Nonspecific Low Back Pain and Return to Work

 

Am Fam Physician. 2019 Dec 1;100(11):697-703.

  Patient information: See related handout on low back pain and return to work.

Author disclosure: No relevant financial affiliations.

Nonspecific low back pain refers to a condition without a distinct etiology to explain its associated symptoms. This pain may become chronic and is a major cause of work loss around the world. Without a specific explanation for a patient's symptoms, the family physician is charged with providing reassurance, while also guiding the patient toward a return to function, which often includes maintaining employment. Evaluating for red flag signs and symptoms helps to eliminate concerning causes of low back pain, such as malignancy, fracture, infection, and cauda equina. Prescribing physical activity, including core strengthening, physical therapy, or yoga, is an important therapeutic intervention. Early return to work should be encouraged when appropriate. There is limited evidence to support workplace modification, medication, or steroid injection for nonspecific low back pain. Early assessment for barriers to recovery, such as fear avoidance beliefs and psychosocial factors, is helpful. Stress management counseling may also be beneficial. Disability guidelines can serve as guideposts for return to work recommendations.

Although low back pain technically describes a symptom, the term refers to a clinical phenomenon associated with a broad number of diseases. Nonspecific low back pain, on the other hand, more narrowly addresses cases of low back pain without evidence of a more concerning diagnosis, such as a tumor, fracture, infection, inflammatory arthritis, or cauda equina. One-fourth of working adults report experiencing low back pain within the previous three months.1 Nearly 5% of all outpatient medical visits are for nonspecific low back pain.2 Despite its prevalence, less than one-third of patients affected by low back pain will seek care from their family physicians.3

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Red flags can help rule out serious underlying etiologies of low back pain.7,8

C

Consensus guideline

Back braces and insoles do not prevent low back pain.1619

A

Systematic reviews of multiple randomized controlled trials

Core strengthening exercises can prevent low back pain.25

B

Cochrane review of low- to moderate-quality studies

Yoga can improve chronic low back pain.27

B

Cochrane review of low- to moderate-quality studies

Physical activity is an effective treatment of low back pain.30

B

Cochrane review of moderate-quality studies


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 ratingComments

Red flags can help rule out serious underlying etiologies of low back pain.7,8

C

Consensus guideline

Back braces and insoles do not prevent low back pain.1619

A

Systematic reviews of multiple randomized controlled trials

Core strengthening exercises can prevent low back pain.25

B

Cochrane review of low- to moderate-quality studies

Yoga can improve chronic low back pain.27

B

Cochrane review of low- to moderate-quality studies

Physical activity is an effective treatment of low back pain.30

B

Cochrane review of moderate-quality studies


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.

 Enlarge     Print

BEST PRACTICES IN ORTHOPEDICS

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Avoid imaging studies (magnetic resonance imaging, computed tomography, or radiography) for acute low back pain without specific indications.

American Society of Anesthesiologists

Do not initially obtain radiographs for injured workers with acute nonspecific low back pain.

American College of Occupational and Environmental Medicine

Do not order an imaging study for back pain without performing a thorough physical examination.

American Academy of Physical Medicine and Rehabilitation

Do not recommend bed rest for low back pain. Patients should remain as active as possible and be encouraged to find positions of comfort and engage in activities that do not worsen symptoms during an acute episode.

North American Spine Society

Avoid protracted use of passive or palliative physical therapeutic modalities for low back pain disorders unless they support the goal(s) of an active treatment plan.

American Chiropractic Association

Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low back pain.

American Chiropractic Association


The Authors

show all author info

BLAIR A. BECKER, MD, is a faculty physician at the Kaiser Permanente Washington Family Medicine Residency in Seattle....

MARC A. CHILDRESS, MD, is associate director of the Primary Care Sports Medicine Fellowship at Virginia Commonwealth University Fairfax (Va.) Family Practice.

Address correspondence to Blair A. Becker, MD, Kaiser Permanente Washington Family Medicine Residency, 125 16th Ave. E., CSB-540, Seattle, WA 98112. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Yang H, Haldeman S, Lu ML, et al. Low back pain prevalence and related workplace psychosocial risk factors: a study using data from the 2010 National Health Interview Survey. J Manipulative Physiol Ther. 2016;39(7):459–472....

2. Feuerstein M, Marcus SC, Huang GD. National trends in nonoperative care for nonspecific back pain. Spine J. 2004;4(1):56–63.

3. Picavet HS, Struijs JN, Westert GP. Utilization of health resources due to low back pain: survey and registered data compared. Spine (Phila Pa 1976). 2008;33(4):436–444.

4. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800.

5. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8–20.

6. Vingård E, Mortimer M, Wiktorin C; Musculoskeletal Intervention Center-Norrtälje Study Group. Seeking care for low back pain in the general population: a two-year follow-up study: results from the MUSIC-Norrtälje Study. Spine (Phila Pa 1976). 2002;27(19):2159–2165.

7. Verhagen AP, Downie A, Popal N, et al. Red flags presented in current low back pain guidelines: a review. Eur Spine J. 2016;25(9):2788–2802.

8. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review [published correction appears in BMJ. 2014;348:g7]. BMJ. 2013;347:f7095.

9. Williams CM, Henschke N, Maher CG, et al. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database Syst Rev. 2013;(1):CD008643.

10. Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev. 2013;(2):CD008686.

11. Punnett L, Prüss-Utün A, Nelson DI, et al. Estimating the global burden of low back pain attributable to combined occupational exposures. Am J Ind Med. 2005;48(6):459–469.

12. Hoogendoorn WE, van Poppel MN, Bongers PM, et al. Physical load during work and leisure time as risk factors for back pain. Scand J Work Environ Health. 1999;25(5):387–403.

13. Coenen P, Gouttebarge V, van der Burght AS, et al. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med. 2014;71(12):871–877.

14. Kwon BK, Roffey DM, Bishop PB, et al. Systematic review: occupational physical activity and low back pain. Occup Med (Lond). 2011;61(8):541–548.

15. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303(13):1295–1302.

16. Sahar T, Cohen MJ, Uval-Ne'eman V, et al. Insoles for prevention and treatment of back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine (Phila Pa 1976). 2009;34(9):924–933.

17. Chuter V, Spink M, Searle A, et al. The effectiveness of shoe insoles for the prevention and treatment of low back pain: a systematic review and meta-analysis of randomised controlled trials. BMC Musculoskelet Disord. 2014;15:140.

18. Steffens D, Maher CG, Pereira LS, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(2):199–208.

19. van Duijvenbode IC, Jellema P, van Poppel MN, et al. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008;(2):CD001823.

20. Ainpradub K, Sitthipornvorakul E, Janwantanakul P, et al. Effect of education on non-specific neck and low back pain: a meta-analysis of randomized controlled trials. Man Ther. 2016;22:31–41.

21. Verbeek JH, Martimo KP, Karppinen J, et al. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database Syst Rev. 2011;(6):CD005958.

22. O'Sullivan K, O'Keeffe M, O'Sullivan L, et al. The effect of dynamic sitting on the prevention and management of low back pain and low back discomfort: a systematic review. Ergonomics. 2012;55(8):898–908.

23. Martimo KP, Verbeek J, Karppinen J, et al. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ. 2008;336(7641):429–431.

24. Schaafsma FG, Anema JR, van der Beek AJ. Back pain: prevention and management in the workplace. Best Pract Res Clin Rheumatol. 2015;29(3):483–494.

25. Saragiotto BT, Maher CG, Yamato TP, et al. Motor control exercise for chronic non-specific low-back pain. Cochrane Database Syst Rev. 2016;(1):CD012004.

26. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;(7):CD010265.

27. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(1):CD010671.

28. Bruce-Low S, Smith D, Burnet S, et al. One lumbar extension training session per week is sufficient for strength gains and reductions in pain in patients with chronic low back pain ergonomics. Ergonomics. 2012;55(4):500–507.

29. Matsudaira K, Hiroe M, Kikkawa M, et al. Can standing back extension exercise improve or prevent low back pain in Japanese care workers? J Man Manip Ther. 2015;23(4):205–209.

30. Dahm KT, Brurberg KG, Jamtvedt G, et al. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.

31. Schaafsma FG, Whelan K, van der Beek AJ, et al. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database Syst Rev. 2013;(8):CD001822.

32. Choi BK, Verbeek JH, Tam WW, et al. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev. 2010;(1):CD006555.

33. Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.

34. Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–1078.

35. Staal JB, de Bie R, de Vet HC, et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. 2008;(3):CD001824.

36. Will JS, Bury DC, Miller JA. Mechanical low back pain. Am Fam Physician. 2018;98(7):421–428. Accessed September 9, 2019. https://www.aafp.org/afp/2018/1001/p421.html

37. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–1580.

38. Franklin GM, Stover BD, Turner JA, et al.; Disability Risk Identification Study Cohort. Early opioid prescription and subsequent disability among workers with back injuries. Spine (Phila Pa 1976). 2008;33(2):199–204.

39. Sowden G, Hill JC, Konstantinou K, et al. Targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study. Fam Pract. 2012;29(1):50–62.

40. Foster NE, Mullis R, Hill JC, et al.; IMPaCT Back Study team. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12(2):102–111.

41. Morone NE, Greco CM, Moore CG, et al. A mind-body program for older adults with chronic low back pain: a randomized clinical trial. JAMA Intern Med. 2016;176(3):329–337.

42. Steenstra IA, Munhall C, Irvin E, et al. Systematic review of prognostic factors for return to work in workers with sub acute and chronic low back pain. J Occup Rehabil. 2017;27(3):369–381.

43. Wynne-Jones G, Cowen J, Jordan JL, et al. Absence from work and return to work in people with back pain: a systematic review and meta-analysis. Occup Environ Med. 2014;71(6):448–456.

44. Rashid M, Kristofferzon ML, Nilsson A, et al. Factors associated with return to work among people on work absence due to long-term neck or back pain: a narrative systematic review. BMJ Open. 2017;7(6):e014939.

45. Wertli MM, Rasmussen-Barr E, Weiser S, et al. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review [published correction appears in Spine J. 14(8):a18]. Spine J. 2014;14(5):816–36.e4.

46. Rashid M, Kristofferzon ML, Nilsson A, et al. Factors associated with return to work among people on work absence due to long-term neck or back pain: a narrative systematic review. BMJ Open. 2017;7(6):e014939.

47. Nguyen C, Poiraudeau S, Revel M, et al. Chronic low back pain: risk factors for chronicity (in French). Rev Rhum. 2009;76:537–542.

48. O'Connell NE, Cook CE, Wand BM, et al. Clinical guidelines for low back pain: a critical review of consensus and inconsistencies across three major guidelines. Best Pract Res Clin Rheumatol. 2016;30(6):968–980.

49. McLellan RK, Haas NS, Kownacki RP, et al. Using electronic health records and clinical decision support to provide return-to-work guidance for primary care practitioners for patients with low back pain. J Occup Environ Med. 2017;59(11):e240–e244.

50. Maness DL, Khan M. Disability evaluations: more than completing a form. Am Fam Physician. 2015;91(2):102–109. Accessed September 9, 2019. https://www.aafp.org/afp/2015/0115/p102.html

51. Guides to the Evaluation of Permanent Impairment. 6th ed. American Medical Association; 2007.

52. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):2940–2952.

53. Nguyen TH, Randolph DC. Nonspecific low back pain and return to work. Am Fam Physician. 2007;76(10):1497–1502. Accessed September 9, 2019. https://www.aafp.org/afp/2007/1115/p1497.html

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article