RISK FACTORS AND CONTEMPORARY MANAGEMENT OF LOW BACK PAIN

Abstract

The broad aim of this thesis was to contribute to a better understanding of the mechanisms and management of non-specific low back pain (LBP) by investigating treatment options, mechanisms and outcomes. Chapter Two provides an overview of risk factors for LBP in an umbrella review of the evidence revealing that individual, biomechanical and psychosocial factors increase risk for a future episode of LBP and sciatica. The study presented in Chapter Three aimed to investigate the extent to which patients can accurately nominate what has triggered their new episode of sudden onset, acute LBP. This study provides evidence that patients can clearly identify an activity that triggered their sudden-onset acute LBP. Chapter Four is a cohort study investigating the course of LBP in older men, if comorbidities/ lifestyle factors can predict the course of LBP in older men and if comorbidities/ lifestyle can increase the risk of developing LBP in older men. Two years after entering the study, older men continued to experience pain. Also, the higher number of comorbidities increased the odds of developing LBP and lifestyle factors influenced its course. Chapter Five investigated the effect of Back School on pain and disability for adults with chronic non-specific LBP in a Cochrane systematic review. Regardless of the comparison used (as well as the outcomes investigated), the results of the meta-analysis shows no difference or a trivial effect in favour of the Back School intervention. Chapter Six appraised the recommendations and methodological quality of international clinical guidelines for the management of vertebral compression fractures. The comparison of clinical guidelines for the management of vertebral compression fractures shows that diagnostic and therapeutic recommendations are generally inconsistent. The evidence available to guideline developers is limited in quantity and quality. Chapter Seven described the evolution of guideline-endorsed red flags for fracture in patients presenting with LBP and described the consistency between guidelines in the endorsement of red flags for fracture. The results shows that the number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data. The studies in this thesis have provided an important contribution to the understanding of contemporary management of LBP. The main implications are: i) individual, biomechanical and psychosocial factors increase risk for a future episode of LBP and sciatica.; ii) patients can accurately nominate an activity that triggered their sudden-onset acute LBP: iii) LBP is typically persistent in older men and a higher number of comorbidities increased the odds of developing LBP; and lifestyle factors such as higher BMI and higher consumption of alcohol influenced its course iv) Back Schools showed no difference or a trivial effect for chronic LBP regardless of the comparison used v) Recommendations in clinical practice guidelines on vertebral compression fractures interventions should be reviewed vi) The number of red flags endorsed in guidelines to screen for fracture has risen over the years; most guidelines do not endorse the same set of red flags.