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How to care for adults with low back pain in the primary care setting

Pfieffer, Mary Lauren DNP, FNP-BC, CPN

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doi: 10.1097/01.NURSE.0000651624.64152.11
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LOW BACK PAIN (LBP) is one of the most frequent patient complaints in primary care.1 An estimated 60% to 80% of individuals will experience back pain during their lifespan.1,2 Further, 30% of those with LBP report experiencing back pain over the past 3 months.3 Back pain is the most common and expensive work-related injury resulting in workers' compensation for patients under age 45.2,4

LBP affects men and women equally across various socioeconomic backgrounds.1 It is seen more often in patients between ages 45 and 50, after which occurrences decline.1 This article focuses on common clinical presentations of LBP and essential physical assessment practices for diagnosis, presents up-to-date findings for managing patients with LBP, and provides recommendations for patient referrals.

Caring for patients with LBP can be frustrating for clinicians as there often is no underlying diagnosis.2,5 Eighty percent of patients who report to primary care settings have LBP with nonspecific causes.6 Successful evaluation and treatment often requires an interprofessional team and a multimodal treatment plan.3 Patients are most successful seeing both a primary care provider and a physical therapist and participating in an exercise program. Additionally, although controversial, chiropractic care is often considered by patients with LBP.7

Risk factors

Risk factors for LBP include age, obesity, and female gender. Other considerations include psychological factors such as depression, lifestyle factors such as a physically demanding profession, and pre-existing comorbidities such as osteoarthritis.3,8 Addressing risk factors during the initial assessment can help prevent chronic LBP.9

The financial burden to both the patient with LBP and the healthcare system is substantial given the often prolonged length of time for diagnosis and treatment. It is estimated that LBP and neck pain have an annual cost of $87.6 billion in the US alone.10 Activity-limiting LBP has a worldwide lifetime prevalence of approximately 39%, and most individuals who experience LBP will have recurrent episodes.11

Focused history

Evaluating how long the patient has been experiencing LBP is essential. LBP can be grouped into three categories: acute, subacute, and chronic. Acute LBP lasts up to 4 weeks; subacute LBP can last from 4 to 12 weeks; and chronic LBP lasts for longer than 12 weeks.12 Nurses should ask patients about the onset, location, and duration of their pain and associated factors, such as radiation or paresthesias. They should also have patients describe the quality, severity, and aggravating or alleviating factors. Nurses should inquire about previous treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and the response to those treatments. Additionally, they should ask about the impact of LBP on the patient's quality of life.

LBP can be further differentiated according to whether the pain is exacerbated by certain movements, such as bending over or changing body positions.13 Clinicians should assess whether trauma may have caused the pain or if it may be caused by coughing or sneezing.

Medication reconciliation is also important and can influence treatment. For example, NSAIDs should be avoided for patients on anticoagulation, and patients with opioid addictions or who have been prescribed chronic opioids may be referred to a practitioner with expertise in pain management.

Cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurologic, integumentary, and psychiatric systems must be reviewed as well as constitutional symptoms. Screening for depression may be indicated because psychiatric disorders may be associated with back pain. Clinicians should also be suspicious of causes related to a recent infection.5 (See Differential diagnoses for LBP.)

Red flag symptoms, such as progressive neurologic signs and symptoms, may suggest a malignancy, fracture, cauda equina syndrome (CES), or spinal infection.14 If a patient presents with clinical manifestations of such serious disorders, expedited evaluation and treatment are required to prevent further injury and complications (see Red flags for LBP).

Physical findings

A thorough physical assessment is vital. Often, if the physical exam is comprehensive, diagnostic testing will not be necessary.

The cardiovascular assessment should include cardiac auscultation, noting the presence of any murmurs or other abnormalities, such as an S3 or S4. Assessments for peripheral edema, peripheral pulses, and capillary refill time are also necessary, as these may indicate cardiac differentials such as peripheral artery disease.

The respiratory system assessment should include anterior and posterior auscultation of breath sounds, noting any abnormalities such as pulmonary crackles. The abdominal assessment should include auscultating for bruits and light and deep palpation of the abdomen. If the patient's history includes a loss of normal bowel function, consider assessing rectal tone.

Skin assessment includes looking for lesions or rashes such as varicella zoster lesions. Genitourinary assessment includes percussing for bilateral costovertebral angle tenderness.

Healthcare providers typically spend the most time on the musculoskeletal and neurologic assessments of patients with LBP. The musculoskeletal assessment starts with inspection of the spine for structural abnormalities. Palpation of spinous processes could reveal pain or tenderness, potentially indicating a spinal infectious process, arthropathy, or metastasis.5 It is also helpful to palpate the paraspinal muscles for abnormalities such as tenderness.

Performing specific exam techniques is also important. These include the straight leg raise, retrograde filling (Trendelenburg) test, FABER (Femoral, Abduction External Rotation) test, range of motion of the spine, bilateral hip range of motion, bilateral knee extension, and gait observation.5,13,15

The motor system, including muscle strength, and the sensory system, including sensation of the extremities, are assessed during the neurologic exam, as well as grading deep tendon reflexes.5,13 Assessing for saddle (S3-S5) anesthesia could indicate that the patient's LBP is due to CES.16 Bilateral lower extremity pain is the classic presentation that raises concern for CES, but motor weakness and sensory abnormalities may also be present.5,17 Patients with CES are admitted to the ED.3

Provider awareness of nonorganic signs (Waddell signs) is important, including superficial tenderness, patient overreaction during physical exam, straight leg raise that improves when the patient is distracted, and unexplainable neurologic deficits (nondermatomal distribution of sensory loss). Pain elicited by axial loading (pressing down on top of head or rotating the body at hips or shoulders) suggests a psychologic component to a patient's pain.5,18

Diagnostic studies

Lab and imaging studies are not performed initially for patients with acute back pain unless the clinician finds red flag signs or symptoms.5 Lab tests are not essential for diagnosing most patients with LBP but may help to rule out a few differentials. Erythrocyte sedimentation rate (ESR), complete blood cell count, and/or C-reactive protein (CRP) can be drawn if a provider suspects infection or spinal malignancy.5,13 ESR and CRP can be useful for diagnosing ankylosing spondylitis.5

Diagnostic imaging for LBP may include plain radiologic films of the spine, MRI, or computed tomography (CT). In one study, no difference in patient outcomes was noted in comparing patients who had plain films done to those who received more-costly CT or MRI.3 Another study demonstrated that patient knowledge of MRI diagnostic findings did not alter primary clinical outcomes in those with acute LBP and radiculopathy.19

If imaging is warranted, plain films of the lumbar spine could be used to diagnose patients at risk for vertebral fracture.3 CT or MRI should be considered if patients present with suspicious neurologic abnormalities.3 CT is preferred when investigating specific orthopedic concerns and should be done for those patients with a history of cancer in whom metastasis is suspected. MRI is preferred when investigating neurologic abnormalities or suspected infectious process.20

Electrodiagnostic studies measure the electrical activity of the muscles and nerves; common studies include electromyography (EMG) and nerve conduction velocity (NCV). EMG and NCV are not performed regularly for patients with LBP, but they are useful for patients with suspected neuromuscular weakness.19,21 They are also beneficial when imaging does not confirm radicular pain or lumbar-disk herniation.19,21 Electrodiagnostic studies are also beneficial for identifying the location of spinal lesions and whether an injury is new or old.22 Overall, imaging should be done to rule out disk herniation, but it is not necessary for diagnosing radicular pain. EMG and NCV can be useful for patients with disabling radicular pain, but these studies are not initially required to confirm a diagnosis and begin treatment.20,21

The most common diagnoses associated with LBP are nonspecific LBP, acute lumbosacral radiculopathy with radicular pain, lumbar-disk herniation, spinal infection, and ankylosing spondylitis.21,22 Sciatica is a nonspecific term used to describe a variety of low back and lower extremity symptoms and should be avoided when referring to radicular pain.

Nonspecific LBP accounts for 80% of cases. It may be diagnosed once the physical assessment is complete and other differential diagnoses and red flags are ruled out. No imaging or lab studies are required.

There is a correlation of nonspecific LBP with progression to chronic LBP. Some research relates this to biopsychosocial factors, but there is not enough data to support this.3 If pain does not improve within 12 weeks, further evaluation for the etiology is warranted.5

Radicular pain involves the function of the nerve roots of the lumbosacral spine.21 Physical assessment for patients with radicular pain should focus on the lumbar 5 and sacral 1 (L5 and S1) nerve roots because nerve impingement commonly occurs in these areas.5 (See Right lateral view of the vertebral column.) Assessing ankle dorsiflexion strength and great-toe dorsiflexion strength (the L5 nerve root), plantar flexion strength (S1), ankle and knee reflexes (S1 and L4), and dermatomal sensory loss will help providers diagnose radicular pain.2 EMG and NCV studies can be useful for patients with disabling radicular pain, but they are not initially required.21

Lumbar-disk herniation is more common in patients with acute back pain and is frequently associated with lifting or straining injuries. Physical assessment should focus on the musculoskeletal and neurologic systems. The straight leg raise is sensitive and specific to disk herniation.2 MRI or CT are useful in diagnosing lumbar-disk herniation, and electrodiagnostic tests may help confirm the diagnosis.

Spinal infection is a potential differential diagnosis for LBP. Patients will present with fever and possible vertebral tenderness.2 Physical activity can cause increased back pain that radiates to the lower extremities.23 This pain is generally acute in nature.23 Musculoskeletal and neurologic assessments should be performed, as well as an abdominal exam to assess whether the infection has spread to the abdomen.23 Assess for a positive psoas sign, which consists of pain elicited when the examiner passively extends the right hip of the patient while the patient is lying on the left side. An elevated white blood cell (WBC) count, ESR, and CRP in patients with a positive psoas sign may indicate appendicitis, peritonitis, or the spread of an abdominal infection into the spine.

Ankylosing spondylitis is related to an inflammatory process of the spine.24 Other features often seen with it include uveitis, psoriasis, and inflammatory bowel disease. Findings from the patient history can help differentiate ankylosing spondylitis from LBP, as these patients are often younger than age 40 and report gradual onset of the pain, improvement with exercise, no improvement with rest, and nocturnal pain.24 If patients present with LBP and a positive history of the aforementioned specifics, ankylosing spondylitis can be confirmed with an elevated ESR and CRP.23 Synovial fluid analysis can confirm ankylosing spondylitis with an elevated WBC count.24 Ankylosing spondylitis can also result in clinical evidence of chest wall disease including limitation of chest wall expansion to 2.5 cm when measured at the level of the fourth intercostal space.2

Figure
Figure:
Right lateral view of the vertebral column

LBP management

Treatment of LBP is specific to the underlying etiology. Many patients with LBP will require a multimodal treatment approach, including nonpharmacologic and pharmacologic options. Using more than one class of medications combined with a nonpharmacologic approach will typically help alleviate the pain.3 In certain situations, referrals to specialists, such as pain management specialists, may be necessary.

Nonpharmacologic interventions. Providers should not refer patients for nonpharmacologic treatments unless a patient has experienced LBP for more than 3 weeks because many patients will spontaneously improve during that time.25 Physical therapy (PT), exercise, acupuncture, massage, spinal manipulation, and transcutaneous electrical nerve stimulation are common nonpharmacologic interventions. Evidence is emerging about nonpharmacologic care as a way to provide adequate pain management and subsequently reduce the need for opioid medications.26,27 To prevent future LBP, patients should exercise as they are able, wear back braces when lifting heavy items, use ergonomic furniture at work if appropriate, and avoid putting excessive strain on their spine.26

PT and exercise play an important role in treating patients with LBP. Bed rest is no longer recommended, as evidence shows that it generally delays improvement of LBP.2 Yoga, Tai Chi, and Pilates have been studied and shown to improve outcomes when compared with no intervention.28,29 When performed appropriately, no adverse reactions are associated with these exercises.

PT is a great option for patients with subacute, chronic, or recurrent LBP. It may improve motor control, core strength, joint flexion and extension, directional preference, and general physical fitness.30 Directional preference refers to a therapy that avoids painful movements in favor of movements that lessen pain related to LBP.31 Physical therapists evaluate patient responses and develop an individual therapy plan, ensuring that they perform the exercises correctly and maintain spinal alignment. Patients are instructed on exercises to do at home when discharged from the PT program.

Acupuncture, a safe mode of treatment, may provide short-term pain relief for patients with LBP.27,32 However, it has not been shown to improve function.12 Additional long-term studies are required to support acupuncture as an effective treatment option.13,32

Massage may provide short-term pain improvement in patients with acute, subacute, and chronic LBP, and some patients receiving massage for LBP have reported higher satisfaction.27,33 As with acupuncture, it has not been shown to improve function, and some studies have shown that it may increase the intensity of pain in some patients.33,34

Spinal manipulation is performed by chiropractic providers. It is a form of manual therapy that involves the movement of a joint near the end of the clinical range of motion.27 This technique may provide short-term pain reduction and improve function.30 Spinal manipulation should be utilized only when combined with other treatment methods.26 Spinal manipulation also has the potential to worsen LBP.30

Transcutaneous electrical nerve stimulation (TENS) can be used for LBP management. TENS involves the use of a small battery-operated device to provide continuous electrical impulses via surface electrodes, with the goal of providing symptomatic relief by modifying pain perception.30 Evidence of the effectiveness of TENS therapies is mixed, with some reports showing short-term improvement and some showing none.3

Pharmacotherapy. Nonopioid analgesics, opioids, skeletal muscle relaxants, and adjuvant analgesics can be used for patients with LBP.3 However, long-term studies regarding pharmacologic treatment for back pain are lacking.3

The most common nonopioid analgesics are NSAIDs and acetaminophen. A Cochrane review from 2016 shows that acetaminophen did not improve LBP compared with placebo.25,35 Risks for acetaminophen include hepatotoxicity.27 Caution is advised when administering acetaminophen in patients with hepatic dysfunction or active hepatic disease, alcohol use disorder, chronic malnutrition, severe hypovolemia, or severe kidney dysfunction. Not enough research has been conducted to include acetaminophen as a first-line treatment.12

For patients with no contraindications or cardiovascular or gastrointestinal (GI) risk factors, NSAIDs are a first-line treatment for symptom relief in acute LBP.2,13,27 They are used in short-term therapies (2 to 4 weeks). Educate patients about the risk of cardiovascular events, dyspepsia, GI bleeding, hepatotoxicity, hypertension, heart failure, renal toxicity, and exacerbation of asthma.3

Given the risk of misuse and dependence, nonopioid analgesics are a better treatment option than opioid-based medications.3Opioids may be used in the short term for patients with acute LBP, but they should not be used to treat chronic LBP.3 To reduce the potential for misuse and dependence, the CDC does not recommend the use of opioids for acute pain beyond 3 days.36,37 Given a lack of long-term documented efficacy, they are not a first-line treatment option for nonmalignant pain.

Potential adverse reactions to opioids include sedation, respiratory depression, constipation, and nausea.27 Opioids are contraindicated for patients with a history of substance abuse, addiction, or misuse.

Despite their questionable use in the treatment of LBP, opioid medications continue to be prescribed. One study demonstrated that they were prescribed in 45% of patients presenting with LBP.38

Although they are generally used as adjunctive therapy to NSAIDs, skeletal muscle relaxants(SMRs) may also be utilized in patients with LBP to help with pain associated with muscle spasms.27 The most commonly prescribed SMRs include carisoprodol, tizanidine, and cyclobenzaprine. Common adverse reactions to SMRs, such as dizziness and sedation, make the use of these medications risky, especially in patients over age 65.2,3 Long-term studies for treatment of chronic LBP using SMRs are still needed.3

Adjuvant analgesics such as antidepressants and antiepileptic drugs (AEDs) are also used in the treatment of subacute and chronic LBP, but they are not used for acute LBP. Overall evidence suggests that antidepressants are no more effective than placebos.3,26 However, duloxetine, a serotonin and norepinephrine reuptake inhibitor, is FDA-approved for chronic musculoskeletal pain and has demonstrated some positive outcomes in patients with chronic LBP.3,12 It is a good choice for patients with chronic LBP and comorbid depression.3,12

AEDs such as gabapentin and topiramate are used for subacute and chronic LBP with radicular symptoms. Topiramate has been shown to help compared with placebo.3 These medications are considered off-label for this indication. The most common adverse reactions associated with gabapentin are fatigue, dizziness, problems with concentration, dry mouth, and loss of coordination.39 The most common adverse reactions associated with topiramate are somnolence, trouble with concentration, vision trouble, and anorexia.40

Referrals

Primary care providers can care for most patients with LBP. However, patients should be referred to an orthopedist or neurologist for treatment of serious disorders such as CES, which requires immediate hospitalization; disk herniation; spinal stenosis; spinal fractures; and spinal infections. Referral to a specialist is also indicated for patients with a suspected or confirmed aortic or thoracic aneurysm. Patients with ankylosing spondylitis should be referred to a rheumatologist to help manage the autoimmune component of the disease.

Implications for nursing

The prevalence of patients with LBP is significant, and nurses must be comfortable assessing these patients. After the red flags have been ruled out with a comprehensive history and physical assessment, most patients with acute LBP improve in 1 month with or without intervention.12

Nonpharmacologic interventions are preferred over pharmacologic interventions.12 Multimodal treatment approaches are often needed for clinical management, and patient education is important. There are many ways patients can prevent acute and chronic LBP, but exercise is the only treatment demonstrated to prevent recurrence.

Differential diagnoses for LBP3,5,13

  • ankylosing spondylitis
  • cystitis
  • pyelonephritis
  • depression
  • disk herniation and/or degenerative disk disease
  • mechanical back strain
  • nephrolithiasis
  • obesity
  • osteoarthritis
  • osteoporosis
  • pelvic inflammatory disease
  • piriformis syndrome
  • pneumonia
  • pregnancy
  • prostatitis
  • radiculitis
  • referred pain (aortic aneurysm, pancreatic cancer)
  • sacroiliac joint dysfunction
  • spinal malignancy
  • spinal fractures
  • spinal infection (epidural abscess, vertebral osteomyelitis)
  • spinal stenosis
  • varicella-zoster virus infection

Red flags for LBP3,5,13

  • bladder and/or bowel dysfunction
  • fever over 100.4°F (38°C)
  • gait abnormalities
  • history of cancer
  • history of long-term corticosteroid use or immunosuppressants
  • history of trauma
  • increased pain at night
  • I.V. drug use
  • saddle anesthesia or perineal numbness
  • unexplained weight loss

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Keywords:

ankylosing spondylitis; cauda equina syndrome; electromyography; LBP; low back pain; lumbar-disk herniation; nerve conduction velocity test; radicular pain; sciatica; spinal infection

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