Editing Low back pain

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{{Infobox medical condition (new)
| name            = Low back pain
| image           = Lumbar region in human skeleton.svg
| caption         = Location of the [[lumbar]] region (pink) in relation to the human skeleton
| field           = [[Orthopedics]], [[rheumatology]], [[rehabilitation medicine]]
| synonyms        = Lower back pain, lumbago
| pronounce       = Lumbago {{IPAc-en|l|ʌ|m|ˈ|b|eɪ|ɡ|oʊ}}
| symptoms        = 
| complications   = 
| onset           = 20 to 40&nbsp;years of age<ref name=casazza_2012/>
| duration        = ~65% get better in 6 weeks<ref name=menezes_2012/>
| types           = Acute (less than 6 weeks), sub-chronic (6 to 12 weeks), chronic (more than 12 weeks)<ref name=koes_2010/>
| causes          = Usually non-specific, occasionally significant underlying cause<ref name=casazza_2012/><ref name=NIH2015/>
| risks           = 
| diagnosis       = [[Medical imaging]] (if ''red flags'')<ref name=manusov_2012_diag/>
| differential    = 
| prevention      = 
| treatment       = Continued normal activity, non-medication based treatments, NSAIDs<ref name=menezes_2012/><ref name=Qas2017/>
| medication      = 
| prognosis       = 
| frequency       = ~25% in any given month<ref name=hoy_2012/><ref name=vos_2012/>
| deaths          = 
}}
<!-- Definition and symptoms -->

'''Low back pain''' or [[wiktionary:lumbago#Etymology|'''lumbago''']] is a common [[musculoskeletal disorders|disorder involving the muscles, nerves, and bones]] of the [[back]], in between the lower edge of the ribs and the lower fold of the buttocks. [[Pain]] can vary from a dull constant ache to a sudden sharp feeling.<ref name="NIH2015">{{cite web |date=3 November 2015 |title=Low Back Pain Fact Sheet |url=http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm |url-status=live |archive-url=https://web.archive.org/web/20160304051951/http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm |archive-date=4 March 2016 |access-date=5 March 2016 |website=National Institute of Neurological Disorders and Stroke}}</ref> Low back pain may be classified by [[Pain#Chronic versus acute|duration]] as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks).<ref name=koes_2010>{{cite journal | vauthors = Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C | title = An updated overview of clinical guidelines for the management of non-specific low back pain in primary care | journal = European Spine Journal | volume = 19 | issue = 12 | pages = 2075–2094 | date = December 2010 | pmid = 20602122 | pmc = 2997201 | doi = 10.1007/s00586-010-1502-y }}</ref> The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or [[referred pain]].<ref name=manusov_2012_diag>{{cite journal | vauthors = Manusov EG | title = Evaluation and diagnosis of low back pain | journal = Primary Care | volume = 39 | issue = 3 | pages = 471–479 | date = September 2012 | pmid = 22958556 | doi = 10.1016/j.pop.2012.06.003 }}</ref> The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.<ref name=menezes_2012>{{cite journal | vauthors = ((da C Menezes Costa L)), Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO | title = The prognosis of acute and persistent low-back pain: a meta-analysis | journal = CMAJ | volume = 184 | issue = 11 | pages = E613–E624 | date = August 2012 | pmid = 22586331 | pmc = 3414626 | doi = 10.1503/cmaj.111271 }}</ref>

<!--Cause and diagnosis  -->
In most episodes of low back pain a specific underlying cause is not identified or even looked for, with the pain believed to be due to mechanical problems such as [[muscle strain|muscle]] or [[joint strain]].<ref name=casazza_2012>{{cite journal | vauthors = Casazza BA | title = Diagnosis and treatment of acute low back pain | journal = American Family Physician | volume = 85 | issue = 4 | pages = 343–350 | date = February 2012 | pmid = 22335313 }}</ref><ref name=NIH2015/> If the pain does not go away with conservative treatment or if it is accompanied by "red flags" such as unexplained weight loss, [[fever]], or significant problems with feeling or movement, further testing may be needed to look for a serious underlying problem.<ref name=manusov_2012_diag/> In most cases, imaging tools such as [[X-ray computed tomography]] are not useful or recommended for low back pain that lasts less than 6 weeks (with no red flags) and carry their own risks.<ref>{{Cite web |last1=American Academy of Family Physicians |last2=Choosing Wisely |date=2023 |title=Imaging for Low Back Pain |url=https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/cw-back-pain.html |access-date=2023-07-21 |website=aafp.org}}</ref> Despite this, the use of imaging in low back pain has increased.<ref name=deyo_2009>{{cite journal | vauthors = Deyo RA, Mirza SK, Turner JA, Martin BI | title = Overtreating chronic back pain: time to back off? | journal = Journal of the American Board of Family Medicine | volume = 22 | issue = 1 | pages = 62–68 | year = 2009 | pmid = 19124635 | pmc = 2729142 | doi = 10.3122/jabfm.2009.01.080102 }}</ref> Some low back pain is caused by damaged [[intervertebral disc]]s, and the [[straight leg raise|straight leg raise test]] is useful to identify this cause.<ref name=manusov_2012_diag/> In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events.<ref name=salzberg_2012>{{cite journal | vauthors = Salzberg L | title = The physiology of low back pain | journal = Primary Care | volume = 39 | issue = 3 | pages = 487–498 | date = September 2012 | pmid = 22958558 | doi = 10.1016/j.pop.2012.06.014 }}</ref> Chronic non-specific low back pain (CNSLBP) is a highly prevalent musculoskeletal condition that not only affects the body, but also a person's social and economic status. It would be greatly beneficial for people with CNSLBP to be screened for genetic issues, unhealthy lifestyles and habits, and psychosocial factors on top of musculoskeletal issues.<ref name="ReferenceA">{{Cite journal |last1=Herrero |first1=Pablo |last2=Val |first2=Paula |last3=Lapuente-Hernández |first3=Diego |last4=Cuenca-Zaldívar |first4=Juan Nicolás |last5=Calvo |first5=Sandra |last6=Gómez-Trullén |first6=Eva María |date=2024-02-20 |title=Effects of Lifestyle Interventions on the Improvement of Chronic Non-Specific Low Back Pain: A Systematic Review and Network Meta-Analysis |journal=Healthcare |volume=12 |issue=5 |page=505 |doi=10.3390/healthcare12050505 |doi-access=free |issn=2227-9032 |pmc=10931043 |pmid=38470617}}</ref> Chronic lower back pain is defined as back pain that lasts more than three months.<ref name=":9">{{Cite book |date=2023 |title=WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings |url=https://www.who.int/publications/i/item/9789240081789 |publisher=World Health Organization |isbn=978-92-4-008178-9}}</ref>

<!-- Treatment -->
The symptoms of low back pain usually improve within a few weeks from the time they start, with 40–90% of people recovered by six weeks.<ref name="menezes_2012" /> Normal activity should be continued as much as the pain allows.<ref name="menezes_2012" /> Initial management with non-medication based treatments is recommended.<ref name=Qas2017/> Non–medication based treatments include superficial [[Heat therapy|heat]], [[massage]], [[acupuncture]], or [[spinal manipulation]].<ref name="Qas2017" /> If these are not sufficiently effective, [[NSAIDs]] are recommended.<ref name=Qas2017>{{cite journal | vauthors = Qaseem A, Wilt TJ, McLean RM, Forciea MA, Denberg TD, Barry MJ, Boyd C, Chow RD, Fitterman N, Harris RP, Humphrey LL, Vijan S | display-authors = 6 | title = Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians | journal = Annals of Internal Medicine | volume = 166 | issue = 7 | pages = 514–530 | date = April 2017 | pmid = 28192789 | doi = 10.7326/M16-2367 | doi-access = free }}</ref><ref>{{Cite journal |last1=Cashin |first1=Aidan G. |last2=Wand |first2=Benedict M. |last3=O'Connell |first3=Neil E. |last4=Lee |first4=Hopin |last5=Rizzo |first5=Rodrigo Rn |last6=Bagg |first6=Matthew K. |last7=O'Hagan |first7=Edel |last8=Maher |first8=Christopher G. |last9=Furlan |first9=Andrea D. |last10=van Tulder |first10=Maurits W. |last11=McAuley |first11=James H. |date=2023-04-04 |title=Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=4 |pages=CD013815 |doi=10.1002/14651858.CD013815.pub2 |issn=1469-493X |pmc=10072849 |pmid=37014979}}</ref> A number of other options are available for those who do not improve with usual treatment. [[Opioid]]s may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects,<ref name=":5" /> including high rates of addiction, accidental overdose and death.<ref name=":6" /> Surgery may be beneficial for those with disc-related chronic pain and disability or [[spinal stenosis]].<ref name=manusov_2012_surg/><ref name=chou_2009_surgery>{{cite journal | vauthors = Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD | title = Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline | journal = Spine | volume = 34 | issue = 10 | pages = 1094–1109 | date = May 2009 | pmid = 19363455 | doi = 10.1097/BRS.0b013e3181a105fc | s2cid = 1504909 }}</ref> No clear benefit of surgery has been found for other cases of non-specific low back pain.<ref name=manusov_2012_surg>{{cite journal | vauthors = Manusov EG | title = Surgical treatment of low back pain | journal = Primary Care | volume = 39 | issue = 3 | pages = 525–531 | date = September 2012 | pmid = 22958562 | doi = 10.1016/j.pop.2012.06.010 }}</ref> Low back pain often affects mood, which may be improved by [[psychological counseling|counseling]] or [[antidepressant]]s.<ref name="miller_2012">{{cite journal |vauthors=Miller SM |date=September 2012 |title=Low back pain: pharmacologic management |journal=Primary Care |volume=39 |issue=3 |pages=499–510 |doi=10.1016/j.pop.2012.06.005 |pmid=22958559}}</ref><ref name=henschke_2010>{{cite journal | vauthors = Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, Main CJ | title = Behavioural treatment for chronic low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD002014 | date = July 2010 | volume = 2011 | pmid = 20614428 | pmc = 7065591 | doi = 10.1002/14651858.CD002014.pub3 }}</ref> Additionally, there are many [[alternative medicine]] therapies, but there is not enough evidence to recommend them confidently.<ref name=marlowe_2012/> The evidence for [[chiropractic]] care<ref name=walker_2011>{{cite journal | vauthors = Walker BF, French SD, Grant W, Green S | title = A Cochrane review of combined chiropractic interventions for low-back pain | journal = Spine | volume = 36 | issue = 3 | pages = 230–242 | date = February 2011 | pmid = 21248591 | doi = 10.1097/BRS.0b013e318202ac73 | s2cid = 26310171 }}</ref> and [[spinal manipulation]] is mixed.<ref name=marlowe_2012>{{cite journal | vauthors = Marlowe D | title = Complementary and alternative medicine treatments for low back pain | journal = Primary Care | volume = 39 | issue = 3 | pages = 533–546 | date = September 2012 | pmid = 22958563 | doi = 10.1016/j.pop.2012.06.008 }}</ref><ref name=dagenais_2010>{{cite journal | vauthors = Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM | title = NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain | journal = The Spine Journal | volume = 10 | issue = 10 | pages = 918–940 | date = October 2010 | pmid = 20869008 | doi = 10.1016/j.spinee.2010.07.389 }}</ref><ref name=rubinstein_2011>{{cite journal | vauthors = Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for chronic low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD008112 | date = February 2011 | pmid = 21328304 | doi = 10.1002/14651858.CD008112.pub2 | hdl-access = free | veditors = Rubinstein SM | hdl = 1887/117578 }}</ref><ref name=rubinstein_2012>{{cite journal | vauthors = Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for acute low-back pain | journal = The Cochrane Database of Systematic Reviews | volume = 9 | issue = 9 | pages = CD008880 | date = September 2012 | pmid = 22972127 | pmc = 6885055 | doi = 10.1002/14651858.CD008880.pub2 | hdl = 1871/48563 }}</ref>

<!-- Epidemiology -->
Approximately 9–12% of people (632&nbsp;million) have low back pain at any given point in time,<ref name=":4">{{cite journal | vauthors = Ferreira ML, de Luca K, Haile LM, Steinmetz JD, Culbreth GT, Cross M, Kopec JA, Ferreira PH, Blyth FM, Buchbinder R, Hartvigsen J | display-authors = 6 | collaboration = GBD 2021 Low Back Pain Collaborators | title = Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021 | journal = The Lancet. Rheumatology | volume = 5 | issue = 6 | pages = e316–e329 | date = June 2023 | pmid = 37273833 | pmc = 10234592 | doi = 10.1016/S2665-9913(23)00098-X }}</ref> and nearly 25% report having it at some point over any one-month period.<ref name=hoy_2012/><ref name=vos_2012>{{cite journal | vauthors = Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, Birbeck G, Black JA, Blencowe H, Blore JD, Blyth F, Bolliger I, Bonaventure A, Boufous S, Bourne R, Boussinesq M, Braithwaite T, Brayne C, Bridgett L, Brooker S, Brooks P, Brugha TS, Bryan-Hancock C, Bucello C, Buchbinder R, Buckle G, Budke CM, Burch M, Burney P, Burstein R, Calabria B, Campbell B, Canter CE, Carabin H, Carapetis J, Carmona L, Cella C, Charlson F, Chen H, Cheng AT, Chou D, Chugh SS, Coffeng LE, Colan SD, Colquhoun S, Colson KE, Condon J, Connor MD, Cooper LT, Corriere M, Cortinovis M, de Vaccaro KC, Couser W, Cowie BC, Criqui MH, Cross M, Dabhadkar KC, Dahiya M, Dahodwala N, Damsere-Derry J, Danaei G, Davis A, De Leo D, Degenhardt L, Dellavalle R, Delossantos A, Denenberg J, Derrett S, Des Jarlais DC, Dharmaratne SD, Dherani M, Diaz-Torne C, Dolk H, Dorsey ER, Driscoll T, Duber H, Ebel B, Edmond K, Elbaz A, Ali SE, Erskine H, Erwin PJ, Espindola P, Ewoigbokhan SE, Farzadfar F, Feigin V, Felson DT, Ferrari A, Ferri CP, Fèvre EM, Finucane MM, Flaxman S, Flood L, Foreman K, Forouzanfar MH, Fowkes FG, Franklin R, Fransen M, Freeman MK, Gabbe BJ, Gabriel SE, Gakidou E, Ganatra HA, Garcia B, Gaspari F, Gillum RF, Gmel G, Gosselin R, Grainger R, Groeger J, Guillemin F, Gunnell D, Gupta R, Haagsma J, Hagan H, Halasa YA, Hall W, Haring D, Haro JM, Harrison JE, Havmoeller R, Hay RJ, Higashi H, Hill C, Hoen B, Hoffman H, Hotez PJ, Hoy D, Huang JJ, Ibeanusi SE, Jacobsen KH, James SL, Jarvis D, Jasrasaria R, Jayaraman S, Johns N, Jonas JB, Karthikeyan G, Kassebaum N, Kawakami N, Keren A, Khoo JP, King CH, Knowlton LM, Kobusingye O, Koranteng A, Krishnamurthi R, Lalloo R, Laslett LL, Lathlean T, Leasher JL, Lee YY, Leigh J, Lim SS, Limb E, Lin JK, Lipnick M, Lipshultz SE, Liu W, Loane M, Ohno SL, Lyons R, Ma J, Mabweijano J, MacIntyre MF, Malekzadeh R, Mallinger L, Manivannan S, Marcenes W, March L, Margolis DJ, Marks GB, Marks R, Matsumori A, Matzopoulos R, Mayosi BM, McAnulty JH, McDermott MM, McGill N, McGrath J, Medina-Mora ME, Meltzer M, Mensah GA, Merriman TR, Meyer AC, Miglioli V, Miller M, Miller TR, Mitchell PB, Mocumbi AO, Moffitt TE, Mokdad AA, Monasta L, Montico M, Moradi-Lakeh M, Moran A, Morawska L, Mori R, Murdoch ME, Mwaniki MK, Naidoo K, Nair MN, Naldi L, Narayan KM, Nelson PK, Nelson RG, Nevitt MC, Newton CR, Nolte S, Norman P, Norman R, O'Donnell M, O'Hanlon S, Olives C, Omer SB, Ortblad K, Osborne R, Ozgediz D, Page A, Pahari B, Pandian JD, Rivero AP, Patten SB, Pearce N, Padilla RP, Perez-Ruiz F, Perico N, Pesudovs K, Phillips D, Phillips MR, Pierce K, Pion S, Polanczyk GV, Polinder S, Pope CA, Popova S, Porrini E, Pourmalek F, Prince M, Pullan RL, Ramaiah KD, Ranganathan D, Razavi H, Regan M, Rehm JT, Rein DB, Remuzzi G, Richardson K, Rivara FP, Roberts T, Robinson C, De Leòn FR, Ronfani L, Room R, Rosenfeld LC, Rushton L, Sacco RL, Saha S, Sampson U, Sanchez-Riera L, Sanman E, Schwebel DC, Scott JG, Segui-Gomez M, Shahraz S, Shepard DS, Shin H, Shivakoti R, Singh D, Singh GM, Singh JA, Singleton J, Sleet DA, Sliwa K, Smith E, Smith JL, Stapelberg NJ, Steer A, Steiner T, Stolk WA, Stovner LJ, Sudfeld C, Syed S, Tamburlini G, Tavakkoli M, Taylor HR, Taylor JA, Taylor WJ, Thomas B, Thomson WM, Thurston GD, Tleyjeh IM, Tonelli M, Towbin JA, Truelsen T, Tsilimbaris MK, Ubeda C, Undurraga EA, van der Werf MJ, van Os J, Vavilala MS, Venketasubramanian N, Wang M, Wang W, Watt K, Weatherall DJ, Weinstock MA, Weintraub R, Weisskopf MG, Weissman MM, White RA, Whiteford H, Wiersma ST, Wilkinson JD, Williams HC, Williams SR, Witt E, Wolfe F, Woolf AD, Wulf S, Yeh PH, Zaidi AK, Zheng ZJ, Zonies D, Lopez AD, Murray CJ, AlMazroa MA, Memish ZA | display-authors = 6 | title = Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 | journal = Lancet | volume = 380 | issue = 9859 | pages = 2163–2196 | date = December 2012 | pmid = 23245607 | pmc = 6350784 | doi = 10.1016/S0140-6736(12)61729-2 }}</ref> About 40% of people have low back pain at some point in their lives,<ref name=hoy_2012/> with estimates as high as 80% among people in the [[developed world]].<ref name=malhotra_2011>{{cite book |author1=Vinod Malhotra |author2=Yao, Fun-Sun F. |author3=Fontes, Manuel da Costa |title=Yao and Artusio's Anesthesiology: Problem-Oriented Patient Management |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2011 |pages=Chapter 49 |isbn=978-1-4511-0265-9 |url=https://books.google.com/books?id=qOhuwkoN15MC&pg=PT1390 |url-status=live |archive-url=https://web.archive.org/web/20170908185118/https://books.google.com/books?id=qOhuwkoN15MC&pg=PT1390 |archive-date=8 September 2017 }}</ref> Low back pain is the greatest contributor to lost productivity, absenteeism, disability and early retirement worldwide.<ref name=":4" /> Difficulty with low back pain most often begins between 20 and 40 years of age.<ref name=casazza_2012/> Women and older people have higher estimated rates of lower back pain and also higher disability estimates.<ref name=":9" /> Low back pain is more common among people aged between 40 and 80 years, with the overall number of individuals affected expected to increase as the population ages.<ref name=hoy_2012>{{cite journal | vauthors = Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf A, Vos T, Buchbinder R | display-authors = 6 | title = A systematic review of the global prevalence of low back pain | journal = Arthritis and Rheumatism | volume = 64 | issue = 6 | pages = 2028–2037 | date = June 2012 | pmid = 22231424 | doi = 10.1002/art.34347 | doi-access = free }}</ref> According to the World Health Organizations, lower back pain is the top medical condition world-wide from which the most number of people world-wide can benefit from improved rehabilitation.<ref name=":9" />
[[File:Low Back Pain.webm|thumb|upright=1.3|Video explanation]]
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==Signs and symptoms==
In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning.<!--<ref name=casazza_2012/> --> The description of the symptoms may range from tenderness at a particular point, to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing.<!--<ref name=casazza_2012/> --> Pain radiating down the legs (known as [[sciatica]]) may be present.<!--<ref name=casazza_2012/> --> The first experience of acute low back pain is typically between the ages of 20 and 40.<!--<ref name=casazza_2012/> --> This is often a person's first reason to see a medical professional as an adult.<ref name=casazza_2012/> Recurrent episodes occur in more than half of people<ref name=Stanton2010/> with the repeated episodes being generally more painful than the first.<ref name=casazza_2012/>

Other problems may occur along with low back pain. Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep.<ref name=kelly_2011>{{cite journal | vauthors = Kelly GA, Blake C, Power CK, O'keeffe D, Fullen BM | title = The association between chronic low back pain and sleep: a systematic review | journal = The Clinical Journal of Pain | volume = 27 | issue = 2 | pages = 169–181 | date = February 2011 | pmid = 20842008 | doi = 10.1097/AJP.0b013e3181f3bdd5 | s2cid = 19569862 }}</ref> In addition, {{Request quotation span|date=May 2025|a majority of those with chronic low back pain |reason=According to someone who has access, the second reference given here states that the prevalence of anxiety and depression is at 9.5% and 13.7%, while the first reference shows depression prevalence at less than 50%—not enough to indicate 'a majority.'}} show symptoms of [[Depression (mood)|depression]]<ref name=miller_2012/> or [[anxiety]].<ref name=marlowe_2012/>

==Causes==
[[File:Lagehernia.png|thumb|A herniated disc as seen on MRI, one possible cause of low back pain]]
Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness.<ref name=borczuk_2013>{{cite journal | vauthors = Borczuk P | title = An evidence-based approach to the evaluation and treatment of low back pain in the emergency department | journal = Emergency Medicine Practice | volume = 15 | issue = 7 | pages = 1–23; Quiz 23–24 | date = July 2013 | pmid = 24044786 | url = http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=371 | url-status = live | archive-url = https://web.archive.org/web/20130814141409/http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=371 | archive-date = 14 August 2013 }}</ref> The majority of low back pain does not have a clear cause<ref name=casazza_2012/> but is believed to be the result of non-serious muscle or skeletal issues such as [[sprain]]s or [[Strain (injury)|strain]]s.<ref name=NIH_2013>{{cite web |url=http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm |title=Low Back Pain Fact Sheet |work=National Institute of Neurological Disorders and Stroke |publisher=National Institute of Health |access-date=12 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20130719200618/http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm |archive-date=19 July 2013 }}</ref> Obesity, smoking, weight gain during pregnancy, [[Psychological stress|stress]], poor physical condition, and poor sleeping position may also contribute to low back pain.<!-- This sentence is copied verbatim from the NIH website, which is public domain --><ref name=NIH_2013/> There is no consensus as to whether [[spinal posture]] or certain physical activities are causal factors.<ref>{{cite journal | vauthors = Swain CT, Pan F, Owen PJ, Schmidt H, Belavy DL | title = No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews | journal = Journal of Biomechanics | volume = 102 | page = 109312 | date = March 2020 | pmid = 31451200 | doi = 10.1016/j.jbiomech.2019.08.006 | s2cid = 201756091 }}</ref> A full [[differential diagnosis|list of possible causes]] includes many less common conditions.<ref name=manusov_2012_diag/> Physical causes may include [[osteoarthritis]], [[degenerative disc disease|degeneration of the discs]] between the [[vertebrae]] or a [[spinal disc herniation]], [[vertebral fracture|broken vertebra(e)]] (such as from [[osteoporosis]]) or, rarely, an infection or tumor of the spine.<ref name=NIH_2009>{{cite web |url=http://www.niams.nih.gov/Health_Info/Back_Pain/back_pain_ff.asp#b |title=Fast Facts About Back Pain |author=<!--Staff writer(s); no by-line.--> |date=September 2009 |website=National Institute of Arthritis and Musculoskeletal and Skin Diseases |publisher=National Institute of Health |access-date=10 June 2013 |url-status=live |archive-url=https://web.archive.org/web/20130605004734/http://www.niams.nih.gov/health_info/Back_Pain/back_pain_ff.asp#b |archive-date=5 June 2013 }}</ref>

Women may have acute low back pain from medical conditions affecting the female reproductive system, including [[endometriosis]], [[ovarian cyst]]s, [[ovarian cancer]], or [[uterine fibroid]]s.<ref name=medline_lbp_acute_2012>{{cite web |title=Low back pain – acute |url=https://www.nlm.nih.gov/medlineplus/ency/article/007425.htm |publisher=U.S. Department of Health and Human Services – National Institutes of Health |access-date=1 April 2013 |url-status=live |archive-url=https://web.archive.org/web/20130401120321/http://www.nlm.nih.gov/medlineplus/ency/article/007425.htm |archive-date=1 April 2013 }}</ref> Nearly half of all pregnant women report pain in the low back during pregnancy, which is attributed to changes in posture and the relocation of the center of gravity, leading to strain on the musculoskeletal system, including muscles, ligaments, and joints.<ref name=majchrzycki_2010>{{cite journal | vauthors = Majchrzycki M, Mrozikiewicz PM, Kocur P, Bartkowiak-Wieczorek J, Hoffmann M, Stryła W, Seremak-Mrozikiewicz A, Grześkowiak E | display-authors = 6 | title = [Low back pain in pregnant women] | language = pl | journal = Ginekologia Polska | volume = 81 | issue = 11 | pages = 851–855 | date = November 2010 | pmid = 21365902 }}</ref>

Low back pain can be broadly classified into four main categories:
*Musculoskeletal – mechanical (including [[muscle strain]], [[muscle spasm]], or [[osteoarthritis]]); herniated nucleus pulposus, [[Spinal disc herniation|herniated disc]]; [[spinal stenosis]]; or [[compression fracture]]
*Inflammatory – HLA-B27 associated arthritis including [[ankylosing spondylitis]], [[reactive arthritis]], [[psoriatic arthritis]], inflammation within the reproductive system, and [[inflammatory bowel disease]]
*Malignancy – [[bone metastasis]] from lung, breast, prostate, thyroid, among others
*Infectious – [[osteomyelitis]], abscess, [[urinary tract infection]].<ref name="EM2011">{{cite journal | vauthors = Lane DR, Takhar SS | title = Diagnosis and management of urinary tract infection and pyelonephritis | journal = Emergency Medicine Clinics of North America | volume = 29 | issue = 3 | pages = 539–552 | date = August 2011 | pmid = 21782073 | doi = 10.1016/j.emc.2011.04.001 }}</ref>

==Pathophysiology==

===Back structures===
{{multiple image
| align = right
| image1 = Illu vertebral column.svg
| width1 = 200
| alt1 = The lumbar region in regards to the rest of the spine 
| caption1 = The five lumbar vertebrae define the lower back region.
| image2 = ACDF oblique annotated english.svg
| width2 = 200
| alt2 = The nerve and bone components of the vertebrae
| caption2 = The structures surrounding and supporting the vertebrae can be sources of low back pain.
| footer = 
}}

The lumbar (or lower back) region is the area between the lower ribs and gluteal fold which includes five lumbar [[vertebrae]] (L1–L5) and the sacrum. In between these vertebrae are [[fibrocartilage|fibrocartilaginous]] [[intervertebral discs|discs]], which act as cushions, preventing the vertebrae from rubbing together while at the same time protecting the [[spinal cord]]. Nerves come from and go to the [[spinal cord]] through [[intervertebral foramina|specific openings]] between the vertebrae, receiving sensory input and sending messages to muscles. Stability of the spine is provided by the ligaments and muscles of the back and abdomen. Small joints called [[zygapophysial joints|facet joints]] limit and direct the motion of the spine.<ref name=floyd_2008>Floyd, R., & Thompson, Clem. (2008). ''Manual of structural kinesiology''. New York: McGraw-Hill Humanities/Social Sciences/Languages. {{ISBN?}}{{page needed|date=July 2021}}</ref>

The [[multifidus muscle]]s run up and down along the back of the spine, and are important for keeping the spine straight and stable during many common movements such as sitting, walking and lifting.<ref name=salzberg_2012 /> A problem with these muscles is often found in someone with chronic low back pain, because the back pain causes the person to use the back muscles improperly in trying to avoid the pain.<ref name=freedman_2010>{{cite journal | vauthors = Freeman MD, Woodham MA, Woodham AW | title = The role of the lumbar multifidus in chronic low back pain: a review | journal = PM & R | volume = 2 | issue = 2 | pages = 142–6; quiz 1 p following 167 | date = February 2010 | pmid = 20193941 | doi = 10.1016/j.pmrj.2009.11.006 | s2cid = 22246810 }}</ref> The problem with the multifidus muscles continues even after the pain goes away, and is probably an important reason why the pain comes back.<ref name=freedman_2010 /> Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program.<ref name=freedman_2010 />

An intervertebral disc has a [[Nucleus pulposus|gelatinous core]] surrounded by a [[Annulus fibrosus disci intervertebralis|fibrous ring]].<ref name=hughes_2012>{{cite journal | vauthors = Hughes SP, Freemont AJ, Hukins DW, McGregor AH, Roberts S | title = The pathogenesis of degeneration of the intervertebral disc and emerging therapies in the management of back pain | journal = The Journal of Bone and Joint Surgery. British Volume | volume = 94 | issue = 10 | pages = 1298–1304 | date = October 2012 | pmid = 23015552 | doi = 10.1302/0301-620X.94B10.28986 | url = http://www.boneandjoint.org.uk/highwire/filestream/61400/field_highwire_article_pdf/0/1298.full-text.pdf | access-date = 25 June 2013 | archive-url = https://web.archive.org/web/20131004234019/http://www.boneandjoint.org.uk/highwire/filestream/61400/field_highwire_article_pdf/0/1298.full-text.pdf | archive-date = 4 October 2013 }}</ref> When in its normal, uninjured state, most of the disc is not served by either the [[circulatory system|circulatory]] or [[nervous systems]] – blood and nerves only run to the outside of the disc.<ref name=hughes_2012 /> Specialized cells that can survive without direct blood supply are in the inside of the disc.<ref name=hughes_2012 /> Over time, the discs lose flexibility and the ability to absorb physical forces.<ref name=borczuk_2013 /> This decreased ability to handle physical forces increases stresses on other parts of the spine, causing the ligaments of the spine to thicken and bony growths to develop on the vertebrae.<ref name=borczuk_2013 /> As a result, there is less space through which the spinal cord and nerve roots may pass.<ref name=borczuk_2013 /> When a disc degenerates as a result of injury or disease, the makeup of a disc changes: blood vessels and nerves may grow into its interior and/or herniated disc material can push directly on a nerve root.<ref name=hughes_2012 /> Any of these changes may result in back pain.<ref name=hughes_2012 />

===Pain sensation===
Pain erupts in response to a [[Stimulus (physiology)|stimulus]] that either damages or can potentially damage the body's tissues. There are four main stages:  [[Transduction (physiology)|transduction]], transmission, [[perception]], and [[neuromodulation|modulation]].<ref name=salzberg_2012/> The nerve cells that detect pain have cell bodies located in the [[dorsal root ganglia]] and fibers that transmit these signals to the spinal cord.<ref name=patel_2010>{{cite book |title=Guide to Pain Management in Low-Resource Settings |chapter=Chapter 3: Physiology of Pain |vauthors=Patel NB |veditors=Kopf A, Patel NB |year=2010 |chapter-url=http://www.iasp-pain.org/AM/Template.cfm?Section=Guide_to_Pain_Management_in_Low_Resource_Settings&Template=/CM/ContentDisplay.cfm&ContentID=12162 |archive-url=https://web.archive.org/web/20131005010917/http://www.iasp-pain.org/AM/Template.cfm?Section=Guide_to_Pain_Management_in_Low_Resource_Settings&Template=%2FCM%2FContentDisplay.cfm&ContentID=12162 |archive-date=5 October 2013 |access-date=26 May 2017 }}</ref> The process of pain sensation starts when the pain-causing event triggers the endings of appropriate [[nociceptor|sensory nerve cells]]. This type of cell converts the event into an electrical signal by transduction. Several different types of nerve fibers carry out the transmission of the electrical signal from the transducing cell to the [[posterior horn of spinal cord]], from there to the [[brainstem|brain stem]], and then from the brain stem to the various parts of the brain such as the [[thalamus]] and the [[limbic system]]. In the brain, the pain signals are processed and given context in the process of pain [[perception]]. Through modulation, the brain can modify the sending of further nerve impulses by decreasing or increasing the release of [[neurotransmitter]]s.<ref name=salzberg_2012/>

Parts of the pain sensation and processing system may not function properly; creating the feeling of pain when no outside cause exists, signaling too much pain from a particular cause, or signaling pain from a normally non-painful event. Additionally, the pain modulation mechanisms may not function properly. These phenomena are involved in chronic pain.<ref name=salzberg_2012/>

==Diagnosis==
As the structure of the low back is complex, the reporting of pain is [[subjectivity|subjective]], and is affected by social factors, the diagnosis of low back pain is not straightforward.<ref name=manusov_2012_diag/> While most low back pain is caused by muscle and joint problems, this cause must be separated from neurological problems, spinal tumors, fracture of the spine, and infections, among others.<ref name=koes_2010/><ref name=casazza_2012/> The ICD 10 code for low back pain is M54.5.

===Classification===
There are a number of ways to classify low back pain with no consensus that any one method is best.<ref name=manusov_2012_diag/> There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, [[herniated disc]]s, compressed [[nerve root]]s, [[degenerative disc disease|degenerative disc]]s or [[degenerative joint disease|joint disease]], and broken vertebra), non-mechanical back pain ([[neoplastic disease|tumors]], inflammatory conditions such as [[spondyloarthritis]], and infections), and [[referred pain]] from internal organs ([[biliary colic|gallbladder disease]], [[kidney stone]]s, [[kidney infection]]s, and [[aortic aneurysm]], among others).<ref name=manusov_2012_diag/> Mechanical or musculoskeletal problems underlie most cases (around 90% or more),<ref name=manusov_2012_diag/><ref name=cohen_2008>{{cite journal | vauthors = Cohen SP, Argoff CE, Carragee EJ | title = Management of low back pain | journal = BMJ | volume = 337 | pages = a2718 | date = December 2008 | pmid = 19103627 | doi = 10.1136/bmj.a2718 | s2cid = 78716905 }}</ref> and of those, most (around 75%) do not have a specific cause identified, but are thought to be due to muscle strain or injury to ligaments.<ref name=manusov_2012_diag/><ref name=cohen_2008/> Rarely, complaints of low back pain result from systemic or psychological problems, such as [[fibromyalgia]] and [[somatoform disorders]].<ref name=cohen_2008/>

Low back pain may be classified based on the signs and symptoms. Diffuse pain that does not change in response to particular movements, and is localized to the lower back without radiating beyond the [[buttock]]s, is classified as ''nonspecific'', the most common classification.<ref name=manusov_2012_diag/> Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation), or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers is ''radicular'', making up 7% of cases.<ref name=manusov_2012_diag/> Pain that is accompanied by red flags such as trauma, fever, a history of cancer or significant muscle weakness may indicate a more serious underlying problem and is classified as ''needing urgent or specialized attention''.<ref name=manusov_2012_diag/>

The symptoms can also be classified by duration as acute, sub-chronic (also known as sub-acute), or chronic. The specific duration required to meet each of these is not universally agreed upon, but generally pain lasting less than six weeks is classified as ''acute'', pain lasting six to twelve weeks is ''sub-chronic'', and more than twelve weeks is ''chronic''.<ref name=koes_2010/> Management and prognosis may change based on the duration of symptoms.

===Red flags===
{| class="wikitable" style="float: right; margin-left:15px; text-align:center"
|+ align="bottom" style="caption-side: bottom; text-align: center; font-style: normal; font-weight: normal; font-size: smaller;"| Red flags are warning signs that may indicate a more serious problem
|-
! Red flag<ref name=ACR_2011>{{cite report |vauthors=Davis PC, Wippold II FJ, Cornelius RS, etal |title=American College of Radiology ACR Appropriateness Criteria – Low Back Pain |year=2011 |url=http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf |archive-url=https://web.archive.org/web/20121222060920/http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/LowBackPain.pdf |archive-date=22 December 2012 }}</ref>
! Possible cause<ref name=casazza_2012/>
|-
| Previous history of cancer || rowspan="2"|Cancer
|-
| [[Unintentional weight loss]]<!--<ref name="NASSfive">-->
|-
| Loss of bladder or bowel control || rowspan="3"|[[Cauda equina syndrome|Cauda<br />equina<br />syndrome]]
|-
| Significant motor weakness<br />or sensory problems
|-
| Loss of sensation in the<br />buttocks ([[saddle anesthesia]])
|-
| Significant trauma related to age || rowspan="3"|Fracture
|-
| Chronic corticosteroid use
|-
| [[Osteoporosis]]<!--<ref name="NASSfive">-->
|-
| Severe pain after lumbar<br />surgery in past year || rowspan="5"|Infection
|-
| Fever
|-
| Urinary tract infection
|-
| [[Immunosuppression]]
|-
| [[Intravenous drug use]]
|}
The presence of certain signs, termed ''red flags'', indicate the need for further testing to look for more serious underlying problems, which may require immediate or specific treatment.<ref name=manusov_2012_diag/><ref name="NASSfive">{{Citation |author1 = North American Spine Society |author1-link = North American Spine Society |date = February 2013 |title = Five Things Physicians and Patients Should Question |publisher = North American Spine Society |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/north-american-spine-society/ |access-date = 25 March 2013}}, which cites
* {{cite journal | vauthors = Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK | title = Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society | journal = Annals of Internal Medicine | volume = 147 | issue = 7 | pages = 478–491 | date = October 2007 | pmid = 17909209 | doi = 10.7326/0003-4819-147-7-200710020-00006 | collaboration = Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel | doi-access = free }}
* {{cite journal | vauthors = Forseen SE, Corey AS | title = Clinical decision support and acute low back pain: evidence-based order sets | journal = Journal of the American College of Radiology | volume = 9 | issue = 10 | pages = 704–712.e4 | date = October 2012 | pmid = 23025864 | doi = 10.1016/j.jacr.2012.02.014 }}</ref> The presence of a red flag does not mean that there is a significant problem. It is only suggestive,<ref name=":8">{{Cite journal |last1=Williams |first1=Christopher M. |last2=Henschke |first2=Nicholas |last3=Maher |first3=Christopher G. |last4=van Tulder |first4=Maurits W. |last5=Koes |first5=Bart W. |last6=Macaskill |first6=Petra |last7=Irwig |first7=Les |date=2023-11-28 |title=Red flags to screen for vertebral fracture in patients presenting with low-back pain |journal=The Cochrane Database of Systematic Reviews |volume=11 |issue=11 |pages=CD008643 |doi=10.1002/14651858.CD008643.pub3 |issn=1469-493X |pmc=10683370 |pmid=38014846}}</ref><ref name=henschke_2013_spinmal>{{cite journal | vauthors = Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L | title = Red flags to screen for malignancy in patients with low-back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 2 | pages = CD008686 | date = February 2013 | pmid = 23450586 | doi = 10.1002/14651858.CD008686.pub2 | pmc = 10631455 }}</ref> and most people with red flags have no serious underlying problem.<ref name=koes_2010/><ref name=casazza_2012/> If no red flags are present, performing [[diagnostic imaging]] or laboratory testing in the first four weeks after the start of the symptoms has not been shown to be useful.<ref name=manusov_2012_diag/>

The usefulness of many red flags is poorly supported by evidence.<ref name=Down2013>{{cite journal | vauthors = Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG | display-authors = 6 | title = Red flags to screen for malignancy and fracture in patients with low back pain: systematic review | journal = BMJ | volume = 347 | issue = dec11 1 | pages = f7095 | date = December 2013 | pmid = 24335669 | pmc = 3898572 | doi = 10.1136/bmj.f7095 }}</ref><ref name=":8" /> The most useful for detecting a fracture are: older age, [[corticosteroid]] use, and significant trauma especially if it results in skin markings.<ref name=Down2013/> The best determinant of the presence of cancer is a history of the same.<ref name=Down2013/>

With other causes ruled out, people with non-specific low back pain are typically treated symptomatically, without exact determination of the cause.<ref name=koes_2010/><ref name=casazza_2012/> Efforts to uncover factors that might complicate the diagnosis, such as depression, substance abuse, or an agenda concerning insurance payments may be helpful.<ref name=manusov_2012_diag/>

===Tests===
{{multiple image
| align             = right
| image1            = Straight-leg-test.gif
| width1            = 200
| alt1              = 
| caption1          = 
| image2            = L4-l5-disc-herniation.png
| width2            = 150
| alt2              = 
| caption2          = 
| footer            = The straight leg raise test can detect pain originating from a herniated disc.  When warranted, imaging such as MRI can provide clear detail about disc related causes of back pain (L4–L5 disc herniation shown).
}}

Imaging is indicated when there are red flags, ongoing neurological symptoms that do not resolve, or ongoing or worsening pain.<ref name=manusov_2012_diag/> In particular, early use of imaging (either MRI or CT) is recommended for suspected cancer, infection, or [[cauda equina syndrome]].<ref name=manusov_2012_diag/> MRI is slightly better than CT for identifying disc disease; the two technologies are equally useful for diagnosing spinal stenosis.<ref name=manusov_2012_diag/> Only a few physical diagnostic tests are helpful.<ref name=manusov_2012_diag/> The [[straight leg raise]] test is almost always positive in those with disc herniation,<ref name=manusov_2012_diag/> and [[lumbar provocative discography]] may be useful to identify a specific disc causing pain in those with chronic high levels of low back pain.<ref name=manchikanti_2009_disco>{{cite journal | vauthors = Manchikanti L, Glaser SE, Wolfer L, Derby R, Cohen SP | title = Systematic review of lumbar discography as a diagnostic test for chronic low back pain | journal = Pain Physician | volume = 12 | issue = 3 | pages = 541–559 | year = 2009 | pmid = 19461822 | doi = 10.36076/ppj.2009/12/541 | doi-access = free }}</ref> Therapeutic procedures such as nerve blocks can also be used to determine a specific source of pain.<ref name=manusov_2012_diag/> Some evidence supports the use of [[facet joint injections]], transforminal epidural injections and sacroiliac injections as diagnostic tests.<ref name=manusov_2012_diag/> Most other physical tests, such as evaluating for [[scoliosis]], muscle weakness or wasting, and impaired reflexes, are of little use.<ref name=manusov_2012_diag/>

Complaints of low back pain are one of the most common reasons people visit doctors.<ref name="AHRQ_2013">{{cite web |year=2013 |title=Use of imaging studies for low back pain: percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI, CT scan) within 28 days of the diagnosis |url=http://www.qualitymeasures.ahrq.gov/content.aspx?id=38884 |archive-url=https://web.archive.org/web/20131004235722/http://www.qualitymeasures.ahrq.gov/content.aspx?id=38884 |archive-date=4 October 2013 |access-date=11 June 2013}}</ref><ref name=AAFPfive>{{Citation |author1 = American Academy of Family Physicians |author1-link = American Academy of Family Physicians |title = Ten Things Physicians and Patients Should Question |publisher = [[American Academy of Family Physicians]] |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/ |access-date = 5 September 2012 |url-status = live |archive-url = https://web.archive.org/web/20130210005137/http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/ |archive-date = 10 February 2013 }}</ref> For pain that has lasted only a few weeks, the pain is likely to subside on its own.<ref name=ACPfive>{{Citation |author1 = American College of Physicians |author1-link = American College of Physicians |title = Five Things Physicians and Patients Should Question |publisher = [[American College of Physicians]] |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-college-of-physicians/ |access-date = 5 September 2013 |url-status = live |archive-url = https://web.archive.org/web/20130901100148/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-physicians/ |archive-date = 1 September 2013 }}</ref> Thus, if a person's [[medical history]] and [[physical examination]] do not suggest a specific disease as the cause, medical societies advise against imaging tests such as [[X-ray]]s, [[X-ray computed tomography|CT scan]]s, and [[Magnetic resonance imaging|MRI]]s.<ref name=AAFPfive/> Individuals may want such tests but, unless red flags are present,<ref name="chou_2009_imaging">{{cite journal |vauthors=Chou R, Fu R, Carrino JA, Deyo RA |date=February 2009 |title=Imaging strategies for low-back pain: systematic review and meta-analysis |journal=Lancet |volume=373 |issue=9662 |pages=463–472 |doi=10.1016/S0140-6736(09)60172-0 |pmid=19200918 |s2cid=31602395}}</ref><ref name=crownover_2013>{{cite journal | vauthors = Crownover BK, Bepko JL | title = Appropriate and safe use of diagnostic imaging | journal = American Family Physician | volume = 87 | issue = 7 | pages = 494–501 | date = April 2013 | pmid = 23547591 }}</ref> they are [[unnecessary health care]].<ref name=AHRQ_2013/><ref name=ACPfive/> Routine imaging increases costs, is associated with higher rates of surgery with no overall benefit,<ref name=chou_2011>{{cite journal | vauthors = Chou R, Qaseem A, Owens DK, Shekelle P | title = Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians | journal = Annals of Internal Medicine | volume = 154 | issue = 3 | pages = 181–189 | date = February 2011 | pmid = 21282698 | doi = 10.7326/0003-4819-154-3-201102010-00008 | collaboration = Clinical Guidelines Committee of the American College of Physicians | s2cid = 1326352 }}</ref><ref name=flynn_2011>{{cite journal | vauthors = Flynn TW, Smith B, Chou R | title = Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good | journal = The Journal of Orthopaedic and Sports Physical Therapy | volume = 41 | issue = 11 | pages = 838–846 | date = November 2011 | pmid = 21642763 | doi = 10.2519/jospt.2011.3618 | s2cid = 207399397 }}</ref> and the radiation used may be harmful to one's health.<ref name=chou_2011/> Fewer than 1% of imaging tests identify the cause of the problem.<ref name=AHRQ_2013/> Imaging may also detect harmless abnormalities, encouraging people to request further unnecessary testing or to worry.<ref name=AHRQ_2013/> Even so, MRI scans of the lumbar region increased by more than 300% among United States Medicare beneficiaries from 1994 to 2006.<ref name=deyo_2009/>

==Prevention==
Exercise is recommended when experiencing non-specific lower back pain (LBP). The most effective way to decrease pain intensity is by focusing on trunk, pelvic, and leg stretching. Relaxation and postural exercise are not effective in reducing the pain intensity.<ref>{{Cite journal |last1=Quentin |first1=Chloé |last2=Bagheri |first2=Reza |last3=Ugbolue |first3=Ukadike C. |last4=Coudeyre |first4=Emmanuel |last5=Pélissier |first5=Carole |last6=Descatha |first6=Alexis |last7=Menini |first7=Thibault |last8=Bouillon-Minois |first8=Jean-Baptiste |last9=Dutheil |first9=Frédéric |date=2021-08-10 |title=Effect of Home Exercise Training in Patients with Nonspecific Low-Back Pain: A Systematic Review and Meta-Analysis |journal=International Journal of Environmental Research and Public Health |language=en |volume=18 |issue=16 |page=8430 |doi=10.3390/ijerph18168430 |doi-access=free |issn=1660-4601 |pmc=8391468 |pmid=34444189}}</ref>

[[Physical exercise|Exercise]] alone, or along with education, appears to be useful for preventing low back pain.<ref name="JAMA2016">{{cite journal | vauthors = Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, Teixeira-Salmela LF, Hancock MJ | display-authors = 6 | title = Prevention of Low Back Pain: A Systematic Review and Meta-analysis | journal = JAMA Internal Medicine | volume = 176 | issue = 2 | pages = 199–208 | date = February 2016 | pmid = 26752509 | doi = 10.1001/jamainternmed.2015.7431 | doi-access = free }}</ref><ref name=":7" /> Exercise is also probably effective in preventing recurrences in those with pain that has lasted more than six weeks.<ref name="choi_2010">{{cite journal | vauthors = Choi BK, Verbeek JH, Tam WW, Jiang JY | title = Exercises for prevention of recurrences of low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD006555 | date = January 2010 | volume = 2010 | pmid = 20091596 | pmc = 8078403 | doi = 10.1002/14651858.CD006555.pub2 | veditors = Choi BK }}</ref> Assessing chronic low back pain, a 2007 review concluded that a firm mattress is less likely to alleviate pain compared to a medium-firm mattress,<ref name="chou_2007">{{cite journal | vauthors = Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK | title = Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society | journal = Annals of Internal Medicine | volume = 147 | issue = 7 | pages = 478–491 | date = October 2007 | pmid = 17909209 | doi = 10.7326/0003-4819-147-7-200710020-00006 | collaboration = Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, American Pain Society Low Back Pain Guidelines Panel | doi-access = free }}</ref> while a 2020 review stated that studies have been inadequate to comment on mattress firmness.<ref name="Heg2020">{{cite journal | vauthors = Hegmann KT, Travis R, Andersson GB, Belcourt RM, Carragee EJ, Donelson R, Eskay-Auerbach M, Galper J, Goertz M, Haldeman S, Hooper PD, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS | display-authors = 3 | title = Non-Invasive and Minimally Invasive Management of Low Back Disorders | journal = Journal of Occupational and Environmental Medicine | volume = 62 | issue = 3 | pages = e111–e138 | date = March 2020 | pmid = 31977923 | doi = 10.1097/JOM.0000000000001812 | doi-access = free }}</ref> There is little to no evidence that [[back belt]]s are any more helpful in preventing low back pain than education about proper lifting techniques.<ref name="JAMA2016" /><ref name=":7" /> [[Shoe insoles]] do not help prevent low back pain.<ref name="JAMA2016" /><ref name="sahar_2009">{{cite journal | vauthors = Sahar T, Cohen MJ, Uval-Ne'eman V, Kandel L, Odebiyi DO, Lev I, Brezis M, Lahad A | display-authors = 6 | title = Insoles for prevention and treatment of back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group | journal = Spine | volume = 34 | issue = 9 | pages = 924–933 | date = April 2009 | pmid = 19359999 | doi = 10.1097/BRS.0b013e31819f29be | s2cid = 22162952 }}</ref><ref name=":7" />

Studies have proven that interventions aimed to reduce pain and functional disability need to be accompanied by psychological interventions to improve a patient's motivation and attitude toward their recovery. Education about an injury and how it can effect a person's mental health is just as important as the physical rehabilitation. However, all of these interventions should occur in partnership with a structured therapeutic exercise program and assistance from a trained physical therapist.<ref name="ReferenceA" />  

==Management==
Most people with acute or subacute low back pain improve over time no matter the treatment.<ref name=Qas2017/> There is often improvement within the first month.<ref name=Qas2017/> Although fear in those suffering from low back pain often leads to avoiding activity, this is found to lead to greater disability.<ref name=":7" /> The recommendations include remaining active, avoiding activity that worsen the pain, and understanding self-care of the symptoms.<ref name=Qas2017/> Management of low back pain depends on which of the three general categories is the cause: mechanical problems, non-mechanical problems, or referred pain.<ref name=sprouse_2012>{{cite journal | vauthors = Sprouse R | title = Treatment: current treatment recommendations for acute and chronic undifferentiated low back pain | journal = Primary Care | volume = 39 | issue = 3 | pages = 481–486 | date = September 2012 | pmid = 22958557 | doi = 10.1016/j.pop.2012.06.004 }}</ref> For acute pain that is causing only mild to moderate problems, the goals are to restore normal function, return the individual to work, and minimize pain. The condition is normally not serious, resolves without much being done, and recovery is helped by attempting to return to normal activities as soon as possible within the limits of pain.<ref name=koes_2010/> Providing individuals with [[coping skills]] through reassurance of these facts is useful in speeding recovery.<ref name=casazza_2012/>

For those with sub-chronic or chronic low back pain, multidisciplinary treatment programs may help.<ref name="momsen_2012">{{cite journal | vauthors = Momsen AM, Rasmussen JO, Nielsen CV, Iversen MD, Lund H | title = Multidisciplinary team care in rehabilitation: an overview of reviews | journal = Journal of Rehabilitation Medicine | volume = 44 | issue = 11 | pages = 901–912 | date = November 2012 | pmid = 23026978 | doi = 10.2340/16501977-1040 | doi-access = free }}</ref> For chronic lower back pain, initial management with non–medication based treatments is recommended<ref name="Qas2017" /> Non–medication based treatments include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, and progressive relaxation.<ref name="Qas2017" /> If these are not sufficiently effective, [[NSAIDs]] are recommended.<ref name="Qas2017" /> [[Paracetamol|Acetaminophen]] and systemic [[steroid]]s are not recommended as both medications are not effective at improving pain outcomes in acute or subacute low back pain.<ref name="Qas2017" />

Physical therapy stabilization exercises for lumbar spine and manual therapy have shown decrease in pain symptoms in patients. Manual therapy and stabilization effects have similar effects on low back pain which overweighs the effects of general exercises.<ref>{{cite journal | vauthors = Gomes-Neto M, Lopes JM, Conceição CS, Araujo A, Brasileiro A, Sousa C, Carvalho VO, Arcanjo FL | display-authors = 6 | title = Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis | journal = Physical Therapy in Sport | volume = 23 | pages = 136–142 | date = January 2017 | pmid = 27707631 | doi = 10.1016/j.ptsp.2016.08.004 }}</ref> The most effective types of exercise to improve low back pain symptoms are core strengthening and mixed exercise types. An appropriate type of exercise recommended is an aerobic exercise program for 12 hours of exercise over a duration of 8 weeks.<ref>{{Cite journal |last1=Hayden |first1=Jill A |last2=Ellis |first2=Jenna |last3=Ogilvie |first3=Rachel |last4=Malmivaara |first4=Antti |last5=van Tulder |first5=Maurits W |date=2021-09-28 |editor-last=Cochrane Back and Neck Group |title=Exercise therapy for chronic low back pain |journal=Cochrane Database of Systematic Reviews|volume=2021 |issue=10 |pages=CD009790 |doi=10.1002/14651858.CD009790.pub2 |pmc=8477273 |pmid=34580864}}</ref>

Distress due to low back pain contributes significantly to overall pain and disability experienced. Therefore, treatment strategies that aim to change beliefs and behaviours, such as cognitive-behavioural therapy can be of use.<ref name=":7" />

Access to care as recommended in medical guidelines varies considerably from the care that most people with low back pain receive globally. This is due to factors such as availability, access and payment models (e.g. insurance, health-care systems).<ref>{{Cite journal |last1=Foster |first1=Nadine E |last2=Anema |first2=Johannes R |last3=Cherkin |first3=Dan |last4=Chou |first4=Roger |last5=Cohen |first5=Steven P |last6=Gross |first6=Douglas P |last7=Ferreira |first7=Paulo H |last8=Fritz |first8=Julie M |last9=Koes |first9=Bart W |last10=Peul |first10=Wilco |last11=Turner |first11=Judith A |last12=Maher |first12=Chris G |last13=Buchbinder |first13=Rachelle |last14=Hartvigsen |first14=Jan |last15=Cherkin |first15=Dan |date=2018 |title=Prevention and treatment of low back pain: evidence, challenges, and promising directions |journal=The Lancet |volume=391 |issue=10137 |pages=2368–2383 |doi=10.1016/s0140-6736(18)30489-6 |pmid=29573872 |s2cid=205989057 |issn=0140-6736}}</ref>

===Physical management===
<!--Acute  -->

==== Management of acute low back pain ====
Increasing general physical activity has been recommended, but no clear relationship to pain or disability or returning to work has been found when used for the treatment of an acute episode of pain.<ref name=choi_2010/><ref name=hendrick_2011>{{cite journal | vauthors = Hendrick P, Milosavljevic S, Hale L, Hurley DA, McDonough S, Ryan B, Baxter GD | title = The relationship between physical activity and low back pain outcomes: a systematic review of observational studies | journal = European Spine Journal | volume = 20 | issue = 3 | pages = 464–474 | date = March 2011 | pmid = 21053026 | pmc = 3048226 | doi = 10.1007/s00586-010-1616-2 }}</ref><ref>{{cite journal | vauthors = Schaafsma FG, Whelan K, van der Beek AJ, van der Es-Lambeek LC, Ojajärvi A, Verbeek JH | title = Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 8 | pages = CD001822 | date = August 2013 | pmid = 23990391 | pmc = 7074637 | doi = 10.1002/14651858.CD001822.pub3 }}</ref> For acute pain, low- to moderate-quality evidence supports walking.<ref name=hendrick_2010>{{cite journal | vauthors = Hendrick P, Te Wake AM, Tikkisetty AS, Wulff L, Yap C, Milosavljevic S | title = The effectiveness of walking as an intervention for low back pain: a systematic review | journal = European Spine Journal | volume = 19 | issue = 10 | pages = 1613–1620 | date = October 2010 | pmid = 20414688 | pmc = 2989236 | doi = 10.1007/s00586-010-1412-z }}</ref> [[Aerobic exercise]]s like progressive walking appears useful for subacute and acute low back pain, is strongly recommended for chronic low back pain, and is recommended after surgery.<ref name="Heg2020" /> Directional exercises, which try to limit low back pain, are recommended in sub-acute, chronic and [[Radicular pain|radicular]] low back pain. These exercises only work if they are limiting low back pain.<ref name="Heg2020" /> Exercise programs that incorporate stretching only are not recommended for acute low back pain. Stretching, especially with limited [[range of motion]], can impede future progression of treatment like limiting strength and limiting exercises.<ref name="Heg2020" /> [[Yoga]] and [[Tai chi]] are not recommended in case of acute or subacute low back pain, but are recommended in case of chronic back pain.<ref name="Heg2020" />

Treatment according to [[McKenzie method]] is somewhat effective for recurrent acute low back pain, but its benefit in the short term does not appear significant.<ref name="casazza_2012" /> There is tentative evidence to support the use of [[heat therapy]] for acute and sub-chronic low back pain<ref>{{cite journal | vauthors = French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ | title = Superficial heat or cold for low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD004750 | date = January 2006 | volume = 2011 | pmid = 16437495 | doi = 10.1002/14651858.CD004750.pub2 | pmc = 8846312 }}</ref> but little evidence for the use of either heat or cold therapy in chronic pain.<ref name="middelkoop_2011">{{cite journal | vauthors = van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW | title = A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain | journal = European Spine Journal | volume = 20 | issue = 1 | pages = 19–39 | date = January 2011 | pmid = 20640863 | pmc = 3036018 | doi = 10.1007/s00586-010-1518-3 }}</ref> Weak evidence suggests that back belts might decrease the number of missed workdays, but there is nothing to suggest that they help with the pain.<ref name="guild_2012">{{cite journal |vauthors=Guild DG |date=September 2012 |title=Mechanical therapy for low back pain |journal=Primary Care |volume=39 |issue=3 |pages=511–516 |doi=10.1016/j.pop.2012.06.006 |pmid=22958560}}</ref> Ultrasound and shock wave therapies do not appear effective and therefore are not recommended.<ref>{{cite journal | vauthors = Ebadi S, Henschke N, Forogh B, Nakhostin Ansari N, van Tulder MW, Babaei-Ghazani A, Fallah E | title = Therapeutic ultrasound for chronic low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 7 | pages = CD009169 | date = July 2020 | pmid = 32623724 | pmc = 7390505 | doi = 10.1002/14651858.CD009169.pub3 }}</ref><ref>{{Cite book| vauthors = ((National Institute for Health and Care Excellence)) |title=Low back pain and sciatica in over 16s: assessment and management.|date=2016|publisher=National Institute for Health and Care Excellence (NICE)|isbn=978-1-4731-2186-7|location=Manchester|oclc=1198756858}}</ref> Lumbar traction lacks effectiveness as an intervention for radicular low back pain.<ref>{{Cite book |url=https://www.ncbi.nlm.nih.gov/books/NBK350276/ |title=Noninvasive Treatments for Low Back Pain| vauthors = Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E | display-authors = 6 |date=2016|publisher=Agency for Healthcare Research and Quality (US)|series=AHRQ Comparative Effectiveness Reviews|location=Rockville (MD)|pmid=26985522}}</ref> It is also unclear whether lumbar supports are an effective treatment intervention.<ref>{{cite journal | vauthors = van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW | title = Lumbar supports for prevention and treatment of low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001823 | date = April 2008 | volume = 2008 | pmid = 18425875 | pmc = 7046130 | doi = 10.1002/14651858.cd001823.pub3 }}</ref>

<!--Chronic  -->==== Management of chronic low back pain ====
[[Exercise therapy]] is effective in decreasing pain and improving physical function, trunk muscle strength and the mental health for those with chronic low back pain.<ref name=":0">{{cite journal | vauthors = Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW | title = Exercise therapy for chronic low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 9 | issue = 10 | pages = CD009790 | date = September 2021 | pmid = 34580864 | pmc = 8477273 | doi = 10.1002/14651858.cd009790.pub2 }}</ref> It also improves long-term function<ref name="middelkoop_2011" /> and appears to reduce recurrence rates for as long as six months after the completion of the program.<ref name=smith_2010>{{cite journal | vauthors = Smith C, Grimmer-Somers K | title = The treatment effect of exercise programmes for chronic low back pain | journal = Journal of Evaluation in Clinical Practice | volume = 16 | issue = 3 | pages = 484–491 | date = June 2010 | pmid = 20438611 | doi = 10.1111/j.1365-2753.2009.01174.x }}</ref> The observed treatment effect for the exercise when compared to no treatment, usual care or placebo, improved pain (low‐certainty evidence), but improvements were small for functional limitations outcomes (moderate‐certainty evidence).<ref name=":0" /> There is no evidence that one particular type of exercise therapy is more effective than another,<ref name=middelkoop_2010>{{cite journal | vauthors = van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW | title = Exercise therapy for chronic nonspecific low-back pain | journal = Best Practice & Research. Clinical Rheumatology | volume = 24 | issue = 2 | pages = 193–204 | date = April 2010 | pmid = 20227641 | doi = 10.1016/j.berh.2010.01.002 }}</ref><ref>{{cite journal | vauthors = Wewege MA, Booth J, Parmenter BJ | title = Aerobic vs. resistance exercise for chronic non-specific low back pain: A systematic review and meta-analysis | journal = Journal of Back and Musculoskeletal Rehabilitation | volume = 31 | issue = 5 | pages = 889–899 | date = 2018-10-25 | pmid = 29889056 | doi = 10.3233/BMR-170920 | s2cid = 47013227 }}</ref> so the form of exercise used can be based on patient or practitioner preference, availability and cost. The [[Alexander technique]] appears useful for chronic back pain,<ref name=woodman_2012>{{cite journal | vauthors = Woodman JP, Moore NR | title = Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review | journal = International Journal of Clinical Practice | volume = 66 | issue = 1 | pages = 98–112 | date = January 2012 | pmid = 22171910 | doi = 10.1111/j.1742-1241.2011.02817.x | s2cid = 7579458 | doi-access = free }}</ref> and there is some evidence to support small benefits from the use of [[yoga]].<ref name=ernst_2011>{{cite journal | vauthors = Posadzki P, Ernst E | title = Yoga for low back pain: a systematic review of randomized clinical trials | journal = Clinical Rheumatology | volume = 30 | issue = 9 | pages = 1257–1262 | date = September 2011 | pmid = 21590293 | doi = 10.1007/s10067-011-1764-8 | s2cid = 17095187 }}</ref><ref>{{cite journal |vauthors=Wieland LS, Skoetz N, Pilkington K, Harbin S, Vempati R, Berman BM |date=November 2022 |title=Yoga for chronic non-specific low back pain |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=11 |pages=CD010671 |doi=10.1002/14651858.CD010671.pub3 |pmid=36398843|pmc=9673466 |s2cid=253627174 }}</ref> If a person with chronic low back pain is motivated, it is recommended to use yoga and tai chi as a form of treatment, but this is not recommended to treat acute or subacute low back pain.<ref name=Heg2020 /> Motor control exercise, which involves guided movement and use of normal muscles during simple tasks which then builds to more complex tasks, improves pain and function up to 20 weeks, but there was little difference compared to manual therapy and other forms of exercise.<ref>{{cite journal | vauthors = Saragiotto BT, Maher CG, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, Macedo LG | title = Motor control exercise for chronic non-specific low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD012004 | date = January 2016 | volume = 2016 | pmid = 26742533 | doi = 10.1002/14651858.cd012004 | pmc = 8761501 }}</ref> Motor control exercise accompanied by manual therapy also produces similar reductions in pain intensity when compared to general strength and condition exercise training, yet only the latter also improved muscle endurance and strength, whilst concurrently decreased self-reported disability.<ref>{{cite journal | vauthors = Tagliaferri SD, Miller CT, Ford JJ, Hahne AJ, Main LC, Rantalainen T, Connell DA, Simson KJ, Owen PJ, Belavy DL | display-authors = 6 | title = Randomized Trial of General Strength and Conditioning Versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcomes | journal = Journal of Clinical Medicine | volume = 9 | issue = 6 | page = 1726 | date = June 2020 | pmid = 32503243 | pmc = 7355598 | doi = 10.3390/jcm9061726 | doi-access = free }}</ref> [[Aquatic therapy]] is recommended as an option in those with other preexisting conditions like extreme [[obesity]], [[degenerative joint disease]], or other conditions that limit progressive walking. Aquatic therapy is recommended for chronic and subacute low back pain in those with a preexisting condition. Aquatic therapy is not recommended for people that have no preexisting condition that limits their progressive walking.<ref name="Heg2020" /> There is low-to-moderate quality evidence that supports [[pilates]] in low back pain for the reduction of pain and disability,<ref name=Heg2020 /><ref name=":1">{{cite journal | vauthors = Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo RW, Cabral CM, Menezes Costa LC, Costa LO | display-authors = 6 | title = Pilates for low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD010265 | date = July 2015 | volume = 2015 | pmid = 26133923 | pmc = 8078578 | doi = 10.1002/14651858.CD010265.pub2 | collaboration = Cochrane Back and Neck Group }}</ref> however there is no conclusive evidence that pilates is better than any other form of exercise for low back pain.<ref name=":1" />

Patients with chronic low back pain receiving multidisciplinary biopsychosocial rehabilitation (MBR) programs are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status of the patient compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs.<ref>{{cite journal | vauthors = Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW | title = Multidisciplinary biopsychosocial rehabilitation for chronic low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD000963 | date = September 2014 | volume = 2014 | pmid = 25180773 | doi = 10.1002/14651858.cd000963.pub3 | pmc = 10945502 }}</ref>

[[Electroanalgesia#Peripheral nerve stimulation|Peripheral nerve stimulation]], a minimally-invasive procedure, may be useful in cases of chronic low back pain that do not respond to other measures, although the evidence supporting it is not conclusive, and it is not effective for pain that radiates into the leg.<ref name="nizard_2012">{{cite journal | vauthors = Nizard J, Raoul S, Nguyen JP, Lefaucheur JP | title = Invasive stimulation therapies for the treatment of refractory pain | journal = Discovery Medicine | volume = 14 | issue = 77 | pages = 237–246 | date = October 2012 | pmid = 23114579 }}</ref> Evidence for the use of shoe insoles as a treatment is inconclusive.<ref name="sahar_2009" /> [[Transcutaneous electrical nerve stimulation]] (TENS) has not been found to be effective in chronic low back pain.<ref name="dubinsky_2009">{{cite journal | vauthors = Dubinsky RM, Miyasaki J | title = Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology | journal = Neurology | volume = 74 | issue = 2 | pages = 173–176 | date = January 2010 | pmid = 20042705 | doi = 10.1212/WNL.0b013e3181c918fc | doi-access = free }}</ref> There has been little research that supports the use of lumbar extension machines and thus they are not recommended.<ref name="Heg2020" />

===Medications===
If initial management with non–medication based treatments is insufficient, medication may be recommended.<ref name="Qas2017" /> As pain medications are only somewhat effective, expectations regarding their benefit may differ from reality, and this can lead to decreased satisfaction.<ref name=miller_2012/>

The medication typically prescribed first are acetaminophen (paracetamol), [[NSAIDs]] (though not aspirin), or [[skeletal muscle relaxants]] and these are enough for most people.<ref name="Cashin23" /><ref name=miller_2012/><ref name=Qas2017/><ref>{{cite journal |title=Acute low back pain without radiculopathy |website=English.prescrire.org |date=October 2019 |url=https://english.prescrire.org/en/80188408EDC746152D5D5227261812E0/Download.aspx |access-date=15 November 2019}}</ref> Benefits with NSAIDs is thought to be small,<ref name=Machado2017>{{cite journal | vauthors = Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML | title = Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis | journal = Annals of the Rheumatic Diseases | volume = 76 | issue = 7 | pages = 1269–1278 | date = July 2017 | pmid = 28153830 | doi = 10.1136/annrheumdis-2016-210597 | s2cid = 22850331 }}</ref><ref name=":3">{{cite journal | vauthors = van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW | title = Non-steroidal anti-inflammatory drugs for acute low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 4 | pages = CD013581 | date = April 2020 | pmid = 32297973 | pmc = 7161726 | doi = 10.1002/14651858.CD013581 }}</ref> but is more effective than Acetaminophen (paracetamol), which may be no more effective than placebo at improving pain, quality of life, or function.<ref>{{cite journal | vauthors = Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG | title = Paracetamol for low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD012230 | date = June 2016 | volume = 2019 | pmid = 27271789 | pmc = 6353046 | doi = 10.1002/14651858.CD012230 }}</ref><ref>{{cite journal | vauthors = Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML | display-authors = 6 | title = Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials | journal = BMJ | volume = 350 | pages = h1225 | date = March 2015 | pmid = 25828856 | pmc = 4381278 | doi = 10.1136/bmj.h1225 }}</ref> For adults with both acute and chronic lower back pain, NSAIDs can also reduce disability.<ref name="Cashin23">{{cite journal | vauthors = Cashin AG, Wand BM, O'Connell N, Lee H, Rizzi RR, Bagga MK, O'Hagan E, Maher CG, Furlan AD, Tulder MW, McAuley JH |title=Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews | journal = The Cochrane Database of Systematic Reviews | date = April 2023 | pmid = 37014979 | doi = 10.1002/14651858.CD012230 | pmc = 6353046 }}</ref> NSAIDs however, carry a greater risk of side effects, including [[Renal failure|kidney failure]], [[stomach ulcers]] and possibly [[cardiovascular disease|heart problems]], so it is used at the lowest effective dosage for the shortest possible time.<ref name=":7" /> NSAIDs are available in several different classes; there is no evidence to support the use of [[COX-2 inhibitor]]s over any other class of NSAIDs with respect to benefits.<ref name=Machado2017/><ref name=miller_2012/><ref>{{cite journal | vauthors = Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes BW | title = Non-steroidal anti-inflammatory drugs for chronic low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2 | pages = CD012087 | date = February 2016 | issue = 8 | pmid = 26863524 | pmc = 7104791 | doi = 10.1002/14651858.CD012087 }}</ref> With respect to safety [[naproxen]] may be best.<ref>{{cite journal | vauthors = Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C | display-authors = 6 | title = Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials | journal = Lancet | volume = 382 | issue = 9894 | pages = 769–779 | date = August 2013 | pmid = 23726390 | pmc = 3778977 | doi = 10.1016/S0140-6736(13)60900-9 | collaboration = Coxib and traditional NSAID Trialists' (CNT) Collaboration) }}</ref> [[Muscle relaxant]]s may be minimally beneficial.<ref name=miller_2012/> Muscle relaxants and benzodiazepines are shown to have small benefits compared to placebo for pain relief for acute lower back pain, and a higher chance of improving physical function. However they also come with an increased risk of adverse events. For chronic back pain, there may be a benefit in regards to use of benzodiazepines, with muscle relaxants in this context showing low-certainty evidence for no adverse reaction compared to placebo.<ref name="Cashin23" />

Systemic [[Corticosteroid|corticosteriods]] are sometimes suggested for low back pain and may have a small benefit in the short-term for radicular low back pain, however, the benefit for non-radicular back pain and the optimal dose and length of treatment is unclear.<ref>{{cite journal | vauthors = Chou R, Pinto RZ, Fu R, Lowe RA, Henschke N, McAuley JH, Dana T | title = Systemic corticosteroids for radicular and non-radicular low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 10 | pages = CD012450 | date = October 2022 | pmid = 36269125 | pmc = 9585990 | doi = 10.1002/14651858.CD012450.pub2 }}</ref>

As of 2022, the CDC has released a guideline for prescribed opioid use in the management of chronic pain.<ref name=":5">{{cite journal | vauthors = Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R | title = CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022 | journal = MMWR. Recommendations and Reports | volume = 71 | issue = 3 | pages = 1–95 | date = November 2022 | pmid = 36327391 | pmc = 9639433 | doi = 10.15585/mmwr.rr7103a1 }}</ref> It states that opioid use is not the preferred treatment when managing chronic pain due to the excessive risks involved, including high risks of addiction, accidental overdose and death.<ref name=":6">{{cite journal | vauthors = Deyo RA, Von Korff M, Duhrkoop D | title = Opioids for low back pain | journal = BMJ | volume = 350 | issue = jan05 10 | pages = g6380 | date = January 2015 | pmid = 25561513 | doi = 10.1136/bmj.g6380 | pmc = 6882374 }}</ref> 

In chronic back pain, there's high-certainty evidence that tapentadol offers a small reduction in pain compared to placebo, and moderate-certainty evidence for a small benefit from strong opioids in reducing both pain and disability. [[Tramadol]] also shows low to moderate-certainty evidence for small reductions in pain and disability, while [[Buprenorphine|buprenorphine]] has very low to low-certainty evidence for similar small benefits. Overall, opioid use is associated with a low-certainty increased risk of adverse events like nausea, headaches, constipation, and dizziness.<ref name="Cashin23" /> Specialist groups advise against general long-term use of opioids for chronic low back pain.<ref name="miller_2012" /><ref>{{cite journal |vauthors=Franklin GM |date=September 2014 |title=Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology |journal=Neurology |volume=83 |issue=14 |pages=1277–1284 |doi=10.1212/WNL.0000000000000839 |pmid=25267983 |doi-access=free}}</ref> If the pain is not managed adequately, short-term use of [[opioid]]s such as [[morphine]] may be suggested,<ref>{{cite journal | vauthors = Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC | title = Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review | journal = Spine | volume = 39 | issue = 7 | pages = 556–563 | date = April 2014 | pmid = 24480962 | doi = 10.1097/BRS.0000000000000249 | s2cid = 25356400 }}</ref><ref name="miller_2012" /> although low back pain outcomes are poorer in the long-term.<ref name=":7" /> If prescribed, a person and their clinician should have a realistic plan to discontinue its use in the event that the risks outweigh the benefit.<ref name="Dow2016">{{cite journal |vauthors=Dowell D, Haegerich TM, Chou R |date=March 2016 |title=CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 |journal=MMWR. Recommendations and Reports|volume=65 |issue=1 |pages=1–49 |doi=10.15585/mmwr.rr6501e1 |pmid=26987082 |doi-access=free|pmc=6390846 }}</ref> These medications carry a risk of addiction, may have negative interactions with other drugs, and have a greater risk of side effects, including dizziness, nausea, and constipation.<ref name=miller_2012/> Opioid treatment for chronic low back pain increases the risk for lifetime illicit drug use<ref>{{cite journal | vauthors = Shmagel A, Krebs E, Ensrud K, Foley R | title = Illicit Substance Use in US Adults With Chronic Low Back Pain | journal = Spine | volume = 41 | issue = 17 | pages = 1372–1377 | date = September 2016 | pmid = 27438382 | pmc = 5002230 | doi = 10.1097/brs.0000000000001702 }}</ref> and the effect of long-term use of opioids for lower back pain is unknown.<ref>{{cite journal | vauthors = Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ | title = Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis | journal = JAMA Internal Medicine | volume = 176 | issue = 7 | pages = 958–968 | date = July 2016 | pmid = 27213267 | doi = 10.1001/jamainternmed.2016.1251 | s2cid = 29903177 | doi-access = free }}</ref> For older people with chronic pain, opioids may be used in those for whom NSAIDs present too great a risk, including those with diabetes, stomach or heart problems. They may also be useful for a select group of people with [[neuropathic pain]].<ref name="de_leon_2013">{{cite journal | vauthors = de Leon-Casasola OA | title = Opioids for chronic pain: new evidence, new strategies, safe prescribing | journal = The American Journal of Medicine | volume = 126 | issue = 3 Suppl 1 | pages = S3-11 | date = March 2013 | pmid = 23414718 | doi = 10.1016/j.amjmed.2012.11.011 }}</ref>

[[SNRI]] antidepressants may have small effects on chronic low back pain, but are associated with adverse effects. Evidence is lacking for the use of [[SSRIs]] and [[tricyclic antidepressants]].<ref>{{cite journal | vauthors = Ferraro MC, Urquhart DM, Ferreira GE, Wewege MA, Shaheed CA, Traeger AC, Hoving JL, Visser EJ, McAuley JH, Cashin AG | title = Antidepressants for low back pain and spine-related leg pain | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD001703 | date = March 2025 | volume = 2025 | pmid = 40058767 | doi = 10.1002/14651858.CD001703.pub4 | pmc = 11890917 | pmc-embargo-date = March 10, 2026 }}</ref><ref name="Cashin23" /> Although the antiseizure drugs [[gabapentin]], [[pregabalin]], and [[topiramate]] are sometimes used for chronic low back pain evidence does not support a benefit.<ref>{{cite journal | vauthors = Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, Maher CG, Lin CC | display-authors = 6 | title = Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis | journal = CMAJ | volume = 190 | issue = 26 | pages = E786–E793 | date = July 2018 | pmid = 29970367 | pmc = 6028270 | doi = 10.1503/cmaj.171333 }}</ref> 
Systemic oral [[steroids]] have not been shown to be useful in low back pain.<ref name="casazza_2012" /><ref name="miller_2012" /> Facet joint injections and steroid injections into the discs have not been found to be effective in those with persistent, non-radiating pain; however, they may be considered for those with persistent sciatic pain.<ref name="chou_2009_rehab">{{cite journal | vauthors = Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM | display-authors = 6 | title = Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society | journal = Spine | volume = 34 | issue = 10 | pages = 1066–1077 | date = May 2009 | pmid = 19363457 | doi = 10.1097/BRS.0b013e3181a1390d | collaboration = American Pain Society Low Back Pain Guideline Pane | s2cid = 10658374 }}</ref> [[Epidural]] corticosteroid injections provide a slight and questionable short-term improvement in those with sciatica but are of no long-term benefit.<ref name="pinto_2012">{{cite journal | vauthors = Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH | display-authors = 6 | title = Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis | journal = Annals of Internal Medicine | volume = 157 | issue = 12 | pages = 865–877 | date = December 2012 | pmid = 23362516 | doi = 10.7326/0003-4819-157-12-201212180-00564 | s2cid = 21203011 }}</ref> There are also concerns of potential side effects.<ref>{{cite web|title=Epidural Corticosteroid Injection: Drug Safety Communication – Risk of Rare But Serious Neurologic Problems|url=https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm394530.htm|work=FDA|access-date=24 April 2014|date=2014-04-23|url-status=dead|archive-url=https://web.archive.org/web/20140424142502/https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm394530.htm|archive-date=24 April 2014}}</ref>

===Surgery===
Surgery may be useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control.<ref name=manusov_2012_surg/> It may also be useful in those with [[spinal stenosis]].<ref name=chou_2009_surgery/> In the absence of these issues, there is no clear evidence of a benefit from surgery.<ref name=manusov_2012_surg/>

[[Discectomy]] (the partial removal of a disc that is causing leg pain) can provide pain relief sooner than nonsurgical treatments.<ref name=manusov_2012_surg/> Discectomy has better outcomes at one year but not at four to ten years.<ref name=manusov_2012_surg/> The less invasive [[microdiscectomy]] has not been shown to result in a different outcome than regular discectomy.<ref name=manusov_2012_surg/> For most other conditions, there is not enough evidence to provide recommendations for surgical options.<ref name=manusov_2012_surg/> The long-term effect surgery has on degenerative disc disease is not clear.<ref name=manusov_2012_surg/> Less invasive surgical options have improved recovery times, but evidence regarding effectiveness is insufficient.<ref name=manusov_2012_surg/>

For those with pain localized to the lower back due to disc degeneration, fair evidence supports [[spinal fusion]] as equal to intensive physical therapy and slightly better than low-intensity nonsurgical measures.<ref name=chou_2009_surgery/> Fusion may be considered for those with low back pain from [[isthmic spondylolisthesis|acquired displaced vertebra]] that does not improve with conservative treatment,<ref name=manusov_2012_surg/> although only a few of those who have spinal fusion experience good results,<ref name=chou_2009_surgery/> and there may be no clinically important difference between disk replacement and fusion surgery.<ref>{{cite journal | vauthors = Jacobs W, Van der Gaag NA, Tuschel A, de Kleuver M, Peul W, Verbout AJ, Oner FC | title = Total disc replacement for chronic back pain in the presence of disc degeneration | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD008326 | date = September 2012 | pmid = 22972118 | doi = 10.1002/14651858.CD008326.pub2 | hdl = 1871/48560 | hdl-access = free }}</ref> There are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others.<ref>{{cite journal | vauthors = Lee CS, Hwang CJ, Lee DH, Kim YT, Lee HS | title = Fusion rates of instrumented lumbar spinal arthrodesis according to surgical approach: a systematic review of randomized trials | journal = Clinics in Orthopedic Surgery | volume = 3 | issue = 1 | pages = 39–47 | date = March 2011 | pmid = 21369477 | pmc = 3042168 | doi = 10.4055/cios.2011.3.1.39 }}</ref> Adding spinal implant devices during fusion increases the risk but provides no added improvement in pain or function.<ref name=deyo_2009/> Spinal cord stimulation using implanted electrodes is not supported by evidence due to the potential risks and costs.<ref>{{Cite journal |last1=Traeger |first1=Adrian C |last2=Gilbert |first2=Stephen E |last3=Harris |first3=Ian A |last4=Maher |first4=Christopher G |date=2023-03-07 |editor-last=Cochrane Back and Neck Group |title=Spinal cord stimulation for low back pain |journal=Cochrane Database of Systematic Reviews|volume=2023 |issue=8 |pages=CD014789 |doi=10.1002/14651858.CD014789.pub2 |pmc=9990744 |pmid=36878313 }}</ref>

===Alternative medicine===
It is unclear if alternative treatments are useful for non-chronic back pain.<ref>{{cite journal | vauthors = Rothberg S, Friedman BW | title = Complementary therapies in addition to medication for patients with nonchronic, nonradicular low back pain: a systematic review | journal = The American Journal of Emergency Medicine | volume = 35 | issue = 1 | pages = 55–61 | date = January 2017 | pmid = 27751598 | doi = 10.1016/j.ajem.2016.10.001 | s2cid = 34520820 | url = https://zenodo.org/record/891043 }}</ref> [[Chiropractic]] care or [[spinal manipulation]] therapy (SMT) appear similarly effective to other recommended treatments.<ref>{{cite journal | vauthors = Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW | title = Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials | journal = BMJ | volume = 364 | pages = l689 | date = March 2019 | pmid = 30867144 | pmc = 6396088 | doi = 10.1136/bmj.l689 }}</ref><ref>{{cite journal | vauthors = Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for acute low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD008880 | date = September 2012 | volume = 2012 | pmid = 22972127 | doi = 10.1002/14651858.CD008880.pub2 | pmc = 6885055 | collaboration = Cochrane Back and Neck Group }}</ref><ref name="rubinstein_2011" /> National guidelines differ, with some not recommending SMT, some describing manipulation as optional, and others recommending a short course for those who do not improve with other treatments.<ref name=koes_2010/> A 2017 review recommended SMT based on low-quality evidence.<ref name=Qas2017/> There is insufficient evidence to recommend [[manipulation under anaesthesia]], or medically assisted manipulation.<ref name=dagenais_2008>{{cite journal | vauthors = Dagenais S, Mayer J, Wooley JR, Haldeman S | title = Evidence-informed management of chronic low back pain with medicine-assisted manipulation | journal = The Spine Journal | volume = 8 | issue = 1 | pages = 142–149 | year = 2008 | pmid = 18164462 | doi = 10.1016/j.spinee.2007.09.010 }}</ref> SMT does not provide significant benefits compared to motor control exercises.<ref>{{cite journal | vauthors = Macedo LG, Saragiotto BT, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, Maher CG | title = Motor control exercise for acute non-specific low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD012085 | date = February 2016 | issue = 2 | pmid = 26863390 | doi = 10.1002/14651858.cd012085 | pmc = 8734597 }}</ref>

The evidence supporting [[acupuncture]] treatment for providing clinically beneficial acute and chronic pain relief is very weak.<ref name=":2">{{cite journal |vauthors=Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L |date=December 2020 |title=Acupuncture for chronic nonspecific low back pain |journal=The Cochrane Database of Systematic Reviews |volume=2020 |issue=12 |pages=CD013814 |doi=10.1002/14651858.CD013814 |pmc=8095030 |pmid=33306198}}</ref> When compared to a 'sham' treatment, no differences in pain relief or improvements in a person's quality of life were found.<ref name=":2" /> There is very weak evidence that acupuncture may be better than no treatment at all for immediate relief.<ref name=":2" /> A 2012 systematic review reported the findings that for people with chronic pain, acupuncture may improve pain a little more than no treatment and about the same as medications, but it does not help with disability.<ref name="furlan_2012">{{cite journal |display-authors=6 |vauthors=Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Gagnier J, Ammendolia C, Dryden T, Doucette S, Skidmore B, Daniel R, Ostermann T, Tsouros S |year=2012 |title=A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain |journal=Evidence-Based Complementary and Alternative Medicine |volume=2012 |page=953139 |doi=10.1155/2012/953139 |pmc=3236015 |pmid=22203884 |doi-access=free}}</ref> This pain benefit is only present right after treatment and not at follow-up.<ref name="furlan_2012" /> Acupuncture may be an option for those with chronic pain that does not respond to other treatments like conservative care and medications,<ref name="casazza_2012" /><ref name="lin_2011">{{cite journal |vauthors=Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW |date=July 2011 |title=Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review |journal=European Spine Journal |volume=20 |issue=7 |pages=1024–1038 |doi=10.1007/s00586-010-1676-3 |pmc=3176706 |pmid=21229367}}</ref> however this depends on patient preference, the cost, and on how accessible acupuncture is for the person.<ref name=":2" />

[[Massage therapy]] does not appear to provide much benefit for acute low back pain.<ref name=casazza_2012/> Massage therapy has been found to be more effective for acute low back pain than no treatment; the benefits were found to be limited to the short term<ref name=And2015/> and there was no effect for improving function.<ref name=And2015/> For chronic low back pain, massage therapy was better than no treatment for both pain and function, though only in the short-term.<ref name=And2015/> The overall quality of the evidence was low and the authors had no confidence that massage therapy is an effective treatment for low back pain.<ref name=And2015>{{cite journal | vauthors = Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M | title = Massage for low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD001929 | date = September 2015 | volume = 2015 | pmid = 26329399 | doi = 10.1002/14651858.CD001929.pub3 | pmc = 8734598 }}</ref> Massage therapy is recommended for selected people with subacute and chronic low back pain, but it should be paired with another form of treatment like aerobic or strength exercises. For acute or chronic radicular pain syndromes massage therapy is recommended only if low back pain is considered a symptom. Mechanical massage tools are not recommended for the treatment of any form of low back pain.<ref name=Heg2020 />

[[Prolotherapy]] – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body's healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy.<ref name=marlowe_2012/>

Herbal medicines, as a whole, are poorly supported by evidence.<ref>{{cite journal | vauthors = Gagnier JJ, Oltean H, van Tulder MW, Berman BM, Bombardier C, Robbins CB | title = Herbal Medicine for Low Back Pain: A Cochrane Review | journal = Spine | volume = 41 | issue = 2 | pages = 116–133 | date = January 2016 | pmid = 26630428 | doi = 10.1097/brs.0000000000001310 | s2cid = 42119774 }}</ref> The herbal treatments [[Harpagophytum|Devil's claw]] and [[white willow]] may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant.<ref name=marlowe_2012/> [[Capsicum]], in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.<ref name=marlowe_2012/>

[[Behavioral therapy]] may be useful for chronic pain.<ref name=henschke_2010/> There are several types available, including [[operant conditioning]], which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors; [[cognitive behavioral therapy]], which helps people identify and correct negative thinking and behavior; and [[respondent conditioning]], which can modify an individual's physiological response to pain.<ref name=marlowe_2012/> The benefit however is small.<ref>{{cite journal | vauthors = Cherkin DC, Herman PM | title = Cognitive and Mind-Body Therapies for Chronic Low Back Pain and Neck Pain: Effectiveness and Value | journal = JAMA Internal Medicine | volume = 178 | issue = 4 | pages = 556–557 | date = April 2018 | pmid = 29507946 | doi = 10.1001/jamainternmed.2018.0113 | s2cid = 3680364 }}</ref> Medical providers may develop an integrated program of behavioral therapies.<ref name=marlowe_2012/> The evidence is inconclusive as to whether [[mindfulness-based stress reduction]] reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.<ref name=cramer_2012>{{cite journal | vauthors = Cramer H, Haller H, Lauche R, Dobos G | title = Mindfulness-based stress reduction for low back pain. A systematic review | journal = BMC Complementary and Alternative Medicine | volume = 12 | page = 162 | date = September 2012 | pmid = 23009599 | pmc = 3520871 | doi = 10.1186/1472-6882-12-162 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H | title = Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis | journal = Annals of Internal Medicine | volume = 166 | issue = 11 | pages = 799–807 | date = June 2017 | pmid = 28437793 | doi = 10.7326/M16-1997 | s2cid = 1157568 }}</ref>

Tentative evidence supports [[neuroreflexotherapy]] (NRT), in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain.<ref>{{cite journal | vauthors = Urrútia G, Burton AK, Morral A, Bonfill X, Zanoli G | title = Neuroreflexotherapy for non-specific low-back pain | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD003009 | date = 2004-04-19 | volume = 2011 | pmid = 15106186 | doi = 10.1002/14651858.cd003009.pub2 | pmc = 8992702 }}</ref><ref name=urrutia_2005>{{cite journal | vauthors = Urrútia G, Burton K, Morral A, Bonfill X, Zanoli G | title = Neuroreflexotherapy for nonspecific low back pain: a systematic review | journal = Spine | volume = 30 | issue = 6 | pages = E148–E153 | date = March 2005 | pmid = 15770167 | doi = 10.1097/01.brs.0000155575.85223.14 | s2cid = 31140257 }}</ref><ref name="marlowe_2012"/> Multidisciplinary biopsychosocial rehabilitation (MBR), targeting physical and psychological aspects, may improve back pain but evidence is limited.<ref>{{cite journal | vauthors = Marin TJ, Van Eerd D, Irvin E, Couban R, Koes BW, Malmivaara A, van Tulder MW, Kamper SJ | display-authors = 6 | title = Multidisciplinary biopsychosocial rehabilitation for subacute low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 6 | pages = CD002193 | date = June 2017 | pmid = 28656659 | pmc = 6481490 | doi = 10.1002/14651858.cd002193.pub2 }}</ref> There is a lack of good quality evidence to support the use of radiofrequency denervation for pain relief.<ref>{{cite journal | vauthors = Maas ET, Ostelo RW, Niemisto L, Jousimaa J, Hurri H, Malmivaara A, van Tulder MW | title = Radiofrequency denervation for chronic low back pain | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008572 | date = October 2015 | volume = 2015 | pmid = 26495910 | doi = 10.1002/14651858.cd008572.pub2 | pmc = 8782593 }}</ref>

[[KT tape|KT Tape]] has been found to be no different for management of chronic non-specific low back pain than other established pain management strategies.<ref>{{cite journal | vauthors = Luz Júnior MA, Almeida MO, Santos RS, Civile VT, Costa LO | title = Effectiveness of Kinesio Taping in Patients With Chronic Nonspecific Low Back Pain: A Systematic Review With Meta-analysis | journal = Spine | volume = 44 | issue = 1 | pages = 68–78 | date = January 2019 | pmid = 29952880 | doi = 10.1097/BRS.0000000000002756 | s2cid = 49486200 }}</ref>

=== Education ===
There is strong evidence that [[education]] may improve low back pain, with a 2.5 hour educational session more effective than usual care for helping people return to work in the short- and long-term. This was more effective for people with acute rather than chronic back pain.<ref>{{cite journal | vauthors = Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW | title = Individual patient education for low back pain | journal = The Cochrane Database of Systematic Reviews | volume = 2008 | issue = 1 | pages = CD004057 | date = January 2008 | pmid = 18254037 | pmc = 6999124 | doi = 10.1002/14651858.cd004057.pub3 | hdl = 2066/69744 }}</ref> The benefit of training for preventing back pain in people who work manually with materials is not clear, however moderate quality evidence does not show a role in preventing back pain.<ref>{{cite journal | vauthors = Verbeek JH, Martimo KP, Karppinen J, Kuijer PP, Viikari-Juntura E, Takala EP | title = Manual material handling advice and assistive devices for preventing and treating back pain in workers | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD005958 | date = June 2011 | pmid = 21678349 | doi = 10.1002/14651858.CD005958.pub3 }}</ref>

==Prognosis==
Overall, the outcome for acute low back pain is positive. Pain and disability usually improve a great deal in the first six weeks, with complete recovery reported by 40 to 90%.<ref name=menezes_2012/> In those who still have symptoms after six weeks, improvement is generally slower with only small gains up to one year. At one year, pain and disability levels are low to minimal in most people. Distress, previous low back pain, and [[job satisfaction]] are predictors of long-term outcome after an episode of acute pain.<ref name=menezes_2012/> Certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain.<ref name=miller_2012/> Following a first episode of back pain, recurrences occur in more than half of people.<ref name=Stanton2010>{{cite journal | vauthors = Stanton TR, Latimer J, Maher CG, Hancock MJ | title = How do we define the condition 'recurrent low back pain'? A systematic review | journal = European Spine Journal | volume = 19 | issue = 4 | pages = 533–539 | date = April 2010 | pmid = 19921522 | pmc = 2899839 | doi = 10.1007/s00586-009-1214-3 }}</ref>

For persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. At one year, those with chronic low back pain usually continue to have moderate pain and disability.<ref name=menezes_2012/> People at higher risk of long-term disability include those with poor coping skills or with fear of activity (2.5 times more likely to have poor outcomes at one year),<ref name=chou_2010>{{cite journal | vauthors = Chou R, Shekelle P | title = Will this patient develop persistent disabling low back pain? | journal = JAMA | volume = 303 | issue = 13 | pages = 1295–1302 | date = April 2010 | pmid = 20371789 | doi = 10.1001/jama.2010.344 }}</ref> those with a poor ability to cope with pain, functional impairments, poor general health, or a significant psychiatric or psychological component to the pain ([[Waddell's signs]]).<ref name=chou_2010/>

Prognosis may be influenced by expectations, with those having positive expectations of recovery related to higher likelihood of returning to work and better recovery outcomes.<ref>{{cite journal | vauthors = Hayden JA, Wilson MN, Riley RD, Iles R, Pincus T, Ogilvie R | title = Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 11 | date = November 2019 | pmid = 31765487 | pmc = 6877336 | doi = 10.1002/14651858.cd011284.pub2 }}</ref>

==Epidemiology==
Low back pain that lasts at least one day and limits activity is a common complaint.<ref name=hoy_2012/> Globally, about 40% of people have low back pain at some point in their lives,<ref name=hoy_2012/> with estimates as high as 80% of people in the developed world.<ref name=malhotra_2011/> Approximately 9 to 12% of people (632&nbsp;million) have low back pain at any given point in time, which was calculated to 7460 per 100,000 globally in 2020.<ref name=":4" /> Nearly one quarter (23.2%) report having it at some point over any one-month period.<ref name=hoy_2012/><ref name=vos_2012 /> Difficulty most often begins between 20 and 40&nbsp;years of age.<ref name=casazza_2012/> However, low back pain becomes increasingly common with age, and is most common in the age group of 85.<ref name=":4" /> Older adults more greatly affected by low back pain; they are more likely to lose mobility and independence and less likely to continue to participate in social and family activities.<ref name=":4" />

Women have higher rates of low back pain than men within all age groups, and this difference becomes more marked in older age groups (above 75 years).<ref name=":4" /> In a 2012 review which found a higher rate in females than males, the reviewers thought this may be attributable to greater rates of pains due to osteoporosis, menstruation, and pregnancy among women, or possibly because women were more willing to report pain than men.<ref name=hoy_2012/> An estimated 70% of women experience back pain during [[pregnancy]] with the rate being higher the further along in pregnancy.<ref>{{cite book| vauthors = Cunningham F |title=Williams Obstetrics|year=2009|publisher=McGraw Hill Professional|isbn=978-0-07-170285-0|page=210|url=https://books.google.com/books?id=PYO2RUc4sQMC|edition=23|url-status=live|archive-url=https://web.archive.org/web/20170908185118/https://books.google.com/books?id=PYO2RUc4sQMC|archive-date=8 September 2017}}</ref>

Although the majority of low back pain has no specific underlying cause, workplace ergonomics, smoking and obesity are associated with low back pain in approximately 30% of cases.<ref name=":4" /> Low levels of activity is also associated with low back pain.<ref name=":7">{{Cite journal |last1=Hartvigsen |first1=Jan |last2=Hancock |first2=Mark J |last3=Kongsted |first3=Alice |last4=Louw |first4=Quinette |last5=Ferreira |first5=Manuela L |last6=Genevay |first6=Stéphane |last7=Hoy |first7=Damian |last8=Karppinen |first8=Jaro |last9=Pransky |first9=Glenn |last10=Sieper |first10=Joachim |last11=Smeets |first11=Rob J |last12=Underwood |first12=Martin |last13=Buchbinder |first13=Rachelle |last14=Hartvigsen |first14=Jan |last15=Cherkin |first15=Dan |date=June 2018 |title=What low back pain is and why we need to pay attention |journal=The Lancet |volume=391 |issue=10137 |pages=2356–2367 |doi=10.1016/s0140-6736(18)30480-x |pmid=29573870 |s2cid=4354991 |issn=0140-6736}}</ref> Workplace ergonomics associated with low back pain include lifting, bending, vibration and physically demanding work, as well as prolonged sitting, standing and awkward postures.<ref name=":4" /> Current smokers – and especially those who are adolescents – are more likely to have low back pain than former smokers, and former smokers are more likely to have low back pain than those who have never smoked.<ref name="shiri_2010">{{cite journal | vauthors = Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E | title = The association between smoking and low back pain: a meta-analysis | journal = The American Journal of Medicine | volume = 123 | issue = 1 | pages = 87.e7–87.35 | date = January 2010 | pmid = 20102998 | doi = 10.1016/j.amjmed.2009.05.028 }}</ref>

The overall number of individuals affected expected to increase with population growth and as the population ages,<ref name=":4" /> with the largest increases expected in low- and middle-income countries.<ref name=":7" />

==History==
[[File:Harvey Cushing, Doris Ulmann 1920s.jpg|thumb|right|Harvey Williams Cushing, 1920s]]
Low back pain has been with humans since at least the [[Bronze Age]]. The oldest known surgical treatise – the [[Edwin Smith Papyrus]], dating to about 1500 BCE – describes a diagnostic test and treatment for a vertebral sprain. [[Hippocrates]] ({{circa|460 BCE}} – {{circa|370 BCE}}) was the first to use a term for sciatic pain and low back pain; [[Galen]] (active mid to late second century CE) described the concept in some detail. Physicians through the end of the first millennium recommended [[watchful waiting]]. Through the [[Medieval period]], folk medicine practitioners provided treatments for back pain based on the belief that it was caused by spirits.<ref name=maharty_2012>{{cite journal | vauthors = Maharty DC | title = The history of lower back pain: a look "back" through the centuries | journal = Primary Care | volume = 39 | issue = 3 | pages = 463–470 | date = September 2012 | pmid = 22958555 | doi = 10.1016/j.pop.2012.06.002 }}</ref>

At the start of the 20th century, physicians thought low back pain was caused by inflammation of or damage to the nerves,<ref name=maharty_2012/> with neuralgia and neuritis frequently mentioned by them in the medical literature of the time.<ref name=lutz_2003>{{cite journal | vauthors = Lutz GK, Butzlaff M, Schultz-Venrath U | title = Looking back on back pain: trial and error of diagnoses in the 20th century | journal = Spine | volume = 28 | issue = 16 | pages = 1899–1905 | date = August 2003 | pmid = 12923482 | doi = 10.1097/01.BRS.0000083365.41261.CF | s2cid = 25083375 }}</ref> The popularity of such proposed causes decreased during the 20th century.<ref name=lutz_2003/> In the early 20th century, American neurosurgeon [[Harvey Williams Cushing]] increased the acceptance of surgical treatments for low back pain.<ref name=manusov_2012_surg/> In the 1920s and 1930s, new theories of the cause arose, with physicians proposing a combination of nervous system and psychological disorders such as nerve weakness ([[neurasthenia]]) and [[female hysteria]].<ref name=maharty_2012/> [[Muscular rheumatism]] (now called [[fibromyalgia]]) was also cited with increasing frequency.<ref name=lutz_2003/>

Emerging technologies such as [[radiography|X-rays]] gave physicians new diagnostic tools, revealing the intervertebral disc as a source for back pain in some cases. In 1938, orthopedic surgeon Joseph S. Barr reported on cases of disc-related sciatica improved or cured with back surgery.<ref name=lutz_2003/> As a result of this work, in the 1940s, the vertebral disc model of low back pain took over,<ref name=maharty_2012/> dominating the literature through the 1980s, aiding further by the rise of new imaging technologies such as CT and MRI.<ref name=lutz_2003/> The discussion subsided as research showed disc problems to be a relatively uncommon cause of the pain. Since then, physicians have come to realize that it is unlikely that a specific cause for low back pain can be identified in many cases and question the need to find one at all as most of the time symptoms resolve within 6 to 12 weeks regardless of treatment.<ref name=maharty_2012/>

==Society and culture==
Low back pain results in large [[economic cost]]s. In the United States, it is the most common type of pain in adults, responsible for a large number of missed work days, and is the most common musculoskeletal complaint seen in the emergency department.<ref name=borczuk_2013/> In 1998, it was estimated to be responsible for $90 billion in annual health care costs, with 5% of individuals incurring most (75%) of the costs.<ref name=borczuk_2013/> Between 1990 and 2001 there was a more than twofold increase in spinal fusion surgeries in the US, despite the fact that there were no changes to the indications for surgery or new evidence of greater usefulness.<ref name=deyo_2009/> Further costs occur in the form of lost income and productivity, with low back pain responsible for 40% of all missed work days in the United States.<ref name=manchikanti_2009_epi>{{cite journal | vauthors = Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA | title = Comprehensive review of epidemiology, scope, and impact of spinal pain | journal = Pain Physician | volume = 12 | issue = 4 | pages = E35–E70 | year = 2009 | pmid = 19668291 | doi = 10.36076/ppj.2009/12/E35 | doi-access = free }}</ref> Low back pain causes disability in a larger percentage of the [[workforce]] in Canada, Great Britain, the Netherlands and Sweden than in the US or Germany.<ref name=manchikanti_2009_epi/> In the United States, low back pain is highest of Years Lived With Disability (YLDs) rank{{Failed verification span|text=, rate, and percentage change|date=March 2025| reason = The reference supports only first ranking of YLDs.  Nothing about "rate" and "percentage change".}} for the 25 leading causes of disability and injury, between 1990 and 2016.<ref>{{cite journal | vauthors = Mokdad AH, Ballestros K, Echko M, Glenn S, Olsen HE, Mullany E, Lee A, Khan AR, Ahmadi A, Ferrari AJ, Kasaeian A, Werdecker A, Carter A, Zipkin B, Sartorius B, Serdar B, Sykes BL, Troeger C, Fitzmaurice C, Rehm CD, Santomauro D, Kim D, Colombara D, Schwebel DC, Tsoi D, Kolte D, Nsoesie E, Nichols E, Oren E, Charlson FJ, Patton GC, Roth GA, Hosgood HD, Whiteford HA, Kyu H, Erskine HE, Huang H, Martopullo I, Singh JA, Nachega JB, Sanabria JR, Abbas K, Ong K, Tabb K, Krohn KJ, Cornaby L, Degenhardt L, Moses M, Farvid M, Griswold M, Criqui M, Bell M, Nguyen M, Wallin M, Mirarefin M, Qorbani M, Younis M, Fullman N, Liu P, Briant P, Gona P, Havmoller R, Leung R, Kimokoti R, Bazargan-Hejazi S, Hay SI, Yadgir S, Biryukov S, Vollset SE, Alam T, Frank T, Farid T, Miller T, Vos T, Bärnighausen T, Gebrehiwot TT, Yano Y, Al-Aly Z, Mehari A, Handal A, Kandel A, Anderson B, Biroscak B, Mozaffarian D, Dorsey ER, Ding EL, Park EK, Wagner G, Hu G, Chen H, Sunshine JE, Khubchandani J, Leasher J, Leung J, Salomon J, Unutzer J, Cahill L, Cooper L, Horino M, Brauer M, Breitborde N, Hotez P, Topor-Madry R, Soneji S, Stranges S, James S, Amrock S, Jayaraman S, Patel T, Akinyemiju T, Skirbekk V, Kinfu Y, Bhutta Z, Jonas JB, Murray CJ | display-authors = 6 | title = The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States | journal = JAMA | volume = 319 | issue = 14 | pages = 1444–1472 | date = April 2018 | pmid = 29634829 | pmc = 5933332 | doi = 10.1001/jama.2018.0158 }}</ref>

Workers who experience acute low back pain as a result of a work injury may be asked by their employers to have x-rays.<ref name="ACOEMfive">{{Citation |author1 = American College of Occupational and Environmental Medicine |author1-link = American College of Occupational and Environmental Medicine |date = February 2014 |title = Five Things Physicians and Patients Should Question |publisher = American College of Occupational and Environmental Medicine |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |access-date = 24 February 2014 |url-status = live |archive-url = https://web.archive.org/web/20140911001813/http://www.choosingwisely.org/doctor-patient-lists/american-college-of-occupational-and-environmental-medicine/ |archive-date = 11 September 2014 }}, which cites
* {{cite book | vauthors = Talmage J, Belcourt R, Galper J | veditors = Hegmann KT |title=Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers|date=2011|publisher=American College of Occupational and Environmental Medicine |chapter=Low back disorders |pages=336, 373, 376–77|location=Elk Grove Village, IL|isbn=978-0-615-45227-2|edition=3rd|display-authors=etal}}</ref> As in other cases, testing is not indicated unless red flags are present.<ref name="ACOEMfive"/> An employer's concern about legal liability is not a medical indication and should not be used to justify medical testing when it is not indicated.<ref name="ACOEMfive"/> There should be no legal reason for encouraging people to have tests which a health care provider determines are not indicated.<ref name="ACOEMfive"/>

==Research==
[[Intervertebral disc arthroplasty|Total disc replacement]] is an experimental option,<ref name="hughes_2012" /> but no significant evidence supports its use over [[lumbar fusion]].<ref name=manusov_2012_surg/> Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human [[growth factor]]s, implanted substances, [[cell therapy]], and [[tissue engineering]].<ref name="hughes_2012" />

== References ==
{{Reflist}}

== External links ==
{{Medical resources
|DiseasesDB     =
|ICD10          = {{ICD10|M|54|5|m|50}}
|ICD9           = {{ICD9|724.2}}
|ICDO           =
|OMIM           =
|MedlinePlus    = 007422
|eMedicineSubj  = pmr
|eMedicineTopic = 73
|MeshID         = D017116
}}
{{Wiktionary|lumbago}}

*[https://medlineplus.gov/backpain.html Back Pain at MedlinePlus.gov]

{{Occupational safety and health}}
{{Dorsopathies}}
{{pain}}

{{Authority control}}

{{DEFAULTSORT:Low Back Pain}}
[[Category:Human back]]
[[Category:Pain]]
[[Category:Wikipedia emergency medicine articles ready to translate]]
[[Category:Symptoms and signs: musculoskeletal system]]
[[Category:Wikipedia medicine articles ready to translate (full)]]