Aspecific Low Back Pain

Currently, the prevalence of Low Back Pain is estimated to be between 18.3% and 30.8% people who experience episodes of Low Back Pain every month, which places Low Back Pain 6th on the list of Overall disease burden worldwide. However, Low back pain is not a serious condition, and often resolves seemingly spontaneously. Roughly 90% of cases of Low Back Pain are deemed to be aspecific, which implies that there is no clear pathoanatomical cause. Specific disorders affecting the lumbar spine, such as radiculopathy, or spinal canal stenosis are deemed to be specific causes of low back pain. Pain caused by structures such as facet joints, vertebral disks, and musculature are deemed to be aspecific.

When dealing with aspecific low back pain, it is important to maintain our physical activity. For that reason, it is also important that despite temptation, people suffering from low back pain should avoid bed rest as much as possible. By gradually increasing our exercise levels we promote active recovery of symptomatic structures, and we don’t run the risk of damaging any structures in the lower back. If low back pain is keeping a person out of work, a gradual return to work, sometimes with an adjusted workload has been shown to improve patient outcomes in the long term.

A 2016 Randomised Control trial investigated the effects of Mindfulness-Based Stress Reduction and Cognitive Behavioral Therapy (Cherkin et al, 2016) found that Mindfulness-Based Stress Reduction techniques, alongside general rehabilitation showed a greater improvement in symptoms of low back pain than rehabilitation alone. The interventions examined in this trial included Mindfulness-Based Stress Reduction techniques such as yoga, and breathwork, alongside techniques with their grounding in psychology, such as Cognitive Behavioural Therapy, and Rational Emotive Therapy. It was shown that patients who were exposed to Mindfulness-Based Stress Reduction as part of their rehabilitation had less pain scores, and fewer functional limitations.

The role of clear communication between patient and physiotherapist has long been established when treating low back pain. A 2008 study by Engers et al demonstrated the importance of patient education on the treatment of low back pain. They found that patients who received education on the nature of the pain, the physiological reason behind pain, and the expected course of treatment had better outcomes both in the short and the long term when recovering from an episode. This shows the importance of both physiotherapists and patients working together to clearly communicate the nature of the condition in order to bolster the patients understanding of their pain, which can lead to better outcomes.

• Identifying involved structures in assessment is essential to determining whether pain is Specific/Aspecific and what bracket the patient may fall in to.
• Treatment should be based on a return to healthy activity, rather than specific goals such as Range of Motion or building strength.
• Patients should be educated clearly and comprehensively about the nature of their condition.
• A gradual increase in or return to exercise will not damage the back, in fact it leads to better outcomes.
• A combination of Mindfulness-Based Stress Reduction and physiotherapeutic treatment can lead to better outcomes.

• Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., & Turner, J. A. (2016). Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. Jama, 315(12), 1240-1249.

• Engers, A. J., Jellema, P., Wensing, M., van der Windt, D. A., Grol, R., & van Tulder, M. W. (2008). Individual patient education for low back pain. Cochrane database of systematic reviews, (1).

• Heneweer, H., Staes, F., Aufdemkampe, G., van Rijn, M., & Vanhees, L. (2011). Physical activity and low back pain: a systematic review of recent literature. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 20(6), 826–845. https://doi.org/10.1007/s00586-010-1680-7

• Maher, C., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. The Lancet, 389 (10070), 736-747.

• Staal, J. B., Hendriks, E. J. M., Heijmans, M., Kiers, H., Lutgers-Boomsma, A. M., Rutten, G., … & Custers, J. W. (2013). KNGF Clinical Practice Guideline for Physical Therapy in patients with low back pain. KNGF Clinical Practice Guideline for Physical Therapy in patients with low back pain. Amersfoort, The Netherlands: Royal Dutch Society for Physical Therapy (KNGF).