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20120329_Apr2012-Guidelines-LowBackPain Acute acute_lbp Acute Low Back Pain acute_lbp Acute Low Back Pain Back Pain Back Pain back_pain_ff What Is Back Pain Back_Pain_French_FINAL Mal de dos Back_Pain_French_FINAL Mal de dos Backpain_July_2011 Chapter 2 Spine Low Back and Neck Pain Chronic low back pain KCE reports vol. 48 C Chronic Low Back Pain Diagnosis and classification of chronic low backpain disorders Maladaptive movement and motor control impairments as underlying mechanism Diagnosis and classification of chronic low backpain disorders Maladaptive movement and motor control impairments as underlying mechanism doc_22 Early management of persistent non-specific low back pain Effective Treatment of Chronic Low Back Pain in Humans Reverses Abnormal Brain Anatomy and Function Evidence-based Management of Acute Musculoskeletal Pain Evidence-informed management of chronic low back pain with opioid analgesics file Low Back Pain file Low Back Pain files_100729lowbackpain Healing_Back_Pain_The_Mind HEALING BACK PAIN in the clinic LBPGUIDELINESNov25 Low Back Pain (1) Low Back Pain BASIC EXERCISES FOR THE LOW BACK Low back pain early management of persistent non-specific low back pain Low Back Pain What is low back pain Low back pain low-back-pain-frazier Low Back Pain Rehabilitation Exercises Lumbar Supports for Prevention and Treatment of Low Back Pain Managing_acute_-_subacute_low_back_pain MPOC Acute Low Back Pain Acute Lower Back Pain National practice guidelines for physical therapy in patients with low back pain neckpain ﺍﻻﻧﺰﻻﻕ ﺍﻟﻐﻀﺮﻭﻓﻰ ﻭ ﺍﻻﻡ ﺍﻟﻈﻬﺮ New Zealand Acute Low Obesity and Low Back Pain (Derek Tobin; Tom Shaw Oswestry Low Back Pain Scale Please rate the severity of your pain by circling a number below Perceived disadvantages caused by low back pain Primary Care Interventions to Prevent Low Back Pain A Brief Evidence Update for the U.S. Preventive Services Task Force Radiography for low back pain a randomised controlled trial and observational study in prim
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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
