Signpost for back complaints

Low back pain is common. Back complaints also have many manifestations and variations. Then there are several doctors and therapists who say they can help. The question is of course: what do I have, and what can I do to get rid of it? There is no easy answer to that. With the step-by-step plan presented here, it is possible to give direction to the answer.

Hopefully you realize that with this signpost you cannot make a personal diagnosis. For this you should consult a doctor specialized in the musculoskeletal system. For comments and suggestions you can contact me via the contact page

 

Examination of low back pain

(see also article on causes back pain)

The question

Action

Possibilities

Is there a specific cause of the complaints? (explanation on specific)

Consult an expert physician *)

Herniation of a disc (nuclei pulposi)

Fracture

Shear vertebra (spondylolisthesis)

Inflammation in vertebra (spondylitis)

Cancer (malignancy metastases)

Infection

Spinal canal constriction (stenose)

Osteoporosis

Scoliosis

Do the complaints come from the back itself or from elsewhere?

Consult an expert physician *)

Kidneys

Gut

Aorta

Internal pelvic origin

Is there a radicular syndrome? (irritation nerve)

Consult an expert physician *)

Herniation of a disc (nuclei pulposi)

Clamping nerve elsewhere (eg m. piriformis)

Are there non-specific complaints? (explanation on non-specific)

Consult an expert physician **)

Simple non-specific complaints:

- recognizable complaint

- previously spontaneously improved within a few weeks

- recently emerged

- clear cause (eg, overuse)

- impact on daily activities limited

- good general health

   

Complex non-specific complaints:

- has been present for a long time (chronicity)

- the complaints are never gone

- there are more complaints than just the low back

- there are psychosocial problems

*) expert physician: starting with the general practitioner, then (if indicated!) referring to neurologist, orthopedist, rheumatologist. The physician musculoskeletal medicine can also be consulted outside this circuit.

**) expert physician specialized in the musculoskeletal system such as a general practitioner with extra expertise (training musculoskeletal medicine) or physician musculoskeletal medicine - broadly oriented.

 

Treatment for low back pain

(see also article on treatment of back pain)

Type of back complaint

To who

What does he/she do

Specific

Depending on severity and diagnosis, or no reference to:

 
 

- neurologist

- examination and advice (eg waiting, referral for operation)

 

- orthopedist

- examination and advice (eg waiting, operation)

 

- neurosurgeon

- examination and advice (eg waiting, operation)

 

- reumatologist

- examination and advice (eg medication)

 

- physician musculoskeletal medicine

- only with stenosis: examination and possible treatment

Complaints not related from the back To relevant specialist (urologist, gynecologist, gastrointestinal specialist, surgeon, vascular surgeon)  
Radicular - general practitioner - acts according to (inter)national guidelines
 

- neurologist

- acts according to (inter)national guidelines

 

 

- neurosurgeon

- operates on indication

 

- orthopedist

- operates on indication

 

- physician musculoskeletal medicine

- MDT physiotherapist

- examines whether non-operative treatment makes sense; limited group can be treated with exercises (discogenic syndrome)

Non-specific back pain – simple

Several possibilities:

 
  - yourself! - with most people, the symptoms will improve spontaneously by staying active, with possibly short-term painkiller use
 

- general practitioner

- acts according to (inter)national guidelines with advice, activating policy, painkillers and limited number of controls

 

- physiotherapist

- acts according to (inter)national guidelines with often multiple treatments with advice and exercises

 

- manual therapist

- acts according to (inter)national guidelines with often multiple treatments with advice, exercises, spinal column/joint manipulations

 

- exercise therapist

- acts according to (inter)national guidelines; multiple treatments with advice and exercises aimed at posture development

 

- physician musculoskeletal medicine

- examines type of non-specific back pain (classifies) for individual approach with advice, exercises, treatment techniques from various schools; limited number of treatments

 

- alternative working doctor

- there is limited evidence for effectiveness in acupuncture

 

- chiropractor or osteopath

- usually repeated treatments with manipulations of spine/joints

Non-specific back pain – complex

Several possibilities:

 
 

- general practitioner

- acts according to (inter)national guidelines; refers, if necessary, with psychosocial, chronic or other additional problems

 

- psychologist

- there is evidence for effectiveness cognitive behavioral therapy

 

- rehabilitation doctor

- examines problems and often acts in combination with a team

 

- physician musculoskeletal medicine

- examines type of non-specific back pain (classifies) for individual approach with advice, exercises, treatment techniques from various schools; limited number of treatments

 

Some references

van Tulder M et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006 Mar;15 Suppl 2:S169-91.

Airaksinen O et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006 Mar;15 Suppl 2:S192-300.

Bons SCS et al. NHG-Standaard Aspecifieke lage rugpijn (Tweede herziening) 2017.

Wambeke P van et al. KCE Report 287As. Klinische richtlijn rond lage rugpijn en radiculaire pijn 2017.

Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 2003, 28:1363-1371, discussion 1372.

Henschke N et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009;60(10):3072-80.

Jorritsma W et al. Beroepsprofiel Arts Musculoskeletale Geneeskunde. Dutch Society of Musculoskeletal Medicine 2016.

Karayannis NV. Physiotherapy movement based classifications approaches to low back pain: comparison of subgroups through review and developer/expert survey. BMC Musculoskeletal Disord. 2012; 20:13-24.

Waddell G. The back pain revolution 2nd ed. Churchill Livingstone 2004.