Low Back Pain
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Low back pain (LBP) or lumbago is a common disorder involving the muscles, nerves, and bones of the
back The human back, also called the dorsum, is the large posterior area of the human body, rising from the top of the buttocks to the back of the neck. It is the surface of the body opposite from the chest and the abdomen. The vertebral column run ...
, in between the lower edge of the ribs and the lower fold of the buttocks.
Pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by
duration Duration may refer to: * The amount of time elapsed between two events * Duration (music) – an amount of time or a particular time interval, often cited as one of the fundamental aspects of music * Duration (philosophy) – a theory of time and ...
as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks). The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or
referred pain Referred pain, also called reflective pain, is pain perceived at a location other than the site of the painful stimulus. An example is the case of angina pectoris brought on by a myocardial infarction (heart attack), where pain is often felt in ...
. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks. In most episodes of low back pain, a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as
muscle Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscl ...
or
joint strain A sprain, also known as a torn ligament, is an acute soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers ...
. If the pain does not go away with conservative treatment or if it is accompanied by "red flags" such as unexplained weight loss,
fever Fever, also referred to as pyrexia, is defined as having a body temperature, temperature above the human body temperature, normal range due to an increase in the body's temperature Human body temperature#Fever, set point. There is not a single ...
, or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem. In most cases, imaging tools such as
X-ray computed tomography An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30  ...
are not useful and carry their own risks. Despite this, the use of imaging in low back pain has increased. Some low back pain is caused by damaged
intervertebral disc An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...
s, and the straight leg raise test is useful to identify this cause. In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events. Initial management with non-medication based treatments is recommended. NSAIDs are recommended if these are not sufficiently effective. Normal activity should be continued as much as the pain allows. A number of other options are available for those who do not improve with usual treatment.
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 opioid us ...
s may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects. Surgery may be beneficial for those with disc-related chronic pain and disability or
spinal stenosis Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
. No clear benefit of surgery has been found for other cases of non-specific low back pain. Low back pain often affects mood, which may be improved by
counseling Counseling is the professional guidance of the individual by utilizing psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes. This is a list of co ...
or
antidepressant Antidepressants are a class of medication used to treat major depressive disorder, anxiety disorders, chronic pain conditions, and to help manage addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, hea ...
s. Additionally, there are many
alternative medicine Alternative medicine is any practice that aims to achieve the healing effects of medicine despite lacking biological plausibility, testability, repeatability, or evidence from clinical trials. Complementary medicine (CM), complementary and alt ...
therapies, including the Alexander technique and
herbal remedies Herbal medicine (also herbalism) is the study of pharmacognosy and the use of medicinal plants, which are a basis of traditional medicine. With worldwide research into pharmacology, some herbal medicines have been translated into modern remedie ...
, but there is not enough evidence to recommend them confidently. The evidence for
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 pseudosci ...
care and spinal manipulation is mixed. Approximately 9–12% of people (632 million) have LBP at any given point in time, and nearly 25% report having it at some point over any one-month period. About 40% of people have LBP at some point in their lives, with estimates as high as 80% among people in the
developed world A developed country (or industrialized country, high-income country, more economically developed country (MEDC), advanced country) is a sovereign state that has a high quality of life, developed economy and advanced technological infrastruct ...
. Difficulty most often begins between 20 and 40 years of age. Men and women are equally affected. Low back pain is more common among people aged between 40 and 80 years, with the overall number of individuals affected expected to increase as the population ages.


Signs and symptoms

In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as
sciatica Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described ...
) may be present. The first experience of acute low back pain is typically between the ages of 20 and 40. This is often a person's first reason to see a medical professional as an adult. Recurrent episodes occur in more than half of people with the repeated episodes being generally more painful than the first. Other problems may occur along with low back pain. Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep. In addition, a majority of those with chronic low back pain show symptoms of depression or
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
.


Causes

Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness. The majority of LBP does not have a clear cause but is believed to be the result of non-serious muscle or skeletal issues such as
sprain A sprain, also known as a torn ligament, is an acute soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers ...
s or
strain Strain may refer to: Science and technology * Strain (biology), variants of plants, viruses or bacteria; or an inbred animal used for experimental purposes * Strain (chemistry), a chemical stress of a molecule * Strain (injury), an injury to a mu ...
s. Obesity, smoking, weight gain during pregnancy,
stress Stress may refer to: Science and medicine * Stress (biology), an organism's response to a stressor such as an environmental condition * Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
, poor physical condition, and poor sleeping position may also contribute to low back pain. There is no consensus as to whether
spinal posture Spinal posture is the position of the spine in the human body. It is debated what the optimal spinal posture is, and whether poor spinal posture causes lower back pain. Neutral spine Looking directly at the front or back of the body, the 33 verteb ...
or certain physical activities are causal factors. A full list of possible causes includes many less common conditions. Physical causes may include
osteoarthritis 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 ...
, degeneration of the discs between the
vertebrae The spinal column, a defining synapomorphy shared by nearly all vertebrates,Hagfish are believed to have secondarily lost their spinal column is a moderately flexible series of vertebrae (singular vertebra), each constituting a characteristic i ...
or a
spinal disc herniation Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
, broken vertebra(e) (such as from
osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...
) or, rarely, an infection or tumor of the spine. Women may have acute low back pain from medical conditions affecting the female reproductive system, including
endometriosis Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, f ...
,
ovarian cyst An ovarian cyst is a fluid-filled sac within the ovary. Often they cause no symptoms. Occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either breaks open or causes ...
s,
ovarian cancer Ovarian cancer is a cancerous tumor of an ovary. It may originate from the ovary itself or more commonly from communicating nearby structures such as fallopian tubes or the inner lining of the abdomen. The ovary is made up of three different c ...
, or
uterine fibroid Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bl ...
s. Nearly half of all pregnant women report pain in the lower back or
sacral Sacral may refer to: *Sacred Sacred describes something that is dedicated or set apart for the service or worship of a deity; is considered worthy of spiritual respect or devotion; or inspires awe or reverence among believers. The property ...
area during pregnancy, due to changes in their posture and center of gravity causing muscle and ligament strain. Low back pain can be broadly classified into four main categories: *Musculoskeletal – mechanical (including
muscle strain A strain is an acute or chronic soft tissue injury that occurs to a muscle, tendon, or both. The equivalent injury to a ligament is a sprain. Generally, the muscle or tendon overstretches and partially tears, under more physical stress th ...
,
muscle spasm A spasm is a sudden involuntary contraction of a muscle, a group of muscles, or a hollow organ such as the bladder. A spasmodic muscle contraction may be caused by many medical conditions, including dystonia. Most commonly, it is a muscle c ...
, or
osteoarthritis 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 ...
); herniated nucleus pulposus,
herniated disc Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
;
spinal stenosis Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
; or
compression fracture A compression fracture is a collapse of a vertebra. It may be due to trauma or due to a weakening of the vertebra (compare with burst fracture). This weakening is seen in patients with osteoporosis or osteogenesis imperfecta, lytic lesions from ...
*Inflammatory – HLA-B27 associated arthritis including
ankylosing spondylitis Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis. Occasionally areas affected may include other joints such as the shoulders or hip ...
,
reactive arthritis Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can ...
,
psoriatic arthritis Psoriatic arthritis is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. Thi ...
, inflammation within the reproductive system, and
inflammatory bowel disease Inflammatory bowel disease (IBD) is a group of inflammation, inflammatory conditions of the colon (anatomy), colon and small intestine, Crohn's disease and ulcerative colitis being the principal types. Crohn's disease affects the small intestine a ...
*Malignancy –
bone metastasis Bone metastasis, or osseous metastatic disease, is a category of cancer metastases that results from primary tumor invasion to bone. Bone-originating primary tumors such as osteosarcoma, chondrosarcoma, and Ewing's sarcoma are rare; the most common ...
from lung, breast, prostate, thyroid, among others *Infectious –
osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
; abscess Low back pain can also be caused by an
urinary tract infection A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney ...
.


Pathophysiology


Back structures

The lumbar (or lower back) region is the area between the lower ribs and gluteal fold which includes five lumbar
vertebrae The spinal column, a defining synapomorphy shared by nearly all vertebrates,Hagfish are believed to have secondarily lost their spinal column is a moderately flexible series of vertebrae (singular vertebra), each constituting a characteristic i ...
(L1–L5) and the sacrum. In between these vertebrae are
fibrocartilaginous Fibrocartilage consists of a mixture of white fibrous tissue and cartilaginous tissue in various proportions. It owes its inflexibility and toughness to the former of these constituents, and its Elasticity (physics), elasticity to the latter. It ...
discs, which act as cushions, preventing the vertebrae from rubbing together while at the same time protecting the
spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
. Nerves come from and go to the
spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...
through specific openings between the vertebrae, providing the skin with sensations and sending messages to muscles. Stability of the spine is provided by the ligaments and muscles of the back and abdomen. Small joints called
facet joints Facets () are flat faces on geometric shapes. The organization of naturally occurring facets was key to early developments in crystallography, since they reflect the underlying symmetry of the crystal structure. Gemstones commonly have facets cut ...
limit and direct the motion of the spine.Floyd, R., & Thompson, Clem. (2008). ''Manual of structural kinesiology''. New York: McGraw-Hill Humanities/Social Sciences/Languages. The
multifidus muscle The multifidus (multifidus spinae : ''pl. multifidi'' ) muscle consists of a number of fleshy and tendinous fasciculi, which fill up the groove on either side of the spinous processes of the vertebrae, from the sacrum to the axis. While very thin ...
s run up and down along the back of the spine, and are important for keeping the spine straight and stable during many common movements such as sitting, walking and lifting. A problem with these muscles is often found in someone with chronic low back pain, because the back pain causes the person to use the back muscles improperly in trying to avoid the pain. The problem with the multifidus muscles continues even after the pain goes away, and is probably an important reason why the pain comes back. Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program. An intervertebral disc has a gelatinous core surrounded by a fibrous ring. When in its normal, uninjured state, most of the disc is not served by either the
circulatory The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
or
nervous systems In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes th ...
– blood and nerves only run to the outside of the disc. Specialized cells that can survive without direct blood supply are in the inside of the disc. Over time, the discs lose flexibility and the ability to absorb physical forces. This decreased ability to handle physical forces increases stresses on other parts of the spine, causing the ligaments of the spine to thicken and bony growths to develop on the vertebrae. As a result, there is less space through which the spinal cord and nerve roots may pass. When a disc degenerates as a result of injury or disease, the makeup of a disc changes: blood vessels and nerves may grow into its interior and/or herniated disc material can push directly on a nerve root. Any of these changes may result in back pain.


Pain sensation

Pain is generally an unpleasant feeling in response to an
event Event may refer to: Gatherings of people * Ceremony, an event of ritual significance, performed on a special occasion * Convention (meeting), a gathering of individuals engaged in some common interest * Event management, the organization of e ...
that either damages or can potentially damage the body's tissues. There are four main steps in the process of feeling pain: transduction, transmission,
perception Perception () is the organization, identification, and interpretation of sensory information in order to represent and understand the presented information or environment. All perception involves signals that go through the nervous system ...
, and
modulation In electronics and telecommunications, modulation is the process of varying one or more properties of a periodic waveform, called the ''carrier signal'', with a separate signal called the ''modulation signal'' that typically contains informatio ...
. The nerve cells that detect pain have cell bodies located in the
dorsal root ganglia A dorsal root ganglion (or spinal ganglion; also known as a posterior root ganglion) is a cluster of neurons (a ganglion) in a dorsal root of a spinal nerve. The cell bodies of sensory neurons known as first-order neurons are located in the do ...
and fibers that transmit these signals to the spinal cord. The process of pain sensation starts when the pain-causing event triggers the endings of appropriate sensory nerve cells. This type of cell converts the event into an electrical signal by transduction. Several different types of nerve fibers carry out the transmission of the electrical signal from the transducing cell to the
posterior horn of spinal cord The posterior grey column (posterior cornu, dorsal horn, spinal dorsal horn, posterior horn, sensory horn) of the spinal cord is one of the three grey columns of the spinal cord. It receives several types of sensory information from the body, inc ...
, from there to the
brain stem The brainstem (or brain stem) is the posterior stalk-like part of the brain that connects the cerebrum with the spinal cord. In the human brain the brainstem is composed of the midbrain, the pons, and the medulla oblongata. The midbrain is conti ...
, and then from the brain stem to the various parts of the brain such as the
thalamus The thalamus (from Greek θάλαμος, "chamber") is a large mass of gray matter located in the dorsal part of the diencephalon (a division of the forebrain). Nerve fibers project out of the thalamus to the cerebral cortex in all directions, ...
and the
limbic system The limbic system, also known as the paleomammalian cortex, is a set of brain structures located on both sides of the thalamus, immediately beneath the medial temporal lobe of the cerebrum primarily in the forebrain.Schacter, Daniel L. 2012. ''Ps ...
. In the brain, the pain signals are processed and given context in the process of pain
perception Perception () is the organization, identification, and interpretation of sensory information in order to represent and understand the presented information or environment. All perception involves signals that go through the nervous system ...
. Through modulation, the brain can modify the sending of further nerve impulses by decreasing or increasing the release of
neurotransmitter A neurotransmitter is a signaling molecule secreted by a neuron to affect another cell across a synapse. The cell receiving the signal, any main body part or target cell, may be another neuron, but could also be a gland or muscle cell. Neuro ...
s. Parts of the pain sensation and processing system may not function properly; creating the feeling of pain when no outside cause exists, signaling too much pain from a particular cause, or signaling pain from a normally non-painful event. Additionally, the pain modulation mechanisms may not function properly. These phenomena are involved in chronic pain.


Diagnosis

As the structure of the lumbago back is complex and the reporting of pain is subjective and affected by social factors, the diagnosis of low back pain is not straightforward. While most low back pain is caused by muscle and joint problems, this cause must be separated from neurological problems, spinal tumors, fracture of the spine, and infections, among others.


Classification

There are a number of ways to classify low back pain with no consensus that any one method is best. There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains,
herniated disc Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical ...
s, compressed
nerve root A nerve root (Latin: ''radix nervi'') is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as: *cranial nerves, Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of crania ...
s, degenerative discs or
joint disease An arthropathy is a disease of a joint. Types Arthritis is a form of arthropathy that involves inflammation of one or more joints, while the term arthropathy may be used regardless of whether there is inflammation or not. Joint diseases can be cla ...
, and broken vertebra), non-mechanical back pain (
tumors A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
, inflammatory conditions such as
spondyloarthritis Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra ...
, and infections), and
referred pain Referred pain, also called reflective pain, is pain perceived at a location other than the site of the painful stimulus. An example is the case of angina pectoris brought on by a myocardial infarction (heart attack), where pain is often felt in ...
from internal organs (
gallbladder disease Gallbladder diseases are diseases involving the gallbladder and is closely linked to biliary disease, with the most common cause being gallstones (cholelithiasis). The gallbladder is designed to aid in the digestion of fats by concentrating and ...
,
kidney stone Kidney stone disease, also known as nephrolithiasis or urolithiasis, is a crystallopathy where a solid piece of material (kidney stone) develops in the urinary tract. Kidney stones typically form in the kidney and leave the body in the urine s ...
s,
kidney infection Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications may ...
s, and
aortic aneurysm An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. They usually cause no symptoms except when ruptured. Occasionally, there may be abdominal, back, or leg pain. The prevalence of abdominal aortic ...
, among others). Mechanical or musculoskeletal problems underlie most cases (around 90% or more), and of those, most (around 75%) do not have a specific cause identified, but are thought to be due to muscle strain or injury to ligaments. Rarely, complaints of low back pain result from systemic or psychological problems, such as
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 hyp ...
and
somatoform disorders A somatic symptom disorder, formerly known as a somatoform disorder,(2013) dsm5.org. Retrieved April 8, 2014. is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general ...
. Low back pain may be classified based on the signs and symptoms. Diffuse pain that does not change in response to particular movements, and is localized to the lower back without radiating beyond the
buttock The buttocks (singular: buttock) are two rounded portions of the exterior anatomy of most mammals, located on the posterior of the pelvic region. In humans, the buttocks are located between the lower back and the perineum. They are composed ...
s, is classified as ''nonspecific'', the most common classification. Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation), or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers is ''radicular'', making up 7% of cases. Pain that is accompanied by red flags such as trauma, fever, a history of cancer or significant muscle weakness may indicate a more serious underlying problem and is classified as ''needing urgent or specialized attention''. The symptoms can also be classified by duration as acute, sub-chronic (also known as sub-acute), or chronic. The specific duration required to meet each of these is not universally agreed upon, but generally pain lasting less than six weeks is classified as ''acute'', pain lasting six to twelve weeks is ''sub-chronic'', and more than twelve weeks is ''chronic''. Management and prognosis may change based on the duration of symptoms.


Red flags

The presence of certain signs, termed ''red flags'', indicate the need for further testing to look for more serious underlying problems, which may require immediate or specific treatment., which cites * * The presence of a red flag does not mean that there is a significant problem. It is only suggestive, and most people with red flags have no serious underlying problem. If no red flags are present, performing
diagnostic imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
or laboratory testing in the first four weeks after the start of the symptoms has not been shown to be useful. The usefulness of many red flags is poorly supported by evidence. The most useful for detecting a fracture are: older age,
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
use, and significant trauma especially if it results in skin markings. The best determinant of the presence of cancer is a history of the same. With other causes ruled out, people with non-specific low back pain are typically treated symptomatically, without exact determination of the cause. Efforts to uncover factors that might complicate the diagnosis, such as depression, substance abuse, or an agenda concerning insurance payments may be helpful.


Tests

Imaging is indicated when there are red flags, ongoing neurological symptoms that do not resolve, or ongoing or worsening pain. In particular, early use of imaging (either MRI or CT) is recommended for suspected cancer, infection, or
cauda equina syndrome Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around th ...
. MRI is slightly better than CT for identifying disc disease; the two technologies are equally useful for diagnosing spinal stenosis. Only a few physical diagnostic tests are helpful. The straight leg raise test is almost always positive in those with disc herniation, and lumbar provocative discography may be useful to identify a specific disc causing pain in those with chronic high levels of low back pain. Therapeutic procedures such as nerve blocks can also be used to determine a specific source of pain. Some evidence supports the use of facet joint injections, transforminal epidural injections and sacroiliac injections as diagnostic tests. Most other physical tests, such as evaluating for
scoliosis Scoliosis is a condition in which a person's spine has a sideways curve. The curve is usually "S"- or "C"-shaped over three dimensions. In some, the degree of curve is stable, while in others, it increases over time. Mild scoliosis does not t ...
, muscle weakness or wasting, and impaired reflexes, are of little use. Complaints of low back pain are one of the most common reasons people visit doctors. For pain that has lasted only a few weeks, the pain is likely to subside on its own. Thus, if a person's
medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
and
physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...
do not suggest a specific disease as the cause, medical societies advise against imaging tests such as
X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
s, CT scans, and
MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
s. Individuals may want such tests but, unless red flags are present, they are
unnecessary health care Unnecessary health care (overutilization, overuse, or overtreatment) is health care provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the ...
. Routine imaging increases costs, is associated with higher rates of surgery with no overall benefit, and the radiation used may be harmful to one's health. Fewer than 1% of imaging tests identify the cause of the problem. Imaging may also detect harmless abnormalities, encouraging people to request further unnecessary testing or to worry. Even so, MRI scans of the lumbar region increased by more than 300% among United States Medicare beneficiaries from 1994 to 2006.


Prevention

Exercise Exercise is a body activity that enhances or maintains physical fitness and overall health and wellness. It is performed for various reasons, to aid growth and improve strength, develop muscles and the cardiovascular system, hone athletic ...
appears to be useful for preventing low back pain. Exercise is also probably effective in preventing recurrences in those with pain that has lasted more than six weeks. Medium-firm mattresses are more beneficial for chronic pain than firm mattresses. There is little to no evidence that
back belt Back belts, or lumbar support belts, are generally lightweight belts worn around the lower back to provide support to the lumbar. Industrial back belts tend to be similar to weight lifting belts or special belts used in medical rehabilitation thera ...
s are any more helpful in preventing low back pain than education about proper lifting techniques. There is no quality data that supports medium firm mattresses over firm mattresses. A few studies that have contradicted this notion have also failed to include sleep posture and mattress firmness. The most comfortable sleep surface may be preferred.
Shoe insoles A removable shoe insert, otherwise known as a foot orthosis, insole or inner sole accomplishes many purposes, including daily wear comfort, height enhancement, plantar fasciitis treatment, arch support, foot and joint pain relief from arthritis ...
do not help prevent low back pain.


Management

Most people with acute or subacute low back pain improve over time no matter the treatment. There is often improvement within the first month. Recommendations include remaining active, avoiding activity that worsen the pain, and understanding self-care of the symptoms. Management of low back pain depends on which of the three general categories is the cause: mechanical problems, non-mechanical problems, or referred pain. For acute pain that is causing only mild to moderate problems, the goals are to restore normal function, return the individual to work, and minimize pain. The condition is normally not serious, resolves without much being done, and recovery is helped by attempting to return to normal activities as soon as possible within the limits of pain. Providing individuals with
coping skills Coping refers to conscious strategies used to reduce unpleasant emotions. Coping strategies can be cognitions or behaviours and can be individual or social. Theories of coping Hundreds of coping strategies have been proposed in an attempt to ...
through reassurance of these facts is useful in speeding recovery. For those with sub-chronic or chronic low back pain, multidisciplinary treatment programs may help. Initial management with non–medication based treatments is recommended Non–medication based treatments include superficial
heat In thermodynamics, heat is defined as the form of energy crossing the boundary of a thermodynamic system by virtue of a temperature difference across the boundary. A thermodynamic system does not ''contain'' heat. Nevertheless, the term is al ...
,
massage Massage is the manipulation of the body's soft tissues. Massage techniques are commonly applied with hands, fingers, elbows, knees, forearms, feet or a device. The purpose of massage is generally for the treatment of body stress or pain. In Eu ...
,
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 scientifi ...
, or spinal manipulation. If these are not sufficiently effective, NSAIDs are recommended.
Acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...
and systemic
steroid A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
s are not recommended as both medications are not effective at improving pain outcomes in acute or subacute low back pain. 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 exercise Aerobic exercise (also known as endurance activities, cardio or cardio-respiratory exercise) is physical exercise of low to high intensity that depends primarily on the aerobic energy-generating process. "Aerobic" is defined as "relating to, inv ...
s 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 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 Heat therapy, also called thermotherapy, is the use of heat in therapy, such as for pain relief and health. It can take the form of a hot cloth, hot water bottle, ultrasound, heating pad, hydrocollator packs, whirlpool baths, cordless Far infrar ...
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-consciou ...
and
Tai chi Tai chi (), short for Tai chi ch'üan ( zh, s=太极拳, t=太極拳, first=t, p=Tàijíquán, labels=no), sometimes called "shadowboxing", is an neijia, internal Chinese martial art practiced for defense training, health benefits and medita ...
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 Range of motion (or ROM), is the linear or angular distance that a moving object may normally travel while properly attached to another. It is also called range of travel (or ROT), particularly when talking about mechanical devices and in mechanic ...
, can impede future progression of treatment like limiting strength and limiting exercises.

Management of chronic low back pain

Exercise therapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
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-consciou ...
. 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 Aquatic therapy refers to treatments and exercises performed in water for relaxation, fitness, physical rehabilitation, and other therapeutic benefit. Typically a qualified aquatic therapist gives constant attendance to a person receiving treat ...
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 we ...
, degenerative joint disease, 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 Pilates (; ) is a type of mind-body exercise developed in the early 20th century by German physical trainer Joseph Pilates, after whom it was named. Pilates called his method "Contrology". It is practiced worldwide, especially in countries suc ...
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 Transcutaneous electrical nerve stimulation (TENS or TNS) is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneously applied currents ...
(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 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 Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as eit ...
, stomach ulcers and possibly
heart problems Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, ...
. 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 inhibitor COX-2 inhibitors are a type of nonsteroidal anti-inflammatory drug (NSAID) that directly targets cyclooxygenase-2, COX-2, an enzyme responsible for inflammation and pain. Targeting selectivity for COX-2 reduces the risk of peptic ulceration and i ...
s over any other class of NSAIDs with respect to benefits. With respect to safety
naproxen Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formulati ...
may be best.
Muscle relaxant 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 therapeu ...
s 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 opioid us ...
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 analgesic, pain medication, and is also commonly used recreational drug, recreationally, or to make ...
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 Neuropathic pain is pain caused by damage or disease affecting the somatosensory system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous ...
.
Antidepressants Antidepressants are a class of medication used to treat major depressive disorder, anxiety disorders, chronic pain conditions, and to help manage addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, heada ...
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 diabet ...
,
pregabalin Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic and anxiolytic medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless leg syndrome, opioid withdrawal and generalized anxiety disord ...
, and
topiramate Topiramate, sold under the brand name Topamax among others, is a carbonic anhydrase inhibitor medication used to treat epilepsy and prevent migraines. It has also been used in alcohol dependence. For epilepsy this includes treatment for gener ...
are sometimes used for chronic low back pain evidence does not support a benefit. Systemic oral
steroids A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
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 Epidural administration (from Ancient Greek ἐπί, , upon" + ''dura mater'') is a method of medication administration in which a medicine is injected into the epidural space around the spinal cord. The epidural route is used by physicians an ...
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 ta ...
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 Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in on ...
. In the absence of these issues, there is no clear evidence of a benefit from surgery.
Discectomy A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...
(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 A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an in ...
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 Spinal fusion, also called spondylodesis or spondylosyndesis, is a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and pre ...
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 pseudosci ...
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, 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 scientifi ...
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 Massage is the manipulation of the body's soft tissues. Massage techniques are commonly applied with hands, fingers, elbows, knees, forearms, feet or a device. The purpose of massage is generally for the treatment of body stress or pain. In Eu ...
does not appear to provide much benefit for acute low back pain. According to a 2015
Cochrane review Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
, 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 Prolotherapy, also called proliferation therapy, is an injection-based treatment used in chronic musculoskeletal conditions. It has been characterised as an alternative medicine practice. Medical uses A 2015 review found no evidence that prolother ...
– 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 an ...
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 Solanum, nightshade family Solanaceae, native to Americas, the Americas, cultivated worldwide for their chili pepper or bell pepper fruit. Etymology and names The generic name may come f ...
, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.
Behavioral therapy Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or o ...
may be useful for chronic pain. There are several types available, including
operant conditioning Operant conditioning, also called instrumental conditioning, is a learning process where behaviors are modified through the association of stimuli with reinforcement or punishment. In it, operants—behaviors that affect one's environment—are c ...
, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors;
cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a psycho-social intervention that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders. CBT focuses on challenging and changing cognitive distortions (suc ...
, which helps people identify and correct negative thinking and behavior; and
respondent conditioning Classical conditioning (also known as Pavlovian or respondent conditioning) is a behavioral procedure in which a biologically potent stimulus (e.g. food) is paired with a previously neutral stimulus (e.g. a triangle). It also refers to the learni ...
, 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 Medica ...
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 (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 Elastic therapeutic tape, also called kinesiology tape or kinesiology therapeutic tape, Kinesio tape, k-tape, or KT is an elastic cotton strip with an Acrylic resin, acrylic adhesive that is purported to ease pain and disability from athletic in ...
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. Va ...
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 Job satisfaction, employee satisfaction or work satisfaction is a measure of workers' contentedness with their job, whether they like the job or individual aspects or facets of jobs, such as nature of work or supervision. Job satisfaction can be ...
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 Waddell's signs are a group of physical signs, first described in a 1980 article in '' Spine'', and named for the article's principal author, Professor Gordon Waddell (1943–2017), a Scottish Orthopedic Surgeon. Waddell's signs may indicate n ...
). 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 ca ...
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 The Edwin Smith Papyrus is an ancient Egyptian medical text, named after Edwin Smith who bought it in 1862, and the oldest known surgical treatise on trauma. From a cited quotation in another text, it may have been known to ancient surgeons as t ...
, 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 of ...
( – ) 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 one of ...
(active mid to late second century CE) described the concept in some detail. Physicians through the end of the first millennium recommended
watchful waiting Watchful waiting (also watch and wait or WAW) is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed. Related terms include ''expec ...
. Through the
Medieval period In the history of Europe, the Middle Ages or medieval period lasted approximately from the late 5th to the late 15th centuries, similar to the post-classical period of global history. It began with the fall of the Western Roman Empire a ...
, 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 disease. ...
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 Neurasthenia (from the Ancient Greek νεῦρον ''neuron'' "nerve" and ἀσθενής ''asthenés'' "weak") is a term that was first used at least as early as 1829 for a mechanical weakness of the nerves and became a major diagnosis in North A ...
) and
female hysteria Female hysteria was once a common medical diagnosis for women, which was described as exhibiting a wide array of symptoms, including anxiety, shortness of breath, fainting, nervousness, sexual desire, insomnia, fluid retention, heaviness in the ...
. 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 hyp ...
) was also cited with increasing frequency. Emerging technologies such as
X-rays An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 Picometre, picometers to 10 Nanometre, nanometers, corresponding to frequency, ...
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 cost Economic cost is the combination of losses of any goods that have a value attached to them by any one individual. Economic cost is used mainly by economists as means to compare the prudence of one course of action with that of another. The comparis ...
s. 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 The workforce or labour force is a concept referring to the Pooling (resource management), pool of human beings either in employment or in unemployment. It is generally used to describe those working for a single types of companies, company or ...
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 Artificial disc replacement (ADR), or total disc replacement (TDR), is a type of arthroplasty. It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial disc implants in the lumbar (l ...
is an experimental option, but no significant evidence supports its use over
lumbar fusion Spinal fusion, also called spondylodesis or spondylosyndesis, is a neurosurgical or orthopedic surgical technique that joins two or more vertebrae. This procedure can be performed at any level in the spine (cervical, thoracic, or lumbar) and pre ...
. 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 regu ...
s, implanted substances,
cell therapy Cell therapy (also called cellular therapy, cell transplantation, or cytotherapy) is a therapy in which viable cells are injected, grafted or implanted into a patient in order to effectuate a medicinal effect, for example, by transplanting T-c ...
, and
tissue engineering Tissue engineering is a biomedical engineering discipline that uses a combination of Cell (biology), cells, engineering, Materials science, materials methods, and suitable biochemistry, biochemical and physicochemical factors to restore, maintai ...
.


References


External links

*
Back Pain at MedlinePlus.gov
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