Mechanical Low Back Pain

 

Am Fam Physician. 2018 Oct 1;98(7):421-428.

  See related handout on low back pain.

Author disclosure: No relevant financial affiliations.

Low back pain is usually nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. Clinical clues, or red flags, may help identify cases of nonmechanical low back pain and prompt further evaluation or imaging. Red flags include progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age. Imaging on initial presentation should be reserved for when there is suspicion for cauda equina syndrome, malignancy, fracture, or infection. Plain radiography of the lumbar spine is appropriate to assess for fracture and bony abnormality, whereas magnetic resonance imaging is better for identifying the source of neurologic or soft tissue abnormalities. There are multiple treatment modalities for mechanical low back pain, but strong evidence of benefit is often lacking. Moderate evidence supports the use of nonsteroidal anti-inflammatory drugs, opioids, and topiramate in the short-term treatment of mechanical low back pain. There is little or no evidence of benefit for acetaminophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain. There is strong evidence for short-term effectiveness and moderate-quality evidence for long-term effectiveness of yoga in the treatment of chronic low back pain. Various spinal manipulative techniques (osteopathic manipulative treatment, spinal manipulative therapy) have shown mixed benefits in the acute and chronic setting. Physical therapy modalities such as the McKenzie method may decrease the recurrence of low back pain and use of health care. Educating patients on prognosis and incorporating psychosocial components of care such as identifying comorbid psychological problems and barriers to treatment are essential components of long-term management.

Mechanical low back pain refers to back pain that arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. This includes lumbosacral muscle strain, disk herniation, lumbar spondylosis, spondylolisthesis, spondylolysis, vertebral compression fractures, and acute or chronic traumatic injury.1 Repetitive trauma and overuse are common causes of chronic mechanical low back pain, which is often secondary to workplace injury. Most patients who experience activity-limiting low back pain go on to have recurrent episodes. Chronic low back pain affects up to 23% of the population worldwide, with an estimated 24% to 80% of patients having a recurrence at one year.2,3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Do not order initial imaging studies unless there is concern for cauda equina syndrome, malignancy, fracture, or infection.

B

5, 6, 811

Nonsteroidal anti-inflammatory drugs, opioids, and topiramate (Topamax) are more effective than placebo in the short-term treatment of nonspecific chronic low back pain.

A

12, 13, 15, 16

Acetaminophen, antidepressants (except duloxetine [Cymbalta]), lidocaine patches, and transcutaneous electrical nerve stimulation are not consistently more effective than placebo in the treatment of chronic low back pain.

B

12, 18, 20, 22, 33

Consider referral to physical therapy for McKenzie method techniques to reduce the risk of recurrence and need for health care services.

B

24, 25, 4547

Intensive patient education that includes advice to stay active, avoid aggravating movements, and return to normal activity as soon as possible, and a discussion of the often benign nature of acute low back pain is effective in patients with nonspecific pain.

B

36


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Do not order initial imaging studies unless there is concern for cauda equina syndrome, malignancy, fracture, or infection.

B

5, 6, 811

Nonsteroidal anti-inflammatory drugs, opioids, and topiramate (Topamax) are more effective than placebo in the short-term treatment of nonspecific chronic low back pain.

A

12, 13, 15, 16

Acetaminophen, antidepressants (except duloxetine [Cymbalta]), lidocaine patches, and transcutaneous electrical nerve stimulation are not consistently more effective than placebo in the treatment of chronic low back pain.

B

12, 18, 20, 22, 33

Consider referral to physical therapy for McKenzie method techniques to reduce the risk of recurrence and need for health care services.

B

24, 25, 4547

Intensive patient education

The Authors

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JOSHUA SCOTT WILL, DO, FAAFP, is the director of the Family Medicine Residency Program at Martin Army Community Hospital, Fort Benning, Ga....

DAVID C. BURY, DO, FAAFP, is a residency faculty member at Martin Army Community Hospital.

JOHN A. MILLER, DPT, is chief of the Department of Rehabilitative Services at Martin Army Community Hospital.

Address correspondence to Joshua Scott Will, DO, Martin Army Community Hospital, 6600 Van Aalst Blvd., Fort Benning, GA 31905. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

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