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Low-Back Pain (LBP)
Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD. Register for e-Notifications to be alerted via e-mail of when this section is updated.
By: Bach SM, Holten KB. J Fam Pract. 2009 Dec;58(12):E11. Accessed 2/3/10.
Acute low back pain has been reported as the fifth most common reason for physician outpatient visits. This brief article, written for primary care practitioners, provides a concise summary of recent guidelines for adult acute low back pain. It reviews graded recommendations for management of the first six-week acute phase of low back pain and includes a table that lists the important "red flag" considerations for more serious conditions.
From: Institute for Clinical Systems Improvement (ICSI); 2008; 67 pages. Access checked 1/12/09.
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society By: Chou R, Qaseem A, Snow V, et al. Annals of Internal Medicine. 2007(Oct);147(7):478-491. Accessed 1/15/09.
Also of interest, background papers that review the evidence for drug and nondrug therapies on which the guidelines above were based. Access to both checked 1/15/09.
Evaluation and Treatment of Acute Low Back Pain From: American Academy of Family Physicians (AAFP); 2007; 8 pages. Access checked 1/15/09.
Older articles of interest from AAFP...
Clinic on Low-Back Pain in Interdisciplinary Practice (CLIP) Guidelines From: Agency for Health & Social Services; Montreal, Canada; 2007; 43 pages. Access checked 1/15/09.
From: University of Michigan Health System; Revised 2005; 13 pages. Access checked 1/15/09.
Evaluation and Treatment of Low Back Pain in Family Practice By: Rives PA, Douglass AB. Journal of the American Board of Family Medicine. 2004;17:S23-31. Access checked 1/15/09.
European Guidelines for Prevention in Low Back Pain From: European Commission Working Groups; 2004; 53 pages. Access checked 1/15/09. This guideline is based on the concept that prevention can reduce the impact and consequences of low-back pain even when it is difficult to prevent a first-time incident. While risk factor modifications can reduce the number of episodes, disability, care-seeking, and work loss, it may not be possible to achieve total prevention. Interventions and potential outcomes are discussed for different populations (children, workers, general population) based on evidence from studies and review papers.
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It is estimated that 7 of every 10 persons will experience low-back pain (LBP), with or without sciatica, at some point in their lives. Nearly 20% of adults suffer from back pain of some sort in any given year. Although LBP is often self-limiting, and many patients self-treat their discomfort, back pain is one of the most common reasons for visits to healthcare providers. The various overview papers recommended in this section address this ubiquitous, oftentimes persistent, and difficult to treat condition.
For additional and more specific back-pain topics, see the following sections….
Guideline Update: What’s the Best Approach to Acute Low Back Pain
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The ICSI guideline begins with evaluation and includes indicators to aid differentiation between the need for emergent vs urgent care. The section for the management of acute and chronic low-back pain and sciatica includes an algorithm with levels of evidence for conservative treatment and active rehabilitation. A discussion of indications for timely evaluation plus guidelines for medical, surgical, and nonsurgical referrals are included. Recommendations also are made for prevention, self-care, and lifestyle modifications for acute and chronic pain.
This evidence-based guideline for the evaluation and management of acute and chronic low-back pain in primary care settings was developed through a collaborative effort of the American College of Physicians and the American Pain Society. The guideline focuses on adults presenting with low-back pain unassociated with major trauma, and with or without referred leg pain. Two algorithms are presented: 1) diagnostic evaluations and interpretation which can aid clinicians in identifying a general back pain category during the patient’s first visit, and 2) pain management that includes drug and nonpharmacologic therapies. Clinicians are encouraged to use the guidelines to expand treatment recommendations and explore the benefits and drawbacks of traditional treatment methods. Guidelines for invasive procedures are not included.
This review article concisely addresses the diagnosis and treatment of acute low-back pain. A guide to differential diagnosis includes a table that defines “red flag” findings of concern and provides additional evaluation strategies. Key recommendations for treatment are presented in an evidence-based rating guide, and there is a succinct summary of outcomes for a wide range of treatment modalities. Return-to-work guidelines for patients with acute low-back pain also are included.
This practice guideline was developed by the Robert-Sauvé Research Institute in Workplace Health and Safety and 5 collaborating Canadian organizations representing primary healthcare professionals. It serves as an evidence-based evaluation and practice management tool for low-back pain in all healthcare disciplines. Three classifications of low-back pain (acute, subacute, and persistent) are divided into 3 stages based on length of disability. Based on evidence that supports the influence of specific clinical, psychosocial, and work-related factors on the probability of returning to usual activities of daily living, several questionnaires are provided as assessment tools. Therapeutic interventions based on 4 levels of evidence are presented for initial and remedial treatment. The guideline also makes recommendations for the evaluation and management of disability in patients with persistent pain lasting more than 12 weeks.
These guidelines cover the diagnostic evaluation and initial treatment decisions, plus re-evaluation approaches at 2, 4, 6, and 12-week time points. Assessment tools include an algorithm with considerations for “red flags” and differential diagnosis, as well as a guide to the evaluation of muscle strength and reflexes. Evidence-based treatment recommendations are made separately for radiating and non-radiation low-back pain. Suggestions for pharmacotherapy, nondrug treatment, and patient education include guidelines for patient follow-up.
This 9-page article begins with a categorization of low-back pain based on etiology and a brief discussion of factors related to prevalence. Emphasis is on diagnosis, including the need for a thorough history and physical, with a discussion of the considerations in differential diagnosis. An algorithm includes an evaluation and management timeline. A concise summary of treatment options includes recommendations for the treatment of any existing comorbid conditions and psychosocial issues.