Trauma 2011; 13: 5764

The diagnosis and management of common

non-specific back pain a clinical review
Grahame Brown

The assessment and management of common non-specific back pain that is

associated with considerable personal morbidity and cost to society is reviewed and
set in a bio-psycho-social context.
Key words: non-specific back pain; bio-psycho-social

Introduction
Most of us appreciate the difficulties of people who
suffer back pain because up to 80% of us will
experience it at sometime in our life. In any group of
people the point prevalence is estimated to be
between 15% and 30% (CSAG, 1994). Although
most episodes of back pain get better naturally, it is
not uncommon for people to experience another
episode within a year (Croft et al., 1998). Back pain is
one of the commonest reasons for people consulting
their GP and taking time off work. For others,
attending an Accident & Emergency department
when they are distressed with back pain might be
their first encounter with a health care professional
for the problem. Misconceptions surrounding back
pain and activity or exercise, often inadvertently
reinforced by clinicians, are a major contributory
factor for the increasing prevalence of back pain
related disability in industrialised countries.
Throughout the world, published guidelines based
on research evidence demonstrate a genuine consensus over management (Waddell and Burton, 2000;
Koes et al., 2001; Chou et al., 2007; NICE, 2009).
Clinicians who work in primary care and occupational health should now be aware of these guidelines.
Orthopaedic, Musculoskeletal, Sports & Exercise Physician,
The Royal Orthopaedic Hospital NHS Foundation Trust,
Birmingham, UK.
Address for correspondence: Dr Grahame Brown,
Orthopaedic, Musculoskeletal, Sports & Exercise Physician,
The Royal Orthopaedic Hospital NHS Foundation Trust,
Birmingham, B31 2AP, UK.
E-mail: grahamebrown50@hotmail.com

The Author(s), 2011. Reprints and permissions:

http://www.sagepub.co.uk/journalsPermissions.nav

If the back pain is not the presenting problem, it may

be an associated co-morbid clinical problem in many
medical specialties. This review is aimed at clinicians
in secondary care and in the specialty training grades
who may not be familiar with changes in the
management of these problems.

Different kinds of back pain

For the most part of the twentieth century, the
problem of back pain was viewed from a predominantly bio-medical model of injury to spinal structures. In this model, emphasis is on looking for the
pathological lesion that causes back pain which in
turn is likely to generate inappropriate investigations and treatment and contribute to the persistence of symptoms (CSAG, 1994; Hadler, 1999).
Waddell (1998) has called the dominance of a
medical model for the enigma of human back pain a
twentieth century health care disaster.
Back pain frequently starts for no apparent reason
or after an every day activity, and recovery (or lack
of it) is also frustratingly unpredictable. Only a small
proportion (55%) of people with back pain have a
diagnosable condition from a bio-medical and histopathological perspective (such as vertebral collapse due to osteoporosis) and very few (51%) have a
serious medical problem (CSAG, 1994).
So the vast majority of people have no specific
diagnosis or medical reason for their back pain.
It is often said that most peoples back pain
resolves within 68 weeks, and only 1520% go
on to develop persistent and disabling back pain.
Given the number of us that can expect to
10.1177/1460408610385758

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G Brown

experience the problem at least sometime in our life,

this is a massive cost in terms of personal morbidity,
health care, work loss and incapacity benefits.
However, the neat division into acute back pain
that resolves quickly and completely and persistent
pain that does not is too simplistic and misleading.
Many people have a long term and episodic
problem, characterised by periods of relatively
little or no pain interspersed with acute episodes
of disabling pain. Many people continue to experience considerable pain and disability but stop
consulting their GP (Croft et al., 1998). The high
rate of resolution of acute back pain is more
perceived than actual. Whether the problem is
acute, chronic, or acute relapses of a chronic
condition makes little fundamental difference to
the advice and care people need and should receive.
Management should depend on whether people are
likely to be able to help themselves effectively by
following simple, appropriate advice, or are distressed, fearful, struggling to cope and have, or at
risk of developing, a long-term disabling problem.

How is it diagnosed?
The triage system has been developed in most
industrialised countries to help identify those who
have features (mostly in the history) that might predict
possible serious pathology (the red flags) (Box 1).

The second triage is those who have nerve root pain,

and the third is common (non-specific) back pain.
The management of possible serious pathology that
includes infection, fracture, osteoporosis, inflammatory arthropathy or tumour, and the management of
nerve root pain, is not covered in this review.
Non-specific back pain is defined as symptoms
without a clear specific histopathological cause.
The symptoms are generated on a spectrum of
dysfunctions including movements of the joints,
strain on the ligaments and discs and dysfunctions
in the neuromuscular system. The physiology of pain
signalling in these non-specific disorders is on a
spectrum from entirely nociceptive through
to neurogenic (also termed neuropathic) with
probably most patients having a mixture of both.
The physiology of pain signalling and perception is an
exceptionally complex process and although knowledge is incomplete, neurophysiological research over
the past few decades have helped us to understand
better the plasticity of the pain sensory system and the
gating of pain signals that is thought to occur mostly
within the dorsal horn of the spinal cord.
At least 90% of patients will have non-specific
back pain. Many health care professionals will use
different labels in an attempt to classify this very
heterogeneous group of patients. For example,
general practitioners may use lumbago, osteopaths
may use dysfunctions, physiotherapists hyperextension or derangements, chiropractors subluxations.
Surgeons favour degenerative disc disease. However,
at present no reliable and valid classification system
exists for most cases of non-specific back pain.

Box 1 Red flag conditions indicating possible underlying

spinal pathology or nerve root problems
Red Flags
 Onset age 520 or4 55 years
 Non-mechanical pain (unrelated to time or activity)
 Previous history of carcinoma, steroids, HIV
 Feeling unwell, weight loss
 Widespread neurological symptoms
 Structural spinal deformity
 Loss of bladder or bowel control
 Thoracic pain
 Major trauma
Indicators for nerve root problems
 Unilateral leg pain 4 low back pain
 Radiates to foot or toes
 Numbness or paraesthesia in same distribution
 Straight leg raising test induces more leg pain
 Localised neurology (limited to one nerve root)

Trauma 2011; 13: 5764

How useful is imaging?

Anomalies commonly seen on X-ray and magnetic
resonance imaging, such as narrow joint spaces,
grade 1(up to 25% slippage) spondylolisthesis,
degenerative discs, disc bulges, cracks, protrusions
and herniations, and the occurrence of non-specific
back pain are generally poorly associated (Jensen
et al., 1994; van Tulder et al., 1997; Kjaer et al.,
2005). There is, however, a stronger association
between Modic changes (bone oedema in vertebrae,
only seen on magnetic resonance imaging) and
persistent non-specific low back pain (Kjaer et al.,
2005; Albert and Manniche, 2007; Jensen et al.,
2008). It is important that clinicians do not make

Common non-specific back pain

potentially false assumptions and diagnoses based
on imaging findings because this may lead to the
patient learning unhelpful and negative health
beliefs or being offered unnecessary invasive treatment. Current guidelines advise that imaging should
be reserved for those patients with red flags or nerve
root pain. Imaging can be helpful for the patient
with non-specific back pain who is experiencing
persistent disease related anxiety that cannot be
alleviated by examination and explanation, provided the clinician makes it clear beforehand
precisely what imaging can and cannot do. Basic
blood count, inflammatory markers and biochemistry also have an important role to play if the
clinician is uncertain about possible serious
pathology.

Management of non-specific
back pain
There has been an exponential growth over the last
50 years in certified back pain disability, occurring
despite huge improvements in working environments. There is clear epidemiological evidence that
cultural changes have led to a greater awareness of
more minor back symptoms and willingness to
report them (Croft, 2000; Palmer et al., 2000). In the
same period, the number of treatments available
and the number of treatment sessions delivered have
also risen exponentially and are indicative of the
failure of the attempt to fit the symptom of back
pain into the model of disease and pathology
(CSAG, 1994; Waddell, 1998).
What is said to the patient and how it is said will
have far more impact on the clinical outcome than
what is done to the patient (Burton et al., 1999;
Roland et al., 2002). People experiencing back pain
without an identifiable medical problem need to
receive clear, accurate and realistic information that
promotes recovery. Additionally, those at risk of
developing a chronic problem must be identified
and monitored closely. It is very easy for busy
clinicians and therapists to be (or perceived as)
dismissive of peoples problems. Recent onset of
back pain must be acknowledged as being very
painful, debilitating and worrying, but people need
to be reassured their condition is very unlikely to
indicate a serious underlying disorder or lead to
long-term disability. Advice and management

59

perceived as uninterested, dismissive or lacking

conviction can be misinterpreted by the distressed
person and be counter-productive.
Although it may seem counter-intuitive to someone who experiences pain when they move, encouraging people to stay active is the single most
effective measure in preventing the development of
persistent disabling problems (Hagen et al., 2005).
Advice to avoid activities or take time off work is
almost always unhelpful and increases the chance of
long-term disability (Waddell and Burton 2000;
NICE, 2009). Following an acute episode, people
might take things easier for a few days to let
the pain settle, but even during this time they must
be advised and encouraged to move gently and be
active. An over cautious attitude to pain by the
health professional can easily be transferred to
patients and reinforce inappropriate health beliefs
and behaviours (Bishop and Foster, 2005).
Reducing the likelihood of an acute episode of
back pain becoming persistent is a key aim of
management, because while only a relatively small
percentage of people have disabling, chronic back
pain they are responsible for 80% of back pain
health care use and expenditure.
The main reasons for someone with acute pain
going on to develop chronic, disabling problems are
psychological, behavioural and social and have
been termed the yellow flags (Kendall et al.,
1997) (Box 2). These are very strong predictors of
chronic and disabling problems and must be
acknowledged and addressed where possible for a
successful outcome (Linton, 2000; Pincus et al.,
2002).

Box 2 Yellow flags; risk factors for developing and or

maintaining long-term pain and disability










Belief that pain and activity is harmful

Belief that pain will persist
Sickness, avoidant and excessive safety behaviours
(like extended rest, guarded movements)
Low or negative moods, anger, distress, social withdrawal
Treatment that does not fit with best practice
Claims and compensation for pain-related disability
Problems with work, sickness absence, low job satisfaction
Overprotective family or lack of support
Placing responsibility on others to get them better
(external locus of control)

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G Brown

Acknowledge that back pain is not just a

mechanical problem
Empathetic exploration of psychological and social
factors can be helpful in understanding what might
contribute to peoples problems, but risks being
misconstrued as dismissing their problems as all in
the mind. However, a sensitive explanation of how
anxiety, depression, exhaustion, insufficient restorative sleep, negative life events and over or under
activity can act as a pain volume control via the
pain gate system is often extremely helpful and
frequently patients recognise in themselves.

Too little activity or too much?

Many people avoid activities that cause pain in the
belief that they cause harm (fear-avoidance). Such
beliefs are understandable, but this leads to them
becoming less and less active and more and more
disabled and dependant. This results in muscle
weakness and physical de-conditioning and more
distress, and hence more pain. Conversely, other
people do too much at once (for example a
prolonged bout of gardening) to get it over and
done with, or spend long periods in a poor working
environment and with undesirable posture. These
behaviours are sometimes combined in a sequence
of booms and busts. Once identified, teaching
pacing of activity with skills to assist relaxation
(for example active relaxation through breathing
control, sometimes called Yoga breathing) helps to
provide more control over pain.

than unsupervised general exercise, but any exercise/physical activity is far better than none.

How effective are commonly

available treatments?
More than 1000 randomised controlled trials have
been published evaluating all types of conservative,
complementary and surgical treatments for back
pain in primary and secondary care. In many
Western countries, clinical guidelines have been
issued for the management of acute back pain.
In general, recommendations are similar across
guidelines. Box 3 summarises the main recommendations for diagnosis and treatment for acute low
back pain from 11 countries. For chronic (variable
definition but generally symptoms persisting longer
than 12 months) low back pain, far fewer guidelines
are available. Box 4 shows the recommendations
from the European clinical guidelines for chronic
low back pain. The UK guidelines published by
NICE (2009) for the management of non-specific
low back pain of between 6 weeks and 12 months
duration is summarised in Box 5.

What is the role of invasive

procedures in non-specific back pain?
van Tulder et al. (2006) published an evidence-based
review summarising the efficacy of surgery and
Box 3 Summary of recommendations of 11 national clinical
guidelines for acute low back pain (adapted from Koes et al.,
2001)

Support return to activity and exercise

People with long standing pain and failed management are often highly resistant to the notion that
exercise and activity are beneficial. In fact, exercise
is very beneficial for people with chronic pain, even
those who do not think it will help them (Moffett
et al., 1999). Exercise frequently involves some
initial discomfort, and many people need support,
reassurance and encouragement at this stage.
Graded or paced exercise, in which activity levels
are initially low and progressively increased towards
clearly identified functional goals, is more appropriate than traditional advice to let pain be your
guide. Supervised exercise, either by a physiotherapist or fitness instructor, is probably more effective
Trauma 2011; 13: 5764

Diagnosis
 Diagnostic triage (non-specific back pain, nerve root
pain, specific pathology)
 History taking and physical examination to exclude red
flags and neurological screening
 Consider psychosocial factors if there is no improvement
 X-rays are not useful for non-specific back pain
Treatment
 Reassure patients (favourable prognosis)
 Advise patients to stay active
 Prescribe medication if necessary, preferably at fixed
intervals
 Discourage bed rest
 Consider spinal manipulation for pain relief
 Do not advise back-specific exercises

Common non-specific back pain

other invasive interventions for back pain and
sciatica. A number of interventions, including
facet joint, epidural, trigger point, and sclerosing
injections, have not clearly been shown to be
effective. Such treatments can be very effective in
carefully selected individual cases but the causes of
non-specific back pain, and factors that might serve
to perpetuate the symptoms and disability are
multifactorial. Identifying sub groups of patients
who may benefit from these interventions is the
challenge for clinicians and research. In clinical
practice, when these interventions are used they
should ideally be combined with other rehabilitation
strategies, such as graded physical activity and
cognitive behavioural management. The UK NICE
guidelines (2009) for the management of nonspecific low back pain of between 6 weeks and
12 months duration go so far as to advise that
injections of therapeutic substances should not be
offered.
Surgical micro-discectomy may be considered for
selected patients with nerve root pain due to lumbar
disc prolapse who have not responded to conservative management (van Tulder et al., 2006). The role
of surgical fusion surgery for chronic low back pain

Box 4 Recommendations in the European clinical guidelines

for diagnosis and treatment of chronic low back pain (adapted
from Airaksinen et al., 2006)
Diagnosis
 Diagnostic triage (non-specific back pain, nerve root pain,
specific pathology
 Assessment of prognostic factors (yellow flags)
 Imaging is recommended only if specific pathological cause
is strongly suspected
 Magnetic resonance imaging is best option for radicular
symptoms, discitis, or neoplasm
 Plain radiographs are best option for structural deformities
Treatment
Recommended Cognitive behavioural therapy, supervised
exercise therapy, brief educational interventions and
multidisciplinary (biopsychosocial) treatment
To be considered Back schools and short courses of
manipulation and mobilisation, tricyclic antidepressants
(for example, amitriptyline)
Not recommended passive treatments (for example,
ultrasound and short wave), gabapentine. Invasive
treatments are in general not recommended in chronic
low back pain.

61

is under debate, summarised by Gibson (2007).

Recent randomised clinical trials comparing fusion
surgery with conservative treatment showed conflicting results (Fritzell et al., 2001; Brox et al., 2003;
Fairbank et al., 2005). Recommendations that
fusion surgery should be applied in carefully
selected patients are difficult to follow because no
clear and validated criteria exist to identify those
patients in advance.

Recent developments
Little and colleagues (2008) designed and implemented a randomised control trial of Alexander
lessons and technique for patients with chronic and

Box 5 Summary of the United Kingdom NICE guidelines for

the management of persistent non-specific low back pain of
between 6 weeks and 12 months duration (adapted from NICE,
2009)
Assessment
 X-rays should not be used in non-specific low back pain
 MRI should only be considered for suspicion of red flags,
malignancy, sepsis, fracture, cauda equina syndrome,
inflammatory disease or in the context of referral for
opinion on spinal fusion.
Initial treatment recommendations
 Education
 Maintain active lifestyle
 Oral analgesia including a tri-cyclic antidepressant
 Consider a course of manual therapy or acupuncture of up
to 12 weeks
Structured exercise programmes
 In patients not suitable for manual treatment
 Patient choice
 Individual no better than group but group more cost
effective
Combined physical and psychological programmes
 High intensity of more than 40 hours intervention should be
made available to patients with a high level of disability,
with psychosocial distress or after one or more previous
treatments
Surgery
 Should be reserved for a small group of selected individuals
who fail to respond to a combined physical and
psychological treatment programme.

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G Brown

recurrent back pain and demonstrated long-term

(over 12 months) benefit. Lessons in the Alexander
technique offer an individualised approach to
develop skills that help people recognise, understand, and avoid poor habits affecting postural tone
and neuromuscular coordination.
Stirling et al. (2001) showed an association
between sciatica and propionibacterium acnes. The
possible association between Modic changes on
magnetic resonance imaging and chronic back pain
has recently been tested in an uncontrolled pilot
study: the clinical effect of 90 days of antibiotic
treatment was large in a group of 29 patients
suffering chronic low back who had Modic changes
on imaging following a disc herniation and who had
not responded to previous active conservative
treatment (Albert et al., 2008).
Prolotherapy treatment has been advocated for a
variety of soft tissue conditions, including nonspecific low back pain (Ongley et al., 1987; Klein
and Eck, 1997). The procedure was initially used for
treatment of spinal pain in the 1930s. Conclusions
drawn about the effectiveness of the treatment from
published trials have been mixed (Yellend et al.,
2004). The reasons might be a result of the
methodology of the studies and the application of
the treatment in these studies for a very diverse
heterogeneous group of chronic low back pain
patients. As with other interventions, the challenge
is identifying sub-groups of patients who will most
likely benefit. The sacroiliac joint is a source of pain
in the lower back and buttocks and thigh in about
15% of the population (Dreyfuss et al., 2004), and
there is evidence that dysfunction of this joint could,
similar to herniated lumbar discs, produce pain
along the same distribution as the sciatic nerve
(Fortin et al., 1994, 2003). A recent prospective
study of 25 patients identified as having pain and
dysfunction in excess of 6 months arising from the
sacroiliac joint and who had not responded to active
physical therapy were given three prolotherapy
treatments to the posterior sacroiliac ligaments.
Clinical scores all improved significantly in those
followed up at 3, 12 and 24 months (Cusi et al.,
2010). Chakraverty and Dias (2004) showed similar
results when prolotherapy was offered to a carefully
selected group of patients whose pain was thought
to be arising from the sacroiliac joint.
Detecting relevant subgroups of patients
with non-specific low back pain has been
Trauma 2011; 13: 5764

highlighted as a priority area for research, as this

could enable better secondary prevention through
the targeting of prognostic indicators (the yellow
flags) for persistent, disabling symptoms. A brief
nine-question screening tool (STarT) that covers
referred leg pain, comorbid pain, disability, bothersomeness, catastrophising, fear, anxiety and depression looks very promising, and easy to use, in a
clinical setting (Hill et al., 2008).

Conclusion
The causes of non-specific back pain are multifactorial and consequently management must be
multi-modal. Over recent years, there has been a
paradigm shift in the assessment and management
of these problems away from a purely medical
model towards a bio-psycho-social model. Key
messages to give to patients with non specific back
pain is summarised in Box 6. Box 7 provides a guide
to some important messages for clinicians working
with patients who present with these problems.
Neurophysiological advances are helping us to
understand how pain can persist in the absence of
tissue injury and under the influence of belief,
emotional, social and cultural factors. It is much
more important to know what sort of a patient has a
disease than what sort of a disease a patient has
quoted Sir William Osler (18491919); in the light of
emerging evidence for the management of low back
pain clinicians would be wise to remember this.

Declaration of interest
Dr Brown works within a multidisciplinary, secondary care, clinical team. He offers interventions
to selected patients with persistent non-specific back
pain, which include deep dry needling (medical
acupuncture), osteopathic manual treatment, tricyclic antidepressant medication, physical, postural
(Alexander) and relaxation (Yoga) exercises and
graded physical aerobic exercise and prolotherapy.
He integrates brief psychological and behavioural
treatment strategies into consultations and treatment sessions. He runs educational workshops open
to all health care professionals on psychological
approaches to pain management and has published
a book (2009) called How to liberate yourself from

Common non-specific back pain

63

Summary

References

Box 6 Key messages to give to patients with non-specific

back pain

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Box 7 Key messages for clinicians working with patients with

non-specific back pain
Listen carefully to the patient
Carefully observe the patients behaviour
Attend not only to what is said but also to how it is said
Attempt to understand how the patient feels
Offer encouragement to disclose fears and feelings
Offer reassurance that you accept the reality of the pain
Correct misunderstandings or miscommunications about
the consultation
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biases (such as catastrophising)
 Understand the patients general social and economic
circumstances
 Use terms like learning to manage pain or taking back
control rather than psychological treatment









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occupational health professionals and employers to
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retention, He has not been involved with the
promulgation of any of the published guidelines
referred to in the article.

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