Non-Specific Low Back Pain: Everything You Need To Know

Non-Specific Low Back Pain 

At the Spine and Sports Injury Clinic I see a number of patients suffering from spinal pain. Back pain can be impossible to accurately diagnose, even with scanning such as MRI investigations. This blog provides an introduction to what the term ‘non-specific low back pain’ means, why it’s used and why recovery is still achievable even though there isn’t a clear diagnosis.

What is non-specific low back pain?

In most back pain cases it’s very difficult to clearly identify a specific cause [3], and when the reason for pain is unclear then the back painbecomes classified as ‘non-specific’ [1, 2, 3]. This is because the way pain is communicated and processed isn’t fully understood, and is partly why a patients description of pain is not very helpful in identifying the type or extent of damage that’s occurred. Even with a detailed physical examination (such as by an Osteopath or Physiotherapist) it is often impossible to identify the specific pain causing tissue or structure [3].  Though patients can find this frustrating; back pain, and more specifically non-specific back pain, is highly common in the general population [1, 2, 3, 4] and is the number one cause of disability globally [3]. 

Why is this diagnosis used?

MRI scans of pain free people have identified a high percentage of the general population as having a range of pathologies or ‘injuries’ to the low back. Things like disc pathologies, such as a bulge or 

degenerative changes, or joint degeneration can be far more prevalent in normally functioning people than people realise (5). This can help explain why there are studies showing that, even with detailed scanning, it’s difficult to accurately identify a source of a patients pain. Because we now know a high number of people can have these types of findings and be pain free and function normally, how can we tell if a back pain patient with these types of findings has these as a coincidence or is the cause of their pain? The nerve pathways used to communicate pain are very complex and can be influenced by many factors outside of physical injury. This adds to the difficulty of identifying a specific reason for the severity and nature of pain. Though very non-specific in its description, this diagnosis can more fairly represent the nature of what’s occurring, in that we don’t have any way to know what the exact reason for pain is. In some cases a specific ‘label’ or diagnosis can lead to a patient becoming unnecessarily fearful of their back condition, especially if they also have a misconception of what that means for the venerability of their back. I have certainly had experience of this in my clinical practice, .

Can I recover without a specific diagnosis?

The short answer is YES! Though there isn’t a specific diagnosis to work with, treatment and recovery plans work by addressing the issues in a persons function. That is, you look at a patients limitations in movement and work to improve these in a controlled way. There are lots of ways to manage low back pain, with evidence showing things like manual therapy (techniques such as soft tissue manipulation, joint mobilising, manipulation therapy), exercise therapy, mindfulness techniques and active lifestyles can all play a role in controlling pain and aiding recovery [1, 2, 4, 6]. One key point is to work within the boundaries set by the pain. Pushing the area too hard and increasing pain nature often is unhelpful (though not at risk of further injury) as it heightens pain sensitivity and can result in more pain. At the start of a recovery journey the pain may be very limiting, forcing an individual to commence with very low levels of movement and activity. If you’re unsure on how to find the right balance then seeking professional guidance can be a huge asset. 

Would a scan give a clearer diagnosis?

We now have studies that have assessed thousands of pain free low back MRI scans and the amount of people that will have a range of different pathological findings is surprisingly high [3, 5]. This is why studies are now identifying that MRI findings often provide little help in determining the source of back pain, and are unable to guide the prognosis and speed of recovery. For example, no study has accurately identified a disc problem as a source of back pain, and there’s no widely accepted standard for identifying disc based pain in a patient [3(14)]. The Framingham Heart study couldn’t identify an association between osteoarthritis (wear and tear changes) of the low back joints and the presence of low back pain [3(16)]. Most importantly, studies are demonstrating that early scanning (such as MRI scans) for low back pain doesn’t contribute to a better outcome in the patients recovery [3]. There are of course some scenarios where a more urgent scan is needed, though often severity of pain is not that indicator. The decision for further scanning is best reviewed by a healthcare professional who has the medical understanding to be able to identify the concerning symptoms to make that call. So in short to answer the question, no, a scan often won’t provide a clearer diagnosis and carries with it an unnecessary cost to either the patient (if scanning privately) or to the NHS. 

Final Thoughts 

Non-specific low back pain simply is a sweeping term for back pain and is used because it is almost impossible to specifically identify a single cause for the pain, even with further imaging such as MRI scans. Recovery is more focused on the disability or dysfunction caused by the pain, allowing a patient to successfully recover using a range of interventions. If you’re unsure on the best way to manage or recovery from an episode of low back pain, always seek guidance from a healthcare professional that has experience in managing patients with musculoskeletal injuries, such as an Osteopath or Physiotherapist. 

 Alexander Pouros BSc (Hons.)

Registered Osteopath 

References:

1. N. E. Foster et al.; Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions; The Lancet, Vol 391 (P 2368-2383); 2018

2. A. Rathnayake, v. Sparkes, L Sheeran; What is the Effect of Low Back Pain Self-management Interventions with Exercise Components Added? A Systematic Review with Meta-analysis; Musculoskeletal Science & Practice, 56 (102469); 2021

3. J. Hartvigsen et al.; What Low Back Pain Is and Why We Need To Pay Attention; The Lancet, vol 391(P 2356-2367); 2018

4. N. Akkarakittichoke, P. Waongenngarm, P. Janwantankul; The Effects of Active Break and Postural Shift Interventions on Recovery From and Recurrence of Neck and Low Back Pain in Office Workers: A 3-arm Cluster-Randomised Controlled Trial; Musculoskeletal Science & Practice, Musculoskeletal Science & Practice, 56 (102451); 2021

5. W. Brinjikji et al.; Systematic Literature Review of Imaging Findings of Spinal Degeneration in Asymptomatic Populations; American Journal of Neurology, Vol 36 (P 811-816); 2015

6. NHS Website: https://www.nhs.uk/conditions/back-pain/treatment/ (Accessed 14/5/22)