Nonespecific Low Backpain

Perspective
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The contemporary management of

nonspecific lower back pain
Ronaldo Fernando de Oliveira1 , Junior Vitorino Fandim1 , Iuri Fioratti1 , Lı́via Gaspar
Fernandes1 , Bruno Tirotti Saragiotto1 & Leonardo Oliveira Pena Costa*,1
1
Masters & Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil
*Author for correspondence: lcos3060@gmail.com
Practice points
• Nonspecific low back pain (LBP) represents an enormous burden in terms of disability and costs worldwide.
• Most patients with a first episode of LBP have good prognosis with rapid recovery within the first 6 weeks;
however, many patients still develop chronic or persistent back pain.
• The known risk factors for LBP includes poor general health, physical and psychological stress and individual
characteristics.
• The contemporary management of LBP includes simple first-line care with advice on avoiding bed rest and
maintain usual activities. Second-line care would include more complex treatments mostly based on
nonpharmacological options, such as physical and psychological therapies.
Low back pain (LBP) is extremely common and causes an enormous burden on the society. This perspective
article aims to provide an evidence-based summary in the field of LBP. More specifically, we aimed to
present epidemiological data on cost, diagnosis, prognosis, prevention and interventions for patients with
LBP. It is critical that both clinicians and policymakers follow best practices by using high-value care for
patients with LBP. In addition, nonevidence-based procedures must be immediately abandoned. These
actions are likely to reduce societal costs and will improve the quality of life of these patients.
First draft submitted: 10 April 2019; Accepted for publication: 16 July 2019; Published online:
27 August 2019
Keywords: diagnosis • intervention • low back pain • prognosis
Low back pain (LBP) is a common condition worldwide [1]. LBP is defined as pain in the posterior part of the
body that extends from the last ribs to the lower gluteus [1] and may or may not be associated with pain referred to
one or both lower limbs [1,2]. LBP is usually classified according to the duration of symptoms in acute (lasting up
to 6 weeks), subacute (6–12 weeks) or chronic (over 12 weeks) [3]. The diagnostic triage of LBP allocates patients
to one of three categories: those with serious specific spinal pathologies (<1% of cases) such as cancer, fractures,
infections; nerve root compromise such as spinal stenosis, radiculopathy (5–10% of all cases) and nonspecific LBP,
which corresponds to approximately 90–95% of the cases [4].
Epidemiology & costs

The Global Burden of Disease Study examined the impact of diseases in 195 countries between 1990 and 2015.
This study identified a 54% increase in years lived with disability associated with LBP [1]. Overall, within the
291 conditions studied, LBP is the first in the ranking in terms of years lived with disability [5–8]. The years lived
with disability associated with LBP increased from 58.2 million in 1990 to 83 million in 2010, and it was higher
between the ages of 35 and 50 years [5].
The largest systematic review investigating the LBP prevalence estimated a point prevalence of 18% and a lifetime
prevalence of 39% [5]. LBP is more common in women, individuals aged between 40 and 69 years [2,9], and from
high-income countries (32.9%), compared with middle-income (25.4%) and low-income (16.7%) countries [1,9].
The costs involved in LBP management vary widely between countries, with influence from culture, social
systems and beliefs [1]. For example, the health insurance system managed by the US government (Medicare) report
a 629% increase in expenses with epidural steroid injections, 423% with opioids, 307% with magnetic resonance
10.2217/pmt-2019-0016
C 2019 Future Medicine Ltd Pain Manag. (Epub ahead of print) ISSN 1758-1869
Perspective Oliveira, Fandim, Fioratti, Fernandes, Saragiotto & Costa
imaging and 220% with spinal fusion surgery rates [1,10]. It is estimated that Medicare could have a reduction
of $362 million per year if the management of LBP was performed according to clinical practice guidelines [11].
Therefore, an evidence-based approach to the management of LBP is likely to reduce costs and may reduce the
burden of LBP worldwide.
Prognosis
A large number of studies have analyzed the prognosis of LBP in adults over the last decade. The most recent
systematic review with meta-analysis included a total of 33 prospective cohort studies (pooled n = 11.166 people
with acute or persistent LBP) [12]. The authors of this review observed that the clinical course of acute LBP is
initially favorable and benign with a significant reduction of pain and disability in the first 6 weeks of symptoms.
The mean reduction in pain intensity in the first 6 weeks was 23 points (95% CI: 21–25 points) and the mean
disability reduction was 24 points (95% CI: 23–26 points), both outcomes measured on a 0–100 points scale.
After 6 weeks, these patients experienced a small improvement in both pain and disability lasting up to one year.
In addition, this review demonstrated that 35% of patients were completely recovered (pain-free, no disability and
returned to work) at 9 months and up to 41% at 12 months. Finally, patients with persistent LBP also showed
substantial improvements in the first 6 weeks with a mean pain intensity in of 33 points (95% CI: 29–38 points)
and disability of 21 points (95% CI: 25–31 points) on a 0–100 scale [12]. However, between 6 weeks and 1 year
the reduction of pain and disability was small, and these patients typically presented moderate levels of pain and
disability after 1 year.
Despite the favorable clinical course of acute and persistent LBP, these patients commonly present episodes
of recurrence over time. A systematic review summarized the current evidence related to the recurrence of LBP
in patients who recovered from a previous episode. The review included seven observational studies and one
randomized controlled trial (pooled n = 2147 participants) [13]. The authors observed that 33% (95% CI: 28–38%)
of patients developed recurrence within 1 year after a previous episode of LBP.
Several studies have been dedicated to understand the prognostic factors that influence the clinical course of
people with LBP. Costa et al. [12]. summarized a wide variety of prognostic factors in LBP. The authors found that
the presence of two or more positive neurological signs (odds ratio [OR]: 3.7; 95% CI: 1.4–9.5), high-somatic
awareness (OR: 4.1; 95% CI: 1.7–10) and distress (OR: 4.6; 95% CI: 1.8–11.5) were associated with poor recovery
after 3 months. Other factors such as previous medical leave due to LBP (Hazard ratio (HR): 0.7; 95% CI: 0.5–1.0),
low educational level (HR: 0.7; 95% CI: 0.5–1.0) and high-perceived risk of persistent pain (HR: 0.9; 95% CI:
0.9–1.0) were also associated with a poor recovery in terms of pain intensity. Finally, factors such as high-perceived
risk of persistent pain (HR: 0.9; 95% CI: 0.8 to 0.9) and high disability at the onset of symptoms (HR: 0.7; 95%
CI: 0.6–0.9) were associated with poor recovery in terms of disability. The authors of this review reported that the
strength of the associations was inconsistent between the included studies and the variability of the characteristics
of the studies prevented the use of meta-analytic techniques [12–14].
Risk factors
Research on risk factors for LBP has been increasing over the years in attempt to reduce the burden of LBP
worldwide and to potentially reduce people’s exposure to these [15]. Recently, an overview of systematic reviews on
risk factors for LBP and sciatica [16] investigated more than 50 risk factors described in the literature. The authors
found 34 risk factors related to the characteristics of individuals, general health and physical or psychological
variables. We have described data from the most recent systematic reviews related to risk factors for LBP below and
presented the measure of association and quality of evidence in Table 1.
Individual risk factors

A systematic review (41 studies, n = 28,403) investigated individual factors for the development of LBP, Taylor
et al. [15]. The results show that people between the ages of 44 and 75 years were less likely to have the first episode
of LBP than people between the ages of 18 and 44 years. People with a history of LBP were more likely to have
another episode of LBP than people who have never had LBP. The authors also found that people over 170 cm
height have an increased risk of developing LBP. There was no evidence that gender is a risk factor for LBP.
10.2217/pmt-2019-0016 Pain Manag. (Epub ahead of print) future science group

The contemporary management of nonspecific lower back pain Perspective
Table 1. Risk factors for low back pain.

Risk factor Odds ratio (95% CI) Quality of evidence†
Age (18–44 years) 2.8 (1.3–5.9) Moderate
History of low back pain 6.1 (4.1–9.1) Moderate
Obesity (body mass index ⬎24) 1.4 (0.9–1.0) High
Height (⬎170 cm) 1.7 (1.0–2.6) Moderate
Chronic diseases 1.7 (1.2–2.4) Moderate
Sleep problems 3.2 (1.9–5.5) Moderate
Frequently feeling tired 1.8 (1.4–2.3) Moderate
Another regional pain 1.7 (1.2–2.4) Moderate
Puberty 1.5 (1.2–1.8) Moderate
Smoking 1.9 (1.3–2.7) Low
Lifting (⬎25 kg) 1.1 (1.0–1.2) High
Lifting (frequency) 1.1 (1.0–1.2) High
Prolonged standing or walking 2.9 (1.5–5.5) Moderate
Time driving (⬎2 h) 4.8 (1.4–16.4) Moderate
Pulling (⬎56 lb) 2.1 (1.2–3.4) Moderate
Kneeling (⬎15 min) 2.1 (1.3–3.3) Moderate
Squatting (⬎15 min) 1.8 (1.1–3.1) Moderate
Bending forward and backward 2.2 (1.4–3.4) Moderate
Hands above shoulders workers 1.6 (1.1–2.4) Moderate
Military active duty 1.4 (1.1–1.9) Moderate
Monotonous work 2.3 (1.1–5.1) Moderate
Mental distress 2.2 (1.3–3.7) Moderate
Dissatisfaction with life 1.8 (1.2–2.6) Moderate
Psychosomatic factors 2.5 (1.2–5.1) Moderate
Comfort of car seat 1.9 (1.0–3.7) Moderate
Depression 1.6 (1.3–2.0) Moderate
† Adapted with permission from [16]
C Elsevier (2018).
Poor general health

There are several factors related to poor general health that can increase the odds of having LBP. A systematic
review [15] (41 studies, n = 28,403) investigated several of these factors and found that people who have other
chronic diseases, who experience pain in other regions of the body, people with sleep disorders, and those who
often feel tired were more likely to develop LBP. Two recent systematic reviews reported that obesity (with a BMI
higher than 24) and smoking habits were both associated with an increased risk for developing LBP [17,18]. Another
systematic review reported that adolescents (up to 19 years) were more likely to develop LBP during puberty (5
studies, n = 13,232) [19].
Physical stress
A systematic review [20] (8 studies) reported that physical stress with lifting objects weighing more than 25 kg and
increasing the frequency of lifting objects increase the risk of developing LBP. Another systematic review [15] (41
studies, n = 28,403) found that people who stand or walk for more than 2 h or drive for more than 2 h were more
likely to develop LBP. This review also reported risk factors related to poor posture (e.g., kneeling or squatting
>15 min, working with arm movements above the shoulder), pulling or lifting objects (e.g., higher loads) and
the comfort of the car seat (the more uncomfortable the greater the risk of LBP). However, there is a protective
association for women who remain seated for more than 2 h a day (OR: 0.4; 95% CI: 0.2–0.7). Finally, there is
some evidence that military training activities and body vibration training were associated with new episodes of
LBP [15,21].
future science group 10.2217/pmt-2019-0016

Psychosocial factors
There has been a greater interest in psychosocial factors and how they can be considered as a risk factor for LBP.
The review by Pinheiro et al. [22]. (13 studies, n = 4579) demonstrated that people with a history of symptoms
of depression were more likely to develop LBP. Another systematic review [15] (41 studies, n = 28,403) showed
that socio-environmental factors, such as monotony at work, excessive stress (feeling nervous or tense), general
dissatisfaction with life and general psychosomatic factors may increase a person’s risk of developing LBP.
Data from observational studies and systematic reviews are often related to high-income countries. The risk factors
for LBP may differ according to the socioeconomic status of the population [1,23]. Thus, there is a need for more
studies in low- and middle-income countries to further understand risk factors of LBP in these populations [15,24,25].
Prevention
For decades, researchers assumed that prevention of nonspecific LBP should involve the modification of mechanical
and postural aspects, mostly related to work due to the high prevalence of injuries in the working population [26,27].
However, interventions such as back belts, ergonomics, mattresses and pillows and workplace modification have all
failed on preventing episodes of LBP [24]. According to emerging evidence, the prevention of nonspecific LBP has
a new perspective of which exercise and education play an important role [28].
A recent systematic review [29] reported data from 21 randomized controlled trials (n = 30,850) investigating
prevention strategies for nonspecific LBP. The authors found that exercise programs with or without education
were effective to prevent new episodes of LBP in the short term. Exercise alone was also effective for preventing sick
leave in the long term. Education alone, back belts and shoe insoles did not reduce the risk of LBP episodes or sick
leave. Most studies look at populations that already had an earlier episode of LBP, characterizing secondary health
prevention, emphasizing the need to study strategies of primary prevention for healthy people in adult populations.
In summary, there is a clinical recommendation for physical exercise and the addition of education to for the
secondary prevention of nonspecific LBP in adults with short-term effects. The majority of the studies analyzed
present data from high-income countries, highlighting a special need to conduct studies in low-middle income
countries, expanding the observation of the consequences of prevention processes to diverse populations.
Management
Given its natural history and rare link with serious spinal pathology, LBP should be effectively managed in primary
care settings [30]. Accurate clinical examination is mandatory aiming screening for the presence of red flags, such
as age over 50 years, history of malignancy, severe trauma and/or use of corticosteroids. Although the screening
for red flags lacks appropriate sensitivity and are used mostly empirically, patients showing suspected symptoms
should be referred to specialists to establish a clinical diagnosis or at least to rule out serious spinal pathologies,
such as cancer [4]. Despite consideration, isolated presence of red flags has low probability of developing into
severe conditions [31]. In the absence of red flags or progressive neurological symptoms, the use of imaging is not
indicated [32,33].
The use of risk assessment and stratification tools are recommended at first contact with a health profes-
sional [30,32]. As an example, the STarT Back model of care aims to assess patients’ risk of developing persistent
back-related disability and matches each group to a package of better suitable treatment [34]. Despite the heterogene-
ity of results found with the implementation of STarT Back tool in other countries than UK [35,36], the utilization of
stratification tools, in general, can assist reducing disability, encouraging early return to work, prioritizing patients’
needs and can guide the use of resources effectively for the management of LBP [30].
A summary of first and second-line management evidence is described in Table 2. The first-line management
of patients with nonspecific LBP relies on advice regarding the nature of LBP, reassurance of benign course and
improvement of symptoms, and encouragement to remain active and avoid bed rest [32]. First-line management
recommendations also endorse staying at work (or return as soon as possible), patient education and adoption
of self-management strategies [30,32]. Mansell et al. [37]. examined self-management interventions compared with
minimal or no intervention and reported a small significant effect on pain and disability at short term. Further,
Traeger et al. [38], in a recent randomized clinical trial (n = 202), found that the addition of intensive patient
education on first-line care was no more effective than placebo education for reducing pain in patients with acute
nonspecific LBP. Therefore, there is no recommendation for offering intensive patient education once first-line care
is ongoing. Nowadays, only 20% of patients are provided with education and advice [32].

Table 2. Effects of interventions for management of low back pain regarding short-term pain outcomes.
First line Intervention (comparator) Effect size Quality of evidence Ref.
Nonpharmacological Bed rest vs stay active 0.4 (-3.2 to 4.0) Low [39]
Heat vs sham -32.2 (-38.7 to 25.2) Very low [40]
Exercise vs no treatment, sham or placebo 0.6 (-11.5 to 12.7) High [41]
Exercise vs other conservative treatment -0.3 (-5.1 to 4.2) High [41]
Pharmacological NSAIDs vs placebo -8.4 (-12.7 to -4.1) High [42]
Muscle relaxants vs placebo -21.3 (-29.0 to -13.5) High [43]
Second line
Nonpharmacological Exercise vs no treatment, sham, or placebo -8.6 (-18.5 to -1.3) High [41]
Exercise vs other conservative treatment -4.5 (-7.4 to -1.5) High [41]
Manual therapy vs ineffective, sham, or inert -6.1 (-11.5 to -0.6) Very low [44]
control
Manual therapy vs effective interventions -3.0 (-5.9 to -0.1) Very low [44]
Cognitive behavioral therapy vs waiting list -12.0 (-19.4 to -4.4) Moderate [45]
control
Behavioral treatment vs usual care -5.2 (-9.8 to -0.6) Moderate [45]
Behavioral treatment vs other treatments -2.3 (-6.3 to –1.7) Moderate [45]
(exercise)
Multidisciplinary treatment vs usual care -11.0 (-7.4 to -0.8) Moderate [46]
Multidisciplinary treatment vs physical treatments -6.0 (-10.8 to -1.2) Moderate [46]
Invasive nonsurgical procedures Steroid plus anesthetic vs anesthetic 0.9 (0.8 to 1.2) Low [47]
Radiofrequency denervation facet joint vs placebo -14.7 (-22.8 to -6.7) Low [48]
Radiofrequency denervation disc vs placebo -4.1 (-15.4 to 7.2) Low [48]
Radiofrequency denervation vs placebo -21.2 (-54.5 to 12.1) Low [48]
NSAID: Nonsteroidal anti-inflammatory drug.
The use of pharmacological interventions is discouraged in first-line care. Paracetamol is no longer recommended
since its efficacy was no better than placebo for pain and disability [49]. Nonsteroidal anti-inflammatory drugs are
endorsed by guidelines as an option to be used for the shortest period and lowest effective dose possible [32]; however,
according to recent evidence, effect sizes are small and may not be clinically important [50]. Muscle relaxants are also
recommended for acute LBP with moderate quality evidence [51]. Despite controversy among guidelines regarding
the prescription of strong opioids, all consent on cautious prescription and are against prolonged use, supporting
its use exclusively when benefits exceed the risks of addiction and overdoses [52].
Second-line care is designed to patients that: failed to respond to first-line management, present medium/high
risk of chronification identified by stratification tools, and/or present chronic or persistent nonspecific LBP.
Nonpharmacological interventions based on exercise therapy should be the preferred approach, recommended as
a solely therapy or as a component of a comprehensive rehabilitation program [30,32]. The type of exercise appears
to be less important though [53]. Passive techniques such as acupuncture, use of electrophysical agents and the
use of back belts are discouraged [32]. All clinical guidelines are against spinal traction [32]. Manual therapy and
psychological therapies combined with exercise program are recommended to achieve long-term benefits for pain
and disability [30,32].
Regarding invasive nonsurgical procedures and surgical treatment, most guidelines discourage the use of these
interventions [30,32]. The UK guideline supports, with caution, the use of local anesthetic injections and radiofre-
quency denervation procedure in acute and severe sciatica or radiculopathy for patients who did not respond to
nonsurgical treatments [54]. Surgery is consistently not recommended for managing nonspecific LBP [30,32].
Future perspective
LBP is a global problem that affects millions of people. The current evidence shows that exercise and education
are still the most recommended interventions for both prevention and management of nonspecific LBP. Further
research on the implementation of guidelines for the management of LBP is urgently needed in the field. Cultural,
political and socioeconomic contexts must be taken into account and further adaptations might be needed aiming
proper fitting into worldwide realities.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or finan-
cial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria,
stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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The contemporary management of

Keywords: diagnosis • intervention • low back pain • prognosis

Epidemiology & costs

Individual risk factors

10.2217/pmt-2019-0016 Pain Manag. (Epub ahead of print) future science group

Table 1. Risk factors for low back pain.

Poor general health

future science group 10.2217/pmt-2019-0016

10.2217/pmt-2019-0016 Pain Manag. (Epub ahead of print) future science group

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Financial & competing interests disclosure

10.2217/pmt-2019-0016 Pain Manag. (Epub ahead of print) future science group

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10.2217/pmt-2019-0016 Pain Manag. (Epub ahead of print) future science group

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