More patients consult general practitioners about low back pain than any other musculoskeletal condition (ACSQHC 2019).
About 16% of Australians (4 million) are currently affected by low back pain, and about 70 to 90% of people are expected to experience it at some point during their lifetime (AIHW 2020; ACSQHC 2019).
Back pain is a leading cause of disability that may adversely affect all aspects of daily functioning (Mayo Clinic 2020; Better Health Channel 2019). Between 10 and 40% of adults with low back pain are estimated to experience persistent and disabling symptoms (Wheeler, Karran & Harvie 2018).
Despite the prevalence of low back pain in the community, research suggests that 28% of healthcare for low back pain in Australia does not follow clinical guidelines. Often, the mismanagement of low back pain involves unnecessary treatments that do more harm than good (Wheeler, Karran & Harvie 2018).
Effectively managing low back pain is therefore essential in ensuring patients are able to enjoy a high quality of life.
What is Low Back Pain?
The spine is comprised of bones known as vertebrae, which stack on top of one another to form a column in the shape of an ‘S’ (Better Health Channel 2019).
Low back pain affects the lumbar spine, which comprises the vertebrae L1, L2, L3, L4 and L5. The lumbar spine carries a significant amount of weight from the upper body (NINDS 2020).
Most low back pain is acute, lasting between a few days to a few weeks. However, in some cases it may become chronic, persisting for 12 weeks or more even after the initial cause has been treated (NINDS 2020).
Causes of Low Back Pain
While there are many potential causes of low back pain, it usually originates from the muscles, ligaments and joints rather than being caused by damage to the spine itself (Better Health Channel 2019).
Serious conditions such as a broken bone in the spine, an infection or cancer.
However, only about 8 to 15% of low back pain has a particular pathoanatomical cause. Most low back pain is instead classified as ‘non-specific’ (Wheeler, Karran & Harvie 2018).
The most common causes of low back pain are ‘triggers’ such as:
Lifting, carrying, pushing or pulling objects incorrectly
Repetitive actions (bending, lifting or sitting)
Bad posture (slouching or being hunched over)
Standing or bending down for a prolonged period of time
Driving for a prolonged period of time
Overusing muscles (e.g. due to sport or repetitive movements)
Exposure to a whole body vibration
Muscle tension from stress
Lack of physical activity.
(Healthdirect 2019; Better Health Channel 2019)
Risk Factors for Low Back Pain
Being overweight (as this puts more pressure on the spine)
Lack of exercise
Smoking (which may damage tissues in the back or indicate an unhealthy lifestyle overall)
Pregnancy (as this puts more pressure on the spine)
Prolonged use of medicines that weaken bones, such as corticosteroids
Stress (which may cause muscle tension in the back)
Depression (this may cause a cycle wherein back pain causes feelings of depression, leading the patient to gain weight, which then further exacerbates pain and continues the cycle).
Symptoms of Low Back Pain
Low back pain varies depending on the cause. Onset may be sudden or gradual, and symptoms may range from mild to debilitating. Furthermore, the pain may be dull or sharp in intensity (Peloza 2017; NINDS 2020).
Symptoms may include:
Dull, achy pain in the low back
Stinging, burning pain that travels from the low back to the thighs, lower legs or feet and may include numbness or tingling (sciatica)
Tightness and muscle spasms in the low back, pelvis or hips
Pain that is exacerbated by standing or sitting
Difficulty standing up straight, walking, or getting up from a seated position
Psychological symptoms such as distress, anxiety and mood issues if the pain is prolonged.
(Peloza 2017; Better Health Channel 2019)
The following symptoms may indicate a serious underlying problem:
Numbness near the rectum or genitals
Numbness, pins and needles or weakness in the legs
Unexplained weight loss
Nausea and vomiting
Unrelenting pain at night.
(SA Health 2020)
Anyone experiencing any of the above symptoms is encouraged to seek medical advice immediately (SA Health 2020).
Investigating Low Back Pain
A major issue regarding the care of patients with low back pain is the unnecessary use of spinal imaging to assist in diagnosis or rule out a serious medical condition (Wheeler, Karran & Harvie 2018).
While routine spinal imaging might seem like an effective way to reassure patients, it has actually been found to decrease patients’ sense of wellbeing and cause unnecessary anxiety. Patients may become concerned about age-related degenerative changes that are found through imaging, causing them to be fearful or avoidant. These behaviours, in turn, may increase the patient’s disability (Wheeler, Karran & Harvie 2018).
Furthermore, unless ‘red flag’ signs or symptoms are present, a serious medical problem is unlikely to be present. In many cases, patients are referred for spinal imaging when there is no evidence it will benefit them (Wheeler, Karran & Harvie 2018).
Patients who receive high-quality education without unnecessary imaging are more likely to have a positive outcome (Wheeler, Karran & Harvie 2018).
Managing Low Back Pain
International guidelines for the clinical care of low back pain are generally consistent (Wheeler, Karran & Harvie 2018). The general consensus regarding care is that:
First-step care should comprise encouraging the patient to stay active, providing high-quality education and reassuring the patient that there is no serious disease present.
Second-step care for acute low back pain should comprise at least one of the following: physical therapy, psychological therapy and complementary therapy.
Second-step care for chronic low back pain should comprise physical therapy, psychological therapy and/or complementary therapy.
Third-step care for chronic low back pain should comprise interprofessional pain management.
Low back pain should preferably be treated without the use of medicines. If pain medicine is required, however, first-line treatment should be a nonsteroidal anti-inflammatory medicine at the lowest effective dose for the shortest time possible. Note: This should only be discussed with the patient if you are a healthcare professional who is qualified to do so.
Opioids should be avoided as a treatment option where possible.
Patients with chronic, non-specific low back pain should not be offered injectable steroid medicines.
Routine spinal imaging should be avoided unless ‘red flag’ signs or symptoms are present.
(Traeger et al. 2019)
Overall, evidence suggests that unnecessary care (spinal imaging, spinal injections, hospitalisation and surgery) adversely affects patients in most cases (Traeger et al. 2019).
Therefore, when investigating and managing low back pain, it is important to:
Communicate with the patient in a positive way
Encourage the patient to return to normal activity as soon as possible, as most low back pain improves after four to six weeks
If imaging is required, refer to evidence-based guidelines when educating the patient
Remember that radiological abnormalities are common and are not necessarily related to the pain
If imaging finds age-related changes, explain these to the patient using reassuring, non-threatening language, and provide epidemiological context
Refer to other healthcare professionals if needed.
The Low Back Pain Clinical Care Standard
The Australia Commission on Safety and Quality in Health Care is currently in the process of developing a new Low Back Pain Clinical Care Standard. This standard will aim to support evidence-based management and reduce the use of unnecessary, ineffective and harmful treatments (ACSQHC 2019).
This section will be updated when more information about the new standard becomes available.