Persistent low back pain is low back pain that has lasted for longer than six weeks. Like acute low back pain, most persistent low back pain is non-specific. Non-specific means the cause of the pain is not serious or trigged from arthritis, infection or sciatica (an irritated nerve in your back). It also means that it is not possible to find a specific source of the pain (eg, joint, muscle, ligament, disc). Even the best quality imaging techniques (eg, a CT scan or an MRI) cannot identify what causes most persistent low back pain.
What causes persistent non-specific low back pain?
Studies have identified some risk factors for developing persistent low back pain after an acute episode. Your risk of getting persistent low back pain is increased if you have high levels of pain or pain that extends into the leg, or if you are feeling down, depressed, or very worried about your recovery. On their own, these factors only increase your risk of persistent low back pain by a small amount. In combination, they can double your risk of developing persistent low back pain.
How do I know if I have persistent non-specific low back pain?
Your physiotherapist is trained to distinguish between serious and non-serious causes of low back pain. They will do this by asking you a series of questions about your low back pain and by examining your back. Imaging is not needed to diagnose persistent non-specific low back pain. It can be tempting for clinicians to make an educated guess about which back structure is responsible for the pain. Many patients and clinicians find ‘non-specific’ hard to accept. However, specific diagnoses for example, disc injury and facet joint problem are not well supported by scientific evidence. Most importantly, treatments directed at these specific structures (eg, an injection of steroid-based medications into the ‘problematic’ joint) have not been shown to be effective for persistent low back pain.
How can physiotherapy help with persistent non-specific low back pain?
A physiotherapist can help confirm that you have non-specific low back pain and rule out other conditions that require additional testing and treatment. Once a diagnosis of persistent non-specific low back pain is confirmed, they can help you decide how to manage it. This will usually involve a combination of physiotherapy treatment and things that you can do at home. Physiotherapy treatment might include hands-on therapy, education, exercises or a combination of these.
Physiotherapists also work in pain clinics and contribute to the team-based care that may be required for some people with persistent non-specific low back pain. For example, persistent low back pain can be associated with feelings of depression, poor lifestyle habits, and difficulties participating in work and social activities. Different professionals, including physiotherapists, GPs and psychologists, work together to help with these different aspects of low back pain.
How effective is physiotherapy for persistent non-specific low back pain?
Many studies have now looked at the effectiveness of physiotherapy treatments for people with persistent non-specific low back pain. There is high quality evidence that exercise can help reduce pain. Believe it or not, the effects of exercise on pain are similar to those of opioid drugs (eg, codeine, oxycodone, tramadol). There is also some evidence that massage and other hands-on treatments can reduce pain.
There a lots of treatment options for low back pain. Examples of interventions that have been shown to be ineffective for persistent low back pain include: antidepressant medication, paracetamol, ultrasound, electrical stimulation eg, TENS, as well as spinal fusion. Machines that were once popular in physiotherapy (eg, ultrasound, electrotherapy, traction) have been shown to be no more effective than fake machines. On their own these therapies are not useful.
Your physiotherapist will be able to discuss the pros and cons of different treatments. They can help design an effective exercise program for you and this program is likely to reduce your pain in the short term.
What can I do at home?
Staying physically active is likely to be helpful. Gradually upgrading your activity levels using the principle of pacing (do a bit more each week but not too much more) is also recommended. Remaining at work is important. If your work provokes your back pain, a physiotherapist might be able to suggest some strategies to modify your work tasks and build your physical capacity.
How long until I feel better?
Just because you have persistent low back pain does not mean you cannot recover. Some (nearly one in two) people with persistent low back pain recover in 12 months. Many people with ongoing persistent low back pain have relatively mild pain or mild disability. In cases where pain lasts longer, tackling the problem from different angles can help. For some people, this is where a pain clinic may help.