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Low back pain is a common reason for adults to visit their physician. Based on a systematic review of 165 studies from 54 countries, the lifetime prevalence of low back pain is approximately 40%. 1 Globally, low back pain is the most prevalent and disabling condition that benefits from rehabilitation and is the highest generator of health care expenditure and disability. 2–4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Routine imaging is not recommended without clinical indications. Imaging should be performed when red flags are present, there is a neuromuscular deficit, or chronic low back pain, with or without nerve-root involvement, does not resolve with conservative therapy. 33,36 | C | Clinical guidelines and expert opinion |
| In the absence of conditions that require specific medical or surgical attention, non-pharmacologic treatments are the first-line choice for management of chronic low back pain, including modalities that are based on varying levels of evidence, such as behavioral counseling, exercise and physical therapy, spinal manipulation, massage, heat, dry needling, acupuncture, and transcutaneous electrical nerve stimulation. 22,36 | C | Clinical guidelines and expert opinion |
| Studies on the treatment of back pain support the benefit of early patient education that focuses on two issues: (1) the importance of remaining physically active and avoiding bed rest; and (2) setting expectations for a positive treatment response because this may help improve outcomes. 36,46 | C | Multiple practice guidelines |
| Spinal manipulation results in small improvements in pain and function in patients with chronic low back pain, with outcomes that are comparable with, but not superior to, other recommended therapies. 22,58–60 | B | Cochrane review and other systematic reviews and meta-analyses |
| NSAIDs are considered the best initial pharmacologic treatment for chronic low back pain. There is evidence that NSAIDs are more effective than placebo with respect to pain and disability. 22,36,46,67–69 | B | Cochrane reviews and clinical guidelines |
| Studies demonstrate that muscle relaxants have no benefit for chronic low back pain compared with controls; studies also show that benzodiazepines have no benefit compared with placebo and there is significant risk of harm. 24,25,69 | B | Cochrane and other systematic reviews and meta-analyses |
| Epidural corticosteroid injections are not effective for providing long-term relief of disability or pain. Based on limited data, they may provide a slight reduction in short-term... |