Unintentional weight loss 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.[47][53] For acute pain, low- to moderate-quality evidence supports walking.[54] 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.[4] There is tentative evidence to support the use of heat therapy for acute and sub-chronic low back pain[55] but little evidence for the use of either heat or cold therapy in chronic pain.[56] Weak evidence suggests that back belts might decrease the number of missed workdays, but there is nothing to suggest that they will help with the pain.[49] Ultrasound and shock wave therapies do not appear effective and therefore are not recommended.[57][58] Lumbar traction lacks effectiveness as an intervention for radicular low back pain.[59] Exercise therapy is effective in decreasing pain and improving function for those with chronic low back pain.[49] It also appears to reduce recurrence rates for as long as six months after the completion of program[60] and improves long-term function.[56] There is no evidence that one particular type of exercise therapy is more effective than another.[61] The Alexander technique appears useful for chronic back pain,[62] and there is tentative evidence to support the use of yoga.[63] Transcutaneous electrical nerve stimulation (TENS) has not been found to be effective in chronic low back pain.[64] Evidence for the use of shoe insoles as a treatment is inconclusive.[50] 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.[65]MedicationsThe 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.[10] The medication typically recommended first are NSAIDs (though not aspirin) or skeletal muscle relaxants and these are enough for most people.[10][9] Benefits with NSAIDs; however, is often small.[66] High-quality reviews have found acetaminophen (paracetamol) to be no more effective than placebo at improving pain, quality of life, or function.[67][68] 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.[69][10][70] With respect to safety naproxen may be best.[71] Muscle relaxants may be beneficial.[10] If the pain is still not managed adequately, short term use of opioids such as morphine may be useful.[72][10] 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.[10] The effect of long term use of opioids for lower back pain is unknown.[73] Opioid treatment for chronic low back pain increases the risk for lifetime illicit drug use.[74] Specialist groups advise against general long-term use of opioids for chronic low back pain.[10][75] As of 2016, the CDC has released a guideline for prescribed opioid use in the management of chronic pain.[76] 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.[76] 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.[77] Antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects.[10] Although the antiseizure drugs gabapentin, pregabalin, and topiramate are sometimes used for chronic low back pain evidence does not support a benefit.[78] Systemic oral steroids have not been shown to be useful in low back pain.[4][10] 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.[79] Epidural corticosteroid injections provide a slight and questionable short-term improvement in those with sciatica but are of no long term benefit.[80] There are also concerns of potential side effects.[81]SurgerySurgery 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.[12] It may also be useful in those with spinal stenosis.[11] In the absence of these issues, there is no clear evidence of a benefit from surgery.[12] Discectomy (the partial removal of a disc that is causing leg pain) can provide pain relief sooner than nonsurgical treatments.[12] Discectomy has better outcomes at one year but not at four to ten years.[12] The less invasive microdiscectomy has not been shown to result in a different outcome than regular discectomy.[12] For most other conditions, there is not enough evidence to provide recommendations for surgical options.[12] The long-term effect surgery has on degenerative disc disease is not clear.[12] Less invasive surgical options have improved recovery times, but evidence regarding effectiveness is insufficient.[12]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.[11] Fusion may be considered for those with low back pain from acquired displaced vertebra that does not improve with conservative treatment,[12] although only a few of those who have spinal fusion experience good results.[11] There are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others.[82] Adding spinal implant devices during fusion increases the risks but provides no added improvement in pain or function.[7] Alternative medicineIt is unclear if among those with non-chronic back pain alternative treatments are useful.[83] For chiropractic care or spinal manipulation therapy (SMT) it is unclear if it improves outcomes more or less than other treatments.[14] Some reviews find that SMT results in equal or better improvements in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up;[16][17][84] other reviews find it to be no more effective in reducing pain than either inert interventions, sham manipulation, or other treatments, and conclude that adding SMT to other treatments does improve outcomes.[15][18] National guidelines reach different conclusions, with some not recommending spinal manipulation, some describing manipulation as optional, and others recommending a short course for those who do not improve with other treatments.[1] A 2017 review recommended spinal manipulation based on low quality evidence.[9] Manipulation under anaesthesia, or medically assisted manipulation, has not enough evidence to make any confident recommendation.[85] Acupuncture is no better than placebo, usual care, or sham acupuncture for nonspecific acute pain or sub-chronic pain.[219] 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.[219] This pain benefit is only present right after treatment and not at follow-up.[86] Acupuncture may be a reasonable method to try for those with chronic pain that does not respond to other treatments like conservative care and medications.[4][87]Massage therapy does not appear to provide much benefit for acute low back pain.[4] A 2015 Cochrane review found that for acute low back pain massage therapy was better than no treatment for pain only in the short-term.[225] There was no effect for improving function.[225] For chronic low back pain massage therapy was no better than no treatment for both pain and function, though only in the short-term.[225] 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.[88]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.[15]Herbal medicines, as a whole, are poorly supported by evidence.[89] The herbal treatments Devil's claw and white willow may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant.[15] Capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.[15] Behavioral therapy may be useful for chronic pain.[13] 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.[15] The benefit however is small.[90] Medical providers may develop an integrated program of behavioral therapies.[15] The evidence is inconclusive as to whether mindfulness-based stress reduction reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.[91][92]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.[93][94] PrognosisOverall, 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%.[3] 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.[3] Certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain.[10] Following a first episode of back pain, recurrences occur in more than half of people.[95] 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.[3] 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),[96] 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).[96] EpidemiologyLow back pain that lasts at least one day and limits activity is a common complaint.[22] Globally, about 40% of people have LBP at some point in their lives,[22] with estimates as high as 80% of people in the developed world.[97] 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.[22][98] Difficulty most often begins between 20 and 40 years of age.[4] Low back pain is more common among people aged 40{{endash}}80{{nbsp}}years, with the overall number of individuals affected expected to increase as the population ages.[22] It is not clear whether men or women have higher rates of low back pain.[22][19] A 2012 review reported a rate of 9.6% among males and 8.7% among females.[19] 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.[22] An estimated 70% of women experience back pain during pregnancy with the rate being higher the further along in pregnancy.[99] 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.[100] HistoryLow back pain has been with humans since at least the Bronze Age. 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 (c. 460 BCE – c. 370 BCE) was the first to use a term for sciatic pain and low back pain; Galen (active mid to late second century CE) described the concept in some detail. Physicians through the end of the first millennium did not attempt back surgery and 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.[101] At the start of the 20th century, physicians thought low back pain was caused by inflammation of or damage to the nerves,[101] with neuralgia and neuritis frequently mentioned by them in the medical literature of the time.[102] The popularity of such proposed causes decreased during the 20th century.[102] In the early 20th century, American neurosurgeon Harvey Williams Cushing increased the acceptance of surgical treatments for low back pain.[12] 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.[101] Muscular rheumatism (now called fibromyalgia) was also cited with increasing frequency.[102] Emerging technologies such as X-rays 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.[102] As a result of this work, in the 1940s, the vertebral disc model of low back pain took over,[101] dominating the literature through the 1980s, aiding further by the rise of new imaging technologies such as CT and MRI.[102] 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.[101] Society and cultureLow 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.[24] 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.[24] 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.[7] 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.[103] 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.[103] Workers who experience acute low back pain as a result of a work injury may be asked by their employers to have x-rays.[104] As in other cases, testing is not indicated unless red flags are present.[104] 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.[104] There should be no legal reason for encouraging people to have tests which a health care provider determines are not indicated.[104] ResearchTotal disc replacement is an experimental option,[31] but no significant evidence supports its use over lumbar fusion.[12] Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human growth factors, implanted substances, cell therapy, and tissue engineering.[31]References1. ^1 2 3 4 5 6 7 {{cite journal |vauthors=Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C |title=An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. |journal=European Spine Journal |date=December 2010 |volume=19 |issue=12 |pages=2075–94 |pmid=20602122 |doi=10.1007/s00586-010-1502-y |pmc=2997201}} 2. ^1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 {{cite journal |author=Manusov EG |title=Evaluation and diagnosis of low back pain |journal=Prim. 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New York, NY: McGraw-Hill Humanities/Social Sciences/Languages. 30. ^1 2 {{cite journal |vauthors=Freedman MD, Woodham MA, Woodham AW |title=The role of the lumbar multifidus in chronic low back pain: a review. |journal=PM&R |volume=2 |issue=2 |pages=142–6 |date=March 2010 |pmid=20193941 |doi=10.1016/j.pmrj.2009.11.006 |url=}} 31. ^1 2 3 4 5 6 {{cite journal |vauthors=Hughes SP, Freemont AJ, Hukins DW, McGregor AH, Roberts S |title=The pathogenesis of degeneration of the intervertebral disc and emerging therapies in the management of back pain |journal=J Bone Joint Surg Br |volume=94 |issue=10 |pages=1298–304 |date=October 2012 |pmid=23015552 |doi=10.1302/0301-620X.94B10.28986 |url=http://www.boneandjoint.org.uk/highwire/filestream/61400/field_highwire_article_pdf/0/1298.full-text.pdf |deadurl=yes |archiveurl=https://web.archive.org/web/20131004234019/http://www.boneandjoint.org.uk/highwire/filestream/61400/field_highwire_article_pdf/0/1298.full-text.pdf |archivedate=4 October 2013 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– Low Back Pain |year=2011 |url=http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf |deadurl=no |archiveurl=https://web.archive.org/web/20121222060920/http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf |archivedate=22 December 2012 |df=dmy-all }} 35. ^-->|-| Loss of bladder or bowel control || rowspan="3"|Cauda equina syndrome|-| Significant motor weakness or sensory problems|-| Loss of sensation in the buttocks (saddle anesthesia)|-| Significant trauma related to age || rowspan="3"|Fracture|-| Chronic corticosteroid use|-| Osteoporosis|-| Severe pain after lumbar surgery in past year || rowspan="5"|Infection|-| Fever|-| Urinary tract infection|-| Immunosuppression|-| Intravenous drug use|}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.[{{Citation |author1 = North American Spine Society 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External links {{Medical resources | DiseasesDB = | M|54|5|m|50}} | 724.2}} | ICDO = | OMIM = | MedlinePlus = 007422 | eMedicineSubj = pmr | eMedicineTopic = 73 | MeshID = D017116 }}- {{DMOZ|Health/Conditions_and_Diseases/Musculoskeletal_Disorders/Back_and_Spine/|Back and spine}}
{{Dorsopathies}}{{pain}}{{Authority control}}{{DEFAULTSORT:Low Back Pain}} 5 : Symptoms and signs: musculoskeletal system|Pain|Human back|RTT(full)|RTTEM |