Non-specific low back pain

Minor ailments account for 20% of primary care consultations and can be effectively managed through self care. This is the first of a series of articles examining the most commonly presenting minor ailments, summarising the information to share with patients

WHAT IS NON-SPECIFIC LOW BACK PAIN?

Non-specific low back pain is caused by problems with muscles, ligaments, tendons, joints or discs. It presents as soreness or stiffness in the area of the lower back lying below the rib cage and above the top of the legs. Rarely is non-specific low back pain due to a serious condition, such as inflammatory disorders, fracture, infection, cancer or compression of the spinal cord ('cauda equine syndrome')

HOW COMMON IS IT?

Non-specific low back pain is very common in the UK, affecting about eight out of ten people at some time in their lives.

WHAT CAN PATIENTS EXPECT?

In most cases, back pain resolves within 12 weeks - often much sooner. But, in some people, it may last longer. Particularly if pain is severe, this can be highly distressing. Back pain can also impair quality of life considerably, impacting on activities of daily living, sleep, mood and ability to work.

People with back pain often expect further investigation, such as spinal X-rays or Magnetic Resonance Imaging (MRI), but these are not routine assessments and are reserved for cases with suspected specific underlying causes, such as infection, cancer or a fracture, or prior to referral for possible surgery.

Patients should be advised it is normal to experience occasional twinges and aches for weeks and months. However, despite their pain, advise getting gradually back to normal activities.

WHAT CAN PEOPLE DO TO HELP THEMSELVES?

Non-specific low back pain is not always completely curable, and treatments usually aim to help people manage their condition, recover more quickly and prevent recurrences in the future.

Staying active and continuing with normal activities should be encouraged, and taking adequate analgesia can help, without increasing the risk of damage to the back. Hot or cold packs may also help reduce the pain, e.g. a hot water bottle or bag of frozen vegetables or packs from the pharmacy. Pain can be debilitating, so staying positive helps. It is important to avoid aggravating factors, such as repetitive lifting, uncomfortable postures or long periods of sitting. Taking part in exercise classes may also help, and tips for simple back exercises are available at http://www.nhs.uk/Conditions/Back-pain/Pages/Prevention.aspx.

WHICH OTC PREPARATIONS CAN PEOPLE USE?

Paracetamol is widely available and effective as first-line treatment. If regular paracetamol is not effective, a non-steroidal anti-inflammatory drug (NSAID), or preparations containing codeine are suitable alternatives or additions (while being aware of contraindications or cautions, such as aspirin-sensitive asthma for NSAIDs).

WHEN SHOULD PATIENTS RETURN?

Patients should seek further medical advice if their symptoms deteriorate or don't resolve, or if new symptoms develop, to ensure that the low back pain is not caused by a serious underlying condition. Ensure patients are made aware of this information at the initial consultation.

WHAT ARE THE NEXT STEPS?

Healthcare professionals need to consider people's personal preferences and needs when discussing the management options. If the back pain is very severe, stronger opioids or tricyclic antidepressants (but not selective serotonin reuptake inhibitors, SSRIs) may be offered. A range of healthcare professionals such as physiotherapists, chiropractors, osteopaths, acupuncturists, psychologists and back specialists may provide specialised treatments, although not all are available on the NHS. GPs should offer patients a choice of exercise classes, a course of manual therapy that includes manipulation of the spine, a course of acupuncture - or a combination of these. Patients should not be offered interventions such as back injections, laser therapy, traction, lumbar support and others as there is no strong evidence for their effectiveness.

The symptoms and signs in Box 1 - Red flags - may suggest a more serious underlying problem.

SUMMARY

Back pain is common but rarely serious and usually settles spontaneously, though symptoms can be severe. Tests are rarely needed, but the presence of red flags should prompt immediate assessment by a health professional. The sooner people get back to normal activities, the better.