Diagnosis And Treatment Of Low Back Pain
Publication Date: January 1, 2020
Last Updated: March 14, 2022
Recommendations
Diagnosis
There is insufficient evidence to make a recommendation for or against the use of innominate kinematics for the assessment of sacroiliac joint pain. (I)
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There is insufficient evidence to make a recommendation for or against the use of pain localization in predicting response to a diagnostic injection. (I)
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There is insufficient evidence to make a recommendation for or against the assessment of centralization or peripheralization for the prediction of discography results. (I)
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There is insufficient evidence to indicate that body mass index (BMI) is a potential predictor of a recurrence of low back pain. (I)
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It is suggested that history of low back pain is a potential predictor of a recurrence of low back pain. (B)
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It is recommended that psychosocial factors and workplace factors be assessed when counseling patients regarding the risk of conversion from acute to chronic low back pain. (A)
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It is recommended that psychosocial factors be used as prognostic factors for return to work following an episode of acute low back pain. (A)
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It is recommended that pain severity and functional impairment be used to stratify risk of conversion from acute to chronic low back pain. (A)
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It is suggested that prior episodes of low back pain be considered a prognostic factor for the conversion from acute to chronic low back pain. (B)
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There is insufficient evidence to assess sleep quality as a prognostic variable to predict recovery from acute low back pain. (I)
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There is insufficient evidence to make a recommendation for or against the use of smoking and/or obesity as prognostic factors for the conversion from acute to chronic low back pain. (I)
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A nonstructural cause of low back pain may be considered in patients with diffuse low back pain and tenderness. (C)
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There is insufficient evidence to make a recommendation for or against the use of fear avoidance behavior to determine the likelihood of a structural cause of low back pain. (I)
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There is insufficient evidence to make a recommendation for or against the presence of diffuse back tenderness for the prediction of the presence of disc degeneration on radiographs. (I)
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There is insufficient evidence to make a recommendation for or against obtaining laboratory tests to assess for inflammatory disease in patients with sacroiliac joint pain. (I)
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Work Group Consensus Statement:
In the absence of reliable evidence supporting an absolute indication for advanced imaging based upon history and physical examination in the specifically-defined patient population, it is the work group’s opinion that, in patients with severe and intractable pain syndromes who have failed medical/ interventional treatment, advanced imaging may be indicated. Subgroups of patients have been shown to have a higher or lower incidence of radiographic abnormalities based upon acuity of low back pain, tenderness to palpation and provocation maneuvers; however, the utility of these findings in guiding treatment is not clear. ()
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Imaging
There is insufficient evidence to make a recommendation for or against an association between low back pain and spondylosis using routine radiography. (I)
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There is insufficient evidence that unique magnetic resonance imaging (MRI) sequences can be considered preferential or optimal. (I)
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There is insufficient evidence to make a recommendation for or against obtaining imaging in the absence of red flags. (I)
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There is insufficient evidence for or against imaging findings correlating with the presence of low back pain. (I)
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There is insufficient evidence to determine whether imaging findings contribute to decision-making by health care providers to guide treatment. (I)
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Medical and Psychological Treatment
There is insufficient evidence to make a recommendation for or against the use of anticonvulsants for the treatment of low back pain. (I)
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Antidepressants are not recommended for the treatment of low back pain. (A)
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There is insufficient evidence to make a recommendation for or against the use of Vitamin D for the treatment of low back pain. (I)
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Non-selective NSAIDs are suggested for the treatment of low back pain. (B)
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There is insufficient evidence to make a recommendation for or against the use of selective NSAIDs for the treatment of low back pain. (I)
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It is suggested that the use of oral or IV steroids is not effective for the treatment of low back pain. (B)
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It is suggested that the use of opioid pain medications should be cautiously limited and restricted to short duration for the treatment of low back pain. (B)
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There is insufficient evidence to make a recommendation for or against the use of lidocaine patch for the treatment of low back pain. (I)
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Topical capsicum is recommended as an effective treatment for low back pain on a short-term basis (3 months or less). (A)
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Cognitive behavioral therapy is recommended in combination with physical therapy, as compared with physical therapy alone, to improve pain levels in patients with low back pain over 12 months. (A)
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Cognitive behavioral therapy in combination with physical therapy, compared to physical therapy alone, is suggested to improve functional outcomes (disability) and return to work in patients with low back pain. (B)
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There is conflicting evidence to make a recommendation for or against cognitive behavioral therapy for improving depression or anxiety in patients with low back pain. (I)
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There is insufficient evidence to make a recommendation for or against the addition of cognitive behavioral therapy or psychosocial intervention for patients undergoing interventional or surgical treatment for low back pain and whether it would provide incremental benefit. (I)
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There is conflicting evidence to make a recommendation for or against the use of patient education to improve treatment compliance and outcomes, including duration of pain, intensity of pain, functional outcomes, anxiety, depression and return to work status. (I)
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Treatments targeting fear avoidance combined with physical therapy are recommended compared to physical therapy alone to improve low back pain in the first six months. (A)
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It is suggested that kinesiophobia is a negative prognostic factor for predicting response to low back pain treatment. (B)
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Physical Medicine and Rehabilitation
Recommendation Grading
Overview
Title
Diagnosis And Treatment Of Low Back Pain
Authoring Organization
North American Spine Society
Publication Month/Year
January 1, 2020
Last Updated Month/Year
July 5, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Management, Treatment
Diseases/Conditions (MeSH)
D017116 - Low Back Pain
Keywords
pain, low back pain (LBP), chronic low back pain
Source Citation
Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC 3rd, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL Jr, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. 2020 Jul;20(7):998-1024. doi: 10.1016/j.spinee.2020.04.006. Epub 2020 Apr 22. Erratum in: Spine J. 2021 Feb 24;: PMID: 32333996.