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MSK Non-Specific Back Pain
Lower back pain that cannot be attributed to a…
Lower back pain that cannot be attributed to a known or recognisable pathology
Scientific Aspects
Aetiology
Idiopathic
However, there seem to be identifiable risk factors
Identified Risk Factors
Community Setting
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sitting, standing or walking >2hrs per day
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perceived inadequacy i.e. income, job
Occupational Setting
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sitting, standing or walking >2hrs per day
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perceived inadequacy i.e. income, job
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Epidemiology
- Common - 16% of Aus - 16% of aussies suffer and Globally is Leading Cause of Years Lived with Disability
- Commonest MSK presentation at GP
- Elderly Prevalence
- M=W
Clinical Aspects
Clinical Presentations
- MAJOR SYMPTOM - Pain localised to the llumbar spine and is described as "mechanical pain"
- Variance - Said to be Mechanical Pain since it varies with posture or activity
- Alleviated - By rest, especially lying Flat
- Exacerbated - with activity or any movement of lower-back (e.g. coughing, sneezing)
Red Flag Symptoms
- Age at onset (<20j. or > 55j.),
- Significant trauma,
- Unexplained weight loss
- widespread neurologic changes
If present, these signs would support reassessing diagnosis of nsLBP and consider the LBP secondary to another pathology
Diagnosis
A diagnostic triage approach is used is used to differentiate patients with non-specific lower back pain, from those with an identifiable cause
Diagnostic Triage
Diagnosis of exclusion
If LBP fails to be explained by these pathologies, then it is diagnosed as non-specific.
1. Does the pain originate from beyond the lumbar spine
- Nephropathy
- Aortic dissection etc
2. Is it explained by Neurological Deficit
- Radiculopathy
- Spinal canal stenosis,
- Cauda equina syndrome
3. Is there evidence indicating a serious Spinal Pathology
- Malignancy
- Infection
- Fracture
4. Are the features of presentation explained by an inflammatory MSK pathology
- Spondyloarthritis
- Rheumatoid Arthritis
Management
Risk Assessment and Stratification
- Two approaches to managing nsLBP
- Stratifying Pts based on Chronicity of Symptoms - acute, subacute or chronic nsLBP
- Stratifying Pts based on their Risk of degenerating - use prediction tools
First Line of Care
Treatment follows a graded approached, whereby therapy provided expands incrementally
- Minimal/No treatment - since most pts improve regardless/inspite of treatment
- Inaction is only sensible if clinician has conducted a thorough assessment (i.e. correctly diagnosed nsLBP and applied risk stratification appropriately)
- Simple analgesics (paracetamol) is discouraged (no more effective than placebo)
- Advise, Reassure, Encourage continued Physical Activity - avoid bed rest, continue daily activities
- Educate Pts to self manage nsLBP - inform that nsLBP is benign, most people have favourable prognosis + substantial improvement in 1st month, unlikely that a serious disease is present, imaging is not required and will not change management.
- Address Questions and Pre-emptively calrify any Misconceptions
- Review Progress at 1-2 weeks
Second Line of Care
- Controversy between International Guidelines over role of Pharmacotherapy - US guidelines include pharmacology, Danish guidelines do not
- Manual + Psycholgical Therapy > Pharmacological Interventions - massage and spinal manipulation + CBT
2nd Line Treatment of Chronic nsLBP
- Exercise - specifically Tai Chi, yoga, aerobic
- group exercise recommended as more economical for pt.
- Multidisciplinary Rehabilitation - consulting physio, psychotherapist, masseuse, personal/group trainer etc.
Pharmacotherapy
- Discuss potential harm and realistic benefits
- Shortest Time at Lowest Effective Dose - limit side effects (GIT) and dependency
- Regularly Review Prescription - evidence of benefit assessed
- NSAIDs
- Opiods - preference weak opioids and use only where NSAIDs are contraindicated
- Only used if expected benefits outweigh risks (additicion + SE's + OD)