Original Article

Mechanical or inammatory low back pain. What are the

potential signs and symptoms?
Bruce F. Walker
a,
*
, Owen D. Williamson
b
a
School of Chiropractic and Sports Science, Faculty of Health Sciences, Murdoch University, 6150 Murdoch, Western Australia, Australia
b
Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Victoria, Australia
Received 7 November 2007; received in revised form 12 March 2008; accepted 10 April 2008
Abstract
Non-specic low back pain (NSLBP) is commonly conceptualised and managed as being inammatory and/or mechanical in
nature. This study was designed to identify common symptoms or signs that may allow discrimination between inammatory
low back pain (ILBP) and mechanical low back pain (MLBP). Experienced health professionals from ve professions were surveyed
using a questionnaire listing 27 signs/symptoms.
Of 129 surveyed, 105 responded (81%). Morning pain on waking demonstrated high levels of agreement as an indicator of ILBP.
Pain when lifting demonstrated high levels of agreement as an indicator of MLBP. Constant pain, pain that wakes, and stiness
after resting were generally considered as moderate indicators of ILBP, while intermittent pain during the day, pain that develops
later in the day, pain on standing for a while, with lifting, bending forward a little, on trunk exion or extension, doing a sit up, when
driving long distances, getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally
considered as moderate indicators of MLBP.
This study identied two groups of factors that were generally considered as indicators of ILBP or MLBP. However, none of
these factors were thought to strongly discriminate between ILBP and MLBP.
2008 Elsevier Ltd. All rights reserved.
Keywords: Low back pain; Inammatory; Mechanical; Signs; Symptoms
1. Introduction
Lowback pain (LBP) is a common problemwith point
prevalence ranging from 12% to 33%, 1-year prevalence
22e65% and lifetime prevalence 11e84% (Walker,
2000). While LBP is usually self-limiting, it can persist
resulting in a substantial personal, social and economic
burden (Walker et al., 2003). In the majority of cases,
a specic diagnosis for LBPcannot be dened on the basis
of anatomical or physiological abnormalities. Although
imaging strategies can be employed to exclude serious
causes of LBP (such as tumours and infections), anatom-
ical abnormalities, such as those associated with the aging
process, are commonly observed in otherwise asymptom-
atic, healthy individuals (Deyo, 2002). While specic ther-
apies can be employed to correct identiable anatomical
or physiological abnormalities, non-specic low back
pain (NSLBP) can only be treated empirically.
Systematic reviews (Van Tulder et al., 2000; Assendelft
et al., 2004) have described the benet of a broad range of
physical and pharmacological interventions over natural
history or placebotherapies, but have concededthat eect
sizes are small, with little dierence in outcomes observed
when alternative therapies are compared. This apparent
lack of eect may, at least in part, be due to the tendency
to treat NSLBP as a homogenous condition, rather than
* Corresponding author. Tel.: 61 08 93601297; fax: 61 8 9360
1299.
E-mail address: bruce.walker@murdoch.edu.au (B.F. Walker).
1356-689X/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2008.04.003
Available online at www.sciencedirect.com
Manual Therapy 14 (2009) 314e320
www.elsevier.com/math
a heterogeneous collection of as yet undened but dier-
ing conditions, some of which might respond and others
that do not respond to a particular therapy.
There is therefore a need to identify subgroups within
the broad classication of NSLBP, and given the failure
of classication on the basis of anatomical and physio-
logical abnormalities, attempts have been made to iden-
tify subgroups on the basis of symptoms and physical
signs (Kent et al., 2005). This syndromic approach has
been limited in the past because of the poor inter-rater
reliability of proposed classications. More recently,
however, several subgroup classication systems have
been demonstrated to have moderate or good inter-rater
reliability (Fritz and George, 2000; Flynn et al., 2002;
Kilpikoski et al., 2002; Fritz et al., 2006). Subsequent
randomised controlled trials (Fritz et al., 2003; Childs
et al., 2004; Long et al., 2004; Brennan et al., 2006)
have indicated that patients with NSLBP who receive
treatment matched to subgroup classications have bet-
ter outcomes than those who receive alternative thera-
pies. It therefore seems likely NSLBP does represent
a heterogeneous collection of conditions and that the
identication of subgroups can result in improved out-
comes through directed therapies.
NSLBP is commonly described as being mechanical
(Batt and Todd, 2000; Chaudhary et al., 2004; Valat,
2005) or inammatory (Saal, 1995; Ross, 2006).
Although these labels have no universally accepted deni-
tions, there is evidence to support the involvement of both
mechanical and inammatory factors in the generation of
LBP (Biyani and Andersson, 2004; Hurri and Karppinen,
2004; Igarashi et al., 2004; Abbott et al., 2006; Al-Eisa
et al., 2006; Ross, 2006). Further, there are two distinct
types of treatment for LBP that seem to follow this noso-
logical separation. That is, mechanical treatments such
as mobilisation, manipulation, traction and exercise are
contrasted with notionally anti-inammatory treat-
ments like non-steroidal anti-inammatory medications
andcorticosteroid injections. There are studies that exam-
ine signs and symptoms of specic inammatory arthriti-
des of the spine such as ankylosing spondylitis (AS)
(Rudwaleit et al., 2006). But once conditions like AS
have been ruled out there are no studies that determine
whether or not inammatory low back pain (ILBP) and
mechanical low back pain (MLBP) subgroups can be dif-
ferentiated within the NSLBP classication.
It would therefore seem useful to attempt to divide
LBP suerers into groups that may respond more read-
ily to two types of treatment, mechanical or inamma-
tory. If this were possible the number of inappropriate
therapy decisions could be decreased.
The aims of this study were to identify common
symptoms or signs that may allow discrimination
between ILBP and MLBP and determine whether the
dierent groups involved in the management of LBP
interpret these signs and symptoms in a similar manner.
2. Methods
Prior to the commencement of the study, the authors
designed a questionnaire listing 26 symptoms and signs
relating to LBP. The signs and symptoms were drawn
from the a priori knowledge of the authors to be possibly
related to LBP. The questionnaire was then pre-tested
on a group of four practitioners: a spine surgeon, rheu-
matologist, chiropractor and manipulative physiothera-
pist, resulting in the addition of a further question. The
nal 27 signs and symptoms are found in Table 1. The
questionnaire also contained an additional row for
other signs and symptoms beyond the 27 nominated.
This row could be lled out at the discretion of the
respondent if they thought that there were other associ-
ated factors. Those surveyed were asked Please circle
the number (0e10) which in your opinion best matches
the sign or symptom as being from [mechanical]/[inam-
matory] low back pain.
Responses were assessed on an 11-point semantic
dierential scale (Streiner and Norman, 2003) requiring
the participants to indicate the degree, from strongly dis-
agree (0) tostrongly agree (10), withwhichthey associated
each symptom or sign with ILBP and/or MLBP. Partici-
pants were instructed to use the middle number (5) to
indicate neither disagree nor agree and to leave the answer
scale blank to indicate dont know. Respondents were
advised that it was important to assume that all serious
causes of LBP were excluded, including cancer, infection
and associated systemic disease.
In this study the low back was dened as the area
between the costal margins and inferior gluteal folds.
A convenience sample of health professionals experi-
enced in the diagnosis and treatment of LBP were sur-
veyed. The sample included both orthopaedically and
neurosurgically trained spine surgeons, rheumatologists,
medical practitioners with a special interest in musculo-
skeletal medicine, chiropractors and manipulative
Table 1
Potential signs and symptoms of ILBP or MLBP.
Morning pain on waking Pain on trunk extension
Intermittent pain during day Pain on lateral bending
Pain later in the day Palpatory pain of muscles
Straight leg raising hurts Palpatory pain of spinous process
Pain wakes the person up Stiffness after resting
(includes sitting)
Pain on sitting for a while Morning and afternoon pain
Pain when standing
for a while
Doing a sit up is painful
Pain when lifting Driving long distances is painful
Pain bending forward a little Pain on walking more than 50 m
Burning pain Pain on running
Aching pain Pain on repetitive bending
Stabbing pain Pain getting out of a chair
Constant pain Pain on cough or sneeze
Pain on trunk exion
315 B.F. Walker, O.D. Williamson / Manual Therapy 14 (2009) 314e320
physiotherapists. Key informants identied from within
each group provided the names of Australian practi-
tioners who were highly regarded within their profes-
sions and likely to have an informed opinion about
the topic.
The Dillman method (Dillman, 1978) was used for
the dissemination of the questionnaire, explanatory
information, and follow up procedures. The sample
population initially received a herald postcard, then 2
weeks later the questionnaire followed by a reminder
which was sent to non-responders after 2, 4 and 6 weeks.
At 4-weeks a second questionnaire was also included
with the reminder. Each questionnaire was coded to
identify the profession of the respondent. The question-
naires had no other identifying information recorded on
them and were anonymous.
The study had ethics approval from James Cook
University and Monash University.
The same mode of data collection was used for the
entire sample. Data were analysed using SPSS/PC Ver-
sion 14 (SPSS Inc., Chicago).
The median score and 10th and 90th centiles were
calculated for each statement by ILBP and MLBP.
This method is often used when the data have a skewed
distribution (Altman and Bland, 1994).
The signicance of median scores of agreement was
subjectively set and the scores are shown in Table 2.
For example a median score of 8 or more was regarded
as indicating high levels of agreement that the symptom
or sign was an indicator of ILBP or MLBP. While
a median score of 2 or less was regarded as indicating
high levels of disagreement that the symptom or sign
was an indicator of ILBP or MLBP.
In addition, the dierence between ILBP and MLBP
scores was calculated for each question, by respondent,
and a median dierence in scores of 4 or more was
regarded as potentially indicating that the question
could be used to potentially dierentiate between
ILBP and MLBP. Non-parametric statistics were used
to compare paired responses to statements (Wilcoxon
ranked sign test) and score dierences by profession
(KruskaleWallis test).
A chi-squared analysis was used to compare response
rates by profession. Given the multiple comparisons
between profession groups, a Bonferroni correction
was applied, hence p <0.005 was interpreted as indicat-
ing dierences between profession groups.
3. Results
One hundred and thirty-four questionnaires were sent
out. Five were returned as undeliverable leaving 129
possible respondents. Of these, 105 respondents (81%)
completed the questionnaire, comprising 29 spine sur-
geons, 28 rheumatologists, 25 medical practitioners
with a special interest in musculoskeletal medicine, 26
chiropractors and 26 manipulative physiotherapists.
There was no dierence in response rates between the
professional groups (c
4
2
6.072; p 0.194).
Several respondents completed the other signs and
symptoms row which allowed the addition of a new sign
or symptom. When these were analysed there were no
new signs and symptoms but instead minor variations
or repetition of signs and symptoms from the existing list.
Morning pain on waking (median 8) demonstrated
high levels of agreement as an indicator of ILBP. Pain
when lifting (median 8) demonstrated high levels of
agreement as an indicator of MLBP.
Constant pain, pain that wakes, and stiness after
resting (median 7) were generally considered as mod-
erate indicators of ILBP, while intermittent pain during
the day, pain that develops later in the day, pain on
standing for a while, pain bending forward a little,
pain on trunk exion or extension, pain doing a sit up,
pain when driving long distances, pain getting out of
a chair, and pain on repetitive bending, running, cough-
ing or sneezing (median 7) were all generally consid-
ered as moderate indicators of MLBP (Table 3). There
was, however, no consistency of agreement either
between or within professional groups. No statements
were associated with a median score of 3 or less indicat-
ing signicant disagreement that any symptom or sign
was not an indicator of ILBP or MLBP to some extent.
Those signs and symptoms with a median score between
4 and 6 (weak or no agreement) are also seen in Table 3.
No statements were associated with a median score of
more than 7 for both ILPB and MLBP suggesting that
no statement indicated both types of pain, while no
statements were associated with a median score of 3 or
less for both ILBP and MLBP suggesting that no state-
ment excludes both types of pain. Although there was
a statistically signicant dierence ( p <0.05) in paired
responses to all statements apart from that relating to
aching pain, no statements were found to be associated
with a score of 7 or greater for one type of LBP and 3 or
less for the other indicating that none of the factors were
thought to strongly discriminate between ILBP and
Table 2
Median scores and their relative signicance.
Median score Signicance
10 Absolute agreement
9 Very high agreement
8 High agreement
7 Moderate agreement
6 Weak agreement
5 Neutral
4 Weak disagreement
3 Moderate disagreement
2 High disagreement
1 Very high disagreement
0 Absolute disagreement
316 B.F. Walker, O.D. Williamson / Manual Therapy 14 (2009) 314e320
MLBP. The only statement that was associated with
a dierence in response of 4 or greater was that relating
to morning pain on waking; suggesting that this was the
only statement that was thought to generally distinguish
ILBP from MLBP.
There were signicant dierences between professions
with respect to many of the statements being able to dis-
tinguish ILBP from MLBP (Table 3). For example, rheu-
matologists were more likely to regard constant pain and
pain that wakes a person as inammatory and pain on
straight leg raising, lifting, running, repetitive bending,
coughing and sneezing as mechanical than the other
groups. Physiotherapists were more likely to regard pain
on lifting or repetitive bending as mechanical. Medical
practitioners with a special interest in musculoskeletal
medicine did not agree as strongly that pain wakes me
up or that constant pain is a sign of ILBP.
4. Discussion
Although NSLBP is commonly described as being
mechanical or inammatory in nature and is treated
by mechanical and anti-inammatory therapies, there
have been no previous attempts to distinguish these sub-
groups on the basis of symptoms or clinical signs. How-
ever, Rudwaleit et al. (2006) did study the clinical
history of 101 AS patients and 112 patients without
AS thereafter labeled as MLBP patients. In their
methods they used an external reference standard
known as the New York Criteria (Van der Linden
et al., 1984) to diagnose AS. They found four factors
that potentially separated the two groups, these were
morning stiness greater than 30 min, improvement
with exercise but not with rest, awakening because of
back pain in the second half of the night and alternating
buttock pain. However, despite some similarity in their
results, their study diers from ours insofar as they com-
pared a specic inammatory arthritide (AS) with all
other cases of back pain which they tagged MLBP.
In contrast we asked expert respondents to compare
non-specic ILBP with non-specic MLBP. In our ques-
tionnaire there were no pre-determined denitions or
external reference standards (other than exclusions) to
categorise non-specic ILBP or MLBP. Indeed this
was the reason for our study, to measure the opinion
Table 3
Twenty-seven signs and symptoms.
Sign or symptom ILBP (median,
10, 90 centiles)
MLBP (median,
10, 90 centiles)
Dierence ILBP MLBP
(median, 10, 90 centiles)
Signicance of dierence
by profession ( p value)
Morning pain on waking
a
8 (3, 10) 4 (1, 8) 4 (3, 8) 0.338
Intermittent pain during day
d
4 (1, 7) 7 (5, 9) 2.5 (7, 1) 0.001
Pain later in the day
d
5 (1.5, 7.5) 7 (4, 9) 2 (6, 2.5) 0.124
Straight leg raising hurts* 5 (1, 8) 6 (3, 9) 2 (7, 2) 0.002
Pain wakes the person up
c
7 (3, 9) 4 (1, 7) 3 (1, 7) 0.043
Pain on sitting for a while
e
5.5 (2, 8) 6 (4, 8) 0 (5, 2) 0.063
Pain when standing for a while
d
5 (2, 8) 7 (4, 8) 1 (5, 1) 0.096
Pain when lifting
b
4 (1.2, 8) 8 (5, 9) 3 (7, 0) 0.024
Pain bending forward a little
d
5 (2, 8) 7 (4, 9) 2 (6, 2) 0.012
Burning pain
e
5 (2, 8) 5 (2, 7) 0 (2, 5) 0.001
Aching pain
e
6 (3, 8) 6 (3, 8) 0 (4, 3) 0.130
Stabbing pain
e
5 (2, 8) 6 (3, 8) 1 (6, 3) 0.283
Constant pain
c
7 (3, 9) 5 (3, 7) 2 (2, 2) 0.000
Pain on trunk exion
d
5 (2, 8) 7 (5, 9) 1 (6, 1) 0.028
Pain on trunk extension
d
5 (1.5, 8) 7 (4.5, 9) 1 (6, 2) 0.008
Pain on lateral bending
e
5 (1.5, 7.5) 6 (5, 8.5) 1 (6, 2) 0.006
Palpatory pain of muscles
e
5 (1, 7.7) 5 (3, 8) 0 (5, 3) 0.000
Palpatory pain of spinous process
e
5 (1, 8) 6 (3, 8) 0 (4, 2) 0.192
Stiness after resting (includes sitting)
c
7 (5, 10) 5 (2, 8) 2 (2, 7) 0.035
Morning and afternoon pain
e
6 (3.5, 8.5) 5 (2, 8) 0 (2, 5) 0.443
Doing a sit up is painful
d
5 (2, 7) 7 (5, 9) 2 (6, 0) 0.098
Driving long distances is painful
d
5 (2, 8) 7 (5, 8) 1 (5, 1) 0.495
Pain on walking more than 50 m
e
5 (1, 8) 6 (3, 8) 1 (6, 2.8) 0.002
Pain on running
d
5 (1, 7) 7 (5, 9) 2 (6.5, 1) 0.000
Pain on repetitive bending
d
5 (1.5, 8) 7 (5, 9) 2 (6, 0) 0.011
Pain getting out of a chair
d
5 (2, 8) 7 (5, 9) 1 (6, 1) 0.020
Pain on cough or sneeze
d
4 (1, 8) 7 (2.5, 9) 2 (7, 2.6) 0.001
Survey results.
a
High level of agreement as an indicator of ILBP.
b
High level of agreement as an indicator of MLBP.
c
Moderate indicators of ILBP.
d
Moderate indicators of MLBP.
e
Variables not considered indicative of either inammatory or mechanical.
317 B.F. Walker, O.D. Williamson / Manual Therapy 14 (2009) 314e320
of experts about the extent to which MLBP and ILBP
can be distinguished by signs and symptoms.
Our study demonstrated some evidence that a number
of signs and symptoms are possible indicators of ILBP
or MLBP. However, there was no clear agreement either
within or between professions regarding whether state-
ments based on common signs and symptoms of LBP
are either indicative of, or can distinguish between
inammatory or mechanical causes of LBP.
An ideal statement for inclusion in an instrument that
distinguishes between ILBP and MLBP would have
a high score for one form of LBP, a low score for the
other form, a signicant dierence between the scores
for both forms and no signicant dierence between
professions with respect to interpretation. None of the
studied statements met each of these criteria.
Although morning pain on waking (median dier-
ence 4) and pain that wakes the person up (median dif-
ference 3) were thought to be broadly indicative of
ILBP and pain on lifting (median dierence 3) was
thought to be broadly indicative of mechanical pain,
this was not universally recognised either within or be-
tween professional groups. Of these, morning pain on
waking is commonly used as a marker of pain due to in-
ammation (Garrett et al., 1994; Yazici et al., 2004).
The fact that morning pain is used as a marker of dis-
ease severity in inammatory spondyloarthopathies
such as AS (Garrett et al., 1994) could explain why sev-
eral respondents suggested that this marker should have
been expanded in our survey to reect the length of time
the pain lasted in the morning.
The relationship between inammation and pain,
however, is not clear. Although a recent study found
that the mean intensity of pain over 24 h was indepen-
dently associated with high levels of high sensitivity C
reactive protein in patients with acute sciatica (less
than 8 weeks), this association was not found in patients
with chronic LBP (Stu rmer et al., 2005).
Similarly, the relationship between pain that wakes
a patient up and inammation is not clear. Sleep distur-
bance is commonly reported in people with non-specic
chronic pain, as well as those with inammatory arthri-
tis (Menefee et al., 2000). The mechanisms by which
pain and inammation cause sleep disturbance have
not, however, been well described and may dier.
Although the levels of inammatory cytokines, such as
interleukin-6 may alter sleep behaviour (Mullington et al.,
2001), there did not appear to be an association between
improvements in pain and joint stiness, and improve-
ments insleep disturbance, ina small groupof patients be-
ing treated for rheumatoid arthritis with non-steroidal
anti-inammatory drugs (Lavie et al., 1991).
Although pain on lifting is commonly thought to rep-
resent mechanical pain, the relationship between spinal
load and pain is not clear. Whilst there is strong evi-
dence that work activities such as lifting, bending,
twisting and vibration are a risk factor for the onset
and reporting of NSLBP, overall it appears that the
size of the eect is less than that of other individual fac-
tors (Waddell and Burton, 2000). It is postulated that
load, posture and creep may alter the mechanical prop-
erties of the spine, resulting in stress concentration in in-
nervated tissues such as the intervertebral discs, facet
joints and ligaments (Adams et al., 2002), but there is lit-
tle direct evidence that such factors are important in
NSLBP (Waddell, 2004). In overview the results could
be interpreted to suggest that movement or activity-re-
lated symptoms are more broadly indicative of MLBP
and that pain at rest is more indicative of ILBP.
Interestingly no variable was considered to represent
both ILBPand MLBP and using our analysis, 10 variables
were not considered indicative of either ILBP or MLBP.
While it is possible that varying educational para-
digms could explain variability between professional
groups, it does not obviously explain the variability we
found within groups. As the key participants (experts)
in this study were selected on their academic and profes-
sional standing, it is likely that these dierences will be
transmitted down through the ranks of each profession
and sustains the inadequacy of the evidence.
The strength of this study is its good response rate and
its generalisability to a wide range of practitioners; how-
ever, the study does have some limitations. First, the
respondents were not randomly selected from within
their professional groups, therefore one cannot general-
ise the results to the entire population of professionals
in each group. However, our purposeful intention was
to get the opinion of approximately 20 experts from
each group. In this way the answers to our primary ques-
tions are more likely to have content validity. Secondly,
the best method for dening subgroups within the broad
diagnosis of NSLBP has not been established.
The approach of this study was to suggest two possible
subgroups, ILBP and MLBP and investigate whether
experts within relevant professional groups could inde-
pendently agree on certain symptoms and signs. This
approach highlighted the variation within and between
participating groups. A similar approach would be to
use the Delphi technique (using an iterative/consensus
method) to dene a set of symptoms and signs that could
be measured in trials of mechanical and anti-inamma-
tory therapies. If symptoms and signs could be used to
dene subgroups of patients with ILBP and MLBP, trials
could be conducted to determine if those who receive sub-
group specic treatment do better with the subgroup-spe-
cic treatment rather than non-specic treatment,
thereby conrming the validity of the subgroups. Despite
the limitations of this study, it is clear that considerable
diversity of opinion exists regarding symptoms or signs
that might be used to distinguish between MLBP and
ILBP, both within and between the professional groups
involved in the management of NSLBP.
318 B.F. Walker, O.D. Williamson / Manual Therapy 14 (2009) 314e320
NSLBP is commonly labelled, conceptualised and
managed as being inammatory and/or mechanical in
nature and this study identied two groups of factors
that were generally considered as indicators of ILBP
or MLBP. However, we identied few, if any, signs or
symptoms that members of professions involved in the
management of NSLBP could highly agree distinguished
between these aetiologies. While the general absence of
agreement regarding signs and symptoms of ILBP and
MLBP does not invalidate the pathophysiological para-
digms of mechanical and inammatory pains, it does,
however, signal the need for further research.
This research should be aimed at testing the 17 indica-
tors identied for their ability to predict the outcome of
mechanical and anti-inammatory treatments of LBP.
If further study establishes that they are able to predict
the outcome of the two treatment types, the number of in-
appropriate decisions to use either may be decreased.
Acknowledgments
The authors acknowledge that this paper was rst
presented at the Spine Society of Australia Conference
2006 and that the abstract is published in the conference
proceedings, Journal of Bone and Joint Surgery, 88B,
Supp III: 448.
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