Non-specific low back pain and osteopathy

More than 80% of us will develop a painful episode in the lower back at some point in life. Fortunately, in the majority of cases, this will not be attributable to a specific pathology (fracture, infection, tumour, etc.). For more than 90% of these patients, the origin of the pain cannot be determined, so we speak of “non-specific low back pain” [1].

 

 

 

 

ORIGINS:

 

Non-specific low back pain is defined as low back pain that cannot be linked to a recognizable and known pathology. Many structures in the lower back can cause these ailments. This leads some practitioners, dissatisfied with the established tradition of labeling almost all cases of low back pain as non-specific, to argue that different underlying causes (facetogenic, discogenic or sacroiliac) exist and can be identified. . However, the evidence suggesting the existence of these subgroups is currently insufficient [2].

 

 

In addition, it should be kept in mind that the correspondence between the clinic and routine medical imaging is very bad for the back. Indeed, “abnormalities” of the spine are frequent (protrusion, herniated disc, discopathy, osteoarthritis) and are not the cause of your pain. Used improperly, imaging can have a deleterious effect by giving a catastrophic picture showing structural lesions that do not correspond to the clinical reality of the patient. This increases medical interventions, induces a negative perception and poor functional results in low back pain patients [3]. It is therefore important to focus on the clinic first and foremost.

 

The link that connects the occurrence of low back pain with poor postures is often reported by
patients. To answer this question, Canadian researchers have synthesized all the
published data on the causal links between uncomfortable postures at work and the occurrence of low back pain [4]. More than 40 trades are listed, the most represented of which were administrative workers, followed by nurses, plumbers and postal workers. Their conclusion was that there is no relationship between occupational postures and low back pain in the populations of workers studied. The mechanical factors in the genesis of low back pain are therefore probably not as present as we thought. However, being overweight and a sedentary lifestyle increase the risk of low back pain. A healthy and dynamic lifestyle is therefore ideal to prevent your ailments. It is also interesting to note that only physical exercises have been shown to be effective in preventing low back pain [5].

 

 

Finally, it should be noted that the absence of clear data on the origin of low back pain is also explained by
the fact that this pathology involves a multitude of genetic, physical,
psychological, environmental, cultural and societal.

 

 

 

TREATMENTS:

 

The recommendations of most clinical practice guidelines (guidelines) agree on the use of a biopsychosocial framework to guide management. They include a
initial non-pharmacological treatment, education that supports self-management and the resumption of normal activities and exercise, and psychological (cognitive-behavioural) programs for people with persistent symptoms. In addition, they recommend careful use of drugs, imaging and surgery [6].

 

Spinal manipulations, used in particular by osteopaths, are also included
in the therapeutic arsenal of these guidelines for treating low back pain. Their effectiveness remains
controversial, like all the treatments offered elsewhere.

 

Finally, there is no perfect treatment, each of them has a low effectiveness when compared to a placebo. If subgroups of patients, designed on the basis of their positive response to certain treatments, could be reliably identified, this would represent a breakthrough.
significant in the treatment of low back pain. In the meantime, it is therefore important to take the patient’s preferences into account.

 

 

 

 

OSTEOPATHIC CARE

 

When a patient presents with acute low back pain, the first step will be to ensure that he
has no contraindication to osteopathic treatment (through a series of questions and certain clinical tests). These are the famous red flags. The latter will have a semiological value all the more important as they are numerous. For example, waking up at night in pain during acute low back pain is not uncommon and is not associated with a serious underlying pathology if this sign is isolated [7].

 

Once these specific pathologies have been ruled out and the musculoskeletal origin is
confirmed it is important to identify patients at risk of developing chronic pain and long-term disability: these are the yellow flags. These yellow flags include inappropriate attitudes and beliefs about back pain (back pain indicates serious damage or illness), inappropriate behavior (avoidance behavior and reduced activity levels), and difficulties related to work and/or emotional. These patients will be invited to follow a multidisciplinary management [8].

 

Patients with no contraindications and wishing to be treated by spinal manipulation will be able to benefit from it. Spinal manipulations are known as High Velocity Low Amplitude (HBVA) techniques where audible sound is usually present.

 

Although the mechanism making these techniques effective is not yet fully understood, the hypothesis suggested in the scientific literature is that the mechanical force of spinal manipulation primarily affects afferent neurons in the paraspinal tissue and triggers a cascade of neurophysiological responses in the spinal cord. peripheral and central nervous system, ultimately leading to pain inhibition [9].

 

Studies have also highlighted the modification of certain biomarkers [10] as well as of the autonomic nervous system [9] following spinal manipulations. Finally, and most important for patients, a 2017 meta-analysis [11] showed moderate efficacy of these techniques in patients with low back pain for less than 6 weeks on pain and functional impairment. However, the heterogeneity of the studies included in this meta-analysis was significant. Linking the neurophysiological effects of spinal manipulations to changes in perceived pain would increase their relevance from a therapeutic point of view, possibly identify subgroups of patients and allow for more individualized treatment.

 

 

 

 

CONCLUSION:

 

The most promising scientific advances for the management of low back pain patients
are those that align practice with evidence, reduce the focus on spinal abnormalities, and promote activity and function, including work participation. Current knowledge, the clinical experience of the practitioner and the preferences of the patient must be taken into account.

 

Do you suffer from back problems? Our physiotherapists and osteopaths are there to help you.

 

 

                                                           WE CARE, U PERFORM.

 

 

Bibliographie:

 

• [1] Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6. PMID: 21982256.

 

• [2] Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft PR, Hay E. Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):181-91. doi: 10.1016/j.berh.2009.11.003. PMID: 20227640.

 

• [3] Rajasekaran S, Dilip Chand Raja S, Pushpa BT, Ananda KB, Ajoy Prasad S, Rishi MK. The
  catastrophization effects of an MRI report on the patient and surgeon and the benefits of clinical reporting: results from an RCT and blinded trials. Eur Spine J. 2021 Jul;30(7):2069-2081. doi: 10.1007/s00586-021-06809-0. Epub 2021 Mar 21. PMID: 33748882.

 

• [4] Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J. 2010 Jan;10(1):89-99. doi: 10.1016/j.spinee.2009.09.003. Epub 2009 Nov 11. PMID: 19910263.

 

• [5] Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J. 2009 Feb;9(2):147-68. doi: 10.1016/j.spinee.2008.11.001. PMID: 19185272.

 

• [6] Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 Jun 9;391(10137):2368- 2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21. PMID: 29573872.

 

• [7] 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.

 

• [8] Jonckheer P, Desomer A, Depreitere B, Berquin A, Bruneau M, Christiaens W, Coeckelberghs E, Demoulin C, Pierre Duquenne (CHC Liège), Forget P, Fraselle V, Godderis L, Hans G, Hoste D, Kohn L, Mairiaux P, Munting E, Nielens H, Orban T, Parlevliet T, Pirotte B, Van Boxem K, Van Lerbeirghe J, Van Schaeybroeck P, Van Wambeke P, Van Zundert J, Vanderstraeten J, Vanhaecht K, Verhulst D. Low back pain and radicular pain: development of a clinical pathway. Health Services Research (HSR) Brussels: Belgian Health Care Knowledge Centre (KCE). 2017. KCE Reports 295. D/2017/10.273/87.

 

• [10] Kovanur-Sampath K, Mani R, Cotter J, Gisselman AS, Tumilty S. Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis. Musculoskelet Sci Pract. 2017 Jun; 29:120-131. doi: 10.1016/j.msksp.2017.04.004. Epub 2017 Apr 5. PMID: 28399479.

 

• [11] Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, Branson R, Tang B, Morton SC, Shekelle PG. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017 Apr 11;317(14):1451- 1460. doi: 10.1001/jama.2017.3086. Erratum in: JAMA. 2017 Jun 6;317(21):2239. Erratum in: JAMA. 2017 Nov 28;318(20):2048. PMID: 28399251; PMCID: PMC5470352.