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                           in the clinic

                           Low Back Pain
                           Prevention                                                        page ITC5-2


                           Diagnosis                                                         page ITC5-3


                           Treatment                                                         page ITC5-7


                           Practice Improvement                                             page ITC5-13


                           CME Questions                                                    page ITC5-16



Section Editors            The content of In the Clinic is drawn from the clinical information and
Christine Laine, MD, MPH   education resources of the American College of Physicians (ACP), including
David Goldmann, MD         PIER (Physicians’ Information and Education Resource) and MKSAP (Medical
                           Knowledge and Self-Assessment Program). Annals of Internal Medicine
Science Writer             editors develop In the Clinic from these primary sources in collaboration with
Jennifer F. Wilson         the ACP’s Medical Education and Publishing Division and with the assistance
                           of science writers and physician writers. Editorial consultants from PIER and
                           MKSAP provide expert review of the content. Readers who are interested in these
                           primary resources for more detail can consult http://pier.acponline.org and other
                           resources referenced in each issue of In the Clinic.

                           The information contained herein should never be used as a substitute for clinical
                           judgment.

                           © 2008 American College of Physicians
                                                   ow back pain has a lifetime prevalence of nearly 80% and is the fifth

                                          L        most common reason for physician visits in the United States (1). It
                                                   is also costly, accounting for a large and increasing proportion of
                                          health care expenditures without evidence of corresponding improvements in
                                          outcomes (2). Most low back pain is due to nonspecific musculoskeletal
                                          strain, and episodes generally resolve within days to a few weeks with self-
                                          care. Up to one third of patients, however, reports persistent back pain of at
                                          least moderate intensity 1 year after an acute episode, and 1 in 5 report sub-
                                          stantial limitations in activity (3). Because low back pain is common, chronic,
                                          and can lead to substantial disability, it is important that physicians be profi-
                                          cient with its evaluation and management.

                             Prevention
                                          What factors are associated                Are specific preventive measures
                                          with the development of low                effective in preventing low back
   Factors Associated with                back pain?                                 pain at work?
   Low Back Pain or Disability
                                          Factors associated with the devel-         People whose jobs require heavy
   Claims for Low Back Pain:                                                         lifting and other physical work are
                                          opment of low back pain include
   • Work that requires heavy                                                        thought to be at greater risk for
     lifting; bending and                 obesity, physical inactivity, occupa-      low back pain than people in less
     twisting; or whole-body              tional factors, and depression and
     vibration, like truck driving                                                   physically demanding occupations.
   • Physical inactivity                  other psychological conditions.            Low back pain is a common cause
   • Obesity                              Such strategies as maintenance of          of days lost from work and the need
   • Arthritis or osteoporosis            normal body weight and physical            for workers’ compensation. Studied
   • Pregnancy                            fitness and avoidance of activities        approaches to prevent low back
   • Age > 30 years
                                          that can injure the back should            pain in the workplace include edu-
   • Bad posture                                                                     cational interventions and mechani-
   • Stress or depression                 decrease the risk for low back pain,
                                                                                     cal supports. Results regarding their
                                          but direct evidence documenting            effectiveness in the primary and
                                          the value of such interventions is         secondary prevention of low back
1. Deyo RA, Mirza SK,
                                          not available.                             pain have generally not shown large
   Martin BI. Back pain
   prevalence and visit
                                                                                     benefits. A large randomized, con-
   rates: estimates from
                                          It is important to keep in mind that       trolled trial (RCT) of an educa-
   U.S. national surveys,
   2002. Spine. 2006;
                                          back pain (the symptom), a health          tional program to prevent low back
   31:2724-7. [PMID:                      care visit for back pain, and work         pain among mail carriers who did
   17077742]
2. Martin BI, Deyo RA,                    loss or disability due to back pain        or did not have previous low back
   Mirza SK, et al. Expen-
   ditures and health                     are not necessarily different aspects      pain did not report any benefits (5).
   status among adults
                                          of the same construct. Symptom             Similarly, a large trial in workers in
   with back and neck
                                                                                     physically demanding jobs did not
   problems. JAMA.                        severity does not correlate well with
   2008;299:656-64.                                                                  report any benefits of a work-site
   [PMID: 18270354]                       utilization or functional outcome.         prevention program (6), and another
3. Von Korff M, Saun-
   ders K. The course of                                                             trial using education and lumbar
   back pain in primary                   Should clinicians advise patients
   care. Spine. 1996;                                                                supports also showed no reduction
   21:2833-7; discussion                  about preventing low back pain?            in low back pain compared with
   2838-9. [PMID:
    9112707]                              In 2005, the U.S. Preventive Ser-          usual care (7). Furthermore, evidence
4. U.S. Preventive Ser-
   vices Task Force. Pri-                 vices Task Force concluded that the        is lacking that external back support,
   mary care interven-
   tions to prevent low
                                          evidence was insufficient to recom-        such as with a back brace or belt,
   back pain in adults:                   mend for or against the routine use        provides benefit (8).
   recommendation
   statement. Am Fam                      of interventions in primary care           A recent randomized trial compared use of a
   Physician. 2005;
   71:2337-8. [PMID:                      settings to prevent low back pain in       patient-selected lumbar support with no
   15999872]
5. Daltroy LH, Iversen                    healthy adults (4). The Task Force         support for home care workers with a his-
   MD, Larson MG, et al.                  noted that, although exercise has          tory of low back pain. Although patients in
   A controlled trial of
                                                                                     the support groups reported fewer days
   an educational pro-                    not been shown to prevent low
   gram to prevent low                                                               with low back pain, work absenteeism rates
   back injuries. N Engl J                back pain, regular physical activity       were high and statistically similar in both
   Med. 1997; 337:322-8.
   [PMID: 9233870]                        has other proven health benefits.          the intervention and control groups (9).



© 2008 American College of Physicians     ITC5-2            In the Clinic            Annals of Internal Medicine     6 May 2008
  Prevention... Regular exercise and maintenance of fitness may be helpful in pre-
  venting low back pain. Evidence is insufficient to support the use of any specific
  preventive interventions, including educational interventions, work-site prevention
  programs, or mechanical supports.


                                                               CLINICAL BOTTOM LINE

                                                                                                          Diagnosis
What elements of history and                         shows the history and physical
physical examination should                          examination findings for different
clinicians incorporate into the                      types of back pain.
evaluation of low back pain?
                                                     When evaluating a patient with
History and physical examination
                                                     low back pain, clinicians should
should aim to place the patient into                 identify features that indicate a
1 of 3 categories: nonspecific low                   serious underlying cause, or radicu-
back pain, back pain potentially                     lopathy, and psychosocial factors
associated with radiculopathy or                     that could delay recovery. Key ele-
spinal stenosis, or back pain poten-                 ments of the physical examination
tially associated with another specific              include checking for sensory loss,
systemic or spinal cause. Table 1                    muscle weakness, or limited range

 Table 1. Common History and Physical Examination Features for Different Back Pain Causes
 Disease                            History                           Physical Examination                    Notes
 Degenerative joint                 Nonspecific                       Nonspecific                               Common radiological abnormalities that
  disease                                                                                                       may or may not be related to symptoms
 Degenerative disk                  Sciatic pain                      Impaired ankle or patella reflex;         Common cause of nerve root
  disease with herniation                                             positive ipsilateral or crossed straight- impingement and radicular symptoms
                                                                      leg–raise test; great toe, ankle,
                                                                      or quadriceps weakness; lower
                                                                      extremity sensory loss
 Spinal stenosis                    Severe leg pain;                  Wide-based gait; abnormal Romberg More common with advancing age,
                                    pseudoclaudication;               test results; thigh pain after 30         uncommon before age 50 y
                                    no pain when seated               seconds of lumbar extension
 Ankylosing spondylitis             Gradual onset; morning            Decreased spinal range of motion          Usual onset before age 40 y
                                    stiffness; improves with
                                    exercise; pain > 3 mo; pain
                                    not relieved when supine
 Osteomyelitis or spinal abscess    Source of infection, such as      Fever and localized tenderness          Can cause cord compression
                                    urinary tract infection, skin
                                    infection, or history of
                                    intravenous drug abuse
 Malignancy in the spine            Weight loss or other symptoms     Localized tenderness                    Metastatic disease. Commonly from
  or surrounding structures         of malignancy; known past or                                              prostate, breast, and lung cancer; can
                                    current cancer diagnosis;                                                 cause cord compression; more common
                                    failure to improve after 4 wk;                                            in patients > 50 y
                                    no relief with bed rest
 Intra-abdominal visceral disease   Depends on affected viscera       Depends on affected viscera             Peptic ulcer, pancreatitis, nephro-
                                                                                                              lithiasis, pyelonephritis, prostatitis,
                                                                                                              pelvic infection or tumor, and aortic
                                                                                                              dissection can cause back pain
 Metabolic bone disease with or     Nonspecific pain; osteoporosis    Localized tenderness if vertebral       Best example is osteoporosis with
  without compression fracture      or osteoporosis risk factors;     fracture                                compression fracture
                                    trauma; corticosteroid use
 Herpes zoster                      Unilateral pain in distribution   Unlilateral dermatomal rash             Most common in elderly or
                                    of dermatome                                                              immune-compromised patients
 Psychosocial distress              Symptoms do not follow a          Physical examination findings that      Patients with psychosocial distress
                                    clear clinical or anatomical      do not follow a clear clinical or       and low back pain are at high risk for
                                    pattern; psychological and        anatomical pattern                      poor outcomes
                                    emotional distress




6 May 2008           Annals of Internal Medicine             In the Clinic                    ITC5-3             © 2008 American College of Physicians
                                        of motion in the legs and feet and         therapies on the basis of symptom
   Classification of Low
                                        characterizing the pain level.             duration.
   Back Pain by Duration
   Acute: Lasts <4 weeks                What serious underlying systemic           Although there is no strong evidence-
   Subacute: Lasts 4–12 weeks           conditions should clinicians
   Chronic: Lasts >12 weeks
                                                                                   based method for classifying
                                        consider as possible causes of low         duration of acute back pain, it is
                                        back pain?                                 generally defined as back pain last-
                                        Underlying systemic disease that
                                                                                   ing less than 4 weeks. Usually the
                                        causes back pain is rare but must be
                                                                                   result of trauma or arthritis, acute
                                        considered. Prevalence is 4% for
                                        compression fracture, less than 1%         low back pain is the most common
                                        for nonskin cancer, 0.3% for anky-         type of low back pain. Most acute
6. IJzelenberg H,
    Meerding WJ, Bur-                   losing spondylitis, and 0.01% for          back pain resolves within 4 weeks
    dorf A. Effectiveness
                                        infection (10).                            with self care. Subacute low back
    of a back pain pre-
    vention program: a                                                             pain lasts between 4 to 12 weeks
    cluster randomized
    controlled trial in an
                                        Factors associated with cancer             and may require clinical interven-
    occupational setting.               include history of cancer, unex-           tion. Chronic back pain is defined
    Spine. 2007;32:711-9.
                                        plained weight loss, no relief with
    [PMID: 17414902]                                                               as pain that lasts longer than 12
7. van Poppel MN,                       bed rest, pain lasting more than 1
    Koes BW, van der                                                               weeks. It is often progressive, and
    Ploeg T, et al. Lum-                month, and increased age.
    bar supports and                                                               identifying a specific cause is often
    education for the
    prevention of low                   Osteomyelitis should be considered         difficult. People with low back pain
    back pain in indus-
    try: a randomized
                                        if there is a history of intravenous       usually have at least 1 episode of
    controlled trial.                   drug use, urinary tract infection, or      recurrence and can develop “acute-
    JAMA. 1998;
    279:1789-94.                        fever. Increased age, white race,          on-chronic” symptoms.
    [PMID: 9628709]
8. Jellema P, van Tulder
                                        trauma, or prolonged corticosteroid
    MW, van Poppel MN,                  use are associated with compression        Is there a role for standardized
    et al. Lumbar sup-
    ports for prevention                fractures.                                 low back pain assessment
    and treatment of
    low back pain: a sys-
                                                                                   instruments in the evaluation of
                                        Patients with at least 4 of the
    tematic review                                                                 patients with low back pain?
    within the frame-                   following characteristics require
    work of the
                                        further evaluation for ankylosing          Quantitative scales that gauge
    Cochrane Back
    Review Group.                       spondylitis: morning stiffness,            pain and function provide objective
    Spine. 2001;26:377-
    86. [PMID: 11224885]                decreased discomfort with exercise,        measures for judging response to
9. Roelofs PD, Bierma-
    Zeinstra SM, van                    onset of back pain before age 40,          therapy. Questions addressing pain,
    Poppel MN, et al.                   slow onset of symptoms, and pain           back-specific function, general
    Lumbar supports to
    prevent recurrent                   persisting for more than 3 months.         health status, work disability,
    low back pain
    among home care
                                        However, because of the low preva-         psychological status, and patient
    workers: a random-                  lence of ankylosing spondylitis, the       satisfaction can be used to assess
    ized trial. Ann Intern
    Med. 2007;147:685-                  positive predictive value of any of        the extent of work disability as a
    92. [PMID: 18025444]
10. Deyo RA, Rainville J,
                                        these characteristics is still very low.   result of low back pain. Commonly
    Kent DL. What can
    the history and                     The absence of any of these worri-         used quantitative measures include
    physical examina-
    tion tell us about                  some features is highly sensitive but      the Roland–Morris modification
    low back pain?
    JAMA. 1992;268:760-                 not very specific for excluding            of the Sickness Impact Profile and
    5. [PMID: 1386391]                  patients with systemic illness. The        the Oswestry Disability Question-
11. Fairbank JC, Couper
    J, Davies JB, et al.                presence of these features may indi-       naire (11, 12). Although a meaning-
    The Oswestry low
    back pain disability
                                        cate the need for further evaluation.      ful change is not precisely defined,
    questionnaire. Phys-
    iotherapy. 1980;
                                                                                   a 2- to 3-point change on these
                                        Is the classification of low back
    66:271-3. [PMID:                                                               instruments is a commonly pro-
    6450426]                            pain by duration of symptoms
12. Roland M, Morris R.
                                        clinically useful?                         posed threshold (13, 14). These
    A study of the natu-
    ral history of back                 Classifying patients according to          quantitative measures have been
    pain. Part I: develop-
    ment of a reliable                  duration of low back pain (acute,          validated and are often used in
    and sensitive meas-
    ure of disability in                subacute, or chronic) is useful            research settings, but there are no
    low-back pain.                      because evidence does suggest              data that their use in clinical
    Spine. 1983;8:141-4.
    [PMID: 6222486]                     different effectiveness of some            settings improves patient outcomes.



© 2008 American College of Physicians   ITC5-4             In the Clinic           Annals of Internal Medicine   6 May 2008
What factors should lead                       What psychosocial issues are
                                                                                              Physical Examination Maneuvers
clinicians to suspect nerve root               important for clinicians to
                                                                                              that Suggest Herniated Disk
involvement?                                   consider in evaluating patients
                                               with low back pain?                            Straight-leg–raising test:
When patients present with back                                                                 Passive lifting of the affected leg
and leg pain, nerve root involve-              An important factor predicting the               by the examiner to an angle less
                                               course of low back pain is the                   than 60 degrees reproduces pain
ment must be considered. Nerve
                                               presence of psychosocial distress.               radiating distal to the knee.
root involvement can cause neuro-              Psychosocial distress is more                  Crossed straight-leg–raising test:
logic compromise at the level of the           common in patients with chronic                  Passive lifting of the unaffected leg
nerve root (common causes include              low back pain, and attention to this             by the examiner reproduces pain in
                                                                                                the affected (opposite) leg.
lumbar disk herniation in patients             distress may be beneficial to recov-
under age 50 years and spinal                  ery. Clinicians should consider the
stenosis in older patients) or the             following factors associated with
upper motor neuron (causes include             poor outcomes in patients with low
tumor or central-disk herniation).             back pain: job dissatisfaction,
                                               depression, substance abuse, and
When upper motor neurons are                   desire for disability compensation.
involved, urgent specialist consulta-          A cross-sectional study of workers in the
tion is required (10). Signs and               general population concluded that such
symptoms that suggest upper                    individual psychological factors as distress
motor neuron involvement include               and such work place factors as work load
bowel or bladder dysfunction,                  were highly related to the development of
                                                                                                                   13. Childs JD, Piva SR,
                                               back pain (15).                                                         Fritz JM. Responsive-
diminished perineal sensation,                                                                                         ness of the numeric
sciatica, sensory motor deficits, and          A cohort study of patients presenting to                                pain rating scale in
                                                                                                                       patients with low
severe or progressive motor deficits.          primary care providers with first-onset low                             back pain. Spine.
                                                                                                                       2005;30:1331-4.
                                               back pain found that psychological factors                              [PMID: 15928561]
Patients with leg pain that is worse           were strongly associated with persisting                            14. Ostelo RW, de Vet
                                               symptoms at 3 months (16).                                              HC. Clinically impor-
than back pain, a positive straight-                                                                                   tant outcomes in
                                                                                                                       low back pain. Best
leg–raising test, and unilateral               When should clinicians consider                                         Pract Res Clin
                                                                                                                       Rheumatol. 2005;
neurologic symptoms in the foot                imaging studies for patients with                                       19:593-607.
are very likely to have a herniated            low back pain?                                                          [PMID: 15949778]
                                                                                                                   15. Linton SJ. Do psy-
disk with nerve root compression as            Radiographic examinations are usu-                                      chological factors
                                                                                                                       increase the risk for
the source. The most common sites              ally of limited use in patients with                                    back pain in the
for lumbar disk herniation are at              low back pain unless the history or                                     general population
                                                                                                                       in both a cross-sec-
L4–5 or L5–S1. Pain that radiates              physical examination suggests a                                         tional and prospec-
                                                                                                                       tive analysis? Eur J
from the back through the buttocks             specific underlying cause. X-ray                                        Pain. 2005;9:355-61.
                                               findings correlate poorly with low                                      [PMID: 15979015]
to the legs (sciatica) is common,                                                                                  16. Grotle M, Brox JI,
                                               back symptoms (17). Spinal imag-                                        Veierød MB, et al.
and the more distal the pain radia-            ing studies in asymptomatic indi-                                       Clinical course and
                                                                                                                       prognostic factors in
tion, the more specific the symptom            viduals commonly reveal anatomical                                      acute low back pain:
is for nerve root involvement.                 findings, such as bulging or herni-
                                                                                                                       patients consulting
                                                                                                                       primary care for the
Other common symptoms of disk                  ated disks, spinal stenosis, annular                                    first time. Spine.
                                                                                                                       2005;30:976-82.
herniation include weakness of the             tears, and disk degeneration, which                                     [PMID: 15834343]
                                                                                                                   17. Bigos SJ. Acute Low
ankle and great toe dorsiflexors,              may not be clinically relevant and                                      Back Problems in
loss of ankle reflex, and sensory loss         can reduce the specificity of imag-                                     Adults. Clinical Prac-
                                                                                                                       tice Guideline no. 14.
in the feet.                                   ing tests (18). Thus, the demonstra-                                    Rockville, MD: U.S.
                                                                                                                       Department of
                                               tion of an anatomical abnormality                                       Health and Human
Symptoms of vascular claudication              should not automatically lead the                                       Services; 1994;(14):iii-
                                                                                                                       iv, 1-25. AHCPR pub-
can be difficult to distinguish from           clinician to assume that it is the                                      lication no. 95-0642

spinal stenosis, and clinicians                cause of the pain.                                                      [PMID: 7987418]
                                                                                                                   18. Jarvik JG, Deyo RA.
                                                                                                                       Diagnostic evalua-
should consider vascular disease in            Imaging is important, however, for                                      tion of low back
                                                                                                                       pain with emphasis
patients with risk factors for cardio-         detecting some causes of low back                                       on imaging. Ann
vascular disease before attributing            pain. The American College of Radi-                                     Intern Med. 2002;
                                                                                                                       137:586-97. [PMID:
symptoms to spinal stenosis.                   ology has developed appropriateness                                     12353946]




6 May 2008       Annals of Internal Medicine         In the Clinic                  ITC5-5      © 2008 American College of Physicians
                                                   criteria for radiographic procedures                      In summary, imaging is most useful
Imaging is most useful                             in the evaluation of patients with low                    when the pretest probability of
when the pretest probability                       back pain, where were last updated                        underlying serious disease requiring
                                                   in 2005 (Table 2) (19). These crite-                      surgical intervention is high. There
of underlying serious                              ria are meant to guide clinicians’                        is no consensus on when a negative
disease requiring surgical                         decision-making depending on                              result on plain radiographs should
                                                   careful consideration of each                             be followed by an advanced imaging
intervention is high.                              patient’s clinical circumstances.                         study or when the physician should
                                                                                                             go directly to an advanced study. A
                                                   A 2007 guideline developed by the
                                                                                                             negative plain film does not defini-
                                                   American College of Physicians
                                                                                                             tively exclude cancer or infection
                                                   and the American Pain Society
                                                                                                             in someone at high risk for these
                                                   recommends that clinicians not
                                                                                                             conditions. For such persons, early
                                                   routinely obtain imaging or other
                                                                                                             advanced imaging may be appropri-
                                                   diagnostic tests in patients with
                                                                                                             ate. Of note, patients with low back
                                                   nonspecific low back pain; that
                                                   clinicians perform diagnostic imag-                       pain often expect radiographic
                                                   ing and testing for patients with                         procedures.
                                                   low back pain when severe or pro-                         An RCT of routine radiography for patients
                                                   gressive neurologic deficits are                          with low back pain of at least 6 weeks in
                                                   present or when serious underlying                        duration reported more patient satisfaction
                                                   conditions are suspected; and that                        with their health care but worse pain and
                                                   they evaluate patients with persist-                      function scores (21).
                                                   ent low back pain and signs or
                                                   symptoms of radiculopathy or                              Under what circumstances should
                                                   spinal stenosis with magnetic reso-                       clinicians consider
                                                   nance imaging (preferred) or com-                         electromyography and other
                                                   puted tomography only if they are                         laboratory tests?
                                                   potential candidates for surgery or                       Clinicians should reserve electro-
                                                   epidural steroid injection (for                           myography and nerve conduction
                                                   suspected radiculopathy). The                             tests for patients in whom there is
                                                   guideline developers rated these                          diagnostic uncertainty about the
                                                   recommendations as strong and                             relationship of leg symptoms to
                                                   based on moderate-quality                                 anatomical findings on advanced
                                                   evidence (20).                                            imaging. Electrophysiologic tests



 Table 2. American College of Radiology Appropriateness Criteria for Lumbar Spine Radiographic Procedures in Patients with
 Low Back Pain*
 Radiographic Procedure                                                          Clinical Scenario
                                   Uncomplicated      Low-Velocity         Suspicion of           Radiculopathy     Past Lumbar        Cauda Equina
                                       LBP               Trauma,            Cancer or                                 Surgery            Syndrome
                                                      Osteoporosis,      Immunosupression
                                                      or age >70 y
 X-ray                                    2                 6                     5                      3                5                  3
 CT without contrast                      2                 6                     4                      5                6                  4†
 MRI without contrast                     2                 8                     8                      8                6                  9
 MRI with and without contrast            2                 3                     7                      5                8                  8
 Nuclear bone scan, targeted              2                 4                     5                      2                5                  2
 X-ray myelography                        2                 1                     2                      2                2                  2
 CT myelography                           2                 1                     2                      5                5                  6

 * How to use this table: If you are considering radiologic procedures for a patient with one of the clinical scenarios displayed in the table, choose the test
 or tests with the highest numeric appropriateness rating. If all tests have low appropriateness ratings, consider whether a radiologic procedure is likely
 to inform decision-making before proceeding with testing. Rating scale: 1 = least appropriate; 9 = most appropriate. CT = computed tomography;
 LBP = low back pain; MRI = magnetic resonance imaging.
 † With and without contrast.




© 2008 American College of Physicians              ITC5-6                   In the Clinic                    Annals of Internal Medicine            6 May 2008
can assess suspected myelopathy,                muscles until a patient has signifi-
radiculopathy, neuropathy, and                  cant limb symptoms for more than
myopathy. With radiculopathy or                 3 to 4 weeks, so testing should not
neuropathy, electromyography                    be done in patients with a duration
results might be unreliable in limb             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. Clinicians should classify low back pain
  as acute, subacute, or chronic because 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 sys-
  temic illness, fracture, cord compression, or spinal stenosis or if surgery is being
  considered.

                                                       CLINICAL BOTTOM LINE                                    19. ACR Appropriate-
                                                                                                                   ness Criteria. Reston,
                                                                                                                   VA: American Col-
                                                                                                                   lege of Radiology;
                                                                                                                   2005. Accessed at

                                                                                           Treatment               www.acr.org/Sec-
                                                                                                                   ondaryMainMenu-
                                                                                                                   Categories/quality_
                                                                                                                   safety/app_criteria
                                                                                                                   .aspx on 17 March
What are reasonable goals for                   What psychosocial factors                                          2008.
                                                                                                               20. Chou R, Qaseem A,
clinicians and patients for                     influence recovery in patients                                     Snow V, et al. Clinical
                                                with low back pain?                                                Efficacy Assessment
treatment of low back pain?                                                                                        Subcommittee of
Most acute, nonspecific pain                    Psychosocial factors and emotional                                 the American Col-
                                                                                                                   lege of Physicians.
resolves over time without treat-               distress are stronger predictors of                                Diagnosis and treat-

ment. Controlling pain and main-                low back pain outcomes than either                                 ment of low back
                                                                                                                   pain: a joint clinical
taining function while symptoms                 physical examination findings or                                   practice guideline
                                                                                                                   from the American
                                                severity and duration of pain
diminish on their own is the goal                                                                                  College of Physicians
                                                (22–24). Assessment of psycho-                                     and the American
for most individuals with acute low                                                                                Pain Society. Ann
                                                social factors, such as depression,                                Intern Med. 2007;
back pain. Clinicians should inform             unemployment, job dissatisfaction,                                 147:478-91.
                                                                                                                   [PMID: 17909209]
patients that back pain is common,              somatization disorder, or psycho-                              21. Kendrick D, Fielding
that the spontaneous recovery rate              logical distress, identifies patients
                                                                                                                   K, Bentley E, et al.
                                                                                                                   Radiography of the
is more than 50% to 75% at 4                    who may have delayed recovery and                                  lumbar spine in pri-
                                                                                                                   mary care patients
weeks and more than 90% at 6                    could help target behavioral inter-                                with low back pain:
                                                                                                                   randomised con-
weeks, and that most people do                  ventions, such as intensive multi-                                 trolled trial. BMJ.
not need surgery even with herni-                                                                                  2001;322:400-5.
                                                disciplinary rehabilitation.                                       [PMID: 11179160]
ated disks.                                                                                                    22. Pengel LH, Herbert
                                                What should clinicians advise                                      RD, Maher CG, et al.
                                                                                                                   Acute low back pain:
Subacute or chronic low back pain               patients regarding level of activity                               systematic review of
                                                                                                                   its prognosis. BMJ.
can be difficult to treat, and                  and exercise?                                                      2003;327:323.
exacerbations can recur over time.              A wealth of evidence suggests that                                 [PMID: 12907487]
                                                                                                               23. Fayad F, Lefevre-
Patients should understand that the             prolonged bed rest or inactivity is                                Colau MM,
                                                                                                                   Poiraudeau S, et al.
goal of therapy is to maintain func-            associated with worse outcomes for                                 [Chronicity, recur-

tion and manage psychosocial                    patients with acute, subacute, or                                  rence, and return to
                                                                                                                   work in low back
                                                chronic low back pain. Clinicians                                  pain: common prog-
distress, even if it is not possible to                                                                            nostic factors]. Ann
                                                should encourage patients to main-                                 Readapt Med Phys.
achieve complete resolution of pain.
                                                tain activity levels as near to normal                             2004;47:179-89.
The patient should be encouraged                as possible but advise against back-
                                                                                                                   [PMID: 15130717]
                                                                                                               24. Pincus T, Burton AK,
to take personal responsibility for             specific exercises while in acute                                  Vogel S, et al. A sys-
                                                                                                                   tematic review of
the continued management and                    pain. Although work might need to                                  psychological factors
                                                                                                                   as predictors of
prevention of further exacerbations             be modified on a short-term basis                                  chronicity/disability
and chronicity. Functional outcome              to accommodate patient recovery,                                   in prospective
                                                                                                                   cohorts of low back
depends more on patient behavior                most patients with nonspecific                                     pain. Spine. 2002;
                                                                                                                   27:E109-20. [PMID:
than on medical treatments.                     occupational low back pain can                                     11880847]




6 May 2008        Annals of Internal Medicine        In the Clinic                ITC5-7      © 2008 American College of Physicians
                                        return to work quickly. Lacking any                   that exercise offers slight benefits in pain
                                        warning signs of serious underlying                   and function in adults with chronic low
25. Malmivaara A, Häkki-                pathologic conditions, clinicians                     back pain, especially in health care rather
    nen U, Aro T, et al.                                                                      than occupational settings. In patients
    The treatment of                    should encourage patients to mini-
    acute low back
                                        mize bed rest, to be as active as                     with subacute pain, some evidence sup-
    pain—bed rest,                                                                            ported the effectiveness of graded exercise
    exercises, or ordinary              possible, and to return to work as
    activity? N Engl J                                                                        programs in improving work absenteeism,
    Med. 1995;332:351-                  soon as possible even if not entirely                 but the evidence was inconclusive for other
    5. [PMID: 7823996]
26. Hagen KB, Jamtvedt
                                        pain-free.                                            outcomes. For patients with acute low
    G, Hilde G, et al. The                                                                    back pain, exercise therapy was as effective
    updated cochrane                    A randomized trial that enrolled 186
    review of bed rest                                                                        as no therapy or other conservative treat-
    for low back pain                   employees of the city of Helsinki, Finland,
                                                                                              ments (28).
    and sciatica. Spine.                who presented to an occupational health
    2005;30:542-6.
    [PMID: 15738787]                    center with acute, nonspecific low back               A review of 43 trials that included 72 exer-
27. Liddle SD, Baxter                   pain found that patients assigned to con-             cise treatment groups and 31 comparison
    GD, Gracey JH. Exer-
    cise and chronic low                tinue usual activities had better recovery at         groups found that exercise therapy deliv-
    back pain: what                     3 and 12 weeks than those assigned to bed             ered under supervision and consisting of
    works? Pain.
    2004;107:176-90.                    rest for 2 days or back-mobilizing exercises.         individually tailored programs that include
    [PMID: 14715404]                    Recovery was slowest among patients                   stretching or strengthening may improve
28. Hayden JA, van Tul-
    der MW, Tomlinson                   assigned to bed rest (25).                            pain and function for patients with chronic,
    G. Systematic
    review: strategies for                                                                    nonspecific low back pain. Available trials
                                        A 2005 systematic review of RCTs investi-
    using exercise ther-                                                                      were heterogeneous and of variable qual-
    apy to improve out-                 gating bed rest for patients with acute low
    comes in chronic                                                                          ity, so the authors were unable to make
                                        back pain concluded that people with
    low back pain. Ann                                                                        definitive conclusions about the relation-
    Intern Med. 2005;                   low back pain without sciatica who receive
    142:776-85. [PMID:                                                                        ship of outcomes with patient characteris-
                                        advice for bed rest have more pain and
    15867410]                                                                                 tics or exercise type (29).
29. Hayden JA, van Tul-                 worse functional recovery than those
    der MW, Malmivaara                  advised to continue normal activities. Pain
    AV, et al. Meta-analy-                                                                    An RCT compared 12-week sessions of
    sis: exercise therapy               and functional outcomes were similar for              yoga, conventional exercise, or a self-care
    for nonspecific low                 patients with sciatica whether they foll-
    back pain. Ann                                                                            book in 101 adults with chronic low back
    Intern Med. 2005;                   owed bed rest or remained active (26).                pain. Patients in the yoga group had the
    142:765-75. [PMID:
    15867409]                                                                                 best outcomes with respect to pain and
                                        Another systematic review of 39 random-
30. Sherman KJ, Cherkin                                                                       function, followed by exercise then self-
    DC, Erro J, et al.                  ized trials that involved 7347 patients with
    Comparing yoga,                                                                           care (30).
    exercise, and a self-               acute, subacute, or chronic symptoms
    care book for                       concluded that advice to stay active was              What other physical interventions
    chronic low back
    pain: a randomized,                 sufficient for acute low back pain. Advice            are effective in the treatment of
    controlled trial. Ann               delivered as part of an educational pro-
    Intern Med. 2005;                                                                         low back pain?
    143:849-56. [PMID:                  gram (“back school”) seemed effective for
    16365466]                           patients with subacute symptoms, but the              Physical interventions for treatment
31. van Tulder MW,
                                        quality of the evidence for subacute low              of low back pain include physical
    Koes BW, Bouter LM.
    Conservative treat-                 back pain was limited and of poor quality.            therapy and complementary–
    ment of acute and
    chronic nonspecific                 For chronic low back pain, there is strong            alternative medicine approaches,
    low back pain. A sys-               evidence to support advice to remain                  such as spinal manipulation and
    tematic review of
    randomized con-                     active in addition to specific advice about           massage. There is limited evidence
    trolled trials of the               exercise and self-management (27).                    that physical treatments help to
    most common inter-
    ventions. Spine.                                                                          prevent recurrent back pain, and
    1997;22:2128-56.                    Various back-specific exercise pro-                   their use is associated with
    [PMID: 9322325]
32. Bronfort G, Haas M,                 grams have been advocated begin-                      increased cost. Nevertheless, physi-
    Evans RL, et al. Effi-              ning when acute symptoms subside,                     cal treatments may be helpful in
    cacy of spinal
    manipulation and                    but there is little evidence to support               improving function and reducing
    mobilization for low
    back pain and neck
                                        any specific exercise therapy. Clini-                 pain in symptomatic acute and sub-
    pain: a systematic                  cians should advise patients that                     acute low back pain (31–33). Clini-
    review and best evi-
    dence synthesis.                    attainment and maintenance of                         cians should consider physical
    Spine J. 2004;4:335-
    56. [PMID: 15125860]
                                        general physical fitness may help                     interventions for patients with
33. Assendelft WJ, Mor-                 to prevent recurrences of low                         acute symptoms that persist after 1
    ton SC, Yu EI, et al.
    Spinal manipulative                 back pain.                                            to 2 weeks. It is possible that pre-
    therapy for low back
    pain. A meta-analy-                 A meta-analysis of 61 RCTs that included              scribed physical therapy can help
    sis of effectiveness
    relative to other                   6390 patients with acute (11 trials), suba-           reduce disability by encouraging
    therapies. Ann Intern               cute (6 trials), chronic (43 trials), or uncertain-   patients to be active in a safe,
    Med. 2003;138:871-
    81. [PMID: 12779297]                duration (1 trial) low back pain concluded            supervised setting.


© 2008 American College of Physicians   ITC5-8                  In the Clinic                 Annals of Internal Medicine      6 May 2008
A 2007 systematic review of nonpharma-            Although opiates are commonly
cologic therapies for acute and chronic           prescribed for acute, subacute, and
low back pain considered the benefits and         chronic low back pain, they have
harms of acupuncture, back schools, psy-
                                                  not been shown to be more effec-
chological therapies, exercise therapy,                                                                            34. Chou R, Huffman LH.
functional restoration, interdisciplinary
                                                  tive than acetaminophen or                                           American Pain Soci-

therapy, massage, physical therapies              NSAIDs and are associated with                                       ety. Nonpharmaco-
                                                                                                                       logic therapies for
(inferential therapy, low-level laser therapy,    more side effects, including the                                     acute and chronic
                                                                                                                       low back pain: a
lumbar supports, short-wave diathermy,            potential for addiction (37, 39).                                    review of the evi-
superficial heat, traction, transcutaneous                                                                             dence for an Ameri-
                                                                                                                       can Pain Society/
electrical nerve stimulation, and ultra-          A systematic review of studies of opioids for                        American College of
sonography), spinal manipulation, and             the treatment of chronic back pain in non-                           Physicians clinical
                                                                                                                       practice guideline.
yoga. According to these authors, there is        pregnant adults found that opioid pre-                               Ann Intern Med.
good evidence of moderate efficacy in             scription rates in 11 studies varied widely                          2007; 147:492-504.
                                                                                                                       [PMID: 17909210]
chronic or subacute low back pain for cog-        (3% to 66%). In 4 short-term, randomized                         35. Schnitzer TJ, Ferraro
nitive behavioral therapy, exercise, spinal       trials that compared opioids with placebo                            A, Hunsche E, et al. A
                                                                                                                       comprehensive
manipulation, and interdisciplinary reha-         or nonopioid analgesics, opioids did not                             review of clinical tri-
bilitation. For acute low back pain, the only     provide better pain relief. In poor-quality,                         als on the efficacy
                                                                                                                       and safety of drugs
therapy with good evidence of efficacy was        heterogeneous studies, the prevalence of                             for the treatment of
superficial heat (34).                            current substance abuse disorders in                                 low back pain. J Pain
                                                                                                                       Symptom Manage.
                                                  patients taking long-term opioids for back                           2004;28:72-95.
When should drug therapies be                     pain was as high as 43%. Aberrant med-                               [PMID: 15223086]
                                                                                                                   36. van Tulder MW,
considered for the treatment of                   ication-taking behaviors varied from 5% to                           Scholten RJ, Koes
low back pain and which drugs                     24% (40).                                                            BW, et al. Nons-
                                                                                                                       teroidal anti-inflam-
are effective?                                                                                                         matory drugs for
                                                                                                                       low back pain: a sys-
Various drug therapies are used for               The role of antidepressants in                                       tematic review
low back pain (Table 3). Evidence                 treating chronic low back pain in                                    within the frame-
                                                                                                                       work of the
is insufficient to identify one med-              patients without depression is                                       Cochrane Collabora-
                                                                                                                       tion Back Review
ication as offering a clear overall               uncertain. Antidepressants that                                      Group. Spine.
advantage because of complex                      inhibit norepinephrine reuptake                                      2000;25:2501-13.
                                                                                                                       [PMID: 11013503]
trade-offs between benefits and                   (for example, tricyclic and tetra-                               37. Chou R, Huffman LH.
harms, but acetaminophen or non-                  cyclic antidepressants) may improve                                  American Pain Soci-
                                                                                                                       ety. Medications for
steroidal anti-inflammatory drugs                 symptoms in patients with chronic                                    acute and chronic
                                                                                                                       low back pain: a
(NSAIDs) should be used as                        low back pain, but antidepressants                                   review of the evi-
first-line drug therapy. The latter               lacking inhibition of norepineph-                                    dence for an Ameri-
                                                                                                                       can Pain Society/
have been shown to reduce low                     rine reuptake (for example, selective                                American College of
                                                                                                                       Physicians clinical
back pain compared with placebo                   serotonin reuptake inhibitors) have                                  practice guideline.
in systematic reviews of clinical                 not shown benefit in pain relief or                                  Ann Intern Med.
                                                                                                                       2007;147:505-14.
trials (35, 36). Although no random-              functional status (41). A review of                                  [PMID: 17909211]
ized trials of acetaminophen in low               9 RCTs found that tricyclic anti-
                                                                                                                   38. van Tulder MW,
                                                                                                                       Touray T, Furlan AD,
back pain are available, it is reason-                                                                                 et al. Cochrane Back
                                                  depressants were more effective                                      Review Group. Mus-
able to recommend it as appropri-
                                                  than placebo in reducing the sever-                                  cle relaxants for
ate therapy because of its known                                                                                       nonspecific low
                                                  ity of pain but not in improving                                     back pain: a system-
effectiveness and safety as an                                                                                         atic review within
                                                  functional status in chronic back                                    the framework of
analgesic.
                                                  pain (42). Antidepressants are not                                   the cochrane collab-
                                                                                                                       oration. Spine.
Short courses of muscle relaxants                 appropriate therapy for acute low                                    2003;28:1978-92.
                                                                                                                       [PMID: 12973146]
or opiates should be considered as                back pain.                                                       39. Deshpande A,
                                                                                                                       Furlan A, Mailis-
adjunctive therapy only when                                                                                           Gagnon A, et al. Opi-
needed for patients who do not                    Anticonvulsants, such as carbemaza-                                  oids for chronic low-

respond to first-line analgesics.                 pine or gabapentin, are sometimes                                    back pain. Cochrane
                                                                                                                       Database Syst Rev.
Muscle relaxants are more effective               used to treat chronic low back pain                                  2007:CD004959.
                                                                                                                       [PMID: 17636781]
than placebo in reducing pain and                 and have demonstrated efficacy in                                40. Martell BA, O’Connor
relieving symptoms. However,                      treating sciatica, but evidence is                                   PG, Kerns RD, et al.
                                                                                                                       Systematic review:
studies have not shown them to be                 lacking about their effectiveness in                                 opioid treatment for
                                                                                                                       chronic back pain:
more effective than NSAIDs, and                   the management of low back                                           prevalence, efficacy,
                                                  pain. Similarly, limited evidence                                    and association with
the muscle relaxants have more side                                                                                    addiction. Ann
effects, including adverse central                supports the use of tramadol. There                                  Intern Med. 2007;
                                                                                                                       146:116-27. [PMID:
nervous system effects (37, 38).                  is good evidence that systemic                                       17227935]




6 May 2008          Annals of Internal Medicine         In the Clinic                  ITC5-9     © 2008 American College of Physicians
 Table 3. Drug Treatment for Low Back Pain*
 Agent                               Mechanism of Action                   Side Effects                        Notes
 Acetaminophen, 500–1000 mg          Inhibition of prostaglandin           Antipyretic effect may mask       First-line analgesic therapy for low
 q 4–6 h (max daily dose 4 g)        synthesis in the CNS.                 fever. Hepatotoxicity at high     back pain. Avoid dosing >4 g/d,
                                                                           doses.                            especially in patients who use
                                                                                                             combination products. Inexpensive.
 Salicylates/NSAIDs,                 Decrease prostaglandins produced Gastrointestinal upset or              First-line analgesic therapy for low
   Aspirin, 500–1000 mg              by the arachidonic acid cascade in ulceration. Decreased renal blood back pain. Generic agents are
     q4–6h (max daily dose, 4 g)     response to noxious stimuli, thereby flow. Inhibition of platelet       inexpensive. No evidence that
   Ibuprofen, 400–800 mg, q 6–8 h decreasing the number of pain           aggregation. Antipyretic effect    COX-2–selective agents are more
     (max daily dose, 2400 mg)       impulses received by the CNS.        may mask fever in patients in whom effective than nonselective agents.
   Naproxen, 250–275 mg, q 8–12 h                                         fever would be an important        Anecdotal reports indicate benefit
     (max daily dose, 1250 mg)                                            clinical clue. COX-2–selective     in patients with bone-related pain.
                                                                          agents, and potentially NSAIDs,
                                                                          are associated with increased
                                                                          cardiovascular risk.
 Short-acting opioids,               Activate endogenous pain             Constipation, nausea, and sedation Short courses can be considered as
   Codeine (alone, or in acetamin- modulating systems and produce         are common side effects. Dry       adjunctive therapy only when needed
     ophen with codeine), 30–        analgesia by mimicking the action mouth, pruritus, mental confusion, for patients who do not respond to
     60 mg, q 4 h                    of endogenous opioid compounds. biliary spasm, urinary retention, first-line analgesics. Should not be
   Hydrocodone (alone or with                                             and myoclonus or respiratory       used long-term to treat chronic low
     acetaminophen, aspirin, or                                           depression (at high doses) are     back pain. Use equianalgesic
     ibuprofen), 5–10 mg, q 4 h                                           less-common side effects.          conversion to convert between
   Oxycodone (alone or with                                               Addiction potential.               different opioids and different routes.
     acetaminophen), 5–10 mg, q 4 h                                                                          Evidence lacking to show greater
                                                                                                             efficacy than first-line analgesic
                                                                                                             agents.
 Muscle relaxants,                   Reduce muscle spasm that may         CNS effects.                       Short courses can be used as adjunct-
   Baclofen, start with 5 mg PO      be contributing to symptoms.                                            ive therapy for patients who do not
     tid, increase slowly, max daily                                                                         respond to first-line analgesics. More
     dose 80 mg given in 3–4                                                                                 effective than placebo in reducing
     divided doses                                                                                           pain and relieving symptoms, but no
   Cyclobenzaprine, 5 mg tid                                                                                 more effective than first-line anal-
                                                                                                             gesics. Insufficient evidence to recom-
                                                                                                             mend one over another.
 Antidepressants,                    Affects pathways that lead to        Drowsiness, dry mouth,             Most evidence of effectiveness for
   Amitriptyline, doses of 10–150 neuropathic pain.                       dizziness, and constipation are    tricyclic antidepressants. Paroxetine
     mg/d PO can be used. Start                                           common. Trials not designed to     and trazadone did not show effect-
     at low doses and gradually                                           assess serious adverse events,     iveness. Insufficient evidence to judge
     increase as needed.                                                  such as overdose, suicidality,     relative effectiveness of tricyclic
                                                                          or arrhythmias.                    antidepressants versus selective sero-
                                                                                                             tonin reuptake inhibitors. Should not
                                                                                                             be used for acute low back pain.
                                                                                                             More effective than placebo for pain
                                                                                                             relief, but had no clear benefit on
                                                                                                             function.
 Anticonvulsants,                    Affect pathways that lead to         Sedation. Need to adjust           Limited evidence or effectiveness.
   Gabapentin, 300–900 mg tid        neuropathic pain.                    gabapentin dose on the basis of Can be expensive. Other, newer
     (start 300 mg, qhs, and titrate                                      renal function.                    agents being evaluated for use in
     quickly to max daily dose 3600                                                                          neuropathic pain include lamotrigine
     mg)                                                                                                     and topiramate.
   Carbamazepine, 200–600 mg bid
 Tramadol, 100 mg PO daily of the Centrally acting analgesic with a       Flushing, insomnia, orthostatic    More effective than placebo for
  extended-release tablets.          dual mechanism of action. It is a    hypotension, weakness, rigors,     short-term improvement in pain and
   Titrate in 100-mg increments      µ-opioid receptor agonist and a      and anorexia. Other side effects function. No trials available that
   every 5 days, if needed, up to    weak inhibitor of norepinephrine     include dizziness, vertigo, dry    compare tramadol with first-line
   max daily dose 300 mg. Con-       and serotonin reuptake.              mouth, gastrointestinal symptoms analgesics.
   comitant use of the extended-                                          diaphoresis, and CNS effects.
   release tablets with other
   tramadol products is not
   recommended.

 * bid = twice daily; CNS = central nervous system; COX-2 = cyclooxygenase 2; GI = gastrointestinal; NSAID = nonsteroidal anti-inflammatory drug;
   PO = orally; qd = once daily; qhs = every night; qid = four times daily; tid = three times daily.




© 2008 American College of Physicians           ITC5-10                 In the Clinic                   Annals of Internal Medicine         6 May 2008
corticosteroids do not improve                  A Cochrane review concluded that there is
chronic low back pain (37).                     some evidence that taking 240 mg of wil-
                                                low bark extract (salicin) per day provides
Are complementary–alternative                   short-term benefit for acute exacerbations
medicine therapies effective in                 of chronic, nonspecific low back pain (45).
the treatment of low back pain?
                                                A Cochrane review concluded that there is
Complementary–alternative medi-
                                                strong evidence that taking devil’s claw
cine therapies are commonly used
                                                containing 50 to 100 mg of harpagoside
for back pain. Among the interven-              per day was better than placebo for short-
tions that probably have some                   term improvement of acute or chronic
benefit are spinal manipulation,                back pain. There is no evidence to support
massage, and acupuncture. Some                  long-term use of devil’s claw, and safety
evidence supports the use of willow             has not been carefully studied (45).
bark extract, also known as salicin,                                                                           41. Staiger TO, Gaster B,
                                                                                                                   Sullivan MD, et al.
and devil’s claw. There is only                 What are the indications for                                       Systematic review of
limited research on homeopathic                 surgical intervention for low                                      antidepressants in
                                                                                                                   the treatment of
remedies, acupressure, and chon-                back pain?                                                         chronic low back
                                                                                                                   pain. Spine. 2003;
droitin sulfate. Treatments with                Most cases of low back pain do not                                 28:2540-5. [PMID:
unknown effectiveness include glu-              require surgery. However, patients                                 14624092]
                                                                                                               42. Salerno SM, Brown-
cosamine, balneotherapy or spa                  with suspected cord or cauda                                       ing R, Jackson JL.
                                                                                                                   The effect of anti-
therapy, and pilates. Alternative               equina compression or spinal infec-                                depressant treat-
therapies that are probably ineffec-            tion require urgent surgical referral                              ment on chronic
                                                                                                                   back pain: a meta-
tive include bipolar magnets, the               for possible decompression or de-                                  analysis. Arch Intern
                                                                                                                   Med. 2002;162:19-
Feldenkrais Method, and reflexology.            bridement to prevent loss of neuro-                                24. [PMID: 11784215]
                                                logic function. Nonurgent surgical                             43. Furlan AD, Brosseau
                                                                                                                   L, Imamura M, et al.
A Cochrane review of massage concluded          evaluation is also appropriate in                                  Massage for low-
that for subacute and early, chronic low        patients with worsening suspected
                                                                                                                   back pain: a system-
                                                                                                                   atic review within
back pain, moderate evidence suggests
                                                spinal stenosis, neurologic deficits,                              the framework of
that massage improves pain intensity                                                                               the Cochrane Col-
                                                or intractable pain that is resistant                              laboration Back
and pain quality, compared with sham                                                                               Review Group.
treatment. However, these effects were          to conservative treatment. Standard                                Spine. 2002;27:

similar to the effects for exercise and         surgery for spinal stenosis is poster-                             1896-910. [PMID:
                                                                                                                   12221356]
manipulation (43).                              ior decompressive laminectomy.                                 44. Furlan AD, van Tul-
                                                                                                                   der MW, Cherkin DC,
                                                                                                                   et al. Acupuncture
A systematic evidence review concluded          In a study that enrolled patients with                             and dry-needling for
                                                imaging-confirmed lumbar spinal stenosis                           low back pain.
that spinal manipulation is efficacious                                                                            Cochrane Database
compared with placebo in the short term         without spondylolisthesis and at least                             Syst Rev. 2005:
                                                                                                                   CD001351. [PMID:
for both acute and chronic low back pain,       12 weeks of symptoms in either a random-                           15674876]
but evidence does not support it as being       ized cohort (n = 289) or an observational                      45. Gagnier JJ, van
                                                                                                                    Tulder MW, Berman
more effective than other standard treat-       cohort (n = 365), 67% of patients randomly                         B, et al. Herbal medi-
ments (33).                                     assigned to surgery and 43% of those ran-                          cine for low back
                                                                                                                   pain: a Cochrane
                                                domly assigned to nonsurgical care had                             review. Spine.
The most recent Cochrane review of              surgery. In the randomized cohort, pain                            2007;32:82-92.
                                                                                                                   [PMID: 17202897]
acupuncture and dry-needling for low            but not functional outcomes were better                        46. Weinstein JN, Toste-
back pain included 35 RCTs. It noted            among those assigned to surgery than                               son TD, Lurie JD, et
                                                                                                                   al. SPORT Investiga-
evidence of pain relief and functional          among those assigned to nonsurgical                                tors. Surgical versus
improvement for chronic low back pain           care. In an analysis of both cohorts,                              nonsurgical therapy
                                                                                                                   for lumbar spinal
(immediately after therapy or on short-         patients who had surgery had better pain                           stenosis. N Engl J
term follow-up). Although the effects are       and functional outcomes at 3 months                                Med. 2008;358:794-
                                                                                                                   810. [PMID:
small, acupuncture used as an adjunct to        and at 2 years than those who did not                              18287602]
conventional therapies appears to relieve       have surgery (46).                                             47. Weinstein JN, Lurie
                                                                                                                   JD, Tosteson TD, et
pain and improve function in chronic low                                                                           al. Surgical vs non-
back pain more than the conventional            A prospective cohort study of patients with                        operative treatment
                                                                                                                   for lumbar disk
therapies alone. Only 3 of the studies          disk herniations treated at 13 U.S. spine                          herniation: the Spine
looked at acute low back pain, so the           centers found that patients with sciatica                          Patient Outcomes
                                                                                                                   Research Trial
authors were unable to draw conclusions         who chose operative intervention reported                          (SPORT) observa-
about efficacy of acupuncture for acute         greater improvements than those who                                tional cohort. JAMA.
                                                                                                                   2006;296:2451-9.
symptoms (44).                                  chose nonsurgical care (47).                                       [PMID: 17119141]




6 May 2008        Annals of Internal Medicine         In the Clinic               ITC5-11     © 2008 American College of Physicians
                                        Signs that urgent surgical interven-           back pain. The follow-up history
                                        tion may be necessary include                  should address patient response to
                                        bowel- or bladder-sphincter dys-               treatment, resolution of symptoms,
                                        function, particularly urinary reten-          and development of complications.
                                        tion or incontinence; diminished               It is important to assess the proba-
                                        perineal sensation, sciatica, or sen-          bility of a transition to the subacute
                                        sory motor deficits; and bilateral or          or chronic phase of back pain.
                                        unilateral motor deficits that are             Patients with acute back pain who
                                        severe and progressive. Signs that             are still moderately symptomatic at
                                        nonurgent surgical intervention                4 weeks are more likely to develop
                                        may be necessary include weakness              chronic symptoms than those who
                                        of the ankle and great toe dorsi-              report improved symptoms. If
                                        flexors, loss of ankle reflex, sensory         recovery is delayed, consider reeval-
                                        loss in the feet as manifestations of          uation for possible underlying
                                        the most common disk hernia-                   causes of back pain. Development
                                        tions, neurogenic claudication or              of symptoms of neurologic dys-
                                        “pseudoclaudication,” and leg pain             function or systemic disease should
                                        in addition to and more severe than            prompt additional evaluation.
                                        back pain.
                                                                                       Reinforcement of healthy lifestyle
                                        Although definitive evidence on                messages and patient education is
                                        the effectiveness of facet joint               an important part of management
                                        injections or nerve blocks is not
                                                                                       and prevention of recurrence. This
                                        available, such procedures are often
                                                                                       should include advice on treatment,
                                        done in patients who do not
                                                                                       prognosis, and recommendations
                                        respond to conservative care.
                                                                                       on general exercise and fitness. In
                                        How should clinicians follow                   particular, patients with low back
                                        patients with low back pain?                   pain should be encouraged to con-
                                        Follow-up, based on the suspected              tinue normal activities. For patients
                                        cause and course of disease in                 with chronic low back pain, the
                                        patients with low back pain, is an             addition of individually specific
                                        important component of treatment.              advice about the most appropriate
                                        On the basis of consensus, clini-              exercise and functional activities is
                                        cians should consider scheduling an            required. Regular follow-up contact
                                        office visit or a telephone call after         is also thought to reinforce efforts
                                        2 to 4 weeks of treatment to assess            and to develop ways to overcome
                                        progress in patients with acute low            barriers to regular physical activity.


                                          Treatment... Most acute nonspecific pain will resolve over days to weeks even
                                          without medical intervention. Clinicians should discourage bed rest and encourage
                                          all patients to maintain normal activities as much as possible. When symptoms
                                          persist, clinicians should consider nondrug, physical interventions, such as physical
                                          therapy, exercise, spinal manipulation, and massage. When analgesia is necessary,
                                          acetaminophen or NSAIDs should be used as first-line therapy. Short courses of
48. U.S. Preventive Ser-                  muscle relaxants or opiates should be used cautiously, and antidepressants may be
    vices Task Force. Pri-
    mary Care Interven-
                                          helpful in some patients with chronic symptoms. Psychosocial factors are strong
    tions to Prevent Low                  predictors of low back pain outcomes, but good evidence is lacking to support
    Back Pain: Brief Evi-
    dence Update.
                                          specific strategies for addressing them. Urgent surgical referral is indicated when
    Rockville, MD:                        infection, cancer, acute nerve compression, or the cauda equina syndrome is sus-
    Agency for Health-                    pected. Nonurgent surgical referral may be appropriate for patients with persistent
    care Research and
    Quality; 2004.                        back pain and signs of nonacute nerve compression or spinal stenosis.
    Accessed at www
    .ahrq.gov/clinic/
    3rduspstf/lowback/
    lowbackup.htm on                                                                            CLINICAL BOTTOM LINE
    17 March 2008.




© 2008 American College of Physicians   ITC5-12             In the Clinic              Annals of Internal Medicine     6 May 2008
                                                                                                    Practice
                                                                                                    Improvement
What do professional
organizations recommend
                                               Recommendations from the Joint Clinical Practice
regarding the management of
                                               Guideline from the American College of
patients with low back pain?                   Physicians and the American Pain Society (20):
In 2007, the American College
                                                   Recommendation 1: Clinicians should conduct a
of Physicians and American                     focused history and physical examination to help place
Pain Society released guidelines               patients with low back pain into 1 of 3 broad cate-
on the diagnosis and treatment                 gories: nonspecific low back pain, back pain potentially
of low back pain (20). The                     associated with radiculopathy or spinal stenosis, or back
guidelines included 7 key                      pain potentially associated with another specific spinal
                                               cause. The history should include assessment of psycho-
recommendations for guiding                    social risk factors, which predict risk for chronic dis-
diagnosis and treatment (see                   abling back pain (strong recommendation, moderate-
Box).                                          quality evidence).
                                                   Recommendation 2: Clinicians should not routinely
Several other low back pain                    obtain imaging or other diagnostic tests in patients
guidelines are available. In                   with nonspecific low back pain (strong recommenda-
1994, the Agency for Health                    tion, moderate-quality evidence).
Care Policy and Research pub-                      Recommendation 3: Clinicians should perform diag-
                                               nostic imaging and testing for patients with low back
lished practice guidelines for                 pain when severe or progressive neurologic deficits are
the assessment and treatment                   present or when serious underlying conditions are sus-
of acute low back problems in                  pected on the basis of history and physical examina-
adults (17). Topics covered                    tion (strong recommendation, moderate-quality
include the initial assessment,                evidence).
identification of signs that sug-                   Recommendation 4: Clinicians should evaluate
                                               patients with persistent low back pain and signs or
gest esrious underlying disease,               symptoms of radiculopathy or spinal stenosis with
management, and diagnostic                     magnetic resonance imaging (preferred) or computed
considerations. An update pub-                 tomography only if they are potential candidates for
lished in 2004 reported new                    surgery or epidural steroid injection (for suspected
evidence that back schools and                 radiculopathy) (strong recommendation, moderate-
                                               quality evidence).
back belts (lumbar supports)
                                                   Recommendation 5: Clinicians should provide
are ineffective in preventing                  patients with evidence-based information on low back
low back pain (48).                            pain with regard to their expected course, advise patients
                                               to remain active, and provide information about effec-
In 2005, the American College                  tive self-care options (strong recommendation,
of Sports Medicine released                    moderate-quality evidence).
guidelines for exercise testing                    Recommendation 6: For patients with low back pain,
and prescription in healthy per-               clinicians should consider the use of medications with
                                               proven benefits in conjunction with back care informa-
sons and individuals with dis-
                                               tion and self-care. Clinicians should assess severity of
ease, including guidance for                   baseline pain and functional deficits, potential benefits,
low back pain (49).                            risks, and relative lack of long-term efficacy and safety                      49. American College of
                                                                                                                                  Sports Medicine.
                                               data before initiating therapy (strong recommendation,                             ACSM’s Guidelines
A 2001 study of guidelines on                  moderate-quality evidence). For most patients, first-line                          for Exercise Testing
low back pain compared clinical                medication options are acetaminophen or NSAIDs.                                    and Prescription. 7th
                                                                                                                                  ed. Philadelphia:
guidelines from 11 countries                       Recommendation 7: For patients who do not                                      Lippincott Williams
                                               improve with self-care options, clinicians should consider                         & Wilkins; 2005.
and found that their content                                                                                                  50. Koes BW, van Tulder
                                               the addition of nonpharmacologic therapy with proven
was similar regarding diagnos-                 benefits—for acute low back pain, spinal manipulation;
                                                                                                                                  MW, Ostelo R, et al.
                                                                                                                                  Clinical guidelines
tic classification and the use of              for chronic or subacute low back pain, intensive inter-                            for the management
                                                                                                                                  of low back pain in
diagnostic and therapeutic                     disciplinary rehabilitation, exercise therapy, acupuncture,                        primary care: an
interventions (50) but noted                   massage therapy, spinal manipulation, yoga, cognitive-                             international com-
                                                                                                                                  parison. Spine.
discrepancies for recommenda-                  behavioral therapy, or progressive relaxation (weak                                2001;26:2504-13;
                                               recommendation, moderate-quality evidence).                                        discussion 2513-4.
tions regarding exercise                                                                                                          [PMID: 11707719]




6 May 2008       Annals of Internal Medicine              In the Clinic                  ITC5-13             © 2008 American College of Physicians
                                             therapy, spinal manipulation, mus-                           specific and relevant. Patient educa-
                                             cle relaxants, and patient informa-                          tion about low back pain should
                                             tion. In 2004, a systematic review                           inform patients that back pain is
                                             of 17 available guidelines for acute                         common, that the spontaneous
                                             low back pain concluded that the                             recovery rate is more than 50% to
                                             overall quality of the evidence
                                                                                                          75% at 4 weeks and more than 90%
                                             suppporting recommendations was
                                                                                                          at 6 months, and that most people
                                             disappointing (51), but the diag-
                                             nostic and therapeutic recommen-                             do not need surgery even with
                                             dations of the guidelines were                               herniated disks. Clinicians should
                                             largely similar.                                             advise patients to remain active and
                                                                                                          encourage weight control and
                                             What is the role of patient                                  should counsel patients about the
51. van Tulder MW, Tuut                      education in the management of                               role of psychosocial distress.
    M, Pennick V, et al.
    Quality of primary
                                             low back pain?
    care guidelines for                      Patient education is important in                            A randomized trial in 162 patients with
    acute low back pain.
    Spine. 2004;29:E357-                     the overall management of low                                back pain compared patients’ use of a
    62. [PMID: 15534397]
52. Burton AK, Waddell
                                             back pain, and all patients should                           booklet entitled “The Back Book” to more
    G, Tillotson KM, et al.                  receive information about the treat-                         traditional educational materials. Patients
    Information and
    advice to patients                       ment of back pain and its progno-                            who received the experimental booklet
    with back pain can                       sis. Information and advice given to
    have a positive
                                                                                                          showed an improvement in beliefs about
    effect. Spine.                           patients about the management of                             back pain and some improvement in dis-
    1999;24:2481-91.
    [PMID: 10626311]                         back pain needs to be individually                           ability measures (52).




                                                                                                                                 in the clinic
                                        PIER Modules
                                        www.pier.acponline.org
                                        Access the following PIER Modules: Low Back Pain, Back Pain (Complementary/
                                        Alternative Medicine). PIER modules provide evidence-based guidance for clinical
                                        decisions at the point-of-care.

                                        Patient Education Resources
      in the clinic                     www.annals.org/intheclinic/toolkit




      Tool Kit
                                        Access the patient information material that appears on the following page for
                                        duplication and distribution to patients.
                                        www.annals.org/cgi/content/summary/147/7/478
                                        Access a “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.

      Low Back Pain                     Clinical Guidelines
                                        American College of Physicians/American Pain Society
                                        www.annals.org/cgi/reprint/147/7/478.pdf
                                        Access the 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
                                        Access an audio summary of the American College of Physicians/American Pain Society
                                        guidelines.

                                        Agency for Healthcare Research and Quality
                                        www.ahrq.gov/clinic/3rduspstf/lowback/lowbackrs.htm
                                        Access the US Preventive services Task Force recommendations on primary care
                                        interventions to prevent low back pain in adults.

                                        American College of Radiology
                                        www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/
                                        ExpertPanelonNeurologicImaging/LowBackPainDoc7.aspx
                                        Access the American College of Radiology Appropriateness Criteria for radiographic
                                        procedures in patients with low back pain.




© 2008 American College of Physicians        ITC5-14                   In the Clinic                      Annals of Internal Medicine     6 May 2008
What you should know about                                                                 In the Clinic
                                                                           Annals of Internal Medicine
Low Back Pain                                                                                annals.org



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 to years.
If you have low back pain:                               The American College of Physicians and the
• Do not lift heavy things or do strenuous               American Pain Society published guidelines on
  activity                                               the diagnosis and treatment of low back pain in
                                                         December 2007. For a “Summary for Patients”
• Try to keep doing everyday activities and              of these guidelines go to www.annals.org/
  walking, even if it hurts                              cgi/reprint/147/7/478.pdf
• Do not stay in bed longer than 1 to 2 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, ibuprofen—read the labels)
• Heating pads or hot showers
• Massage
See a doctor if:
• Pain runs down the leg below the knee
• The leg, foot, groin, or rectal area feels numb
• Fever, nausea or vomiting, stomachache,




                                                                                                                       Patient Information
  weakness, or sweating occurs
• Bowel or bladder control is lost
• Pain was caused by an injury
• Pain is so bad you can’t move around
• Pain doesn’t seem to be getting better after 2
  to 3 weeks




                                                                      For More Information
                                                                                                    MedlinePlus
                                                                http://www.nlm.nih.gov/medlineplus/backpain.html
                                                                                   The Arthritis Foundation
                                                    http://ww2.arthritis.org/conditions/DiseaseCenter/back_pain.asp
                                                            National Institutes of Neurological Disorders and Stroke
                                                          http://www.ninds.nih.gov/disorders/backpain/backpain.htm
                                                               American Academy of Family Physicians
                                                            (information available in English and Spanish)
                                                           http://familydoctor.org/online/famdoces/home/common/
                                                                                            pain/treatment/117.html
   CME Questions

1. A 51-year-old woman with chronic low            and patellar and ankle reflexes are              Physical examination shows difficulty
   back pain has a 2-week history of moder-        symmetric.                                       moving; pulse rate is 92/min and blood
   ate low back pain radiating down her            Which of the following is the most               pressure is 150/92 mm Hg; body mass
   right leg to her right foot following a         appropriate next step in the management          index is 28. Left straight-leg raise causes
   paroxysm of sneezing. She has no leg            of this patient’s back pain?                     pain at 45 degrees, his great toe dorsi-
   weakness or numbness. She takes no pre-                                                          flexion is weak, and his ankle jerk is
   scription medications. Her medical history        A.   Cyclobenzaprine                           diminished. Anal wink is present, the
   is notable for a hysterectomy.                    B.   Psychological evaluation                  prostate gland is enlarged, and sphincter
                                                     C.   Epidural corticosteroid injection         tone is normal. No sensory level is
   Temperature is 36.9˚C (98.5˚F). The lum-
                                                     D.   Radiography of the lumbar spine           detectable. He says that he has never had
   bar paraspinal muscles are tender to pal-
                                                     E.   MRI of the lumbar spine                   pain like this before, and he asks for pain
   pation. A straight-leg–raising test is posi-
                                                                                                    pills and to be able to go lie down. Lum-
   tive on the right. Her perineal sensation
                                                                                                    bosacral spine films are normal and ery-
   and rectal sphincter tone are intact. She 3. A 67-year-old man undergoes urgent
                                                   evaluation for a 2-month history of low          throcyte sedimentation rate is 10 mm/h.
   has difficulty extending her right great
   toe against resistance, but lower-extrem-       back pain radiating down his right leg          In addition to analgesics and clinical
   ity strength, sensation, and reflexes are       that has worsened over the past 3 days,         follow-up, what is the best management?
   otherwise normal. Radiography of the            causing him walking difficulty due to leg         A. Lumbosacral traction therapy
   spine shows some degenerative changes           weakness. He has also been unable to
                                                                                                     B. Chiropractic adjustments
   but no disk narrowing or vertebral              urinate for the past 24 hours. His medical
                                                   history is notable for chronic obstructive
                                                                                                     C. Physical therapy back school and
   collapse.
                                                   pulmonary disease, diabetes mellitus,                 exercise program
   Which of the following is the most                                                                D. Referral to an orthopedic surgeon
                                                   prostate cancer, and hyperlipidemia.
   appropriate initial management of this                                                            E. Activity as tolerated
                                                   Medications include bronchodilator
   patient?
                                                   inhalers, insulin, leuprolide, simvastatin,
     A. Referral to orthopedic surgeon             and aspirin.                                 5. A 28-year-old man who underwent renal
     B. Bed rest for 7 days                                                                        transplantation 1 year ago is evaluated
                                                   He is in obvious discomfort. The tempera-       because of a 5-week history of back pain.
     C. MRI of the lumbar spine                    ture is normal, pulse rate is 88/min, and       Pain is present at all times, even at rest,
     D. NSAIDs                                     blood pressure is 148/72 mm Hg. He has          but is particularly severe with any jarring
     E. Back exercises                             severe lower-lumbar tenderness to palpa-        motion of the spine. The patient does not
                                                   tion, with no bony abnormalities. Lower-        have fever, lower extremity numbness,
2. A 45-year-old male warehouse worker is          extremity strength is 4/5 bilaterally, and      muscle weakness, or difficulty urinating.
   evaluated for a back injury he experi-          the straight-leg–raising test is positive on    He takes combination immunosuppressive
   enced 4 months ago when lifting a box;          the right. On rectal examination, there is      therapy.
   he has been bedridden intermittently            decreased rectal sphincter tone, dimin-
   since then. Today he is asking for a dis-                                                       Temperature is 37.1˚C (98.8˚F); other vital
                                                   ished sensation over the perineal region
   ability form to be completed. His back                                                          signs are also normal. Palpation of the
                                                   and buttocks, and prostate is asymmetric
   pain does not radiate and he has no                                                             spine reveals localized tenderness and
                                                   and hard.
   lower-extremity weakness; however, he                                                           muscle spasm at the upper lumbar spine.
                                                   Which of the following is the most              Neurologic examination is normal.
   reports that both legs are completely
                                                   appropriate diagnostic imaging evalua-
   numb. He takes over-the-counter NSAIDs                                                          A radiograph of the lumbar spine shows
                                                   tion for this patient?                          demineralization of the endplates and
   but no prescription medications. He has
   no history of injection drug use and is           A. CT of the lumbar spine                     loss of definition of the anterior aspect of
   otherwise healthy.                                B. MRI of the lumbar spine                    the bony L1–L2 margin. Tuberculin skin
                                                     C. Radiography of the lumbar spine            testing 7 mm of induration. A chest radio-
   Temperature is normal, pulse rate is
                                                     D. Positron emission tomography               graph is normal.
   74/min, and blood pressure is 126/82 mm
   Hg. The patient has exquisite diffuse lum-        E. Radionuclide bone scan                     Which of the following diagnostic studies
   bar and paraspinal tenderness to light                                                          should be done next?
   palpation, with no areas of erythema or      4. A 57-year-old man with a long history of          A. CT-guided needle biopsy of the
   warmth; his spinal range of motion is           intermittent back pain related to his work            spinal lesion
   decreased. Pressing downward on his             as a truck driver presents with severe
                                                                                                     B. CT scan of the chest
   head elicits lower back pain. He is able to     back pain radiating down his left leg
   passively extend his legs without pain          that began 2 days ago when he was                 C. MRI of the entire spine
   when sitting down, but has back pain            helping a friend move. He says that his           D. Serum protein electrophoresis and
   radiating down his right leg with a             left leg feels weak. He has to urinate 1              urine immunoelectrophoresis
   supine straight-leg–raising test.               or 2 times per night and has slight               E. Testicular ultrasonography and
   Lower-extremity motor strength is intact,       urinary hesitancy.                                    whole-body positron


        Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/
           to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.




   © 2008 American College of Physicians        ITC5-16               In the Clinic               Annals of Internal Medicine       6 May 2008

				
DOCUMENT INFO
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