Low Back Pain

Low Back Pain
Physician Writer
Roger Chou, MD
Section Editors
Deborah Cotton, MD, MPH
Jaya K. Rao, MD, MHS
Darren Taichman, MD, PhD
Sankey Williams, MD
Prevention
page ITC6-2
Diagnosis
page ITC6-3
Treatment
page ITC6-8
Practice Improvement
page ITC6-13
Tool Kit
page ITC6-14
Patient Information
page ITC6-15
CME Questions
page ITC6-16
The content of In the Clinic is drawn from the clinical information and education
resources of the American College of Physicians (ACP), including ACP Smart
Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals
of Internal Medicine editors develop In the Clinic from these primary sources in
collaboration with the ACPs Medical Education and Publishing divisions and with
the assistance of science writers and physician writers. Editorial consultants from
ACP Smart Medicine and MKSAP provide expert review of the content. Readers
who are interested in these primary resources for more detail can consult
http://smartmedicine.acponline.org, http://www.acponline.org/products_services/
mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.
CME Objective: To review current evidence for prevention, diagnosis, treatment,
and practice improvement of low back pain.
The information contained herein should never be used as a substitute for clinical
judgment.
2014 American College of Physicians
In theClinic
In the Clinic
ow back pain has a lifetime prevalence of nearly 80%, and spinal

disorders are the fourth most common primary diagnosis for office
visits in the United States (1). Low back pain is also costly, accounting for a large and increasing proportion of health care expenditures
without evidence of corresponding improvements in outcomes (2). In
most patients, the specific cause of low back pain cannot be identified,
and episodes generally resolve within days to a few weeks with self-care.
Up to one third of patients, however, report persistent back pain of at
least moderate intensity 1 year after an acute episode, and 1 in 5 report
substantial limitations in activity (3). Because low back pain is common,
can lead to substantial disability, and can become chronic, proficiency in
evaluation and management is important.
Prevention
Factors Associated With Low
Back Pain or Disability Claims
for Low Back Pain
Work that requires heavy lifting;
bending and twisting; or wholebody vibration, such as truck
driving
Physical inactivity
Obesity
Arthritis or osteoporosis
Pregnancy
Age >30 years
Bad posture
Stress or depression
Smoking
1. Centers for Disease

Control and Prevention. National Ambulatory Medical Care
Survey: 2010 Summary Tables. Atlanta, GA:
Centers for Disease
Control and Prevention; 2011. Accessed
at www.cdc.gov/
nchs/data/ahcd/nam
cs_summary/2010_n
amcs_web_tables.pd
f on 10 April 2014.
2. Martin BI, Deyo RA,
Mirza SK, Turner JA,
Comstock BA,
Hollingworth W, et al.
Expenditures and
health status among
adults with back and
neck problems.
JAMA. 2008;299:65664. [PMID: 18270354]
3. Von Korff M, Saunders
K. The course of back
pain in primary care.
Spine (Phila Pa 1976).
1996;21:2833-7.
[PMID: 9112707]
What factors are associated with

development of low back pain?
Factors associated with development of low back pain include
obesity, physical inactivity, occupational factors, and depression
and other psychological conditions (see the Box: Factors Associated With Low Back Pain or
Disability Claims for Low Back
Pain). Such strategies as maintaining normal body weight, exercising, and avoiding activities that
can injure the back may decrease
risk for low back pain, but direct
evidence of the value of such interventions is not available.
shown to prevent low back pain,

regular physical activity has other
proven health benefits. A systematic review found that a posttreatment exercise program can prevent recurrence in patients with
an episode of low back pain (5).
Clinicians should remember that

back pain (the symptom), a health
care visit for back pain, and work
loss or disability due to back pain
do not necessarily reflect the same
underlying construct. Symptom
severity does not correlate well with
health care seeking or functional
outcome.
Are specific preventive measures

effective for prevention?
People whose jobs require heavy
lifting and other physical work
are believed to be at greater risk
for low back pain than those in
less physically demanding occupations. Low back pain is a common cause of days lost from work
and the need for workers compensation. Studied approaches to
preventing low back pain in the
workplace include educational interventions and mechanical supports. Results regarding their effectiveness in the primary and
secondary prevention of low back
pain have generally not shown
large benefits.
Should clinicians advise patients

about preventing low back pain?
In 2005, the U.S. Preventive
Services Task Force concluded
that the evidence was insufficient
to recommend for or against routine use of interventions in primary care settings to prevent low
back pain in healthy adults (4).
The Task Force noted that
although exercise has not been
A systematic review of 9 randomized, controlled trials (RCTs) and 9 cohort studies

found no evidence that advice or training
workers in correct lifting techniques was effective in preventing low back pain (6).
Another systematic review found that external back supports, such as a back brace
or belt, were also not effective for preventing back pain (7). Similarly, a large trial in
workers in physically demanding jobs did
not report any benefits of a worksite prevention program (8).
ITC6-2
Annals of Internal Medicine
In the Clinic
3 June 2014
Prevention... Regular exercise and maintenance of fitness may be helpful in preventing low back pain. Evidence is insufficient to support the use of any specific
preventive interventions, including educational interventions, worksite prevention
programs, or mechanical supports.
CLINICAL BOTTOM LINE
Diagnosis
What elements of history and
physical examination should
clinicians incorporate into the
evaluation of low back pain?
History and physical examination
should aim to place the patient into
1 of 3 categories: nonspecific low
back pain, back pain potentially associated with radiculopathy or spinal
stenosis, or back pain potentially associated with another specific systemic or spinal cause. Table 1 shows
the history and physical examination

findings for different types of back
pain.
When evaluating a patient with
low back pain, clinicians should
identify features that may indicate
a serious underlying cause (red
flags), or radiculopathy, and psychosocial factors associated with
development of persistent disabling
low back pain (yellow flags). Key
Table 1. Common History and Physical Examination Features for Back Pain Causes
Disease
Characteristics on History
Physical Examination Findings
Notes
Degenerative disk
disease
Degenerative disk
disease with
herniation
Nonspecific
Nonspecific
Sciatic pain
Common radiologic abnormality that

may be related to symptoms
Common cause of nerve root
impingement and radicular
symptoms, most commonly at
L5 and S1 levels
Spinal stenosis
Severe leg pain;

pseudoclaudication;
no pain when patient
is seated
Gradual onset; morning
stiffness; improves with
exercise; pain for >3 mo;
pain not relieved when
patient is supine
Recent infection or history
of intravenous drug use
Weight loss or other cancer
symptoms; known past or
current cancer diagnosis;
failure to improve after 4 wk;
no relief with bed rest
Depends on affected viscera
Impaired ankle or patella

reflex; positive ipsilateral
or crossed straight-leg
raising test result; great
toe, ankle, or quadriceps
weakness; lower extremity
sensory loss
Wide-based gait; pseudo- More common with advancing age;
claudication; thigh pain after uncommon before age 50 y
30 s of lumbar extension
Ankylosing spondylitis
Osteomyelitis, spinal abscess, epidural abscess

Cancer in the spine or
surrounding structures
Intra-abdominal visceral
disease
3 June 2014
Decreased spinal range of

motion
Usual onset before age 40 y
Fever and localized

tenderness
Localized tenderness
Can cause cord compression
Depends on affected viscera
In the Clinic
Metastatic disease, commonly from

prostate, breast, and lung cancer; can
cause cord compression; more common
in patients aged 50 y
Gastrointestinal: peptic ulcer or
pancreatitis
Genitourinary: nephrolithiasis,
pyelonephritis, prostatitis, pelvic
infection, or tumor
Vascular: aortic dissection
All of these illnesses can cause back
pain
ITC6-3
4. U.S. Preventive Services Task Force. Primary

care interventions to
prevent low back
pain in adults: recommendation statement. Am Fam Physician. 2005;71:2337-8.
[PMID: 15999872]
5. Choi BK, Verbeek JH,
Tam WW, Jiang JY. Exercises for prevention
of recurrences of lowback pain. Cochrane
Database Syst Rev.
2010:CD006555.
[PMID: 20091596]
6. Verbeek JH, Martimo
KP, Kuijer PP, Karppinen J, Viikari-Juntura E, Takala EP. Proper
manual handling
techniques to prevent low back pain, a
Cochrane systematic
review. Work. 2012;41
Suppl 1:2299-301.
[PMID: 22317058]
7. van Duijvenbode IC,
Jellema P, van Poppel
MN, van Tulder MW.
Lumbar supports for
prevention and treatment of low back
pain. Cochrane Database Syst Rev.
2008:CD001823.
[PMID: 18425875]
8. IJzelenberg H, Meerding WJ, Burdorf A. Effectiveness of a back
pain prevention program: a cluster randomized controlled
trial in an occupational setting. Spine
(Phila Pa 1976).
2007;32:711-9.
[PMID: 17414902]
Table 1. Common History and Physical Examination Features for Back Pain Causes (continued)
Disease
Characteristics on History
Physical Examination Findings
Notes
Metabolic bone disease with

or without compression
fracture
Nonspecific pain; osteoporosis

or osteoporosis risk factors
Localized tenderness if
vertebral fracture
Best example is osteoporosis with

compression fracture
Unilateral dermatomal rash
Most common in elderly or immunocompromised patients

Patients with psychosocial distress
and low back pain are at high risk
for delayed recovery, chronic pain,
and poor functional outcomes
Herpes zoster
Psychosocial distress
Physical Examination Maneuvers

That Suggest Herniated Disk
Straight-legraising test:
Passive lifting of the affected leg by
the examiner to an angle less
than 60 degrees reproduces pain
radiating distal to the knee.
Crossed straight-legraising test:

Passive lifting of the unaffected leg
by the examiner reproduces pain
in the affected (opposite) leg.
9. Deyo RA, Rainville J,

Kent DL. What can
the history and physical examination tell
us about low back
pain? JAMA.
1992;268:760-5.
[PMID: 1386391]
10. Fairbank JC, Couper
J, Davies JB, OBrien
JP. The Oswestry low
back pain disability
questionnaire. Physiotherapy.
1980;66:271-3.
[PMID: 6450426]
11. Roland M, Morris R.
A study of the natural history of back
pain. Part I: development of a reliable
and sensitive measure of disability in
low-back pain. Spine
(Phila Pa 1976).
1983;8:141-4.
[PMID: 6222486]
12. Ostelo RW, de Vet
HC. Clinically important outcomes in
low back pain. Best
Pract Res Clin
Rheumatol.
2005;19:593-607.
[PMID: 15949778]
Trauma; corticosteroid use

Unilateral pain in distribution
of dermatome
Symptoms do not follow a
clear clinical or anatomical
pattern; psychological and
emotional distress
Physical examination findings

that do not follow a clear
clinical or anatomical pattern
elements of the physical examination include checking for sensory

loss, muscle weakness, or limited
range of motion in the legs and feet
and characterizing the pain level
(see the Box: Physical Examination
Maneuvers That Suggest Herniated
Disk).
What serious underlying systemic
conditions should clinicians
consider as possible causes?
Underlying systemic disease that
causes back pain is rare but must be
considered. Prevalence is 4% for
compression fracture, less than 1%
for nonskin cancer, 0.3% for ankylosing spondylitis, and 0.01% for
infection (9).
A history of cancer is the strongest
risk factor for cancer-related back
pain; other factors, such as unexplained weight loss, no relief with
bed rest, pain lasting more than
1 month, and increased age are also
risk factors but only increase risk
slightly.
years, slow symptom onset, and

pain persisting for more than
3 months. However, because of the
low prevalence of ankylosing
spondylitis, the positive predictive
value of these characteristics is still
low.
The absence of any of these worrisome features is highly sensitive but
not specific for excluding patients
with systemic illness. The presence
of these features may indicate a
need for further evaluation.
Is the classification by duration of
symptoms clinically useful?
Classifying patients according to
duration of low back pain (acute,
subacute, or chronic) is useful because the trajectory for improvement
differs depending on the duration
of symptoms, and evidence suggests
differential effectiveness of some
therapies depending on when they
are administered.
Patients with at least 4 of the following characteristics require further evaluation for ankylosing
spondylitis: morning stiffness, decreased discomfort with exercise,
onset of back pain before age 40
Although there is no strong evidence-based method for classifying

duration of acute back pain, it is
generally defined as back pain lasting less than 4 weeks. In most
patients with acute back pain, the
cause cannot be determined with
certainty but may be related to
trauma or musculoligamentous
strain. Most acute back pain resolves within 4 weeks with selfcare. Chronic back pain is often
defined as pain that lasts longer
than 12 weeks. Patients with chronic
low back pain often have little
ITC6-4
Osteomyelitis should be considered if there is a history of intravenous drug use, recent infection,
or fever. Increased age, white race,
trauma, or prolonged corticosteroid use are associated with
compression fractures.
In the Clinic
3 June 2014
alleviation of their symptoms and

are at risk for long-term pain or
functional disability. People who
have had low back pain often have
at least 1 episode of recurrence and
can develop repeated acute-onchronic symptoms. Subacute low
back pain, often defined as 412
weeks after onset of symptoms, may
be considered a transition period between acute and chronic back pain,
during which improvement is not as
pronounced as in the acute phase
(see the Box: Classification of Low
Back Pain, by Duration).
Do standardized assessment
instruments have a role in
evaluation?
Quantitative scales that gauge
pain and function provide measures for judging the impact of low
back pain and the response to
therapy. It is important to assess
pain and function because the
severity of pain does not necessarily correlate with effects on function. Questions addressing pain,
back-specific function, general
health status, work disability, psychological status, and patient satisfaction can be used to assess the
overall effect of low back pain.
Pain is commonly measured using
a 10-point numerical rating scale.
Commonly used quantitative
measures of function include the
modified RolandMorris Disability
Questionnaire and the Oswestry
Disability Index (10, 11). A 2- to
3-point change on the Roland
Morris scale or a 5- to 10-point
change on the Oswestry Disability
Index has been proposed as
thresholds for clinically meaningful change (12). The STarT Back
Screening Tool, which assesses
pain, function, and psychosocial
Classification of Low Back Pain, by

Duration
Acute: Lasts <4 weeks
Subacute: Lasts 412 weeks
Chronic: Lasts >12 weeks
3 June 2014
predictors of chronicity, was recently found to be more effective than

usual for categorizing a patients
risk for a poor outcome and targeting interventions accordingly (13).
What factors should lead
clinicians to suspect nerve root
involvement?
When patients present with back
and leg pain, nerve root involvement must be considered. Nerve
root involvement can cause neurologic compromise at the level of
the nerve root (common causes include lumbar disk herniation in
patients younger than 50 years and
spinal stenosis in older patients) or
the upper motor neuron (causes
include tumor or central disk herniation). Nerve root involvement
of the cauda equina, or the area
below the termination of the
spinal cord, requires immediate
imaging and surgical evaluation to
prevent permanent neurologic
damage. Signs and symptoms of
the cauda equina syndrome include bowel or bladder dysfunction
and saddle anesthesia.
When upper motor neurons are
involved due to compression of
the spinal cord above the conus
medullaris, urgent specialist consultation is also required (9). Signs
and symptoms that suggest upper
motor neuron involvement include
weakness, decreased motor control,
altered muscle tone, and spasticity
or clonus. Presence of severe or
progressive motor deficits generally
warrants urgent evaluation, regardless of the origin.
Patients with leg pain that is worse
than back pain, a positive straightlegraising test result, and unilateral neurologic symptoms in the foot
are very likely to have nerve root
compression as the source, most
frequently from a herniated disk.
The most common sites for lumbar
disk herniation are at L45 or
L5S1. Pain that radiates from the
back through the buttocks to the
In the Clinic
ITC6-5
13. Hill JC, Whitehurst

DG, Lewis M, Bryan
S, Dunn KM, Foster
NE, et al. Comparison of stratified primary care management for low back
pain with current
best practice (STarT
Back): a randomised
controlled trial.
Lancet.
2011;378:1560-71.
[PMID: 21963002]
14. Keefe FJ, Brown GK,
Wallston KA, Caldwell DS. Coping with
rheumatoid arthritis
pain: catastrophizing
as a maladaptive
strategy. Pain.
1989;37:51-6.
[PMID: 2726278]
15. Waddell G, McCulloch JA, Kummel E,
Venner RM. Nonorganic physical signs
in low-back pain.
Spine (Phila Pa
1976). 1980;5:117-25.
[PMID: 6446157]
16. Chou R, Shekelle P.
Will this patient develop persistent disabling low back
pain? JAMA.
2010;303:1295-302.
[PMID: 20371789]
legs (sciatica) is common, and the

more distal the pain radiation,
the more specific the symptom is
for nerve root involvement. Other
common symptoms of disk herniation include weakness of the ankle
and great toe dorsiflexors, loss of
ankle reflex, and sensory loss in the
feet. Causes of leg pain that may
coexist with low back pain but are
not due to nerve root compression
include the piriformis syndrome,
iliotibial band syndrome, trochanteric bursitis, and hip osteoarthritis.
17. Chou R, Qaseem A,
Owens DK, Shekelle
P; Clinical Guidelines
Committee of the
American College of
Physicians. Diagnostic imaging for low
back pain: advice for
high-value health
care from the American College of Physicians. Ann Intern
Med. 2011;154:1819. [PMID: 21282698]
18. Chou R, Qaseem A,
Snow V, Casey D,
Cross JT Jr, Shekelle
P, et al; Clinical Efficacy Assessment Subcommittee of the
American College of
Physicians. Diagnosis
and treatment of
low back pain: a
joint clinical practice
guideline from the
American College of
Physicians and the
American Pain Society. Ann Intern Med.
2007;147:478-91.
[PMID: 17909209]
19. Davis PC, Wippold FJ
2nd, Brunberg JA,
Cornelius RS, De La
Paz RL, Dormont PD,
et al. ACR Appropriateness Criteria on
low back pain. J Am
Coll Radiol.
2009;6:401-7.
[PMID: 19467485]
20. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for
low-back pain: systematic review and
meta-analysis.
Lancet.
2009;373:463-72.
[PMID: 19200918]
21. Henschke N, Maher
CG, Refshauge KM.
Screening for malignancy in low back
pain patients: a systematic review. Eur
Spine J.
2007;16:1673-9.
[PMID: 17566791]
22. Hagen KB, Hilde G,
Jamtvedt G, Winnem
M. Bed rest for acute
low-back pain and
sciatica. Cochrane
Database Syst Rev.
2004:CD001254.
[PMID: 15495012]
Spinal stenosis can also result in

bilateral nerve root compression.
Symptoms of vascular claudication
can be difficult to distinguish from
spinal stenosis but are characterized
by leg pain that occurs with exertion rather than with changes in
position. Clinicians should consider
vascular disease in patients with
risk factors for cardiovascular disease before attributing symptoms to
spinal stenosis.
What psychosocial issues are
important for clinicians to
consider when evaluating patients
with low back pain?
An important factor predicting
the course of low back pain is the
presence of psychosocial distress.
Psychosocial distress is more common in patients with chronic low
back pain, and attention to this
distress may be beneficial to recovery. Clinicians should evaluate
patients for psychiatric comorbid
conditions, somatization, or maladaptive coping strategies, all of
which are associated with poor
outcomes in patients with low
back pain. Maladaptive coping
strategies include avoidance
(avoidance of work, movement, or
other activities due to fear that
they will damage or worsen the
back) and catastrophizing (pain
coping characterized by excessively negative thoughts and statements about the future) (14). The
presence of Waddell signs on
physical examination may indicate
ITC6-6
In the Clinic
a nonorganic or psychological
component to low back pain. Such
signs include nondermatomal distribution of sensory loss, pain on
axial loading, nonreproducibility
of pain when the patient is distracted, regional weakness or sensory change, and exaggerated and
inconsistent painful responses
(15).
A systematic review found that the presence of nonorganic signs, high levels of
maladaptive pain coping behaviors, high
baseline functional impairment, presence
of psychiatric comorbid conditions, and
low general health status were the
strongest predictors of worse low back
pain outcomes at 1 year (16). Variables related to the work environment were also
associated with outcomes but were less
useful.
When should clinicians consider

imaging studies?
Radiographic examinations are usually of limited use in patients with
low back pain unless the history or
physical examination suggests a
specific underlying cause. Radiographic findings correlate poorly
with low back symptoms. Spinal
imaging studies in asymptomatic
individuals commonly reveal
anatomical findings, such as
bulging or herniated disks, spinal
stenosis, annular tears, and disk degeneration, which may not be clinically relevant and can reduce the
specificity of imaging tests. Thus,
the demonstration of an anatomical
abnormality should not automatically lead the clinician to assume
that it is the cause of the pain.
Routine imaging also increases
costs and is associated with a
greater likelihood of invasive procedures, such as surgery, without improved patient outcomes (17).
A guideline developed by the
American College of Physicians
and the American Pain Society in
2007 recommends that clinicians
not routinely obtain imaging or
other diagnostic tests in patients
with nonspecific low back pain,
3 June 2014
that they perform diagnostic

imaging and testing in patients
with low back pain when severe or
progressive neurologic deficits are
present or when serious underlying
conditions are suspected, and that
they evaluate patients with persistent low back pain and signs or
symptoms of radiculopathy or
spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if the patients are potential candidates for
surgery or epidural steroid injection
(for suspected radiculopathy). The
guideline developers rated these
recommendations as strong and
based on moderate-quality evidence
(18). The American College of
Physicians subsequently published
best-practice advice for high-value,
cost-conscious low back imaging,
including indications for imaging
and use of magnetic resonance imaging, based on the presence and
type of risk factors found (Table 2)

(17). The American College of Radiology has also developed appropriateness criteria for radiographic
procedures in the evaluation of patients with low back pain (19).
These criteria are meant to guide
clinician decision making in the
context of each patients clinical
circumstances.
In summary, imaging is more useful
as the pretest probability of underlying serious disease requiring
surgical or other intervention increases. A negative plain film does
not definitively exclude cancer or
infection in someone at high risk
for these conditions. For such persons, additional advanced imaging
may be appropriate.
A systematic review of 6 RCTs found no
difference between immediate lumbar
imaging and usual care without immediate imaging for pain or function at
Table 2. Suggestions for Imaging in Patients With Acute Low Back Pain
Imaging Action
Clinical Situations With Suggestions for Initial Imaging
Immediate imaging
Radiography plus erythrocyte sedimentation rate*

Major risk factors for cancer (new onset of low back pain with history of
cancer, multiple risk factors for cancer, or strong clinical suspicion for cancer)
Magnetic resonance imaging
Risk factors for spinal infection (new onset of low back pain with fever and
history of intravenous drug use or recent infection)
Risk factors for or signs of cauda equina syndrome (new urine retention, fecal
incontinence, or saddle anesthesia)
Severe neurologic deficits (progressive motor weakness or motor deficits at
multiple neurologic levels)
Radiography with or without erythrocyte sedimentation rate
Weaker risk factors for cancer (unexplained weight loss, age >50 y)
Risk factors for or signs of ankylosing spondylitis (morning stiffness,
improvement with exercise, alternating buttock pain, awakening due to back
pain during the second half of the night, younger age [20s to 30s])
Risk factors for vertebral compression fracture (history of osteoporosis, use of
corticosteroids, significant trauma, older age [>65 y for women, >75 y for men])
Magnetic resonance imaging
Signs and symptoms of radiculopathy (back pain with leg pain in an L4, L5, or
S1 nerve root distribution; positive straight-legraising or crossed straightlegraising test result) in patients who are candidates for surgery or epidural
steroid injection
Risk factors for or symptoms of spinal stenosis (radiating leg pain, older age,
pseudoclaudication) in patients who are candidates for surgery
No criteria for immediate imaging and back pain alleviated or resolved after
1-mo trial of therapy
Previous spinal imaging with no change in clinical status
Deferred imaging after trial of therapy
No imaging
* Clinicians should consider magnetic resonance imaging if the initial imaging result is negative but a high degree of clinical suspicion for cancer remains.
3 June 2014
In the Clinic
ITC6-7
23. Hayden JA, van Tulder MW, Tomlinson

G. Systematic review: strategies for
using exercise therapy to improve outcomes in chronic
low back pain. Ann
Intern Med.
2005;142:776-85.
[PMID: 15867410]
24. Hayden JA, van Tulder MW, Malmivaara
AV, Koes BW. Metaanalysis: exercise
therapy for nonspecific low back pain.
Ann Intern Med.
2005;142:765-75.
[PMID: 15867409]
25. Cramer H, Lauche R,
Haller H, Dobos G. A
systematic review
and meta-analysis of
yoga for low back
pain. Clin J Pain.
2013;29:450-60.
[PMID: 23246998]
26. Rubinstein SM, van
Middelkoop M, Assendelft WJ, de Boer
MR, van Tulder MW.
Spinal manipulative
therapy for chronic
low-back pain: an
update of a
Cochrane review.
Spine (Phila Pa
1976). 2011;36:E82546. [PMID: 21593658]
27. Furlan AD, Imamura
M, Dryden T, Irvin E.
Massage for low
back pain: an updated systematic review
within the framework of the
Cochrane Back Review Group. Spine
(Phila Pa 1976).
2009;34:1669-84.
[PMID: 19561560]
28. Lam M, Galvin R,
Curry P. Effectiveness
of acupuncture for
nonspecific chronic
low back pain: a systematic review and
meta-analysis. Spine
(Phila Pa 1976).
2013;38:2124-38.
[PMID: 24026151]
29. Sodha R, Sivanadarajah N, Alam M. The
use of glucosamine
for chronic low back
pain: a systematic review of randomised
control trials. BMJ
Open. 2013;3.
[PMID: 23794557]
short-term (up to 3 months) or longterm (612 months) follow-up (20).
Under what circumstances should

clinicians consider electromyography and other laboratory tests?
Additional diagnostic and laboratory tests are not indicated in
most patients with low back pain.
A highly elevated erythrocyte sedimentation rate is associated with
the presence of cancer and might
be considered in patients suspected of having cancer with negative
lumbar radiography (21). Clinicians
may consider electromyography
and nerve conduction tests for patients in whom there is diagnostic
uncertainty about the relationship

of leg symptoms to anatomical
findings on advanced imaging, although evidence to define appropriate strategies for using such
tests is not available. Electrophysiologic tests can assess suspected
myelopathy, radiculopathy, neuropathy, and myopathy. With
radiculopathy or neuropathy, electromyography results might be
unreliable in limb muscles until a
patient has significant limb symptoms for more than 34 weeks, so
testing should not be done in patients with a duration of symptoms less than 4 weeks.
Diagnosis... Clinical evaluation of patients with low back pain should focus on
identification of features that indicate a potential serious underlying condition,
radiculopathy, and psychosocial factors associated with development of chronicity.
Clinicians should classify low back pain as acute, subacute, or chronic because the
trajectory for improvement varies and treatment options can differ with duration.
Most patients with acute symptoms will not require imaging tests, which should
be reserved for patients with a high pretest probability of serious underlying systemic illness, fracture, cord compression, or spinal stenosis or for whom surgery is
being considered.
30. Gagnier JJ, van Tulder MW, Berman B,
Bombardier C.
Herbal medicine for
low back pain: a
Cochrane review.
Spine (Phila Pa
1976). 2007;32:82-92.
[PMID: 17202897]
31. Chou R, Huffman LH;
American Pain Society. Nonpharmacologic therapies for
acute and chronic
low back pain: a review of the evidence
for an American Pain
Society/American
College of Physicians
clinical practice
guideline. Ann Intern Med.
2007;147:492-504.
[PMID: 17909210]
32. Ostelo RW, van Tulder MW, Vlaeyen JW,
Linton SJ, Morley SJ,
Assendelft WJ. Behavioural treatment
for chronic low-back
pain. Cochrane
Database Syst Rev.
2005:CD002014.
[PMID: 15674889]
33. Guzmn J, Esmail R,
Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation
for chronic low back
pain: systematic review. BMJ.
2001;322:1511-6.
[PMID: 11420271]
Treatment
What are reasonable goals for

clinicians and patients for
treatment of low back pain?
Most acute, nonspecific low back
pain resolves over time without
treatment. Controlling pain and
maintaining function while symptoms diminish on their own is the
goal for most patients with acute low
back pain. Clinicians should inform
patients that back pain is common,
that the spontaneous recovery rate is
more than 50%75% at 4 weeks and
more than 90% at 6 weeks, and that
most people do not need surgery
even if they have herniated disks.
is to maintain function, even if it is

not possible to achieve complete
resolution of pain. Addressing psychosocial factors associated with
chronicity is critical, and patients
should be encouraged to engage in
management of his or her low back
pain. In many patients, improvement
in functional outcome depends more
on addressing psychosocial factors
and interventions focused on movement and activity than on medical
treatments.
Chronic low back pain can be difficult to treat, and exacerbations can
recur over time. Patients should
understand that the goal of therapy
What psychosocial factors

influence recovery?
Psychosocial factors and emotional
distress are stronger predictors of low
back pain outcomes than physical
examination findings or severity and
duration of pain (16). Assessment of
ITC6-8
In the Clinic
3 June 2014
psychosocial factors, such as depression, maladaptive coping behaviors, unemployment, job dissatisfaction, somatization disorder, or
psychological distress, identifies
patients who may have delayed recovery and could help target interventions, such as supervised
exercise therapy, cognitive behavioral therapy, or intensive multidisciplinary rehabilitation.
What advice should clinicians give
to patients regarding level of
activity and exercise?
Ample evidence suggests that prolonged bed rest or inactivity is associated with worse outcomes for patients
with acute, subacute, or chronic low
back pain. Clinicians should encourage patients to maintain activity
levels as near to normal as possible, although back-specific exercises do not
need to be started while the patient is
in acute pain. Although work might
need to be modified on a short-term
basis to accommodate patient recovery, most patients with nonspecific occupational low back pain can return to
work quickly. If warning signs of serious underlying pathologic conditions
are lacking, clinicians should encourage patients to minimize bed rest, to
be as active as possible, and to return
to work as soon as possible even if
they are not entirely pain-free.
A 2010 systematic review of RCTs investigating bed rest for patients with acute
low back pain concluded that people
who have low back pain without sciatica
and receive advice for bed rest have
more pain and worse functional recovery than those advised to continue normal activities (22). Pain and functional
outcomes were similar for patients with
sciatica regardless of whether they had
bed rest or remained active.
Various back-specific exercise programs that begin when acute

symptoms subside have been advocated. Evidence indicates that several types of exercise programs are
effective in patients with back
pain, with no clear advantage of
one specific exercise therapy over
3 June 2014
another. Yoga, which involves exercise as well as breathing and relaxation components, has also been
found to be effective for low back
pain. Clinicians should advise patients that attaining and maintaining general physical fitness may
help to prevent recurrence of low
back pain and is associated with
other health benefits.
A meta-analysis of 61 RCTs that included
6390 patients with acute (11 trials), subacute (6 trials), chronic (43 trials), or uncertain-duration (1 trial) low back pain
concluded that exercise offers slight benefits
in pain and function in adults with chronic
low back pain, especially in health care
rather than occupational settings. In patients with subacute pain, some evidence
supported the effectiveness of graded exercise programs in reducing work absenteeism, but the evidence was inconclusive
for other outcomes. For patients with acute
low back pain, exercise therapy was as effective as no therapy or other conservative
treatments (23). Additional analysis of the
studies included in the systematic review
found that exercise therapy delivered under
supervision and consisting of individually
tailored programs that include stretching or
strengthening seemed to be associated
with the greatest effects on pain and function for patients with chronic, nonspecific
low back pain. However, available trials
were heterogeneous and varied in quality,
so the authors were unable to make definitive conclusions about the relationship of
outcomes with patient characteristics or
exercise type (24).
A meta-analysis of 10 RCTs that included
967 patients with chronic low back pain
found that yoga was associated with beneficial effects on short- and long-term pain
and back-specific disability. Evidence was
strong for short-term pain, back-specific
disability, and long-term pain and was
moderate for long-term back-specific
disability (25).
Are complementaryalternative
medicine therapies effective?
Complementaryalternative medicine therapies are commonly used
for back pain. Among the interventions that probably have some
benefit are spinal manipulation,
massage, and acupuncture. Evidence is limited on the use of
In the Clinic
ITC6-9
34. Karjalainen K, Malmivaara A, van Tulder

M, Roine R, Jauhiainen M, Hurri H, et
al. Multidisciplinary
biopsychosocial rehabilitation for subacute low back pain
in working-age
adults: a systematic
review within the
framework of the
Cochrane Collaboration Back Review
Group. Spine (Phila
Pa 1976).
2001;26:262-9.
[PMID: 11224862]
35. Roelofs PD, Deyo RA,
Koes BW, Scholten
RJ, van Tulder MW.
Non-steroidal antiinflammatory drugs
for low back pain.
Cochrane Database
Syst Rev.
2008:CD000396.
[PMID: 18253976]
36. Chou R, Huffman LH;
American Pain Society. Medications for
acute and chronic
low back pain: a review of the evidence
for an American Pain
Society/American
College of Physicians
clinical practice
guideline. Ann Intern Med.
2007;147:505-14.
[PMID: 17909211]
37. van Tulder MW,
Touray T, Furlan AD,
Solway S, Bouter LM.
Muscle relaxants for
non-specific low
back pain. Cochrane
Database Syst Rev.
2003:CD004252.
[PMID: 12804507]
willow bark extract (also known as

salicin) and devils claw but suggests possible benefit. Treatments
with unknown effectiveness include glucosamine and chondroitin. Alternative therapies that are
probably ineffective include bipolar magnets, the Feldenkrais
Method, and reflexology.
A systematic review of RCTs found lumbar
spinal manipulation to be similar in effectiveness to general practitioner care, analgesics, physical therapy exercises, or back
school (26).
A systematic review of RCTs concluded
that for subacute and early chronic low
back pain, moderate evidence suggests
that massage might be beneficial compared with joint mobilization, relaxation
therapy, physical therapy, acupuncture,
sham laser, and self-care education, particularly when combinws with exercise
and education (27).
38. Deshpande A, Furlan

A, Mailis-Gagnon A,
Atlas S, Turk D. Opioids for chronic lowback pain. Cochrane
Database Syst Rev.
2007:CD004959.
[PMID: 17636781]
39. Martell BA, OConnor PG, Kerns RD,
Becker WC, Morales
KH, Kosten TR, et al.
Systematic review:
opioid treatment for
chronic back pain:
prevalence, efficacy,
and association with
addiction. Ann Intern Med.
2007;146:116-27.
[PMID: 17227935]
40. Chou R, Fanciullo GJ,
Fine PG, Miaskowski
C, Passik SD,
Portenoy RK. Opioids
for chronic noncancer pain: prediction and identification of aberrant
drug-related behaviors: a review of the
evidence for an
American Pain Society and American
Academy of Pain
Medicine clinical
practice guideline. J
Pain. 2009;10:131-46.
[PMID: 19187890]
A meta-analysis of 25 RCTs found that

acupuncture was associated with decreased levels of self-reported pain versus
sham acupuncture and improved function
versus no treatment. However, heterogeneity of study characteristics and
methodological shortcomings in the trials
make interpretation of these findings
challenging (28). Some trials have found
sham acupuncture (needles placed in
nonacupuncture points) to be as effective
as true acupuncture. Whether the effectiveness of sham acupuncture is due to
some attribute of needling or is solely a
placebo effect is unclear.
products involving herbal preparations are

not strictly regulated and quality control is
often uncertain.
What other physical interventions

are effective?
Many physical modalities, in addition to those already discussed, have
been used for treatment of low back
pain. These include superficial heat,
traction, transcutaneous electrical
nerve stimulation, ultrasound, lowlevel laser therapy, interferential therapy, and short-wave diathermy. For
most of these, RCTs have found little evidence of benefits, although
they generally seem safe. Patient expectations of benefit and placebo effects may play a role in their therapeutic value, but any such potential
benefits must be weighed against the
costs of using unproven therapies.
A 2007 systematic review of nonpharmacologic therapies for acute and chronic
low back pain considered the benefits and
harms of physical modalities (inferential
therapy, low-level laser therapy, lumbar
support, short-wave diathermy, superficial
heat, traction, transcutaneous electrical
nerve stimulation, and ultrasonography).
No good evidence was found for any of
these interventions, except for superficial
heat for acute low back pain (31).
A Cochrane review found some evidence

that taking 240 mg of willow bark extract
per day provides short-term benefit for
acute exacerbations of chronic, nonspecific low back pain. The review also found
strong evidence that taking devils claw
containing 50100 mg of harpagoside per
day was better than placebo for shortterm alleviation of acute or chronic back
pain. There is no evidence to support longterm use of devils claw, and safety has not
been carefully studied (30). In addition, the
applicability of research studies to clinical
practice is uncertain because commercial
What psychological therapies are

effective?
Various psychological approaches to
patients with low back pain have
been evaluated. The best evidence is
for cognitive behavioral therapy in
persons with subacute or chronic
low back pain (32). Results for other
types of psychological therapies are
less conclusive. Psychological therapies may be most effective when targeted at persons with psychosocial
risk factors for chronic disabling low
back pain (13). For patients with
chronic disabling low back pain,
particularly those with psychosocial
risk factors, intensive interdisciplinary or multidisciplinary therapy
consisting of physical, vocational,
and behavioral interventions
provided by multiple health care
professionals is more effective than
ITC6-10
A systematic review of 3 RCTs found conflicting results and insufficient evidence to

determine the effects of glucosamine for
low back pain (29).
In the Clinic
3 June 2014
standard care and is an important

treatment option (33, 34).
When should drug therapies be
considered, and which drugs are
effective?
Various drug therapies are used for
low back pain (Appendix Table 1,
available at www.acponline.org).
Acetaminophen or nonsteroidal
anti-inflammatory drugs (NSAIDs)
are considered first-line drug therapy. These drugs have been shown
to reduce low back pain compared
with placebo in systematic reviews
of clinical trials (35). Although no
randomized trials of acetaminophen specifically in low back pain
are available, it can be reasonably
recommended as an appropriate
therapy because of its known effectiveness and safety as an analgesic
for other pain conditions.
Short courses of muscle relaxants or
opiates should be considered as adjunctive therapy only when needed
for patients who do not respond to
first-line analgesics. Muscle relaxants are more effective than placebo
in reducing pain and relieving
symptoms. However, studies have
not shown them to be more effective than NSAIDs, and they have
more adverse effects, including
such adverse central nervous system
effects as sedation (36, 37).
Although opioids are commonly
prescribed for acute, subacute, and
chronic low back pain, they have not
been shown to be more effective
than acetaminophen or NSAIDs
and are associated with more adverse effects, including the potential for addiction (36, 38, 39).
Opioids are not a first-line treatment for low back pain but may be
appropriate for short-term use in
patients with severe acute low back
pain. Opioids should be used with
caution for long-term treatment of
carefully selected patients with
chronic back pain. Tools are available to assess opioid risk before
prescribing (40). Tramadol is a
3 June 2014
dual-action opioid agonist with

effects on neurotransmitters as well
as weak -opioid receptor affinity.
A systematic review of 4 short-term RCTs
found that opioids did not provide better
pain relief than placebo or nonopioid analgesics. In poor-quality, heterogeneous studies, the prevalence of current substance
abuse disorders in patients taking long-term
opioids for back pain was as high as 43%.
Aberrant medication-taking behaviors varied from 5%24%. However, the studies had
poorly described or validated methods for
identifying aberrant behaviors (39).
Antidepressants have been used to

treat low back pain. Those that seem
effective are those that inhibit norepinephrine reuptake (for example, tricyclic or tetracyclic antidepressants
and serotoninnorepinephrine reuptake inhibitors) but not those lacking
inhibition of norepinephrine reuptake (for example, selective serotonin
reuptake inhibitors). However, several
meta-analyses evaluating the effect of
antidepressants versus placebo for
short-term therapy of chronic low
back pain have reported conflicting
results, with some showing mild beneficial effects on pain relief and others showing no effect (4143). More
recently, the U.S. Food and Drug
Administration approved duloxetine
for chronic back pain. Three randomized trials found duloxetine to be
more effective than placebo for
chronic low back pain, although differences were small (<1 point on pain
or function scales of 010) and discontinuation due to adverse effects
was more likely with duloxetine
(4446). Depression is common in
patients with chronic low back pain
and should be assessed and treated
appropriately. Antidepressants are not
appropriate for acute low back pain.
Anticonvulsants, such as carbamazepine, gabapentin, or pregabalin, have
limited evidence suggesting some efficacy in treating radiculopathy, but
evidence is lacking about their effectiveness in the management of low
back pain without radiculopathy.
There is good evidence that systemic
41. Salerno SM, Browning R, Jackson JL.

The effect of antidepressant treatment
on chronic back
pain: a meta-analysis. Arch Intern Med.
2002;162:19-24.
[PMID: 11784215]
42. Staiger TO, Gaster B,
Sullivan MD, Deyo
RA. Systematic review of antidepressants in the treatment of chronic low
back pain. Spine
(Phila Pa 1976).
2003;28:2540-5.
[PMID: 14624092]
43. Urquhart DM, Hoving JL, Assendelft
WW, Roland M, van
Tulder MW. Antidepressants for nonspecific low back
pain. Cochrane
Database Syst Rev.
2008:CD001703.
[PMID: 18253994]
44. Skljarevski V, Desaiah
D, Liu-Seifert H,
Zhang Q, Chappell
AS, Detke MJ, et al.
Efficacy and safety of
duloxetine in patients with chronic
low back pain. Spine
(Phila Pa 1976).
2010;35:E578-85.
[PMID: 20461028]
ITC6-11
In the Clinic
corticosteroids do not alleviate

chronic low back pain (36).
What are the indications for
surgical intervention?
Most cases of low back pain do not
require surgery. Patients with suspected cord or cauda equina compression or spinal infection require
immediate surgical referral for possible decompression or debridement to prevent loss of neurologic
function. Signs that urgent surgical
intervention may be necessary include bowel- or bladder-sphincter
dysfunction, particularly urine retention or urinary incontinence;
diminished perineal sensation, sciatica, or sensory motor deficits; and
bilateral or unilateral motor deficits
that are severe and progressive.
Less urgent surgical evaluation is
also appropriate in patients with
worsening suspected spinal stenosis, neurologic deficits, or intractable pain that is resistant to
conservative treatment. Signs that
surgical intervention may be necessary include weakness of the ankle
and great toe dorsiflexors, loss of
ankle reflex, sensory loss in the feet
as manifestations of the most common disk herniations, neurogenic
claudication or pseudoclaudication, and persistent leg pain in
addition to and more severe than
back pain. Standard surgery is posterior decompressive laminectomy
for spinal stenosis and diskectomy
for herniated disk.
45. Skljarevski V, Ossanna M, Liu-Seifert H,

Zhang Q, Chappell
A, Iyengar S, et al. A
double-blind, randomized trial of duloxetine versus
placebo in the management of chronic
low back pain. Eur J
Neurol.
2009;16:1041-8.
[PMID: 19469829]
46. Skljarevski V, Zhang
S, Desaiah D, Alaka
KJ, Palacios S, Miazgowski T, et al. Duloxetine versus
placebo in patients
with chronic low
back pain: a 12week, fixed-dose,
randomized, doubleblind trial. J Pain.
2010;11:1282-90.
[PMID: 20472510]
47. Weinstein JN, Tosteson TD, Lurie JD,
Tosteson AN, Blood
E, Hanscom B, et al;
SPORT Investigators.
Surgical versus nonsurgical therapy for
lumbar spinal stenosis. N Engl J Med.
2008;358:794-810.
[PMID: 18287602]
48. Weinstein JN, Lurie
JD, Tosteson TD,
Skinner JS, Hanscom
B, Tosteson AN, et al.
Surgical vs nonoperative treatment for
lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT)
observational cohort. JAMA.
2006;296:2451-9.
[PMID: 17119141]
In a study that enrolled patients with imaging-confirmed lumbar spinal stenosis

without spondylolisthesis and at least
12 weeks of symptoms in either a randomized cohort (n = 289) or an observational
cohort (n = 365), 67% of patients randomly assigned to surgery and 43% of those
randomly assigned to nonsurgical care
had surgery. In the randomized cohort,
pain relief, but not functional outcomes,
was better among those assigned to surgery than among those assigned to nonsurgical care. In an analysis of both
cohorts, patients who had surgery had
better pain and functional outcomes at
3 months and at 2 years than those who
did not have surgery (47).
ITC6-12
In the Clinic
A prospective cohort study of patients with

radiculopathy and associated disk herniations treated at 13 U.S. spine centers found
that patients with sciatica who chose surgical intervention reported greater
improvements than those who chose nonsurgical care (48).
The role of surgery in patients with

chronic back pain without neurologic findings is less clear. Spinal fusion
is the most common procedure for
nonradicular low back pain with degenerative findings. However, most
randomized trials of fusion surgery
versus nonsurgical treatment have
found no clear effects on pain or
function. Although definitive evidence on the effectiveness of facet
joint injections or radiofrequency
denervation is not available, such
procedures are often done in patients with nonradicular low back
pain who do not respond to conservative care.
A systematic review of 4 RCTs found that
disability outcomes between fusion and
nonsurgical treatment did not meet criteria for clinically meaningful differences.
One trial found fusion surgery superior to
unstructured nonsurgical therapy at
2-year follow-up; the other 3 trials found
no clear or clinically relevant difference between surgery and intensive interdisciplinary rehabilitation but were underpowered or had high crossover (49).
Epidural steroid injections are

often performed for patients with
radiculopathy due to herniated
disk, but evidence suggests small
short-term benefits that dissipate
with longer follow-up (50).
How should clinicians follow
patients with low back pain?
Follow-up, based on the suspected
cause and course of disease in patients with low back pain, is an
important component of treatment.
Patients with uncomplicated acute
back pain who improve over 24
weeks may not require additional follow-up. Patients should be informed
of the expected course of low back
pain and the need for follow-up after
34 weeks if they have not improved.
3 June 2014
The follow-up history should address

patient response to treatment, resolution of symptoms, and development
of complications. It is important to
assess the probability of a transition
to the subacute or chronic phase of
back pain. Patients with acute back
pain who are still moderately symptomatic at 4 weeks are more likely
to develop chronic symptoms than
those who report alleviation of symptoms. If recovery is delayed, clinicians
should consider reevaluation for possible underlying causes of back pain
and ensure that psychosocial factors
are addressed. Development of
symptoms of neurologic dysfunction
or systemic disease should prompt
additional evaluation.
Reinforcement of healthy lifestyle

messages and patient education is
an important part of management
and prevention of recurrence. This
should include advice on treatment and prognosis and recommendations on general exercise
and fitness. In particular, patients
with low back pain should be encouraged to continue normal activities. For patients with chronic
low back pain, the addition of individualized advice about the most
appropriate exercise and functional activities is required. Regular
follow-up is also believed to reinforce efforts and to develop ways
to overcome barriers to regular
physical activity.
Treatment... Most acute nonspecific pain will resolve over days or weeks, even without medical intervention. Clinicians should discourage bed rest and encourage all patients to maintain normal activities to the extent possible. When symptoms persist,
clinicians should consider nondrug interventions, such as exercise therapy, spinal manipulation, acupuncture, massage, and psychological therapies. When analgesia is necessary, acetaminophen or NSAIDs should be used as first-line therapy. Short courses of
muscle relaxants or opioids should be used cautiously, and antidepressants may be
helpful in some patients with chronic symptoms. Psychosocial factors are strong predictors of low back pain outcomes, and recent evidence has shown the effectiveness
of a risk-stratified approach to management. Urgent surgical referral is indicated
when infection, cancer, acute nerve compression, or the cauda equina syndrome is
suspected. Nonurgent surgical referral may be appropriate for patients with persistent
back pain and signs of nonacute nerve compression or spinal stenosis.
What do professional organizations

recommend for the treatment of
patients with low back pain?
In 2007, the American College of
Physicians and American Pain Society released guidelines on the diagnosis and treatment of low back
pain (http://annals.org/article.aspx
?articleid=736814) (18). The guidelines included 7 key recommendations for guiding diagnosis and
treatment. The American College
of Physicians subsequently published advice for high-value, costconscious health care in the area of
low back pain imaging (17).
3 June 2014
In 2004, a systematic review of 17

available guidelines for acute low
back pain concluded that the overall
quality of the evidence supporting
recommendations was disappointing
(52) but the diagnostic and therapeutic recommendations of the
guidelines were largely similar.
49. Mirza SK, Deyo RA.

Systematic review of
randomized trials
comparing lumbar
fusion surgery to
nonoperative care
for treatment of
chronic back pain.
Spine (Phila Pa
1976). 2007;32:81623. [PMID: 17414918]
50. Pinto RZ, Maher CG,
Ferreira ML, Hancock
M, Oliveira VC,
McLachlan AJ, et al.
Epidural corticosteroid injections in
the management of
sciatica: a systematic
review and metaanalysis. Ann Intern
Med. 2012;157:86577. [PMID: 23362516]
51. American College of
Sports Medicine.
ACSMs Guidelines
for Exercise Testing
and Prescription. 7th
ed. Philadelphia: Lippincott Williams &
Wilkins; 2005.
ITC6-13
In 2005, the American College of

Sports Medicine released guidelines
for exercise testing and prescription
in healthy persons and those with
disease, including guidance for low
back pain (51).
In the Clinic
Practice
Improvement
In the Clinic
Tool Kit
6 months, and that most people do

not need surgery even if they have
herniated disks. Clinicians should advise patients to remain active, encourage weight control, and counsel
patients about the role of psychosocial distress.
A randomized trial in 162 patients with
back pain compared patients use of a
booklet entitled The Back Book with more
traditional educational materials. Patients
who received the experimental booklet
showed an improvement in beliefs about
back pain and some improvement in disability measures (53).
ACP Smart Medicine Module

http://smartmedicine.acponline.org/searchresults.aspx#q=low%20back
%20pain
Access the American College of Physicians Smart Medicine
modules on low back pain and back pain
(complementaryalternative medicine).
Patient Information
Low Back Pain
http://annals.org/article.aspx?articleID=736950
Summary for Patients of the American College of
Physicians/American Pain Society guidelines on the diagnosis
and treatment of low back pain for duplication and
distribution to patients.
Clinical Guidelines
www.annals.org/cgi/reprint/147/7/478.pdf
2008 American College of Physicians/American Pain Society
guidelines on the diagnosis and treatment of low back pain.
www.annals.org/cgi/content/full/147/7/478/DC1
Audio summary of the American College of
Physicians/American Pain Society guidelines.
http://annals.org/article.aspx?articleid=746774
2011 best practice advice from the American College of
Physicians on imaging for low back pain.
www.uspreventiveservicestaskforce.org/3rduspstf/lowback/lowbackrs
.htm
U.S. Preventive Services Task Force recommendations on
primary care interventions to prevent low back pain in adults.
www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/
LowBackPain.pdf
American College of Radiology Appropriateness Criteria for
radiographic procedures in patients with low back pain.
ITC6-14
In the Clinic
In the Clinic
52. van Tulder MW, Tuut

M, Pennick V, Bombardier C, Assendelft
WJ. Quality of primary care guidelines
for acute low back
pain. Spine (Phila Pa
1976). 2004;29:E35762. [PMID: 15534397]
53. Burton AK, Waddell
G, Tillotson KM,
Summerton N. Information and advice
to patients with
back pain can have a
positive effect. A
randomized controlled trial of a novel educational booklet in primary care.
Spine (Phila Pa
1976). 1999;24:248491. [PMID: 10626311]
What is the role of patient education in the management of low

back pain?
Patient education is important in
the overall management of low back
pain, and all patients should receive
information about treatment and
prognosis. Information and advice
given to patients about the management of back pain needs to be individualized and relevant. Patient
education about low back pain
should inform patients that back pain
is common, that the spontaneous recovery rate is more than 50%75%
at 4 weeks and more than 90% at
3 June 2014
WHAT YOU SHOULD KNOW

ABOUT LOW BACK PAIN
In the Clinic
Many people have low back pain at some time in their

lives. Back pain is rarely caused by a serious health
condition. It often gets better within a few days or
weeks. Low back pain can become chronic, meaning
that it comes and goes over months or years.
If you have low back pain:
Do not lift heavy things or do strenuous activity.
Try to keep doing everyday activities and walking,
even if it hurts.
Do not stay in bed longer than 12 days because it
can make your recovery slower.
To help you feel better, try some of these things at
home:
Medicines from the drug store to reduce pain
(acetaminophen or ibuprofenread the labels).
Heating pads or hot showers.
Massage.
See a doctor if:
The leg, foot, groin, or rectal area feels numb.
Pain was caused by an injury.
Fever, nausea or vomiting, stomachache, weakness,

or sweating occurs.
Pain is so bad you cannot move around.
Bowel or bladder control is lost.
Pain does not seem to be getting better after 23

weeks.
For More Information

www.annals.org/cgi/reprint/147/7/478.pdf
Patient summary of guideline from the American College of

Physicians and the American Pain Society on the diagnosis and
treatment of low back pain.
www.nlm.nih.gov/medlineplus/backpain.html
MedlinePlus.
www.ninds.nih.gov/disorders/backpain/backpain.htm
National Institute of Neurological Disorders and Stroke.

http://familydoctor.org/familydoctor/en/diseases-conditions/low-back
-pain.htmlTool Kit
American Academy of Family Physicians (information available in

English and Spanish).
Patient Information
Pain runs down the leg below the knee.
CME Questions
1. A 43-year-old man is evaluated for low

back pain. Five days ago, he was playing
squash when he felt a popping sensation
in his back and a shooting pain down his
leg. The pain worsened over the next
23 days, causing some difficulty with
sleeping. He started taking ibuprofen on
day 2 and has improved slightly since
then. He currently rates his pain as
5 or 6 out of 10. He has no numbness,
weakness, or bladder or bowel
incontinence.
On physical examination, vital signs are
normal. Body mass index is 25 kg/m2.
Straight-legraising test on both the left
and right side reproduces pain in the left
leg. The ankle reflex is diminished on the
left side compared with the right side. He
is able to walk with some discomfort. No
motor or sensory deficits are observed.
Saddle anesthesia is not present. Rectal
tone is normal.
Which of the following is the most
appropriate management of this patient?
A. Analgesics and mobilization as

tolerated
B. Complete blood count and
erythrocyte sedimentation rate
C. Epidural corticosteroid injection
D. Lumbar spine MRI
E. Lumbar spine radiograph
2. A 32-year-old man is evaluated for an
insidious onset of low back pain of
3 months duration. The pain occurs in
the morning and evening, is mild in
intensity, and does not radiate to the legs
or buttocks. He has pain at night, and
rest does not alleviate it. He has tried
acetaminophen and naproxen without
relief. Family history is significant for his
father, who has spondyloarthritis.
normal. Musculoskeletal examination
reveals pain and restricted movement on
lumbar motion. There is no pain to
palpation over the sacroiliac joints.
Laboratory studies reveal a C-reactive

protein level of 152.4 nmol/L.
An anteroposterior radiograph of the
pelvis, radiographs of the lumbar spine,
and MRI of the lumbosacral spine are
normal.
appropriate diagnostic test to perform
next in this patient?
A. HLA-B27 testing
B. HACA assay
C. Radiographs of the cervical spine
D. Rheumatoid factor
3. A 75-year-old woman is evaluated for
low back pain. The pain began several
months ago and is getting worse. Its
intensity is now 6 or 7 (on a scale of
110) most days. It worsens with activity
and is reduced with sitting. She has been
unable to walk or exercise because of the
pain and has gained 9.0 kg (20 lb) in the
past year. She has not had bowel or
bladder incontinence, lower extremity
numbness or tingling, fevers, or chills.
Medical history is significant for
hypertension, hyperlipidemia, and peptic
ulcer disease. She stopped smoking
10 years ago and does not use alcohol.
Her current medications are hydrochlorothiazide, lisinopril, simvastatin,
omeprazole, and aspirin. She has been
taking additional aspirin, which has been
providing modest pain relief.

appropriate treatment for this patients
symptoms?
A. Acetaminophen
B. Amitriptyline
C. Cyclobenzaprine
D. Ibuprofen
Disclosures: Dr. Chou, ACP Contributing
Author, has disclosed the following
conflicts of interest: Payment for
manuscript preparation: American
College of Physicians. Consultancy:
Palladian. Grants/grants pending:
Agency for Healthcare Research and
Quality. Royalties: UptoDate.
Disclosures can also be viewed at
www.acponline.org/authors/icmje/
ConflictOfInterestForms.do?msNum
=M14-1032

normal. Body mass index is 34 kg/m2.
There is mild tenderness to palpation
over the lower lumbar paravertebral
muscles. Patellar and ankle jerk reflexes
are 1+ and symmetric. Sensation to light
touch and pinprick is symmetric, and
strength is 5/5 in the lower extremities.
Complete blood count and metabolic
panel are normal.
A radiograph of the lumbar spine shows
degeneration of the L4 and L5 vertebrae,
osteophyte formation, and facet arthropathy with spinal canal narrowing.
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.
ITC6-16
In the Clinic
3 June 2014
Copyright American College of Physicians 2014.

Low Back Pain

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Low Back Pain

Enviado por

Direitos autorais:

Formatos disponíveis

Low Back Pain

ow back pain has a lifetime prevalence of nearly 80%, and spinal

1. Centers for Disease

2014 American College of Physicians

What factors are associated with

shown to prevent low back pain,

Clinicians should remember that

Are specific preventive measures

Should clinicians advise patients

A systematic review of 9 randomized, controlled trials (RCTs) and 9 cohort studies

Annals of Internal Medicine

CLINICAL BOTTOM LINE

the history and physical examination

Physical Examination Findings

Common radiologic abnormality that

Severe leg pain;

Impaired ankle or patella

Osteomyelitis, spinal abscess, epidural abscess

Annals of Internal Medicine

Decreased spinal range of

Usual onset before age 40 y

Fever and localized

Can cause cord compression

Depends on affected viscera

Metastatic disease, commonly from

4. U.S. Preventive Services Task Force. Primary

2014 American College of Physicians

Physical Examination Findings

Metabolic bone disease with

Nonspecific pain; osteoporosis

Best example is osteoporosis with

Unilateral dermatomal rash

Most common in elderly or immunocompromised patients

Physical Examination Maneuvers

Crossed straight-legraising test:

9. Deyo RA, Rainville J,

2014 American College of Physicians

Trauma; corticosteroid use

Physical examination findings

elements of the physical examination include checking for sensory

years, slow symptom onset, and

Although there is no strong evidence-based method for classifying

Annals of Internal Medicine

alleviation of their symptoms and

Classification of Low Back Pain, by

Annals of Internal Medicine

predictors of chronicity, was recently found to be more effective than

13. Hill JC, Whitehurst

2014 American College of Physicians

legs (sciatica) is common, and the

2014 American College of Physicians

Spinal stenosis can also result in

When should clinicians consider

Annals of Internal Medicine

that they perform diagnostic

type of risk factors found (Table 2)

Clinical Situations With Suggestions for Initial Imaging

Radiography plus erythrocyte sedimentation rate*

Deferred imaging after trial of therapy

Annals of Internal Medicine

23. Hayden JA, van Tulder MW, Tomlinson

2014 American College of Physicians

short-term (up to 3 months) or longterm (612 months) follow-up (20).

Under what circumstances should