What is back pain? A current perspective.

General

Back pain is the most common cause of disability and discomfort worldwide (1). 37% of adults suffer from it within a one-year period. More people in middle age and more women than men are affected (2). 19.6% of 20- to 59-year-olds and 25.4% of those over 60 suffer from back pain lasting longer than 3-6 months (3). The trend since the turn of the millennium has been toward an increasing number of patients with chronic back pain (4). The rising costs are straining not only the healthcare system but also social security systems (5). In Germany, the total annual cost of back pain amounts to €48.96 billion, equivalent to 2.2% of the gross domestic product (6). According to the Federal Statistical Office, this equates to 247,000 years of lost working life. For Switzerland, the annual direct costs amount to CHF 4.4 billion (7) and the indirect costs, according to the Federal Department of Home Affairs, to CHF 7.5 billion. Acute back pain can disappear on its own (8) and usually does (9). However, back pain is often a recurring and sometimes a long-lasting problem (10).

Causes of back pain

Disease-related causes, such as infections, fractures, arthritis, cancer, or cauda equina syndrome, are rare (11). In these cases, imaging procedures are important, and patients should be under medical care. More often, however, the cause of back pain is not a specific disease, and the pain is not related to an injured physical structure. Imaging procedures are therefore not appropriate. So-called psychosocial factors make a measurable contribution

to pain and are associated with limitations in daily life (12). According to the 2017 National Guideline for the Care of Non-Specific Low Back Pain, these factors (e.g., excessive physical inactivity, anxiety, avoidance behavior, negative stress, and hopelessness), along with workplace-related factors (e.g., strenuous physical labor, monotonous posture, and job dissatisfaction), can lead to more persistent pain (Fig. 1).

So-called findings, such as various asymmetries, spinal deviations, intervertebral disc degeneration, psoas tension, muscle status, and pelvic findings, have more to do with beliefs than with scientific evidence (13). Hypermobility, scoliosis, and spinal posture are also not directly related to back pain. In addition to lifestyle, a wide variety of factors play a role: biological, psychological, and social (Fig. 2) (14).

Even a vertebral arch fracture or spondylolisthesis is not necessarily a cause of back pain (15).

Classification of back pain

Biomedical approaches that focus on the seemingly easily injured spine have not been able to prevent the rising costs, the increase in chronic pain, and greater limitations in daily life. Rather, back pain is associated with a variety of individual factors that influence each other (16). If the pain is ruled out in the context of neurological deficits and suspected specific diseases, so-called non-specific back pain remains (Fig. 3). This can manifest itself, for example, directly during movement or when maintaining a position (sitting/standing).

Therapy for back pain

Based on the further classification of the most common types of back pain, an individualized strategy is chosen (Fig. 4). It is important that the individual, with their unique characteristics, is at the center of the therapy. The goals and content of the therapy are derived from this (16).

Bibliography

1. Collaborators GDaIIaP. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-59.

2. Hoy D, March L, Brooks P, Woolf A, Blyth F, Vos T, et al. Measuring the global burden of low back pain. Best Pract Res Clin Rheumatol. 2010;24(2):155-65.

3. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015;49.

4. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-8.

5. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84(1):95-103.

6. Wenig CM, Schmidt CO, Kohlmann T, Schweikert B. Costs of back pain in Germany. Eur J Pain. 2009;13(3):280

7. Wieser S, Horisberger B, Schmidhauser S, Eisenring C, Brügger U, Ruckstuhl A, et al. Cost of low back pain in Switzerland in 2005. Eur J Health Econ. 2011;12(5):455-67.

8. McIntosh G, Hall H. Low back pain (acute). BMJ Clin Evid. 2011;2011.

9. Wet MJ. How to approach the problem of low back pain: an overview. J Family Community Med. 2005;12(1):3-9.

10. Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res Clin Rheumatol. 2013;27(5):601-12.

11. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-67.

12. O'Sullivan K, O'Sullivan PB, O'Keeffe M. The Lancet series on low back pain: reflections and clinical implications. Br J Sports Med. 2019;53(7):392-3.

13. Lederman E. The case of the postural-structural-biomechanical model in manual and physical therapies: illustrated by lower back pain. J Bodyw Mov Ther. 2011;15(2):131-8.

14. O'Sullivan P, Smith A, Beales D, Straker L. Understanding Adolescent Low Back Pain From a Multidimensional Perspective: Implications for Management. J Orthop Sports Phys Ther. 2017;47(10):741-51.

15. Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V. Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. Eur Spine J. 2015;24(6):1289-95.

16. O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, et al. Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Phys Ther. 2018;98(5):408