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Chronic Low Back Pain

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Chronic Low Back Pain

  • See Also
  1. Acute Low Back Pain
  2. Lumbar Spine Anatomy
  3. Low Back Pain History
  4. Low Back Pain Red Flags
  5. Low Back Exam
  6. Differential Diagnosis of Low Back Pain
  7. Lumbar Disc Disease
  8. Chronic Low Back Pain Management
  9. Low Back Imaging
  10. Rheumatologic Conditions affecting the Low Back
  11. Low Back Pain in Children
  12. Low Back Pain in Teen Athletes
  13. Thoracolumbar Trauma
  • Definitions
  1. See Low Back Pain
  2. Chronic Low Back Pain
    1. Low Back Pain persisting >12 weeks
  • Epidemiology
  1. Chronic Low Back Pain represents a small subsegment of Low Back Pain (<5%)
    1. Most patients with Low Back Pain will have Musculoskeletal Low Back Pain (95% will resolve within 6 weeks)
  2. Frequent, severe Low Back PainPrevalence occurs in 8% or 11.8 of 145 Million Employed Adults (U.S., 2015)
    1. Ages 18-29: 5.9% (1.99 Million)
    2. Ages 30-44: 7.9% (3.74 Million)
    3. Ages 45-64: 9.7% (5.52 Million)
    4. Age >65: 8.7% (0.63 Million)
    5. CDC Low Back Pain
      1. https://wwwn.cdc.gov/Niosh-whc/chart/ohs-lowback/illness?OU=FS_PAINLB&T=A&V=R
  3. Chronic Low Back Pain Prevalence
    1. U.S.: 13% (severe in 30% of this subset with Chronic Low Back Pain)
    2. Worldwide: 23%
  • Risk Factors
  1. More intense Low Back Pain
  2. Consistently symptomatic Acute Low Back Pain at 4 weeks
  3. Obesity
  4. Major Depression
  5. Anxiety Disorder
  6. Poor coping skills
  7. Smoking
  8. High intensity physical labor
  • History
  1. See Low Back Pain History
  2. See Serious Low Back Symptoms (Low Back Pain Red Flags)
  3. See Thoracolumbar Trauma
  4. Careful history and examination is the most important evaluation measure in Low Back Pain
  • Exam
  1. Back should be exposed (e.g. in gown) to allow for adequate palpation and visualization
  2. See Lumbar Spine Anatomy
  3. Low Back Exam
    1. See Low Back Exam
    2. See Standing Low Back Exam
    3. See Sitting Low Back Exam
    4. See Supine Low Back Exam
    5. Straight Leg Raise and Crossed Straight Leg Raise
  4. Neurologic Exam
    1. See Sensory Exam
    2. See Reflex Exam
    3. See Motor Exam
    4. Active Knee Extension (L4)
    5. Walk on heels (L5)
    6. Walk on toes (S1)
    7. Clonus (suggests Upper Motor Neuron involvement)
  • Differential Diagnosis
  1. See Low Back Pain Red Flags
  2. See Differential Diagnosis of Low Back Pain
  • Labs
  1. Not routinely indicated
  2. Consider lab testing in suspected cancer, infection or inflammatory disorders
  • Imaging
  1. See Low Back Imaging
  2. See Low Back Pain Red Flags
  3. Imaging is typically indicated in Chronic Low Back Pain
    1. Contrast with Acute Low Back Pain, in which imaging is limited to Low Back Pain Red Flags and Trauma
  4. Avoid catastrophizing imaging findings
    1. Imaging often demonstrates asymptomatic changes unrelated to the patients symptoms and signs
    2. Describing imaging as normal with age related changes benefits patient outcomes
      1. Better treatment efficacy and higher resulting function
      2. Rajasekaran (2021) Eur Spine J 30(7): 2069-81 [PubMed]
  1. Not recommended if radiculopathy is obvious from exam
  2. Indications: Radiculopathy, Neuropathy, Myelopathy, Myopathy
    1. Persistent symptoms >6 weeks AND
    2. Suspected nerve root dysfunction with neuromuscular deficit
      1. Radicular Pain
      2. Muscle Weakness
      3. Sensory Loss
      4. Muscle atrophy
  • Management
  1. See Low Back Pain Management
  2. See Return to Work in Lumbar Back Pain
  3. See Low Back Rehabilitation
  4. See Low Back Muscle Fusion Rehabilitation
  5. See McKenzie Method
  • Prevention
  1. See Low Back Rehabilitation
  2. Prevent the transition from Acute Low Back Pain to Chronic Low Back Pain
  3. Regular Exercise
    1. Protective factor in the prevention of Chronic Low Back Pain
  • Prognosis
  1. Risk of progression from Acute Low Back Pain to Chronic Low Back Pain
    1. PICKUP Score
      1. https://www.evidencio.com/models/show/1119
    2. Orebro Musculoskeletal Pain Screening Questionnaire
      1. https://orthotoolkit.com/ompsq-sf/
    3. STarT Back Calculator
      1. https://startback.hfac.keele.ac.uk/training/resources/startback-online/
  2. Psychosocal red flags associated with delayed improvement
    1. Belief that pain and activity are harmful
    2. Worker Compensation claims or prolonged Sick Leave
    3. Depressed Mood
    4. Social isolation, social withdrawal, or lack of social support
    5. Exaggerated illness response
    6. Overprotective family
  3. References
    1. New Zealand Acute Low Back Pain Guide
      1. https://www.acc.co.nz/assets/provider/lower-back-pain-guide-acc1038.pdf
  • Resources
  1. Keele STarT Back Approach (YouTube) for patients at risk of progressing to Chronic Low Back Pain
    1. https://www.youtube.com/watch?v=tHMJf74buW4
  2. Bob and Brad's Back Pain Playlist (YouTube)
    1. https://www.youtube.com/playlist?list=PL8l32k1r15l73-noQNhmHILi3BvtMpvU7
  • References
  1. Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
  2. Arce (2001) Am Fam Physician 64(4):631-8 [PubMed]
  3. Atlas (2001) J Gen Intern Med 16:123 [PubMed]
  4. Bratton (1999) Am Fam Physician 60(8):2299-306 [PubMed]
  5. Bueff (1996) Prim Care 23:345-64 [PubMed]
  6. Jarvik (2002) Ann Intern Med 137:586-97 [PubMed]
  7. Joines (2001) J Gen Intern Med 16:14-23 [PubMed]
  8. Maharty (2024) Am Fam Physician 109(3): 233-44 [PubMed]
  9. Patel (2000) Am Fam Physician 61(6):1779-86 [PubMed]
  10. Rose-Innes (1998) Geriatrics 53:26-40 [PubMed]
  11. Swenson (1999) Neurol Clin 17:43-63 [PubMed]
  12. Will (2018) Am Fam Physician 98(7):421-8 [PubMed]