See related handout on low back painwritten by the author of this article and by Richard B. Sisson, a medical student at Georgetown University School of Medicine. Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon.

In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments.

Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments. Low back pain affects a reported 5.

Family physicians treat more patients with back pain than any other subspecialist, and about as many as orthopedists and neurosurgeons combined. Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain.

Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain. Heat therapy may be helpful in reducing pain and increasing function in patients with acute low back pain.

Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care. For information about the SORT evidence rating system, see page or http: Acute low back pain is defined as pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs and that is of less than six weeks' duration.

Sciatica is pain that radiates down the posterior or lateral leg beyond the knee. Serious conditions such as cancer, infection, and visceral disease account for only a small percentage of back pain cases, and vertebral compression fractures account for less than 5 percent Table 1 37 — Herniated disks, which are often managed initially like lumbar strains, account for only 4 percent of back pain cases.

The prevalence of these disorders varies with age, with herniated disks being most common in patients between 20 and 50 years, and degenerative processes e. Pain better when spine is flexed or when seated, aggravated by walking downhill more than uphill; symptoms often bilateral. Pain with activity, usually better with rest; usually detected with imaging; controversial as cause of significant pain.

Information from references 3 and 7 through The natural history of back pain is favorable overall; studies show that 30 to 60 percent of patients recover in one week, 60 to 90 percent recover in six weeks, and 95 percent recover in 12 weeks. The goal of the clinical examination is to identify patients who require immediate surgical evaluation and those whose symptoms suggest a more serious underlying condition such as malignancy or infection. Patients with signs of cauda equina syndrome, such as progressive neurologic deficits, bowel or bladder dysfunction, bilateral sciatica or leg weakness, or numbness in a saddle distribution, require urgent surgical referral.

Physicians should inquire about red flag findings and order appropriate imaging and laboratory studies if necessary Table 2 Typical signs and symptoms of other causes of back pain are listed in Table 1.

Fevers, chills, recent urinary tract or skin infection, penetrating wound near spine. Saddle anesthesia, bilateral sciatica or leg weakness, difficulty urinating, fecal incontinence. Information from reference Screening tests to detect a herniated disk include asking about the presence of sciatica, the straight leg raise, the crossed straight leg raise i. Herniated disks are unlikely in patients with no history of sciatica i. Four percent of patients with acute low back pain have a herniated disk, but 95 percent of patients with herniation have sciatica; therefore, the likelihood of a symptomatic herniated disk in a patient with acute back pain but no symptoms of sciatica is approximately one in Physical examination findings are useful in localizing the level of the disk herniation Table 3.

Because acute low back pain typically does not have a serious etiology, and because most cases resolve with conservative treatment, immediate imaging is rarely indicated. All major guidelines on the treatment of acute low back pain have similar recommendations regarding imaging. Suggested evaluations for patients with red flag findings are outlined in Table 2. If clinical suspicion is sufficiently high, it may be necessary to proceed directly to advanced imaging.

If magnetic resonance imaging MRI is not readily available, or if the cost is prohibitive, computed tomography may be adequate. Diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. In studies of lumbar spine MRI evaluation in asymptomatic adults, herniated disks were found in 9 to 76 percent of patients, bulging disks in 20 to 81 percent, degenerative disks in 46 to 93 percent, and annular tears in 14 to 56 percent.

Treatment methods for acute low back pain and the evidence to support them are reviewed in the following. Oral nonsteroidal anti-inflammatory drugs NSAIDs are recommended for the treatment of acute low back pain.

One systematic review of 51 randomized controlled trials comparing NSAIDs with placebo found strong evidence that NSAIDs significantly improve pain control. There is conflicting evidence about whether NSAIDs are superior to acetaminophen for treatment of acute low back pain.

Some patients with acute low back pain, and more commonly those with sciatica, require oral opioids to control the pain. Opioids should be considered a second- or third-line analgesic option and should be used only for a short period for most patients. There is little evidence from well-designed studies regarding the benefits and harms of opioid use in acute low back pain, and there have been few comparisons with other pain relievers. Several small studies have shown no significant advantage of opioid use in symptom relief or return to work when compared with NSAIDs or acetaminophen.

Two meta-analyses provide strong evidence that muscle relaxants are helpful in the treatment of nonspecific acute low back pain. There is some evidence that skeletal muscle relaxants lead to additional improvement when used with NSAIDs. Side effects of skeletal muscle relaxants include drowsiness and dizziness and may limit the usefulness of these drugs. Patients taking cyclobenzaprine at a dosage of 10 mg three times per day were nearly two times more likely to report side effects than those taking placebo 53 versus 28 percent, respectively.

Metaxalone Skelaxin and low-dose cyclobenzaprine i.

No studies support the use of oral steroids in patients with acute low back pain. Epidural steroid injections may be helpful in patients with radicular symptoms that do not respond to two to six weeks of conservative therapy. Randomized trials have demonstrated short-term i. Bed rest provides no benefit to patients who have acute low back pain with or without sciatica. For nonspecific low back pain, there is strong evidence that advice to stay active rather than rest in bed results in less time missed from work, improved functional status, and less pain.

There is limited evidence for the benefit of educating patients about low back pain. Patient education focusing on activity, aggravating factors, the natural history of the disease, its relatively benign etiology, and expected time course for improvement may speed recovery and prevent chronic pain.

Recommendations should include staying active but avoiding heavy lifting, bending, twisting, and prolonged sitting.

Modification of work duties may be required; however, patients should be encouraged to return to work at light duty rather than wait for complete resolution of the pain see Table 4 38 for specific recommendations. No prolonged sitting, standing, or walking without a five-minute break every 30 minutes.

Driving car or light truck up scottrade forex review six hours per day; driving heavy vehicle or equipment up to four hours per day. Times until return to full duty will vary with severity and role and are typical for ages 35 to 55 years. Times for younger workers are approximately 20 to 30 percent shorter.

Specific back exercises for patients with acute low back pain are not helpful. A meta-analysis of 10 trials of structured exercise therapy compared with no exercise in patients with acute low back pain demonstrated no benefit with exercise programs.

Two systematic reviews found insufficient evidence to make a reliable recommendation regarding massage for acute low back pain. No commission forex broker is limited evidence about the use of acupuncture in the treatment of acute low back pain.

Higher-quality trials provide moderate evidence that it is not beneficial. One lower-quality trial using a combination of acupuncture, herbs, and moxibustion versus herbal therapy alone found a small benefit with acupuncture, whereas another lower-quality trial of acupuncture versus moxibustion found no benefit. There is minimal evidence regarding the use of cold therapy in the treatment of acute low back pain.

Four good-quality systematic reviews of spinal manipulative therapy in acute low back pain are available. Newer studies that were not included in the reviews have mixed results. A study involving patients with acute low back pain and sciatica found that patients receiving spinal manipulative therapy were significantly less likely to have pain at six months than those receiving sham manipulation.

Studies of physical therapy for acute low back pain are heterogeneous because the intervention method differs: Two meta-analyses regarding the McKenzie method of physical therapy are available. Individualized education during physical therapy, particularly when it is focused on fear avoidance and staying active, appears to be helpful.

Because relapses of back pain are common and the societal burden of chronic back pain is large, strategies to prevent initial injuries or to prevent acute back pain from becoming chronic may be useful. Preventive Services Acuity stock brokers sri lanka Force USPSTF 64 and the COST B13 Working Group on European Guidelines for Prevention in Low Back Pain 65 have synthesized the evidence on prevention.

The USPSTF concluded that there is insufficient evidence to recommend for or against the routine use of exercise interventions to prevent back pain. The European guidelines recommend exercise to prevent work absence and the occurrence or prolongation of further back pain episodes; the authors found stronger evidence of the effectiveness of exercise to prevent low back pain and recurrences in the subpopulation of workers.

Recommendations how do you get lots of neopoints on neopets mixed regarding back schools, and neither of the guidelines recommends the use of lumbar supports or back belts for prevention of low back pain.

There is strong evidence that lumbar supports do not prevent low back pain. There stock market crash of 1987 recovery strong evidence that several psychosocial factors correlate with the development of chronic back pain Table 5.

Fear avoidance exaggerated pain or fear that activity will cause permanent damage. Information from references 66 through Already a member or subscriber? He received his medical degree from the University of Texas Medical School in Houston. Kinkade completed a family medicine residency at Martin Army Community Hospital in Fort Benning, Ga.

Address correspondence to Scott Kinkade, M. Reprints are not available from the author. Loney PL, Stratford PW. The prevalence of low back pain in adults: Dillon C, Paulose-Ram R, Hirsch R, Gu Q. Skeletal muscle relaxant use in the United States: Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.

Best Pract Res Clin Rheumatol. Malanga G, Nadler S, Agesen T. Cole AJ, Herring SA, eds. The Low Back Pain Handbook: A Guide for the Practicing Clinician.

Hanley and Belfus, Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS. Patterns and perceptions of care for treatment of back and neck pain: Deyo RA, Weinstein JN. N Engl J Med. Early diagnostic evaluation of low back pain. J Karachi internet trading system Intern Med.

Deyo RA, Diehl AK. Cancer as a cause of back pain: Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain?. Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care.

McNally EG, Wilson DJ, Ostlere SJ. Limited magnetic resonance imaging in low back pain instead of plain radiographs: Carragee EJ, Hannibal M. Diagnostic evaluation of low back pain. Orthop Clin North Am. Carey TS, Garrett JM, Jackman A, Hadler N. Recurrence and care seeking after acute back pain: North Carolina Back Pain Project.

Bradley WG Binary options true or scam, Seidenwurm DJ, Brunberg JA, Davis PC, De La Paz RL, Dormont D, et al. Accessed January 10,at: Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. Institute for Clinical Systems Improvement. The Norwegian Back Pain Network. Acute low back pain: European guidelines for the management of acute nonspecific low back pain in primary care.

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Diagnostic evaluation of low back pain with emphasis on imaging. Nonsteroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. Bandolier Extra, February Accessed February 14,at: Browning R, Jackson JL, O'Malley PG. Cyclobenzaprine and back pain: Muscle relaxants for non-specific low back cme fx options handbook. Beebe FA, Barkin RL, Barkin S. A volatility edge in options trading rar and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions.

Chou R, Peterson K, Helfand M.

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Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: J Pain Symptom Manage.

Toth PP, Urtis J. Commonly used muscle relaxant therapies for acute bbc.co.uk/stock market back pain: Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: Nelemans PJ, de Bie RA, de Vet HC, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Wilson-MacDonald J, Burt G, Griffin D, Glynn C.

Epidural steroid injection for nerve root compression: J Bone Joint Surg Br. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low-back pain and sciatica. Hilde G, Hagen KB, Jamtvedt G, Winnem M. Advice to stay active as a single treatment for low back pain and sciatica. Henrotin YE, Cedraschi C, Duplan B, Bazin T, Duquesnoy B. Information and low back fast cash loans online in south africa management: Burton AK, Waddell G, Tillotson KM, Summerton N.

Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W.

A comparison of physical therapy, chiropractic manipulation, ncfm forex module provision of an educational booklet for the treatment of patients with low back pain. Moffett JK, Mannion AF.

What is the value of physical therapies for back pain?. Work Loss Data Institute, Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Furlan AD, Brosseau L, Imamura M, Irvin E.

Massage for low back pain. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, et al. Acupuncture and dry-needling for low back pain. Manheimer E, White A, Berman B, Forys K, Ernst E. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Mayer JM, Ralph L, Look M, Erasala GN, Verna JL, Matheson LN, et al.

Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW. Continuous low-level heatwrap therapy for treating acute nonspecific low back pain.

Arch Phys Med Rehabil. Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Hinkle RT, Beth Goodale M, et al. Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Nadler SF, Steiner DJ, Petty SR, Erasala GN, Hengehold DA, Weingand KW. Overnight use of continuous low-level heatwrap therapy for relief of low back pain.

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Active warming during emergency transport relieves acute low back pain. Tao XG, Bernacki EJ. A randomized clinical trial of continuous low-level heat therapy for acute muscular low back pain in the workplace. J Occup Environ Med. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. Bronfort G, Haas M, Evans RL, Bouter LM.

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Efficacy of spinal manipulation and mobilization for low back pain and neck pain: Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. J Manipulative Physiol Ther. Outcome of non-invasive treatment modalities on back pain: Santilli V, Beghi E, Finucci S.

Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: UK BEAM Trial Team. United Kingdom back pain exercise and manipulation UK BEAM randomised trial: Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM.

A randomized trial of chiropractic and medical care for patients with low back pain: Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, et al. Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: Hoiriis KT, Pfleger B, McDuffie FC, Cotsonis G, Elsangak O, Hinson R, et al.

A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.

Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Machado LA, de Souza MS, Ferreira PH, Ferreira ML. The McKenzie method for low back pain: Clarke JA, van Tulder MW, Blomberg SE, de Vet HC, van der Heijden GJ, Bronfort G.

Traction for low-back pain with or without sciatica. Preventive Services Task Force. Burton AK, Balague F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, et al. How to prevent low back pain [Published correction appears in Best Pract Res Clin Rheumatol ; Best Pract Res Clin Rheumatol ; Persistent low back pain. Pincus T, Burton AK, Vogel S, Field AP. Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, Reis S. Cognitive-behavioral therapy and psychosocial factors in low back pain: Cedraschi C, Allaz AF.

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Apr 15, Issue. Evaluation and Treatment of Acute Low Back Pain. Abstract Diagnosis Treatment Prevention References. Article Sections Abstract Diagnosis Treatment Prevention References.

C 16 — 20 Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain. A 2224 — 26 Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. A 3233 Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain.

C 3437 Specific back exercises for patients with acute low back pain are not helpful. A 39 Heat therapy may be helpful in reducing pain and increasing function in patients with acute low back pain. B 45 — 50 Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care.

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Typical modified duty Mild low back pain Severe low back pain Sciatica Light work i. Table 4 Return-to-Work Guidelines for Patients with Acute Low Back Pain Activity level Expected return to unmodified work with: Table 5 Psychosocial Factors Associated with an Increased Likelihood of Developing Chronic Back Pain Disputed compensation claims Fear avoidance exaggerated pain or fear that activity will cause permanent damage Job dissatisfaction Pending or past litigation related to the back pain Psychological distress and depression Reliance on passive treatments rather than active patient participation Somatization Information from references 66 through Read the full article.

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Continue reading from April 15, Previous: A Fall in the Dark Next: Diffuse pain in lumbar muscles; some radiation to buttocks. Localized lumbar pain; similar findings to lumbar strain.

Leg pain often worse than back pain; pain radiating below knee. Spine tenderness; often history of trauma. Spine tenderness; weight loss.

Morning stiffness, improves with exercise. Spine tenderness; constitutional symptoms. Pelvic organs—prostatitis, pelvic inflammatory disease, endometriosis. Lower abdominal symptoms common. Usually involves abdominal symptoms; abnormal urinalysis. Epigastric pain; pulsatile abdominal mass. Gastrointestinal system—pancreatitis, cholecystitis, peptic ulcer. Epigastric pain; nausea, vomiting. Unilateral, dermatomal pain; distinctive rash. Unrelenting night pain or pain at rest. Progressive motor or sensory deficit.

History of cancer or strong suspicion for current cancer. Chronic oral steroid use. Failure to improve after six weeks of conservative therapy.

No lifting more than 5 lb 2. No lifting more than 25 lb No prolonged standing or walking without a minute break every hour. Pending or past litigation related to the back pain. Psychological distress and depression. Reliance on passive treatments rather than active patient participation.

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