Lumbar Spondylosis

Dries Meeusen, Robin Petroons, Matthias Proost, Kevin Ruelens,  Marie AvauDebby Decock, Laura Bronckaerts, Matthias Proost, Simisola Ajeyalemi and Rachael LoweDebby Decock, Farrie Bakalli, Laure-Anne Callewaert


Definition/Description

Lumbar spondylosis can be described as all degenerative conditions affecting the discs, vertebral bodies, and associated joints of the lumbar vertebrae.[1] Spondylosis is not a clinical diagnosis but instead a descriptive term utilized to designate spinal problems. Within the literature, lumbar spondylosis encompasses numerous associated pathologies including spinal stenosis, degenerative spondylolisthesis, osteoarthritis and many others. It also captures effects of aging, trauma and just the daily use of the intervertebral discs, the vertebrae, and the associated joints.[2] Concerning older patients, the disease is said to be progressive and irreversible. Often is the lumbar region the most affected, because of the exposure to mechanical stress. When a patient suffers from lumbar spondylosis, it is possible that osteophytes are formed. These osteophytes are bony overgrowths that occur due to the stripping of the periosteum from the vertebral body. Pain can be produced when a neural foraminal stenosis is formed, which comes from the formation of osteophytes. The patient can also experience joint stiffness, which can limit motion. Patients with lumbar spondylosis also have neurologic claudication, which includes: lower back pain, leg pain, numbness when standing and walking.[3][4][5]

Clinically Relevant Anatomy


Spondylosis (degeneration of the lumbar spine) generally initiates from the intervertebral disc. At this level progressive biochemical and structural changes take place leading to a modification in the physical properties of elasticity and mechanical resistance. Disc lesions cause pathological changes in the vertebral bodies, where osteophytes appear, Most osteophytes are anterior or lateral in projection. Posterior vertebral osteophytes are less common and only rarely impinge upon the spinal cord or nerve roots.[6][1][7]
Stephen Kishner, MD, MHA Professor of Clinical Medicine, Lumbar Spine Anatomy, Louisiana State University School of Medicine in New Orleans, Medscape: http://emedicine.medscape.com/article/1899031-overview, 2015

https://www.spineuniverse.com/treatments/surgery/transforaminal-selective-endoscopic-discectomy-extremely-minimally-invasive

https://www.spineuniverse.com/conditions/spondylolisthesis
See Lumbar stenosis and Lumbar strain physiopedia pages for a detailed anatomy of the lumbar region.

Epidemiology /Etiology

Spondylosis is a form of lower back pain and is an important clinical, social, economic and public health problem affecting the worldwide population. It is a disorder with many possible etiologies and many definitions. The incidence of lumbar spondylosis is 27-37% of the asymptomatic lower back pain population. For example, In the United States, more than 80% of individuals older than 40 years have lumbar spondylosis, increasing from 3% of individuals aged 20-29 years.[8]

Approximately 84% of men and 74% of women have vertebral osteophytes, most frequently at T9-10 and L3 levels. Approximately 30% of men and 28% of women aged 55-64 years have lumbar osteophytes. Approximately 20% of men and 22% of women aged 45-64 years have lumbar osteophytes. Sex ratio reports have been variable but are essentially equal.[9] Muraki et al, did a cross-sectional study in a large population, which revealed a high prevalence of radiographic lumbar spondylosis in elderly subjects. Gender seems to be distinctly in the form of lumbar spondylosis, and disc space narrowing with or without osteophytes in women may be a risk factor for low back pain.[10]

Lumbar spondylosis can begin in persons as young as 20 years. It increases with, and perhaps is an inevitable concomitant of, old age. That is why it appears to be a nonspecific aging phenomenon, also known as spinal arthritis. Most international studies suggest no relation to lifestyle, height, weight, body mass, physical activity, cigarette and alcohol consumption, or reproductive history. Adiposity is seen as a risk factor in British populations, but not in Japanese populations. The effects of heavy physical activity are controversial, as is a purported relation to disk degeneration.[11] Spondylosis can therefore be seen as a cascade- anatomical changes of the spine occurs, which leads to more degeneration and changes in other spine structures. These changes combine to cause spondylosis and its symptoms.[12]

Characteristics/Clinical Presentation

Patients with lumbar spondylosis have pain in the axial spine. The location of these degenerate changes is not surprising as nociceptive pain generators that were identified within facet joints, intervertebral disks, sacroiliac joints, nerve root dura and myofascial structures. These changes may peak in different clinical presentations such asSpinal sstenosis,Disk herniation, Bulging of the ligamentum flavum and Spondylolisthesis

Patients suffering lumbar spondylosis also have neurologic claudication, which includes lower back pain, leg pain, numbness when standing and walking. These symptoms improve in sitting and supine positioning.[1]

Other characteristics:
• Pedicle anteroposterior dimension, obliquity and the relative interarticular process-interpedicle dimensions are important osteological determinants of the presence and size of lateral recesses at different vertebral lumbar levels.
• The osteo-ligamentous nerve root canals and their terminal intervertebral canals show significant normal narrowing at the level of the opposed intervertebral discs and facet joint capsules. This narrowing causes a “grain” appearance in the normal nerve root canals and of the appearance of long-necked gourds in the osteo-ligamentous intervertebral canals. The narrowing of the disc intervertebral is an important cause of many of the degenerative changes in the lumbar spine. [13]

Differential Diagnosis


When a patient is suffering from low back pain, there are a lot of possible pathologies that could be the cause of this pain. Along with lumbar spondylosis(and its sub-divisions), there are other causes as well.


Rheumatoid arthritis- We can understand why some clinicians would include rheumatoid arthritis, because there are sub-divisions of lumbar spondylosis that have a lot of similarities with arthritis. 
Minor back trauma- As said in the article of Middleton et al., minor back trauma can be the cause of degenerative pathologies such as spondylosis. It is the job of the physiotherapist to take lumbar spondylosis, and other degenerative diseases for that matter, when a patiënt is diagnosed with a minor back trauma 
• Excessive exercise
Back strain
Bekhterev’s disease (Ankylosing Spondylitis)
Coccyx Pain
• Spinal Masses (If the physiotherapist performs a bad investigation, this could be an option, but normally this would be noticed with palpation.)
Infection
Disk Herniation
Discitis
Lumbar Compression Fracture
Lumbar Degenerative Disk Disease
• Lumbar Facet Arthropathy (see Lumbar Facet Syndrome and/or Facet Joint Syndrome)
• Mechanical Low Back Pain
Overuse Injury[14]

Diagnostic Procedures

For the clinical diagnosis of lumbar spondylosis, a thorough investigation is necessary to ensure that other pathologies are excluded. In clinical practice we use:

  • MRI: expensive, but shows the greatest details in the spine and is used to visualize the intervertebral discs, including the degree of disc herniation, if present. An MRI is also used to visualize the vertebrae, the facet joints, the nerves, and the ligaments in the spine and can reliably diagnose a pinched nerve
  • X-rays: show bone spurs on vertebral bodies in the spine, thickening of facet joints (the joints that connect the vertebrae to each other), and narrowing of the intervertebral disc spaces.
  • CT scan: able to visualize the spine in greater detail and can diagnose narrowing of the spinal canal (spinal stenosis) when present
  • SPECT: Single-photon emission computed tomography bone scintigraphy is used to further evaluate patients with suspected spondylolysis. Controversy surrounds the designation of one of these tests as most useful in the evaluation of spondylolysis.[15]

These procedures were validated in several studies, which concluded that MRI was effective (92% sensitivity) in identifying pars lesions. CT scan was also used as a diagnostic procedure, but the result weren’t equally positive. That’s the reason why MRI is advised as the best method of diagnosis.[16][17]

As a physiotherapist, it could be helpful that we can search for the probability of lumbar spondylosis with some clinical tests. In the article of Alqarni et al.[18] they wanted to see if those clinical tests are accurate to detect this pathology. They found that only one test could be useful to detect spondylolysthesis is the palpation of the lumbar spinous process, there’s no evidence that a test could be used for spondylolysis.

Outcome Measures

  • Numeric pain rating scale (NPRS): The patient is asked to score 3 pain rating, worse/current/ best over the last 24h. The score for this scale is the average of these 3 values. This scale is a variant of the VAS but also assess pain intensity.[19][20]
  • Roland Morris disability questionnaire (RMDQ): This questionnaire contains sentences that people have used to describe themselves when they have back pain on that specific day. As people read the list they might recognize themselves and then they must tick that box. A score is appointed according to the number of boxes the patient fills in. This questionnaire makes it possible to follow changes in time.[21][20]
  • Oswestry disability index (ODI): This index is made to evaluate how back pain invalidates people in their daily activities (sleeping, self-care, sex life, social life and travelling). Each question contains 6 categories (0: no limitation – 6: most limitation). The score is calculated by the sum of the 10 questions, multiplied by 2. This value represents the percentage of invalidation.[22][23]
  • Pain self-efficacy questionnaire (PSEQ): This questionnaire rates how confident patients feel performing activities despite the pain. This is indicated on a scale from 0 (no confidence) to 6 (completely confident). Al the scores are then added up to a score from 0 to 60. Where the closer to 60 means that the patients have a stronger self-efficacy belief. There are also short versions of this questionnaire available who shows also a great responsiveness.[24][25][22][20]
  • The patient-specific functional scale (PSFS): Questionnaire where patients are asked to identify up to three activities that they had difficulty with or are unable to perform as a result of their back pain. Each item is given a score of 0-10 (unable- able). The total score is assessed by the sum of the activity scores/number of activities (Minimum detectable change (90%CI) for average score = 2 points, Minimum detectable change (90%CI) for single activity score = 3 points)[26][27][28][29]


Outcome measures.jpg


Of all those questionnaires the NRPS is recommended for assessing pain because of his ease of administration and responsiveness. The ODI and RMDQ are recommended for assessing functioning.[20]

Examination

When a physical therapist performs an examination for lumbar spondylosis, it is advised to follow the principles of the general spine examination and apply them to this specific pathology.[30]The examination should begin as soon as you first see the patient and continues with careful observation during the whole consultation. It is essential to observe the patient's gait and posture.


1.) General examination of the spine

  • Inspection of the entire spine
  • Look for any obvious swellings or surgical scars.
  • Assess for deformity: scoliosis, kyphosis, loss of lumbar lordosis or hyperlordosis of the lumbar spine. Look for shoulder asymmetry and pelvic tilt.

2.) Palpation

  • Palpate for tenderness over bone and soft tissues.
  • Perform an abdominal examination to identify any masses and consider a rectal examination to exclude other pathologies in this region

3.) Movement

  • Flexion, extension, lateral flexion and rotation. Examination of the spine must also include examination of the shoulders and examination of the hips to exclude these joints as a cause of the symptoms.

4.) Neurovascular examination

  • Sensation, tone, power and reflexes should be assessed. All peripheral pulses should also be checked, as vascular claudication in the upper and lower limbs can mimic symptoms of radiculopathy or canal stenosis.

Medical Management

There is little consensus about the definitive treatment approach due to a lack of information about the sources of chronic lower back pain, There are different approaches to the management- conservative or surgical. Franz EW. et al (2015) says that there is a surprisingly high percentage of the patients that have misconceptions regarding the diagnosis and the treatment of lumbar spondylosis and that these misconceptions persist in patients with a history of spine surgery. Specifically, patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance. While these results are preliminary, they highlight a need for improved communication and patient education during surgical consultation for lumbar spondylosis.

Non-surgical management

Pharmacologic management
A lot of research has been done to explore the efficacy of different oral medications in the management of lumbar spondylosis, to complement non-pharmacological interventions. Yet, there is no agreement about the golden-standard approach.

  • NSAIDS (non-steroidal anti-inflammatory drugs) are analgesics and anti-inflammatory. It covers wide range selectivity. From the nonselective cyclooxygenase (COX) inhibitors to the preferential COX-2. It is generally accepted to be the first step in the management of lumbar spondylosis.[31]
  • Opioid medication is an alternative therapy for patients suffering from gastrointestinal side-effects due to a poor control of NSAIDS management. Patients who use this type of medication report greater distress/ suffering and higher functional disability scores.
  • Antidepressants: have been used for the treatment of LBP because of their analgesic value at low doses. The use of antidepressants has also been explored for their dual role in the treatment of depression that accompanies lumbar spondylosis syndrome.[32][33]
  • Muscle relaxants may provide benefit with regard to short-term pain relief and overall functioning.[34][35]
  • Epidural steroid injections are the most common injections and target the epidural space (space surrounding the membrane that covers the spine and nerve roots). These are strong anti-inflammatory (combination of a corticosteroid with a local anesthetic pain relief medicine) and give an immediate pain relief. However, there is poor evidence for the effectiveness (improvement in short-term and long-term benefits) and safety of epidural steroid injections for spinal stenosis.[36][37]
  • Lumbar Facet joint injections are minimally invasive injections of medication (intra-articular injection of local anesthetics with or without steroid) into the inflamed facet joints. This medication can temporarily relieve back pain. It can be used as a diagnostic test or as a treatment to relieve inflammation and pain.[38][39]
  • SI joint injections are used for the treatment of sacroiliac joint pain. It consists of injections of local anesthetics and steroids, radiofrequency ablation of the joint capsule, or radiofrequency neurotomy of the lumbosacral lateral branch nerves L5 and S1–S3. No serious complications have been reported after SI joint injection.[40]


Taping

Another non-surgical management could be taping. A lot of studies have shown that taping helps to relieve pain in the lower back. This tape could be standard tape or kinesiotape as it is shown that there is no difference between both tapes. It is also important to note that taping alone is not enough, it should be used during the therapy to improve ROM etc.[41][42]

Lumbar support

Lumbar support with the help of braces are used for stabilization and reducing mechanical forces, they are also produced to limit spine motion and correct deformity of the spine. There is limited evidence-based research available about the efficacy of lumbar supports regarding patient improvement and functional ability to go back to work. An example of a brace for Lumbal support is The Lyon Antikyphosis Brace. This brace has the best results for patients with scoliosis but could also help patients suffering from lumbar spondylosis.[43] Braces may have effects by massaging and heating the painful areas, there is also a probability that the lumbar supports work as a placebo.

Surgical management

Lumbar fusion
Lumbar fusion is generally used when conservative management has failed and the patient still suffers from pain after 6 months. Two vertebrae are fused together and will subsequently act like one solid vertebra. After two years the bony fusion can be considered high.[44]
There are different types of lumbar fusions: anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and posterolateral fusion. The study of Lammli et al. 2014 about ALIF, where they access the spine via the abdominal cavity, has shown a significant decrease in blood loss, hospital stay and operative time.
5-10% of patients treated with surgery still endure serious pain after for example a lumbar fusion. Electrical stimulation of the dorsal columns of the spinal cord , therefore, became a popular “second-line” technique like they call it.[45][46]
Besides ALIF there also exists TLIF but it seems to have the same clinical outcomes as ALIF. [74, Level of evidence 1A] It has been demonstrated that early psychomotor therapy results in a better outcome after cognitive-behavioral training and motor relearning than early exercise therapy does after a lumbar fusion.[47][48]


Artificial Disc Replacement (ADR)
Artificial disc replacement is the replacement of the degenerated intervertebral disc with an artificial disc in people with degenerative disc disease (DDD) of the lumbar or cervical spine that has been unresponsive to nonsurgical treatments for at least 6 months. Unlike spinal fusion, ADR preserves movement of the spine, which is thought to reduce or prevent the development of adjacent segment degeneration. Additionally, a bone graft is not required for ADR, and this alleviates complications, including bone graft donor site pain and pseudoarthrosis. On the other hand, not all patients who suffer from DDD are eligible ADR; it is estimated that about 5% of patients who require surgery for DDD will be candidates for ADR.[49]

Physical Therapy Management


The conservative therapy can be divided into various exercise-based and behavioral interventions:

  • Exercise therapy

It is the main conservative treatment approach for lumbar spondylosis. The therapy must include aerobic exercise, muscle strengthening, and stretching exercises. The exercises and programs have to be of various intensity, duration, and frequency.[50][51] Kumar et al. have concluded that core muscle strengthening exercises together with the strengthening of the gluteus maximus end flexibility training of the lumbar spine is an effective rehabilitation approach for all patients with chronic low back pain.[52]
It is demonstrated that older adults with lumbar spondylosis have a more elevated quality of life when they have a better abdominal strength. [53]

  • Traction

Lumbar traction helps to relieve chronic low back pain. The traction forces open the intervertebral space and decrease spine lordosis. This temporary spine realignment relieves (theoretical) mechanical stress, nerve compression, adhesions of the facet and annulus and disrupts nociceptive pain signals. Nonetheless, little is known about the risks associated with lumbar traction.[54][55]

  • Manual therapy

Its conservative treatment commonly involves manual therapy, more specifically spine manipulation. Even though the precise mechanism for improvement in low back pain remains unclear, spine manipulation proves to be useful.[56] On the other hand, there might be a risk using spine manipulation, there is a risk of calcifications in the spine should be taken into consideration. Depending on the patient condition the risk may be high or low. But if manipulation is possible it certainly should be used in treatment as it is shown by Ruddock et al. (2016) that spine manipulation has a positive effect.[57]

  • Massage

Even though massage therapy needs more researche for the effectiveness, it appears to have a potential role in beneficial pain relief.[58]

  • TENS

Is a frequently used therapeutic modality. It appears to give an immediate reduction in pain symptoms following the therapy. Nevertheless, there remains little evidence of the long-term relief.[59]

  • Patient education

Educating the patient must include reviews of lumbar anatomy, explanations of the concept of posture, ergonomics and giving appropriate back exercises.[60][61]

  • Lumbar back support

Can be beneficial for patients suffering from chronic LBP. It occurs to limit spine motion, stabilize, correct deformity and reduce mechanical forces. There is no consensus if it may function as a placebo or really improve pain and functional ability. (level of evidence 1A) Sitting decreases lumbar lordosis and increase disc pressure, squeeze on the ischium and muscle activity in the lower back. These are all associated with low back pain. The study of Makhsous et al. resulted in a diminished lumbar spine load and lumbar muscular activity with lumbar back support. This may possibly lessen low back pain while sitting.[62]

  • McKenzie exercises

McKenzie method focuses on extension, and has promising results concerning the prevention of further degeneration of the lumbar spine. A review by Busanich B., et al provides evidence that McKenzie therapy results in a decrease in short-term (<3 months) pain and disability for low back pain patients compared with other standard treatments, such as nonsteroidal anti-inflammatory drugs, educational booklet, back massage with back care advice, strength training with therapist supervision, and spinal mobilization.[63]

For more information on McKenzie method, see Mckenzie Method

It is well-known that chronic spinal pain is often associated with bio-psychosocial problems. Therefore, multidisciplinary back therapy is needed. A bio-psychosocial approach involved reinforcement, modified expectations, imagery/relaxation techniques, and learned control of physiological responses aim to reduce a patient’s perception of disability and pain symptoms. (level of evidence 1A)

It has also been showed in several studies that Yoga could be helpful in reducing pain in patients with chronic low back pain. The stretching of muscles is an important part of this technique. The stretching and relaxing of muscles help the patients to cope with the pain and relieving them. It should also be noted that Yoga alone is not a therapy for chronic low back pain, it can be an additional technique in the therapy.[64][65]

Key Evidence

Busanich, Brian M., and Susan D. Verscheure. "Does McKenzie therapy improve outcomes for back pain?." Journal of athletic training 41.1 (2006): 117. [Level of Evidence 1A]

Garet, Matthew, et al. "Nonoperative treatment in lumbar spondylolysis and spondylolisthesis a systematic review." Sports health: a multidisciplinary approach (2013): 1941738113480936. (level of evidence 1A)

CASE STUDY: Deniz, Fatih Ersay, et al. "Traumatic L4–L5 spondylolisthesis: case report." European Spine Journal 17.2 (2008): 232-235. [Level of evidence 3B]

Resources

- http://www.spineuniverse.com/conditions/spondylosis/causes-spondylosis
- http://www.emedicinehealth.com/spondylosis/page5_em.htm#spondylosis_diagnosis

Clinical Bottom Line

Lumbar spondylosis can be described as a degeneration of the lumbar vertebrae. It is a form of low back pain and is an important clinical, social, economic and public health problem affecting the worldwide population. It is a disorder with many possible etiologies and many definitions. For the clinical diagnosis of lumbar spondylosis, a thorough investigation is necessary to ensure that other pathologies are excluded. In clinical practice we use: MRI, CT, SPECT and X-ray and a general examination of the spine. The medical management can be approached by a surgical or non-surgical treatment, there is no consensus about the most effective therapy. The physical therapy management consists of a multidisciplinary approach, which includes lumbar traction, manipulation of the spine, massage therapy, TENS, back school and Lumbar back supports. The choice on which therapy to use, depends on the individual wishes and needs of the patient; there is no standard assessment for every pathology.

References

  1. 1.0 1.1 1.2 Middleton, Kimberley, and David E. Fish. “Lumbar Spondylosis: Clinical Presentation and Treatment Approaches.” Current Reviews in Musculoskeletal Medicine 2, no. 2 (March 25, 2009): 94–104.
  2. Gibson, J. N. Alastair, and Gordon Waddell. “Surgery for Degenerative Lumbar Spondylosis: Updated Cochrane Review.” Spine 30, no. 20 (October 15, 2005): 2312–20.
  3. Singh, V., Montgomery, S. R., Aghdasi, B., Inoue, H., Wang, J. C., & Daubs, M. D. (2013). Factors affecting dynamic foraminal stenosis in the lumbar spine. The Spine Journal, 13(9), 1080-1087. (level of evidence 2B)
  4. Chanapa, P., Yoshiyuki, T., & Mahakkanukrauh, P. (2014). Distribution and length of osteophytes in the lumbar vertebrae and risk of rupture of abdominal aortic aneurysms: a study of dry bones from Chiang Mai, Thailand. Anatomy & cell biology, 47(3), 157-161. (Level of evidence 5]
  5. Deniz, Fatih Ersay, et al. "Traumatic L4–L5 spondylolisthesis: case report." European Spine Journal 17.2 (2008): 232-235. [Level of evidence 3B]
  6. Cherubino P. et al, Spondylosis and lumbar instability: pathologic changes., Chir Organi Mov. 1994 Jan-Mar;79(1):11-8.
  7. Zukowski et al. The influence of sex, age and BMI on the degeneration of the lumbar spine, Pubmed, 4 Nov 2011.
  8. Laxmaiah Manchikanti, Epidemiology of Low Back Pain,Pain Physician, Volume 3, Number 2, pp 167-192, 2000 (level of evidence 5)
  9. Franz EW. et al ‘ Patient misconceptions concerning lumbar spondylosis diagnosis and treatment’ feb 27 2015 ( level of evidence 3B )
  10. Muraki, S., et al, Prevalence of radiographic lumbar spondylosis and its association with low back pain in elderly subjects of population-based cohorts: the ROAD study, Ann Rheum Dis 2009;68:1401-1406 doi:10.1136/ard.2007.087296 (Level of evidence 2B)
  11. Yoshimura N, Dennison E, Wilman C, et al. Epidemiology of chronic disc degeneration and osteoarthritis of the lumbar spine in Britain and Japan: a comparative study. J Rheumatol. 2000 Feb. 27(2):429-33.
  12. Brooks BK et al., Lumbar spine spondylolysis in the adult population: using computed tomography to evaluate the possibility of adult onset lumbar spondylosis as a cause of back pain.,Skeletal Radiol., 2010. (level of evidence 4)
  13. Schneck, C. D. (1985). The anatomy of lumbar spondylosis. Clinical orthopaedics and related research, 193, 20-37. (level of evidence 5)
  14. Beth B Froese, MD , Lumbar Spondylolysis and Spondylolisthesis Differential Diagnoses, American Academy of Physical Medicine and Rehabilitation, American Medical Association, Illinois State Medical Society, 2014.
  15. Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. J Pediatr Orthop. 2013 Apr-May. 33(3):282-8. (level of evidence 2C)
  16. Rush et al, Use of magnetic resonance imaging in the evaluation of spondylolysis., J Pediatr Orthop., 2015. (level of evidence 3A)
  17. Leone et al.,Lumbar spondylolysis: a review.,Skeletal Radiol. 2011 (level of evidence 5)
  18. Alqarni, Abdullah M., et al. "Clinical tests to diagnose lumbar spondylolysis and spondylolisthesis: A systematic review." Physical Therapy in Sport 16.3 (2015): 268-275.(level of evidence 1A)
  19. Childs, J. D., Piva, S. R., & Fritz, J. M. (2005). Responsiveness of the numeric pain rating scale in patients with low back pain. Spine, 30(11), 1331-1334.
  20. 20.0 20.1 20.2 20.3 Chapman, J. R., Norvell, D. C., Hermsmeyer, J. T., Bransford, R. J., DeVine, J., McGirt, M. J., & Lee, M. J. (2011). Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine, 36, S54-S68. (level of evidence 1A)
  21. Roland MO, Morris RW. A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain. Spine 1983; 8: 141-144. Level of evidence 5
  22. 22.0 22.1 Chiarotto, A., Maxwell, L. J., Terwee, C. B., Wells, G. A., Tugwell, P., & Ostelo, R. W. (2016). Roland-Morris Disability Questionnaire and Oswestry Disability Index: Which Has Better Measurement Properties for Measuring Physical Functioning in Nonspecific Low Back Pain? Systematic Review and Meta-Analysis. Physical therapy. (level of evidence 1A)
  23. Fairbank JC, The Oswestry low back pain disability, questionnaire, Physiotherapy, 1980.
  24. Nicholas M.K. Self-efficacy and chronic pain. Paper presented at the annual conference of the British Psychological Society. St. Andrews, 1989.
  25. Nicholas, M. K. (2007). The pain self‐efficacy questionnaire: Taking pain into account. European journal of pain, 11(2), 153-163. (level of evidence 1B)
  26. Stratford P, Gill C, Westaway M et al (1995) Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can 47:258–263 (level of evidence 2B)
  27. Hefford, C., Abbott, J. H., Arnold, R., & Baxter, G. D. (2012). The patient-specific functional scale: validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems. journal of orthopaedic & sports physical therapy, 42(2), 56-65. (level of evidence 2B)
  28. Froud, R., Patel, S., Rajendran, D., Bright, P., Bjørkli, T., Buchbinder, R., ... & Underwood, M. (2016). A systematic review of outcome measures use, analytical approaches, reporting methods, and publication volume by year in low back pain trials published between 1980 and 2012: Respice, adspice, et prospice. PLoS One, 11(10), e0164573. (level of evidence 1A)
  29. Maughan, E. F., & Lewis, J. S. (2010). Outcome measures in chronic low back pain. European Spine Journal, 19(9), 1484-1494. (level of evidence 4)
  30. Spratt, Kevin F. PhD et al, A New Approach to the Low-Back Physical Examination: Behavioral Assessment of Mechanical Signs. ,Spine, February 1990. (level of evidence 4)
  31. Mattia, C, et al., COX-2 inhibitors: pharmacological data and adverse effects, Minerva Anestesiol. 2005. (level of evidence 5)
  32. Fillingim,R.B., et al., Clinical characteristics of chronic back pain as a function of gender and oral opioid use. Spine. 2003. (level of evidence 2B)
  33. Turk, D.C.; Okifuji, A., What factors affect physicians’ decisions to prescribe opioids for chronic noncancer pain patients? Clin J Pain. 1997. (level of evidence 2C)
  34. Tulder, M.W., et al., Outcome of non-invasive treatment modalities on back pain: an evidence-based review. Eur Spine J., 2006. (level of evidence 1A)
  35. Schnitzer, T.J., et al., A comprehensive review of clinical trials on the efficacy and safety of drugs for the treatment of low back pain. J Pain Symptom Manage, 2004. (level of evidence 1A)
  36. Liu, K., et al., Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis, Drug Des Devel Ther, 2015 (level of evidence 2A)
  37. Friedly, J.L., et al., Study protocol- Lumbar Epidural steroid injections for Spinal Stenosis (LESS): a double-blind randomized controlled trial of epidural steroid injections for lumbar spinal stenosis among older adults, BMC Musculoskelet Disord, 2012. (level of evidence 1B)
  38. Bani, A., et al., Indications for and Benefits of Lumbar Facet Joint Block, Neurosurg Focus, 2002. (level of evidence 4)
  39. Cheung, Kenneth M.C. Low-back pain, sciatica, cervical and lumbar spondylosis. Spine,vol 10, nov 2010. P 958-960
  40. Jorgensen, M.J.; Marras, W.S., The effect of lumbar back support tension on trunk muscle activity. Clinical Biomechanics, 2000. (level of evidence 4)
  41. Nelson, N. L. (2016). Kinesio taping for chronic low back pain: A systematic review. Journal of Bodywork and Movement Therapies. (level of evidence 1A)
  42. Luz Júnior, M. A., Sousa, M. V., Neves, L. A., Cezar, A. A., & Costa, L. O. (2015). Kinesio Taping® is not better than placebo in reducing pain and disability in patients with chronic non-specific low back pain: a randomized controlled trial. Brazilian journal of physical therapy, (AHEAD), 0-0. (level of evidence 1B)
  43. De Mauroy, Jean Claude, et al. "The Lyon brace." Disability and Rehabilitation: Assistive Technology 3.3 (2008): 139-145. [Level of evidence 5]
  44. Baliga, S., Low Back Pain: Current Surgical Approach. Asian Spine Journal, 2015. (level of evidence 5)
  45. Lammli, John, et al. "Stand-alone anterior lumbar interbody fusion for degenerative disc disease of the lumbar spine: results with a 2-year follow-up." Spine 39.15 (2014): E894-E901. (level of evidence 4)
  46. McAuley, J., et al., A questionnaire-Based Study on Patients’ Experiences with Rechargeable Implanted Programmable Generators for Spinal Cord Stimulation to Treat Chronic Lumbar Spondylosis Pain. Neuromodulation Journal, 2012. (level of evidence 2B)
  47. Park, P., et al., Electrical stimulation to enhance spinal fusion: a systematic review. Evidence Based Spine Care J., 2014. (level of evidence 1A)
  48. Gibson et al, Surgery for Degenerative Lumbar Spondylosis: Updated Cochrane Review, SPINE, Volume 30 - Issue 20 - pp 2312-2320, Oktober 2015. (level of evidence 1A)
  49. Health Quality Ontario. "Artificial Discs for Lumbar and Cervical Degenerative Disc Disease–Update: An Evidence-Based Analysis." Ontario Health Technology Assessment Series 6.10 (2006): 1. (level of evidence 1A)
  50. Van Middelkoop, M., Rubinstein, S. M., Verhagen, A. P., Ostelo, R. W., Koes, B. W., & van Tulder, M. W. (2010). Exercise therapy for chronic nonspecific low-back pain. Best practice & research Clinical rheumatology, 24(2), 193-204. (level of evidence 1A)
  51. McIntosh, G., & Hall, H. (2011). Low back pain (acute). Clin Evid (Online), 5(1102), 793. (level of evidence 1A)
  52. Kumar, T., et al, Efficacy of core muscle strengthening exercise in chronic low back pain patients. J. Back Muscluloskelet. Rehabil., 2014. (level of evidence 2B)
  53. VIEIRA, S., et al, Abdominal muscle strength is related to quality of life among older adults with lumbar osteoarthritis. Journal of bodywork and movement therapies, 2015. (level of evidence 2A)
  54. Fritz, J.M., et al, A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale. BMC Musculoskelet Disord., 2010. (level of evidence 1B)
  55. Cai, C., et al, A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction. Eur Spine J., 2009. (level of evidence 2B)
  56. Choi, J., et al, Effects of flexion-distraction manipulation therapy on pain and disability in patients with lumbar spinal stenosis. J Phys Ther Sci., 2015. (level of evidence 2B)
  57. Ruddock, Jay K., et al. "Spinal Manipulation Vs Sham Manipulation for Nonspecific Low Back Pain: A Systematic Review and Meta-analysis." Journal of Chiropractic Medicine 15.3 (2016): 165-183. [level of evidence 1A]
  58. Borges, T.P., et al., Occupational low back pain in nursing workers: massage versus pain. Rev Esc Enferm USP, 2014. (level of evidence 1B)
  59. Buchmuller, A. et al, Value of TENS for relief of chronic low back pain with or without radicular pain. Eur J Pain, 2012. (level of evidence 2B)
  60. Sahin, N., et al., Effectiveness of back school for treatment of pain and functional disability in patients with chronic low back pain: A randomized controlled trial. Volume 43, Issue 3, Pages: 224-229. (level of evidence 1B)
  61. Book: Evidence-Based Management of Low Back Pain by Simon Dagenais, Scott Haldeman (level of evidence 5)
  62. Makhsous, M., et al., Biomechanical effects of sitting with adjustable ischial and lumbar support on occupational low back pain: evaluation of sitting load and back muscle activity. BMC Musculoskeletal Disorders, 2009. (level of evidence 5)
  63. Busanich, Brian M., and Susan D. Verscheure. "Does McKenzie therapy improve outcomes for back pain?." Journal of athletic training 41.1 (2006): 117. (level of evidence 1A)
  64. Holtzman, S., & Beggs, R. T. (2013). Yoga for chronic low back pain: a meta-analysis of randomized controlled trials. Pain Research and Management, 18(5), 267-272. (level of Evidence 1A)
  65. Sherman, K. J., Cherkin, D. C., Wellman, R. D., Cook, A. J., Hawkes, R. J., Delaney, K., & Deyo, R. A. (2011). A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Archives of internal medicine, 171(22), 2019-2026. (level of evidence 1A)