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LBP has many possible etiologies (Merskey and Bogduk, 1994) and its diagnosis is made by
exclusion (Negrini et al., 2008). In 85-95% of the cases the etiology of the LBP is unclear and
therefore is termed as idiopathic low back pain (iLBP) or nonspecific LBP (Krismer and Van Tulder,
2007; Op de Beek and Hermans, 2000; Snook, 2004), which is defined as LBP not attributed to
recognisable, known specific pathology (Burton et al., 2006). Balagué et al. (2012), stated that for
the iLBP pathogenesis, epidemiologically and etiologically, there are limits of knowledge of causal
responsibility. Only for the resting 5-15% there is a diagnosis determined via clinical examination
(X-ray, MRI imaging, CT scan) and related to discogenic, neurological, structural, muscular or
ligamentous origin, and therefore is termed as traumatic (Marras, 2008; McGill, 1997; Op de Beek
and Hermans, 2000). According to Waddell (1998), less than 1% of LBP is a serious disease such
as cancer and less than 1% is inflammatory disease (cited in Snook, 2004).
1.5.2.1.
Definition of Pain
Despite the subjectiveness of pain perception, the International Association for the Study of
Pain (IASP) defines pain as un unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage. Moreover, it recognises
psychological reasons as pain source. The psychological dimension of the pain becomes very
relevant in chronic LBP1 (Balagué et al., 2012). However, IASP does not recognise explicitly LBP as
it does with lumbar spinal pain and sacral spinal pain (Merskey and Bogduk, 1994). Therefore, LBP
can be defined as pain perceived as arising from the lumbar or sacral areas or a combination of both
with or without referred pain2 (Bogduk, 2005). It is localized within a region bounded laterally
by the lateral borders of the erector spinae muscles and the imaginary vertical lines through the
posterior superior-to-posterior inferior iliac spines, superiorly by an imaginary transverse line
through the 12 th thoracic spinous process, and inferiorly by a transverse line through the posterior
sacrococcygeal joints, (Bogduk, 2005; Merskey and Bogduk, 1994). Following the topographically
definition of LBP with the help of the IASP lumbar spinal pain and sacral spinal pain definitions, it
is deduced that the origin of LBP may or may not arise from these spine regions as it is based on
the subjective opinion of the patients about where they perceived the source of the pain. Similarly,
the European guidelines for prevention in LBP defines it as pain and discomfort localized below the
costal margin and above the inferior gluteal folds, with or without leg pain (Burton et al., 2006).
1.5.3.
Low Back Pain Pathways
LBP implies a somatic origin for the pain, therefore, only the tissues of the lumbar spine can be
candidates for LBP (Bogduk, 2005). Bogduk (2005), postulated that in order for a spinal element
to be a candidate for a possible source of LBP, it should be evaluated by adopting criteria analogous
to Koch’s postulates for bacterial diseases. Therefore, for any structure to be deemed a cause of
LBP it should (I) be innervated, (II) exist biological plausibility of causing pain, (III) be susceptible
to diseases or injuries that are known to be painful, and (IV) have been shown to be a source of
pain in patients using diagnostic techniques of known reliability and validity.
1
2
Chronic pain lasts more than three months or occurs episodically within a 6 month period.
Pain which perceived at an other location than its origin.
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