeprldavies{at}hotmail.com
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Abstract |
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 TOP Abstract The GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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Acute lower back pain is defined as back pain between the costal margins and the inferior gluteal folds. It is a common and important problem in primary care. The lifetime prevalence for acute low back pain lasting less than 6 weeks is 58% and, in a survey in 1998, 40% of adults said that they had experienced an episode of back pain lasting longer than 24 hours last year. At 6 weeks, 90% of patients are symptom free Department for Work and Pensions. Chronic low back pain lasts over 3 months; if it persists over 12 months, the prognosis worsens significantly. With each new presentation, it is important to assess how the patient has been affected so far by the pain, work together to speed recovery, keep alert to possible serious or sinister causes of back pain, pick up those patients with nerve root pain and identify which patients would benefit from referral onto secondary care.
The GP curriculum (section 15.9 Rheumatology, musculoskeletal & trauma) outlines the skills and attitudes needed to treat low back pain in primary care. It covers primary care management, person-centred care, problem-solving skills, community and holistic approaches to back pain and the specific knowledge base required. GPs in training should be able to:
Both acute back pain and chronic back pain are common and important conditions mentioned specifically. So too are chronic disability due to musculoskeletal problems, chronic inflammatory arthropathies, osteoarthritis, osteoporosis, pain management, polymyalgia rheumatica and allied conditions and somatization/fibromyalgia and allied syndromes. All of which can be associated with back pain.
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History |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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With a new presentation of back pain, it is essential to use the history to pick up any specific causes of low back pain and any associated nerve root pain. The patient should be allowed to tell the story initially, with open questions bringing out as much information as possible from the outset. Then some detailed questions may be used to check for specific points in the history. The patient's age can help suggest the most likely cause and may guide the history taking (Table 1). Any history of injury is important, so is stiffness or pain which eases with movement. This could suggest inflammation such as discitis or spondyloarthropathy. Associated symptoms such as numbness, weakness and bowel or bladder symptoms are important ‘red flags’ which may suggest a complication of underlying serious conditions (Box 1).
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| Box 1. Red Flags Factors that should alert you to the possibility of serious underlying pathology
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‘Yellow flags’ are characteristics that help identify patients at a higher risk of developing chronic problems. This allows for intense intervention at an early stage in the hope of resolving the pain early (Box 2).
| Box 2. Yellow Flags Risk factors for developing chronic pain/long-term disability
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Examination |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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The examination starts the second the patient walks into the consultation room. Watch how easily the patient manages to sit down, as this is a good indication of the current severity of the pain and stiffness. Some patients cannot even sit down and have to pace the room. Others may not be able to get to the surgery at all and require a home visit.
With the patient standing, an inspection of the back can show scoliosis, kyphosis such as that seen in association with ankylosing spondylitis or the loss of lumbar lordosis which is common in mechanical back pain. Finding tenderness or deformity on lumbar vertebrae palpation is rare but may indicate bony pathology such as an osteoporotic fracture; muscle spasm of the para-vertebral muscles is a more common finding.
While the patient is still standing flexion, extension, lateral flexion and rotation of the back can be assessed. Pressing down on the vertex should not exacerbate low back pain.
Another guide to the severity of the patient's symptoms is the ease with which the patient can get onto the examination couch. In the lower limbs, inspect for muscle wasting and leg shortening. Assess the power in the main muscle groups and assess any sensory loss, as well as the knee and ankle reflexes. Signs associated with each nerve root entrapment are shown in (Table 2). Straight leg-raising stretches the nerves coming from the spine into the leg. Pain on doing this is an important indicator of nerve root irritation. Note the angle at which the patient develops pain. Significant bilateral restriction in straight leg raise may indicate central disc prolapse and should alert you to the possibility of cauda equina syndrome.
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In some cases, it may be difficult to distinguish hip pain from back pain. Test the hip joints by moving each hip through its full range of internal and external rotation with the patient's leg bent at the knee.
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Management of acute low back pain |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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In the GP surgery, the initial management depends on the working diagnosis. Many patients believe activity to be harmful and it is important to give a clear message that this is not the case early on. Depending on clinical circumstances, management varies from advising a non-steroidal anti-inflammatory along with advice to stay active for non-specific acute low back pain, to calling an emergency ambulance for a suspected leaking abdominal aortic aneurysm or spinal cord compression. Triage your response according to your findings on history and examination (Fig. 1).
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X-rays are not routinely undertaken initially as abnormalities are found just as often in patients without back pain. Exceptions are in patients with suspected ankylosing spondylitis, young patients under the age of 25 and elderly patients who may have malignancy or osteoporotic collapse. X-ray should also be considered in any patients with red flags or no improvement within 6 weeks.
If cauda equina syndrome or spinal cord compression is suspected (Box 3), then immediate referral for treatment is needed. For patients who do not require immediate referral, explain the natural history of the pain and advise them to avoid bed rest and to try to maintain normal activities. This will reduce the chance of chronic back pain. Prescribe analgesia. Initially try paracetamol and/or a non-steroidal anti-inflammatory. For muscle spasm, codeine and/or diazepam (for short periods only) can also be helpful.
| Box 3. Cauda equina syndrome and spinal cord compression Cauda equina syndrome Cauda equina syndrome results from compression of the cauda equina below L2, for example by disc protrusion at L4/5. Presentation:
Management: Refer or admit as a neurological emergency. Rapid surgical intervention increases the chance of full motor and sphincter recovery. Spinal cord compression in cancer patients Spinal cord compression affects 5% of cancer patients—70% in the thoracic region. Presentation can be subtle. Maintain a high level of suspicion in all cancer patients who complain of back pain—especially those with known bony metastases or tumours likely to metastasize to bone. Presentation:
Management: Prompt treatment (within 24–48 hours of the first neurological symptoms) is needed if there is any hope of restoring function. Once paralysed, less than 5% walk again. Treat with oral dexamethasone 16 mg daily and refer urgently for assessment and surgery/radiotherapy unless in final stages of disease.
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For patients with nerve root irritation or simple backache not returning to normal activities by 6 weeks after onset of pain, refer to physiotherapy. Self-help back exercises (Fig. 2), osteopathic or chiropractic treatment are also options. Do not refer if there is any possible serious pathology such as malignancy or inflammatory arthritis.
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Prognosis of acute back pain
Most patients with acute low back pain have a good prognosis with the majority experiencing rapid improvements in pain and disability within 1 month. However, it is common for patients to have recurrent episodes of acute low back pain. Others may have acute on chronic attacks.
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Management of chronic low back pain |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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The aim of management of chronic low back pain is to help patients accept and cope with pain and to lead as full a life as possible. Through education, exercise and psychological approaches a reduction of disability can be achieved. Exercise therapy and intensive multidisciplinary treatment programs have been shown to be beneficial. Early on, it is important to exclude structural spinal pathology which could be amenable to surgery, such as disc protrusion. Analgesics can help with sleep disturbance and exacerbations. Low dose tricyclic antidepressants, such as amitriptyline 10–75 mg (unlicensed) taken at night, are often used to help with the pain. Back supports, heel raises and transcutaneous electrical nerve stimulation machines may be helpful for some patients.
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Prevention of back pain |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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We can all take a number of steps to help avoid lower back pain. Regular exercise is particularly important to help protect your back. During lifting, try not to bend over and lift the object from your knees by squatting down initially. During lifting, it is also important to keep your back straight, do not twist and keep the object as close to your body as possible. When moving a heavy object, it is better to push than pull, and flat shoes also help. If you have to drive or sit at a desk for long periods, aim to have a break at regular intervals. The Health and Safety Executive is currently running a ‘Better Backs’ campaign and campaign packs are available from the web site www.hse.gov.uk/msd/backpain. Box 4 lists other sources of information for both doctors and patients.
| Box 4. Resources for patients and health-care professionals Patient resources
Professional resources
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Key points
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References |
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TOPAbstractThe GP curriculum and...HistoryExaminationManagement of acute low...Management of chronic low...Prevention of back painReferences |
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Arthritis Research Campaign. Back Pain: an information booklet. Accessed via www.arc.org.uk/arthinfo/patpubs/6002/6002.asp [date last accessed 26.02.08].
Clinical Knowledge Summaries. Back Pain—Lower. Accessed via http://cks.library.nhs.uk/back_pain_lower [date last accessed 26.02.08].
Davies R, Everitt H, Simon C. Oxford General Practice Library: Musculoskeletal problems (2006) Oxford: Oxford University Press.
Department for Work and Pensions. Corporate Medical Group: Back pain. Accessed via www.dwp.gov.uk/medical/med_conditions/major/back_pain/ [date last accessed 1.05.08].
Health and Safety Executive. Back pain in the workplace. Accessed via www.hse.gov.uk/msd/backpain/ [date last accessed 26.02.08].
National Institute for Health and Clinical Excellence. Referral Advice: a guide to appropriate referral from general to specialist services. Accessed via www.nice.org.uk/nicemedia/pdf/Referraladvice.pdf [date last accessed 26.02.08].
New Zealand Guidelines Group. Acute low back pain screening questionnaire from the New Zealand acute low back pain guide incorporating the guide to assessing psychological yellow flags in acute lo back pain. Accessed via www.nzgg.org.nz/guidelines/0072/acc1038_col.pdf [date last accessed 26.02.08].
Office for National Statistics. Adults experiencing back pain: by age and total time suffered in the previous 12 months, 1998: Social Trends 30. Accessed via www.statistics.gov.uk/STATBASE/xsdataset.asp?vlnk=674&;More=Y[date last accessed 26.02.08].
Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: a systematic review of its prognosis. British Medical Journal (2003) 327:323–5.
Royal College of General Practitioners. Curriculum Statement 15.9 Rheumatology and conditions of the musculoskeletal system. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15.9_Rheumatology_and_Musculoskeletal_System2.pdf [date last accessed 26.02.08].
Van Tulder MW, Koes BW. Low back pain: acute. Clinical evidence (2006) London: BMJ Publishing Group.
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