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Non-Specific Chronic Low Back Pain

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It is often incorrectly stated that the cause of low back pain cannot be diagnosed in 85% of cases with exact figure differing with different publications (some say 80%, some say 90%)[1] This "convenient truth" has been proven to be false time and time again. Unlike acute low back pain where the causes are largely unknown, The causes of chronic low back pain are largely known. History and examination are insufficient for diagnosis, but the cause can be established with at least moderate certainty in around 90% of cases as long as there is access to appropriate investigations and the investigations are done in a logical manner.[2][3][4][5][6]

The fact that some authors and clinicians continue to perpetuate the myth that most chronic low back pain is "non-specific low back pain" is likely ideological in nature, rather than based on evidence. Typically the review articles reference yet further review articles, misleadingly only reference red flag prevalence data, or simply make ex cathedra proclamations.

An example of this "train of intellectual dishonesty" regarding the prevalence of "non-specific back pain" is presented here for illustration. The lancet review by Hartvigsen 2018[7] ("nearly all") which has been cited 416 times as of writing references a review by Maher from 2017 ("90%")[8], which in turn references a review by Koes from 2006 ("90%"),[9] which in turn references a review by Deyo from 1992 ("85%"),[10] which in turn references an expert opinion workshop by White from 1982 ("20% to 85%")[11] and speech by Nachemson from 1984.[12] The 1982 workshop figure is unreferenced, and I am unable to access the full 1984 speech. The 2017 review by Maher also dishonestly references a study on acute low back pain,[13] another review by Deyo from 2001 ("85%") which in turn does not reference their figure[14], and another study of older adults that only looked for vertebral fracture in patients with mixed acute and chronic back pain.[15] The reference train runs dry at that point, but note how the 1982 expert opinion figure of "20-85%" became "nearly all," without further appropriate primary references to support this updated figure, and the literature on precision diagnosis has been completely ignored.

Sometimes we find that the reference train leads to a report by the Quebec Task Force in 1987.[16] Another possible source of the 80-90% figure is a 1966 study of British General Practice patients with acute low back pain, where no cause was evident in 79% of men and 88% of women.[17] It goes without saying that history, exam, and plain films were the only tools of diagnosis at that time.

Generally the reviews on the topic display several flaws in logical thinking.

  1. They reference information about the very low rate of red flag conditions, and conclude therefore most causes of low back pain are unknown. The one does not follow the other. A lack of red flag conditions does not equal a lack of a structural source. To diagnose the structural source you need to follow a particular process which has been painstakingly validated over the last 30 years by many researchers.[6]
  2. The fact that in many cases the cause of the chronic low back pain can't be cured does not mean that it is "non-specific." The one does not follow the other. Bacterial infections weren't "non-specific" before the advent of antibiotics. Croup wasn't "non-specific" before it was discovered that oral steroids worked.
  3. They dishonestly ignore the research on precision diagnosis, which shows the extreme limitations of conventional methods of assessment and investigation, and the referencing train leads to articles published at a time before the advent of this methodology, and so the false-negative rate would have been very high. These older articles also commonly confused sciatica, spondylosis, spondylolisthesis, and spondylolysis with causes of low back pain, and so false-positives were likely also common.

In the last 30 years imaging and investigation techniques have drastically improved, and it is now possible to determine the cause in the majority but not all cases.[18] In New Zealand it is usually lack of funding for access to the appropriate diagnostic tools that renders diagnosis impossible, rather than the tools themselves not existing. Whether the cause should be diagnosed, and whether the cause can be cured are two entirely separate questions from whether it can be diagnosed.

The forces driving the overdiagnosis of "non-specific low back pain" are likely complex. There may be strong beliefs in the importance of avoiding biomedical diagnoses and a desire to maintain the status quo. Allowing precision diagnosis in chronic low back pain may be unappealing to a range of different stakeholders including DHBs, pharmaceutical and biotechnology companies that target chronic pain, professional societies, funding agencies, MDT clinics, and the psychosocial academic system. Allowing bio to be part of biopsychosocial management does not lessen the importance of the psychosocial aspects, yet some proponents of the non-specific model use the pseudo-theological argument that pain must be accepted before it can be managed.

References

  1. ↑ Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. Nociplastic pain: towards an understanding of prevalent pain conditions. Lancet. 2021 May 29;397(10289):2098-2110. doi: 10.1016/S0140-6736(21)00392-5. PMID: 34062144.
  2. ↑ DePalma et al.. What is the source of chronic low back pain and does age play a role?. Pain medicine (Malden, Mass.) 2011. 12:224-33. PMID: 21266006. DOI.
  3. ↑ DePalma et al.. Etiology of chronic low back pain in patients having undergone lumbar fusion. Pain medicine (Malden, Mass.) 2011. 12:732-9. PMID: 21481166. DOI.
  4. ↑ DePalma et al.. Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain medicine (Malden, Mass.) 2012. 13:498-506. PMID: 22390231. DOI.
  5. ↑ DePalma et al.. Structural etiology of chronic low back pain due to motor vehicle collision. Pain medicine (Malden, Mass.) 2011. 12:1622-7. PMID: 21958329. DOI.
  6. ↑ 6.0 6.1 DePalma. Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be. Pain medicine (Malden, Mass.) 2015. 16:1453-4. PMID: 26218010. DOI.
  7. ↑ Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-2367. doi: 10.1016/S0140-6736(18)30480-X. Epub 2018 Mar 21. PMID: 29573870.
  8. ↑ Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017 Feb 18;389(10070):736-747. doi: 10.1016/S0140-6736(16)30970-9. Epub 2016 Oct 11. PMID: 27745712.
  9. ↑ Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006 Jun 17;332(7555):1430-4. doi: 10.1136/bmj.332.7555.1430. PMID: 16777886; PMCID: PMC1479671.
  10. ↑ Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992 Aug 12;268(6):760-5. PMID: 1386391.
  11. ↑ White AA 3rd, Gordon SL. Synopsis: workshop on idiopathic low-back pain. Spine (Phila Pa 1976). 1982 Mar-Apr;7(2):141-9. doi: 10.1097/00007632-198203000-00009. PMID: 6211779.
  12. ↑ Nachemson AL. Prevention of chronic back pain. The orthopaedic challenge for the 80's. Bull Hosp Jt Dis Orthop Inst. 1984 Spring;44(1):1-15. PMID: 6326902.
  13. ↑ Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009 Oct;60(10):3072-80. doi: 10.1002/art.24853. PMID: 19790051.
  14. ↑ Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001 Feb 1;344(5):363-70. doi: 10.1056/NEJM200102013440508. PMID: 11172169.
  15. ↑ Enthoven WT, Geuze J, Scheele J, Bierma-Zeinstra SM, Bueving HJ, Bohnen AM, Peul WC, van Tulder MW, Berger MY, Koes BW, Luijsterburg PA. Prevalence and "Red Flags" Regarding Specified Causes of Back Pain in Older Adults Presenting in General Practice. Phys Ther. 2016 Mar;96(3):305-12. doi: 10.2522/ptj.20140525. Epub 2015 Jul 16. PMID: 26183589.
  16. ↑ Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine (Phila Pa 1976). 1987 Sep;12(7 Suppl):S1-59. PMID: 2961086.
  17. ↑ Dillane JB, Fry J, Kalton G. Acute back syndrome-a study from general practice. Br Med J. 1966 Jul 9;2(5505):82-4. doi: 10.1136/bmj.2.5505.82. PMID: 20791052; PMCID: PMC1943081.
  18. ↑ Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021 Jul 3;398(10294):78-92. doi: 10.1016/S0140-6736(21)00733-9. Epub 2021 Jun 8. PMID: 34115979.
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