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Low Back Pain

Original Editors - Fauve simoens

Top Contributors - Admin, Fauve simoens, Kim Jackson, Bo Hellinckx, Angeliki Chorti, Alicia Fernandes, Naomi O'Reilly, Michael Caruso, Laure VanderDonckt, Lucinda hampton, Adu Omotoyosi Johnson, Evan Thomas, Vidya Acharya, Joshua Samuel, Liana Vorslava, Jess Bell, Nikhil Benhur Abburi, Samuel Adedigba, Oluwatosin Osasona, Simisola Ajeyalemi, WikiSysop, George Prudden, Richard Benes, Wanda van Niekerk, Michelle Lee, Cindy John-Chu, Habibu Salisu Badamasi, Rishika Babburu and Rachael Lowe

Definition

© Primal Pictures

There are different definitions of low back pain (LBP) depending on the source.

  • According to the European Guidelines for prevention of LBP, LBP is defined as “pain and discomfort, localised below the costal margin and above the inferior gluteal folds, with or without leg pain"[1]
  • according to S.Kinkade, which resembles the European guidelines is that LBP is “pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs”.[2]
  • The most common form of LBP is the one that is called “non-specific LBP” and is defined as “LBP not attributed to recognisable, known specific pathology”. [1]

Epidemiology

  • Widespread Prevalence: LBP is a common condition, affecting a significant portion of the population.[3]
  • Lifetime Prevalence: Estimates range from 60-80% of adults.[3]
  • Chronic LBP: Up to 23% of adults suffer from chronic LBP.
  • High Recurrence Rate: Chronic LBP patients have a high risk of recurrence.
  • Adolescent LBP: A significant number of 84% adolescents experience back pain.[3]
  • Disability: LBP can lead to disability in a substantial portion of the population11-12%.[4]

Diagnosis and Classification

Back Pain

Timeframe

Based on duration since onset, LBP can be classified as:

  • acute, less than 6 weeks
  • sub-acute ,between 6 and 12 weeks
  • chronic low back pain. pain for 12 weeks or more.[1]

More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for LBP will have persistent moderate pain for one year after an acute episode. [5][6][7] It is estimated that seven million adults in the United States have activity limitations as a result of chronic LBP. [8]

Diagnostic Triage

There has been a recent move away from a pathoanatomical approach to managing individuals with LBP. No longer do we aim to diagnose a structure at fault and aim our treatment at that particular structure. Research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain. [9][10] [11] Instead, a stratified approach to managing LBP has become popular, using diagnostic triage as per international guidelines. [9]

[12]

Initial Screening:

  • Rule out serious causes 1-2% of LBP cases. (e.g., fracture, cancer, infection, ankylosing spondylitis).[9]
  • Rule out specific causes 5-10% of LBP cases of back pain with neurological deficits (e.g., radiculopathy, cauda equina syndrome).[13][10][14]

When serious and specific causes of low back pain have been ruled out individuals are said to have non-specific (or simple or mechanical) back pain.

Non-Specific (Mechanical) Low Back Pain:

  • Over 90% of LBP cases in primary care.[15]
  • Physiotherapy assessment aims to identify impairments that may have contributed to the onset of the pain, or increase the likelihood of developing persistent pain
  • These include biological factors (eg. weakness, stiffness), psychological factors (eg. depression, fear of movement and catastrophisation) and social factors (eg. work environment).[16]
  • The assessment does not focus on identifying anatomical structures (eg. the intervertebral disc) as the source of pain, as might be the case in peripheral joints such as the knee. [16]
  • Previous research and international guidelines suggest it is not possible or necessary to identify the specific tissue source of pain for the effective management of mechanical back pain. [9][10][17]
  • Therefore the use of diagnostic imaging, especially in the first month, is not recommended. Diagnostic management should only be used if LBP does not respond to recommended protocols and the management of the condition needs to be changed or more serious pathology is suspected.[18]
  • Instead, a recent review of international guidelines for diagnosis and conservative management of LBP concluded that it is better to look for yellow, blue and black flags, in order to stratify the risk of chronicity and/or persistent disability. [19]

Classification of Leg Pain

Leg pain is a frequent accompaniment to LBP, arising from disorders of neural or musculoskeletal structures of the lumbar spine. Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology.

Schäfer et al.[20] proposed that low back-related leg pain be divided into four subgroups according to the predominating pathomechanisms involved. Each group presents with a distinct pattern of symptoms and signs although there may be considerable overlap between the classifications.

  • Central Sensitisation:Positive symptoms such as hyperalgesia (increased sensitivity to pain).
  • Denervation: Significant axonal damage causing:Negative sensory symptoms (e.g., numbness).Possible motor loss.
  • Peripheral Nerve Sensitisation:Increased mechanosensitivity of the nerve trunk.
  • Somatic Referred Pain:Pain originating from musculoskeletal structures (e.g., intervertebral disc or facet joints).

Objective Examination

Posture
Gait

1. Posture and Gait Assessment:[21]

  • Assess the patient's overall posture, including any deviations from a neutral alignment. Look for signs of hyperlordosis, kyphosis, or scoliosis.
  • Observe the patient's gait for any abnormalities, such as limping, asymmetry, or compensatory movements[22][23]

2. Range of Motion (ROM) Assessment:

  • Lumbar spine: Assess flexion, extension, lateral flexion, and rotation.
  • Hip joint: Assess flexion, extension, abduction, adduction, internal rotation, and external rotation[24].

3. Muscle Strength Testing:

  • Lumbar extensors: Test the strength of the erector spinae muscles by having the patient perform prone extensions.
  • Hip flexors: Test the strength of the iliopsoas muscles by having the patient perform hip flexion in supine.[25]

4. Neurological Examination:

  • Sensory testing: Assess light touch, pinprick, and temperature sensation in the dermatomes corresponding to the lumbar spine.
  • Motor testing: Test the strength of the muscles innervated by the lumbar nerve roots (e.g., ankle dorsiflexion, toe extension, plantar flexion).
  • Reflex testing: Test the knee jerk and Achilles tendon reflexes.[26]

5. Palpation:

  • Palpate the lumbar spine for tenderness, muscle spasm, and bony abnormalities.
  • Palpate the sacroiliac joints for tenderness.[27]

6. Special Tests:

  • Straight leg raise (SLR): Test for nerve root tension by raising the patient's leg while keeping the knee straight.
  • Crossed SLR: Test for nerve root tension by raising the opposite leg while keeping the knee straight.
  • Prone knee extension: Test for facet joint irritation by extending the patient's knee while lying prone.[28]

7. Functional Assessment:

  • Observe the patient's ability to perform activities of daily living (ADLs), such as bending, lifting, and sitting.
  • Evaluate the patient's work capacity and any limitations related to their occupation.[29]

8. Patient-Reported Outcomes Measures (PROMs):

  • Use validated PROMs to assess the patient's pain intensity, disability, and quality of life.
  • Examples of PROMs: Oswestry Disability Index, Roland Morris Disability Questionnaire, Numeric Pain Rating Scale.[30]

Management Strategies

General

Management strategies are typically categorised into conservative and invasive approaches, often starting with the least invasive methods. Recent guidelines[31][32][33][34] [19]recommend advice and non-pharmacological management such as physiotherapy interventions that include exercise, physical activity, education and manual therapy.

  •  Exercise therapy, including strengthening, stretching, and aerobic conditioning, is widely recommended for the management of LBP. Several studies have demonstrated its effectiveness in reducing pain and improving function . Tailored exercise programs are encouraged to cater to the specific needs of the patient, focusing on core stability, flexibility, and muscular strength.[35]
  • Manual therapy, such as spinal manipulation or mobilization, is another conservative approach that has shown beneficial outcomes for patients with non-specific LBP. This intervention has been found to reduce pain and improve functional outcomes when used in combination with exercise therapy. [36]
  • In a clinical trial study conducted by Finta et al. [37] titled "The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain" recent evidence suggested that diaphragm training has an effect on improving other active stabilisers of the lumbar spine, such as transversus abdominis and lumbar multifidus muscles in the case of LBP.
  • CBT, ( cognitive behavioral therapy ) on the other hand, addresses psychosocial factors such as fear avoidance and depression, which can prolong recovery. [19][38]
  • Acupuncture is now only recommended by the ACP. [33]
  • Evidence on oral, topical or injected pharmacological treatments is currently ambiguous, and the pharmacological approach may be offered to selected and well-phenotyped patients. [19]
  • Pharmacological treatments for LBP include non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. These medications are used primarily for short-term relief of acute LBP but should be carefully prescribed due to the risk of side effects and dependency [39]. A fairly recent study looked at LBP and the treatment with a long course of antibiotics in a certain population. The inclusion criteria was a previous disc herniation, >6 months back pain and type 1 modic changes adjacent to the previous herniation on MRI scan. Modic changes are where oedema is present in the vertebral body. These patients were treated with 100 days of antibiotics and at reassessment and 1 year follow up there was a statistically significant improvement in their pain levels. Therefore this is potentially something to consider in this population. [40][41] However, recent clinical guidelines issued by the NICE in the UK, [31] The Danish Health Authority[32] and American College of Physicians[33] do not mention the use of antibiotics in the treatment of LBP. Another guideline issued by the KCE in Belgium in 2017[34] states that it does not recommend the use of antibiotics, at any stage, for the treatment of LBP or radicular pain.
  •  For chronic LBP, a multidisciplinary approach, integrating physical therapy, psychological support, and occupational therapy, has shown success in managing symptoms and improving long-term outcomes. Evidence suggests that multidisciplinary rehabilitation results in better functional recovery compared to single-modality treatments [42]
  • Surgery is reserved for cases where conservative treatments fail and when there is a clear structural cause of LBP, such as disc herniation or spinal stenosis. Surgical options like discectomy or spinal fusion have been shown to provide relief in certain cases, but the decision to operate must be carefully considered[43] .

Stratified Approaches

A recent study carried out by Ford et al.[44] suggests that individualised physiotherapy for people with LBP, utilising a Specific Treatment of Problems of the Spine (STOPS) approach, may be more effective in managing LBP. To direct these treatment plans stratified care has been suggested as an appropriate approach.[45] Stratified care is the targeting of treatment to subgroups of patients based on characteristics. Foster et al. [45]suggest that there are 3 different approaches to stratification that have good evidence:

  1. Patient prognosis- matching treatment to patients prognosis such as the likelihood of persistent pain and disability (e.g. STarT Back Screening Tool. [46][47]
  2. Responsiveness to treatment - matching treatments to individuals who would benefit from that treatment (e.g. Treatment Based Classification Approach to Low Back Pain, STOPS Trials).
  3. Underlying mechanisms - matching treatment to mechanisms that drive pain and disability such as pathology, pain mechanisms, negative thoughts and behaviours (e.g. Cognitive Functional Approach). [48][49][50]

Recently Almeida et al. [51] suggest two approaches, based on recent clinical guidelines when considering the management of patients with non-specific LBP.

  1. The traditional approach - stratifying patients by symptom duration - acute (less than 6 weeks), sub-acute (6-12 weeks) and chronic (more than 12 weeks) and then using a stepped approach to treatment beginning with simple therapies and only progressing to more complex treatments if there is no significant improvement. This approach is recommended by the US [33] and Danish[32] guidelines.
  2. The use of Risk prediction tools, such as STarT Back, Örebro Musculoskeletal Pain Screening Questionnaire and PICKUP, as suggested by the UK[31] and Belgian[34] guidelines, to determine the best treatment protocol based on their risk of poor clinical outcome.
Management of Low Back Pain: Adapted from Almeida et al[51]

The use of these different stratification approaches vary around the world and there are overlaps between these three different approaches. A perfect subgrouping approach would include all three of these approaches. These models don’t replace clinical reasoning or experience but they do warrant judicious exploration in clinical practice in appropriate settings.

Contraindications

There are few contraindications to physiotherapy interventions for mechanical back pain as long as the diagnostic triage has been applied to identify people with serious causes of LBP[52].

Absolute Contraindications

Relative Contraindications

  • Osteoporosis: While not an absolute contraindication, it may require modifications to treatment techniques to minimize the risk of fractures.[16]
  • Unstable Spinal Joint: If there is evidence of instability in the spine, certain exercises or manual therapy techniques may be avoided.
  • Severe Neurologic Deficits: If there are significant neurological deficits, such as complete paralysis, physiotherapy may be limited.[54]

Prevention

  • Physical Exercise: [1][2][55]
    • Recommended for preventing LBP consequences like work absences and recurring episodes.
    • Focus on strengthening back extensors and trunk flexors combined with regular aerobic training.
    • No specific guidelines on exercise frequency or intensity; individual adjustments are key.
  • Education: [1][55]
    • High-intensity back school programmes are effective for recurrent, persistent LBP but not for prevention.
    • Combining education with exercise and a skills programme yields better results.
    • Education alone, especially with a biomechanical model, has minimal effect.
    • Education using the biopsychosocial model is more effective, focusing on beliefs about LBP and reducing work loss.
    • Individually tailored programmes offer better outcomes compared to group interventions.
  • Supports and Equipment:[2][1][55]
    • Lumbar supports, back belts, and shoe insoles are not recommended for LBP prevention.
    • These supports can negatively impact back pain beliefs and should be avoided.
    • No strong evidence for or against specific mattresses or chairs for LBP prevention.
    • Medium-support mattresses may help reduce existing LBP symptoms.
  • Ergonomics:[56]
    • Work environment adjustments (ergonomics) are useful in supporting an earlier return to work after LBP episodes.
    • Modifications should be tailored to individual needs for effectiveness.
  • Core Stabilisation: Core strengthening exercises, which include the muscles of the abdomen, pelvis, and lower back, are crucial for maintaining spinal stability and preventing LBP . Core stabilization exercises are shown to enhance trunk muscle endurance, reducing the likelihood of LBP recurrence [57][58]
  • Lifestyle Modifications: Weight management and smoking cessation are important lifestyle changes that help reduce the risk of developing LBP. Obesity places extra strain on the spine, while smoking affects blood flow to spinal discs, leading to degeneration[59] [60]
  • Psychosocial Interventions: Addressing psychosocial factors, such as stress, depression, and work dissatisfaction, is increasingly recognized as part of LBP prevention. These factors can contribute to the onset and persistence of LBP. Cognitive-behavioral therapy (CBT) has been shown to be effective in managing LBP by targeting these psychological aspects [61][62]
  • Manual Therapy: While not a standalone preventive measure, manual therapy techniques, such as spinal manipulation and mobilisation, when combined with exercise, can be effective in preventing future LBP episodes[63][64]
  • Adequate Sleep: Poor sleep quality and inadequate rest have been associated with a higher risk of developing LBP. Ensuring good sleep hygiene and using appropriate bedding may help mitigate this risk [65].[66]
Exercises for Low Back Pain

Exercise Protocols

After each type of exercise, the patient should records the level of each exercise for each training session during the eight-week period.[67]

Warm-Up:

  • Back Awareness: Focus on body posture and alignment.
  • Pelvic Tilt: Practice anterior and posterior pelvic tilts to engage core muscles.
  • Lumbar Rotation: Gently rotate the trunk to improve mobility.[68]
  • Arm Movements: Perform overhead and lateral arm raises to warm up the shoulders and upper body.
  • Whole-Body Movement: Engage in light cardio, such as walking or jogging in place, to increase heart rate.

Core Strengthening:[69]

  • Back Extensors: Exercises like back extensions, bird-dog, and superman to strengthen the muscles supporting the spine.
  • Abdominals: Crunches, planks, and leg raises to engage the core muscles.
  • Lateral Buttocks: Side planks and hip abductions to target the gluteus medius.
  • Trunk Rotators: Russian twists and oblique crunches to improve rotational strength.
  • Posterior Buttocks: Hip thrusts and bridges to strengthen the gluteus maximus.
  • Leg Muscles: Squats, lunges, and calf raises to improve lower body strength and stability.

Flexibility:[70]

  • Hamstring Stretches: Lying hamstring stretch, seated hamstring stretch, and standing hamstring stretch.
  • Quadriceps Stretches: Quadriceps stretch in standing or lying position.
  • Hip Flexor Stretches: Lunge stretch and hip flexor stretch on a table.
  • Calf Stretches: Standing calf stretch against a wall.

Additional Considerations:

  • Progressive Overload: Gradually increase the intensity, duration, or frequency of exercises over time.
  • Listen to Your Body: Avoid exercises that cause pain or discomfort.
  • Proper Form: Focus on maintaining correct form to prevent injuries.
  • Regular Practice: Consistency is key for optimal results.
  • Record Progress: Track your progress by noting the level of difficulty for each exercise during each training session.

Resources

World PT Day 2024

The theme of World PT Day for 2024 was LBP. You can find related material e.g. information sheets, posters, banners, etc here. All LBP material target the general public and promote the role of physiotherapists in the management and prevention of LBP. A resource list for facts and additional reading for physiotherapists is also available, along with an advocacy toolkit.

Guidelines

See Low Back Pain Guidelines

See McKenzie Method

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group. 2004: 1-53.
  2. ↑ 2.0 2.1 2.2 Kinkade S. Evaluation and treatment of acute low back pain. Am Ac of Family Phys. 2007: 1182-1188.
  3. ↑ 3.0 3.1 3.2 Casiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK538173/ (last accessed 21.1.2020)
  4. ↑ Balagué F1, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.
  5. ↑ Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.
  6. ↑ Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.
  7. ↑ Chou R, Qaseem A, Snow V, Casey D, Cross TJ, Shekelle P, Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
  8. ↑ Chou R. Pharmacological Management of Low Back Pain. Drugs [online]. 2010;70 (4):387-402. Available from MEDLINE with FULL TEXT. Accessed April 30, 2011.
  9. ↑ 9.0 9.1 9.2 9.3 Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94
  10. ↑ 10.0 10.1 10.2 van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15(Suppl 2):S169–91
  11. ↑ Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
  12. ↑ Physio REHAB. Acute lower back pain release routine / Daily Rehab #16 / Feat. Tim Keeley. Available from: https://www.youtube.com/watch?v=hjpdXzVlAiU[accessed 10/9/2024]
  13. ↑ Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072–80.
  14. ↑ O'Sullivan, P. and Lin, I. Acute low back pain Beyond drug therapies. Pain Management Today, 2014, 1(1):8-14
  15. ↑ Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
  16. ↑ 16.0 16.1 16.2 M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118
  17. ↑ Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
  18. ↑ Hoffmann TC, Del Mar CB, Strong J, et al. Patients’ expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract 2013; 14: 7
  19. ↑ 19.0 19.1 19.2 19.3 Nicol V, Verdaguer C, Daste C, Bisseriex H, Lapeyre É, Lefèvre-Colau MM, Rannou F, Rören A, Facione J, Nguyen C. Chronic Low Back Pain: A Narrative Review of Recent International Guidelines for Diagnosis and Conservative Treatment. J Clin Med. 2023 Feb 20;12(4):1685.
  20. ↑ Axel Schäfer, Toby Hall and Kathy Briffa. Classification of low back-related leg pain—A proposed patho-mechanism-based approach. Manual Therapy, 2009;14(2):222-230
  21. ↑ Sweeting K, Mock M. Gait and posture - assessment in general practice. Aust Fam Physician. 2007 Jun;36(6):398-401, 404-5. PMID: 17565395.
  22. ↑ Opara JA, Fiałkowski T. The Effect of Kinesiology Taping on Posture, Balance, and Gait in Patients Suffering from Low Back Pain.
  23. ↑ KARIMI MT, ZAHRAEE MH, BAHRAMIZADEH M, KHALILIYAN H, ANSARI M, GHAFFARI F, SHARAFATVAZIRI A. A comparative study of kinematic and kinetic analysis of gait in patients with non-specific low back pain versus healthy controls. Health. 2025;2(2):107-16.
  24. ↑ Roussel NA, Truijen S, De Kerf I, Lambeets D, Nijs J, Stassijns G. Reliability of the assessment of lumbar range of motion and maximal isometric strength in patients with chronic low back pain. Arch Phys Med Rehabil. 2008 Apr;89(4):788-91. doi: 10.1016/j.apmr.2007.09.039. PMID: 18374015.
  25. ↑ de Sousa CS, de Jesus FLA, Machado MB, Ferreira G, Ayres IGT, de Aquino LM, Fukuda TY, Gomes-Neto M. Lower limb muscle strength in patients with low back pain: a systematic review and meta-analysis. J Musculoskelet Neuronal Interact. 2019 Mar 1;19(1):69-78. PMID: 30839305; PMCID: PMC6454257.
  26. ↑ Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, Viswanath O, Jones MR, Sidransky MA, Spektor B, Kaye AD. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11;23(3):23. doi: 10.1007/s11916-019-0757-1. PMID: 30854609.
  27. ↑ Nolet PS, Yu H, Côté P, Meyer AL, Kristman VL, Sutton D, Murnaghan K, Lemeunier N. Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review. Chiropr Man Therap. 2021 Aug 26;29(1):33. doi: 10.1186/s12998-021-00384-3. PMID: 34446040; PMCID: PMC8390263.
  28. ↑ Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, Viswanath O, Jones MR, Sidransky MA, Spektor B, Kaye AD. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11;23(3):23. doi: 10.1007/s11916-019-0757-1. PMID: 30854609.
  29. ↑ Demoulin C, Fauconnier C, Vanderthommen M, Henrotin Y. Recommandations pour l'elaboration d'un bilan fonctionnel de base du patient lombalgique [Recommendations for a basic functional assessment of low back pain]. Rev Med Liege. 2005 Jul-Aug;60(7-8):661-8. French. PMID: 16184742.
  30. ↑ Östhols S, Boström C, Rasmussen-Barr E. Clinical assessment and patient-reported outcome measures in low-back pain - a survey among primary health care physiotherapists. Disabil Rehabil. 2019 Oct;41(20):2459-2467. doi: 10.1080/09638288.2018.1467503. Epub 2018 May 9. Erratum in: Disabil Rehabil. 2019 Oct;41(21):2606. doi: 10.1080/09638288.2018.1477280. PMID: 29741958.
  31. ↑ 31.0 31.1 31.2 National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. London: NICE, 2016.
  32. ↑ 32.0 32.1 32.2 Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60-75.
  33. ↑ 33.0 33.1 33.2 33.3 Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514-530.
  34. ↑ 34.0 34.1 34.2 Van Wambeke P, Desomer A, Ailliet L, et al. Summary: Low back pain and radicular pain: assessment and management. KCE report 287Cs. Brussels: Belgian Health Care Knowledge Centre (KCE), 2017.
  35. ↑ Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Medical journal of Australia. 2017 Apr;206(6):268-73.
  36. ↑ Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine. 2011 Jun 1;36(13):E825-46.
  37. ↑ Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. Journal of pain research. 2018 Nov 28:3031-45.
  38. ↑ Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, Main CJ. Behavioural treatment for chronic low‐back pain. Cochrane database of systematic reviews. 2010(7).
  39. ↑ Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians*. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine. 2017 Apr 4;166(7):514-30.
  40. ↑ Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic Treatment in Patients with Chronic Low back Pain and Vertebral Bone Edema (Modic Type 1 Changes): A Double-blind Randomized Clinical Controlled Trial of Efficacy. Euro Spine Journal 2013; 22: 607-707
  41. ↑ British Association of Spinal Surgeons. Antibiotic Treatment for Chronic Low Back Pain. http://www.spinesurgeons.ac.uk/patients/antibiotics-back-pain (accessed 11 October 2015)
  42. ↑ Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder M. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj. 2015 Feb 18;350.
  43. ↑ Fritzell P, Hägg O, Wessberg P, Nordwall A, Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group.
  44. ↑ Ford J, Hahne A, Surkitt L, Chan A, Richards M. The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain. Journal of clinical medicine. 2019 Sep;8(9):1334.
  45. ↑ 45.0 45.1 Foster N.E, Hill J.C, O'Sullivan P, Childs J.D, Hancock M.J. Stratified models of care for low back pain. WCPT Congress, Singapore, 2015
  46. ↑ Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Care and Research 2008;59:632-41.
  47. ↑ Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71.
  48. ↑ K Vibe Fersum, P O’Sullivan,2 JS Skouen, A Smith, and A Kvåle1. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul; 17(6): 916–928.
  49. ↑ Helen Clare, Roger Adams, Chris G Maher. A systematic review of efficacy of McKenzie therapy for spinal pain. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 50(4):209-16 · FEBRUARY 2004
  50. ↑ Tom Petersen. Non-specific Low Back Pain: Classification and treatment. Lund University, 2003
  51. ↑ 51.0 51.1 Almeida M, Saragiotto, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275
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  54. ↑ Farley T, Stokke J, Goyal K, DeMicco R. Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment. Life. 2024 Jun 27;14(7):812.
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  58. ↑ Desai R, Rathi M, Agrawal P, Palekar TJ. Core stabilization exercises versus yoga on feedforward activation of core muscles in chronic mechanical low back pain: An experimental study. Journal of Bodywork and Movement Therapies. 2024 Oct 1;40:203-10.
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