Non-specific low back pain exists. You just don't want to admit it
- Updated on: 2018-11-21
- Read original article here
Non specific low back pain is often a diagnosis that clinicians might feel sheepish about. As if they have failed. As if acknowledging uncertainty is a bad thing that leads to bad care. This isn’t true. It is quite often the only appropriate diagnosis and is the one that is the most accurate. Other acceptable diagnoses are non-specific shoulder pain. Or non-specific knee pain. Because when we say NSLBP we are acknowledging that NO ONE knows the specific anatomical source of nociception/pain. This is not really a debatable issue.
Before you freak out I would certainly note that it is still worth trying to find a specific diagnosis for our patients. Because sometimes they do exist and they are often sinister. But remember, a diagnosis has always been about the STRUCTURE. The structure that is CAUSING the pain. And if you are very honest with the literature we know that we can’t specifically target structures to elicit nociception and we certainly can’t say that a structure is causing pain. Pain is certainly much more multifactorial than that. And a non-specific structural diagnosis of pain opens us up to this wonderful complexity and can even improve our care.
If you think about it, even our “specific’ diagnoses aren’t really that specific. For example, what the hell does Patellofemoral Pain Syndrome actually mean? Your patient comes in and tells you it hurts around their knee cap when they squat and run. You have them squat, find that it hurts, maybe load the knee and find that it reproduces their knee ache, perhaps confirm that the pain isn’t referred from somewhere else and then boom. You put on your serious clinician face, pull out an anatomy text book and break the news that they have “Patellofemoral Pain Syndrome” Loosely translated as, “Knee cap on the leg bone pain syndrome”. Well, the patient just told you their knee cap hurt 30 minutes ago. You haven’t really arrived at some tissue specific diagnosis you’ve just paraphrased what they’ve said. You still don’t know the source of nociception and you certainly don’t know the source of pain.
The same thing holds with the majority of low back pain cases (Maher here). We don’t actually know the tissue source of pain. But this doesn’t mean that our treatment is non-specific. What does a good clinician then do with this anatomical uncertainty?
Working in just the biomechanical world the clinician finds the mechanical aggravators of the person. Some fancy tests like bending or twisting or jumping. When the patient says what movement hurts we then might relabel that simple description as “you have an Active-Extension Pattern”. This was a former classification seen in the CFT research group (but they no longer use this – Evolution is wonderful). But all it really says it what movements aggravates a patient’s pain. You can’t reliably infer what structure is sensitized and it doesn’t matter. That is not a diagnosis although many have advocated thru the years to call this a functional diagnosis. The same can be said if someone has pain flexing their spine. This might be called a flexion impairment or flexion intolerance. Again, this is not a diagnosis. You can’t infer what structure is sensitive from this. We are taught in school to consider the disc but the only research that tried to evaluate “pain” from a disc suggested that it was only the centralization of symptoms from the leg to the spine that would suggest a disc as the source of irritation (source here).
Calling a spine flexion intolerant is like diagnosing stomach pain but saying its burrito induced abdominal distress. That “diagnosis” is accurate and helpful (eat less burritos) but its not a true diagnosis – just like lbp diagnosis which merely catalogues aggravators.
