Chronic Low Back Pain: Difference between revisions

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'''Original Editors - '''[[User:Bryan Jacobson|Bryan Jacobson]], [[User:Tori Westcott|Tori Westcott]], [[User:Ashley Bohanan|Ashley Bohanan]], [[User:Alisha Lopez|Alisha Lopez]]  
'''Original Editors - '''[[User:Bryan Jacobson|Bryan Jacobson]], [[User:Tori Westcott|Tori Westcott]], [[User:Ashley Bohanan|Ashley Bohanan]], [[User:Alisha Lopez|Alisha Lopez]]  


'''Lead Authors '''-  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} <br>
</div>  
</div>  
== Description  ==
== Introduction ==
[[File:Back pain image.jpg|thumb|CLBP: common in society.]]


[[Image:Lumbar region.png|right|300px]]  
Chronic low back pain (CLBP) is defined as lower back pain lasting for longer than 12 weeks or 3 months, even after an initial injury or underlying cause of acute [[Low Back Pain|low back pain]] has been treated.


Low back pain (LBP) is the fifth most common reason for physician visits, which affects nearly 60-80% of people throughout their lifetime. Low back pain that has been present for longer than three months is considered chronic. More than 80% of all health care costs can be attributed to chronic LBP. Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode <ref name="Aure">Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.</ref><ref name="Ferreira">Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.</ref><ref name="Chou, 2007">Chou R, Qaseem A, Snow V, Casey D, Cross TJ, Shekelle P, Owens DK. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.</ref>. It is estimated that seven million adults in the United States have activity limitations as a result of chronic low back pain<ref name="Chou, 2010">Chou R. Pharmacological Management of Low Back Pain. Drugs [online]. 2010;70 (4):387-402. Available from MEDLINE with FULL TEXT. Accessed April 30, 2011.</ref>.
Key Points


== Clinical Presentation  ==
# CLBP develops in roughly 5.0% to 10.0% of low back pain cases.<ref name=":18">Meucci RD, Fassa AG, Faria NM. [https://doi.org/10.1590/S0034-8910.2015049005874 Prevalence of chronic low back pain: systematic review]. Revista de saude publica. 2015 Oct 20;49:73.</ref><ref>NIH Low Back Pain Fact Sheet Available: https://www.ninds.nih.gov/low-back-pain-fact-sheet<nowiki/>(accessed 17.11.2022)</ref>
# CLBP represents the second leading cause of disability worldwide and is a major health and economic problem.
# CLBP has a significant impact on functional capacity and occupational activities, and can also be influenced by psychological factors, such as stress, depression and/or anxiety.<ref name=":0">Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research. 2016;5. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926733/ (accessed 17.11.2022)</ref>
# Patients often have unrealistic expectations of total pain relief, being a large gap between a patient's desired amount of pain reduction and the minimum percentage of improvement that makes a treatment worthwhile. <ref name=":2">AFP Chronic Low Back Pain: Evaluation and Management Available;https://www.aafp.org/pubs/afp/issues/2009/0615/p1067.html (accessed 18.11.2022)</ref>


Low back pain is a common complaint in adults of all ages. Its clinical presentations can vary but most patients' will likely experience pain that is centralized or radiates into the lower extremities. When patients don’t exclusively fit into a specific type of treatment based on clinical prediction rules, and they are predicted to suffer from chronicity from self-report forms, a multi-disciplinary approach is best suited to treat these patients. <br>
== Epidemiology /Aetiology  ==


== Differential Diagnosis  ==
# The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the ageing population, affecting both men and women in all ethnic groups.<ref name=":0" />
# CLBP prevalence varies according to age, prevalence was 4.2% for individuals aged between 24 and 39, and 19.6% for people aged between 20 and 59<ref>Meucci RD, Fassa AG, Faria NM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ Prevalence of chronic low back pain: systematic review]. Rev Saude Publica. 2015;49:1. doi: 10.1590/S0034-8910.2015049005874. Epub 2015 Oct 20. PMID: 26487293; PMCID: PMC4603263.</ref>.
# Higher prevalence in females, people of lower economic status, those with less schooling, and smokers compared to males, people with higher economic status, those with more schooling, and non-smokers, respectively.<ref>Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ (accessed 17.11.2022)</ref>


Low back pain is a frequent condition for patients seeking care from physical therapists in outpatient settings. The challenge for clinicians is to recognize patients in whom low back pain may be related to underlying pathological conditions. Some other possible conditions that could be attributing to the low back pain that are not physical therapy related include: Abdominal Aneurysm, Appendicitis, Ectopic Pregnancy, Endometriosis, Neoplasms, Ovarian Cyst, Pelvic Inflammatory Disease, Prostatitis, Renal Calculi, and Urinary Tract Infections. In the event that these conditions could be present, either a physician referral or immediate attention is required.<br>
== Characteristics/Clinical Presentation  ==


== Examination  ==
CLBP refers to LBP occurring for longer than three months, and possibly occurring episodically. Social contact and work environment will suffer from the impact on the patient's health and wellbeing.   


Research has shown that the patient history and biopsychosocial evaluation are crucial to establish chronic LBP. Patient history and self-report forms help rule out serious pathologies such as cauda equina, [[Ankylosing Spondylitis|ankylosing spondylitis]], nerve compromise and cancer. The [[Fear‐Avoidance Belief Questionnaire|Fear-Avoidance Beliefs Questionnaire]] (FABQ) self-report form has been shown to predict chronicity and psychosocial factors influencing patient prognosis <ref name="George">George S, Fritz J, Bialosky J, et al. The effect of a Fear-Avoidance-Based Physical Therapy Intervention for Patients With Acute Low Back Pain: Results of a Randomized Clinical Trail. Spine. [online]. 2003; 28(23): 2551-2560.</ref>. The focus of the physical examination is to confirm the hypothesis of chronic LBP by eliminating other pathologies or mechanisms&nbsp;<ref name="Chou, 2007" />
Presentation includes:  


== Surgical Approaches<br> ==
* [[Pain Assessment|Pain]] in the lower area of the back, which may radiate into the lower extremities.
* Movement and [[Coordination Exercises|coordination]] impairments
* Difficulty maintaining the neutral position and/or to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities. 
* Carrying objects in the arms, or bending can also provoke complaints.
* [[Activities of Daily Living|Daily activities]] such as household tasks, sports and other recreational activities can be challenging for people with CLBP.
* When pain is generalized, sensory experiences of the patient can also become altered
* Fear-avoidance beliefs, pain catastrophizing (see [[Pain Catastrophizing Scale|Pain Catastrophizing]] ) and depressive thoughts can appear (monitor these [[Yellow Flags]], [[The Flag System|blue flags]] and [[The Flag System|black flags]]).<ref name=":1">Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. [https://www.jospt.org/doi/10.2519/jospt.2012.42.4.A1 Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association]. J Orthop Sports Phys Ther. 2012;42(4):A1-A57. </ref>


{| width="40%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
'''[[Red Flags in Spinal Conditions|Red Flags]]:''' Although uncommon, serious spinal conditions (such as those listed below) may present as chronic LBP in approximately 5% of patients presenting to primary care office:
|-
* [[Cauda Equina Syndrome|Cauda equina syndrome]]
| align="right" |  
* [[Cancer Pain|Cancer]]
{{#ev:youtube|rU8YYESYXzc|250}} <ref>Donald Corenman. Video of L5-S1 Surgery Lumbar Microdiscectomy | Low Back Pain Surgery |Colorado | Spine Surgeon. Available from: http://www.youtube.com/watch?v=rU8YYESYXzc[last accessed 22/03/13]</ref>  
* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]]
* [[Lumbar Spinal Stenosis]]
* Lumbar [[Disc Herniation|disc herniations]]
* [[Lumbar Spine Fracture]]
* [[Spondylodiscitis]]
* [[Abdominal Aortic Aneurysm]]<ref>[[Lumbar Assessment]]</ref>


|}
== Diagnosis ==
In most cases, causes for CLBP are not found using traditional investigations.


Spinal surgery is recommended for certain conditions. However, the rate of spinal surgeries continues to rise each year unnecessarily for unwarranted conditions. There are inherent risks that occur with each spinal surgery, particularly spinal fusions. These risks include: increased chance of blood transfusion, post-operative mortality, instrumentation failure, infection, chronic pain, neural injuries, pulmonary embolus, pseudarthrosis, a high reoperation rate and complications at the bone-donor site <ref name="Deyo">Deyo RA, Nachemson A, Mirza SK. Spinal fusion: the case for restraint. NEJM 2004;350:722-726.</ref>.
* Fewer than 10% of cases are diagnosed with radiography and magnetic resonance imaging (MRI).  
* Degenerative changes and conditions such as spondylolysis and spondylolisthesis are not reliable diagnoses for CLBP, as they are no more common in patients with pain than in asymptomatic individuals.<ref name=":13" />


Patients should be well informed of the risk that occurs with these surgeries and work with their physician to decided what would yield the best possible outcome. According to Whitman et al. patients with lumbar spinal stenosis can benefit from physical therapy instead of opting for a surgical approach. It has been found that manual physical therapy, exercise and a progressive body weight supported treadmill walking program yield the most improvements<ref name="Whitman">Whitman JM, Flynn TW, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis. Spine 2006;31:2541-2549.</ref>. Structured cognitive behavior therapy has also been proven to be beneficial<ref name="Mirza">Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; surgery to nonoperative care for treatment of chronic back pain. 2007;32:816-823.</ref>.
Generally, patients are diagnosed based on their history. The specific diagnosis is then formulated based on the examination and clinical outcomes.  
 
== Examination  ==
== Multidisciplinary Teams  ==
 
When treating patients with chronic LBP it has been shown that having been treated by a multidisciplinary team yields improvements. The multidisciplinary approach includes treating the physical, psychological, emotional, and socioprofessional aspects of the disorder <ref name="Demoulin">Demoulin C, Grosdent S, Vanderthommen M, et al. Effectiveness of a semi-intensive multidisciplinary outpatient rehabilitation program in chronic low back pain. Joint Bone Spine [serial online]. 2010; 77 (1): 58-63. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 30, 2011.</ref>. "Fear of pain in turn is supposed to initiate worrying about the consequences of pain and hence increases avoidance behavior, leading in the long term to increased pain, functional disability, and depression." <ref name="Samwell">Samwell H, Kraaimaat F, Crul B, van Dongen R, Evers A. Multidisciplinary allocation of pain treatment: long term outcome and correlates of cognitive-behavioral processes. Journal of Musculoskeletal Pain [serial online]. March 2009; 17(1): 26-36. Available from: CINAHL plus with Full Text, Ipswich, MA. Accessed April 30, 2011.</ref>.
 
A team is therefore needed to address all the extraneous effects that are produced by living with chronic LBP from months to years. Psychologists, physicians, physical therapists and occupational therapists tend to be the professionals involved in multidisciplinary teams. Multidisciplinary clinics are available to patients for this type of care. However, if a patient cannot get to a clinic, their physician, physical therapist and psychologist should be working together to address the impairments produced by the chronic pain.  
 
== Medical Management <br>  ==
 
'''Pharmacology''':&nbsp;According to Kuijpers et al, pharmacological interventions are the most frequently recommended intervention for back pain. Many factors, such as severity and duration of symptoms, adverse side-effects, prior response to medications and presence of co-morbidities determine which medication is best for the patient. For chronic low back pain, pharmacological management can be used on a continuous basis or as needed <ref name="Chou, 2010" />.
 
*<u>Acetaminophen:</u> The American Pain Society/American College of Physicians guidelines recommend that acetaminophen be used as a first-line option with any duration of low back pain.<span style="mso-spacerun:yes">
</span>
 
 
 
Acetaminophen is an antipyretic and analgesic medication without anti-inflammatory properties.<span style="mso-spacerun:yes">&nbsp; </span>Risk of hepatotoxicity is the main complication, therefore dosing instruction must be followed carefully<ref name="Chou, 2010" />
 
*<u>NSAIDS:</u> Non-steroidal Anti-Inflammatory drugs are another medication recommended as a first-line medication for short-term use.<span style="mso-spacerun:yes">&nbsp; </span>They are pain relieving and anti-inflammatory medications that block the cyclo-oxygenase (COX)-2 enzyme.<span style="mso-spacerun:yes">&nbsp; </span>Side-effects include gastrointestinal and renal complications, such as bleeding ulcers and perforation <ref name="Chou, 2010" />
*<u>Opioids:</u> Opioids are considered an option in patients with moderate or severe pain.<span style="mso-spacerun:yes">
</span>
 
 
 
Research has found opioids moderately effective for pain relief, although effects on functional outcomes were small.<span style="mso-spacerun:yes">&nbsp; </span>Slow-release opioids are recommended when compared to immediate-release opioids to prevent adverse effects, and should be given regularly rather than as needed. Due to the addictive nature of opioids, long-term use should be carefully monitored for misuse <ref name="Chou, 2010" /><ref name="Deshpande">Deshpande A, Furlan AD, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low back pain. The Cochrane Collaboration. [online]. 2010;3:1-34. Available from: The Cochrane Library. Accessed from April 23, 2011.</ref>.
 
*<span style="font-size:9.0pt;font-family:Symbol;mso-fareast-font-family:Symbol; mso-bidi-font-family:Symbol"><span style="mso-list:Ignore">&nbsp;</span></span><u>Anti-depressants:</u> Tricyclic anti-depressants (TCA) are commonly used to treat numerous chronic pain syndromes.<span style="mso-spacerun:yes">
</span>


# Research has shown that patient history and biopsychosocial evaluation are crucial to establish CLBP<ref>McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA. [https://www.tandfonline.com/doi/abs/10.1179/108331904225003955 The biopsychosocial classification of non-specific low back pain: a systematic review.] Physical Therapy Reviews. 2004 Mar 1;9(1):17-30.</ref>.
# The focus of the physical examination is to confirm the hypothesis of CLBP by eliminating other pathologies or mechanisms, such as the aforementioned red flags.<ref name=":3">Chou R, Qaseem A, Snow V, Casey D, Cross Jr JT, Shekelle P, Owens DK. [https://doi.org/10.7326/0003-4819-147-7-200710020-00006 Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.] Annals of internal medicine. 2007 Oct 2;147(7):478-91.</ref>
# There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with subacute LBP. The best predictor is the lumbar spine flexion test. Other differences might be seen in functional tests, sensation in the feet, and in the different pain provocation tests.<ref>Paatelma M, Karvonen E, Heiskanen J. [https://doi.org/10.1179/106698109790818197 Clinical perspective: how do clinical test results differentiate chronic and subacute low back pain patients from" non-patients"?]. Journal of Manual & Manipulative Therapy. 2009 Jan 1;17(1):11-9.</ref>


== Outcome Measures ==
Can be used at baseline and throughout the course of treatment to monitor a change in a patient’s status.<ref name=":1" />
*[[STarT Back Screening Tool|STarT Back]]
*[[Oswestry Disability Index]]
*[[Roland‐Morris Disability Questionnaire]]&nbsp;
*[[Patient Specific Functional Scale|Patient-specific functional scale (PSFS)]]
* The loaded forward-reach test
*[[Pain Self-Efficacy Questionnaire (PSEQ)|Pain self-efficacy questionnaire (PSEQ)]]
== Medical Management ==
All the guidelines currently available stress the importance of a multimodal and multidisciplinary approach in order to determine a strategy to solve CLBP, not simply alleviate symptomatic pain.<ref name=":0" />  See [[Multidisciplinary Care in Pain Management]]


However, there is conflicting evidence on whether there are significant changes in pain relief or disability with chronic LBP.<span style="mso-spacerun:yes">&nbsp; </span>A recent systematic review found that there is evidence of moderate quality indicating that there is no difference in pain relief between anti-depressants and placebo for patients with chronic LBP <ref name="Kuijpers">Kuijpers T, Middelkoop M, Rubinstein S, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. European Spine Journal [online]. 2011;20:40-50.Available from: MEDLINE with FULL TEXT. Accessed April 21, 2011.</ref>.<span style="mso-spacerun:yes">&nbsp; D</span>epression is common in patients with chronic low back pain and should be treated appropriately<ref name="Chou, 2007" />.  
Treatment for chronic low back pain is grouped into into three wide categories: monotherapies, multiidisciplinary therapy, and reductionism.


*<u>Other medications:</u> Skeletal muscle relaxants, benzodiazepines, and anti-epileptic medications are not recommended because of the insufficient evidence towards their effectiveness for chronic low back pain<ref name="Chou, 2010" />.
* Monotherapies: do not work or have limited effectiveness (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery).
* Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on CLPB.
* The reductionist approach, meaning the pursuit of a pathoanatomical diagnosis with the view to target-specific treatment, should be implemented when a specific diagnosis is essential. Searching a pathoanatomical diagnosis has been criticised on the grounds that it ignores the psychosocial aspects of chronic pain. However advocates of reductionism have persisted, as monotherapies and multidisciplinary therapy to date, have not provided a good solution to chronic low back pain.


<br>'''Behavioural Therapy''': Evidence has shown the behavioural therapy has a positive effect on pain intensity, functional status and behavior in patients with chronic LBP. There are three approaches to behavioural therapy: operant conditioning, cognitive and respondent.  
Imaging: Conventional investigations often do not reveal the cause of pain however joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.<ref name=":13">MJA Management of CLBP Available:https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain (accessed 17.11.2022)</ref>


*<u>''Operant treatments''</u>''&nbsp;''uses positive reinforcement of healthy behavior to minimize focus on pain, and spouse support.
'''Multidisciplinary Approach'''


*The focus of the <u>''cognitive approach''</u> is on modifications of thoughts and feelings toward their pain and disability.
In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment.<ref name=":4">Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, Van Tulder MW. [https://doi.org/10.1136/bmj.h444 Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis]. Bmj. 2015 Feb 18;350.</ref>  For more information see - <u>&nbsp;[[Behavioral pain management of chronic low back pain]]</u>


*The <u>''r''</u>''<u>espondent approach&nbsp;</u>''focuses on reducing muscular tension by methods of relaxation.
== Physical Therapy Management  ==
[[File:Core activation 4point kneeling alternate arms.jpeg|thumb|Core activation ]]
Patients with CLBP should receive information about effective self-care options and should be advised to remain active (because muscles that do not move can eventually become hypersensitive to pain). Assessing the response to therapy is focused on improvements in pain, mood, and function.<ref name=":2" /> A multidisciplinary approach in treating chronic low back pain is advised. See also [[Communication in Chronic Pain Conditions]]


The cognitive approach is the most commonly used technique in pain management. Nicholas and George<ref name="Nicholas" /> explain basic cognitive-behavior methods that may be beneficial for patients with chronic low back pain. [http://ptjournal.apta.org/content/91/5/765.full.pdf+html Basic Cognitive-Behavioral Methods Appendix]
Therapy consists of:


'''Graded exposure''' is a behavioural treatment recommended for patients with chronic pain and high fear-avoidance behaviours.<span style="mso-spacerun:yes"> </span>The focus of the treatment is on gradually exposing the patient to activities he or she actively avoids.<span style="mso-spacerun:yes">&nbsp; </span>A recent systematic review of randomized control trials found no advantage when physical therapy was supplemented with graded exposure. However, only 5 of the 15 trials in the systematic review involved patients who had high levels of fear avoidance. Therefore, more randomized trials need to be performed on patients with high fear-avoidance levels to adequately test graded exposure.<ref name="Nicholas">Nicholas M, George S. Psychologically Informed Interventions for Low Back Pain: An update for Physical Therapists. Physical Therapy. 2011;91 (5): 765-777.http://ptjournal.apta.org/content/91/5/765.abstract?etoc .Accessed April 29, 2011.</ref>.  
* '''''Stretching and flexibility exercises'':''' are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion.<ref>Maddalozzo GF, Kuo B, Maddalozzo WA, Maddalozzo CD, Galver JW. [https://doi.org/10.1016/j.jcm.2016.07.001 Comparison of 2 multimodal interventions with and without whole body vibration therapy plus traction on pain and disability in patients with nonspecific chronic low back pain.] Journal of chiropractic medicine. 2016 Dec 1;15(4):243-51.</ref> The aim is to reduce pain, improve movement, and improve functional limitations of movement.
* '''Strengthening and stabilizing the back and abdominal core muscles:''' produces small improvements in pain and functioning in patients with chronic low back pain. Few however studies (i.e., six of the 43 studies included in a Cochrane review)  demonstrated clinically important and statistically significant differences between intervention and control groups.<ref name=":2" />See [[Core Strengthening]]  and [[The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain]]
* Massage is now recommended in both the acute and chronic stages of back pain but modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain.
* [[Cognitive Behavioural Therapy]]: For patients with nonspecific chronic low back pain, more specifically patients who have already had full conservative treatment, a biopsychosocial rehabilitation program might result in positive long term effects on pain and disability.  For more information see: [[CBT Approach to Chronic Low Back Pain]]
* [[Pain Neuroscience Education (PNE)]]: Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view pain. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. PNE aims to increase pain thresholds during exercise, decrease fear related to movement and decreased brain activity in brain regions associated with pain.
[[File:Pain knowing-neurons.jpg|thumb|399x399px]]
Other Options Include:


== Biopsychosocial Approach  ==
* '''Manipulative therapy''': found in the latest meta-analysis to be slightly more effective than sham therapy however no more effective than other forms of care, for example care by a general practitioner, physiotherapy or exercises,<ref name=":13" />
* [[McKenzie Method]]: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises. This obviously might differ across different groups of patients.<ref name=":5">Halliday MH, Pappas E, Hancock MJ, Clare HA, Pinto RZ, Robertson G, Ferreira PH. [https://www.jospt.org/doi/10.2519/jospt.2016.6379 A randomized controlled trial comparing the McKenzie method to motor control exercises in people with chronic low back pain and a directional preference]. Journal of Orthopaedic & Sports Physical Therapy. 2016 Jul;46(7):514-22.</ref>
* Acupunture is no longer supported by the UK and Belgian guidelines but is still supported by the American guidelines state that acupuncture massage and pressure point massage are minimally helpful for reducing CLBP, with benefits lasting for up to one year.<ref name=":14">Qaseem A, Wilt TJ, McLean RM, Forciea MA. [https://doi.org/10.7326/M16-2367 Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.] Annals of internal medicine. 2017 Apr 4;166(7):514-30.</ref>
* Pilates:There is inconsistent evidence that [[pilates]] is effective in reducing pain and disability in people with CLBP, with a lack of long term follow up information.<ref>Wells C, Kolt GS, Marshall P, Hill B, Bialocerkowski A. [https://doi.org/10.1186/1471-2288-13-7 Effectiveness of Pilates exercise in treating people with chronic low back pain: a systematic review of systematic reviews.] BMC medical research methodology. 2013 Dec;13(1):1-2.</ref> The use of Pilates was found to improve ongoing Low Back Pain (LBP) in patients who received conventional physiotherapy treatment, the improvement was most obvious in the female population group.<ref>Pilates [[Pilates]]</ref>
* Yoga: Evidence in recent years has suggested [[yoga]] to be an efficacious adjunctive treatment for chronic low back pain <ref>Holtzman S, Beggs RT. [https://doi.org/10.1155/2013/105919 Yoga for chronic low back pain: a meta-analysis of randomized controlled trials]. Pain Research and Management. 2013 Oct;18(5):267-72.</ref>. Yoga has had a positive impact on pain and function outcomes in patients with CLBP. It has been found to have a statistically significant difference compared to minimal intervention. However, results comparing to exercise and usual physiotherapy are inconsistent. Yoga should be considered as an adjunct to usual physiotherapy until further higher quality studies have been produced.<u></u>
== Resources    ==


Chronic LBP threatens self-identity because it can change coping patterns and the individual’s way of thinking, with people often reporting feelings of helplessness and a loss of self-esteem and experience of a hidden disability. When low back pain becomes chronic, it often does not respond to traditional biomedical treatments. Identification of psychosocial risk factors, or ‘yellow flags’, enable appropriate intervention to be incorporated into vocational rehabilitation treatment as a preventative measure against conditions such as chronic LBP. Yellow flags are factors that increase the risk of developing or perpetuating long-term disability and work loss associated with low back pain. Assessment of these is encouraged in the early stages of intervention after work related injury<ref name="Ashby">Ashby S, Richards K, James C. The effect of fear of movement on the lives of people with chronic low back pain... including commentary by Carleton RN, Poulain C, Meyer K, and Glombiewski JA. International Journal of Therapy &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Rehabilitation [serial online]. May 2010;17(5):232-243. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed May 2, 2011.</ref>.
https://www.youtube.com/watch?v=DBh4_7YtLaA
 
Another important consideration for therapist is the possibility of the patient developing a depressive mood. &nbsp;Low back pain epidemiological literature suggest that it could be a strong prognostic indicator for chronicity. &nbsp;Those that are more depressed are more likely to experience back pain symptoms when compared to people whose moods are not affected <ref name="Hill">Hill J, Fritz J. Psychosocial Influences on Low Back Pain, Disability, and Response to Treatment. Physical Therapy. 2011;91 (5): 712-721. http://ptjournal.apta.org/cgi/content/extract/91/5/735 . Accessed April 29, 2011.</ref>.&nbsp;
 
== Physical Therapy Management  ==
 
'''Intervention:'''
 
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{{#ev:youtube|xSaYreyNIg8|250}} <ref>cataniahesc406. Neutral Gap Manipulation for Lumbar spine. Available from: http://www.youtube.com/watch?v=xSaYreyNIg8[last accessed 22/03/13]</ref>
 
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'''Spinal Manipulation''': There has been conflicting evidence on whether spinal manipulation is beneficial for chronic low back pain patients. Ferreira et al., Cecchi et al., and Aure et al<ref name="Cecchi">Cecchi F, Molino-Lova R, Pasquini G, et al. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clinical Rehabilitation. [online]. 2010;24:26-34. Available from: Medline with FULL TEXT. Accessed April 21, 2011.</ref>. found significant short term and long term improvements in functional capabilities, debilitating pain and return to work. Contrastingly, a Cochrane review published in 2011 reviewing 26 articles found no benefit<ref>Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal Manipulative Therapy for Chronic Low-Back Pain: An Update of a Cochrane Review.Feb 2011. Accessible at [[http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008112/frame.html http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008112/frame.html]] last accessed 7th June 2011</ref>.
 
Even though there is conflicting evidence, spinal manipulation has minimal risk of harm and is cost effective. The decision to use spinal manipulation in treatment must focus on these factors and patient preference<ref name="Rubinstein">Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low back pain. The Cochrane collaboration. [online] 2011;2: 1-178. Available from: The Cochrane Library. Accessed on April 21, 2011.</ref>.
 
'''Exercise''': Motor control exercise protocols have been shown to be an effective treatment of chronic low back pain. Common targeted muscles include transversus abdominis, multifidus, the diaphragm and pelvic floor muscles. The focus of motor control exercises is to improve neuromuscular control of trunk segments involved in movement of the spine.<ref name="Ferreira" /><ref name="Costa">Costa LOP, Majer CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM, McAuley JH, Jennings MD. Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial. Physical Therapy.</ref><ref name="Akbari">Akbari A, Khorashadizadeh S, Abdi G. The Effect of Motor Control Exercise Versus General Exercise on Lumbar Local Stabilizing Muscle Thickness: Randomized Controlled Trial of Patients with Chronic Low Back Pain. Journal of Back and Musculoskeletal Rehabilitation. 2008;21:105-112.</ref><ref name="Macedo">Macedo LG, Maher CG, Latimer J, McAuley JH. Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review. Physical Therapy. 2009;89:9-25.</ref>.<br>
 
Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain.<ref name="Ferreira" /><br>
 
Treatment of chronic low back pain is most effective when spinal manipulation and motor control exercises are used in combination <ref name="Aure" />&nbsp;In addition, treatment plans must be specific to the impairments of the patient.
 
{| width="40%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
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{{#ev:youtube|033ogPH6NNE|250}} <ref>uwaterloo. Waterloo's Dr. Spine, Stuart McGill . Available from: http://www.youtube.com/watch?v=033ogPH6NNE[last accessed 22/03/13]</ref>
 
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'''Modalities: '''Electrical nerve stimulation (TENS and interferential current), low-level laser therapy, shortwave diathermy, and ultrasonography have not been shown to be an effective treatment option due to insufficient evidence <ref name="Chou, 2007" />.<u><br></u>
 
'''Traction:''' Evidence has shown no benefit to continuous or intermittent traction<ref name="Chou, 2007" />.
 
'''Massage: '''Massage has not been shown to be an effective intervention for chronic low back pain<ref name="Chou, 2007" />.
 
== Key Research  ==
 
[https://connect.regis.edu/p20273804/ Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain], Bill Garcia, Evidence in Motion, OMPT Fellowship, 2009
 
== Resources <br>  ==
 
[http://www.apta.org/apta/findapt/index.aspx?navID=10737422525 Find Your Physical Therapist]
 
[http://www.apta.org/ The American Physical Therapy Association]
 
[http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm The National Institute of Health]
 
[http://www.theacpa.org/default.aspx American Chronic Pain Association]
 
[http://www.ampainsoc.org/ American Pain Society]


== Clinical Bottom Line  ==
== Clinical Bottom Line  ==


<span style="font-size:10.0pt;font-family:Helvetica; mso-bidi-font-family:Helvetica;color:#1A1718">Multidimensional treatment approaches that consider physical, cognitive, affective and
A multidisciplinary approach in treating chronic low back pain is advised. Especially in patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programs result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Physical therapy should consist of exercise therapy (and no manual therapy). The exercise therapy might be general exercise therapy, the Mckenzie method, or motor control exercises. Pilates and yoga could be used if the patient has interest in this. Biopsychosocial rehabilitation is advised in patients with nonspecific chronic low back pain, education and graded exercise could also play an important role for these patients. Above all, it’s important to choose a therapy that fits the individual patient.
behavioral components are increasingly used with individuals with chronic low
back pain.<span style="mso-spacerun:yes">&nbsp; </span>The impact of fear of movement on the lives of the participants is multi-faceted, and can have a considerable impact upon occupational functioning. A change of roles and relationships, social isolation, self doubt and interpretation of chronic low back pain impacted upon a person’s functioning, on the vocational rehabilitation process and on return to work outcomes <ref name="Ashby" />.</span>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])<br>  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1BcJI_Rc2aEi3U-Hu0edSrEmVRf8N867FGIQ782WaBlnpeUUDA|charset=UTF-8|short|max=10</rss><br></div>
==  ==
 
== Presentations  ==
<div class="coursebox">
{| width="100%" cellspacing="4" cellpadding="4" border="0" class="FCK__ShowTableBorders"
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rect 0 0 830 452 [http://www.youtube.com/watch?v=9j4AXwT7xQs]
desc none
</imagemap>
| [http://www.youtube.com/watch?v=9j4AXwT7xQs/ '''Multidisciplinary Management of the Chronic Low Back Pain Patient''']
This presentation, created by Lysette Burato, Jessica Charlton, Zach McClung, Kirk Michalec as part of the Texas State University Evidence-based Practice projects for PT7539 Ortho Spine course, discusses the current best evidence for multidisciplinary management of patients with chronic low back pain.  
 
[http://www.youtube.com/watch?v=9j4AXwT7xQs Multidisciplinary Management of the Chronic Low Back Pain Patient / View the presentation]
 
|}
</div> <div class="coursebox">
{| width="100%" cellspacing="4" cellpadding="4" border="0" class="FCK__ShowTableBorders"
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rect 0 0 830 452 [https://connect.regis.edu/p20273804/]
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</imagemap>
| [https://connect.regis.edu/p20273804/ '''Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain''']
This presentation, created by Bill Garcia, as part of the 2009 Regis University OMPT Fellowship, discusses current evidence for Cognitive Behavioural Therapy in the management of chronic low back pain.
 
[https://connect.regis.edu/p20273804/ Evidence for Cognitive-Behavioral Approach for Management of Chronic Low Back Pain/ View the presentation]
 
|}
</div> <div class="coursebox">
{| width="100%" cellspacing="4" cellpadding="4" border="0" class="FCK__ShowTableBorders"
|-
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rect 0 0 830 452 [http://www.eimqa.com/Fellowship/FellowPresent/SteereExForLBP.mp4]
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</imagemap>
| [http://www.eimqa.com/Fellowship/FellowPresent/SteereExForLBP.mp4/ '''Exercise for Low Back Pain: Where Do We Stand?''']
This presentation, created by Jason Steere, as part of the 2011 Evidence in Motion Fellowship, discusses the current best evidence for exercise in the management of low back pain.
 
[http://www.eimqa.com/Fellowship/FellowPresent/SteereExForLBP.mp4 Exercise for Low Back Pain: Where Do We Stand?/ View the presentation]
 
|}
</div> <div class="coursebox">
{| width="100%" cellspacing="4" cellpadding="4" border="0" class="FCK__ShowTableBorders"
|-
| align="center" | <imagemap>
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rect 0 0 830 452 [http://www.youtube.com/watch?v=po4z_pdVuzQ]
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</imagemap>
| [http://www.youtube.com/watch?v=po4z_pdVuzQ/ '''Low Back Pain and Pelvic Floor Disorders''']
This presentation, created by Ashley Aikman, Delesa Monroe, Ashley Trotter, Michael Landin, as part of the Texas State University Evidence-based Practice projects for PT7539 Ortho Spine course, discusses the the relationship between pelvic floor disorders and low back pain.  
 
[http://www.youtube.com/watch?v=po4z_pdVuzQ Low Back Pain and Pelvic Floor Disorders / View the presentation]
 
|}
</div>
== References  ==
== References  ==


<references />  
<references />  


<br>  
<br>
 
[[Category:Texas State University EBP Project]]
[[Category:Texas_State_University_EBP_Project]][[Category:Articles]][[Category:Lumbar]][[Category:Musculoskeletal/Orthopaedics|Orthopaedics]][[Category:Spine]][[Category:Condition]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Conditions]]
[[Category:Lumbar Spine]]  
[[Category:Lumbar Spine - Conditions]]
[[Category:Mental Health]]
[[Category:Mental Health - Conditions]]

Latest revision as of 10:38, 3 March 2024

Introduction[edit | edit source]

CLBP: common in society.

Chronic low back pain (CLBP) is defined as lower back pain lasting for longer than 12 weeks or 3 months, even after an initial injury or underlying cause of acute low back pain has been treated.

Key Points

  1. CLBP develops in roughly 5.0% to 10.0% of low back pain cases.[1][2]
  2. CLBP represents the second leading cause of disability worldwide and is a major health and economic problem.
  3. CLBP has a significant impact on functional capacity and occupational activities, and can also be influenced by psychological factors, such as stress, depression and/or anxiety.[3]
  4. Patients often have unrealistic expectations of total pain relief, being a large gap between a patient's desired amount of pain reduction and the minimum percentage of improvement that makes a treatment worthwhile. [4]

Epidemiology /Aetiology[edit | edit source]

  1. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the ageing population, affecting both men and women in all ethnic groups.[3]
  2. CLBP prevalence varies according to age, prevalence was 4.2% for individuals aged between 24 and 39, and 19.6% for people aged between 20 and 59[5].
  3. Higher prevalence in females, people of lower economic status, those with less schooling, and smokers compared to males, people with higher economic status, those with more schooling, and non-smokers, respectively.[6]

Characteristics/Clinical Presentation[edit | edit source]

CLBP refers to LBP occurring for longer than three months, and possibly occurring episodically. Social contact and work environment will suffer from the impact on the patient's health and wellbeing.

Presentation includes:

  • Pain in the lower area of the back, which may radiate into the lower extremities.
  • Movement and coordination impairments
  • Difficulty maintaining the neutral position and/or to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities.
  • Carrying objects in the arms, or bending can also provoke complaints.
  • Daily activities such as household tasks, sports and other recreational activities can be challenging for people with CLBP.
  • When pain is generalized, sensory experiences of the patient can also become altered
  • Fear-avoidance beliefs, pain catastrophizing (see Pain Catastrophizing ) and depressive thoughts can appear (monitor these Yellow Flags, blue flags and black flags).[7]

Red Flags: Although uncommon, serious spinal conditions (such as those listed below) may present as chronic LBP in approximately 5% of patients presenting to primary care office:

Diagnosis[edit | edit source]

In most cases, causes for CLBP are not found using traditional investigations.

  • Fewer than 10% of cases are diagnosed with radiography and magnetic resonance imaging (MRI).
  • Degenerative changes and conditions such as spondylolysis and spondylolisthesis are not reliable diagnoses for CLBP, as they are no more common in patients with pain than in asymptomatic individuals.[9]

Generally, patients are diagnosed based on their history. The specific diagnosis is then formulated based on the examination and clinical outcomes.

Examination[edit | edit source]

  1. Research has shown that patient history and biopsychosocial evaluation are crucial to establish CLBP[10].
  2. The focus of the physical examination is to confirm the hypothesis of CLBP by eliminating other pathologies or mechanisms, such as the aforementioned red flags.[11]
  3. There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with subacute LBP. The best predictor is the lumbar spine flexion test. Other differences might be seen in functional tests, sensation in the feet, and in the different pain provocation tests.[12]

Outcome Measures[edit | edit source]

Can be used at baseline and throughout the course of treatment to monitor a change in a patient’s status.[7]

Medical Management[edit | edit source]

All the guidelines currently available stress the importance of a multimodal and multidisciplinary approach in order to determine a strategy to solve CLBP, not simply alleviate symptomatic pain.[3] See Multidisciplinary Care in Pain Management

Treatment for chronic low back pain is grouped into into three wide categories: monotherapies, multiidisciplinary therapy, and reductionism.

  • Monotherapies: do not work or have limited effectiveness (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery).
  • Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on CLPB.
  • The reductionist approach, meaning the pursuit of a pathoanatomical diagnosis with the view to target-specific treatment, should be implemented when a specific diagnosis is essential. Searching a pathoanatomical diagnosis has been criticised on the grounds that it ignores the psychosocial aspects of chronic pain. However advocates of reductionism have persisted, as monotherapies and multidisciplinary therapy to date, have not provided a good solution to chronic low back pain.

Imaging: Conventional investigations often do not reveal the cause of pain however joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.[9]

Multidisciplinary Approach

In patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programmes result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Patients in these programmes also have increased odds of being at work compared with patients receiving physical treatment.[13] For more information see -  Behavioral pain management of chronic low back pain

Physical Therapy Management[edit | edit source]

Core activation

Patients with CLBP should receive information about effective self-care options and should be advised to remain active (because muscles that do not move can eventually become hypersensitive to pain). Assessing the response to therapy is focused on improvements in pain, mood, and function.[4] A multidisciplinary approach in treating chronic low back pain is advised. See also Communication in Chronic Pain Conditions

Therapy consists of:

  • Stretching and flexibility exercises: are used to improve hamstring, quadriceps, piriformis, and hip joint capsule range of motion.[14] The aim is to reduce pain, improve movement, and improve functional limitations of movement.
  • Strengthening and stabilizing the back and abdominal core muscles: produces small improvements in pain and functioning in patients with chronic low back pain. Few however studies (i.e., six of the 43 studies included in a Cochrane review) demonstrated clinically important and statistically significant differences between intervention and control groups.[4]See Core Strengthening and The Effectiveness of Core Stability Exercise in the Management of Chronic Non-Specific Low Back Pain
  • Massage is now recommended in both the acute and chronic stages of back pain but modalities such as electrical nerve stimulation, low-level laser therapy, shortwave diathermy and ultrasonography have not been shown to be effective interventions. Exercise focusing on general improvement of strength and cardiovascular endurance is not suggested for optimal outcomes in patients with chronic low back pain.
  • Cognitive Behavioural Therapy: For patients with nonspecific chronic low back pain, more specifically patients who have already had full conservative treatment, a biopsychosocial rehabilitation program might result in positive long term effects on pain and disability.  For more information see: CBT Approach to Chronic Low Back Pain
  • Pain Neuroscience Education (PNE): Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view pain. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. PNE aims to increase pain thresholds during exercise, decrease fear related to movement and decreased brain activity in brain regions associated with pain.
Pain knowing-neurons.jpg

Other Options Include:

  • Manipulative therapy: found in the latest meta-analysis to be slightly more effective than sham therapy however no more effective than other forms of care, for example care by a general practitioner, physiotherapy or exercises,[9]
  • McKenzie Method: Has been shown to be as effective as other exercise therapy. Compared to motor control exercises there is no significant difference in pain and function scores. However patients reported greater improvement in sense of recovery in the short term compared to patients who received motor control exercises. This obviously might differ across different groups of patients.[15]
  • Acupunture is no longer supported by the UK and Belgian guidelines but is still supported by the American guidelines state that acupuncture massage and pressure point massage are minimally helpful for reducing CLBP, with benefits lasting for up to one year.[16]
  • Pilates:There is inconsistent evidence that pilates is effective in reducing pain and disability in people with CLBP, with a lack of long term follow up information.[17] The use of Pilates was found to improve ongoing Low Back Pain (LBP) in patients who received conventional physiotherapy treatment, the improvement was most obvious in the female population group.[18]
  • Yoga: Evidence in recent years has suggested yoga to be an efficacious adjunctive treatment for chronic low back pain [19]. Yoga has had a positive impact on pain and function outcomes in patients with CLBP. It has been found to have a statistically significant difference compared to minimal intervention. However, results comparing to exercise and usual physiotherapy are inconsistent. Yoga should be considered as an adjunct to usual physiotherapy until further higher quality studies have been produced.

Resources[edit | edit source]

https://www.youtube.com/watch?v=DBh4_7YtLaA

Clinical Bottom Line[edit | edit source]

A multidisciplinary approach in treating chronic low back pain is advised. Especially in patients who have already failed a course of conservative treatment, multidisciplinary rehabilitation programs result in better outcomes with respect to long term pain and disability compared with usual care or physical treatments. Physical therapy should consist of exercise therapy (and no manual therapy). The exercise therapy might be general exercise therapy, the Mckenzie method, or motor control exercises. Pilates and yoga could be used if the patient has interest in this. Biopsychosocial rehabilitation is advised in patients with nonspecific chronic low back pain, education and graded exercise could also play an important role for these patients. Above all, it’s important to choose a therapy that fits the individual patient.

References[edit | edit source]

  1. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.
  2. NIH Low Back Pain Fact Sheet Available: https://www.ninds.nih.gov/low-back-pain-fact-sheet(accessed 17.11.2022)
  3. 3.0 3.1 3.2 Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Research. 2016;5. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926733/ (accessed 17.11.2022)
  4. 4.0 4.1 4.2 AFP Chronic Low Back Pain: Evaluation and Management Available;https://www.aafp.org/pubs/afp/issues/2009/0615/p1067.html (accessed 18.11.2022)
  5. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015;49:1. doi: 10.1590/S0034-8910.2015049005874. Epub 2015 Oct 20. PMID: 26487293; PMCID: PMC4603263.
  6. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Revista de saude publica. 2015 Oct 20;49:73.Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603263/ (accessed 17.11.2022)
  7. 7.0 7.1 Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42(4):A1-A57.
  8. Lumbar Assessment
  9. 9.0 9.1 9.2 MJA Management of CLBP Available:https://www.mja.com.au/journal/2004/180/2/management-chronic-low-back-pain (accessed 17.11.2022)
  10. McCarthy CJ, Arnall FA, Strimpakos N, Freemont A, Oldham JA. The biopsychosocial classification of non-specific low back pain: a systematic review. Physical Therapy Reviews. 2004 Mar 1;9(1):17-30.
  11. Chou R, Qaseem A, Snow V, Casey D, Cross Jr JT, Shekelle P, Owens DK. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine. 2007 Oct 2;147(7):478-91.
  12. Paatelma M, Karvonen E, Heiskanen J. Clinical perspective: how do clinical test results differentiate chronic and subacute low back pain patients from" non-patients"?. Journal of Manual & Manipulative Therapy. 2009 Jan 1;17(1):11-9.
  13. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, Van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj. 2015 Feb 18;350.
  14. Maddalozzo GF, Kuo B, Maddalozzo WA, Maddalozzo CD, Galver JW. Comparison of 2 multimodal interventions with and without whole body vibration therapy plus traction on pain and disability in patients with nonspecific chronic low back pain. Journal of chiropractic medicine. 2016 Dec 1;15(4):243-51.
  15. Halliday MH, Pappas E, Hancock MJ, Clare HA, Pinto RZ, Robertson G, Ferreira PH. A randomized controlled trial comparing the McKenzie method to motor control exercises in people with chronic low back pain and a directional preference. Journal of Orthopaedic & Sports Physical Therapy. 2016 Jul;46(7):514-22.
  16. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Annals of internal medicine. 2017 Apr 4;166(7):514-30.
  17. Wells C, Kolt GS, Marshall P, Hill B, Bialocerkowski A. Effectiveness of Pilates exercise in treating people with chronic low back pain: a systematic review of systematic reviews. BMC medical research methodology. 2013 Dec;13(1):1-2.
  18. Pilates Pilates
  19. Holtzman S, Beggs RT. Yoga for chronic low back pain: a meta-analysis of randomized controlled trials. Pain Research and Management. 2013 Oct;18(5):267-72.