Back pain causes significant disability among the population and it is becoming more common, as Steve Titmarsh explains…

Non-specific low back pain, which we will focus on in this article, can be self-managed, mainly through exercise. A greater understanding of the way people experience pain is driving new research that is hoped will help individualise treatment further and potentially produce better outcomes.

Perhaps a measure of how serious the problem of back pain has become is the launch of the World Health Organization’s ‘WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings’.¹

WHO notes that there has a been a 60% increase in cases of lower back pain since 1990 and that it affects around 619 million people worldwide.¹ In the UK, back pain is similarly common. Estimates vary from around a mean 28% prevalence with a peak at age 41–50 years.

There also seems to be a trend of increasing numbers of cases. Chronic low back pain (usually defined as lasting 3 months or more) is thought to affect 3–4% of adults under the age of 45 years and 5–7% of adults aged over 45 years; it is thought that up to 6 in 10 of the population will have low back pain at some point in their lives.²

Risk factors

Factors that put people at risk of non-specific low back pain (pain not attributable to an underlying cause; also be referred to as mechanical, musculoskeletal, or simple low back pain) include:²

• Obesity
• Physical inactivity
• Occupational factors (eg heavy lifting, bending or twisting)
• Stress or depression.

Chronic pain and disability are more likely among people with:²

• Pain lasting longer than 12 weeks
• High baseline pain intensity and disability
• Anxiety and/or depression
• Stressful life events including previous or current physical or emotional trauma.
• Substance misuse
• Maladaptive coping strategies and 'fear avoidance' (avoiding work, movement or other activities due to fear of exacerbating pain or damaging the back), or negative beliefs about pain and activity
• Excessively negative thoughts about pain and the future ('catastrophising') as a means of coping
• History of other chronic pain syndrome(s).

Prognosis

Non-specific low back pain is usually self-limiting and for the majority of people it will clear in a few weeks. However, there is a risk that people with non-specific low back pain will develop chronic back pain.

The STarT Back Tool developed by researchers at Keele University can be used to determine the level of risk – low, medium or high – that people may develop persistent disabling back pain.^3,4

Treatment

People who present for the first time with non-specific low back pain and no ‘red flag’ symptoms (see Box) should be reassured that self-management is likely to help resolve their symptoms. They can be signposted to information sources such as Backcare⁵ a charity that provides information on exercises that can help, as does the STarT Back website, where there is a useful patient information leaflet⁶ and the Chartered Society of Physiotherapy’s website,⁷ which also has a number of information resources.

People with non-specific back pain should be encouraged to keep active and carry on with their normal day-to-day activities, including going to work or school, as soon as possible. They should not rest up in bed for long periods, and although they may experience some pain during normal activity, they can be reassured that they will do no harm if they take things slowly and gradually return to normal activities.² Activities such as walking, yoga, swimming, Pilates, swimming and exercising at a gym have all been found to be beneficial.⁸

Applying a heat or ice pack for short periods of time can help ease pain symptoms.^2,9

Other treatment options for people at greater risk if developing chronic symptoms include:²

• Group exercise programme (biomechanical, aerobic, mind-body or a combination of approaches)
• Physiotherapy for manual therapy (spinal manipulation, mobilisation, or massage) as part of a treatment package including exercise
• Cognitive behavioural therapy (CBT) as part of a treatment package, including exercise, with or without manual therapy, for people with significant psychosocial barriers to recovery, or when other treatments prove ineffective.

Analgesics can be recommended if necessary: over-the-counter non-steroidal anti-inflammatory drugs such as ibuprofen are first choice in this situation if there are no contraindications. The drug should be taken at the lowest effective dosage for the shortest possible time needed to provide relief from symptoms.

In cases where ibuprofen is unsuitable codeine with or without paracetamol can be offered, provided there are no contraindications, and the risk of opioid dependence needs to be borne in mind. Benzodiazepines, opioids, gabapentinoids, antiepileptic drugs and antidepressants should not be recommended.²

Future prospects

As research develops it is becoming clear how individual pain experience is and that personalised treatments are likely to produce the best results in terms of reducing symptoms. As part of the Back Pain Consortium (BACPAC) research program in the US, researchers are trying to develop a model of chronic low back pain that they hope will then help to offer patients sequences or packages of treatment that are most likely to work for them.^10,11

A study recently published in the Lancet found that cognitive functional therapy,¹² which provides individuals with help to deal with ‘unhelpful pain-related cognitions, emotions and behaviours that contribute to pain and disability’, resulted in ‘large and sustained improvements for people with chronic disabling low back pain.¹³

When to refer people with back pain for urgent medical attention is needed – red flags^2,14

Referral for medical treatment is needed for people with back pain who have symptoms of:

• Cancer, eg unexpected weight loss
• Infection, eg fever
• Nerve damage or spinal cord compression, eg numbness, weakness in one or both legs, difficulty emptying the bladder (retention of urine), or loss of bladder or bowel control (urinary incontinence or faecal incontinence) – symptoms that suggest
• Severe pain at night
• Abdominal aortic aneurysm, eg abdominal or chest pain, or pulsing sensation in the upper abdomen—symptoms that suggest an
• A digestive disorder, eg vomiting, severe abdominal pain, or stool that is black or bloody
• Urinary tract disorder, eg difficulty urinating, blood in the urine, or severe crampy pain on one side radiating into the groin.

References

1. World Health Organization (WHO). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings (www.who.int/publications/i/item/9789240081789; accessed April 2024).
2. Clinical Knowledge Summaries. Back pain – low (without radiculopathy): How common is it? (https://cks.nice.org.uk/topics/back-pain-low-without-radiculopathy/background-information/prevalence; accessed April 2024).
3. The Keele STarT Back Screening Tool (https://startback.hfac.keele.ac.uk/wp-content/uploads/2018/11/Keele_STarT_Back9_item.pdf; accessed April 2024).
4. Keele University. STarT Back (https://startback.hfac.keele.ac.uk; accessed April 2024).
5. Back Care (www.backcare.org.uk; accessed April 2024).
6. STarT Back. Your guide to back pain and what you can do about it (https://startback.hfac.keele.ac.uk/wp-content/uploads/2019/03/Start-Patient-Leaflet-1-black-and-white.pdf; accessed April 2024).
7. Chartered Society of Physiotherapy’s (www.csp.org.uk; accessed April 2024).
8. Versus Arthritis. Back pain (https://versusarthritis.org/about-arthritis/conditions/back-pain; accessed April 2024).
9. NHS Inform. Back problems (www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/back-problems; accessed April 2024).
10. National Institutes of Health HEAL initiative. Back pain consortium research program (https://heal.nih.gov/research/clinical-research/back-pain; accessed April 2024).
11. Steinmetz A. Back pain treatment: a new perspective. Ther Adv Musculoskelet Dis 2022;14:1759720X221100293.
12. O'Sullivan PB, Caneiro JP, O'Keeffe M, et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther 2018;98(5):408–23.
13. Kent P, Haines T, O'Sullivan P, et al; RESTORE trial team. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet 2023;401(10391):1866–77.
14. MSD Manual. Low back pain (www.msdmanuals.com/en-kr/home/bone,-joint,-and-muscle-disorders/low-back-and-neck-pain/low-back-pain; accessed April 2024).