Non-specific low back pain

Non-specific low back pain is pain between the lower edge of the ribs and the buttocks that cannot be confidently put down to a particular disease, injury or structural problem. It is the diagnosis in about 90% of cases of low back pain (WHO). Because it has no known anatomical cause, treatment aims at reducing the pain and its effect on your life rather than at fixing one structure (Maher et al., 2017).

What the label does and does not mean

“Non-specific” is a conclusion, not a shrug. Guidelines ask clinicians to first look for the rare serious causes, such as cancer, infection, trauma or inflammatory disease (NICE NG59). Only a small proportion of people with low back pain have a well-understood cause, for example a vertebral fracture, a tumour or an infection (Hartvigsen et al., 2018). When none of these is found, the pain is non-specific. It is still real pain; it is simply not a sign of a particular damaged part.

This is also why scans are not routine. NICE advises against imaging for low back pain outside specialist settings, and in specialist care only if the result is likely to change management (NICE NG59). Wear-and-tear findings are common in people with no pain at all, as explained under lumbar spine.

How non-specific low back pain behaves

• Most episodes settle, but not always completely. Most people with a new episode recover quickly, recurrence is common, and in a small proportion the pain becomes persistent and disabling (Hartvigsen et al., 2018). In 11 primary care studies, 33% had recovered within three months, but 65% still reported some pain a year after it started (Itz et al., 2013).
• It often comes back. Among 250 people who had just recovered, 69% had another episode within a year. Awkward postures, more than five hours of sitting a day and more than two previous episodes predicted it (da Silva et al., 2019).
• Some factors predict a longer course. High pain at the start, psychological distress and pain in several parts of the body raise the risk of persistent, disabling pain (Hartvigsen et al., 2018). Psychological factors like these are often called yellow flags, and kinesiophobia, the fear of movement, is among them.

For the full picture of how it unfolds, see Will back pain go away on its own?

Does sitting cause non-specific low back pain?

The WHO lists low physical activity, smoking, obesity and high physical stress at work as risk factors (WHO). Sitting is more complicated. A review of 41 systematic reviews found sitting and posture associated with low back pain but no consensus that they cause it (Swain et al., 2020), while long daily sitting did predict recurrence in the study above. More on this in lower back pain from sitting.

What helps non-specific low back pain?

• Information and staying active. NICE recommends explaining the nature of the pain and encouraging people to continue normal activities, and advises against belts, corsets, traction and acupuncture (NICE NG59).
• Exercise. A Cochrane review of 249 trials found moderate-certainty evidence that exercise reduces pain in chronic non-specific low back pain compared with no treatment, usual care or placebo. The effect on day-to-day function was smaller (Hayden et al., 2021).
• Prevention. Across 21 trials with 30,850 people, exercise combined with education reduced the risk of a new episode (moderate-quality evidence). Education alone, back belts and shoe insoles did not (Steffens et al., 2016).

Bavelu’s lower back sessions are designed and filmed by physiotherapists; one of their exercises is on lower back stretches.

When to see a doctor

See a GP if the pain hasn’t improved after a few weeks, is stopping your daily activities, is worse at night or when you cough or sneeze, or comes with weight loss you can’t explain. Get urgent advice from your GP or NHS 111 if you feel hot, shivery and unwell, or the pain is severe and getting worse quickly. Call 999 or go to A&E if back pain comes with pain, numbness or weakness in both legs, loss of feeling around the genitals or anus, changes in bladder or bowel control, or chest pain (NHS). Leg pain from a nerve is covered under sciatica, and the full list of warning signs under red flags.