[
Physical therapy stabilization exercises for lumbar spine and manual therapy have shown decrease in pain symptoms in patients. Manual therapy and stabilization effects have similar effects on low back pain which overweighs the effects of general exercises.
]
Physical management
Management of acute low back pain
Increasing general physical activity has been recommended, but no clear relationship to pain or disability has been found when used for the treatment of an acute episode of pain. For acute pain, low- to moderate-quality evidence supports walking. Aerobic exercises like progressive walking appears useful for subacute and acute low back pain, is strongly recommended for chronic low back pain, and is recommended after surgery. Directional exercises, which try to limit low back pain, are recommended in sub-acute, chronic and radicular
Radicular pain, or radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root ( radiculopathy) at its connection to the spinal column. A common form of radicul ...
low back pain. These exercises only work if they are limiting low back pain. Treatment according to McKenzie method
The McKenzie method (full name: McKenzie method of mechanical diagnosis and therapy (MDT)) is a technique primarily used in physical therapy. It was developed in the late 1950s by New Zealand physiotherapist Robin McKenzie (1931–2013). In 1981 ...
is somewhat effective for recurrent acute low back pain, but its benefit in the short term does not appear significant.[ There is tentative evidence to support the use of heat therapy for acute and sub-chronic low back pain but little evidence for the use of either heat or cold therapy in chronic pain.] Weak evidence suggests that back belts might decrease the number of missed workdays, but there is nothing to suggest that they help with the pain.[ Ultrasound and shock wave therapies do not appear effective and therefore are not recommended. Lumbar traction lacks effectiveness as an intervention for radicular low back pain. It is also unclear whether lumbar supports are an effective treatment intervention. Exercise programs that incorporate stretching only are not recommended for low back pain. Generic or non-specific stretching has also been found to not help with acute low back pain. ]Yoga
Yoga (; sa, योग, lit=yoke' or 'union ) is a group of physical, mental, and spiritual practices or disciplines which originated in ancient India and aim to control (yoke) and still the mind, recognizing a detached witness-conscio ...
and Tai chi are not recommended in case of acute or subacute low back pain, but are recommended in case of chronic back pain. Stretching, especially with limited range of motion, can impede future progression of treatment like limiting strength and limiting exercises.
Management of chronic low back pain
Exercise therapy is effective in decreasing pain and improving physical function, trunk muscle strength and the mental health for those with chronic low back pain. It also improves long-term function and appears to reduce recurrence rates for as long as six months after the completion of the program. The observed treatment effect for the exercise when compared to no treatment, usual care or placebo, improved pain (low‐certainty evidence), but improvements were small for functional limitations outcomes (moderate‐certainty evidence). There is no evidence that one particular type of exercise therapy is more effective than another, so the form of exercise used can be based on patient or practitioner preference, availability and cost. The Alexander technique appears useful for chronic back pain, and there is a very small evidence to support the use of yoga
Yoga (; sa, योग, lit=yoke' or 'union ) is a group of physical, mental, and spiritual practices or disciplines which originated in ancient India and aim to control (yoke) and still the mind, recognizing a detached witness-conscio ...
. If a person with chronic low back pain is motivated, it is recommended to use yoga and tai chi as a form of treatment, but this is not recommended to treat acute or subacute low back pain. Motor control exercise, which involves guided movement and use of normal muscles during simple tasks which then builds to more complex tasks, improves pain and function up to 20 weeks, but there was little difference compared to manual therapy and other forms of exercise. Motor control exercise accompanied by manual therapy also produces similar reductions in pain intensity when compared to general strength and condition exercise training, yet only the latter also improved muscle endurance and strength, whilst concurrently decreased self-reported disability. Aquatic therapy is recommended as an option in those with other preexisting conditions like extreme obesity
Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
, degenerative joint disease
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...
, or other conditions that limit progressive walking. Aquatic therapy is recommended for chronic and subacute low back pain in those with a preexisting condition. Aquatic therapy is not recommended for people that have no preexisting condition that limits their progressive walking. There is low-to-moderate quality evidence that supports pilates in low back pain for the reduction of pain and disability, however there is no conclusive evidence that pilates is better than any other form of exercise for low back pain.
Patients with chronic low back pain receiving multidisciplinary biopsychosocial rehabilitation (MBR) programs are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status of the patient compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs.
Peripheral nerve stimulation, a minimally-invasive procedure, may be useful in cases of chronic low back pain that do not respond to other measures, although the evidence supporting it is not conclusive, and it is not effective for pain that radiates into the leg. Evidence for the use of shoe insoles as a treatment is inconclusive. Transcutaneous electrical nerve stimulation (TENS) has not been found to be effective in chronic low back pain. There has been little research that supports the use of lumbar extension machines and thus they are not recommended.
Medications
The management of low back pain often includes medications for the duration that they are beneficial. With the first episode of low back pain the hope is a complete cure; however, if the problem becomes chronic, the goals may change to pain management and the recovery of as much function as possible. As pain medications are only somewhat effective, expectations regarding their benefit may differ from reality, and this can lead to decreased satisfaction.[
The medication typically recommended first are acetaminophen (paracetamol), NSAIDs (though not aspirin), or ]skeletal muscle relaxants
A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therap ...
and these are enough for most people.[ Benefits with NSAIDs; however, is often small.] High-quality reviews have found acetaminophen (paracetamol) to be no more effective than placebo at improving pain, quality of life, or function. NSAIDs are more effective for acute episodes than acetaminophen; however, they carry a greater risk of side effects, including kidney failure, stomach ulcers and possibly heart problems. Thus, NSAIDs are a second choice to acetaminophen, recommended only when the pain is not handled by the latter. NSAIDs are available in several different classes; there is no evidence to support the use of COX-2 inhibitors over any other class of NSAIDs with respect to benefits.[ With respect to safety naproxen may be best. Muscle relaxants may be beneficial.][
If the pain is still not managed adequately, short-term use of ]opioid
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioi ...
s such as morphine
Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies ('' Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. Ther ...
may be useful.[ These medications carry a risk of addiction, may have negative interactions with other drugs, and have a greater risk of side effects, including dizziness, nausea, and constipation.][ The effect of long-term use of opioids for lower back pain is unknown. Opioid treatment for chronic low back pain increases the risk for lifetime illicit drug use. Specialist groups advise against general long-term use of opioids for chronic low back pain.][ , the CDC has released a guideline for prescribed opioid use in the management of chronic pain.] It states that opioid use is not the preferred treatment when managing chronic pain due to the excessive risks involved. If prescribed, a person and their clinician should have a realistic plan to discontinue its use in the event that the risks outweigh the benefit.[
For older people with chronic pain, opioids may be used in those for whom NSAIDs present too great a risk, including those with diabetes, stomach or heart problems. They may also be useful for a select group of people with neuropathic pain.]
Antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects.[ Although the antiseizure drugs ]gabapentin
Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain. It is a first-line medication for the treatment of neuropathic pain caused by diab ...
, pregabalin, and topiramate are sometimes used for chronic low back pain evidence does not support a benefit. Systemic oral steroids have not been shown to be useful in low back pain.[ Facet joint injections and steroid injections into the discs have not been found to be effective in those with persistent, non-radiating pain; however, they may be considered for those with persistent sciatic pain.] Epidural corticosteroid injections provide a slight and questionable short-term improvement in those with sciatica but are of no long-term benefit. There are also concerns of potential side effects.
A study with 80 patients found magnesium
Magnesium is a chemical element with the symbol Mg and atomic number 12. It is a shiny gray metal having a low density, low melting point and high chemical reactivity. Like the other alkaline earth metals (group 2 of the periodic ...
to be useful in those with chronic back pain.
Surgery
Surgery may be useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control.[ It may also be useful in those with spinal stenosis.][ In the absence of these issues, there is no clear evidence of a benefit from surgery.][
Discectomy (the partial removal of a disc that is causing leg pain) can provide pain relief sooner than nonsurgical treatments.][ Discectomy has better outcomes at one year but not at four to ten years.][ The less invasive microdiscectomy has not been shown to result in a different outcome than regular discectomy.][ For most other conditions, there is not enough evidence to provide recommendations for surgical options.][ The long-term effect surgery has on degenerative disc disease is not clear.][ Less invasive surgical options have improved recovery times, but evidence regarding effectiveness is insufficient.][
For those with pain localized to the lower back due to disc degeneration, fair evidence supports spinal fusion as equal to intensive physical therapy and slightly better than low-intensity nonsurgical measures.][ Fusion may be considered for those with low back pain from acquired displaced vertebra that does not improve with conservative treatment,][ although only a few of those who have spinal fusion experience good results.][ There are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others. Adding spinal implant devices during fusion increases the risk but provides no added improvement in pain or function.][
]
Alternative medicine
It is unclear if alternative treatments are useful for non-chronic back pain. Chiropractic
Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudoscien ...
care or spinal manipulation therapy (SMT) appear similarly effective to other recommended treatments. National guidelines differ, with some not recommending SMT, some describing manipulation as optional, and others recommending a short course for those who do not improve with other treatments.[ A 2017 review recommended SMT based on low-quality evidence.][ There is insufficient evidence to recommend ]manipulation under anaesthesia
Manipulation under anesthesia (MUA) or fibrosis release procedures is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. This is accomplished by way of ...
, or medically assisted manipulation. SMT does not provide significant benefits compared to motor control exercises.
Acupuncture
Acupuncture is a form of alternative medicine and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body. Acupuncture is a pseudoscience; the theories and practices of TCM are not based on scient ...
is no better than placebo, usual care, or sham acupuncture for nonspecific acute pain or sub-chronic pain.[ For those with chronic pain, it improves pain a little more than no treatment and about the same as medications, but it does not help with disability.][ This pain benefit is only present right after treatment and not at follow-up.] Acupuncture may be a reasonable option for those with chronic pain that does not respond to other treatments like conservative care and medications.
Massage therapy does not appear to provide much benefit for acute low back pain.[ According to a 2015 Cochrane review, massage therapy was more effective for acute low back pain than no treatment; the benefits were limited to the short term][ and there was no effect for improving function.][ For chronic low back pain, massage therapy was no better than no treatment for both pain and function, though only in the short-term.][ The overall quality of the evidence was low and the authors conclude that massage therapy is generally not an effective treatment for low back pain.] Massage therapy is recommended for selected people with subacute and chronic low back pain, but it should be paired with another form of treatment like aerobic or strength exercises. For acute or chronic radicular pain syndromes massage therapy is recommended only if low back pain is considered a symptom. Mechanical massage tools are not recommended for the treatment of any form of low back pain.
Prolotherapy – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body's healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy.[
Herbal medicines, as a whole, are poorly supported by evidence. The herbal treatments Devil's claw and ]white willow
''Salix alba'', the white willow, is a species of willow native to Europe and western and central Asia.Meikle, R. D. (1984). ''Willows and Poplars of Great Britain and Ireland''. BSBI Handbook No. 4. .Rushforth, K. (1999). ''Trees of Britain ...
may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant.[ ]Capsicum
''Capsicum'' () is a genus of flowering plants in the nightshade family Solanaceae, native to the Americas, cultivated worldwide for their chili pepper or bell pepper fruit.
Etymology and names
The generic name may come from Latin , mean ...
, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.[
Behavioral therapy may be useful for chronic pain.][ There are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors; cognitive behavioral therapy, which helps people identify and correct negative thinking and behavior; and respondent conditioning, which can modify an individual's physiological response to pain.][ The benefit however is small. Medical providers may develop an integrated program of behavioral therapies.][ The evidence is inconclusive as to whether ]mindfulness-based stress reduction
Mindfulness-based stress reduction (MBSR) is an eight-week evidence-based program that offers secular, intensive mindfulness training to assist people with stress, anxiety, depression and pain. Developed at the University of Massachusetts Medical ...
reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.
Tentative evidence supports neuroreflexotherapy Neuroreflexotherapy (NRT) is a type of alternative medicine treatment used for some cases of low back pain (LBP). Small pieces of metal are placed just under the surface of the skin in the ear and back, and are intended to interrupt the neural pain ...
(NRT), in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain. Multidisciplinary biopsychosocial rehabilitation (MBR), targeting physical and psychological aspects, may improve back pain but evidence is limited. There is a lack of good quality evidence to support the use of radiofrequency denervation for pain relief.
KT Tape has been found to be no different for management of chronic non-specific low back pain than other established pain management strategies.
Education
There is strong evidence that education
Education is a purposeful activity directed at achieving certain aims, such as transmitting knowledge or fostering skills and character traits. These aims may include the development of understanding, rationality, kindness, and honesty. ...
may improve low back pain, with a 2.5 hour educational session more effective than usual care for helping people return to work in the short- and long-term. This was more effective for people with acute rather than chronic back pain.
Prognosis
Overall, the outcome for acute low back pain is positive. Pain and disability usually improve a great deal in the first six weeks, with complete recovery reported by 40 to 90%.[ In those who still have symptoms after six weeks, improvement is generally slower with only small gains up to one year. At one year, pain and disability levels are low to minimal in most people. Distress, previous low back pain, and job satisfaction are predictors of long-term outcome after an episode of acute pain.][ Certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain.][ Following a first episode of back pain, recurrences occur in more than half of people.]
For persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. At one year, those with chronic low back pain usually continue to have moderate pain and disability.[ People at higher risk of long-term disability include those with poor coping skills or with fear of activity (2.5 times more likely to have poor outcomes at one year),] those with a poor ability to cope with pain, functional impairments, poor general health, or a significant psychiatric or psychological component to the pain ( Waddell's signs).[
Prognosis may be influenced by expectations, with those having positive expectations of recovery related to higher likelihood of returning to work and overall outcomes.
]
Epidemiology
Low back pain that lasts at least one day and limits activity is a common complaint.[ Globally, about 40% of people have LBP at some point in their lives,][ with estimates as high as 80% of people in the developed world.][ Approximately 9 to 12% of people (632 million) have LBP at any given point in time, and nearly one quarter (23.2%) report having it at some point over any one-month period.] Difficulty most often begins between 20 and 40 years of age.[ Low back pain is more common among people aged 4080years, with the overall number of individuals affected expected to increase as the population ages.][
It is not clear whether men or women have higher rates of low back pain.][ A 2012 review reported a rate of 9.6% among males and 8.7% among females.][ Another 2012 review found a higher rate in females than males, which the reviewers felt was possibly due to greater rates of pains due to osteoporosis, menstruation, and pregnancy among women, or possibly because women were more willing to report pain than men.][ An estimated 70% of women experience back pain during ]pregnancy
Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy usually occurs by sexual intercourse, but ...
with the rate being higher the further along in pregnancy. Current smokers – and especially those who are adolescents – are more likely to have low back pain than former smokers, and former smokers are more likely to have low back pain than those who have never smoked.
History
Low back pain has been with humans since at least the Bronze Age
The Bronze Age is a historic period, lasting approximately from 3300 BC to 1200 BC, characterized by the use of bronze, the presence of writing in some areas, and other early features of urban civilization. The Bronze Age is the second pri ...
. The oldest known surgical treatise – the Edwin Smith Papyrus, dating to about 1500 BCE – describes a diagnostic test and treatment for a vertebral sprain. Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history o ...
( – ) was the first to use a term for sciatic pain and low back pain; Galen
Aelius Galenus or Claudius Galenus ( el, Κλαύδιος Γαληνός; September 129 – c. AD 216), often Anglicized as Galen () or Galen of Pergamon, was a Greek physician, surgeon and philosopher in the Roman Empire. Considered to be on ...
(active mid to late second century CE) described the concept in some detail. Physicians through the end of the first millennium recommended watchful waiting. Through the Medieval period, folk medicine practitioners provided treatments for back pain based on the belief that it was caused by spirits.
At the start of the 20th century, physicians thought low back pain was caused by inflammation of or damage to the nerves,[ with neuralgia and neuritis frequently mentioned by them in the medical literature of the time.] The popularity of such proposed causes decreased during the 20th century.[ In the early 20th century, American neurosurgeon ]Harvey Williams Cushing
Harvey Williams Cushing (April 8, 1869 – October 7, 1939) was an American neurosurgeon, pathologist, writer, and draftsman. A pioneer of brain surgery, he was the first exclusive neurosurgeon and the first person to describe Cushing's dise ...
increased the acceptance of surgical treatments for low back pain.[ In the 1920s and 1930s, new theories of the cause arose, with physicians proposing a combination of nervous system and psychological disorders such as nerve weakness ( neurasthenia) and female hysteria.][ Muscular rheumatism (now called ]fibromyalgia
Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hype ...
) was also cited with increasing frequency.[
Emerging technologies such as ]X-rays
X-rays (or rarely, ''X-radiation'') are a form of high-energy electromagnetic radiation. In many languages, it is referred to as Röntgen radiation, after the German scientist Wilhelm Conrad Röntgen, who discovered it in 1895 and named it ' ...
gave physicians new diagnostic tools, revealing the intervertebral disc as a source for back pain in some cases. In 1938, orthopedic surgeon Joseph S. Barr reported on cases of disc-related sciatica improved or cured with back surgery.[ As a result of this work, in the 1940s, the vertebral disc model of low back pain took over,][ dominating the literature through the 1980s, aiding further by the rise of new imaging technologies such as CT and MRI.][ The discussion subsided as research showed disc problems to be a relatively uncommon cause of the pain. Since then, physicians have come to realize that it is unlikely that a specific cause for low back pain can be identified in many cases and question the need to find one at all as most of the time symptoms resolve within 6 to 12 weeks regardless of treatment.][
]
Society and culture
Low back pain results in large economic costs. In the United States, it is the most common type of pain in adults, responsible for a large number of missed work days, and is the most common musculoskeletal complaint seen in the emergency department.[ In 1998, it was estimated to be responsible for $90 billion in annual health care costs, with 5% of individuals incurring most (75%) of the costs.][ Between 1990 and 2001 there was a more than twofold increase in spinal fusion surgeries in the US, despite the fact that there were no changes to the indications for surgery or new evidence of greater usefulness.][ Further costs occur in the form of lost income and productivity, with low back pain responsible for 40% of all missed work days in the United States.] Low back pain causes disability in a larger percentage of the workforce in Canada, Great Britain, the Netherlands and Sweden than in the US or Germany.[ In the United States, low back pain is highest of Years Lived With Disability (YLDs) rank, rate, and rercentage Change for the 25 leading causes of disability and injury, between 1990 and 2016.]
Workers who experience acute low back pain as a result of a work injury may be asked by their employers to have x-rays.[, which cites
* ] As in other cases, testing is not indicated unless red flags are present. An employer's concern about legal liability is not a medical indication and should not be used to justify medical testing when it is not indicated. There should be no legal reason for encouraging people to have tests which a health care provider determines are not indicated.
Research
Total disc replacement is an experimental option, but no significant evidence supports its use over lumbar fusion.[ Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human ]growth factor
A growth factor is a naturally occurring substance capable of stimulating cell proliferation, wound healing, and occasionally cellular differentiation. Usually it is a secreted protein or a steroid hormone. Growth factors are important for r ...
s, implanted substances, cell therapy, and tissue engineering
Tissue engineering is a biomedical engineering discipline that uses a combination of cells, engineering, materials methods, and suitable biochemical and physicochemical factors to restore, maintain, improve, or replace different types of biologi ...
.
References
External links
*
Back Pain at MedlinePlus.gov
{{DEFAULTSORT:Low Back Pain
Human back
Pain
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