Low back pain
Low back pain or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feeling.[4] Low back pain may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks).[3] The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain.[5] The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.[2]
Low back pain
Lower back pain, lumbago
- Lumbago /lʌmˈbeɪɡoʊ/
20 to 40 years of age[1]
~65% get better in 6 weeks[2]
Acute (less than 6 weeks), sub-chronic (6 to 12 weeks), chronic (more than 12 weeks)[3]
Medical imaging (if red flags)[5]
In most episodes of low back pain a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as muscle or joint strain.[1][4] If the pain does not go away with conservative treatment or if it is accompanied by "red flags" such as unexplained weight loss, fever, or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem.[5] In most cases, imaging tools such as X-ray computed tomography are not useful or recommended for low back pain that lasts less than 6 weeks (with no red flags) and carry their own risks.[9] Despite this, the use of imaging in low back pain has increased.[10] Some low back pain is caused by damaged intervertebral discs, and the straight leg raise test is useful to identify this cause.[5] In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events.[11] Chronic non-specific low back pain (CNSLBP) is a highly prevalent musculoskeletal condition that not only effects the body, but also a person's social and economic status. It would be greatly beneficial for people with CNSLBP to be screened for genetic issues, unhealthy lifestyles and habits, and psychosocial factors on top of musculoskeletal issues. [12]
The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.[2] Normal activity should be continued as much as the pain allows.[2] Initial management with non-medication based treatments is recommended.[6] Non–medication based treatments include superficial heat, massage, acupuncture, or spinal manipulation.[6] If these are not sufficiently effective, NSAIDs are recommended.[6] A number of other options are available for those who do not improve with usual treatment. Opioids may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects,[13] including high rates of addiction, accidental overdose and death.[14] Surgery may be beneficial for those with disc-related chronic pain and disability or spinal stenosis.[15][16] No clear benefit of surgery has been found for other cases of non-specific low back pain.[15] Low back pain often affects mood, which may be improved by counseling or antidepressants.[17][18] Additionally, there are many alternative medicine therapies, but there is not enough evidence to recommend them confidently.[19] The evidence for chiropractic care[20] and spinal manipulation is mixed.[19][21][22][23]
Approximately 9–12% of people (632 million) have low back pain at any given point in time,[24] and nearly 25% report having it at some point over any one-month period.[7][8] About 40% of people have low back pain at some point in their lives,[7] with estimates as high as 80% among people in the developed world.[25] Low back pain is the greatest contributor to lost productivity, absenteeism, disability and early retirement worldwide.[24] Difficulty most often begins between 20 and 40 years of age.[1] Men and women are equally affected.[4] Low back pain is more common among people aged between 40 and 80 years, with the overall number of individuals affected expected to increase as the population ages.[7]
Signs and symptoms[edit]
In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point, to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as sciatica) may be present. The first experience of acute low back pain is typically between the ages of 20 and 40. This is often a person's first reason to see a medical professional as an adult.[1] Recurrent episodes occur in more than half of people[26] with the repeated episodes being generally more painful than the first.[1]
Other problems may occur along with low back pain. Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep.[27] In addition, a majority of those with chronic low back pain show symptoms of depression[17] or anxiety.[19]
Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness.[28] The majority of low back pain does not have a clear cause[1] but is believed to be the result of non-serious muscle or skeletal issues such as sprains or strains.[29] Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, and poor sleeping position may also contribute to low back pain.[29] There is no consensus as to whether spinal posture or certain physical activities are causal factors.[30] A full list of possible causes includes many less common conditions.[5] Physical causes may include osteoarthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an infection or tumor of the spine.[31]
Women may have acute low back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids.[32] Nearly half of all pregnant women report pain in the low back during pregnancy, due to changes in their posture and center of gravity causing muscle and ligament strain.[33]
Low back pain can be broadly classified into four main categories:
Prevention[edit]
Exercise alone, or along with education, appears to be useful for preventing low back pain.[53][54] Exercise is also probably effective in preventing recurrences in those with pain that has lasted more than six weeks.[55] Assessing chronic low back pain, a 2007 review concluded that a firm mattress is less likely to alleviate pain compared to a medium-firm mattress,[56] while a 2020 review stated that studies have been inadequate to comment on mattress firmness.[57] There is little to no evidence that back belts are any more helpful in preventing low back pain than education about proper lifting techniques.[53][54] Shoe insoles do not help prevent low back pain.[53][58][54]
Studies have proven that interventions aimed to reduce pain and functional disability need to be accompanied by psychological interventions to improve a patient's motivation and attitude toward their recovery. Education about an injury and how it can effect a person's mental health is just as important as the physical rehabilitation. However, all of these interventions should occur in partnership with a structured therapeutic exercise program and assistance from a trained physical therapist. [59]
Prognosis[edit]
Overall, the outcome for acute low back pain is positive. Pain and disability usually improve a great deal in the first six weeks, with complete recovery reported by 40 to 90%.[2] In those who still have symptoms after six weeks, improvement is generally slower with only small gains up to one year. At one year, pain and disability levels are low to minimal in most people. Distress, previous low back pain, and job satisfaction are predictors of long-term outcome after an episode of acute pain.[2] Certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain.[17] Following a first episode of back pain, recurrences occur in more than half of people.[26]
For persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. At one year, those with chronic low back pain usually continue to have moderate pain and disability.[2] People at higher risk of long-term disability include those with poor coping skills or with fear of activity (2.5 times more likely to have poor outcomes at one year),[129] those with a poor ability to cope with pain, functional impairments, poor general health, or a significant psychiatric or psychological component to the pain (Waddell's signs).[129]
Prognosis may be influenced by expectations, with those having positive expectations of recovery related to higher likelihood of returning to work and overall outcomes.[130]
Epidemiology[edit]
Low back pain that lasts at least one day and limits activity is a common complaint.[7] Globally, about 40% of people have low back pain at some point in their lives,[7] with estimates as high as 80% of people in the developed world.[25] Approximately 9 to 12% of people (632 million) have low back pain at any given point in time, which was calculated to 7460 per 100,000 globally in 2020.[24] Nearly one quarter (23.2%) report having it at some point over any one-month period.[7][8] Difficulty most often begins between 20 and 40 years of age.[1] However, low back pain becomes increasingly common with age, and is most common in the age group of 85.[24] Older adults more greatly affected by low back pain; they are more likely to lose mobility and independence and less likely to continue to participate in social and family activities.[24]
Women have higher rates of low back pain than men within all age groups, and this difference becomes more marked in older age groups (above 75 years).[24] In a 2012 review which found a higher rate in females than males, the reviewers thought this may be attributable to greater rates of pains due to osteoporosis, menstruation, and pregnancy among women, or possibly because women were more willing to report pain than men.[7] An estimated 70% of women experience back pain during pregnancy with the rate being higher the further along in pregnancy.[131]
Although the majority of low back pain has no specific underlying cause, workplace ergonomics, smoking and obesity are associated with low back pain in approximately 30% of cases.[24] Low levels of activity is also associated with low back pain.[54] Workplace ergonomics associated with low back pain include lifting, bending, vibration and physically demanding work, as well as prolonged sitting, standing and awkward postures.[24] Current smokers – and especially those who are adolescents – are more likely to have low back pain than former smokers, and former smokers are more likely to have low back pain than those who have never smoked.[132]
The overall number of individuals affected expected to increase with population growth and as the population ages,[24] with the largest increases expectedin low- and middle-income countries.[54]
Society and culture[edit]
Low back pain results in large economic costs. In the United States, it is the most common type of pain in adults, responsible for a large number of missed work days, and is the most common musculoskeletal complaint seen in the emergency department.[28] In 1998, it was estimated to be responsible for $90 billion in annual health care costs, with 5% of individuals incurring most (75%) of the costs.[28] Between 1990 and 2001 there was a more than twofold increase in spinal fusion surgeries in the US, despite the fact that there were no changes to the indications for surgery or new evidence of greater usefulness.[10] Further costs occur in the form of lost income and productivity, with low back pain responsible for 40% of all missed work days in the United States.[135] Low back pain causes disability in a larger percentage of the workforce in Canada, Great Britain, the Netherlands and Sweden than in the US or Germany.[135] In the United States, low back pain is highest of Years Lived With Disability (YLDs) rank, rate, and rercentage Change for the 25 leading causes of disability and injury, between 1990 and 2016.[136]
Workers who experience acute low back pain as a result of a work injury may be asked by their employers to have x-rays.[137] As in other cases, testing is not indicated unless red flags are present.[137] An employer's concern about legal liability is not a medical indication and should not be used to justify medical testing when it is not indicated.[137] There should be no legal reason for encouraging people to have tests which a health care provider determines are not indicated.[137]
Research[edit]
Total disc replacement is an experimental option,[37] but no significant evidence supports its use over lumbar fusion.[15] Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human growth factors, implanted substances, cell therapy, and tissue engineering.[37]