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CLINICAL OBJECTIVES
1. List the most common causes of back pain.
2. Apply the “red flag” screening questions to patients
with back pain.
3. Perform a basic back exam.
4. Discuss appropriate treatments for common back
problems.
Low back pain (LBP) is a self-reported symptom of pain that is
experienced in the lower back region. It is important to recog-
nize that LBP is a symptom and does not reflect any specific
etiology or diagnosis and in fact there are multiple possible eti-
ologies. It is typically considered to be acute or chronic (present
!12 weeks) and both presentations usually have very different
management plans.
The prevalence of LBP on any 1 day among adults in the
United States is 5.6% (1), while 18% report having had back
pain in the previous month (2). The lifetime prevalence of low
back pain has been estimated to be at least 60% to 70% (3–5).
The majority of patients with LBP self-treat their pain and
only 25% to 30% seek medical care (6,7). However, back pain
still ranks as one of the top reasons for visits to family physi-
cians, and accounts for at least $26 billion in direct health care
costs and 2.5% of total health care spending in the United
States (8,9). Family physicians treat more patients with back
pain than physicians from any other specialty and about as
many patients with back pain as orthopedic surgeons and neu-
rosurgeons combined (3). Back pain that becomes chronic is an
economic burden in most industrialized countries. About half
of the lost work days due to back pain are generated by the
15% of patients with chronic pain who require !1 month off
work. The remaining other half of the lost work days are due
to the 85% of patients who have self-limited back pain and
are off work "7 work days (10).
A conservative approach to the diagnosis and manage-
ment of LBP is warranted as most cases are self-limited and
more serious cases can be detected by screening for the red flag
conditions. The natural history of LBP overall is favorable with
some studies showing that 60% of patients are better in 1 week,
90% are better in 6 weeks, and 95% are better in 12 weeks (11).
A more conservative estimate is that one-third will be better in
1 week and two-thirds will be better in 6 to 7 weeks (12).
However, relapses and recurrences are common in this condi-
tion, affecting about 25% to 40% of patients within 6 months
(13,14).
CHAPTER
36
Low Back Pain
Scott Kinkade
DIFFERENTIAL DIAGNOSIS
The key elements of the spine are: the vertebral bodies that
articulate with each other via posterior facet joints and the
intervertebral disk; the spinal cord and nerves that exit via the
neural foramina, and ligaments that stabilize the vertebral bod-
ies and paraspinous muscles that stabilize the spine. Figure 36.1
reveals the most common ligaments of the lumbar spine. The
intervertebral disk is composed of a thick outer annulus fibro-
sis and an inner gelatinous nucleus pulposus. Figure 36.2 shows
a cross-section of a normal intervertebral disc unit with the
associated spinal contents and nerve roots.
Most back pain does not have a clear etiology.
Degenerative changes in any of the structures of the back can
lead to pain. Strains of the muscles and ligaments can cause
pain. The etiology of back pain can generally be divided into:
mechanical conditions, non-mechanical causes, and non-spinal
causes. Mechanical back pain implies an anatomic or functional
abnormality that is exacerbated by movement. Patients with
nonmechanical back pain typically have pain both at rest and
with movement. Non-mechanical LBP is usually due to chem-
ical irritation from causes of inflammation or infection. Table
36.1 summarizes the differential diagnosis for LBP.
Lumbar strain or sprain (reflecting soft tissue inflamma-
tion) is the most common cause of back pain and presents with
pain in the lower back that can radiate into the buttocks or
proximal lower extremities.
The syndrome of herniated disk or herniated nucleus pul-
posus with impingement of the nerve root (radiculopathy) is
commonly known as sciatica. Figure 36.3 shows a diagram of a
herniated disk impinging on a nerve root together with its asso-
ciated magnetic resonance imaging (MRI) scan. This radicular
pain typically radiates in a dermatomal pattern down the leg
and below the knee. Whether or not symptoms radiate past the
knee is a key distinguishing feature of sciatica since non-radicular
causes of LBP typically do not radiate below the knee. The
30- to 55-year-old age group has the highest incidence of herni-
ated disks (15). With increasing age, the disk becomes firmer
(less gelatinous) and is less likely to herniate through the annu-
lus fibrosis. The L4–L5 disk and L5–S1 disk account for 95%
of herniations, the L3–L4 disk accounts for the remaining 5%.
Herniation is very rare in disks above L3 (16).
Cauda equina syndrome is diagnosed when acute neuro-
logical impairment occurs in those structures supplied by the
sacral nerve roots, notably causing bowel or bladder dysfunc-
tion or perineal (“saddle”) anesthesia. This is a surgical emer-
gency that requires urgent diagnosis and treatment. The most
common causes are large paracentral disk herniations and
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438 PA R T I I I • C O M M O N P R O B L E M S

Figure 36.1 • Lateral view of ligaments of lumbar spine.

TA B L E 3 6 . 1 Differential Diagnosis of the Patient with Low Back Pain*

I. Mechanical low back pain 97%
Lumbar strain or sprain/idiopathic low back pain 70%
Degenerative disk/facet process 10%
Herniated disk 4%
Spinal stenosis 3%
Osteoporotic compression fracture 4%
Spondylolisthesis 2%
II. Non-mechanical spinal conditions !1%
Neoplasia 0.7%
Infection 0.01%
Inflammatory arthritis 0.3%
III. Non-spinal, visceral disease 2%
Pelvic organs (prostatitis, pelvic inflammatory disease, endometriosis)
Renal (nephrolithiasis, pyelonephritis)
Aortic aneurysm
Gastrointestinal (pancreatitis, cholecystitis, peptic ulcer)
Shingles (Herpes zoster)
*Data from Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363–370.
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Figure 36.2 • Cross-section of lumbar inter-vertebral disk unit.
tumors. Even with prompt decompression, some patients do
not recover completely.
Spinal stenosis occurs primarily in older individuals and
is related to degenerative changes in the spine with resulting
hypertrophy of the facet joints and ligamentum flavum. The
diameter of the spinal canal or neural outlets is compromised,
often at multiple levels.
Vertebral compression fractures typically occur in older
individuals with osteoporosis. The traditional risk factors for
osteoporosis are: female sex, early menopause, Northern
European or Asian ethnicity, cigarette smoking, sedentary
lifestyle, and chronic steroid use. An uncommon but often
overlooked cause is neoplastic disease in the vertebra that leads
to an insufficiency fracture.
CLINICAL EVALUATION
History
Use the same approach to taking a history that you would use
with any patient with a chief complaint of “pain”:
C H A P T E R 3 6 • L O W B A C K PA I N 439
• Onset—Is the pain acute or chronic? Acute pain, especially
after a precipitating event, suggests a disk problem or muscle
strain. Can the patient recall the details of the onset? Pain
that evolves slowly or insidiously is more likely with a degen-
erative process such as spinal stenosis or a rheumatologic
process such as ankylosing spondylitis. Pain associated with
trauma is worrisome for the possibility of a vertebral frac-
ture.
• Character—Ask the patient to describe the pain. Is it sharp,
dull, etc.? Chronic, constant dull pain may increase the
probability of cancer. Burning, altered sensation or pain that
is described as being like an “electric shock” is often typical
of an irritated nerve or nerve root.
• Location and radiation—The typical pain of lumbar strain
is usually in the paraspinous muscles, sometimes radiating
into the buttock(s). Bone pain from metastatic disease or a
compression fracture is often localized to the spine. Pain that
radiates down below the knee suggests a herniated disk.
As noted, cauda equine syndrome typically presents with
“saddle” anesthesia and bilateral leg pains. Spinal stenosis
also causes pain that radiates into the legs.
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440 PA R T I I I • C O M M O N P R O B L E M S
Vertebral
canal
Herniation
of nucleus
pulposus
Nucleus
pulposus
Anulus
fibrosus
Cauda
equina
Compressed
spinal nerve Defect in
root anulus
fibrosus
Herniation
of nucleus
pulposus
Nucleus
pulposus
Figure 36.3 • Herniation of intervertebral disk, diagram and magnetic resonance imaging.
• Intensity—The intensity (or severity) of pain does not cor-
relate well with the seriousness of the etiology. Individual
patient reactions to pain are strongly influenced by psy-
chosocial factors. However, it may be useful to gauge the
patient’s progress over time. The intensity of pain can be
recorded on a visual analog scale (VAS). The VAS is usu-
ally a 10-cm line where zero represents no pain and 10 rep-
resents intense pain (“the worst ever experienced”). Using
this or a similar tool at each visit can assist recognition of
whether improvement is occurring. The severity of the
pain can also be estimated from how it affects daily activi-
ties. For example, does the pain interfere with sleeping or
with certain activities such as putting on shoes, driving, or
walking?
• Duration—As noted, pain lasting longer than 12 weeks is
usually classified as chronic. Pain lasting "12 weeks is acute,
though some authors define 6 to 12 weeks of pain as suba-
cute. Whether the pain is continuous or waxes and wanes
with pain-free intervals can help determine the etiology.
Rheumatic conditions tend to have initial stiffness and pain
that decrease over a few hours. Diskogenic stiffness tends to
decrease after 20 to 30 minutes. Pain from spinal stenosis
tends to increase with increased activity.
• Associated symptoms—Particularly important associated
findings are considered in the “red flag symptoms” section
Posterior
longitudinal
ligament
Herniation of intervertebral disc
Extradural
(epidural) fat
Vertebral
venous
plexus
Cauda
equina in
cerebro-
spinal fluid
Posterolateral
herniation of disc
compressing the
nerve roots
Anulus
fibrosus
below. The presence of associated stiffness that takes time to
resolve may indicate a systemic disorder such as ankylosing
spondylitis. Coexisting urinary, gynecologic, or abdominal
symptoms may help discern non–spine-related diagnoses.
• Aggravating factors—Pain from a herniated disk is usually
worse with maneuvers that increase the intradiscal pressure
such as valsalva, coughing, or bending forward. The leg
pain from spinal stenosis is often called pseudoclaudication
(or neurogenic claudication) because the symptoms tend to
worsen with exercise. The lower leg pains in this case how-
ever are not due to ischemia as with typical vascular claudi-
cation, but rather to narrowing of the spinal canal causing
radicular impingement. Because extension of the spine nar-
rows the diameter of the canal and neural foramina, patients
with spinal stenosis are more likely to have pain when walk-
ing downhill or down stairs. Figure 36.4 represents the pos-
terior narrowing that occurs with extension of the lumbar
spine. Patients with spinal stenosis typically feel better when
they sit, crouch down, or if pushing a shopping cart, when
leaning forward on the basket.
• Relieving factors—Has the patient tried prescription or over-
the-counter medications or nonpharmacologic measures (mas-
sage, stretching, heat or ice, etc.) and found them helpful? Are
there certain positions that relieve the pain? Remember to ask
about the use of complementary and alternative therapies such
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Figure 36.4 • Effects of flexion and extension on the intervertebral disk.
as chiropractic and acupuncture, as well as the use of dietary
supplements.
• Psychosocial—It is critical to ascertain contextual details of how
the pain is affecting the patient’s lifestyle and other psychosocial
factors, including beliefs about the pain and prognosis, coping
strategies, and pending litigation or disability evaluation.
• “Red flag” symptoms:
A focused assessment should be made to exclude serious
underlying disease. Table 36.2 outlines several red flag
symptoms for back pain that may indicate more serious dis-
ease. Negative answers to all four of these questions: (i) age
!50, (ii) personal history of cancer, (iii) unexplained weight
loss, and (iv) failed conservative therapy effectively rules out
cancer as a cause (17). In addition, a patient without urinary
retention is very unlikely to have cauda equine syndrome
("1 in 10,000) (17). Table 36.2 summarizes the accuracy of
selected historical elements in diagnosing patients with LBP.
Physical Exam
A basic physical exam for LBP includes: assessing range of
motion of the lumbar spine, palpation and inspection of the
spinous processes and paraspinous muscles, assessing motor
strength and deep tendon reflexes in the lower extremities and
performing the straight leg raising test. Assessment of motor
strength in the lower extremities, especially ankle dorsiflexion
C H A P T E R 3 6 • L O W B A C K PA I N 441
and extension of the great toe is important. Tables 36.3 and 36.4
summarize the accuracy of selected elements of the physical
exam and the interpretation of common neurological deficits.
Other good motor exam tests include having the patient walk
on the heels and then the toes, or repeatedly lifting heels off the
ground while standing. Asymmetry in strength when heel
walking or toe walking may indicate a neuropathy. Similarly,
fatiguing the muscle with repetitions may reveal asymmetric
weakness. Additional tests may be indicated by the history such
as an abdominal exam, pelvic exam or prostate exam.
The straight leg raising test (SLR) is performed with the
patient supine to see if radicular pain occurs when the leg is
elevated between 30 and 60 degrees. The SLR test is fairly sen-
sitive for a herniated disk, but not very specific. It is consid-
ered positive when the maneuver causes pain to radiate down
the leg—not when the SLR causes or increases LBP. The
crossed SLR test (pain radiating down the leg on lifting the
opposite leg) is more specific for a herniated disk, but less sen-
sitive.
RECOMMENDED DIAGNOSTIC STRATEGY
Because the vast majority of causes of LBP are not due to a seri-
ous underlying condition and since most cases are self-limited,
diagnostic testing can be used sparingly in the absence of red flag
findings and usually only after patients have failed conservative
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442 PA R T I I I • C O M M O N P R O B L E M S

TA B L E 3 6 . 2 Red Flags for Patients with Low Back Pain Indicating More Serious Disease
General
Failure to improve after 4–6 weeks of conservative therapy
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit
Cancer
Age !50
History of cancer or strong suspicion for current cancer
Unexplained weight loss
Infection
Intravenous drug use
Recent urinary tract infection or skin infection or decubitus ulcers
Immunosuppression
Fever or chills
Fracture
Age !50
History of osteoporosis
Chronic oral steroid use
Substance abuse
Significant trauma

TA B L E 3 6 . 3 Diagnosis of Low Back Pain using the History and Physical Examination*
Diagnosis Suggested Clinical Finding Sn Sp LR! LR"
Cancer Age !50 0.77 0.71 2.7 0.32
Previous history of cancer 0.31 0.98 14.7 0.70
Failure to improve with 1 month of therapy 0.31 0.90 3.0 0.77
Unexplained weight loss 0.15 0.94 2.7 0.90
No relief with bedrest !0.90 0.46 1.7 0.21
Age !50 or history of cancer or unexplained 1.00 0.60 2.5 0.0
weight loss or failure of conservative therapy
Compression fracture Age !50 0.84 0.61 2.2 0.26
Age !70 0.22 0.96 5.5 0.81
Trauma 0.30 0.85 2.0 0.82
Corticosteroid use 0.06 0.995 12.0 0.94
Spinal stenosis Pseudoclaudication 0.60 N/A
No pain when seated 0.46 0.93 6.6 0.58
Pseudoclaudication and age !50 0.90 0.70 3.0 0.14
Herniated disk Sciatica by history 0.95 0.88 7.9 0.06
Ipsilateral SLR 0.80 0.40 1.3 0.50
Crossed SLR 0.25 0.90 2.5 0.83
Ankle dorsiflexion weakness 0.35 0.70 1.2 0.93
Great toe extensor weakness 0.50 0.70 1.7 0.71
Sensory loss 0.50 0.50 1.0 1.0
Hx # history; LR$ # positive likelihood ratio; LR% # negative likelihood ratio; SLR # straight leg raising test; Sn # sensitivity; Sp # specificity.
*Data from Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586–597; and Deyo RA,
Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
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C H A P T E R 3 6 • L O W B A C K PA I N 443

Patient presents with acute LBP

Any red flag conditions suspected

from history or physical?

No Yes

Conservative treatment for up to 6 weeks

• May need to re-evaluate in 1-3 weeks if
significant pain or neurologic
complications
• Pain medications, muscle relaxants,
patient education

No
Improvement in back pain? Begin diagnostic evaluation
• Usually start with plain
films
Yes • May include advanced
imaging and lab tests

Follow-up visit to discuss prevention Spinal pathology detected?

No Yes

Continue conservative therapy Surgical evaluation

May add physical therapy
massage, exercise. Consider
surgical referral for herniated
disc with appropriate
symptoms

Figure 36.5 • An algorithm to guide management of low back pain.

management. Therefore for most patients, assuming they do not
have any red flags, conservative management for the first 4 to
6 weeks is appropriate. This approach has been supported by
many treatment studies and is considered the standard of care
across almost all guidelines (18). Patients who have not recovered
after 4 to 6 weeks should be re-evaluated, possibly with plain
radiographs or advanced imaging. Patients who have worrisome
findings on imaging or unresolving complications of a herniated
disk (cauda equina syndrome, intractable pain, or progressive
neurological deficits) should be referred to a spine specialist for
surgical evaluation.
INITIAL MANAGEMENT OF ACUTE LOW BACK PAIN
Figure 36.5 outlines an approach to the management of LBP
outlined in more detail below.
Acute Lumbar Strain
Acute lumbar strain, also previously called lumbago or nonspe-
cific LBP, accounts for the bulk of back pain diagnoses, has a
good prognosis, and can be treated conservatively. In this condi-
tion, no red flags are noted, there are no significant neurologic

TA B L E 3 6 . 4 Neurological Findings on Physical Examination

Level of Disk Nerve Sensory Reflex
Herniation Root Affected Loss Motor Weakness Exam Maneuver Affected
L3–L4 disk L4 Medial foot Knee extension Squat and rise Patellar
L4–L5 disk L5 Dorsal foot Dorsiflexion ankle/great toe Heel walking None
L5–S1 S1 Lateral foot Plantarflexion ankle/toes Walking on toes Achilles
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444 PA R T I I I • C O M M O N P R O B L E M S
findings and it is considered that symptoms result from a combi-
nation of inflammation, ligamentous injury, and muscle spasm.
The goal of treatment is to provide pain relief until symptoms
resolve rather than to “cure” anything. Acetaminophen, nons-
teroidal anti-inflammatory drugs (NSAIDs), mild opioids,
and skeletal muscle relaxants are all effective in treating acute
LBP. There is no evidence that NSAIDs are better than aceta-
minophen or that there are significant differences between
different types of NSAIDs in treating LBP (19,20) (strength of
recommendation [SOR]#A). The most common side effect
of NSAIDs is gastrointestinal toxicity. If this becomes a
problem, acetaminophen can be used. Muscle relaxants, such
as diazepam or cyclobenzaprine are effective in the short-
term treatment of acute LBP (18,21–23) (SOR#A). If
drowsiness is a problem with muscle relaxants, patients can
take a lower dose, use them only at bedtime, or try metax-
alone, which is less sedating. Local heat is an effective option
for back pain.
Patient education is essential when treating back pain.
There is some evidence for the theory that maladaptive coping
(fear and pain avoidance) with acute back pain is a significant
cause of progression to chronic LBP. Patients should be
advised to stay active. There is strong evidence that bed rest
does not decrease pain intensity or improve function and
therefore should be avoided (18,24) (SOR#A).
HERNIATED DISK WITH RADICULOPATHY
Acute radiculopathy from a herniated disk (sciatica) is initially
treated similarly to acute lumbar strain. Some of these cases
may have mild neurological deficits (decreased reflexes or
strength), but are still initially treated conservatively. Consider
analgesics, including NSAIDs and/or muscle relaxants, and
recommend physical activity as tolerated. Specifically, patients
with sciatica who are advised to rest in bed have no significant
difference in pain or functional status compared with patients
advised to stay active (18,24) (SOR#A).
Most patients will improve over 4 to 6 weeks. Patients
with severe or intractable pain or progressive neurologic
deficits should be re-evaluated earlier and may need referral
or imaging. Patients with radicular symptoms (such as lower
extremity radiation of pain, numbness or absent reflexes) that
are not improved at 6 weeks should probably have an MRI to
determine whether there is a lesion that correlates with the
TA B L E 3 6 . 5 Accuracy of Diagnostic Tests for the Patient with Low Back Pain*
Test Sn Sp
Plain film (for cancer) 0.6 0.95–0.995
CT (for HNP) 0.62–0.9 0.7–0.87
CT (for stenosis) 0.9 0.8–0.96
MRI (for cancer) 0.83–0.93 0.90–0.97
MRI (for infection) 0.96 0.92
MRI (for HNP) 0.6–1.0 0.43–0.97
CT # computed tomography; HNP # herniated nucleus pulposus; LR$ # positive likelihood ratio; LR% # negative likelihood ratio; MRI # magnetic
resonance imaging; Sn # sensitivity; Sp # specificity.
*Data from Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586–597.
symptoms. If a persistent abnormality is noted, referral can be
made to a spine surgeon or directly to interventional radiology
for epidural steroid injections. There is good evidence that no
matter what treatment is pursued for the first 6 weeks the out-
comes are essentially equal (18). Therefore, the treatment
modality selected is based on patient preference.
DIAGNOSTIC TESTING
Diagnostic imaging options in evaluation of LBP include plain
radiographs, computed tomography (CT), MRI, and radionu-
clide bone scans. Plain radiographs (typically anteroposterior
and lateral views of the lumbosacral spine) are not highly
sensitive or specific. They are reasonably useful to identify
compression fractures and degenerative changes of the spine.
Findings of cancer and infection may not show up on early
radiographs. CT scanning, which involves more radiation
exposure than other options, is relatively good for revealing
bony spinal pathology. MRI, because it provides the most
detailed images of the soft tissues of the disk and nerve roots, is
the most commonly used advanced imaging modality for back
pain. MRI and CT scanning, because they provide such good
detail, also show many abnormalities that are not causing clin-
ical symptoms, a factor that diminishes their specificity. In the
case of MRI, studies in asymptomatic adults show herniated
disks in about 30% to 40% of patients, bulging disks in about
50% of patients, and degenerative changes in up to 90% of
patients (15). The diagnostic accuracy of common imaging
modalities is shown in Table 36. 5. Radionuclide bone scanning
is particularly helpful in detecting osteomyelitis, bony metas-
tases, and occult fractures.
If the patient has any red flag symptoms or risk factors, a
plain radiograph with or without a complete blood count and
an erythrocyte sedimentation rate is an appropriate first step.
If there is strong suspicion for serious underlying pathology
and initial imaging is nondiagnostic, consider obtaining
advanced imaging with MRI, CT, or a radionuclide bone scan.
CHRONIC LBP
LBP that is present for more than 3 months is considered
chronic LBP. It is frequently a complicated and expensive con-
dition that may prove difficult for the patient, their family,
their employer, and the physician. It is important to maintain a
positive therapeutic relationship with the patient. Monitoring
LR! LR" Approximate Cost ($)
12–120 0.40–0.42 "150
2.1–6.9 0.11–0.54 400–1,000
4.5–22 0.10–0.12
8.3–31 0.07–0.19 750–1,500
12 0.04
1.1–33 0–0.93
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chronic analgesic use and occupational factors such as fitness
for duty and return to usual work can be time consuming. Only
a small percent of patients with acute LBP progress to chronic
LBP, but the longer a patient is off work or disabled, the more
likely that they will never return to work. There are significant
psychosocial risk factors for chronicity that are not completely
understood and not easily treated. These risk factors include:
depressed mood, psychosocial distress, poor coping strategies,
fear avoidance, somatization, workers compensation claims
and litigation (4,25,26) (SOR#B). Many patients with chronic
LBP do not have a demonstrable radiculopathy, neuropathy, or
anatomic abnormality that explains their symptoms.
The treatment goals for patients with chronic LBP are
largely functional: namely to optimize function, moderate or
cope with pain, and decrease utilization of health care serv-
ices. This typically requires a multidisciplinary effort.
Complete eradication of pain is unlikely. Pain medicines such
as acetaminophen, nonsteroidal anti-inflammatory drugs,
and opioids are often used. Antidepressant drug therapy, par-
ticularly with tricyclic antidepressants, should be given a trial,
even in patients without clinical depression (23,27,28)
(SOR#A). Antidepressant therapy decreases pain, but does
not have an impact on functional status.
Chronic pharmacologic therapy is usually not successful in
relieving or curing chronic back pain. Adjunctive nonpharmaco-
logic therapies have shown benefit in chronic back pain, though
not necessarily in acute back pain. Exercise improves function
and decreases pain in patients with chronic low back pain and is
one of the most effective treatments (23,29,30) (SOR#A). Other
nonpharmacologic treatments that may provide some benefit
include spinal manipulation, massage, acupuncture, yoga, and
intensive interdisciplinary rehabilitation (31–35).
PREVENTION
Strategies to prevent LBP, especially chronic LBP, have the
potential to make a large impact given the prevalence of this
C H A P T E R 3 6 • L O W B A C K PA I N 445
symptom. Unfortunately, the multifactorial nature of back
pain makes any single preventive strategy unlikely to account
for much benefit. The most consistently identified risk factor
for LBP is a history of back pain. Other risk factors include
physical determinants such as heavy lifting, frequent bending,
twisting and lifting, repetitive work with exposure to vibra-
tion, and the psychosocial issues mentioned previously.
The most effective prevention strategy seems to be physi-
cal exercise, which may decrease the incidence of new episodes,
recurrences and lost work days (36) (SOR#C). Education in
the form of back schools and instruction on proper lifting tech-
niques does not seem to be helpful in preventing back problems
and is not recommended. Education that assists in coping with
back pain and encourages activity has a small benefit in pre-
venting chronic or recurrent back pain (36,37) (SOR#C).
There is strong evidence that back belts and lumbar supports
are not effective in preventing back pain in workers and should
not be recommended (36,37) (SOR#A). Overall, effective
strategies for preventing initial or recurrent LBP are lacking.
There are a variety of patient education materials that may be
useful to help educate patients about prevention of back pain
and management of common causes (37).
KEY POINTS
• Screen patients with new-onset low back pain for red-flag
symptoms.
• Perform a focused exam: inspection, palpation, range of
motion, straight leg raise, and neurologic exam of the lower
extremities.
• Lumbar strain and most other causes of mechanical back
pain, including herniated disks, can be treated conservatively
with medications for the pain and advice to stay active.
• The goals of treatment for chronic back pain are to improve
function and decrease pain while trying to prevent permanent
disability and the chronic need for narcotic pain medicines.