Low back pain
EBM Guidelines
Apr 8, 2022 • Latest change Oct 9, 2023
Table of contents
- Essentials
- Epidemiology
- Clinical examination
- Psychosocial risk factors
- Classification of diagnostic urgency
- Serious or specific diseases
- Laboratory tests
- Imaging studies
- Neurophysiological investigations
- Sciatic syndrome evd
- Acute low back pain with no radiating symptoms (duration less than 6 weeks) evd
- Low back pain with developing radiating symptom (duration less than 6 weeks)
- Subacute low back pain (duration 6–12 weeks)
- Chronic back pain (duration over 12 weeks)
- Patient educational material
- References
Extract
- Sufficient time for the survey of the history and for the physical examination of the patient
- Early recognition of serious causes of back pain and of nerve root compression
- Organization of further investigations and treatment without delay in situations where conservative treatment may lead to complications (impending cauda equina, severe functional disorders of nerves, such as disturbance of a muscle group, extensive numbness of lower extremity, and other critical "red flag" situations). In such situations the treatment should be organized in a unit capable of urgent MRI and other investigations.
- In patients who are beyond middle age, do not have radicular symptoms but do have pain in the night must be carefully evaluated. If the symptom picture continues after a therapeutic medication trial, more thorough diagnostic investigations should be considered to exclude malignancy.
- In elderly people with no underlying chronic back condition, lower back pain often suggests spinal stenosis.
- Adequate treatment of pain: according to the intensity of pain the choice is paracetamol, a NSAID or a combination of a NSAID and a mild opioid analgesic
- Avoidance of bed rest
- Continuation or resumption of ordinary daily activities as soon as possible
- Provision of adequate and truthful patient information on the frequency of low back pain and its often good prognosis: the pain will usually resolve but has a tendency to recur
- Unless there is a clear disease suggesting dysfunction of radicular origin and requiring spezialiced care, treatment consists of early multidisciplinary and active rehabilitation
Linked evidence summaries
- Advice to rest in bed appears to be less effective than advice to stay active for people with acute low-back pain. For patients with sciatica, there is little or no difference between the two approaches.B
- Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse appears to provide faster pain relief than conservative management, although any positive or negative long-term effects are unclear. Surgical discectomy is more effective than chemonucleolysis which is more effective than placebo.B
- Intensive exercise programs started 4–6 weeks post-surgery appear to be more effective than no treatment or mild exercise programs in improving functional status and reducing pain in the short-term. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.B
- Paracetamol is no better than placebo for relieving acute low back pain (LBP). There is insufficient evidence on the effect of paracetamol in chronic LBP.A
- Non-steroidal anti-inflammatory drugs (NSAIDs) are effective for patients with acute and chronic low-back pain without sciatica, although the effects are small. For patients with sciatica, there is no evidence that NSAIDs are more effective than placebo.A
- Muscle relaxants are more effective than placebo for low back pain, but their use is associated with frequent adverse effects, especially drowsiness and dizziness.A
- Lumbar supports are probably not effective for prevention or treatment of low back pain ?xm-deletion_mark author="jukkap" time="20080421T111206+0200" data=", and there is conflicting evidence on their effectiveness in the treatment of low back pain"? .C
- Spinal manipulative therapy (SMT) appears to be no more effective in the treatment of patients with acute (1 week to 1 month) low-back pain than inert interventions or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies.B
- Traction, either alone or in combination with other treatments, appears to have little or no impact on pain intensity, functional status, global improvement and return to work among people with low back pain (LBP).B↓↓
- Multidisciplinary biopsychosocial rehabilitation programs (MBR ) may offer some benefit compared with usual care for adults with subacute low back pain (LBP), but it is not clear whether MBR is better than some other type of treatment.C
- Antidepressants may not be more effective than placebo in the management of patients with chronic low-back pain.C
- Superficial heat provides a small short-term reduction in pain and disability for patients with acute or subacute back pain.A
- Opioids appear to reduce pain but seem to have minimal effect on function in patients with chronic low back pain.B
- Spinal manipulative therapy (SMT) equals to other interventions like exercise therapy, standard medical care or physiotherapy for reducing pain and improving function in patients with chronic low-back pain.A↑↑
- Transcutaneous electrical nerve stimulation (TENS) may alleviate pain but does not improve function in chronic low back pain.C
- Low level laser therapy might possibly have minimal beneficial effects on subacute and chronic low back pain in the short term, but the evidence is insufficient.D
- Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain.B
- Multidisciplinary bio-psycho-social rehabilitation appears to be modestly effective for pain and function in cronic low back pain compared to usual care and physiotherapy .B
- Massage may be beneficial for patients with subacute and chronic non-specific low-back pain.C
- For patients with acute or subacute low back pain (LBP), intensive patient education may be effective. For patients with chronic LBP, the effectiveness of individual education is unclear.C
Search terms
Analgesics, Anti-Inflammatory Agents, Back Pain, Exercise, G83.4, Intervertebral Disk Displacement, L4 root, L5 root, Low Back Pain, M51.1, M51.3, M54.3, M54.4, M54.5, M54.8, M54.9, Manipulation, Orthopedic, Neoplasms, Orthopaedics, Paraparesis, Physical medicine, S1 root, S1-nerve root, Schober's test, Sciatica, Spinal Stenosis, Spondylitis, Ankylosing, Spondylolisthesis, Sports, Surgery, acute back pain, acute low back pain, bacterial spondylitis, chronic back pain, chronic low back pain, low back pain, subacute, multiprofessional rehabilitation, muscle relaxant, nonspecific low back pain, radicular symptoms, saddle block syndrome, work capacity