Low back pain

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Low back pain

Other names Lower back pain, lumbago

Low back pain is a common and costly complaint.

Lumbago /lʌmˈbeɪɡoʊ/
Pronunciation

Specialty Orthopedics, rheumatology, rehabilitation medicine

Usual onset 20 to 40 years of age[1]

Duration ~65% get better in 6 weeks[2]

Types Acute (less than 6 weeks), sub-chronic (6 to 12

weeks), chronic (more than 12 weeks)[3]

 Causes Usually non-specific, occasionally significant

underlying cause[1][4]

Diagnostic Medical imaging (if red flags )[5]

method

Treatment Continued normal activity, non-medication based

treatments, NSAIDs[2][6]

Frequency ~25% in any given month[7][8]

Low back pain (LBP) is a common disorder involving the muscles, nerves, and

bones of the back.[4] Pain can vary from a dull constant ache to a sudden sharp
feeling.[4] Low back pain may be classified by duration as acute (pain lasting less than
6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks). [3] The
condition may be further classified by the underlying cause as either mechanical,
non-mechanical, or referred pain.[5] The symptoms of low back pain usually improve
within a few weeks from the time they start, with 40–90% of people completely better
by six weeks.[2]
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 or joint strain.[1][4] If the pain does not go away with conservative treatment
or if it is accompanied by "red flags" such as unexplained weight loss, fever, or
significant problems with feeling or movement, further testing may be needed to look
for a serious underlying problem.[5] In most cases, imaging tools such as X-ray
computed tomography are not useful and carry their own risks.[9][10] Despite this, the
use of imaging in low back pain has increased.[11] Some low back pain is caused by
damaged intervertebral discs, and the straight leg raise test is useful to identify this
cause.[5] In those with chronic pain, the pain processing system may malfunction,
causing large amounts of pain in response to non-serious events. [12]
Initial management with non–medication based treatments is recommended.
[6]
 NSAIDs are recommended if these are not sufficiently effective. [6] Normal activity
should be continued as much as the pain allows.[2] Medications are recommended for
the duration that they are helpful.[13] A number of other options are available for those
who do not improve with usual treatment. Opioids may be useful if simple pain
medications are not enough, but they are not generally recommended due to side
effects.[4][13] Surgery may be beneficial for those with disc-related chronic pain and
disability or spinal stenosis.[14][15] No clear benefit has been found for other cases of
non-specific low back pain.[14] Low back pain often affects mood, which may be
improved by counseling or antidepressants.[13][16] Additionally, there are
many alternative medicine therapies, including the Alexander technique and herbal
remedies, but there is not enough evidence to recommend them confidently. [17] The
evidence for chiropractic care[18] and spinal manipulation is mixed.[17][19][20][21]
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. [7][8] About
40% of people have LBP at some point in their lives, [7] with estimates as high as 80%
among people in the developed world.[22] Difficulty most often begins between 20 and
40 years of age.[1] Men and women are equally affected.[4] 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. [7]

Video explanation

Contents

 1Signs and symptoms

 2Causes
 3Pathophysiology
o 3.1Back structures
o 3.2Pain sensation
 4Diagnosis
o 4.1Classification
o 4.2Red flags
o 4.3Tests
 5Prevention
 6Management
o 6.1Physical management
o 6.2Medications
o 6.3Surgery
o 6.4Alternative medicine
o 6.5Education
 7Prognosis
 8Epidemiology
 9History
 10Society and culture
 11Research
 12References
 13External links

Signs and symptoms[edit]

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) 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 [23] with the repeated episodes
[1]

being generally more painful than the first.[1]

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.[24] In addition, a majority of those with chronic low back pain show
symptoms of depression[13] or anxiety.[17]

Causes[edit]

A herniated disc as seen on MRI, one possible cause of low back pain

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. [25] The
majority of LBP does not have a clear cause [1] but is believed to be the result of non-
serious muscle or skeletal issues such as sprains or strains.[26] Obesity, smoking,
weight gain during pregnancy, stress, poor physical condition, poor posture and poor
sleeping position may also contribute to low back pain. [26] A full list of possible
causes includes many less common conditions.[5] Physical causes may
include osteoarthritis, degeneration of the discs between the vertebrae or a spinal
disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an
infection or tumor of the spine.[27]
Women may have acute low back pain from medical conditions affecting the female
reproductive system, including endometriosis, ovarian cysts, ovarian cancer,
or uterine fibroids.[28] Nearly half of all pregnant women report pain in the lower back
or sacral area during pregnancy, due to changes in their posture and center of
gravity causing muscle and ligament strain.[29]
Low back pain can be broadly classified into four main categories:

 Musculoskeletal – mechanical (including muscle

strain, muscle spasm, or osteoarthritis); herniated
nucleus pulposus, herniated disk; spinal stenosis;
or compression fracture
 Inflammatory – HLA-B27 associated arthritis
including ankylosing spondylitis, reactive
arthritis, psoriatic arthritis, and inflammatory bowel
disease
  Malignancy – bone metastasis from lung, breast,
prostate, thyroid, among others
 Infectious – osteomyelitis; abscess

Pathophysiology[edit]
Back structures[edit]

The five lumbar vertebrae define the lower back region.

The structures surrounding and supporting the vertebrae can be sources of low back pain.

The lumbar (or lower back) region is made up of five vertebrae (L1–L5), sometimes

including the sacrum. In between these vertebrae are fibrocartilaginous discs, which
act as cushions, preventing the vertebrae from rubbing together while at the same
time protecting the spinal cord. Nerves come from and go to the spinal
cord through specific openings between the vertebrae, providing the skin with
sensations and messages to muscles. Stability of the spine is provided by the
ligaments and muscles of the back and abdomen. Small joints called facet joints limit
and direct the motion of the spine.[30]
The multifidus muscles 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.[12] 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. [31] The problem with the
multifidus muscles continues even after the pain goes away, and is probably an
important reason why the pain comes back.[31] Teaching people with chronic low back
pain how to use these muscles is recommended as part of a recovery program. [31]
An intervertebral disc has a gelatinous core surrounded by a fibrous ring.[32] When in
its normal, uninjured state, most of the disc is not served by either
the circulatory or nervous systems – blood and nerves only run to the outside of the
disc.[32] Specialized cells that can survive without direct blood supply are in the inside
of the disc.[32] Over time, the discs lose flexibility and the ability to absorb physical
forces.[25] 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.[25] As a result, there is less space through which the spinal
cord and nerve roots may pass.[25] 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. [32] Any of
these changes may result in back pain.[32]
Pain sensation[edit]
Pain is generally an unpleasant feeling in response to an event 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, and modulation.
[12]
 The nerve cells that detect pain have cell bodies located in the dorsal root
ganglia and fibers that transmit these signals to the spinal cord. [33] 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, from there to the brain stem, and then from the brain stem to the various
parts of the brain such as the thalamus and the limbic system. In the brain, the pain
signals are processed and given context in the process of pain perception. Through
modulation, the brain can modify the sending of further nerve impulses by
decreasing or increasing the release of neurotransmitters.[12]
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.[12]

Diagnosis[edit]
As the structure of the back is complex and the reporting of pain is subjective and
affected by social factors, the diagnosis of low back pain is not straightforward.
[5]
 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.[3][1]
Classification[edit]
There are a number of ways to classify low back pain with no consensus that any
one method is best.[5] There are three general types of low back pain by cause:
mechanical back pain (including nonspecific musculoskeletal strains, herniated
discs, compressed nerve roots, degenerative discs or joint disease, and broken
vertebra), non-mechanical back pain (tumors, inflammatory conditions such
as spondyloarthritis, and infections), and referred pain from internal organs
(gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among
others).[5] Mechanical or musculoskeletal problems underlie most cases (around 90%
or more),[5][34] 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. [5][34] Rarely,
complaints of low back pain result from systemic or psychological problems, such
as fibromyalgia and somatoform disorders.[34]
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 buttocks, is classified as nonspecific, the most
common classification.[5] 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.[5] 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.[5]
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.[3] Management and prognosis may change based on the duration of
symptoms.
Red flags[edit]
Red flag[35] Possible cause[1]

Previous history of cancer

Cancer
Unintentional weight loss

Loss of bladder or bowel

control

Cauda
Significant motor weakness
equina
or sensory problems
syndrome

Loss of sensation in the

buttocks (saddle anesthesia)

Significant trauma related to age

Chronic corticosteroid use Fracture

Osteoporosis
 Severe pain after lumbar
surgery in past year

Fever

Infection
Urinary tract infection

Immunosuppression

Intravenous drug use

Red flags are warning signs that may indicate a more serious problem

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.[5][36] The presence of a red flag does not mean that there is a
significant problem. It is only suggestive,[37][38] and most people with red flags have no
serious underlying problem.[3][1] If no red flags are present, performing diagnostic
imaging or laboratory testing in the first four weeks after the start of the symptoms
has not been shown to be useful.[5]
The usefulness of many red flags are poorly supported by evidence. [39][40] The most
useful for detecting a fracture are: older age, corticosteroid use, and significant
trauma especially if it results in skin markings. [39] The best determinant of the
presence of cancer is a history of the same. [39]
With other causes ruled out, people with non-specific low back pain are typically
treated symptomatically, without exact determination of the cause. [3][1] Efforts to
uncover factors that might complicate the diagnosis, such as depression, substance
abuse, or an agenda concerning insurance payments may be helpful. [5]
Tests[edit]
The straight leg raise test can detect pain originating from a herniated disc. When warranted, imaging such
as MRI can provide clear detail about disc related causes of back pain (L4–L5 disc herniation shown)

Imaging is indicated when there are red flags, ongoing neurological symptoms that
do not resolve, or ongoing or worsening pain.[5] In particular, early use of imaging
(either MRI or CT) is recommended for suspected cancer, infection, or cauda equina
syndrome.[5] MRI is slightly better than CT for identifying disc disease; the two
technologies are equally useful for diagnosing spinal stenosis. [5] Only a few physical
diagnostic tests are helpful.[5] The straight leg raise test is almost always positive in
those with disc herniation.[5] Lumbar provocative discography may be useful to
identify a specific disc causing pain in those with chronic high levels of low back
pain.[41] Similarly, therapeutic procedures such as nerve blocks can be used to
determine a specific source of pain.[5] Some evidence supports the use of facet joint
injections, transforminal epidural injections and sacroilliac injections as diagnostic
tests.[5] Most other physical tests, such as evaluating for scoliosis, muscle weakness
or wasting, and impaired reflexes, are of little use. [5]
Complaints of low back pain are one of the most common reasons people visit
doctors.[9][42] For pain that has lasted only a few weeks, the pain is likely to subside on
its own.[43] Thus, if a person's medical history and physical examination do not
suggest a specific disease as the cause, medical societies advise against imaging
tests such as X-rays, CT scans, and MRIs.[42] Individuals may want such tests but,
unless red flags are present,[10][44] they are unnecessary health care.[9][43] Routine
imaging increases costs, is associated with higher rates of surgery with no overall
benefit,[45][46] and the radiation used may be harmful to one's health. [45] Fewer than 1%
of imaging tests identify the cause of the problem. [9] Imaging may also detect
harmless abnormalities, encouraging people to request further unnecessary testing
or to worry.[9] Even so, MRI scans of the lumbar region increased by more than 300%
among United States Medicare beneficiaries from 1994 to 2006. [11]

Prevention[edit]
Exercise appears to be useful for preventing low back pain. [47] Exercise is also
probably effective in preventing recurrences in those with pain that has lasted more
than six weeks.[1][48] Medium-firm mattresses are more beneficial for chronic pain than
firm mattresses.[49] There is little to no evidence that back belts are any more helpful
in preventing low back pain than education about proper lifting techniques. [47][50] 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.
[51]
 Shoe insoles do not help prevent low back pain.[47][52]

Management[edit]
Most people with acute or subacute low back pain improve over time no matter the
treatment.[6] There is often improvement within the first month. [6] Recommendations
include remaining active, avoiding activity that worsen the pain, and understanding
self-care of the symptoms.[6] Management of low back pain depends on which of the
three general categories is the cause: mechanical problems, non-mechanical
problems, or referred pain.[53] 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.[3] Providing individuals with coping skills through
reassurance of these facts is useful in speeding recovery. [1] For those with sub-
chronic or chronic low back pain, multidisciplinary treatment programs may help.
[54]
 Initial management with non–medication based treatments is recommended,
with NSAIDs used if these are not sufficiently effective.[6] Non–medication based
treatments include superficial heat, massage, acupuncture, or spinal manipulation.
[6]
 Acetaminophen and systemic steroids are not recommended as both medications
are not effective at improving pain outcomes in acute or subacute low back pain. [6]
Physical management[edit]
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.[48][55] For acute pain, low- to moderate-quality evidence supports
walking.[56] 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.[1] There is tentative evidence to support the use of heat therapy for acute
and sub-chronic low back pain[57] but little evidence for the use of either heat or cold
therapy in chronic pain.[58] 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.[50] Ultrasound and shock wave therapies do not appear effective and
therefore are not recommended.[59][60] Lumbar traction lacks effectiveness as an
intervention for radicular low back pain. [61] It is also unclear whether lumbar supports
are an effective treatment intervention.[62] Aerobic exercises like progressive walking
appears useful for subacute and acute low back pain, is strongly recommended for
chronic low back pain, and is recommended after surgery. [51] In terms of directional
exercise which try to limit low back pain is recommended in sub-acute, chronic
and radicular low back pain. These exercises only work if they are limiting low back
pain.[51] 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. Stretching, especially with limited range of motion, can
impede future progression of treatment like limiting strength and limiting exercises. [51]
Exercise therapy is effective in decreasing pain and improving physical function,
trunk muscle strength and mental health for those with chronic low back pain. [63] It
also appears to reduce recurrence rates for as long as six months after the
completion of program[64] and improves long-term function.[58] There is no evidence
that one particular type of exercise therapy is more effective than another. [65]
[66]
 The Alexander technique appears useful for chronic back pain,[67] and there is
tentative evidence to support the use of yoga.[68] c and tai chi as a form of treatment,
but not recommended to treat acute or subacute low back pain. [51] Transcutaneous
electrical nerve stimulation (TENS) has not been found to be effective in chronic low
back pain.[69] Evidence for the use of shoe insoles as a treatment is inconclusive.
[52]
 Motor control exercise 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 was little different from manual therapy and other forms
of exercise.[70] 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.[71] Aquatic therapy is recommended as an option in those
with other preexisting conditions like extreme obesity, 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.[51] There has been little research that supports the use of
lumbar extension machines and thus they are not recommended. [51] There is no
quality evidence that supports pilates in low back pain.[51]
Medications[edit]
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. [13]
The medication typically recommended first are acetaminophen
(paracetamol), NSAIDs (though not aspirin), or skeletal muscle relaxants and these
are enough for most people.[13][6][72] Benefits with NSAIDs; however, is often small.
[73]
 High-quality reviews have found acetaminophen (paracetamol) to be no more
effective than placebo at improving pain, quality of life, or function. [74][75] 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. [76][13][77] With respect
to safety naproxen may be best.[78] Muscle relaxants may be beneficial.[13]
If the pain is still not managed adequately, short term use of opioids such
as morphine may be useful.[79][13] 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. [13] The effect of long term use of
opioids for lower back pain is unknown.[80] Opioid treatment for chronic low back pain
increases the risk for lifetime illicit drug use. [81] Specialist groups advise against
general long-term use of opioids for chronic low back pain. [13][82] As of 2016, the CDC
has released a guideline for prescribed opioid use in the management of chronic
pain.[83] 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.[83]
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.[84]
Antidepressants may be effective for treating chronic pain associated with symptoms
of depression, but they have a risk of side effects. [13] Although the antiseizure
drugs gabapentin, pregabalin, and topiramate are sometimes used for chronic low
back pain evidence does not support a benefit.[85] Systemic oral steroids have not
been shown to be useful in low back pain.[1][13] 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.[86] Epidural corticosteroid injections provide a slight and questionable short-term
improvement in those with sciatica but are of no long term benefit. [87] There are also
concerns of potential side effects.[88]
Surgery[edit]
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.[14] It may also be useful in those with spinal stenosis.[15] In the absence of
these issues, there is no clear evidence of a benefit from surgery. [14]
Discectomy (the partial removal of a disc that is causing leg pain) can provide pain
relief sooner than nonsurgical treatments. [14] Discectomy has better outcomes at one
year but not at four to ten years.[14] The less invasive microdiscectomy has not been
shown to result in a different outcome than regular discectomy. [14] For most other
conditions, there is not enough evidence to provide recommendations for surgical
options.[14] The long-term effect surgery has on degenerative disc disease is not clear.
[14]
 Less invasive surgical options have improved recovery times, but evidence
regarding effectiveness is insufficient. [14]
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. [15] Fusion may be considered for
those with low back pain from acquired displaced vertebra that does not improve
with conservative treatment,[14] although only a few of those who have spinal fusion
experience good results.[15] There are a number of different surgical procedures to
achieve fusion, with no clear evidence of one being better than the others. [89] Adding
spinal implant devices during fusion increases the risks but provides no added
improvement in pain or function.[11]
Alternative medicine[edit]
It is unclear if among those with non-chronic back pain alternative treatments are
useful.[90] Chiropractic care or spinal manipulation therapy (SMT) appears similar to
other recommended treatments.[91] 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.[3] A 2017 review recommended spinal manipulation based on low
quality evidence.[6] Manipulation under anaesthesia, or medically assisted
manipulation, has not enough evidence to make any confident recommendation.
  Spinal manipulative does not have a significant benefits over motor control
[92]

exercises.[93]
Acupuncture is no better than placebo, usual care, or sham acupuncture for
nonspecific acute pain or sub-chronic pain.[94] 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.[94] This pain benefit is only present right after treatment and
not at follow-up.[94] 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.[1][95]
Massage therapy does not appear to provide much benefit for acute low back pain.
[1]
 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. [96] There was no effect for
improving function.[96] For chronic low back pain massage therapy was no better than
no treatment for both pain and function, though only in the short-term. [96] 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. [96] 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. [51]
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.[17]
Herbal medicines, as a whole, are poorly supported by evidence. [97] 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.[17] Capsicum, in the form of either a gel or a plaster cast, has been
found to reduce pain and increase function.[17]
Behavioral therapy may be useful for chronic pain.[16] 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.[17] The benefit however is small.[98] Medical providers may develop
an integrated program of behavioral therapies. [17] 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.[99][100]
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.[101][102][103] Multidisciplinary biopsychosocial rehabilitation (MBR), targeting physical
and psychological aspects, may improve back pain but evidence is limited. [104] There
is a lack of good quality evidence to support the use of radiofrequency denervation
for pain relief.[105]
KT Tape has been found to be no different for management of chronic non-specific
low back pain than other established pain management strategies. [106]
Education[edit]
There is strong evidence that education 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.[107]

Prognosis[edit]
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%.[2] 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.
[2]
 Certain psychological problems such as depression, or unhappiness due to loss of
employment may prolong the episode of low back pain. [13] Following a first episode of
back pain, recurrences occur in more than half of people. [23]
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.[2] 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),[108] 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).[108]
Prognosis may be influenced by expectations, with those having positive
expectations of recovery related to higher likelihood of returning to work and overall
outcomes.[109]

Epidemiology[edit]
Low back pain that lasts at least one day and limits activity is a common complaint.
[7]
 Globally, about 40% of people have LBP at some point in their lives, [7] with
estimates as high as 80% of people in the developed world. [22] 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. [7][8] Difficulty
most often begins between 20 and 40 years of age.[1] Low back pain is more common
among people aged 40–80 years, with the overall number of individuals affected
expected to increase as the population ages.[7]
It is not clear whether men or women have higher rates of low back pain. [7][8] A 2012
review reported a rate of 9.6% among males and 8.7% among females. [8] 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.[7] An estimated 70% of women experience back pain
during pregnancy with the rate being higher the further along in pregnancy. [110] 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.[111]

History[edit]

Harvey Williams Cushing, 1920s

Low 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.[112]
At the start of the 20th century, physicians thought low back pain was caused by
inflammation of or damage to the nerves, [112] with neuralgia and neuritis frequently
mentioned by them in the medical literature of the time. [113] The popularity of such
proposed causes decreased during the 20th century. [113] In the early 20th century,
American neurosurgeon Harvey Williams Cushing increased the acceptance of
surgical treatments for low back pain.[14] 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.[112] Muscular rheumatism (now called fibromyalgia) was also cited with
increasing frequency.[113]
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.[113] As a result of this work, in the 1940s, the
vertebral disc model of low back pain took over, [112] dominating the literature through
the 1980s, aiding further by the rise of new imaging technologies such as CT and
MRI.[113] 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.[112]

Society and culture[edit]

Low back pain results in large economic costs. In the United States, it is the most
common type of pain in adults, responsible for a large number of missed work days,
and is the most common musculoskeletal complaint seen in the emergency
department.[25] 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.
[25]
 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.[11] 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.[114] 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.[114]
Workers who experience acute low back pain as a result of a work injury may be
asked by their employers to have x-rays.[115] As in other cases, testing is not indicated
unless red flags are present.[115] 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.[115] There should be no legal reason for encouraging people to have tests
which a health care provider determines are not indicated. [115]

Research[edit]
Total disc replacement is an experimental option,[32] but no significant evidence
supports its use over lumbar fusion.[14] 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.[32]