Review of low back pain guidelines – the role of risk prediction

A review of international guidelines on primary care management of non-specific low back pain (LBP) by was published this week in the Medical Journal of Australia.

Non-specific LBP by definition cannot be attributable to identified tissue pathology. Not the degenerative discs, the muscle spasm, the inflamed facet joint, nor the annular tear. This is in keeping with the poor correlation of LBP with pathology on various scans, including our best – the MRI – and the reason imaging is generally not indicated. A small number of back conditions (less than 5%)  relate to identifiable pathology such as prolapsed disc with nerve root impingement, canal stenosis (both of which predominantly cause leg pain if they are indeed symptomatic), and rarely tumours, infections and fractures. These may present so-called “red flags”, and warrant investigation.

Non-specific LBP  can be acute (less than 12 weeks) or chronic. This recent review also suggests non-specific LBP can be classified on the basis of risk stratification using simple risk prediction tools – STarT Back, OMPSQ or PICKUP to identify “yellow flags”. The purpose of identifying patients with yellow flags is that therapies directed at addressing fear and catastrophic thinking, such as specific education and psychological treatments like CBT, are beneficial for the outcomes of an acute LBP episode and in lessening the risk of chronicity.

Management of non-specific low back pain  
(Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Matheus Almeida, Bruno Saragiotto, Bethan Richards and Chris G Maher. Med J Aust 2018)

This paper is a great summary of current international thinking about the management of non-specific LBP and we recommend you read it. Here is a summary-

Guidelines for managing non-specific LBP

• reassure and educate – the back is strong and the pain will resolve
• stay active, keep moving
• be careful of your language – promote safety not fear
• review at 2 weeks – yellow flags need attention
• NSAIDs and physical therapy can be used if not resolving quickly
• imaging, paracetamol and surgery are not indicated

MyScoreIt has included the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) in its battery of measures. It is not specific to back pain and can be utilised in all musculoskeletal conditions to identify whether unhelpful beliefs about pain may result in the likelihood of a poor outcome. If patients score 50 or over then that represents a “yellow flag” and suggests that person may benefit from additional education around pain, see a previous blog post on this.

The Quebec Back Pain Disability Scale included as a patient reported outcome measure specific to back pain. We would often use these two outcome measures together.