41 Back Pain
Back pain affects roughly 568 million people worldwide and symptoms may vary from a dull ache to a sudden sharp shooting pain (Cieza et al., 2020). After a detailed history and clinical examination back pain is often classified three into broad categories:
- Specific spinal pathology (< 1% of cases)
- Vertebral fracture
- Spinal infection
- Axial Spondyloarthritis
- Cauda equina syndrome
- Radicular syndrome (∼ 5-10% of cases)
- Radicular pain
- Spinal stenosis
- Non-specific LBP (90-95% of cases)
- Presumed lumbar musculoskeletal low back pain. Difficult to reliably specify pathoanatomical source of low back pain
DocMikeEvans: Low Back Pain
Increasingly, research shows that attributing the experience of back pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process (Green et al., 2018; Swain et al., 2020). So-called abnormalities are often normal variations or adaptations, in some cases they may even be advantageous. Even in the case of degenerative changes in the spine, landmark studies have shown that tissue tears revealed on imaging are a part of normal aging (Brinjikji et al., 2015). What’s more is that in the case of herniated discs 60-80% have been shown to spontaneously resorb (Zhong et al., 2017). This disconnect between tissue damage seen on imaging and clinical presentation often creates confusion for both patients and clinicians.
A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.
Red Flags for Serious Spinal Pathology
Red flags are signs and symptoms that raise suspicion of serious underlying pathology, for patients with low back pain there are a number of serious spinal pathologies to be aware of, these are cauda equina syndrome (0.08% of low back pain patients presenting to primary care), spinal fracture, malignancy, and spinal infection (Finucane et al., 2020; Hoeritzauer et al., 2020).
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
- Self-Rated Recovery Question
- Patient-specific Functional Scale
- Oswestry Disability Index
- Roland-Morris Disability Questionnaire
- STarT Back Screening Tool (SBST)
Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.
- Craig’s Test
- Gaenslen’s Test
- Gillet’s Test
- Kemp’s Test (Lower Quadrant Test)
- Kernig/Brudzinski Test
- Rebound Tenderness (McBurney’s Point)
- Piriformis Test (FAIR Test)
- Cluster of Laslett (Sacroiliac Joint Pain Provocation)
- Sacroiliac Compression Test (Squish Test)
- Sacroiliac Distraction Test (Gap Test)
- Slump Test
- Valsalva Maneuver
- Well Leg Raise
- Straight Leg Raise (Lasègue’s sign) or Braggard’s Test
- Bowstring Maneuver
- Prone Gap Test (Hibb’s Test)
- Prone Knee Bend Test/Femoral Nerve Stretch Test (Reversed Lasègue)
Most clinical practice guidelines for low back pain are moving towards an interdisciplinary approach with an emphasis on self-management, physical and psychological therapies and less emphasis on pharmacological and surgical treatments (Foster et al., 2018). Pharmacological treatments options such as opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) have small effects on low back pain (Chou et al., 2020; Kamper et al., 2020; Tucker et al., 2020; van der Gaag et al., 2020). Embracing an interprofessional strategy for pain management can include the use of education, exercise, acupuncture, massage therapy and spinal manipulation as part of a multi-dimensional approach for the management of back pain.
Acute low back pain (less than six weeks duration)
Chronic low back pain (more than 12 weeks duration)
First line treatments
Advice to stay active; patient education
Advice to stay active; patient education; exercise therapy; cognitive behavioral therapy
Second line treatments
Spinal manipulation; massage; acupuncture
Spinal manipulation; massage; acupuncture; yoga; mindfulness-based stress reduction; interdisciplinary rehabilitation
If the above treatments fail
Non-steroidal anti-inflammatory drugs
Non-steroidal anti-inflammatory drugs; selective norepinephrine reuptake inhibitors; surgery
|*Reference – Foster et al., (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet.|
Back to basics: 10 facts every person should know about back pain
Once red flags and serious pathology are excluded, evidence supports that:
- Low back pain (LBP) is not a serious life-threatening medical condition.
- Most episodes of low back pain improve and LBP does not get worse as we age.
- A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.
- Scans do not determine prognosis of the current episode of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.
- Graduated exercise and movement in all directions is safe and healthy for the spine.
- Spine posture during sitting, standing and lifting does not predict LBP or its persistence.
- A weak core does not cause LBP, and some people with LBP tend to tense their ‘core’ muscles. While it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren’t needed.
- Spine movement and loading is safe and builds structural resilience when it is graded.
- Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.
- Effective care for LBP is relatively cheap and safe. This includes education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment).
There have been several studies looking at the use of massage therapy for patients with low back. One study published in the Annals of Internal Medicine randomized 401 people with nonspecific chronic low back pain. The control group in the study received usual care and the other two groups received two different types of massage, what this study found was that massage therapy was beneficial for this patient population and there did not appear to be a meaningful difference between the two types of massage that patients received (Cherkin et al., 2011).
Two additional randomized controlled trials demonstrated that a treatment approach focused on the compression at myofascial trigger points (MTrPs) significantly improved subjective pain scores compared with compression at non-MTrPs for patients suffering for back pain (Takamoto et al., 2015; Kodama et al., 2019).
Structures to be Aware of When Treating Back Pain
A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance, back pain may be caused by disc herniation, spondylolisthesis or soft tissue irritation. Structures to keep in mind while assessing and treating patients suffering from sciatica may include neurovascular structures and investing fascia of:
- Erector Spinae (iliocostalis, longissimus, spinalis)
- Quadratus Lumborum
- Thoracolumbar Fascia and Latissimus Dorsi
- External Obliques, Internal Obliques, and Transverse Abdominis
- Iliopsoas (iliacus and psoas major)
- External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior, and quadratus femoris)
- Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
- Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
- Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as routine healthy sleeping habits, Pilates, resistance training and aerobic exercise may be useful for people with back pain (Hutting et al., 2019; Owen et al., 2020).
International clinical practice guidelines for low back pain contain consistent recommendations including the need for a multi-modal therapeutic approach, advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids (Kamper et al., 2020). A multi-modal approach can involve a number of management strategies that include but is not limited to education, reassurance, analgesic medicines and non-pharmacological therapies (Chou et al., 2018).
Recommendations from The American College of Physicians and The Canadian Medical Association represent a monumental shift in pain management. Physicians now more than ever are recommending conservative treatment options including massage, spinal manipulation, acupuncture and exercise as part of a multi-modal approach for patients suffering from low back pain (Chou et al., 2017; Qaseem et al., 2017; Traeger et al., 2017)
Massage Sloth: Massage Tutorial – Full Back Massage Routine
Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for back pain based on patient-specific assessment findings including, but not limited to:
- Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
- Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
- Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
- Hydrotherapy (hot & cold)
- Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)
References and Sources
Bade, M., Cobo-Estevez, M., Neeley, D., Pandya, J., Gunderson, T., & Cook, C. (2017). Effects of manual therapy and exercise targeting the hips in patients with low-back pain-A randomized controlled trial. Journal of evaluation in clinical practice, 23(4), 734–740. doi:10.1111/jep.12705
Bardin, L. D., King, P., & Maher, C. G. (2017). Diagnostic triage for low back pain: a practical approach for primary care. The Medical journal of Australia, 206(6), 268–273. doi:10.5694/mja16.00828
Brinjikji, W., Diehn, F. E., Jarvik, J. G., Carr, C. M., Kallmes, D. F., Murad, M. H., & Luetmer, P. H. (2015). MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR. American journal of neuroradiology, 36(12), 2394–2399. doi:10.3174/ajnr.A4498
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. doi:10.3174/ajnr.A4173
Buchbinder, R., Underwood, M., Hartvigsen, J., & Maher, C. G. (2020). The Lancet Series call to action to reduce low value care for low back pain: an update. Pain, 161, S57-S64.
Caneiro, J. P., Bunzli, S., & O’Sullivan, P. (2020). Beliefs about the body and pain: the critical role in musculoskeletal pain management. Brazilian journal of physical therapy, S1413-3555(20)30407-X. Advance online publication. https://doi.org/10.1016/j.bjpt.2020.06.003
Cherkin, D. C., Sherman, K. J., Kahn, J., Wellman, R., Cook, A. J., Johnson, E., … Deyo, R. A. (2011). A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Annals of internal medicine, 155(1), 1–9. doi:10.7326/0003-4819-155-1-201107050-00002
Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., … Turner, J. A. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA, 315(12), 1240–1249. doi:10.1001/jama.2016.2323
Cherkin, D. C., Deyo, R. A., & Goldberg, H. (2019). Time to Align Coverage with Evidence for Treatment of Back Pain. Journal of general internal medicine, 34(9), 1910–1912. https://doi.org/10.1007/s11606-019-05099-z
Chou, R., Deyo, R., Friedly, J., Skelly, A., Hashimoto, R., Weimer, M., … Brodt, E. D. (2017). Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Annals of internal medicine, 166(7), 493–505. doi:10.7326/M16-2459
Chou, R., Côté, P., Randhawa, K., Torres, P., Yu, H., Nordin, M., … Cedraschi, C. (2018). The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. European spine journal, 27(Suppl 6), 851–860. doi:10.1007/s00586-017-5433-8
Chou, R., Hartung, D., Turner, J., Blazina, I., Chan, B., Levander, X., … Pappas, M. (2020). Opioid Treatments for Chronic Pain. Agency for Healthcare Research and Quality (US). DOI: https://doi.org/10.23970/AHRQEPCCER229.
Cieza, A., Causey, K., Kamenov, K., Hanson, S. W., Chatterji, S., & Vos, T. (2020). Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (London, England), S0140-6736(20)32340-0. Advance online publication. https://doi.org/10.1016/S0140-6736(20)32340-0
Cook, C. E., George, S. Z., & Reiman, M. P. (2018). Red flag screening for low back pain: nothing to see here, move along: a narrative review. British journal of sports medicine, 52(8), 493–496. doi:10.1136/bjsports-2017-098352
Cook, C. J., Cook, C. E., Reiman, M. P., Joshi, A. B., Richardson, W., & Garcia, A. N. (2020). Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis. European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 29(1), 93–112. https://doi.org/10.1007/s00586-019-06048-4
de Campos, T. F., Maher, C. G., Fuller, J. T., Steffens, D., Attwell, S., & Hancock, M. J. (2020). Prevention strategies to reduce future impact of low back pain: a systematic review and meta-analysis. British journal of sports medicine, bjsports-2019-101436. Advance online publication. https://doi.org/10.1136/bjsports-2019-101436
De Carvalho, D. E., de Luca, K., Funabashi, M., Breen, A., Wong, A., Johansson, M. S., … Hartvigsen, J. (2020). Association of Exposures to Seated Postures With Immediate Increases in Back Pain: A Systematic Review of Studies With Objectively Measured Sitting Time. Journal of manipulative and physiological therapeutics, 43(1), 1–12. https://doi.org/10.1016/j.jmpt.2019.10.001
Deer, T., Sayed, D., Michels, J., Josephson, Y., Li, S., & Calodney, A. K. (2019). A Review of Lumbar Spinal Stenosis with Intermittent Neurogenic Claudication: Disease and Diagnosis. Pain medicine (Malden, Mass.), 20(Suppl 2), S32–S44. doi:10.1093/pm/pnz161
Elder, W. G., Munk, N., Love, M. M., Bruckner, G. G., Stewart, K. E., & Pearce, K. (2017). Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study. Pain medicine (Malden, Mass.), 18(7), 1394–1405. doi:10.1093/pm/pnw347
Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … Lancet Low Back Pain Series Working Group (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet (London, England), 391(10137), 2368–2383. doi:10.1016/S0140-6736(18)30489-6
Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350–372. https://doi.org/10.2519/jospt.2020.9971
Galliker, G., Scherer, D. E., Trippolini, M. A., Rasmussen-Barr, E., LoMartire, R., & Wertli, M. M. (2020). Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. The American journal of medicine, 133(1), 60–72.e14. https://doi.org/10.1016/j.amjmed.2019.06.005
Gao, S., Geng, X., & Fang, Q. (2018). Spontaneous Disappearance of Large Lumbar Disk Herniation. JAMA neurology, 75(1), 123–124. doi:10.1001/jamaneurol.2017.3178
George, S. Z., Goertz, C., Hastings, S. N., & Fritz, J. M. (2020). Transforming low back pain care delivery in the United States. Pain, 161(12), 2667–2673. https://doi.org/10.1097/j.pain.0000000000001989
Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., … Nordin, M. (2018). A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one, 13(6), e0197987. doi:10.1371/journal.pone.0197987
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., … Lancet Low Back Pain Series Working Group (2018). What low back pain is and why we need to pay attention. Lancet (London, England), 391(10137), 2356–2367. doi:10.1016/S0140-6736(18)30480-X
Herman, P. M., Lavelle, T. A., Sorbero, M. E., Hurwitz, E. L., & Coulter, I. D. (2019). Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results From a Markov Model. Spine, 44(20), 1456–1464. doi:10.1097/BRS.0000000000003097
Hodges, P. W., Barbe, M. F., Loggia, M. L., Nijs, J., & Stone, L. S. (2019). Diverse Role of Biological Plasticity in Low Back Pain and Its Impact on Sensorimotor Control of the Spine. The Journal of orthopaedic and sports physical therapy, 49(6), 389–401. doi:10.2519/jospt.2019.8716
Hoeritzauer, I., Wood, M., Copley, P. C., Demetriades, A. K., & Woodfield, J. (2020). What is the incidence of cauda equina syndrome? A systematic review. Journal of neurosurgery: Spine, 1–10. Advance online publication. https://doi.org/10.3171/2019.12.SPINE19839
Hush, J. M. (2020). Low back pain: it is time to embrace complexity. Pain, 161(10), 2248–2251. https://doi.org/10.1097/j.pain.0000000000001933
Hutting, N., Johnston, V., Staal, J. B., & Heerkens, Y. F. (2019). Promoting the Use of Self-management Strategies for People With Persistent Musculoskeletal Disorders: The Role of Physical Therapists. The Journal of orthopaedic and sports physical therapy, 49(4), 212–215. https://doi.org/10.2519/jospt.2019.0605
Kamper, S. J., Logan, G., Copsey, B., Thompson, J., Machado, G. C., Abdel-Shaheed, C., … Hall, A. M. (2020). What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain, 161(4), 694–702. https://doi.org/10.1097/j.pain.0000000000001751
Kikuta, S., Iwanaga, J., Watanabe, K., Haładaj, R., Wysiadecki, G., Dumont, A. S., & Tubbs, R. S. (2020). Posterior Sacrococcygeal Plexus: Application to Spine Surgery and Better Understanding Low-Back Pain. World neurosurgery, 135, e567–e572. https://doi.org/10.1016/j.wneu.2019.12.061
Klerx, S. P., Pool, J., Coppieters, M. W., Mollema, E. J., & Pool-Goudzwaard, A. L. (2019). Clinimetric properties of sacroiliac joint mobility tests: A systematic review. Musculoskeletal science & practice, 102090.
Kodama, K., Takamoto, K., Nishimaru, H., Matsumoto, J., Takamura, Y., Sakai, S., … Nishijo, H. (2019). Analgesic Effects of Compression at Trigger Points Are Associated With Reduction of Frontal Polar Cortical Activity as Well as Functional Connectivity Between the Frontal Polar Area and Insula in Patients With Chronic Low Back Pain: A Randomized Trial. Frontiers in systems neuroscience, 13, 68. doi:10.3389/fnsys.2019.00068
Kongsted, A., Kent, P., Quicke, J. G., Skou, S. T., & Hill, J. C. (2020). Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model?. Pain reports, 5(5), e843. https://doi.org/10.1097/PR9.0000000000000843
Kreiner, D. S., Matz, P., Bono, C. M., Cho, C. H., Easa, J. E., Ghiselli, G., … Yahiro, A. M. (2020). Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. The spine journal: official journal of the North American Spine Society, 20(7), 998–1024. https://doi.org/10.1016/j.spinee.2020.04.006
Layne, E. I., Roffey, D. M., Coyle, M. J., Phan, P., Kingwell, S. P., & Wai, E. K. (2018). Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines?. The spine journal, 18(4), 614–619. doi:10.1016/j.spinee.2017.08.259
Liebenson, C. (2020). Rehabilitation of the Spine: A Patient-Centered Approach (3rd ed.). Wolters Kluwer.
Lederman, E. (2011). The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. Journal of bodywork and movement therapies, 15(2), 131–138. https://doi.org/10.1016/j.jbmt.2011.01.011
Lewis, J., & O’Sullivan, P. (2018). Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British journal of sports medicine, 52(24), 1543–1544. doi:10.1136/bjsports-2018-099198
Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. The Journal of orthopaedic and sports physical therapy, 50(1), 1–4.
Louw, A., Goldrick, S., Bernstetter, A., Van Gelder, L. H., Parr, A., Zimney, K., & Cox, T. (2020). Evaluation is treatment for low back pain. The Journal of manual & manipulative therapy, 1–10. Advance online publication. https://doi.org/10.1080/10669817.2020.1730056
Maher, C., Underwood, M., & Buchbinder, R. (2017). Non-specific low back pain. Lancet (London, England), 389(10070), 736–747. doi:10.1016/S0140-6736(16)30970-9
McGill, S. (2015). Low Back Disorders: Evidence-Based Prevention and Rehabilitation (3rd Ed.). Human Kinetics.
O’Sullivan, P. B., Caneiro, J. P., O’Sullivan, K., Lin, I., Bunzli, S., Wernli, K., & O’Keeffe, M. (2020). Back to basics: 10 facts every person should know about back pain. British journal of sports medicine, 54(12), 698–699. https://doi.org/10.1136/bjsports-2019-101611
Owen, P. J., Miller, C. T., Mundell, N. L., Verswijveren, S., Tagliaferri, S. D., Brisby, H., Bowe, S. J., & Belavy, D. L. (2020). Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British journal of sports medicine, 54(21), 1279–1287. https://doi.org/10.1136/bjsports-2019-100886
Palsson, T. S., Gibson, W., Darlow, B., Bunzli, S., Lehman, G., Rabey, M., … Travers, M. (2019). Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Physical therapy, pzz108.
Pangarkar, S. S., Kang, D. G., Sandbrink, F., Bevevino, A., Tillisch, K., Konitzer, L., & Sall, J. (2019). VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain. Journal of general internal medicine, 34(11), 2620–2629. doi:10.1007/s11606-019-05086-4
Prather, H., Cheng, A., Steger-May, K., Maheshwari, V., & Van Dillen, L. (2017). Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain, With or Without Lower Extremity Pain. The Journal of orthopaedic and sports physical therapy, 47(3), 163–172. doi:10.2519/jospt.2017.6567
Qaseem, A., Wilt, T. J., McLean, R. M., Forciea, M. A., & Clinical Guidelines Committee of the American College of Physicians (2017). Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine, 166(7), 514–530. doi:10.7326/M16-2367
Rampersaud, Y. R., Power, J. D., Perruccio, A. V., Paterson, J. M., Veillette, C., Coyte, P. C., Badley, E. M., & Mahomed, N. N. (2020). Healthcare utilization and costs for spinal conditions in Ontario, Canada – opportunities for funding high-value care: a retrospective cohort study. The spine journal: official journal of the North American Spine Society, 20(6), 874–881. https://doi.org/10.1016/j.spinee.2020.01.013
Skelly, A.C., Chou, R., Dettori, J.R., Turner, J.A., Friedly, J.L., Rundell, S.D., … Ferguson, A.J.R. (2020). Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Agency for Healthcare Research and Quality (US). DOI: https://doi.org/10.23970/AHRQEPCCER227
Stolz, M., von Piekartz, H., Hall, T., Schindler, A., & Ballenberger, N. (2020). Evidence and recommendations for the use of segmental motion testing for patients with LBP – A systematic review. Musculoskeletal science & practice, 45, 102076. https://doi.org/10.1016/j.msksp.2019.102076
Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312. https://doi.org/10.1016/j.jbiomech.2019.08.006
Tagliaferri, S. D., Miller, C. T., Owen, P. J., Mitchell, U. H., Brisby, H., Fitzgibbon, B., … Belavy, D. L. (2019). Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective. Pain practice, 10.1111/papr.12846.
Takamoto, K., Bito, I., Urakawa, S., Sakai, S., Kigawa, M., Ono, T., & Nishijo, H. (2015). Effects of compression at myofascial trigger points in patients with acute low back pain: A randomized controlled trial. European journal of pain (London, England), 19(8), 1186–1196. doi:10.1002/ejp.694
Traeger, A., Buchbinder, R., Harris, I., & Maher, C. (2017). Diagnosis and management of low-back pain in primary care. CMAJ: Canadian Medical Association journal, 189(45), E1386–E1395. doi:10.1503/cmaj.170527
Traeger, A. C., Buchbinder, R., Elshaug, A. G., Croft, P. R., & Maher, C. G. (2019). Care for low back pain: can health systems deliver?. Bulletin of the World Health Organization, 97(6), 423–433. doi:10.2471/BLT.18.226050
Tucker, H. R., Scaff, K., McCloud, T., Carlomagno, K., Daly, K., Garcia, A., & Cook, C. E. (2020). Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review. British journal of sports medicine, 54(11), 664. https://doi.org/10.1136/bjsports-2018-099805
van der Gaag, W. H., Roelofs, P. D., Enthoven, W. T., van Tulder, M. W., & Koes, B. W. (2020). Non-steroidal anti-inflammatory drugs for acute low back pain. The Cochrane database of systematic reviews, 4, CD013581. https://doi.org/10.1002/14651858.CD013581
Vining, R. D., Shannon, Z. K., Minkalis, A. L., & Twist, E. J. (2019). Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations. Journal of manipulative and physiological therapeutics, 42(9), 651–664. https://doi.org/10.1016/j.jmpt.2019.08.002
Vining, R. D., Minkalis, A. L., Shannon, Z. K., & Twist, E. J. (2019). Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain. Journal of manipulative and physiological therapeutics, 42(9), 665–676. https://doi.org/10.1016/j.jmpt.2019.08.003
Zhong, M., Liu, J. T., Jiang, H., Mo, W., Yu, P. F., Li, X. C., & Xue, R. R. (2017). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain physician, 20(1), E45–E52.