Definitions
- 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)
| 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)