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Minimizing Lower Back Pain

The Critical Appraisal - Reading & Recommendations

(Last review: October 2011)

Low back pain is a common problem affecting about 50% of the population in any one year and affecting up to 80% at some time during their lives.(1-3) Poor physical conditioning, obesity, frequent heavy lifting, and specific occupations where lifting of heavy objects is common all predispose to the problem of low back strain. Studies have not found any specific exercises or preventive steps that can be taken to effectively reduce the risks of low back strain. There are some indications that being in good physical condition is helpful. Care in methods of lifting and not bending while lifting may be helpful. (4)

The Critical Appraisal - Is this Acute Low Back Pain Serious?

Over 90% of acute low back strains do not require tests or investigations and will improve after 4 or 5 days and completely clear up after two or three weeks without specific therapy. The most important treatment is to control pain and to continue with daily activities as much as possible. It has been found that returning to normal activities even while uncomfortable will shorten the length of the problem by several days and result in a better recovery.(5,7,8) During the acute phase use of acetaminophen, NSAIDS, tricyclics, muscle relaxants and heat are beneficial. If the problem continues past two weeks, there is some evidence supporting use of acupuncture, spinal manipulation and intensive physiotherapy.(6)

Signs (red flags) that suggest that an episode of low back pain requires assessment and tests include a previous history of a cancer, recent unexplained weight loss, back pain that gets worse when resting and recent trouble with bowel or bladder control. If the pain radiates from the back down the leg to the ankle or at least below the knee, assessment is advised. Persons that have pain, numbness, or weakness in either leg but especially both legs at the same time should seek medical attention immediately. Persons with AIDS or other disease that could suppress the immune system should be assessed for the possibility of infection in the spine. If there is a chance that infection entered the system from injecting street drugs then assessment is required.(6)

The Critical Appraisal - Recommendation

More than 90% of people with acute low back strain recover within three weeks without tests, x-rays, or other medical investigations. Recovery is assisted by returning to normal daily activities as quickly as possible, even if some activities are uncomfortable. Although walking may be initially uncomfortable, pain will often diminish with the distance walked. Symptomatic control of pain and reasonable use of heat applied to the back muscles when in spasm may also relieve symptoms.

There have been no specific therapies or exercises to follow during or after the episode of acute low back strain that have been demonstrated to be beneficial. There is no exercise or educational program that has been found clearly beneficial in preventing recurrences of acute low back strain.(7) If after six weeks from the onset of the acute low back strain, the symptoms have not completely resolved a further review by a physician is necessary.

Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.

The Critical Appraisal - Other Recommendations

The Agency for Health Care Policy and Research of the National Institute of Health in the United States has developed an excellent set of guidelines for the diagnosis and management of acute low back strain. Our recommendations and discussion are based on their recommendations. The US Preventive Services task force gives a "C" recommendation to the use of education or exercise programs designed to prevent acute low back strain.

The guidelines advisory committee has chosen Australian guidelines on managing low back pain as the best available in 2007(10) Since that time there have been no new guidelines. It appears that the advice given then still applies. We have check Canadian Task Force on the Periodic Health exam, The US Preventive Care Task Force, and N.I.C.E. in the UK with no new guidelines.(October 2011)

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Selected References

  1. Andersson GBJ. The epidemiology of spinal disorders. In: Frymoyer JW, ed. The Adult Spine: Principles and Practice. New York: Raven Press Ltd., 1991; 107-146.
  2. Cypress BK. Characteristics of physician visits for back symptoms: A national perspective. Am Public Health 1983; 73(4): 389-395.
  3. Kelsey JL, White AA. Epidemiology and impact of low back pain. Spine 1980;5(2): 133-142.
  4. Lahad A, Maiter AD, Berg AO, et al. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994; 272: 1286-1291.
  5. Nachemeson AL. Newest knowledge of low back pain. A critical look. Clin Orthop 1992; 279:8-20.
  6. Chou R, Huffman LH; American Pain Society; American College of Physicians Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.1: Ann Intern Med. 2007 Oct 2;147(7):478-91
  7. US preventative services task force 2007http://www.ahrq.gov/clinic/uspstf/uspsovar.htm.
  8. Hagen KB, Jamtvedt G, Hilde G, Winnem MF.The updated cochrane review of bed rest for low back pain and sciatica.Cochrane Database Syst Rev. 2005 Jan 25; 8
  9. Agency for Health Care Policy and Research, Depratment of Health and Human Services. Quick reference guide for clinicians. Acute low back problems in adults: Assessment and treatment. Washington D.C. Department of Health and Human Services, 1994. (publication no. 95-0643. 
  10. Australian Acute Musculoskeletal Pain Group. (2003). Evidence-based management of acute musculoskeletal pain. Acute low back pain: Chapter 4, pages 25-62. Process report: Chapter 9, pages 183-188. www.gacguidelines.ca
  11. Ann Intern Med. 2007 Oct 2;147(7):505-14.
    Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Chou R, Huffman LH; American Pain Society; American College of Physicians.
  12. Ann Intern Med. 2007 Oct 2;147(7):478-91.
    Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.
  13. Oregon Health & Science University, Portland, Oregon, USA.
    RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
    RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
    RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
    RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
    RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
    RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
    RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
    PMID: 17909209 [PubMed - indexed for MEDLINE]
  14. Ann Intern Med. 2007.
    Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
  15. Ann Intern Med. 2007
    Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
  16. Schmerz. 2001
    Relevance of nerve blocks in treating and diagnosing low back pain--is the quality decisive?
  17. Pain Physician. 2007
    Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines.
  18. PMID: 17636781 PubMed - indexed for MEDLINE
    AUTHORS' CONCLUSIONS: Despite concerns surrounding the use of opioids for long-term management of chronic LBP, there remain few high-quality trials assessing their efficacy. The trials in this review, although achieving high internal validity scores, were characterized by a lack of generalizability, inadequate description of study populations, poor intention-to treat analysis, and limited interpretation of functional improvement. Based on our results, the benefits of opioids in clinical practice for the long-term management of chronic LBP remains questionable. Therefore, further high-quality studies that more closely simulate clinical practice are needed to assess the usefulness, and potential risks, of opioids for individuals with chronic LBP.
  19. Cochrane Database Syst Rev. 2005
    Transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain.
  20. Cochrane Database Syst Rev. 2005
    NSAIDS or paracetamol, alone or combined with opioids, for cancer pain.
  21. Cochrane Database Syst Rev. 2003
    Muscle relaxants for non-specific low back pain.
  22. Cochrane Database Syst Rev. 2007 Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D.
  23. Opioids for chronic low-back pain.
  24. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004959.
    CONCLUSION: A short course of traditional acupuncture for persistent non-specific low back pain in primary care confers a modest health benefit for minor extra cost to the NHS compared with usual care. Acupuncture care for low back pain seems to be cost effective in the longer term.
    TRIAL REGISTRATION: ISRCTN80764175 [controlled-trials.com].
  25. BMJ. 2006 Sep 23;333(7569):611-2. Ratcliffe J, Thomas KJ, MacPherson H, Brazier J.
    A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis.
    CONCLUSIONS: The evidence base to support the common practice of superficial heat and cold for low back pain is limited, and there is a need for future higher-quality randomized controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and subacute low back pain, and that the addition of exercise further reduces pain and improves function. There is insufficient evidence to evaluate the effects of cold for low back pain and conflicting evidence for any differences between heat and cold for low back pain.
    PMID: 16641776 [PubMed - indexed for MEDLINE
  26. Spine. 2006 Apr 20;31(9):998-1006. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ.
    A Cochrane review of superficial heat or cold for low back pain.
  27. U.S. Preventive Services Task Force (USPSTF): June 2005
    Primary Care Interventions to Prevent Low Back Pain in Adults: Recommendation Statement
    • The USPSTF found no new good evidence for or against the use of back strengthening exercises or risk factor modification (e.g., increased physical activity, smoking cessation, reduced alcohol consumption) for the primary prevention of low back pain in adults. There is limited evidence that educational sessions in occupational settings (e.g., back schools) produce modest, short-term benefits in adults with recurrent or chronic low back pain but no evidence that such education prevents back pain in healthy persons or those at risk for back pain. Some interventions, such as mechanical supports, may increase the risk for low back pain. As a result, the USPSTF could not determine the balance between benefits and harms of the different interventions that may be used to prevent low back pain
    • Office of Disease Prevention and Health Promotion. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Washington, D.C.: Office of Disease Prevention and Health Promotion, 1996. The recommendation is also posted on the Web site of the National Guideline Clearinghouse at http://www.guideline.gov.
    • Krishnaraj R. Primary care interventions to prevent low back pain: a brief evidence update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, 2003. Accessed online March 28, 2005, at: http://www.ahrq.gov/clinic/uspstf/uspsback.htm.
  28. PMID. 15738787 [PubMed - indexed for MEDLINE]
    CONCLUSION: For people with acute low back pain, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active.
  29. PMID. 15674889 [PubMed - indexed for MEDLINE]
    • Combined respondent-cognitive therapy and progressive relaxation therapy are more effective than WLC on short-term pain relief. However, it is unknown whether these results sustain in the long term. No significant differences could be detected between behavioural treatment and exercise therapy. Whether clinicians should refer patients with CLBP to behavioural treatment programs or to active conservative treatment cannot be concluded from this review.
  30. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD002014. Ostelo RW, van Tulder MW, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ. Update of: Cochrane Database Syst Rev. 2000;(2):CD002014.
    • Behavioural treatment for chronic low-back pain.
    • Reviewers' Conclusions: There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain, and improve function and return-to-work status, in the short and intermediate-term, compared to exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodological quality and clinical relevance and evaluate the cost-effectiveness of back schools.
  31. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000261. Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW. Update of: Cochrane Database Syst Rev. 2000;(2):CD000261.
    • Back schools for non-specific low-back pain.
    • Reviewer's Conclusions: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.
  32. PMID: 14973958 [PubMed - indexed for MEDLINE]
  33. Cochrane Database Syst Rev. 2004;(1):CD000447. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG
    • Spinal manipulative therapy for low back pain.