CHRONIC NONSPECIFIC LOW BACK PAIN: APPROACH TO CLINICAL DIAGNOSIS.
Main Article Content
Keywords
Discogenic, Mechanical, Postural, Instability
Abstract
Introduction: Globally low back pain is a major public health issue affecting all age group. A brutal majority of all cases (80% to 90%) are nonspecific in nature without any recognisable aetiology. Hence delayed diagnosis and inadequate treatment leads to chronic low back pain in many cases affecting productivity and consequent loss of man-hours amongst a sizeable working population.
Materials and Methods: 523 cases with low back pain of more than 3 months duration with no specific clinically identifiable cause for back pain were evaluated from August 2019 to July 2021. A detailed history followed by a thorough clinical examination was done for all patients. The clinical criteria for establishing the sub types of chronic non specific low back pain were the predominating symptom and presenting sign. The data were analysed using Microsoft Excel Software.
Results: There were 289 males and 234 females with average age being 43.64 years. Discogenic chronic low back pain (CLBP) was the commonest (48.75%) type, and least being sacroiliitis (1.72%). Facetogenic type was seen in older age (57.3 years) group, as against younger age (29.6 years) in postural chronic low back pain.
Conclusion: Detail history and meticulous clinical examination is the key to diagnose and differentiate various sub types of nonspecific CLBP. Radiological evaluation, diagnostic blocks and provocative tests may enhance the accuracy in diagnosis.
References
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30. Fairbank J, Gwilym SE, France JC, et al. The role of classification of chronic low back pain. Spine (Phila Pa 1976). 2011; 36(21 suppl):S19–S42:
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33. William R. Vanwaye. Non specific Low back pain: Evaluation and treatment tips. J. Fam Pract. 2010 Aug; 59(8): 445-8
34. Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–1078
35. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012; 85 (4):343-350.
36. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review [published correction appears in BMJ. 2014;348:g7]. BMJ. 2013; 347:f7095.
37. Depalma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the location of low back pain predict its source? Pm R. 2011; 3(1):33-39.
38. Gleb Slobodin, Hava Hussein, Itzhak Rosner and Iris Eshed, Sacroiliitis – early diagnosis is key J Inflammation Res 2018; 11: 339–344.
39. Ahn K, Jhun HJ. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskelet Disord. 2015;16(1):97.
40. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine 2008; 75: 388–96.
41. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Familial predisposition and heritability estimation. Joint Bone Spine 2008; 75: 383–87.) 43. Battie MC, Videman T, Levalahti E, Gill K, Kaprio J. Heritability of low back pain and the role of disc degeneration. Pain 2007; 131: 272–80)
42. Battie MC, Videman T, Levalahti E, Gill K, Kaprio J. Heritability of low back pain and the role of disc degeneration. Pain 2007; 131: 272–80)
43. E. Lederman The myth of core stability J. Bodyw. Mov. Ther., 14 (2010), pp. 84-98
44. Leonid Kalichman, David J. Hunter. Lumbar Joint Arthritis: A review Seminars in Arthritis and Rheumatism. Volume 37, Issue 2 October 2007, Page 69-80
45. Dreyer SJ, Dreyfuss PH> Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil 1996; 77: 290-300.
46. Vittorio M Russo, Ranju, T Dhawan, Irene, Baufracco Nishanth Dharmarajah, Anto I. Lazzarino, Adrian T. Casey. Hybrid Bone SPECT/CT imaging in evaluation of Chronic Low Back pain: Correlation with facet joint Arthroplasty, World neurosurgery, Volume 107, November 2017, Pages 732-738.
47. Leonid Kalichman,, Ling Li, David Kim, Ali Guermazi, Valery Berkin, M Christopher J O’ Donnell, Udo Hoffman, Rob Cole, David J Hunter: Facet joint osteoarthritis and low back pain in the community based population: Spine (Phila Pa 1976). 2008 Nov 1; 33(23): 2560-2565.
48. P Suri, D J Hunter, J Rainville A Guermazi, J N Katz: Presence and extent of severe facet joint osteoarthritis are associated with back pain in older adults. Osteoarthritis and cartilage. Volume 21, Issue 9, September 2013, Pages 1999-1206.
49. Laslet M, Young S, Aprill C, Mc Donald B, Diagnosing painful Sacroiliac Joints. A validity study of a Mckemzieevaluation and sacroiliac provocation tests. Aust J Physiother 2003; 49: 89-97
50. Long AL.The centralization phenomenon: Its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study) Spine (Phila Pa 1976) 1995,20: 2513-2520.
51. Donelson R,Aprill C, medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine (Phila Pa 1976) 1997; 22: 1115-1122.
2. Yin-gang Zhang, Tuan-mao Guo, Xiong Guo, Shi-xun Wu Clinical diagnosis for discogenic low back pain. Int J Biol Sci 2009; 5(7):647-658.
3. Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is often impossible. Arch Intern Med. 2002;162:1444–1447).
4. Hartvigsen J, Hancock MJ, Kongsted A, et al What low back pain is and why we need to pay attention. Lancet 2018;391:2356–67,
5. Dr. Federico Balague, Anne F. Mannion, Ferran Pellise, Christine Cedraschi, The Non specific back Pain. The lancet Volume 379, issue 1984, February 4 2012, 482-491.
6. Koes BW, Van Tulder NW, Thomas SS. Diagnosis and treatment of low back pain. BMJ 332: 1430–1434, 2006.
7. Bruce F Walker The Prevalence of Low Back Pain: A Systematic Review of the Literature from 1966 to 1998 July 2000, J Spinal Disord 13(3): 205-17
8. Patrick N, Emanski E, Knaub MA. Acute and chronic low back pain. Med Clin North Am. 2014; 98(4):777–789.
9. Jeff rises LJ, Milanese S F, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine (phila Pa 1976) 2007; 32:2630-37.
10. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010; 24 (6):769–781.
11. From the Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults--United States, 1999. JAMA. 2001; 285(12):1571–1572.
12. Andersson BJ. Epidemiological features of chronic low-back pain. Lancet 354: 581–585, 1999
13. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006; 15(Suppl 2):S192–S300 Japanese Orthopaedic Association. Clinical practice guideline for the management of low back pain. Tokyo: Nankodo Co; 2012
14. Iizuka Y, Iizuka H, Mieda T, et al. Prevalence of chronic nonspecific low back pain and its associated factors among middle-aged and elderly people: an analysis based on data from a musculoskeletal examination in Japan. Asian Spine J 2017; 11:989-997.
15. Meucci RD, Fassa AG, Faria NMX Prevalence of chronic low back pain: systematic review. Rev. Saúde Pública 2015; 49:73.
16. Jenet K Freburger, George M Holmes, Robert P Agans,Anne M Jackman, Jane D Darter, Andrea Wallace, Liana D Castel, William D Kalsbeek, Timothy S carey . The Rising Prevalence of Chronic Low Back pain , Arch Intern med 2009 Feb 9 169(3): 251-258.
17. Duque IL, Para JH, Duvallet A. Aerobic fitness and limiting factors of maximal performance in chronic low back pain patients. J Back Musculoskelet Rehabil 22: 113–119, 200
18. Van den Berg-Emmons RJ, Schasfoort FC, deVos LA, Bussman JB, Stam HJ. Impact of chronic pain on everyday physical activity. Eur J Pain 11: 587–593, 2007.
19. Van Weering M, Vollenbroek-Hutten MM, Kotte EM, Hermens HJ. Daily physical activities of patients with chronic pain or fatigue versus asymptomatic controls. A systematic review. Clin Rehabil 21: 1007–1023, 2007.
20. Bogduk N. The innervation of the lumbar spine. Spine (Phila Pa 1976) 1983; 8:286– 293.
21. Kuslich SD, Ulstrom CL, Michel CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operation on the lumbar spine using local anaesthesia. Orthop Clin North AM1991; 22:181-187.
22. Heuch I, Hagen K, Zwart JA. Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trondelag Health Study. Spine. 2013; 38(2):133-139
23. Goldberg, Mark S, Scott, Susan C. Nancy E. A Review of the Association Between Cigarette Smoking and the Development of Nonspecific Back Pain and Related Outcomes. Spine 25(8): p995-1014, April 15, 2000
24. Alsaadi SM, McAuley JH, Hush JM, et al . Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain. Arthritis Rheumatol. 2014; 66(5):1388-1394.
25. Shaw WS, Means-Christensen AJ, Slater MA, et al. Psychiatric disorders and risk of transition to chronicity in men with first onset low back pain. Pain Med. 2010;11 (9):1391-1400.
26. Melloh M, Elfering A, Egli Presland C, et al. Predicting the transition from acute to persistent low back pain. Occup Med. 2011; 61(2):127-131.
27. PY Yong, NAA Alias, IL Shuaib Correlation of Clinical Presentation, Radiography, and Magnetic Resonance Imaging for Low Back Pain — a Preliminary Survey. J HK Coll Radiol 2003; 6:144-151
28. Vagaska, Eva ; Litavcova, Alexandra; Srotova, Iva, Vlckova, Eva ; Kerkovsky, Milos ; Jarkovsky, Jiri ; Bednarik, Josef ; Adamova, Blanka Do lumbar magnetic resonance imaging changes predict neuropathic pain in patients with chronic non-specific low back pain? Medicine: April 2019-Volume 98-Issue 17 –pe15377
29. Meckenzie R, May. The Human Extremities Mechanical Diagnosis and Therapy. New Zeland: Spinal Publications; 2000.
30. Fairbank J, Gwilym SE, France JC, et al. The role of classification of chronic low back pain. Spine (Phila Pa 1976). 2011; 36(21 suppl):S19–S42:
31. Rosedale R, Rastogi R, May S, et al. Efficacy of exercise intervention as determined by the Mckenzie system of mechanical diagnosis and therapy for knee osteoarthritis: a randomized controlled trial. J Orthop Sports Phys Ther. 2014; 44(3):173-181.
32. Dunsford A, Kumar S, Clarke S. Integrating evidence into practice: useof McKenzie-based treatment for mechanical low back pain. J Multidiscip Healthc. 2011; 4:393-402.
33. William R. Vanwaye. Non specific Low back pain: Evaluation and treatment tips. J. Fam Pract. 2010 Aug; 59(8): 445-8
34. Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–1078
35. Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012; 85 (4):343-350.
36. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review [published correction appears in BMJ. 2014;348:g7]. BMJ. 2013; 347:f7095.
37. Depalma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the location of low back pain predict its source? Pm R. 2011; 3(1):33-39.
38. Gleb Slobodin, Hava Hussein, Itzhak Rosner and Iris Eshed, Sacroiliitis – early diagnosis is key J Inflammation Res 2018; 11: 339–344.
39. Ahn K, Jhun HJ. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskelet Disord. 2015;16(1):97.
40. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine 2008; 75: 388–96.
41. Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Familial predisposition and heritability estimation. Joint Bone Spine 2008; 75: 383–87.) 43. Battie MC, Videman T, Levalahti E, Gill K, Kaprio J. Heritability of low back pain and the role of disc degeneration. Pain 2007; 131: 272–80)
42. Battie MC, Videman T, Levalahti E, Gill K, Kaprio J. Heritability of low back pain and the role of disc degeneration. Pain 2007; 131: 272–80)
43. E. Lederman The myth of core stability J. Bodyw. Mov. Ther., 14 (2010), pp. 84-98
44. Leonid Kalichman, David J. Hunter. Lumbar Joint Arthritis: A review Seminars in Arthritis and Rheumatism. Volume 37, Issue 2 October 2007, Page 69-80
45. Dreyer SJ, Dreyfuss PH> Low back pain and the zygapophysial (facet) joints. Arch Phys Med Rehabil 1996; 77: 290-300.
46. Vittorio M Russo, Ranju, T Dhawan, Irene, Baufracco Nishanth Dharmarajah, Anto I. Lazzarino, Adrian T. Casey. Hybrid Bone SPECT/CT imaging in evaluation of Chronic Low Back pain: Correlation with facet joint Arthroplasty, World neurosurgery, Volume 107, November 2017, Pages 732-738.
47. Leonid Kalichman,, Ling Li, David Kim, Ali Guermazi, Valery Berkin, M Christopher J O’ Donnell, Udo Hoffman, Rob Cole, David J Hunter: Facet joint osteoarthritis and low back pain in the community based population: Spine (Phila Pa 1976). 2008 Nov 1; 33(23): 2560-2565.
48. P Suri, D J Hunter, J Rainville A Guermazi, J N Katz: Presence and extent of severe facet joint osteoarthritis are associated with back pain in older adults. Osteoarthritis and cartilage. Volume 21, Issue 9, September 2013, Pages 1999-1206.
49. Laslet M, Young S, Aprill C, Mc Donald B, Diagnosing painful Sacroiliac Joints. A validity study of a Mckemzieevaluation and sacroiliac provocation tests. Aust J Physiother 2003; 49: 89-97
50. Long AL.The centralization phenomenon: Its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study) Spine (Phila Pa 1976) 1995,20: 2513-2520.
51. Donelson R,Aprill C, medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine (Phila Pa 1976) 1997; 22: 1115-1122.
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Sep 19, 2023
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Dr Sanatan Behera, Prof G S Pattnaik, & Dr Chitrita Behera. (2023). CHRONIC NONSPECIFIC LOW BACK PAIN: APPROACH TO CLINICAL DIAGNOSIS. Journal of Population Therapeutics and Clinical Pharmacology, 30(17), 1735–1744. https://doi.org/10.53555/jptcp.v30i17.2855
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Author Biographies
Dr Sanatan Behera
MBBS, D.Ortho. MS Ortho., Associate Professor, Kalinga Institute of Medical sciences (KIMS),
KIIT University, Flat No B-402, Highland Residency, Sailashree Vihar Chandrasekharpur, Bhubaneswar, Odisha
Prof G S Pattnaik
MBBS, MS Orth., Professor, Postgraduate Department of Orthopaedics, Narayan Medical College, G.T. Road, Jamuhar, Sasaram, Bihar, India
Dr Chitrita Behera
MBBS. Resident Medical Officer, Sankeshwar Mission Hospital, Old P. B. Road, Sankeshwar, District: Belgaum, Karnataka, India.