Clinical Practice Guidelines for the Management of Non‑Specific Low Back Pain in Primary Care: An Updated Overview

European Spine Journal, July 2018

Oliveira Et. Al   

Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista (UNESP), Presidente Prudente, Brazil

Raise your hand if you encounter this scenario on a regular basis:

1. First Visit at Primary Care for Chronic Low Back Pain: Around 3 months ago, your soon-to-be patient had a visit to their primary care provider for their long-standing course of non-specific low back pain. At the visit, the provider immediately both took and reviewed x-rays of the patient’s lumbar spine and then discussed the degenerative nature of the gentleman’s poor degenerative and bulging discs that showed up on the report.  No discussion of psychosocial factors or red flag items were had and although the patient’s reflexes were checked, no further neurological physical examination was carried out.
2. The Provider’s Course of Action: The patient now has a new diagnosis of degenerative disc disease, which, of course, they will certainly inform you of when they meet you. Following the diagnosis, the practitioner then instructed the patient to rest, avoid any activity that may cause pain (as this could be harmful to the patient) and then prescribed a course of prednisone and an opioid to help ease symptoms.
3. The Flare-Up and the Return to Primary Care: Fast forward 2 months from the patient’s primary care visit and now the patient is in urgent care for a flare-up of their persistent low back pain.  Following some more medication from urgent care to ease the symptoms, the patient returned to their primary care practitioner who then decided, “Well, we could always try physical therapy for you as a last effort before we send you to the spine surgeon.”
4. Last Ditch Effort – PT: The patient, fearful of a possible back surgery for their “damaged” spine, is now ready, though skeptical, to see you in PT.

Sadly, this scenario remains prevalent throughout western medicine and complicates the process of recovery for patients as well as the clinicians working with them. Low back pain (LBP) continues to be a major public health concern, with an 18% prevalence and over $100 billion tab in annual cost.  Managment of non-specific low back pain needs to improve in primary care and throughout the healthcare system. To help this process, the European Spine Journal put out an updated overview of clinical practice guidelines for the management of non-specific LBP in the primary care setting.

What We Should Focus On For Non-Specific Low Back Pain 

• A thorough history and examination
  • Red Flags: Malignancy, unexpected weight loss, fracture, significant trauma, prolonged use of corticosteroids, infection, fever, and HIV
  • Yellow Flags: Beliefs that pain and activity are harmful, preferences that don’t fit with best practice (i.e. passive over active treatments) and a lack of social support.
    • >67% of all recommendations in the study include assessing psychosocial factors, such as anxiety and depression, which could be considered yellow flags
  • Neurological Testing: Examining for radiculopathy and sciatic pathology, including tests such as straight leg raise, dermatomal, myotomal, and reflex testing.

• Routine imaging should be avoided unless serious pathology is expected
  • There are many findings on scans that may appear as pathological changes but may, in fact, be a normal process of aging and not associated with the generation of pain or dysfunction.
  • Many other studies have documented the phenomenon of patients perseverating and identifying with imaging findings, which may lead to fear-avoidant behaviors, negative body perceptions, decreased optimism, and decreased resilience: all important towards recovery.

• Utilization of a multi-disciplinary approach
  • This can include but is not limited to: physical therapy for optimizing movement and decreasing movement-related fear avoidance (among many other things) as well as psychological interventions to help address potential co-morbid psychological conditions.
  • 100% of recommendations support utilizing exercise!
    • Although everyone appears to be in consensus that exercise is effective, the mode and delivery of the exercise intervention are still up for debate within this paper.
  • 91% of recommendations supported a cognitive behavior approach.

• Acute low back pain recommendations
  • Patients should receive a quality education and reassured a favorable prognosis.
  • Patients should avoid bed rest and return to normal activities when possible.
  • NSAIDs and weak opioids for only short periods may be recommended and only when necessary.
• Chronic low back pain recommendations
  • Exercise and psychosocial interventions are recommended (see above).
  • NSAIDs and anti-depressants only when necessary.
• Patients should be referred to specialists in cases where there is a suspicion of a serious pathology, radiculopathy, or no improvement over time (>4 weeks).

How does the above scenario sound after seeing these recommendations? Maybe the example patient could have received far better care and fewer dollars spent.

Key Takeaways

The management of low back pain can be messy and all over the place in the real world. Hopefully, these guidelines become more widespread as time goes on. Although these recommendations are written for primary care providers, I think all of us rehab specialists could benefit from several key recommendations in the paper. We need to routinely be screening for red and yellow flags and performing a thorough neurological assessment. Very importantly, we need to cut out fearful, harmful language and de-educate the concept of spines being fragile and degenerative. In its place, we could encourage a favorable prognosis, promote resiliency, and increase our patient’s positive beliefs of the strength of their backs and facilitate their self-efficacy with recovery. With regards to our interventions, let’s opt away from the passive treatments and modalities in favor of getting people up, bending, lifting, and moving.

Tyler Cope

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