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Mechanical Back Pain

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Other Names

  • Myofascial back pain
  • Lumbago
  • Lumbosacral strain
  • Lumbosacral sprain
  • Lumbar strain
  • Lumber sprain
  • Thoracic strain
  • Thoracic sprain
  • Non-specific low back pain
  • Lumbar contusion
  • Musculoligamentous Strain

Background

  • This page refers to nonspecific mechanical back of of the lumbar and thoracic spine
    • Generally defined as back pain not attributable to a known specific pathology
    • There are many causes including strain, sprain, contusion, etc
    • May be acute or chronic
    • If you suspect a structural problem, please refer to that specific diagnosis

History

Epidemiology

  • Healthcare Utilization
    • Picavet et al: less than 1/3 of patients with low back pain consulted their family doctor the previous year[1]
    • Weiser et al: 22.8% of patients sought medical care[2]
  • Prevalence, varies based on definition
    • Ozguler et al: 8% when low back pain defined as requiring sick leave, 45% when it lasted at least a day[3]
    • Prevalence rates of low back pain in athletes range from 1% to 40%[4]
    • In general, prevalence rates thought to be lower in athletes than nonathletes[5]
  • Back injuries occur in 10-15% of athletes[6]

Pathophysiology

  • Mechanical or nonspecific back pain by definition are a symptom of an unknown cause or we currently have no reliable way to identify the pathology
  • Repetitive trauma and overuse are common causes of chronic mechanical low back pain, which is often secondary to workplace injury
  • Frequently, lesions identified on MRI can not be reliable established as the cause of low back pain[7]
  • Inflammation is one proposed pathophysiological entity
    • Tumor necrosis factor alpha (TNFa) found to be significantly higher in patients with low back pain compared to controls[8]
    • Other imnplicated factors include nerve growth factor, substance P production[9]
  • Mechanical factors are implicated
    • No clear independent, causal association with occupational sitting, awkward postures, standing and walking, manual handling or assisting patients, pushing or pulling, bending and twisting, lifting, or carrying[10]
  • Athletes
    • The majority of low back pain in athletes is from a benign source[11]
    • Muscle strain may be the most common cause of low back pain in college athletes[12]

Associated Conditions

Risk Factors

  • History of previous back pain
    • Strongest risk factor for future back pain[14]
  • Obesity
  • Disuse
  • Physical deconditioning
  • Tobacco Use Disorder[15]
  • Genetic
    • Based on twin studies[16]
  • Physical Activity
    • U-shaped relationship with back pain associated with extremes on either end
  • Sports

Differential Diagnosis

Clinical Features

  • General: Physical Exam Back
  • Red Flags[19]
    • Saddle anesthesia
    • Bowel or bladder dysfunction
    • Unexplained weight loss
    • Fevers, chills
    • Night sweats
    • History of violent trauma
    • History of cancer or immunocompromised state
    • Absence of relief after 4 weeks of treatment
    • History of IV drug use
  • Yellow Flags[20]
    • Predict poor response to basic treatment
    • Maladaptive beliefs
    • Poor sleep
    • Mood disorder
    • Job dissatisfaction
    • Poor social support
    • Compensation and/or litigation issues
    • Kinesiophobia
  • History
    • Clarify onset, pain location, severity, timing, aggravating/relieving factors, and radiation
    • Important to consider body habitus, sporting activities, occupation, hobbies
    • Predictors of nerve root compression include dermatomal pattern, pain worse with coughing[21]
    • Predictors of spinal stenosis typically include pain with walking[22]
  • Physical Exam
    • Often normal in mechanical back pain
    • Patients may have localized or point tenderness, worse with range of motion or motor exam
    • Strength, sensation, reflxes and vascular exam should be normal
  • Special Tests

Evaluation

  • Do not order imaging on initial evaluation unless there are serious concerns, trauma or red flags
    • This is a category B recommendation[23]
  • American College of Radiology Appropriateness Criteria for low back pain recommends imaging only if[24]
    • No improvement after six weeks of conservative medical and physical therapies
    • There is high suspicion for cauda equina syndrome, malignancy, fracture, or infection
  • The presence of low back pain with radiculopathy is not an indication for early imaging[25]
  • Early imaging is associated with worse overall outcomes and likely to identify minor, clinically irrelevant abnormalities[24]
  • Jarvik et al compared early MRI to standard radiographs[26]
    • They found both modalities resulted in nearly identical outcomes for primary care patients with low back pain
    • They found no additional benefit to early MRI
    • Also stated it may increase cost of care because of the increased number of spine operations that patients are likely to undergo
  • Survey by Henschke et al asked 25 red flag questions in the primary care setting and 80% (942/1172) had at least one red flag[27]
    • In this same cohort, only 0.9% (11/1172) had serious disease
  • Some researchers have opined that in the absence of red flags, one can be 99% certain that serious spinal disease has not been missed[28]
  • Imaging results in increased rates of surgery[29]

Radiographs

MRI

  • Appropriate to evaluate the neurological and soft tissue abnormalities
  • MRI abnormalities are very common in asymptomatic individuals (need citation)
    • Do not coincide with development of back pain
    • Do not predict response to evidence based therapy for nonspecific low back pain
  • Potential uses for MRI[30]
    • Predictive
    • Diagnostic
    • Assessment of severity
    • Prognostic
    • Assessment of recovery
    • Management planning
    • Therapeutic targeting
    • Occupational screening
  • Indications
    • Progressive neurological deficit
    • Serious underlying condition is suspected

Classification

  • Published work generally distinguishes based on duration of episode[31]
    • Acute <6 weeks
    • Subacute 6-12 weeks
    • Chronic >12 weeks

Management

Prognosis

  • Most episodes of low back pain are self limited, not related to serious illness
  • Most patients with acute low back pain recover reasonably quickly and that only about 10–15% develop chronic symptoms. (need citation)
  • Australian cohort showed that about a third of patients had not recovered fully after 1 year.[32]
  • In another subset of patients whos pain persisted more than 90 days, only about 40% were pain free at 12 months[33]
  • Chronic state
    • Most challenging because it tends not to improve with time, consumes most resources[34]
  • Predictors of persistent, disabling low back pain[35]
    • Maladaptive pain coping behaviours
    • Nonorganic signs
    • Functional impairment
    • Low general health status
    • Presence of psychiatric comorbidities
    • Low recovery expectations
  • Predictors of recovery at 1 year
    • Low levels of fear avoidance
    • Low levels of functional impairment

Prevention

  • Most prospective studies have not been able to identify many strong, modifiable risk factors for true first time low back pain[36]
    • Likely in part because of challenges in identifying the cause
  • Physical Exercise
    • Shown to be effective at prevention of developing low back pain[37]
  • Ineffective
    • Stress management, shoe inserts or insoles, back supports, ergonomics or back education, and reduced lifting programs
    • Lift assist devices, handling advice, training do not appear to be helpful either

Pharmacotherapy

  • NSAIDS
    • Effective for short-term relief of acute and chronic low back pain without radiculopathy[38]
    • Cochrane review: No difference between NSAIDs and placebo for radicular symptoms[39]
    • No difference between different types of NSAIDs and between NSAIDs and other commonly used pharmacotherapies, including opioids and muscle relaxants, when used for chronic pain
  • Acetaminophen
    • No evidence that acetaminophen is better than placebo
    • Recommend taking with NSAID for synergy[40]
  • Tramadol
    • Cochrane review found tramadol was more effective than placebo for pain relief and improving function[41]
  • Opiates
    • Short-term effectiveness for pain relief and functioning, but long-term effectiveness and safety are unclear
    • High risk for misuse, diversion, abuse
  • Topimerate
    • Superior to placebo, safe, effective in treatment of chronic low back pain[42]
  • Antidepressants (except duloxetine [Cymbalta])
    • Cochrane review of 10 antidepressant and placebo trials showed no difference in pain relief or depression severity[43]
    • Duloxetine is approved for chronic low back pain and osteoarthritis, evidence supports use in chronic low back pain[44]
  • Lidocaine Patches
    • No more effective than placebo[45]
  • Gabapentinoids
    • Shanthanna et al: Significant adverse effects without demonstrated benefits in patients with chronic low back pain[46]
  • Oral Corticosteroids
    • Eskin et al: No benefit for acute low back pain according to a single randomized controlled trial[47].
    • A single dose of IM methylprednisolone was no better than placebo for pain relief in patients with acute low back pain[48]
  • Topical Medications
  • Muscle Relaxants
    • Cochrane review: Effective for short term relief of nonspecific acute or chronic back pain[49]
    • High incidence of side effects including drowsiness, dizziness, and other side effects

Physical Modalities

  • Physical Therapy
    • McKenzie method techniques are recommended to reduce the risk of recurrence and need for health care services.
    • Category B recommendation[50]
  • Spinal Manipulation Therapy (SMT)
    • Encompasses chiropractic, osteopathic and massage therapy
    • Moderate evidence of short-term pain relief with acute low back pain treated with SMT[51]
    • Chronic low back pain showed moderate improvement with SMT, which is as effective as NSAIDs, more effective than physical therapy
    • Patients with mixed acute and chronic low back pain had better pain outcomes in the short and long terms compared with McKenzie therapy, medical care, management by physical therapists, soft tissue treatment, and back school
    • Cochrane review: more effective than sham therapy for reducing pain, improving activities of daily living[52]
  • Osteopathic Manipulation
    • Systematic review: safe, effective for reducing symptoms of both acute and chronic low back pain[53]
  • Accupuncture
    • Cochrane review: more effective for pain relief, functional improvement than sham treatment in the short term only for chronic back pain[54]
    • Not more effective than other conventional or alternative treatment, likely a useful adjunct to primary treatments
  • Dry Needling
    • Cochrane review: not more effective than other conventional or alternative treatments</ref name="Ref3">
    • Likely a useful adjunct to primary treatments
  • Massage Therapy
    • Cochrane review: acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up only[55]
    • Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up
  • Therapeutic Ultrasound
    • There are no systemic reviews for ultrasound
  • Low Level Laser Therapy (LLLT)
    • Cochrane review of 7 small studies: insufficient data to either support or refute the effectiveness of LLLT for the treatment of low back pain[56]
    • When combined with NSAIDS, Konstatninovic et al found LLLT improved movement, reduced pain intensity and disability, improved quality of life when compared to controls or sham LLLT [57]

Other Modalities

  • Exercise Therapy
    • In chronic back pain, slightly effective at decreasing pain, improving function [58]
    • In acute low back pain, exercise therapy was no better than no treatment or conservative treatments.
  • Cold Therapy
  • Heat Therapy
    • Cochrane review: moderate evidence supporting superficial heat therapy as reducing pain and disability in patients with acute and subacute low back pain[59]
    • Addition of exercise further reducing pain and improved function
    • Benefit greatest in first week following injury[60]
  • Cognitive Behavioral Therapy
    • In adults with chronic LBP, mindfulness based stress reduction (MBSR) and/or cognitive behavioral therapy (CBT) resulted in greater improvements in back pain, functional limitations at 26 weeks compared to usual care[61]
    • No difference between MBSR and CBT
  • Yoga
    • Systematic review: effective for short term (strong evidence), long term (moderate evidence) for chronic low back pain[62]
  • Transcutaneous Electrical Nerve Stimulation (TENS)
    • Not consistently more effective than placebo in the treatment of chronic low back pain.[63]
  • Multidisiplinary Rehabilitation
    • Defined as multimodal approach including a physical component, psychological component and a social/work component
    • Cochrane review: more effective than usual care for decreasing pain, disability in patients with chronic low back pain[64]
  • Patient Education
    • Sometimes termed 'back school'
    • Cochrane review: strong evidence that 2.5 hour educational session is more effective for return to work, long term pain in patients with acute, subacute back pain[65]
    • Same study found less intensive patient education is no more effective than no intervention
  • Lumbar Brace

Procedures

Operative

  • Consider surgical referral in patients with disabling low back pain impacting quality of life for more than 1 year[68]
  • The role, if any, for surgery in chronic, non-specific low back pain is limited and its overuse has been heavily scrutinized[69]
  • Studies have compared intensive rehab with spinal fusion[70]
    • Similar clinical outcomes
    • More complications, more expenses associated with surgery

Rehab and Return to Play

Rehabilitation

  • 3 phase approach described by Ligia et al. [71]
  • Acute /subacute phase
    • Generally includes few days of rest, icing, ultrasounds, iontophoresis, laser therapy and other modalities
    • Consider aerobic activity in the pool (subacute phase)
    • Emphasis on isometric core strengthening
  • Rehabilitative phase
    • Core stabilisation
    • Depend of pathology mechanism, we shall promote flexion or extension programme
    • Begin the closed chain strengthening and co-activated muscular coordination for improvement muscle balance
  • Sport specific rehabilitation
    • Prepare the athlete to return sporting activities
    • Should be specific program for individual sport
    • Emphasis on decreasing stress forces at the back, to maintain the static of spine and decrease the disc injuries.
    • Goal is minimizing recurrence, improve sport performance.

Return to Play

  • Not a lot of evidence to guide return to play
    • If no structural injury suspected or identified, athletes can often play through pain
  • Experts agree athlete should have full active ROM before full RTP[72]

Complications

  • Recurrence
  • Inability to return to sport
  • Chronic pain
  • Inability to return to work
  • Disability

See Also

References

  1. ↑ Picavet HS, Struijs JN, Westert GP. Utilization of health resources due to low back pain: survey and registered data compared. Spine (Phila Pa 1976) 2008; 33: 436–44.
  2. ↑ Wieser S, Horisberger B, Schmidhauser S, et al. Cost of low back pain in Switzerland in 2005. Eur J Health Econ 2010; published online June 5. DOI:10.1007/s10198-010-0258-y.
  3. ↑ Ozguler A, Leclerc A, Landre MF, Pietri-Taleb F, Niedhammer I. Individual and occupational determinants of low back pain according to various defi nitions of low back pain.
  4. ↑ Bono C. Low back pain in athletes. J Bone Joint Surg Am. 2004;86(2):382-396
  5. ↑ Videman T, Sarna S, Battie MC, et al. The long-term effects of physical loading and exercise lifestyles on backrelated symptoms, disability, and spinal pathology among men. Spine. 1995;20:699-709
  6. ↑ d’Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. 2000;19:663-679
  7. ↑ Endean A, Palmer KT, Coggon D. Potential of magnetic resonance imaging fi ndings to refi ne case defi nition for mechanical low back pain in epidemiological tudies: a systematic review. Spine (Phila Pa 1976) 2011; 36: 160–69.
  8. ↑ Wang H, Schiltenwolf M, Buchner M. The role of TNF-alpha in patients with chronic low back pain—a prospect
  9. ↑ Yamauchi K, Inoue G, Koshi T, et al. Nerve growth factor of cultured medium extracted from human degenerative nucleus pulposus promotes sensory nerve growth and induces substance p in vitro. Spine (Phila Pa 1976) 2009; 34: 2263–69.
  10. ↑ Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6. Review.
  11. ↑ Watkins RG, Dillin WM. Lumbar spine injuries. In: Fu FF, Stone DA, eds. Sports Injuries: Mechanisms, Prevention, Treatment. Baltimore, MD: Williams & Wilkins; 1994:877-94
  12. ↑ Keene JS, Albert MJ, Springer SL, Drummond DS, Clancy WG., Jr Back injuries in college athletes. J Spinal Disord. 1989;2:190-195
  13. ↑ de Schepper EI, Damen J, van Meurs JB, et al. The association between lumbar disc degeneration and low back pain: the infl uence of age, gender, and individual radiographic features. Spine (Phila Pa 1976) 2010; 35: 531–36.
  14. ↑ Papageorgiou AC, Croft PR, Thomas E, Ferry S, Jayson MI, Silman AJ. Infl uence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study Pain 1996; 66: 181–85.
  15. ↑ Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between smoking and low back pain: a meta-analysis. Am J Med 2010; 123: 87 e7–35
  16. ↑ Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine 2008; 75: 388–96.
  17. ↑ Granhed H, Morelli B. Low back pain among retired wrestlers and heavyweight lifters. Am J Sports Med. 1988;16:530-533
  18. ↑ Sward L, Hellstrom M, Jacobsson B, Nyman R, Peterson L. Disc degeneration and associated abnormalities of the spine in elite gymnasts: a magnetic resonance imaging study. Spine. 1991;16:437-443
  19. ↑ Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347
  20. ↑ Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;(Suppl 2):192–300
  21. ↑ van der Windt DA, Simons E, Riphagen I, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low back pain. Cochrane Database Syst Rev 2010; 2: CD007431.
  22. ↑ Cook C, Brown C, Michael K, et al. The clinical value of a cluster of patient history and observational fi ndings as a diagnostic support tool for lumbar spine stenosis. Physiother Res Int 2010; published online Nov 11. DOI:10.1002/pri500.
  23. ↑ Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–1078.
  24. ↑ 24.0 24.1 Patel ND, Broderick DF, Burns J, et al. ACR Appropriateness Criteria low back pain. J Am Coll Radiol. 2016;13(9):1069–1078.
  25. ↑ Chou R, Qaseem A, Owens DK, et al.; Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians [published correction appears in Ann Intern Med. 2012; 156(1 pt 1): 71]. Ann Intern Med. 2011;154(3):181–189.
  26. ↑ Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003;289(21):2810–2818.
  27. ↑ Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009; 60: 3072–80.
  28. ↑ Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low back pain: systematic review and meta-analysis. Lancet 2009; 373: 463–72.
  29. ↑ Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA 2003; 289: 2810–18.
  30. ↑ Sheehan NJ. Magnetic resonance imaging for low back pain: indications and limitations. Ann Rheum Dis 2010; 69: 7–11.
  31. ↑ van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecifi c low back pain in primary care. Eur Spine J 2006; 15 (suppl 2): S169–91.
  32. ↑ Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008; 337: a171.
  33. ↑ Costa Lda C, Maher CG, McAuley JH, et al. Prognosis for patients with chronic low back pain: inception cohort study. BMJ 2009; 339: b3829.
  34. ↑ Krismer M, van Tulder M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specifi c). Best Pract Res Clin Rheumatol 2007; 21: 77–91.
  35. ↑ Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010; 303: 1295–302.
  36. ↑ Burton AK, Balague F, Cardon G, et al. Chapter 2. European guidelines for prevention in low back pain: November 2004. Eur Spine J 2006; 15 (suppl 2): S136–68.
  37. ↑ Bigos SJ, Holland J, Holland C, Webster JS, Battie M, Malmgren JA. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J 2009; 9: 147–68.
  38. ↑ Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016;(6):CD012230.
  39. ↑ Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Nonsteroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008;(1):CD000396.
  40. ↑ Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667.
  41. ↑ Deshpande A, Furlan AD, Mailis-Gagnon A, Atlas S, Turk D. Opioids for chronic low-back pain. Cochrane Database Syst Rev. 2007;(3):CD004959
  42. ↑ Muehlbacher M, Nickel MK, Kettler C, et al. Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. Clin J Pain. 2006;22(6):526–531.
  43. ↑ Urquhart DM, Hoving JL, Assendelft WJJ, Roland M, van Tulder MW. Antidepressants for non-specific low back pain. Cochrane Database Syst Rev. 2008;(1):CD001703.
  44. ↑ Skljarevski V, Desaiah D, Liu-Seifert H, et al. Efficacy and safety of duloxetine in patients with chronic low back pain. Spine (Phila Pa 1976). 2010;35(13): E578-E585
  45. ↑ Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:286.
  46. ↑ Shanthanna H, Gilron I, Rajarathinam M, et al. Benefits and safety of gabapentinoids in chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017;14(8):e1002369.
  47. ↑ Eskin B, Shih RD, Fiesseler FW, et al. Prednisone for emergency department low back pain: a randomized controlled trial. J Emerg Med. 2014;47(1):65–70.
  48. ↑ Friedman BW, Holden L, Esses D, et al. Parenteral corticosteroids for emergency department patients with non-radicular low back pain. J Emerg Med. 2006;31:365-370
  49. ↑ van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low-back pain. Cochrane Database Syst Rev. 2003;(4):CD004252.
  50. ↑ McKenzie R, May S. The Human Extremities Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 2000.
  51. ↑ Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004;4:335-356
  52. ↑ Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain. Cochrane Database Syst Rev. 2004;(1):CD000447
  53. ↑ Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:286.
  54. ↑ Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2005;(1):CD001351.
  55. ↑ Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015;(9):CD001929.
  56. ↑ Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev. 2008;(2):CD005107.
  57. ↑ Konstatntinovic LM, Kanjuh ZM, Milovanovic AN, et al. Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomedicine Laser Surg. 2010;28(4):553-560
  58. ↑ Hayden J, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335
  59. ↑ French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane review of superficial heat or cold for low back pain. Spine. 2006;31(9):998-1006
  60. ↑ Mayer JM, Ralph L, Look M, et al. Treating acute low back pain with continuous low-level heat wrap therapy and/or exercise: a randomized controlled trial. Spine J. 2005;5:395-403
  61. ↑ Cherkin DC, Sherman KJ, Balderson BH, et al. 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. 2016;315(12):1240–1249.
  62. ↑ Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29(5):450–460.
  63. ↑ Buchmuller A, Navez M, Milletre-Bernardin M, et al.; Lombotens Trial Group. Value of TENS for relief of chronic low back pain with or without radicular pain. Eur J Pain. 2012;16(5):656–665.
  64. ↑ Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary bio-psychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ. 2015;350:h444.
  65. ↑ Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057.
  66. ↑ Dagenais S, Yelland MJ, Del Mar C, Schoene ML. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev. 2007;(2):CD004059.
  67. ↑ Savigny P, Kuntze S, Watson P, et al. Low back pain: early management of persistent non-specifi c low back pain. London: National Collaborating Centre for Primary Care and Royal College of Physicians, 2009. http://www.nice.org.uk/nicemedia/ live/11887/44334/44334.pdf (accessed Oct 18, 2010)
  68. ↑ Chou R, Loeser JD, Owens DK, et al.; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34(10):1066–1077.
  69. ↑ Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery—the case for restraint. N Engl J Med 2004; 350: 722–26.
  70. ↑ Brox JI, Nygaard OP, Holm I, Keller A, Ingebrigtsen T, Reikeras O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010; 69: 1643–48.
  71. ↑ Ligia R. How to rehabilitate an athlete with low back pain. British Journal of Sports Medicine 2011;45:e2.
  72. ↑ Eck JC, Riley LH., III Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379
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