•  Low back pain (LBP) is defined as pain and/or discomfort below the costal margin and above the inferior gluteal folds, with or without leg pain
  • Non-specific LBP is defined as tension, soreness and/or stiffness in the lower back that is not - attributed to a known specific pathology

In clinical practice, there are no sharp distinctions between acute, subacute and persistent LBP; however, for research purposes the following definitions have been described:

  • acute – pain present for less than 6 weeks (although some guidelines define this as pain present for less than 4 weeks, and others as less than 3 months)
  • persistent non–specific pain present for more than 6 weeks (although some guidelines define this as being more than 12 weeks)
  • sub-acute – has been used to describe pain that is of intermediate duration (typically 6-12 weeks), although many guidelines and literature sources do not refer to subacute chronicity (pain related disability) at all. The American Guidelines use the starting point for sub-acute pain as 4 weeks.
  • chronic - defined as constant or intermittent pain (in same pain site) for 6 months or longer (in the older adult, this is reduced to 3 months)

Table 1. Evidence for acute and chronic non-specific / simple mechanical back pain

 

Guidelines: see key below

Recommendations

A

B

C

D

E

F

Self Care

Stay active and continue normal daily activities including work

a

a

a

a

a

 

Back Book / handouts

a

a

a

a

a

 

Application of superficial heat

a

x

x

x

   

Stand alone formal educational programmes

       

x

 

Assessment and diagnosis

Focused history and diagnostic triage

a

a

a

a

   

Red Flags

a

a

a

a

   

Risk Factors for chronicity (Flags)

a

a

a

a

a

 

Routine radiographic imaging is not recommended (used for structural deformities)

a

a

a

a

a

 

Routine MRI / CT is not recommended (used in patients with severe or progressive neurological deficits/suspected serious conditions)

a

a

a

a

Only for an opinion on spinal fusion

 

Pharmacological interventions

Paracetamol

a

a

a

a

a

 

NSAIDs

a

a

a

a

a

 

Muscle relaxants

a

x

a

a

   

Antidepressants

x

a

x

a

a

 

Antiepileptics

x

?

x

?

   

Systemic corticosteroids

x

x

       

Weak opioids

a

a

 

a

x

 

Strong opioids (used judiciously/short term use)

a

a

 

x

a

 

Non-pharmacological treatments

Exercise

x

a

x

a

a

 

Manipulation

a

a

a

a

a

 

Acupuncture

x

a

x

x

a

 

Massage

x

a

x

x

x

 

CBT

x

a

x

a

a

 

Multidisciplinary rehabilitation

x

a

x

a

a

a

TENS

x

x

x

x

x

 

Traction

x

x

x

x

x

 

Back school (short term)

x

x

x

a

a

 

Electromyography

x

x

x

     

Laser therapy

   

x

x

x

 

Lumbar supports

x

x

x

x

x

 

Short wave diathermy

?

?

x

     

Interferential therapy

x

x

x

     

Therapeutic ultrasound

   

x

 

x

 

Supervised educational programmes

     

a

   

Interventions

Epidural/intrathecal steroids

x

x

x

x

x

x

 

Intra-articular steroids

     

x

x

 

Facet nerve blocks

     

x

x

x

Botulinum injections

     

x

x

x

Sacroliliac injections of steroids

     

x

x

x

Injections of sclerosants / Prolotherapy

     

x

x

 

Trigger point injections

     

x

x

x

Intradiscal injections

     

x

x

x

Neuroreflexotherapy

     

a

x

 

RF facet denervation

     

x

x

x

Intradiscal radio frequency

     

x

x

 

Electrothermal coagulation

     

x

x

x

Radio-frequency denervation

     

x

x

x

Spinal cord stimulation

     

x

x

x

Fusion surgery

 

Ref spinal surgeon

 

After 2 years and after evidence based treatment exhausted

After a year and after evidence based treatment exhausted

a

Artifical disc replacement

         

?

Key

A = American Low back pain (2007): Acute: less than 4 weeks

B = American Low back pain (2007): Sub acute - chronic: greater than 4 weeks

C = European Acute Back Pain Guidelines (2006): Acute: less than 6 weeks

D = European Chronic Non Specific Low Back Pain (2004): Chronic: 12 weeks or more

E = NICE Low Back Pain Guidelines: Sub-acute to chronic (2008): greater than 6 weeks and up to a year

F = American Pain Society Guidelines Interventional therapies (2009)

References:
Airaksinen O, Brox JI, Cedraschi C. European guidelines for the management of chronic non-specific low back pain. Brussels: European Commission Research Directorate General;2005.
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. AnnInternMed2007;147:478-91.
Clinical Knowledge Summaries (CKS). Back pain low (without radiculopathy). Newcastle upon Tyne:CKS;2009.
McIntosh G,Hall H. Lowbackpain(acute).ClinEvid2008;10:1102-32.
McIntosh G, Hall H. Lowbackpain(chronic).ClinEvid2008;10:1116-44.
National Health and Medical Research Council (NHMRC). Evidence based management of acute musculoskeletal pain. Canberra:NHMRC;2003.
National Institute of Health and Clinical Excellence (NICE). Low back pain. Clinical guideline 88. London: NICE; 2009.
Shiri R, Karppinen J, Leino-Arjas P et al. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol 2010;171:135-54.
Van Tulder M, Becker A, Bekkering T et al. European guidelines for the management of acute nonspecific low back pain in primary care. COST Action B13.Brussels:European Commission Research Directorate General;2004.