USBJD Condition Kit: Low Back Pain
Scope of the Disease
Number and gender of individuals affected
Low back pain is a common and expensive medical condition. Healthcare professionals claim between 70% and 85% of people suffer from low back pain at some time in their lives. Low back pain is the second most common symptom for which people seek treatment. Low back pain affects men and women equally. The onset of symptoms most often occurs between the ages of 30 and 50 years. Low back pain is the most common cause of work-related disability in people under 45 years of age.
Preventing back injuries is a major workplace safety challenge. According to the Bureau of Labor Statistics, more than one million workers suffer back injuries each year, and back injuries account for one of every five workplace injuries or illnesses. Further, one-fourth of all compensation indemnity claims involve back injuries, costing industry billions of dollars on top of the pain and suffering borne by employees.
Of the 1.7 million annual nonfatal injuries and illnesses in private industry causing lost workdays, 25% are back injuries.
Incidence of disease
Episodes of low back pain are usually short, and most people improve over four to six weeks. However, low-grade symptoms or recurrent episodes are common in up to 50% of cases. A small percentage of patients develop conditions such as herniated discs and spinal stenosis, which may require more in-depth treatment.
Cost of disease
Direct health care costs are more than $20 billion dollars per year, and when indirect costs, including lost time from work are added, costs increase to as much as $50 billion per year.
The direct costs of diagnosing and treating low back pain in the United States were estimated in 1991 to be $25 billion annually. Indirect costs, including lost earnings, are even higher.
What Causes Low Back Pain?
Lifestyle factors
Risk factors for acute low back pain include heavy lifting and twisting, bodily vibration, obesity, and poor conditioning. Low back pain is common even in people without these risk factors.
Genetics/structural factors
Low back pain may originate from many spinal structures, including ligaments, joints, discs and muscles. The most common injuries are probably related to the muscles, ligaments, and age-related changes in the intervertebral discs and the small joints (facet joints). There may be changes in the mechanical properties of the disc that also play a role. These injuries are often called sprain, strain or degenerative disc disease, which are nonspecific terms. Only a small percentage of patients have a specific diagnosis or identifiable cause for their pain.
Since most patients with acute low back pain improve, immediate diagnostic studies, such as x-rays, MRIs and CT scans are not generally recommended. Acute low back pain is sometimes called lumbar sprain or strain, or degenerative disc disease, but these are not specific diagnoses, and they are not found on x-ray. There is a weak association between symptoms, examination findings and diagnostic tests in this condition.
Only a small percentage of patients have an identifiable underlying cause for their back pain. Less than 2% of patients have a symptomatic disc herniation that may pinch a nerve and even fewer have a serious disease. Other common problems in the lumbar spine seen with aging include spinal stenosis.
Osteoporosis
People with osteoporosis may incur compression fractures in the spine due to weakening of the bone related to age and other potentially treatable risk factors.
Diagnosis of low back pain
Exam and Medical History
Since the cause of most episodes of acute low back pain is uncertain, the initial examination will usually focus on ruling out potentially serious causes of the pain. A detailed history including information about symptoms, weight change, loss of appetite and fatigue can help in this process. Most people can identify a particular event that produced the immediate onset of low back pain. Common histories include lifting or twisting while holding a heavy object, operating a machine that vibrates, prolonged sitting (e.g. long distance truck driving), involvement in a motor vehicle accident, and falls. Physical examination will include evaluation of posture and flexibility. A more detailed neurological examination is indicated in patients with certain or associated leg symptoms.
Imaging tests
Diagnostic testing such as x-rays or special imaging studies are not usually indicated in the initial few weeks after the onset of symptoms. Findings from both plain x-rays and advanced imaging studies are poorly associated with low back symptoms. The most common causes of nerve root irritation (which often presents with leg pain) cannot be diagnosed on plain x-rays. More detailed imaging studies, such as MRI, may be indicated if there is no improvement in symptoms over time. Findings reflecting lumbar disc degenerative changes begin as early as the fourth decade, and are seen with increasing frequency in patients with low back pain. Findings such as bulging discs, commonly seen on MRI or CT scan, are also common in patients without low back pain. These findings alone are not predictors of low back pain or the healing process.
Treatment of low back pain
Many different health care providers can manage acute low back pain. Primary care physicians, orthopedic surgeons, neurosurgeons, physiatrists, osteopathic physicians, chiropractors, and physical therapists all see and treat patients with low back pain. Initial recommendations are usually non-surgical, and include suggestions for relief of symptoms that may include medications, manual manipulation, exercise or other modalities. It is important to remember that the natural history of low back pain is that it usually improves on its own.
Referral to a specialist and diagnostic testing may be indicated for patients with recurrent low back pain, potentially more serious conditions, signs of leg pain suggesting nerve involvement (radiculopathy), or for those patients who fail to improve.
Staying active
People who resume their usual activities early seem to improve more rapidly than those who are on bed rest. The most common situations to avoid are those that require prolonged sitting and standing. Changing position can cause increases in pain so this may need to be done slowly. Low stress aerobic activity such as walking is the best early activity. Specific exercises are not necessary in the acute phase, but a regular exercise and fitness program may be helpful in preventing future episodes of low back pain. Ice or heat can alleviate acute soreness and pain.
Medication and other therapies
The most commonly prescribed medications are acetaminophen or non-steroidal anti-inflammatory medications such as ibuprofen or naproxen. Muscle relaxants and opioids have not been shown to be more effective. In cases of chronic or on-going back pain or pain radiating into the leg, treatments with manual manipulation may provide some level of pain relief. These treatments generally last up to a few weeks. Patients should also be aware that factors such as stress, job dissatisfaction and other psychological issues can delay some of the benefits of medications and manipulation.
Bracing
For those who need extra support for their back, especially those whose job requires heavy lifting, a variety of braces are available to stabilize the back. However, scientific studies do not support their usefulness.
Surgery
In extreme and prolonged cases of back pain, and for people with problems such as symptomatic herniated discs, degenerative spondylolisthesis, and spinal stenosis, surgery may be the best long-term option. However, most low back conditions do not require surgical treatment. Scoliosis, or curvature of the spine, may require surgical correction in childhood or adolescence. In adults, scoliosis can also be managed surgically if it compromises overall health. The presence of osteoporosis may influence the risks of surgery, and there are special surgical and non-surgical procedures to treat compression fractures.
Prevention
Good Posture
When sitting and standing, good posture is essential to prevent putting too much improper stress upon the spine. While standing, keep one foot in front of the other and bend knees slightly. Sit with knees slightly higher than hips to give the lower back support. This can be accomplished by placing a small box or telephone book under your feet.
Sleeping position
Improper sleeping positions can put up to as much as 55 lbs of pressure on the spine. Sleeping on the side is the best way to reduce such pressure, and putting pillows between the knees when sleeping on ones side or under the knees when sleeping on the back will also decrease the pressure load.
Weight control
Excess weight exerts significant unwanted or adverse pressure on the lower back. It is important to maintain a healthy weight through good eating, regular physical activity, managing stress, and to avoid smoking. Reaching a specific weight is not as important as the lifestyle changes you make to become healthy.
Quitting smoking
The nicotine in tobacco restricts the blood flow to the discs that separate vertebrae, and this may increase the risk of back pain.
Public Education
Studies of the importance of public education in the treatment of low back pain have shown that people who know how to manage their low back pain improve more readily.Many web site and print materials discuss low back pain and provide information on prevention and treatment, and the condition is treated by a wide array of health care professionals. However, there are few identifiable public health initiatives to educate the public about back pain.
One set of guidelines can be found at www.guideline.gov - search for low back pain.
Future Directions of Research
Developments in treatment for low back pain include several different approaches.
Medications: Research is underway in the development of medications that may slow degenerative changes, and even help repair the disc. However these medications are in the early stages of development.
Genetic: Gene therapy may play a part in preventing degenerative changes and repairing the disc. Better understanding of disc generated pain may lead to development of medications to inhibit it.
Diagnosis: Improvements in diagnosis will help to provide patients with more effective treatments, including surgical procedures, physical therapy, or medications. Systematic reviews of commonly used diagnostic studies are being performed to better determine the usefulness of these procedures. Current studies are looking to separate patients with low back pain into different groups that will respond to more specific treatments. Goals of these studies include better localization of the source of pain, and better understanding of the roles of muscles and soft tissue on back pain.
Prevention: Furthermore, efforts at preventing lower back pain will be helped by investigating the role that ergonomic factors have in spinal disorders.
Useful Resources
Federal government
Healthfinder® - Department of Health and Human Services
www.healthfinder.gov
Medline Plus - National Library of Medicine and National Institutes of Health, with links to relevant NIH institutes and other organizations
www.nlm.nih.gov/medlineplus/backpain.html
National Institute of Neurological Disorders and Stroke
http://www.ninds.nih.gov/health_and_medical/pubs/back_pain.htm
For additional linksto a number of sites offering information on low back pain, including organizations participating in the U.S. Bone and Joint Decade, visit:
www.usbjd.org/patients_public/index.cfm
State governments - Every state has a variation on a department of Health and Human Services, and many provide information.
Condition Kit on Back Pain
Produced by the
United States Bone and Joint Decade, NFP
May 2007
United States Bone and Joint Decade
The mission of the United States Bone and Joint Decade (USBJD) organization is "to provide national leadership and coordination of activities in the United States in the worldwide movement to improve patient care, to promote research and to advance understanding and treatment of musculoskeletal conditions during the International Bone and Joint Decade." The worldwide Bone and Joint Decade is an international collaborative movement sanctioned by the United Nations/World Health Organization.
This initiative was developed in response to the staggering statistic that musculoskeletal disease currently affects more than one billion individuals worldwide. In the United States, bone and joint disorders affect one in three Americans, remain the No. 1 reason people visit the doctor, and cost an estimated $300 billion per year. The Decade's aim is to reduce the burden of musculoskeletal disease, and to improve the quality of life for those who are challenged by a musculoskeletal condition by promoting greater awareness, educating the public about prevention, and increasing research to improve diagnosis and treatment.
President Bush proclaimed the Bone and Joint Decade in the United States. All 50 U.S. states have endorsed the Decade. Around 100 U.S. patient, healthcare professional, and other organizations support the Decade, as well as all 125 medical schools and many colleges of medicine.
To learn more about the Decade, visit www.usbjd.org
United States Bone and Joint Decade, NFP
6300 N. River Road
Rosemont, IL 60018
Phone: 847-384-4010
Fax: 847-823-0536
usbjd@usbjd.org
5/16/07
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