今日の臨床サポート

背部痛(back pain)

著者: 須田浩太 北海道せき損センター

著者: 松本聡子 北海道せき損センター

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2022/03/16
患者向け説明資料

概要・推奨   

  1. 腰痛を経験したことがある成人は多く、大半は予後良好である。
  1. Red Flagsの有無を必ず確認する。
  1. 腰椎椎間板ヘルニアを疑う場合、Straight Leg Raising Test(SLRT)を施行するよう推奨される(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
須田浩太 : 特に申告事項無し[2022年]
松本聡子 : 特に申告事項無し[2022年]
監修:酒井昭典 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 一生の間に80%の人が腰痛を経験すると言われている[1]
  1. 大半の腰痛の長期予後は良好である[2]
  1. 心理社会的要因が、慢性腰痛の誘因となる可能性が高い[3]
  1. 急性腰痛の大半は自然に改善し、ルーチンでの画像検査は行うべきではない[4]
  1. Red flags[5]が該当する場合は、しかるべき対処が必要。
  1. Red flagsとは、
  1. 発症年齢<20歳または>55歳
  1. 時間や活動性に関係のない腰痛
  1. 胸部痛
  1. 癌、ステロイド治療、HIV感染の既往
  1. 栄養不良
  1. 体重減少
  1. 広範囲に及ぶ神経症状
  1. 構築性脊柱変形
  1. 発熱
  1. 腰痛を経験したことがある成人は多く、大半は予後良好である(o)。
  1. 腰痛についての複数の研究がある。
  1. 2002年のUS National Health Interview Surveyによると、3万人の回答者のうち26.4%(約8,000人)が過去3カ月に1日以上持続する腰痛を経験したと回答している[6]
  1. カナダでの成人を対象にした研究によると、1年間で18.6%が腰痛を発症し、84.1%がこれまでに腰痛を経験したことがあるとしている[7]
  1. 973人の腰痛患者を経時的に追跡した研究では、72%が1年後には完全に腰痛が改善していたとしている[8]
  1. 腰痛患者の85%以上は確定診断に至らないとする報告もある[9]
  1. 3カ月以内に32%が腰痛を再発し、医療機関を受診しているとする研究もある[10]
  1. これらにより腰痛を経験したことがある成人は多く、大半は予後良好であるといえる。
問診・診察のポイント  
 
  1. 発症から6週間以内を急性(90%は自然に軽快)、6~12週間を亜急性、12週間以上を慢性と分類する。

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文献 

R A Deyo, Y J Tsui-Wu
Descriptive epidemiology of low-back pain and its related medical care in the United States.
Spine (Phila Pa 1976). 1987 Apr;12(3):264-8.
Abstract/Text Accurate United States data on the prevalence of low-back pain (LBP) and its related medical care would assist health care planners, policy makers, and investigators. Data from the second National Health and Nutrition Examination Survey (NHANES II) were analyzed to provide such information. The cumulative lifetime prevalence of LBP lasting at least 2 weeks was 13.8%. In univariate analyses, important variations in prevalence were found by age, race, region, and educational status. Most persons with LBP sought care from general practitioners, with orthopaedists and chiropractors being the next most common sources of care. Sources of care, and in some cases therapy, varied among demographic subgroups. These data demonstrate substantial nonbiologic influences on the prevalence and treatment of LBP, and suggest an agenda for health services researchers.

PMID 2954221
R A Deyo, J Rainville, D L Kent
What can the history and physical examination tell us about low back pain?
JAMA. 1992 Aug 12;268(6):760-5.
Abstract/Text
PMID 1386391
R A Deyo, J N Weinstein
Low back pain.
N Engl J Med. 2001 Feb 1;344(5):363-70. doi: 10.1056/NEJM200102013440508.
Abstract/Text
PMID 11172169
Roger Chou, Paul Shekelle
Will this patient develop persistent disabling low back pain?
JAMA. 2010 Apr 7;303(13):1295-302. doi: 10.1001/jama.2010.344.
Abstract/Text CONTEXT: Low back pain is extremely common. Early identification of patients more likely to develop persistent disabling symptoms could help guide decisions regarding follow-up and management.
OBJECTIVE: To systematically review the usefulness of individual risk factors or risk prediction instruments for identifying patients more likely to develop persistent disabling low back pain.
DATA SOURCES: Electronic searches of MEDLINE (1966-January 2010) and EMBASE (1974-February 2010) and review of the bibliographies of retrieved articles.
STUDY SELECTION: Prospective studies of patients with fewer than 8 weeks of low back pain from which likelihood ratios (LRs) were calculated for prediction of persistent disabling low back pain for findings attainable during the clinical evaluation.
DATA EXTRACTION: Two authors independently assessed studies and extracted data to estimate LRs.
DATA SYNTHESIS: A total of 20 studies evaluating 10,842 patients were identified. Presence of nonorganic signs (median [range] LR, 3.0 [1.7-4.6]), high levels of maladaptive pain coping behaviors (median [range] LR, 2.5 [2.2-2.8]), high baseline functional impairment (median [range] LR, 2.1 [1.2-2.7]), presence of psychiatric comorbidities (median [range] LR, 2.2 [1.9-2.3]), and low general health status (median [range] LR, 1.8 [1.1-2.0]) were the most useful predictors of worse outcomes at 1 year. Low levels of fear avoidance (median [range] LR, 0.39 [0.38-0.40]) and low baseline functional impairment (median [range] LR, 0.40 [0.10-0.52]) were the most useful items for predicting recovery at 1 year. Results were similar for outcomes at 3 to 6 months. Variables related to the work environment, baseline pain, and presence of radiculopathy were less useful for predicting worse outcomes (median LRs approximately 1.5), and a history of prior low back pain episodes and demographic variables were not useful (median LRs approximately 1.0). Several risk prediction instruments were useful for predicting outcomes, but none were extensively validated, and some validation studies showed LRs similar to estimates for individual risk factors.
CONCLUSION: The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.

PMID 20371789
Richard A Deyo, Sohail K Mirza, Brook I Martin
Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.
Spine (Phila Pa 1976). 2006 Nov 1;31(23):2724-7. doi: 10.1097/01.brs.0000244618.06877.cd.
Abstract/Text STUDY DESIGN: Review and analysis of data from two U.S. national surveys in 2002.
OBJECTIVES: To examine the prevalence of back pain and physician visits for back pain in the United States.
SUMMARY OF BACKGROUND DATA: National data on the prevalence of back pain become available only intermittently.
METHODS: We summarized published data from the 2002 National Health Interview Survey (NHIS) on the prevalence of back pain and compared it with earlier surveys. We also analyzed the 2002 National Ambulatory Medical Care Survey (NAMCS) to determine physician visit rates for back pain.
RESULTS: In the 2002 NHIS, there were 31,044 adult respondents. Low back pain lasting at least a whole day in the past 3 months was reported by 26.4% of respondents, and neck pain was reported by 13.8%. Among racial groups, American Indians and Alaska Natives had the highest prevalence of low back pain, and Asian Americans had the lowest. Prevalence generally declined with greater levels of education and increasing income. Prevalence estimates were consistent with those from previous surveys, although methodologic differences limited comparisons. NAMCS data suggested that the proportion of all physician visits attributable to low back pain (2.3% in 2002) has changed little since the early 1990s.
CONCLUSIONS: About one fourth of U.S. adults report low back pain in the past 3 months; the proportion of physician visits attributed to back pain has changed little in the past decade.

PMID 17077742
J D Cassidy, L J Carroll, P Côté
The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults.
Spine (Phila Pa 1976). 1998 Sep 1;23(17):1860-6; discussion 1867.
Abstract/Text STUDY DESIGN: Population-based, cross-sectional, mailed survey.
OBJECTIVES: To determine the lifetime, 6-month period, and point prevalence of low back pain and its related disability among Saskatchewan adults and to investigate the presence and strength of selective response bias.
SUMMARY OF BACKGROUND DATA: There have been many reports of the prevalence of low back pain in different populations, and the estimates vary widely depending on case definition. However, most studies fail to differentiate between trivial and disabling back pain, which raises the issue of the usefulness of these estimates. No studies have yet documented the prevalence of graded low back pain severity and its related disability in a North American, general, population-based survey.
METHODS: The Saskatchewan Health and Back Pain Survey was mailed to a probability sample of 2184 Saskatchewan adults between 20 and 69 years of age. Fifty-five percent of the eligible population responded to the survey. Respondents were compared with nonrespondents, and the presence of selective response bias by back pain status was investigated by wave analysis. The point and lifetime prevalence of low back pain was determined by simple questions, and the 6-month period prevalence of low back pain was determined by the Chronic Pain Questionnaire. All estimates were age standardized to the Saskatchewan population.
RESULTS: The authors estimate that at the time of the survey 28.4% (95% confidence interval, 25.6-31.1) of the Saskatchewan adult population were experiencing low back pain, and 84.1% (95% confidence interval, 81.9-86.3) had experienced it during their lifetime. Overall, 48.9% (95% confidence interval, 45.9-52.0) of the population had experienced low intensity/low-disability low back pain in the previous 6 months, 12.3% (95% confidence interval, 10.3-14.4) had experienced high-intensity/low-disability low back pain, and an additional 10.7% (95% confidence interval, 8.8-12.5) had experienced high-disability low back pain in the previous 6 months. There was little variation in the estimates over age groups, but women experienced more high-disability back pain than men. There was no evidence of selective response bias by low back pain status in the survey.
CONCLUSION: Low-intensity/low-disability low back pain is a common problem in the general population. Approximately 11% of the adult population studied had been disabled by low back pain in the previous 6 months.

PMID 9762743
Nicholas Henschke, Christopher G Maher, Kathryn M Refshauge, Robert D Herbert, Robert G Cumming, Jane Bleasel, John York, Anurina Das, James H McAuley
Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study.
BMJ. 2008 Jul 7;337:a171. Epub 2008 Jul 7.
Abstract/Text OBJECTIVE: To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.
DESIGN: Cohort study with one year follow-up.
SETTING: Primary care clinics in Sydney, Australia.
PARTICIPANTS: An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks' duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.
MAIN OUTCOME MEASURES: Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.
RESULTS: The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.
CONCLUSIONS: In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.

PMID 18614473
M W van Tulder, W J Assendelft, B W Koes, L M Bouter
Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies.
Spine (Phila Pa 1976). 1997 Feb 15;22(4):427-34.
Abstract/Text STUDY DESIGN: A systematic review of published observational studies.
OBJECTIVES: To examine the causal relationship between radiographic findings and nonspecific low back pain.
SUMMARY OF BACKGROUND DATA: The causal relationship between radiographic findings and nonspecific low back pain still is controversial.
METHODS: Two reviewers independently scored the methodologic quality of all relevant, available studies using a standardized set of criteria. The association between radiographic findings and nonspecific low back pain was expressed as an odds ratio with a corresponding 95% confidence interval.
RESULTS: Degeneration, defined by the presence of disc space narrowing, osteophytes, and sclerosis, turned out to be associated with nonspecific low back pain with odds ratios ranging from 1.2 to 3.3. Spondylolysis and spondylolisthesis, spina bifida, transitional vertebrae, spondylosis, and Scheuermann's disease did not appear to be associated with low back pain. The validity scores of the observational studies ranged from 0% to 91% of the maximum score. Only two studies used a prospective design, and most studies lacked control for confounding, an appropriate test for nonspecific low back pain, and blinded assessment of radiographs and low back pain status.
CONCLUSIONS: There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain.

PMID 9055372
D Kendrick, K Fielding, E Bentley, R Kerslake, P Miller, M Pringle
Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.
BMJ. 2001 Feb 17;322(7283):400-5.
Abstract/Text OBJECTIVE: To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.
DESIGN: Randomised unblinded controlled trial.
SETTING: 73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.
SUBJECTS: 421 patients with low back pain of a median duration of 10 weeks.
INTERVENTION: Radiography of the lumbar spine.
MAIN OUTCOME MEASURES: Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.
RESULTS: The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.
CONCLUSIONS: Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.

PMID 11179160
R A Deyo, A K Diehl, M Rosenthal
Reducing roentgenography use. Can patient expectations be altered?
Arch Intern Med. 1987 Jan;147(1):141-5.
Abstract/Text Many roentgenographic tests, including lumbar spine roentgenograms, may be overutilized. We examined the psychological, functional, and financial consequences of omitting spine films for patients with back pain with little risk of underlying systemic illness. Patients were randomized to receive immediate roentgenograms (n = 49) or a brief educational intervention, with roentgenography only for failure to improve (n = 52). After three weeks, 73% of the roentgenography group believed "everyone with back pain should have an x-ray," vs 44% of the education group. After three months, although 31% in the education group had received roentgenograms, overall radiology charges were still far less than those of the roentgenography group. No serious diagnoses were missed, and symptom resolution, functional improvement, and satisfaction were similar for the two groups. Thus, eliminating or delaying spine films need not cause anxiety, dissatisfaction, or dysfunction. This strategy may modify future expectations of roentgenography use and reduce health care costs.

PMID 2948466
Sally Kerry, Sean Hilton, Derek Dundas, Elizabeth Rink, Pippa Oakeshott
Radiography for low back pain: a randomised controlled trial and observational study in primary care.
Br J Gen Pract. 2002 Jun;52(479):469-74.
Abstract/Text BACKGROUND: Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain. Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely. However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care.
AIM: To compare short and long-term physical, social, and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice.
DESIGN OF STUDY: A randomised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial.
SETTING: Ninety-four general practices in south London and the South Thames region.
METHOD: Patients consulting their general practitioner (GP) with low back pain at first presentation were recruited to a randomised controlled trial (RCT) or to an observational group. Patients in the trial were randomly allocated to immediate referral for x-ray or to no referral. All patients were asked to complete questionnaires initially, and then at six weeks and one year after recruitment.
RESULTS: Six hundred and fifty-nine patients were recruited over 26 months: 153 to the randomised trial and 506 to the observational arm. In the RCT referral for x-ray had no effect on physical functioning, pain or disability, but was associated with a small improvement in psychological wellbeing at six weeks and one year. These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation; however, those referred for x-ray had lower depression scores.
CONCLUSIONS: Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.

PMID 12051211
L M Ash, M T Modic, N A Obuchowski, J S Ross, M N Brant-Zawadzki, P N Grooff
Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain.
AJNR Am J Neuroradiol. 2008 Jun;29(6):1098-103. doi: 10.3174/ajnr.A0999. Epub 2008 May 8.
Abstract/Text BACKGROUND AND PURPOSE: We conducted a prospective randomized study of patients with acute low back pain and/or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome. The practice of ordering spinal imaging, perhaps unintentionally, includes a large number of patients for whom the imaging test is performed for purposes of reassurance or because of patient expectations. If this rationale is valid, one would expect to see a measurable effect from diagnostic information, per se.
MATERIALS AND METHODS: A total of 246 patients with acute (<3 weeks) low back pain (LBP) and/or radiculopathy (150 LBP and 96 radiculopathy patients) were recruited. Patients were randomized using a stratified block design with equal allocation to either the unblinded group (MR imaging results provided within 48 hours) or the blinded group (both patient and physician blinded to MR imaging results.) After the initial MR imaging, patients followed 6 weeks of conservative management. Roland function, visual pain analog, absenteeism, Short Form (SF)-36 Health Status Survey, self-efficacy scores, and Fear Avoidance Questionnaire were completed at presentation; 2, 4, 6, and 8 weeks; and 6, 12, and 24 months. Improvement of Roland score by 50% or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome.
RESULTS: Clinical outcome at 6 weeks was similar for unblinded and blinded patients. Self-efficacy, fear avoidance beliefs, and the SF-36 subscales were similar over time for blinded and unblinded patients, except for the general health subscale on the SF-36. General health of the blinded group improved more than for the unblinded group (P = .008).
CONCLUSIONS: Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being.

PMID 18467522
Roger Chou, Amir Qaseem, Vincenza Snow, Donald Casey, J Thomas Cross, Paul Shekelle, Douglas K Owens, Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel
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 Oct 2;147(7):478-91.
Abstract/Text RECOMMENDATION 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). RECOMMENDATION 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). RECOMMENDATION 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). RECOMMENDATION 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). RECOMMENDATION 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. RECOMMENDATION 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

PMID 17909209
R E Anderson, B P Drayer, B Braffman, P C Davis, M D Deck, A N Hasso, B A Johnson, T Masaryk, S J Pomeranz, D Seidenwurm, L Tanenbaum, J C Masdeu
Acute low back pain--radiculopathy. American College of Radiology. ACR Appropriateness Criteria.
Radiology. 2000 Jun;215 Suppl:479-85.
Abstract/Text
PMID 11037459
O Airaksinen, J I Brox, C Cedraschi, J Hildebrandt, J Klaber-Moffett, F Kovacs, A F Mannion, S Reis, J B Staal, H Ursin, G Zanoli, COST B13 Working Group on Guidelines for Chronic Low Back Pain
Chapter 4. European guidelines for the management of chronic nonspecific low back pain.
Eur Spine J. 2006 Mar;15 Suppl 2:S192-300. doi: 10.1007/s00586-006-1072-1.
Abstract/Text
PMID 16550448
Jeffrey G Jarvik, Richard A Deyo
Diagnostic evaluation of low back pain with emphasis on imaging.
Ann Intern Med. 2002 Oct 1;137(7):586-97.
Abstract/Text PURPOSE: To review evidence on the diagnostic accuracy of clinical information and imaging for patients with low back pain in primary care settings.
DATA SOURCE: MEDLINE search (January 1966 to September 2001) for articles and reviews relevant to the accuracy of the clinical and radiographic examination of patients with low back pain.
STUDY SELECTION: The authors reviewed abstracts and selected articles for review on the basis of a combined judgment. Data on the clinical examination were based primarily on recent systematic reviews; data on imaging tests were based primarily on original articles.
DATA EXTRACTION: Diagnostic results were extracted by one or the other author. Quality of methods was evaluated informally. Major potential biases were identified, but neither quantitative data extraction nor scoring was done.
DATA SYNTHESIS: Formal meta-analysis was not used because the diagnostic hardware and software, gold standards, and patient selection methods were heterogeneous and the number of studies was small. Sensitivity for cancer was highest for magnetic resonance imaging (0.83 to 0.93) and radionuclide scanning (0.74 to 0.98); specificity was highest for magnetic resonance imaging (0.9 to 0.97) and radiography (0.95 to 0.99). Magnetic resonance imaging was the most sensitive (0.96) and specific (0.92) test for infection. The sensitivity and specificity of magnetic resonance imaging for herniated discs were slightly higher than those for computed tomography but very similar for the diagnosis of spinal stenosis.
CONCLUSIONS: The data suggest a diagnostic strategy similar to the 1994 Agency for Health Care Policy and Research guidelines. For adults younger than 50 years of age with no signs or symptoms of systemic disease, symptomatic therapy without imaging is appropriate. For patients 50 years of age and older or those whose findings suggest systemic disease, plain radiography and simple laboratory tests can almost completely rule out underlying systemic diseases. Advanced imaging should be reserved for patients who are considering surgery or those in whom systemic disease is strongly suspected.

PMID 12353946
W L Devillé, D A van der Windt, A Dzaferagić, P D Bezemer, L M Bouter
The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs.
Spine (Phila Pa 1976). 2000 May 1;25(9):1140-7.
Abstract/Text STUDY DESIGN: A systematic review of the literature including statistical meta-analysis.
OBJECTIVES: To evaluate published methods of the test of Lasègue or straight leg raising test and the cross straight leg raising test by using a recently developed criteria list and to summarize and explore reasons for variation in diagnostic accuracy.
SUMMARY OF BACKGROUND DATA: Little evidence exists on the diagnostic accuracy of the widely used straight leg raising test and the cross straight leg raising test in diagnosing herniated discs in patients with low back pain.
METHODS: MEDLINE and EMBASE searches up to 1997 showed 17 diagnostic publications evaluating the straight leg raising test with surgery as reference standard. Quality of methods was assessed with a specific checklist. Eleven studies were selected for statistical pooling. Sources of variation and heterogeneity were studied by meta-regression of the diagnostic odds ratio.
RESULTS: All studies were surgical case-series at nonprimary care level. Verification-bias was obvious in one study. Pooled sensitivity for straight leg raising test was 0. 91 (95% CI 0.82-0.94), pooled specificity 0.26 (95% CI 0.16-0.38). Pooled diagnostic odds ratio was 3.74 (95% CI 1.2-11.4). Discriminative power was lower in recent studies, in studies with only inclusion of primary hernias, and with blind assessment of both the index-test (straight leg raising test) and the reference (surgery). For the cross straight leg raising test pooled sensitivity was 0.29 (95% CI 0.24-0.34), pooled specificity was 0.88 (95% CI 0.86-0.90), and the pooled diagnostic odds ratio 4.39 (95% CI 0.74-25.9).
CONCLUSIONS: The diagnostic accuracy of the straight leg raising test is limited by its low specificity. Discriminative power decreased with a more valid design, a more homogenous case-mix, and year of publication. Although the studies may reflect everyday clinical practice, they do not enable a valid evaluation of the diagnostic accuracy of both tests. Diagnostic research should evaluate the validity of the complete diagnostic process and study the evidence of the added value of the different tests used. [Key words: sensitivity, specificity, diagnosis, meta-analysis, test of Lasègue, straight leg raising test]

PMID 10788860
Kristin Thuve Dahm, Kjetil G Brurberg, Gro Jamtvedt, Kåre Birger Hagen
Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.
Cochrane Database Syst Rev. 2010 Jun 16;(6):CD007612. doi: 10.1002/14651858.CD007612.pub2. Epub 2010 Jun 16.
Abstract/Text BACKGROUND: Acute low-back pain (LBP) is a common reason to consult a general practitioner. Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management.
OBJECTIVES: To determine the effects of advice to rest in bed or stay active for patients with acute low-back pain or sciatica.
SEARCH STRATEGY: We searched the Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to May 2009, reference lists of relevant articles, and contacted authors of relevant articles.
SELECTION CRITERIA: Randomised trials of the effectiveness of advice to stay active or rest in bed for patients with acute LBP or sciatica. The main outcomes were pain, functional status, recovery and return to work.
DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed the risk of bias and extracted data. The trials were combined qualitatively or statistically, depending on data availability and presentation.
MAIN RESULTS: We included ten RCTs with varying risk of bias. For patients with acute LBP, results from two trials (N = 401) suggest small improvements in pain relief (SMD 0.22 (95% CI: 0.02 to 0.41) and functional status (SMD 0.29 (95% CI: 0.09 to 0.49) in favour of advice to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain relief (SMD -0.03 (95% CI: -0.24 to 0.18)) or functional status (SMD 0.19 (95% CI: -0.02 to 0.41)), between advice to rest in bed or stay active.Low quality evidence (3 RCTs, N = 931) suggests little or no difference between exercises, advice to rest in bed or stay active for patients with acute LBP. Low quality evidence (1 RCT, N = 250) suggests little or no difference between physiotherapy, advice to rest in bed or stay active for patients with sciatica. No trials that compared different ways of delivering advice.
AUTHORS' CONCLUSIONS: Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed; patients with sciatica experience little or no difference between the two approaches. Low quality evidence suggests little or no difference between those who received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact on the estimate of effect and is likely to change our confidence in it.

PMID 20556780
Reece A Davies, Christopher G Maher, Mark J Hancock
A systematic review of paracetamol for non-specific low back pain.
Eur Spine J. 2008 Nov;17(11):1423-30. doi: 10.1007/s00586-008-0783-x. Epub 2008 Sep 17.
Abstract/Text The objective of this study was to assess the efficacy of paracetamol (acetaminophen) in the treatment of pain and disability in patients with non-specific low back pain. We conducted a systematic review of randomized controlled trials to assess the efficacy of paracetamol in the treatment of pain and disability in patients with non-specific low back pain. A search for randomized controlled trials was conducted using the Medline, Embase and CINAHL databases. Trials were eligible if they were randomized controlled trials comparing paracetamol to no treatment, placebo or another treatment in patients with non-specific low back pain. Two of the authors independently assessed trials for methodological quality on the PEDro Scale and extracted data. Continuous pain and disability data were converted to a common 0-10 scale; ordinal data were dichotomized (e.g., no pain, pain). The data was analyzed using the MIX version 1.61 meta-analysis software. Out of 205 unique articles found in the searches, 7 eligible trials were identified. The trials enrolled a total of 676 participants with 5 investigating acute low back pain, 1 investigating chronic low back pain and 1 investigating both. No trial provided data comparing paracetamol to placebo and only one trial compared paracetamol to no treatment. In general the trials were small (only 1 trial had >25 subjects per group) and of low methodological quality (only 2 had a score above 6 on the quality scale). All but one of the trials provided imprecise estimates of the effects of treatment with confidence intervals spanning clinically important beneficial and also harmful effects of paracetamol. No trial reported a statistically significant difference in favor of paracetamol. There is insufficient evidence to assess the efficacy of paracetamol in patients with low back pain. There is a clear need for large, high quality randomized controlled trials evaluating paracetamol, to provide reliable evidence of paracetamol's effectiveness in patients with low back pain and to establish the validity of the recommendations in clinical guidelines.

PMID 18797937
P D D M Roelofs, R A Deyo, B W Koes, R J P M Scholten, M W van Tulder
Non-steroidal anti-inflammatory drugs for low back pain.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000396. doi: 10.1002/14651858.CD000396.pub3. Epub 2008 Jan 23.
Abstract/Text BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications worldwide and are widely used for patients with low-back pain. Selective COX-2 inhibitors are currently available and used for patients with low-back pain.
OBJECTIVES: The objective was to assess the effects of NSAIDs and COX-2 inhibitors in the treatment of non-specific low-back pain and to assess which type of NSAID is most effective.
SEARCH STRATEGY: We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials up to and including June 2007 if reported in English, Dutch or German. We also screened references given in relevant reviews and identified trials.
SELECTION CRITERIA: Randomised trials and double-blind controlled trials of NSAIDs in non-specific low-back pain with or without sciatica were included.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed methodological quality. All studies were also assessed on clinical relevance, from which no further interpretations or conclusions were drawn. If data were considered clinically homogeneous, a meta-analysis was performed. If data were lacking for clinically homogeneous trials, a qualitative analysis was performed using a rating system with four levels of evidence (strong, moderate, limited, no evidence).
MAIN RESULTS: In total, 65 trials (total number of patients = 11,237) were included in this review. Twenty-eight trials (42%) were considered high quality. Statistically significant effects were found in favour of NSAIDs compared to placebo, but at the cost of statistically significant more side effects. There is moderate evidence that NSAIDs are not more effective than paracetamol for acute low-back pain, but paracetamol had fewer side effects. There is moderate evidence that NSAIDs are not more effective than other drugs for acute low-back pain. There is strong evidence that various types of NSAIDs, including COX-2 NSAIDs, are equally effective for acute low-back pain. COX-2 NSAIDs had statistically significantly fewer side-effects than traditional NSAIDs.
AUTHORS' CONCLUSIONS: The evidence from the 65 trials included in this review suggests that NSAIDs are effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica. However, effect sizes are small. Furthermore, there does not seem to be a specific type of NSAID which is clearly more effective than others. The selective COX-2 inhibitors showed fewer side effects compared to traditional NSAIDs in the RCTs included in this review. However, recent studies have shown that COX-2 inhibitors are associated with increased cardiovascular risks in specific patient populations.

PMID 18253976
M W van Tulder, T Touray, A D Furlan, S Solway, L M Bouter
Muscle relaxants for non-specific low back pain.
Cochrane Database Syst Rev. 2003;(2):CD004252. doi: 10.1002/14651858.CD004252.
Abstract/Text BACKGROUND: The use of muscle relaxants in the management of non-specific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved.
OBJECTIVES: The aim of this review was to determine if muscle relaxants are effective in the treatment of non-specific low back pain.
SEARCH STRATEGY: A computer-assisted search of the Cochrane Library (Issue 2, 2002), MEDLINE (1966 up to October 2001) and EMBASE (1988 up to October 2001) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened.
SELECTION CRITERIA: Randomised and/or double-blinded controlled trials, involving patients diagnosed with non-specific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic modalities, were included for review.
DATA COLLECTION AND ANALYSIS: Two reviewers independently carried out the methodological quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong", "moderate", "limited", "conflicting" or "no" evidence.
MAIN RESULTS: Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality, 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 non-benzodiazepines and two antispasticity muscle relaxants in comparison with placebo. Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute LBP on short-term pain relief. The pooled RR for non-benzodiazepines versus placebo after two to four days was 0.80 [95% CI; 0.71 to 0.89] for pain relief and 0.49 [95% CI; 0.25 to 0.95] for global efficacy. Adverse events, however, with a relative risk of 1.50 [95% CI; 1.14 to 1.98] were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (RR 2.04; 95% CI; 1.23 to 3.37). The various muscle relaxants were found to be similar in performance.
REVIEWER'S CONCLUSIONS: Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or non-steroidal anti-inflammatory drugs.

PMID 12804507
Vladimir Skljarevski, Shuyu Zhang, Durisala Desaiah, Karla J Alaka, Santiago Palacios, Tomasz Miazgowski, Kyle Patrick
Duloxetine versus placebo in patients with chronic low back pain: a 12-week, fixed-dose, randomized, double-blind trial.
J Pain. 2010 Dec;11(12):1282-90. doi: 10.1016/j.jpain.2010.03.002. Epub 2010 May 15.
Abstract/Text UNLABELLED: This randomized, double-blind, placebo-controlled study assessed efficacy and safety of duloxetine in patients with chronic low back pain (CLBP). Adults (n = 401) with a nonneuropathic CLBP and average pain intensity of ≥ 4 on an 11-point numerical scale (Brief Pain Inventory [BPI]) were treated with either duloxetine 60 mg once daily or placebo for 12 weeks. The primary measure was BPI average pain. Secondary endpoints included Patient's Global Impressions of Improvement (PGI-I), Roland Morris Disability Questionnaire (RMDQ-24), BPI-Severity (BPI-S), BPI-Interference (BPI-I), and response rates (either ≥ 30% or ≥ 50% BPI average pain reduction at endpoint). Health outcomes included Short Form-36, European Quality of Life-5 Dimensions, and the Work Productivity and Activity Impairment questionnaire. Safety and tolerability were assessed. Compared with placebo-treated patients, duloxetine-treated patients reported a significantly greater reduction in BPI average pain (P ≤ .001). Similarly, duloxetine-treated patients reported significantly greater improvements in PGI-I, BPI-S, BPI-I, 50% response rates, and some health outcomes. The RMDQ and 30% response rate showed numerical improvements with duloxetine treatment. Significantly more patients in the duloxetine group (15.2%) than patients in the placebo group (5.4%) discontinued because of adverse events (P = .002). Nausea and dry mouth were the most common treatment-emergent adverse events with rates significantly higher in duloxetine-treated patients.
PERSPECTIVE: This study provides clinical evidence of the efficacy and safety of duloxetine at a fixed dose of 60 mg once daily in the treatment of chronic low back pain (CLBP). As of December 2009, duloxetine has not received regulatory approval for the treatment of CLBP.

Copyright © 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.
PMID 20472510
Vladimir Skljarevski, Durisala Desaiah, Hong Liu-Seifert, Qi Zhang, Amy S Chappell, Michael J Detke, Smriti Iyengar, Joseph H Atkinson, Miroslav Backonja
Efficacy and safety of duloxetine in patients with chronic low back pain.
Spine (Phila Pa 1976). 2010 Jun 1;35(13):E578-85. doi: 10.1097/BRS.0b013e3181d3cef6.
Abstract/Text STUDY DESIGN: This was a randomized, double-blind, placebo-controlled clinical trial.
OBJECTIVE: To assess the efficacy and safety of duloxetine in the treatment of chronic low back pain (CLBP).
SUMMARY OF BACKGROUND DATA: Imbalance of serotonin and norepinephrine within modulatory pain pathways has been implicated in the development and maintenance of chronic pain. Duloxetine, a selective reuptake inhibitor of serotonin and norepinephrine, has demonstrated clinical efficacy in 3 distinct chronic pain conditions: diabetic peripheral neuropathic pain, fibromyalgia, and chronic pain because of osteoarthritis.
METHODS: In this randomized double-blind trial, adult nondepressed patients with a non-neuropathic CLBP and a weekly mean of the 24-hour average pain score>or=4 at baseline (0-10 scale) were treated with either duloxetine or placebo for 13 weeks. The dose of duloxetine during first 7 weeks was 60 mg once daily. At week 7, patients reporting<30% pain reduction had their dose increased to 120 mg. The primary outcome measure was the Brief Pain Inventory (BPI) 24-hour average pain rating. Secondary measures included Roland-Morris Disability Questionnaire-24; Patient's Global Impressions of Improvement; Clinical Global Impressions-Severity (CGI-S); BPI-Severity and -Interference (BPI-I); and weekly means of the 24-hour average pain, night pain, and worst pain scores from patient diaries. Quality-of-life, safety, and tolerability outcomes were also assessed.
RESULTS: Compared with placebo-treated patients (least-squares mean change of -1.50), patients on duloxetine (least-squares mean change of -2.32) had a significantly greater reduction in the BPI 24-hour average pain from baseline to endpoint (P=0.004 at week 13). Additionally, the duloxetine group significantly improved on Patient's Global Impressions of Improvement; Roland-Morris Disability Questionnaire-24; BPI-Severity and average BPI-Interference; weekly mean of the 24-hour average pain, night pain, and worst pain. Significantly more patients in the duloxetine group (13.9%) compared with placebo (5.8%) discontinued because of adverse events (P=0.047). The most common treatment-emergent adverse events in the duloxetine group included nausea, dry mouth, fatigue, diarrhea, hyperhidrosis, dizziness, and constipation.
CONCLUSION: Duloxetine significantly reduced pain and improved functioning in patients with CLBP. The safety and tolerability were similar to those reported in earlier studies.

PMID 20461028
V Skljarevski, M Ossanna, H Liu-Seifert, Q Zhang, A Chappell, S Iyengar, M Detke, M Backonja
A double-blind, randomized trial of duloxetine versus placebo in the management of chronic low back pain.
Eur J Neurol. 2009 Sep;16(9):1041-8. doi: 10.1111/j.1468-1331.2009.02648.x. Epub 2009 May 12.
Abstract/Text BACKGROUND: Duloxetine has demonstrated analgesic effect in chronic pain states. This study assesses the efficacy of duloxetine in chronic low back pain (CLBP).
METHODS: Adult patients with non-radicular CLBP entered this 13-week, double-blind, randomized study comparing duloxetine 20, 60 or 120 mg once daily with placebo. The primary measure was comparison of duloxetine 60 mg with placebo on weekly mean 24-h average pain. Secondary measures included Roland-Morris Disability Questionnaire (RMDQ-24), Patient's Global Impressions of Improvement (PGI-I), Brief Pain Inventory (BPI), safety and tolerability.
RESULTS: Four hundred four patients were enrolled, 267 completed. No significant differences existed between any dose of duloxetine and placebo on reduction in weekly mean 24-h average pain at end-point. Duloxetine 60 mg was superior to placebo from weeks 3-11 in relieving pain, but not at weeks 12-13. Duloxetine 60 mg demonstrated significant improvement on PGI-I, RMDQ-24, BPI-average pain and BPI-average interference. Significantly more patients taking duloxetine 120 mg (24.1%) discontinued because of adverse events, versus placebo (8.5%).
CONCLUSIONS: Duloxetine was superior to placebo on the primary objective from weeks 3-11, but superiority was not maintained at end-point. Duloxetine was superior to placebo on many secondary measures, and was well-tolerated.

PMID 19469829
Daniel C Cherkin, Karen J Sherman, Janet Kahn, Robert Wellman, Andrea J Cook, Eric Johnson, Janet Erro, Kristin Delaney, Richard A Deyo
A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial.
Ann Intern Med. 2011 Jul 5;155(1):1-9. doi: 10.7326/0003-4819-155-1-201107050-00002.
Abstract/Text BACKGROUND: Few studies have evaluated the effectiveness of massage for chronic low back pain.
OBJECTIVE: To compare the effectiveness of 2 types of massage and usual care for chronic back pain.
DESIGN: Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384)
SETTING: An integrated health care delivery system in the Seattle area.
PATIENTS: 401 persons 20 to 65 years of age with nonspecific chronic low back pain.
INTERVENTION: Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133).
MEASUREMENTS: Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful.
RESULTS: The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small.
LIMITATION: Participants were not blinded to treatment.
CONCLUSION: Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.
PRIMARY FUNDING SOURCE: National Center for Complementary and Alternative Medicine.

PMID 21727288
S H Snook, B S Webster, R W McGorry, M T Fogleman, K B McCann
The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. A randomized controlled trial.
Spine (Phila Pa 1976). 1998 Dec 1;23(23):2601-7.
Abstract/Text STUDY DESIGN: Eighteen-month, randomized controlled trial with partial crossover.
OBJECTIVES: To test the hypothesis that the control of lumbar flexion in the early morning will significantly reduce chronic, nonspecific low back pain.
SUMMARY OF BACKGROUND DATA: Previous studies have indicated an increased risk of low back pain with bending forward in the early morning, primarily because of increased fluid content in the intervertebral discs at that time.
METHODS: After 6 months of recording baseline data, 85 subjects with persistent or recurring low back pain were randomly assigned to treatment and control groups. The treatment group received instruction in the control of early morning lumbar flexion. The control group received a sham treatment of six exercises shown to be ineffective in reducing low back pain. Six months later, the control group received the experimental treatment, Diaries were used to record daily levels of pain intensity, disability, impairment, and medication usage.
RESULTS: Significant reductions in pain intensity (P < 0.01) were recorded for the treatment group, but not for the control group (point estimate, 33%; 95% confidence interval, 11-55%). After receiving the experimental treatment, the control group responded with similar reductions (P < 0.05). Significant reductions also were observed in total days in pain, disability, impairment, and medication usage.
CONCLUSIONS: Controlling lumbar flexion in the early morning is a form of self-care with potential for reducing pain and costs associated with chronic, nonspecific low back pain.

PMID 9854759
J A Hayden, M W van Tulder, A Malmivaara, B W Koes
Exercise therapy for treatment of non-specific low back pain.
Cochrane Database Syst Rev. 2005 Jul 20;(3):CD000335. doi: 10.1002/14651858.CD000335.pub2. Epub 2005 Jul 20.
Abstract/Text BACKGROUND: Exercise therapy is widely used as an intervention in low-back pain.
OBJECTIVES: To evaluate the effectiveness of exercise therapy in adult non-specific acute, subacute and chronic low-back pain versus no treatment and other conservative treatments.
SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (Issue 3, 2004), MEDLINE, EMBASE, PsychInfo, CINAHL databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews.
SELECTION CRITERIA: Randomized controlled trials evaluating exercise therapy for adult non-specific low-back pain and measuring pain, function, return-to-work/absenteeism, and/or global improvement outcomes.
DATA COLLECTION AND ANALYSIS: Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short, intermediate, and long-term follow-up.
MAIN RESULTS: Sixty-one randomized controlled trials (6390 participants) met inclusion criteria: acute (11), subacute (6) and chronic (43) low-back pain (1 unclear). Evidence was found of effectiveness in chronic populations relative to comparisons at all follow-up periods; pooled mean improvement was 7.3 points (95% CI, 3.7 to 10.9) for pain (out of 100), 2.5 points (1.0 to 3.9) for function (out of 100) at earliest follow-up. In studies investigating patients (i.e. presenting to healthcare providers) mean improvement was 13.3 points (5.5 to 21.1) for pain, 6.9 (2.2 to 11.7) for function, representing significantly greater improvement over studies where participants included those recruited from a general population (e.g. with advertisements). There is some evidence of effectiveness of graded-activity exercise program in subacute low-back pain in occupational settings, though the evidence for other types of exercise therapy in other populations is inconsistent. There was evidence of equal effectiveness relative to comparisons in acute populations [pain: 0.03 points (95% CI, -1.3 to 1.4)].
LIMITATIONS: This review largely reflects limitations of the literature, including low quality studies with heterogeneous outcome measures, inconsistent and poor reporting, and possibility of publication bias.
AUTHORS' CONCLUSIONS: Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in healthcare populations. In subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. In acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.

PMID 16034851
Nicholas Henschke, Raymond Wjg Ostelo, Maurits W van Tulder, Johan Ws Vlaeyen, Stephen Morley, Willem Jj Assendelft, Chris J Main
Behavioural treatment for chronic low-back pain.
Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002014. doi: 10.1002/14651858.CD002014.pub3. Epub 2010 Jul 7.
Abstract/Text BACKGROUND: Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.
OBJECTIVES: To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach.
SEARCH STRATEGY: The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened.
SELECTION CRITERIA: Randomised trials on behavioural treatments for non-specific CLBP were included.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.
MAIN RESULTS: We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.
AUTHORS' CONCLUSIONS: For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

PMID 20614428
J Bart Staal, Rob A de Bie, Henrica C W de Vet, Jan Hildebrandt, Patty Nelemans
Injection therapy for subacute and chronic low back pain: an updated Cochrane review.
Spine (Phila Pa 1976). 2009 Jan 1;34(1):49-59. doi: 10.1097/BRS.0b013e3181909558.
Abstract/Text STUDY DESIGN: A systematic review of randomized controlled trials (RCTs).
OBJECTIVE: To determine if injection therapy is more effective than placebo or other treatments for patients with subacute or chronic low back pain.
SUMMARY OF BACKGROUND DATA: The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to the need for clinically valid comparisons in a literature synthesis.
METHODS: We updated the search of the earlier systematic review and searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases up to March 2007 for relevant trials reported in English, French, German, Dutch, and Nordic languages. We also screened references from trials identified. RCTs on the effects of injection therapy involving epidural, facet, or local sites for subacute or chronic low back pain were included. Studies that compared the effects of intradiscal injections, prolotherapy, or ozone therapy with other treatments were excluded unless injection therapy with another pharmaceutical agent (no placebo treatment) was part of one of the treatment arms. Studies about injections in sacroiliac joints and studies evaluating the effects of epidural steroids for radicular pain were also excluded.
RESULTS: Eighteen trials (1179 participants) were included in this review. The injection sites varied from epidural sites and facet joints (i.e. intra-articular injections, peri-articular injections and nerve blocks) to local sites (i.e. tender-and trigger points). The drugs that were studied consisted of corticosteroids, local anesthetics, and a variety of other drugs. The methodologic quality of the trials was limited with 10 of 18 trials rated as having a high methodologic quality. Statistical pooling was not possible because of clinical heterogeneity in the trials. Overall, the results indicated that there is no strong evidence for or against the use of any type of injection therapy.
CONCLUSION: There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain. However, it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy.

PMID 19127161
U.S. Preventive Services Task Force
Primary care interventions to prevent low back pain in adults: recommendation statement.
Am Fam Physician. 2005 Jun 15;71(12):2337-8.
Abstract/Text
PMID 15999872
A K Burton, F Balagué, G Cardon, H R Eriksen, Y Henrotin, A Lahad, A Leclerc, G Müller, A J van der Beek, COST B13 Working Group on Guidelines for Prevention in Low Back Pain
Chapter 2. European guidelines for prevention in low back pain : November 2004.
Eur Spine J. 2006 Mar;15 Suppl 2:S136-68. doi: 10.1007/s00586-006-1070-3.
Abstract/Text
PMID 16550446
R A Deyo, A K Diehl
Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies.
J Gen Intern Med. 1988 May-Jun;3(3):230-8.
Abstract/Text Back pain is very common. Rarely, it may be the first manifestation of cancer. Although many advocate selective use of laboratory and x-ray tests for back pain patients, the early detection of cancer may be an important reason to obtain such tests. To develop a diagnostic approach that would identify malignancies while remaining parsimonious, the authors evaluated 1,975 walk-in patients with a chief complaint of back pain. Thirteen patients (0.66%) proved to have underlying cancer. Findings significantly associated with underlying cancer (p less than 0.05) were: age greater than or equal to 50 years, previous history of cancer, duration of pain greater than 1 month, failure to improve with conservative therapy, elevated erythrocyte sedimentation rate (ESR), and anemia. Combining historical features and ESR results led to an algorithm that would have limited x-ray utilization to just 22% of subjects while recommending an x-ray for every cancer patient. It would further suggest which patients with negative x-ray findings require further work-up.

PMID 2967893
Abstract/Text Altogether 40 patients aged 13-91 y (average 58 y) with vertebral osteomyelitis were treated at the Bergen University Hospital between July 1987 and June 1997. All patients presented with back pain, 33 (83%) had vertebral tenderness, and 26 (65%) patients were febrile. The duration of symptoms before diagnosis was < 3 weeks in 13 patients, and from 3 to 16 weeks in the remaining 27 patients. C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) were elevated in 39 and 38 patients, respectively. Staphylococcus aureus was the most frequent cause of osteomyelitis followed by Streptococcus spp., Escherichia coli and Mycobacterium tuberculosis. Magnetic resonance imaging was superior to other radiological methods and demonstrated changes consistent with osteomyelitis in all 23 patients examined with this method. 35 patients survived. 18/35 surviving patients had pareses and 17 underwent surgery with drainage of abscesses or laminectomy. All 35 patients made a good recovery and only 3 patients experienced permanent pareses. The diagnosis of vertebral osteomyelitis is easily missed, and treatment is often delayed, particularly in the elderly in whom signs of sepsis may not manifest. However, persisting localized pain and tenderness over the spine together with elevated CRP and ESR should prompt the physician to consider vertebral osteomyelitis. Fever and leukocytosis may support the diagnosis, but may not always be present.

PMID 9730301
M Beronius, B Bergman, R Andersson
Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95.
Scand J Infect Dis. 2001;33(7):527-32.
Abstract/Text Vertebral osteomyelitis (VO) is a rare condition and the diagnosis is often overlooked initially. Delay in diagnosis may result in vertebral destruction or perforation of the spinal canal. We suggest diagnostic criteria in order to simplify the diagnosis and classification of VO. Medical records of 58 patients with VO from Göteborg during the years 1990-95 were studied retrospectively. The incidence, clinical presentation, microbiology and treatment of VO were evaluated. The median age at the time of admission was 59 y (range 13-83 y) and the male:female ratio was 1.6:1. The incidence was 2.2/100,000 inhabitants/y. Sixty-four percent of the patients were natives of Sweden. The patients were classified as definite (67%), probable (26%) and possible (7%) VO. Staphylococcus aureus was the most common infective agent (34%), followed by Mycobacterium tuberculosis (27%). The most common risk factors included recent or current infections, immunosuppressive diseases and previous surgery. CRP and ESR were elevated in 82% and 88% respectively and plain X-ray changes indicating VO were found in 56% of the patients. Radiological changes were found in 34/44 (77%) computerized tomography scans and 10/13 (77%) magnetic resonance imaging examinations. The median duration of intravenous and oral antibiotic treatment were 10 and 179 d respectively. A delay of > I month from the onset of symptoms until diagnosis was found in 38% of the patients. This indicates the need for a standardized protocol for diagnosing VO. In this paper we suggest diagnostic criteria, which have not previously been available.

PMID 11515764
P Kapeller, F Fazekas, D Krametter, M Koch, G Roob, R Schmidt, H Offenbacher
Pyogenic infectious spondylitis: clinical, laboratory and MRI features.
Eur Neurol. 1997;38(2):94-8.
Abstract/Text Pyogenic infectious spondylitis (PIS) is an uncommon but serious inflammatory disorder of the discovertebral junction with frequent involvement of neural structures including the spinal cord. We report a series of 41 patients (age range 21-75 years, mean age 59 years) with primary PIS confirmed by signal abnormality of the intervertebral disk and adjacent vertebral bodies on magnetic resonance imaging. The prevailing clinical symptom was focal back pain aggravated by percussion in 90% of patients. Radicular signs or symptoms were present in 59% and spinal cord symptoms in 29% of patients, respectively. Evidence of inflammation consisted of an elevated sedimentation rate in 76%, leukocytosis in 61% and fever in 61% of individuals. Predisposing factors such as diabetes mellitus, previous nonspinal surgery and other sites of infection or inflammation were identified in 17 (41%) patients and 30 (73%) were older than 50 years. The lumbar spine was most often affected and PIS was associated with an epidural abscess in 15 (37%) patients. Increased alertness for PIS in the context of focal back pain with clinical or laboratory signs of inflammation is needed to speed up its detection.

PMID 9286631

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