Lumbalgia

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Lumbalgia is the medical term for the more common lay description of low back pain or lower back pain. It is used to describe a symptom related to the lower section of the human spine. Persistent and recurring low back pain affects 60 - 80% of people at some stage in their life and is the most common reason for lost work.[1]

Low back pain varies in intensity, frequency, duration, and quality depending on the cause and stage of injury or illness as well as the time of day and activity level. It is considered either acute (of recent origin) or chronic (longer term) in nature, though these give little insight as to a particular cause of the pain. The degree of pain ranges from a mild annoyance that comes and goes to constant and totally disabling.

Etymology

"Lumbalgia" derives from the Latin "Lumbaris" referring to the lower or loin region of the body and "algia" is from the Greek "algos" for pain.

Background

The low back performs two major functions; to act as a weight bearing column that supports upright posture and to act as a conduit that protects the spinal cord and the tender nervous system that transmits through it. As a supporting structure, it carries the weight of the upper torso including the head, arms, thorax, and abdominal contents. Impact forces from actions such as walking or jumping multiply these forces exponentially.

The structures of the adult low back consist of the lower five verterbae along with the ligaments, discs and muscles that support it. Together they are identified as the lumbar region of the spine and are frequently labeled L1 to L5. The range of movement that occurs at the lumbar level combined with flexion of the hips is responsible for the majority of the total range of motion necessary for bending. The lumbar spine sits atop the sacrum which is a wedge shaped bone that rests into a space formed by the left and right innominate bones. The innominates are divided into the ilium, ischium and pubis and, with its attached musculature, make up the pelvic girdle that acts to connect the leg to the torso. Together with the sacrum, the left and right innominates wrap around to the lower abdominal region, creating a "bowl" that supports the organs contained within the abdomen. The joint between the sacrum and each innominate (sacroiliac joint) allows for slight motion with walking and bending. The sacrum and innominates together with their supporting ligaments and muscles are referred to as the pelvis. The resulting circle-like formation is commonly called the pelvic ring. For the lay person, the combination of the lumbar and pelvic regions are effectively called the low back. Low back pain can be generated from injury to any or all of the joints, muscles, ligaments or nerves that make up the region as well as organs in the pelvic bowl that get their nerve supply from the low back.

For the purposes of understanding the causes of low back pain, it is important to note that all pain is a perception of the person that is experiencing it. These perceptions are the result of an intricate relationship between the nerve endings that monitor the condition of the tissues and send that information to the higher centers of the brain where the conscious perception actually occurs. The vast majority of the nerve endings are in the ligaments, muscle and outer layers of the disc tissues that support the boney structures. While bones have a thin 'skin' or periosteum that has a plentiful nerve supply, the bones themselves do not. This is also the case of the inner portions of the normal disc. However, in the degenerating disc, growing evidence suggests that nerves that are specific to the sympathetic nervous system infiltrate deep into the damaged disc resulting in a visceral-type pain that is not seen elsewhere in the musculoskeletal system. This may help us understand the central sensitisation that seems to occur with low back pain and explain why "stress" can play a role in chronic low back pain.[2]

Causes

Radiographic abnormalities of the low back may occur in patients without pain.[3][4] SPECT/CT can identify lesions in some patients and these patients may be more likely to have responses to treatment.[5]

Serious causes of low back pain are uncommon.[6] The majority of acute causes of low back pain are grouped as mechanical type injuries to the ligaments, muscles and joints that are responsible for the function of the vertebral column. The injury may be the result of one traumatic event or multiple, repetitive type traumas. If the cause of these mechanical conditions persist, the pain may develop into a chronic low back pain with a change in symptom quality and frequency depending on the type of structures that become affected, such as discs and nerves. These include diagnoses such as osteoarthritis, degeneration of the discs or a spinal disc herniation.

Some cases of low back pain are related to systemic conditions that affect other regions of the body such as rheumatoid arthritis or cardivascular disease, while a small percentage are caused by tumors (including cancer). There are psychological or emotional components of all disease and low back pain is no exception.

Possible causes of low back pain:

Diagnosis

Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms, such as sciatica, is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an magnetic resonance imaging or x-ray.[7] However, a randomized controlled trial of routinely obtaining an MRI scan in back pain showed no benefit but increased costs.[8]

History and physical examination

The goal of the history and physical examination is to place the patient into one of three categories of back-related etiology, or identify the pain as coming from a source outside the back:[9]

"Back pain potentially associated with another specific spinal cause. The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation (such as tumor, infection, or the cauda equina syndrome), as well as patients with other conditions that may respond to specific treatments (such as ankylosing spondylitis or vertebral compression fractur).".

Diagnostic imaging

"MRI or CT is recommended in patients who have severe or progressive neurologic deficits or are suspected of having a serious underlying condition (such as vertebral infection, the cauda equina syndrome, or cancer with impending spinal cord compression)". Obtaining imaging for lesser reasons may lead to increased costs of unnecessary tests, unnecessary follow-up, and possibly even unnecessary treatment of incidental findings [8] without benefit.[10][11]

Electrodiagnosis

Nerve conduction studies and electromyography may be useful.

Laboratory studies

Hematological and biochemical tests are rarely needed, except when ruling out specific etiologies. Urinalysis and renal function tests may be useful if there is a suspicion of genitourinary system causation, especially in an exacerbation. Complete blood count (CBC) and erythrocyte sendimentation rate (ESR) are appropriate when fever is present, or if an abscess or osteomyelitis is being considered; ESR is a nonspecific screening test.

Treatment

Clinical practice guidelines American College of Physicians[9][12][13][14] and American Pain Society[15] are available to guide treatment choices; however, 2 years after their publication physicians do not reliably follow the guidelines[16]. Increasingly, health care providers are not following guidelines for the management of low back pain.[17]


Listed alphabetically, some of those evaluations include:

Home or Outpatient

Nondrug treatments

Acupuncture

Acupuncture has uncertain benefit for chronic back pain.[18] While acupuncture may be better than usual care[19], acupuncture does not seem to be better than sham acupuncture which questions whether it has benefit beyond placebo[20].

Exercise

Clinical practice guidelines are available.[9]

Back-mobilizing exercises in acute settings are helpful for acute and chronic pain.[21][22][23] Over the long-term, the amount of exercise is more important than the type of exercise.[24]

'Back schools', in an occupational setting, can help.[25]

Heat therapy

Heat therapy is useful for back spasms or other conditions in acute or subacute situations.[26]

Massage

Massage has shown some benefit for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education.[27].

Pilates

A randomized controlled trial found benefit of Pilates for chronic low back pain.[28]

Psychological treatments

Respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain as well as exercise therapy.[29][12].

Spinal manipulation

The role of spinal manipulation is difficult to assess.

Though considered safe, spinal manipulation is not without risk.[35]

The patients most likely to benefit have at least four out of the following five criteria: 1) symptoms for less than 16 days, 2) no symptoms below the knee[35], 3) low fear of engaging in work or physical activity[36], 4) at least 1 hypomobile lumbar joint, and 5) at least 1 hip with more than 35° of internal rotation.[37]

Spinal mobilization

Spinal mobilization does not seem to add to standard treatment of acute lumbalgia[38] and is less effective than manipulation.[39][40]

Work place modifications

Work place and home habit modifications help most people through assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc.[25].

Yoga

Yoga either Viniyoga[41], Iyengar[42], or Hatha[43] might help with the best evidence, albeit only fair-quality evidence, supporting Viniyoga.[12] More recently, a randomized controlled trial supports the use of Viniyoga with supervision.[23]

Medications

Opioid analgesics

Opioid analgesics are also used.[13] Opioids may benefit acute low back pain.[13] Opioids may increase exercise test performance[51]; however, in chronic benign pain, opioids may not clearly[52] increase actual physical activity - at least in comparison to other medications[53]. Patients that use opioid analgesics should be monitored.[13]

Combination therapies

Difficulties in treating chronic back pain have to lead to investigations of combined modalities. One trial found some benefit from combining exercise with cognitive behavioral therapy. [54]

Surgery

There are a number of different types of spine surgery to treat a variety of back conditions. Surgery should be considered if a patient has a significant neurological deficit, or if they fail non-surgical therapy. There is particular concern if back pain is associated with loss of bowel or bladder function and may indicate Cauda equina syndrome or Conus medularis syndrome. Urgent surgical considerations are necessary for these conditions.

Surgery has uncertain benefit for chronic pain.[55]

Some of the more common forms of surgery are:[56]

  • Discectomy/microdiscectomy, usually used to treat pain (especially pain that radiates down the arm or leg) from herniated disks.
  • Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.

Treatments with uncertain or doubtful benefit

Prognosis

40-50% of patients have functional impairment or pain 90 days after being seen in the emergency room for lumbalgia.[62]

Criteria by the United States of America Social Security Administration for disability are available on line.[63]

Prevention

In some setting, lumbar supports may be able to prevent back pain.[64]

References

  1. ↑ Waddell G, Burton AK(2000) Occupational health guidelines for the management of low back pain at work: evidence review. London:Faculty of Occupational Medicine. PDF version
  2. ↑ Edgar MA (September 2007). "The nerve supply of the lumbar intervertebral disc". The Journal of Bone and Joint Surgery. British Volume 89 (9): 1135–9. DOI:10.1302/0301-620X.89B9.18939. PMID 17905946. Retrieved on 2009-10-19. Research Blogging.
  3. ↑ Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS (1994). "Magnetic resonance imaging of the lumbar spine in people without back pain.". N Engl J Med 331 (2): 69-73. DOI:10.1056/NEJM199407143310201. PMID 8208267. Research Blogging.
  4. ↑ Cheung KM, Karppinen J, Chan D, Ho DW, Song YQ, Sham P et al. (2009). "Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals.". Spine (Phila Pa 1976) 34 (9): 934-40. DOI:10.1097/BRS.0b013e3181a01b3f. PMID 19532001. Research Blogging.
  5. ↑ Lee I, Budiawan H, Moon JY, Cheon GJ, Kim YC, Paeng JC et al. (2014). "The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain.". J Korean Med Sci 29 (12): 1711-6. DOI:10.3346/jkms.2014.29.12.1711. PMID 25469075. PMC PMC4248596. Research Blogging.
  6. ↑ Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J et al. (2009). "Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.". Arthritis Rheum 60 (10): 3072-80. DOI:10.1002/art.24853. PMID 19790051. Research Blogging.
  7. ↑ Ullrich PE (2007). What's a Herniated Disc, Pinched Nerve, Bulging Disc. . . ? - Spine-health.com. Retrieved on 2007-11-09.
  8. ↑ 8.0 8.1 Jarvik JG, Hollingworth W, Martin B, et al (2003). "Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial". JAMA 289 (21): 2810–8. DOI:10.1001/jama.289.21.2810. PMID 12783911. Research Blogging.
  9. ↑ 9.0 9.1 9.2 9.3 Chou R, Qaseem A, Snow V, et al (2007). "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. 147 (7): 478–91. PMID 17909209. [e]
  10. ↑ Chou R, Fu R, Carrino JA, Deyo RA (February 2009). "Imaging strategies for low-back pain: systematic review and meta-analysis". Lancet 373 (9662): 463–72. DOI:10.1016/S0140-6736(09)60172-0. PMID 19200918. Research Blogging.
  11. ↑ Chou R, Qaseem A, Owens DK, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians (2011). "Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians.". Ann Intern Med 154 (3): 181-189. DOI:10.1059/0003-4819-154-3-201102010-00008. PMID 21282698. Research Blogging.
  12. ↑ 12.0 12.1 12.2 12.3 Chou R, Huffman LH (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann. Intern. Med. 147 (7): 492–504. PMID 17909210. [e]
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Chou R, Huffman LH (2007). "Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann. Intern. Med. 147 (7): 505–14. PMID 17909211. [e]
  14. ↑ (2007) "Summaries for patients. Diagnosis and treatment of low back pain: recommendations from the American College of Physicians/American Pain Society". Ann. Intern. Med. 147 (7): I45. PMID 17909203. [e]
  15. ↑ Chou R, Loeser JD, Owens DK, et al. (May 2009). "Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society". Spine 34 (10): 1066–77. DOI:10.1097/BRS.0b013e3181a1390d. PMID 19363457. Research Blogging.
  16. ↑ Williams, Christopher M.; Christopher G. Maher, Mark J. Hancock, James H. McAuley, Andrew J. McLachlan, Helena Britt, Salma Fahridin, Christopher Harrison, Jane Latimer (2010-02-08). "Low Back Pain and Best Practice Care: A Survey of General Practice Physicians". Arch Intern Med 170 (3): 271-277. DOI:10.1001/archinternmed.2009.507. Retrieved on 2010-02-09. Research Blogging.
  17. ↑ Mafi JN, McCarthy EP, Davis RB, Landon BE (2013). "Worsening trends in the management and treatment of back pain.". JAMA Intern Med 173 (17): 1573-81. DOI:10.1001/jamainternmed.2013.8992. PMID 23896698. Research Blogging.
  18. ↑ Furlan A, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. "Acupuncture and dry-needling for low back pain.". Cochrane Database Syst Rev: CD001351. PMID 15674876.
  19. ↑ Thomas K, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell M, Roman M, Walters S, Nicholl J (2006). "Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain.". BMJ 333 (7569): 623. PMID 16980316.
  20. ↑ Cherkin DC, Sherman KJ, Avins AL, et al. (May 2009). "A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain". Arch. Intern. Med. 169 (9): 858–66. DOI:10.1001/archinternmed.2009.65. PMID 19433697. Research Blogging.
  21. ↑ Hayden J, van Tulder M, Malmivaara A, Koes B. "Exercise therapy for treatment of non-specific low back pain.". Cochrane Database Syst Rev: CD000335. PMID 16034851.
  22. ↑ Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V (1995). "The treatment of acute low back pain--bed rest, exercises, or ordinary activity?". N Engl J Med 332 (6): 351-5. PMID 7823996.
  23. ↑ 23.0 23.1 Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K et al. (2011). "A Randomized Trial Comparing Yoga, Stretching, and a Self-care Book for Chronic Low Back Pain.". Arch Intern Med 171 (22): 2019-26. DOI:10.1001/archinternmed.2011.524. PMID 22025101. Research Blogging.
  24. ↑ Aleksiev AR (2014). "Ten-year follow-up of strengthening versus flexibility exercises with or without abdominal bracing in recurrent low back pain.". Spine (Phila Pa 1976) 39 (13): 997-1003. DOI:10.1097/BRS.0000000000000338. PMID 24732860. Research Blogging.
  25. ↑ 25.0 25.1 Heymans M, van Tulder M, Esmail R, Bombardier C, Koes B. "Back schools for non-specific low-back pain.". Cochrane Database Syst Rev: CD000261. PMID 15494995.
  26. ↑ 26.0 26.1 French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ (2006). "A Cochrane review of superficial heat or cold for low back pain". Spine 31 (9): 998-1006. DOI:10.1097/01.brs.0000214881.10814.64. PMID 16641776. Research Blogging.
    A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain
  27. ↑ Furlan AD, Imamura M, Dryden T, Irvin E (2008). "Massage for low-back pain". Cochrane Database Syst Rev (4): CD001929. DOI:10.1002/14651858.CD001929.pub2. PMID 18843627. Research Blogging.
    A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that massage "massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education"
  28. ↑ Natour J, Cazotti LD, Ribeiro LH, Baptista AS, Jones A (2014). "Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial.". Clin Rehabil. DOI:10.1177/0269215514538981. PMID 24965957. Research Blogging.
  29. ↑ Ostelo R, van Tulder M, Vlaeyen J, Linton S, Morley S, Assendelft W. "Behavioural treatment for chronic low-back pain.". Cochrane Database Syst Rev: CD002014. PMID 15674889.
  30. ↑ Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S (1999). "A comparison of osteopathic spinal manipulation with standard care for patients with low back pain". N. Engl. J. Med. 341 (19): 1426–31. PMID 10547405. [e]
  31. ↑ Jüni P, Battaglia M, Nüesch E, Hämmerle G, Eser P, van Beers R et al. (2009). "A randomised controlled trial of spinal manipulative therapy in acute low back pain.". Ann Rheum Dis 68 (9): 1420-7. DOI:10.1136/ard.2008.093757. PMID 18775942. Research Blogging.
  32. ↑ Assendelft W, Morton S, Yu E, Suttorp M, Shekelle P. "Spinal manipulative therapy for low back pain.". Cochrane Database Syst Rev: CD000447. PMID 14973958.
  33. ↑ Cherkin D, Sherman K, Deyo R, Shekelle P (2003). "A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain.". Ann Intern Med 138 (11): 898-906. PMID 12779300.
  34. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2003). "Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies". Ann. Intern. Med. 138 (11): 871–81. PMID 12779297. [e]
  35. ↑ 35.0 35.1 Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992). "Spinal manipulation for low-back pain". Ann. Intern. Med. 117 (7): 590–8. PMID 1388006. [e]
  36. ↑ Waddell G, Newton M, Henderson I, Somerville D, Main CJ (1993). "A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability". Pain 52 (2): 157–68. PMID 8455963. [e]
  37. ↑ Childs JD, Fritz JM, Flynn TW, et al (2004). "A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study". Ann. Intern. Med. 141 (12): 920–8. PMID 15611489. [e]
  38. ↑ Hancock MJ, Maher CG, Latimer J, et al (2007). "Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial". Lancet 370 (9599): 1638–43. DOI:10.1016/S0140-6736(07)61686-9. PMID 17993364. Research Blogging.
  39. ↑ Hadler NM, Curtis P, Gillings DB, Stinnett S (1987). "A benefit of spinal manipulation as adjunctive therapy for acute low-back pain: a stratified controlled trial". Spine 12 (7): 702–6. PMID 2961085. [e]
  40. ↑ Cleland JA, Fritz JM, Kulig K, Davenport TE, Eberhart S, Magel J et al. (2009). "Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial.". Spine (Phila Pa 1976) 34 (25): 2720-9. DOI:10.1097/BRS.0b013e3181b48809. PMID 19940729. Research Blogging.
  41. ↑ Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA (2005). "Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial". Ann. Intern. Med. 143 (12): 849–56. PMID 16365466. [e]
  42. ↑ Williams KA, Petronis J, Smith D, et al (2005). "Effect of Iyengar yoga therapy for chronic low back pain". Pain 115 (1-2): 107–17. DOI:10.1016/j.pain.2005.02.016. PMID 15836974. Research Blogging.
  43. ↑ Galantino ML, Bzdewka TM, Eissler-Russo JL, et al (2004). "The impact of modified Hatha yoga on chronic low back pain: a pilot study". Alternative therapies in health and medicine 10 (2): 56–9. PMID 15055095. [e]
  44. ↑ Hancock MJ, Maher CG, Latimer J, et al (2007). "Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial". Lancet 370 (9599): 1638–43. DOI:10.1016/S0140-6736(07)61686-9. PMID 17993364. Research Blogging.
  45. ↑ Williams, Christopher M; Christopher G Maher, Jane Latimer, Andrew J McLachlan, Mark J Hancock, Richard O Day, Chung-Wei Christine Lin (2014-07). "Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial". The Lancet. DOI:10.1016/S0140-6736(14)60805-9. ISSN 01406736. Retrieved on 2014-07-28. Research Blogging.
  46. ↑ van Tulder M, Touray T, Furlan A, Solway S, Bouter L. "Muscle relaxants for non-specific low back pain.". Cochrane Database Syst Rev: CD004252. PMID 12804507.
  47. ↑ Urquhart D, Hoving J, Assendelft W, Roland M, van Tulder M (2008). "Antidepressants for non-specific low back pain". Cochrane Database Syst Rev (1): CD001703. DOI:10.1002/14651858.CD001703.pub3. PMID 18253994. Research Blogging.
  48. ↑ Salerno SM, Browning R, Jackson JL (2002). "The effect of antidepressant treatment on chronic back pain: a meta-analysis". Arch. Intern. Med. 162 (1): 19–24. PMID 11784215. [e]
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  50. ↑ van Tulder M, Scholten R, Koes B, Deyo R. "Non-steroidal anti-inflammatory drugs for low back pain.". Cochrane Database Syst Rev: CD000396. PMID 10796356.
  51. ↑ Rashiq S, Koller M, Haykowsky M, Jamieson K (2003). "The effect of opioid analgesia on exercise test performance in chronic low back pain.". Pain 106 (1-2): 119-25. PMID 14581118. [e]
  52. ↑ Kalso E, Edwards JE, Moore RA, McQuay HJ (2004). "Opioids in chronic non-cancer pain: systematic review of efficacy and safety". Pain 112 (3): 372–80. DOI:10.1016/j.pain.2004.09.019. PMID 15561393. Research Blogging.
  53. ↑ Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E (2006). "Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects". CMAJ 174 (11): 1589–94. DOI:10.1503/cmaj.051528. PMID 16717269. Research Blogging.
  54. ↑ Johnson RE, Jones GT, Wiles NJ, et al (2007). "Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial". Spine 32 (15): 1578-85. DOI:10.1097/BRS.0b013e318074f890. PMID 17621203. Research Blogging. PMID 1762120
  55. ↑ Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O (2010). "Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain.". Ann Rheum Dis 69 (9): 1643-8. DOI:10.1136/ard.2009.108902. PMID 19635718. PMC PMC2938881. Research Blogging.
  56. ↑ 56.0 56.1 56.2 Birkmeyer N, Weinstein J, Tosteson A, Tosteson T, Skinner J, Lurie J, Deyo R, Wennberg J (2002). "Design of the Spine Patient outcomes Research Trial (SPORT).". Spine 27 (12): 1361-72. PMID 12065987.
  57. ↑ Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P (2008). "Injection therapy for subacute and chronic low-back pain". Cochrane Database Syst Rev (3): CD001824. DOI:10.1002/14651858.CD001824.pub3. PMID 18646078. Research Blogging.
  58. ↑ Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A et al. (2011). "Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial.". BMJ 343: d5278. DOI:10.1136/bmj.d5278. PMID 21914755. PMC PMC3172149. Research Blogging.
  59. ↑ Dagenais S, Yelland MJ, Del Mar C, Schoene ML (2007). "Prolotherapy injections for chronic low-back pain". Cochrane Database Syst Rev (2): CD004059. DOI:10.1002/14651858.CD004059.pub3. PMID 17443537. Research Blogging.
  60. ↑ Dechow E, Davies RK, Carr AJ, Thompson PW (1999). "A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain.". Rheumatology (Oxford) 38 (12): 1255-9. PMID 10587555. [e]
  61. ↑ Hagen K, Hilde G, Jamtvedt G, Winnem M. "Bed rest for acute low-back pain and sciatica.". Cochrane Database Syst Rev: CD001254. PMID 15495012.
  62. ↑ Friedman BW, O'Mahony S, Mulvey L, Davitt M, Choi H, Xia S et al. (2012). "One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain.". Ann Emerg Med 59 (2): 128-133.e3. DOI:10.1016/j.annemergmed.2011.09.012. PMID 22265130. Research Blogging.
  63. ↑ Anonymous (2006). 1.00 Musculoskeletal System - Adult. Social Security Administration. Retrieved on 7/22/2008.
  64. ↑ Roelofs PD, Bierma-Zeinstra SM, van Poppel MN, et al (2007). "Lumbar supports to prevent recurrent low back pain among home care workers: a randomized trial". Ann. Intern. Med. 147 (10): 685–92. PMID 18025444. [e]

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