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Low back pain
Low back pain
Low back pain
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Low back pain
Other namesLower back pain, lumbago
Location of the lumbar region (pink) in relation to the human skeleton
Pronunciation
SpecialtyOrthopedics, rheumatology, rehabilitation medicine
Usual onset20 to 40 years of age[1]
Duration~65% get better in 6 weeks[2]
TypesAcute (less than 6 weeks), sub-chronic (6 to 12 weeks), chronic (more than 12 weeks)[3]
CausesUsually non-specific, occasionally significant underlying cause[1][4]
Diagnostic methodMedical imaging (if red flags)[5]
TreatmentContinued normal activity, non-medication based treatments, NSAIDs[2][6]
Frequency~25% in any given month[7][8]

Low back pain or lumbago is a common 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.[4] Low back pain may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks).[3] The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain.[5] 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.[2]

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 or joint strain.[1][4] 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.[5] 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.[9] Despite this, the use of imaging in low back pain has increased.[10] Some low back pain is caused by damaged intervertebral discs, and the straight leg raise test is useful to identify this cause.[5] In those with chronic pain, the pain processing system may malfunction, causing large amounts of pain in response to non-serious events.[11] 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.[12] Chronic lower back pain is defined as back pain that lasts more than three months.[13]

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.[2] Normal activity should be continued as much as the pain allows.[2] Initial management with non-medication based treatments is recommended.[6] Non–medication based treatments include superficial heat, massage, acupuncture, or spinal manipulation.[6] If these are not sufficiently effective, NSAIDs are recommended.[6][14] A number of other options are available for those who do not improve with usual treatment. Opioids may be useful if simple pain medications are not enough, but they are not generally recommended due to side effects,[15] including high rates of addiction, accidental overdose and death.[16] Surgery may be beneficial for those with disc-related chronic pain and disability or spinal stenosis.[17][18] No clear benefit of surgery has been found for other cases of non-specific low back pain.[17] Low back pain often affects mood, which may be improved by counseling or antidepressants.[19][20] Additionally, there are many alternative medicine therapies, but there is not enough evidence to recommend them confidently.[21] The evidence for chiropractic care[22] and spinal manipulation is mixed.[21][23][24][25]

Approximately 9–12% of people (632 million) have low back pain at any given point in time,[26] and nearly 25% report having it at some point over any one-month period.[7][8] About 40% of people have low back pain at some point in their lives,[7] with estimates as high as 80% among people in the developed world.[27] Low back pain is the greatest contributor to lost productivity, absenteeism, disability and early retirement worldwide.[26] Difficulty with low back pain most often begins between 20 and 40 years of age.[1] Women and older people have higher estimated rates of lower back pain and also higher disability estimates.[13] 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.[7] According to the World Health Organization in 2023, lower back pain is the top medical condition world-wide from which the most number of people world-wide can benefit from improved rehabilitation.[13]

Video explanation

Signs and symptoms

[edit]

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. 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. Pain radiating down the legs (known as sciatica) may be present. The first experience of acute low back pain is typically between the ages of 20 and 40. This is often a person's first reason to see a medical professional as an adult.[1] Recurrent episodes occur in more than half of people[28] with the repeated episodes being generally more painful than the first.[1]

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.[29] In addition, a majority of those with chronic low back pain[need quotation to verify] show symptoms of depression[19] or anxiety.[21]

Causes

[edit]
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.[30] The majority of low back pain does not have a clear cause[1] but is believed to be the result of non-serious muscle or skeletal issues such as sprains or strains.[31] Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, and poor sleeping position may also contribute to low back pain.[31] There is no consensus as to whether spinal posture or certain physical activities are causal factors.[32] A full list of possible causes includes many less common conditions.[5] Physical causes may include osteoarthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, broken vertebra(e) (such as from osteoporosis) or, rarely, an infection or tumor of the spine.[33]

Women may have acute low back pain from medical conditions affecting the female reproductive system, including endometriosis, ovarian cysts, ovarian cancer, or uterine fibroids.[34] 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.[35]

Low back pain can be broadly classified into four main categories:

Pathophysiology

[edit]

Back structures

[edit]
The lumbar region in regards to the rest of the spine
The five lumbar vertebrae define the lower back region.
The nerve and bone components of the vertebrae
The structures surrounding and supporting the vertebrae can be sources of low back pain.

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 fibrocartilaginous 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 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 facet joints limit and direct the motion of the spine.[37]

The multifidus muscles 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.[11] 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.[38] The problem with the multifidus muscles continues even after the pain goes away, and is probably an important reason why the pain comes back.[38] Teaching people with chronic low back pain how to use these muscles is recommended as part of a recovery program.[38]

An intervertebral disc has a gelatinous core surrounded by a fibrous ring.[39] When in its normal, uninjured state, most of the disc is not served by either the circulatory or nervous systems – blood and nerves only run to the outside of the disc.[39] Specialized cells that can survive without direct blood supply are in the inside of the disc.[39] Over time, the discs lose flexibility and the ability to absorb physical forces.[30] 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.[30] As a result, there is less space through which the spinal cord and nerve roots may pass.[30] 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.[39] Any of these changes may result in back pain.[39]

Pain sensation

[edit]

Pain erupts in response to a stimulus that either damages or can potentially damage the body's tissues. There are four main stages: transduction, transmission, perception, and modulation.[11] 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.[40] The process of pain sensation starts when the pain-causing event triggers the endings of appropriate 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 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 neurotransmitters.[11]

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.[11]

Diagnosis

[edit]

As the structure of the low back is complex, the reporting of pain is subjective, and is affected by social factors, the diagnosis of low back pain is not straightforward.[5] 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.[3][1] The ICD 10 code for low back pain is M54.5.

Classification

[edit]

There are a number of ways to classify low back pain with no consensus that any one method is best.[5] There are three general types of low back pain by cause: mechanical back pain (including nonspecific musculoskeletal strains, herniated discs, compressed nerve roots, degenerative discs or joint disease, and broken vertebra), non-mechanical back pain (tumors, inflammatory conditions such as spondyloarthritis, and infections), and referred pain from internal organs (gallbladder disease, kidney stones, kidney infections, and aortic aneurysm, among others).[5] Mechanical or musculoskeletal problems underlie most cases (around 90% or more),[5][41] 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.[5][41] Rarely, complaints of low back pain result from systemic or psychological problems, such as fibromyalgia and somatoform disorders.[41]

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 buttocks, is classified as nonspecific, the most common classification.[5] 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.[5] 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.[5]

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.[3] Management and prognosis may change based on the duration of symptoms.

Red flags

[edit]
Red flags are warning signs that may indicate a more serious problem
Red flag[42] Possible cause[1]
Previous history of cancer Cancer
Unintentional weight loss
Loss of bladder or bowel control Cauda
equina
syndrome
Significant motor weakness
or sensory problems
Loss of sensation in the
buttocks (saddle anesthesia)
Significant trauma related to age Fracture
Chronic corticosteroid use
Osteoporosis
Severe pain after lumbar
surgery in past year		 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.[5][43] The presence of a red flag does not mean that there is a significant problem. It is only suggestive,[44][45] and most people with red flags have no serious underlying problem.[3][1] 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.[5]

The usefulness of many red flags is poorly supported by evidence.[46][44] The most useful for detecting a fracture are: older age, corticosteroid use, and significant trauma especially if it results in skin markings.[46] The best determinant of the presence of cancer is a history of the same.[46]

With other causes ruled out, people with non-specific low back pain are typically treated symptomatically, without exact determination of the cause.[3][1] Efforts to uncover factors that might complicate the diagnosis, such as depression, substance abuse, or an agenda concerning insurance payments may be helpful.[5]

Tests

[edit]
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.[5] In particular, early use of imaging (either MRI or CT) is recommended for suspected cancer, infection, or cauda equina syndrome.[5] MRI is slightly better than CT for identifying disc disease; the two technologies are equally useful for diagnosing spinal stenosis.[5] Only a few physical diagnostic tests are helpful.[5] The straight leg raise test is almost always positive in those with disc herniation,[5] and lumbar provocative discography may be useful to identify a specific disc causing pain in those with chronic high levels of low back pain.[47] Therapeutic procedures such as nerve blocks can also be used to determine a specific source of pain.[5] Some evidence supports the use of facet joint injections, transforminal epidural injections and sacroiliac injections as diagnostic tests.[5] Most other physical tests, such as evaluating for scoliosis, muscle weakness or wasting, and impaired reflexes, are of little use.[5]

Complaints of low back pain are one of the most common reasons people visit doctors.[48][49] For pain that has lasted only a few weeks, the pain is likely to subside on its own.[50] 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-rays, CT scans, and MRIs.[49] Individuals may want such tests but, unless red flags are present,[51][52] they are unnecessary health care.[48][50] Routine imaging increases costs, is associated with higher rates of surgery with no overall benefit,[53][54] and the radiation used may be harmful to one's health.[53] Fewer than 1% of imaging tests identify the cause of the problem.[48] Imaging may also detect harmless abnormalities, encouraging people to request further unnecessary testing or to worry.[48] Even so, MRI scans of the lumbar region increased by more than 300% among United States Medicare beneficiaries from 1994 to 2006.[10]

Prevention

[edit]

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.[55]

Exercise alone, or along with education, appears to be useful for preventing low back pain.[56][57] Exercise is also probably effective in preventing recurrences in those with pain that has lasted more than six weeks.[58] 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,[59] while a 2020 review stated that studies have been inadequate to comment on mattress firmness.[60] There is little to no evidence that back belts are any more helpful in preventing low back pain than education about proper lifting techniques.[56][57] Shoe insoles do not help prevent low back pain.[56][61][57]

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.[12]

Management

[edit]

Most people with acute or subacute low back pain improve over time no matter the treatment.[6] There is often improvement within the first month.[6] Although fear in those suffering from low back pain often leads to avoiding activity, this is found to lead to greater disability.[57] The recommendations include remaining active, avoiding activity that worsen the pain, and understanding self-care of the symptoms.[6] Management of low back pain depends on which of the three general categories is the cause: mechanical problems, non-mechanical problems, or referred pain.[62] 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.[3] Providing individuals with coping skills through reassurance of these facts is useful in speeding recovery.[1]

For those with sub-chronic or chronic low back pain, multidisciplinary treatment programs may help.[63] For chronic lower back pain, initial management with non–medication based treatments is recommended[6] Non–medication based treatments include exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, and progressive relaxation.[6] If these are not sufficiently effective, NSAIDs are recommended.[6] Acetaminophen and systemic steroids are not recommended as both medications are not effective at improving pain outcomes in acute or subacute low back pain.[6]

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.[64] 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.[65]

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.[57]

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).[66]

Physical management

[edit]

Management of acute low back pain

[edit]

Increasing general physical activity has been recommended, but no clear relationship to pain, disability or returning to work occurred when used for treating an acute episode of pain.[58][67][68] For acute pain, low- to moderate-quality evidence supports walking.[69] Aerobic exercise, such as progressive walking, appears useful for subacute and acute low back pain, is strongly recommended for chronic low back pain, and is recommended after surgery.[60] Directional exercises, which try to limit low back pain, are recommended in sub-acute, chronic and radicular low back pain. These exercises only work if they are limiting low back pain.[60] 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 from strength exercises.[60] Yoga and Tai chi are not recommended for acute or subacute low back pain, but are recommended for chronic back pain.[60] A 2023 review of low-quality studies concluded that exercise therapy of six weeks or less for low back pain had no clinical benefit.[70]

Treatment according to the McKenzie method is somewhat effective for recurrent acute low back pain, but its benefit in the short term does not appear significant.[1] There is tentative evidence to support the use of heat therapy for acute and sub-chronic low back pain,[71] but little evidence for the use of either heat or cold therapy in chronic pain.[72] 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.[73] Ultrasound and shock wave therapies do not appear effective and therefore are not recommended.[74][75] Lumbar traction lacks effectiveness as an intervention for radicular low back pain.[76] It is also unclear whether lumbar supports are an effective treatment intervention.[77]

Management of chronic low back pain

[edit]

Physical therapy is effective in decreasing pain and improving physical function, trunk muscle strength, and the mental health for those with chronic low back pain.[78] It also improves long-term function[72] and appears to reduce recurrence rates for as long as six months after the completion of the program.[79] The observed treatment effect for exercise when compared to no treatment, usual care or placebo, improved pain (low‐certainty evidence), but improvements were small for functional limitations (moderate‐certainty evidence).[78] There is no evidence that one particular type of exercise therapy is more effective than another,[80][81] so the form of exercise used can be based on preference, availability and cost.

The Alexander technique appears useful for chronic back pain,[82] and there is some evidence to support small benefits from the use of yoga.[83][84] Motor control exercise, which involves guided movement and use of normal muscles during simple tasks building 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.[85] 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 improved muscle endurance and strength, while concurrently decreasing self-reported disability.[86] 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 not recommended for people with no preexisting condition that limits their progressive walking.[60] There is low-to-moderate quality evidence that supports pilates in low back pain for the reduction of pain and disability,[60][87] although there is no conclusive evidence that pilates is better than any other form of exercise for low back pain.[87]

People with chronic low back pain receiving multidisciplinary biopsychosocial rehabilitation programs may have less pain and disability than those receiving typical care or physiotherapy.[88]

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.[89] Evidence for the use of shoe insoles as a treatment is inconclusive.[61] Transcutaneous electrical nerve stimulation has not been found to be effective in chronic low back pain.[90] There has been little research that supports the use of lumbar extension machines and thus they are not recommended.[60]

Medications

[edit]

If initial management with non–medication based treatments is insufficient, medication may be recommended.[6] As pain medications are only somewhat effective, expectations regarding their benefit may differ from reality, and this can lead to decreased satisfaction.[19]

The medication typically prescribed first are acetaminophen (paracetamol), NSAIDs (though not aspirin), or skeletal muscle relaxants and these are enough for most people.[91][19][6][92] Benefits with NSAIDs is thought to be small,[93][94] but is more effective than Acetaminophen (paracetamol), which may be no more effective than placebo at improving pain, quality of life, or function.[95][96] For adults with both acute and chronic lower back pain, NSAIDs can also reduce disability.[91] NSAIDs however, carry a greater risk of side effects, including kidney failure, stomach ulcers and possibly heart problems, so it is used at the lowest effective dosage for the shortest possible time.[57] NSAIDs are available in several different classes; there is no evidence to support the use of COX-2 inhibitors over any other class of NSAIDs with respect to benefits.[93][19][97] With respect to safety naproxen may be best.[98] Muscle relaxants may be minimally beneficial.[19] 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.[91]

Systemic 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.[99]

As of 2022, the CDC has released a guideline for prescribed opioid use in the management of chronic pain.[15] 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.[16]

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 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.[91] Specialist groups advise against general long-term use of opioids for chronic low back pain.[19][100] If the pain is not managed adequately, short-term use of opioids such as morphine may be suggested,[101][19] although low back pain outcomes are poorer in the long-term.[57] 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.[102] 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.[19] Opioid treatment for chronic low back pain increases the risk for lifetime illicit drug use[103] and the effect of long-term use of opioids for lower back pain is unknown.[104] 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.[105]

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.[106][91] Although the antiseizure drugs gabapentin, pregabalin, and topiramate are sometimes used for chronic low back pain evidence does not support a benefit.[107] Systemic oral steroids have not been shown to be useful in low back pain.[1][19] 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.[108] Epidural corticosteroid injections provide a slight and questionable short-term improvement in those with sciatica but are of no long-term benefit.[109] There are also concerns of potential side effects.[110]

Surgery

[edit]

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.[17] It may also be useful in those with spinal stenosis.[18] In the absence of these issues, there is no clear evidence of a benefit from surgery.[17]

Discectomy (the partial removal of a disc that is causing leg pain) can provide pain relief sooner than nonsurgical treatments.[17] Discectomy has better outcomes at one year but not at four to ten years.[17] The less invasive microdiscectomy has not been shown to result in a different outcome than regular discectomy.[17] For most other conditions, there is not enough evidence to provide recommendations for surgical options.[17] The long-term effect surgery has on degenerative disc disease is not clear.[17] Less invasive surgical options have improved recovery times, but evidence regarding effectiveness is insufficient.[17]

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.[18] Fusion may be considered for those with low back pain from acquired displaced vertebra that does not improve with conservative treatment,[17] although only a few of those who have spinal fusion experience good results,[18] and there may be no clinically important difference between disk replacement and fusion surgery.[111] There are a number of different surgical procedures to achieve fusion, with no clear evidence of one being better than the others.[112] Adding spinal implant devices during fusion increases the risk but provides no added improvement in pain or function.[10] Spinal cord stimulation using implanted electrodes is not supported by evidence due to the potential risks and costs.[113]

Alternative medicine

[edit]

It is unclear if alternative treatments are useful for non-chronic back pain.[114] Chiropractic care or spinal manipulation therapy (SMT) appear similarly effective to other recommended treatments.[115][116][24] 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.[3] A 2017 review recommended SMT based on low-quality evidence.[6] There is insufficient evidence to recommend manipulation under anaesthesia, or medically assisted manipulation.[117] SMT does not provide significant benefits compared to motor control exercises.[118]

The evidence supporting acupuncture treatment for providing clinically beneficial acute and chronic pain relief is very weak.[119] When compared to a 'sham' treatment, no differences in pain relief or improvements in a person's quality of life were found.[119] There is very weak evidence that acupuncture may be better than no treatment at all for immediate relief.[119] 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.[120] This pain benefit is only present right after treatment and not at follow-up.[120] Acupuncture may be an option for those with chronic pain that does not respond to other treatments like conservative care and medications,[1][121] however this depends on patient preference, the cost, and on how accessible acupuncture is for the person.[119]

Massage therapy does not appear to provide much benefit for acute low back pain.[1] 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[122] and there was no effect for improving function.[122] For chronic low back pain, massage therapy was better than no treatment for both pain and function, though only in the short-term.[122] 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.[122] 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.[60]

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.[21]

Herbal medicines, as a whole, are poorly supported by evidence.[123] The herbal treatments 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.[21] Capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.[21]

Behavioral therapy may be useful for chronic pain.[20] 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.[21] The benefit however is small.[124] Medical providers may develop an integrated program of behavioral therapies.[21] 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.[125][126]

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.[127][128][21] Multidisciplinary biopsychosocial rehabilitation (MBR), targeting physical and psychological aspects, may improve back pain but evidence is limited.[129] There is a lack of good quality evidence to support the use of radiofrequency denervation for pain relief.[130]

KT Tape has been found to be no different for management of chronic non-specific low back pain than other established pain management strategies.[131]

Education

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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.[132] 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.[133]

Prognosis

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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%.[2] 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.[2] Certain psychological problems such as depression, or unhappiness due to loss of employment may prolong the episode of low back pain.[19] Following a first episode of back pain, recurrences occur in more than half of people.[28]

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.[2] 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),[134] 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).[134]

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.[135]

Epidemiology

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Low back pain that lasts at least one day and limits activity is a common complaint.[7] Globally, about 40% of people have low back pain at some point in their lives,[7] with estimates as high as 80% of people in the developed world.[27] Approximately 9 to 12% of people (632 million) have low back pain at any given point in time, which was calculated to 7460 per 100,000 globally in 2020.[26] Nearly one quarter (23.2%) report having it at some point over any one-month period.[7][8] Difficulty most often begins between 20 and 40 years of age.[1] However, low back pain becomes increasingly common with age, and is most common in the age group of 85.[26] 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.[26]

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).[26] 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.[7] An estimated 70% of women experience back pain during pregnancy with the rate being higher the further along in pregnancy.[136]

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.[26] Low levels of activity is also associated with low back pain.[57] Workplace ergonomics associated with low back pain include lifting, bending, vibration and physically demanding work, as well as prolonged sitting, standing and awkward postures.[26] 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.[137]

The overall number of individuals affected expected to increase with population growth and as the population ages,[26] with the largest increases expected in low- and middle-income countries.[57]

History

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Harvey Williams Cushing, 1920s

Humans have suffered low-back pain since at least the Bronze Age. The oldest-known surgical treatise – the Edwin Smith Papyrus from ancient Egypt, dating to about 1500 BCE – describes a diagnostic test and treatment for a vertebral sprain. Hippocrates (c. 460 BCE – c. 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.[138] English-speakers adopted the Latin term lumbago (as "lumbaga", defined as "a Pain in the Muscles of the Loins") from as early as 1684.[139]

At the start of the 20th century, physicians thought that low-back pain was caused by inflammation of or damage to the nerves,[138] with neuralgia and neuritis frequently mentioned by them in the medical literature of the time.[140] The popularity of such proposed explanations decreased during the 20th century.[140] In the early-20th century, American neurosurgeon Harvey Williams Cushing (1869-1939) increased the acceptance of surgical treatments for low-back pain.[17] 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.[138] Muscular rheumatism (now called fibromyalgia) was also cited with increasing frequency.[140]

Emerging technologies such as 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.[140] As a result of this work, in the 1940s, the vertebral-disc model of low-back pain took over,[138] dominating the literature through the 1980s, aided further by the rise of new imaging-technologies such as CT and MRI.[140] 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.[138] Modern treatment may devolve on physiotherapists.[141]

Society and culture

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Low back pain results in large economic costs. 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.[30] 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.[30] 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.[10] 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.[142] 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.[142] In the United States, low back pain is highest of Years Lived With Disability (YLDs) rank, rate, and percentage change[failed verification] for the 25 leading causes of disability and injury, between 1990 and 2016.[143]

Workers who experience acute low back pain as a result of a work injury may be asked by their employers to have x-rays.[144] As in other cases, testing is not indicated unless red flags are present.[144] 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.[144] There should be no legal reason for encouraging people to have tests which a health care provider determines are not indicated.[144]

Research

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Total disc replacement is an experimental option,[39] but no significant evidence supports its use over lumbar fusion.[17] Researchers are investigating the possibility of growing new intervertebral structures through the use of injected human growth factors, implanted substances, cell therapy, and tissue engineering.[39]

References

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Low back pain

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Low back pain, often abbreviated as LBP, is a prevalent musculoskeletal condition characterized by discomfort, tension, or stiffness in the lower portion of the spine and surrounding tissues, typically located below the and above the crease of the buttocks. It can manifest as acute (lasting less than six weeks), subacute (six to twelve weeks), or chronic (more than twelve weeks) and is frequently accompanied by reduced mobility or radiating pain into the legs, known as . Globally, low back pain affected approximately 629 million people as of (95% uncertainty interval 552–701 million), making it the leading cause of and years lived with worldwide, with the number of cases increasing by about 63% since 1990 due to and aging. In the United States, about 26% of adults experience low back pain at any given time, with lifetime reaching up to 84% depending on diagnostic criteria. The condition imposes a significant socioeconomic burden, contributing to lost productivity and healthcare costs estimated in billions annually. Common causes of low back pain include mechanical issues such as muscle or strains, disc herniation, , or degenerative changes in the spine, as well as inflammatory conditions like or infections, though in most cases no specific pathology is identified (nonspecific LBP). Risk factors encompass advancing age (onset often around 30-40 years), , , , poor posture, heavy lifting, psychological factors such as stress or depression, and dietary factors such as high intake of refined carbohydrates and sugars leading to systemic inflammation, particularly associated with increased risk and severity in chronic cases. Symptoms typically involve a dull ache, sharp stabbing sensation, burning, or shooting pain that may worsen with movement, prolonged sitting, or standing, often accompanied by muscle spasms or limited .

Clinical Presentation

Signs and symptoms

Low back pain commonly manifests as discomfort in the region, ranging from a dull, aching sensation to sharp, stabbing, or burning pain that may intensify with movement. Pain that dissipates with a simple position change strongly suggests a positional etiology and is likely responsive to conservative care like physical therapy. in the lower back and muscle spasms are frequent accompanying features, often resulting in reduced flexibility and difficulty maintaining certain postures. The pain can be localized to the back or radiate along the path of the into the buttocks, thighs, or calves, a condition referred to as , which may present as shooting or electric-like discomfort. In cases involving nerve irritation, patients may experience associated symptoms such as numbness, tingling, or weakness in the legs. Severe presentations can include bowel or dysfunction, signaling potential urgency. Pain duration helps classify low back pain as acute (less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks), with acute episodes often resolving more readily than persistent ones. Symptoms typically interfere with daily activities, exacerbating during , lifting, prolonged sitting, or standing, thereby limiting mobility and productivity. Low back pain can be categorized by dominant pain mechanisms: nociceptive (mechanical), featuring localized aching and stiffness aggravated by physical exertion or tissue damage; neuropathic, involving radiating, burning sensations due to nerve damage or compression, accompanied by sensory disturbances like ; and nociplastic, characterized by central without evident nociceptive or neuropathic sources, often seen in chronic non-specific cases with features such as widespread , , disturbances, and emotional distress.

Classification

Low back pain is commonly classified based on its duration to distinguish acute episodes from more persistent conditions, aiding in and management planning. Acute low back pain is defined as lasting less than 6 weeks, subacute as 6 to 12 weeks, and chronic as exceeding 12 weeks. This temporal framework helps clinicians anticipate recovery patterns, with acute cases often resolving spontaneously while requires multidisciplinary approaches. Etiological classification divides low back pain into non-specific and specific categories, reflecting the presence or absence of an identifiable structural or pathological cause. Non-specific low back pain accounts for approximately 90% of cases, where no precise anatomical source can be determined despite thorough evaluation. In contrast, specific low back pain arises from identifiable etiologies such as herniated or , which may involve nerve compression or degenerative changes. Further subtypes differentiate pain based on its distribution and underlying mechanisms. Radicular low back pain involves radiating discomfort into the lower extremities due to irritation or compression, often presenting as shooting or burning sensations along a dermatomal . Non-radicular pain, by comparison, is confined to the back without such radiation, typically stemming from musculoskeletal sources like strain or issues. Severity assessment employs validated scales to quantify pain intensity and functional impairment, informing treatment escalation. The Numeric Pain Rating Scale (NPRS) measures pain on a 0-10 continuum, where 0 indicates no pain and 10 the worst imaginable, providing a simple, reliable metric for tracking changes over time. The Oswestry Disability Index (ODI) evaluates functional limitations through a 10-item , yielding a percentage score that reflects disability in daily activities such as personal care and mobility, with higher scores indicating greater impact. The World Health Organization's 2023 guidelines specifically address chronic primary low back pain in , defining it as persistent pain lasting more than 12 weeks without evidence of serious underlying or identifiable specific causes, emphasizing a non-specific presentation in community settings. This classification prioritizes holistic care for the majority of chronic cases encountered in routine practice.

Anatomy of the back

The lumbar spine, or lower back, comprises five vertebrae designated L1 through L5, which are the largest and strongest in the vertebral column to accommodate substantial mechanical loads from the upper body. Each lumbar vertebra features a robust body, a vertebral arch forming the posterior elements, and transverse processes that serve as attachment sites for muscles and ligaments; the L5 vertebra uniquely articulates with the at the lumbosacral junction, contributing to the transition between mobile lumbar segments and the rigid . Intervertebral discs separate the , providing cushioning and flexibility; each disc consists of a central gel-like nucleus pulposus surrounded by a fibrous annulus fibrosus, which resists compressive forces while permitting limited motion. Facet joints, or zygapophyseal joints, connect adjacent vertebrae posteriorly, with superior and inferior articular processes that guide gliding motions and limit excessive rotation in the region. Key ligaments stabilize the lumbar spine, including the spanning the ventral surfaces of the vertebral bodies to resist hyperextension, and the lining the posterior vertebral canal to prevent hyperflexion. Additional stabilizers encompass the ligamentum flavum between laminae for elasticity during flexion, interspinous and supraspinous ligaments connecting spinous processes to resist forward bending, and the iliolumbar ligaments anchoring L5 to the ilium for pelvic stability. Muscles of the lumbar back include the erector spinae group—comprising the , , and —which run longitudinally along the spine to extend and laterally bend the trunk, and the multifidus muscles, deep transversospinalis fibers that provide segmental stability and proprioceptive feedback. Other contributors, such as the quadratus lumborum and psoas major, assist in lateral flexion and hip movement, respectively, while the envelops these structures to unify force transmission. The terminates at the L1-L2 level, giving way to the —a bundle of and sacral nerve roots suspended in within the lumbar cistern—that exits via intervertebral foramina to innervate the lower limbs. The originates from the L4-S3 roots, forming the largest peripheral and supplying the posterior , , and foot. Innervation of structures derives primarily from dorsal rami of spinal nerves for paraspinal muscles and posterior elements, with ventral rami contributing to anterior abdominal and pelvic musculature; sensory input arises from sinuvertebral nerves innervating discs and ligaments. Blood supply to the lumbar spine arises from segmental arteries, including lumbar arteries branching from the to nourish vertebral bodies and paraspinal tissues via anterior and posterior spinal arteries, with venous drainage through a rich around the vertebrae. Biomechanically, the lumbar spine bears up to 80% of body weight during upright posture, distributing compressive loads through vertebral bodies and discs while facet joints and ligaments ensure stability against shear and torsional forces; this configuration allows approximately 50-60 degrees of flexion-extension and limited lateral bending, essential for bipedal locomotion and daily activities. With aging, discs undergo degeneration characterized by progressive dehydration and loss of content in the nucleus pulposus, leading to reduced disc height and increased stiffness by age 40-50 in many individuals. diminishes vertebral bone mineral density, particularly in trabecular bone, heightening fracture risk and altering load distribution; facet joints develop with thinning and formation, while muscles like the multifidus exhibit fatty infiltration and , compromising stability. These changes can disrupt normal , potentially contributing to signals from irritated structures.

Mechanisms of pain

Low back pain arises from the activation of nociceptors, specialized sensory receptors in peripheral tissues that detect potentially harmful stimuli such as mechanical , thermal changes, or chemical irritants. These nociceptors, primarily free nerve endings in structures like muscles, ligaments, and intervertebral discs, transduce noxious inputs into electrical signals that initiate the response. In low back , mechanical deformation from or strain commonly triggers this nociceptive process, leading to localized at the site of tissue damage. Once activated, nociceptive signals are transmitted via primary afferent neurons to the dorsal horn of the , where second-order neurons integrate and process the input. From the dorsal horn, these signals ascend primarily through the , a key anterolateral pathway that carries and to the and subsequently to cortical areas for and localization. This pathway enables the conscious experience of but can become altered in low back pain, contributing to referred sensations or diffuse discomfort. In chronic low back pain, central sensitization emerges as a critical mechanism, involving neuroplastic changes in the that amplify pain signals beyond the initial injury. This process enhances neuronal excitability and synaptic efficacy in nociceptive pathways, resulting in (increased pain to noxious stimuli) and (pain from non-noxious stimuli) through mechanisms like and reduced inhibition. Such adaptations persist even after peripheral damage resolves, perpetuating pain via altered membrane properties and circuit remodeling in the and . Tissue damage in low back pain also triggers the release of inflammatory mediators that sensitize and sustain pain signaling. Pro-inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) promote the recruitment of immune cells and enhance responsiveness, while prostaglandins, synthesized via enzymes, lower activation thresholds for pain receptors. These mediators create a feedback loop that prolongs and contributes to the transition from acute to states. The integrates these biological processes with psychological factors, highlighting how stress and emotions modulate pain pathways. Chronic stress activates descending pathways involving the hypothalamic-pituitary-adrenal axis, releasing glucocorticoids that can exacerbate and reduce endogenous pain inhibition, while negative emotions like anxiety amplify pain perception through interactions. This interplay underscores the role of cognitive-emotional states in sustaining low back pain beyond purely peripheral mechanisms.

Etiology

Mechanical causes

Mechanical low back pain refers to pain originating from structural or biomechanical issues within the spine, intervertebral discs, or surrounding soft tissues, without involvement of systemic diseases. These causes typically result from , , or improper loading on the region, leading to localized discomfort that may radiate but does not involve neurological deficits unless compression occurs. Approximately 90% of low back pain cases are classified as non-specific mechanical in nature, particularly in acute presentations. Disc-related pathologies represent a primary subset of mechanical causes, encompassing herniation, degeneration, and annular tears. disc herniation occurs when the inner nucleus pulposus protrudes through the outer annulus fibrosus, often due to age-related weakening or acute trauma, compressing nearby structures and eliciting pain. involves progressive loss of disc hydration and height, leading to and that contributes to chronic axial pain. Annular tears, or disruptions in the disc's outer layer, can cause localized pain through chemical irritation of nociceptors, even without herniation. Discogenic pain from these issues accounts for approximately 39% of chronic low back pain cases, making it the most common identifiable mechanical etiology. Joint-related problems, such as facet joint arthritis, , , and , also contribute significantly to mechanical low back pain. Facet joint arthritis, or osteoarthritis of the zygapophyseal joints, results from breakdown and synovial , often exacerbated by extension or , and is implicated in 15% to 45% of low back pain episodes. This degeneration leads to , stiffness, and patterns. involves anterior slippage of one over another, commonly degenerative in adults over 50, causing instability and load redistribution that provokes pain during movement. , the narrowing of the due to degenerative changes like ligamentum flavum or formation, compresses neural elements and is a common cause of low back pain with leg symptoms in older adults. , involving dysfunction or of the , accounts for 15-30% of chronic low back pain cases and often presents with unilateral pain in the lower back or buttocks, worsened by prolonged standing or stair climbing. These joint disorders often coexist with disc changes, amplifying mechanical stress on the spine. Muscle and strains constitute another frequent mechanical cause, arising from acute trauma, sudden twisting, or chronic overuse. sprains involve stretching or tearing of ligaments stabilizing the spine, while strains affect muscles like the erector spinae or quadratus lumborum, resulting in sharp and reduced mobility. These injuries are self-limiting in most cases but can recur if healing is incomplete, contributing to recurrent episodes. Biomechanical imbalances, including poor posture and repetitive lifting, promote uneven spinal loading and fatigue of supporting structures. Conditions such as lower crossed syndrome, characterized by weak core muscles (e.g., abdominals and gluteals) and tight hip flexors, perpetuate chronic low back pain by inducing anterior pelvic tilt, excessive lumbar lordosis, and sustained tissue stress on the spine. Prolonged forward flexion or asymmetric postures alters lumbar lordosis, increasing intradiscal pressure and facet loading, which over time leads to tissue microtrauma. Repetitive heavy lifting, common in occupational settings, induces cumulative shear forces on the lumbosacral junction, heightening strain risk. These factors often underlie acute flares in otherwise asymptomatic individuals. Many mechanical causes can present unilaterally on the right side, including muscle strains or sprains from injury or overuse, herniated discs with right-sided nerve root compression leading to sciatica, sacroiliac joint dysfunction, spinal stenosis with asymmetric symptoms, or facet joint arthritis. Overall, mechanical causes predominate in acute low back among working-age adults (18-65 years), accounting for the majority of episodes. Most cases are mechanical and improve with rest and conservative management, resolving spontaneously in 80-90% within without specific intervention, but persistent or severe pain requires medical evaluation to rule out serious conditions.

Non-mechanical causes

Non-mechanical causes of low back encompass systemic conditions that originate outside the primary musculoskeletal structures of the spine, often involving , , , visceral organs, or metabolic bone disorders. These etiologies account for a minority of cases but are critical to identify due to their potential severity and need for prompt intervention. Unlike mechanical , which typically relates to local tissue strain, non-mechanical may present with systemic symptoms or atypical patterns, such as night or unremitting discomfort. Inflammatory arthropathies represent a key category of non-mechanical causes. , a seronegative spondyloarthropathy, primarily affects young adults and manifests as chronic inflammatory with morning stiffness lasting over 30 minutes, often improving with exercise but worsening with rest; it involves inflammation that progresses to . , an , less commonly targets the lumbar spine but can cause low back pain through formation and synovial inflammation in facet joints or atlantoaxial extending to the lower segments, particularly in longstanding cases. Infectious processes, such as vertebral and , arise from hematogenous spread or direct inoculation, leading to localized vertebral destruction and severe, progressive often accompanied by fever and elevated erythrocyte sedimentation rates. is the most frequent pathogen, accounting for up to 50% of cases, with risk factors including intravenous drug use, , and ; symptoms may include neurological deficits if abscess formation compresses the . Neoplastic conditions contribute to low back pain through direct spinal involvement or metastatic spread. Metastases from primary cancers like or are common, with up to 70% of advanced patients and nearly all with metastatic developing bone lesions, presenting as insidious, unrelenting pain exacerbated at night due to periosteal stretching and pathologic fractures. Primary malignancies, such as , cause lytic lesions in the vertebrae, resulting in acute or from structural compromise. Visceral disorders can refer pain to the low back via shared neural pathways. often produces deep, constant back pain from pressure on surrounding tissues, particularly if expanding, and may radiate to the flanks in symptomatic cases greater than 5 cm in diameter. , due to ureteral obstruction by stones, causes intense, colicky flank pain radiating to the lower back and , typically lasting minutes to hours and associated with . , affecting 10-15% of reproductive-age women, leads to cyclic low back pain from ectopic endometrial tissue irritating pelvic nerves, often worsening during menses and coexisting with . Right-sided low back pain may particularly arise from referred pain due to right kidney conditions (e.g., stones or infection), appendicitis, or gynecological issues in women (e.g., endometriosis); less common but serious causes include abdominal aortic aneurysm or tumors. Other non-mechanical causes include metabolic bone diseases and compressive neuropathies. Osteoporotic vertebral compression fractures, prevalent in postmenopausal women and those with low , present with acute, band-like back pain following minimal trauma, potentially leading to height loss and . Paget's disease of bone involves disordered remodeling, affecting the spine in up to 50% of multifocal cases and causing chronic low from vertebral enlargement, sclerosis, or fractures. Cauda equina syndrome, a rare emergency from central disc herniation or tumor compression, features , bowel/ dysfunction, and low back pain with bilateral leg weakness. These conditions often signal red flags like unexplained , fever, or progressive , warranting urgent evaluation to differentiate from benign mechanical pain.

Risk factors

Risk factors for low back pain can be categorized as non-modifiable or modifiable, with additional influences from occupational and psychosocial domains. Non-modifiable factors include advancing age, particularly beyond 40 years, which is associated with increased prevalence due to degenerative changes in the spine. Female sex also elevates susceptibility, with women experiencing higher lifetime prevalence rates compared to men, potentially linked to hormonal and biomechanical differences. Genetic predisposition, such as familial tendencies toward intervertebral disc disease, further contributes, as evidenced by twin studies showing heritability in lumbar disc degeneration. Modifiable risk factors encompass lifestyle elements like obesity, defined by a body mass index (BMI) greater than 30, which heightens mechanical stress on the spine and is linked to a 1.3- to 2-fold increased risk of low back pain. Smoking impairs intervertebral disc nutrition by reducing blood flow and oxygen supply, accelerating degeneration and elevating pain risk. A sedentary lifestyle similarly promotes vulnerability, with prolonged inactivity associated with a moderate elevation in low back pain incidence across adults. Dietary patterns represent an additional modifiable factor. A high-carbohydrate diet rich in refined carbohydrates and low in fiber can promote systemic inflammation, as evidenced by elevated levels of C-reactive protein (CRP) and interleukin-6 (IL-6), which is associated with increased risk, severity, and pain sensitivity in chronic low back pain. Energy-dense diets high in refined grains and added sugars show a positive association with chronic low back pain, including an odds ratio of 1.13 (95% CI 1.01–1.32) for higher adherence to such patterns and 49% increased odds of chronic spinal pain with higher added sugar intake. In contrast, high-fiber carbohydrates may mitigate inflammation and potentially offer protective effects. Occupational exposures play a significant role, including heavy lifting, which imposes excessive axial loads on the lumbar spine and is a well-established predictor of acute and chronic episodes. Prolonged sitting, common in desk-based jobs, contributes through sustained static postures that strain paraspinal muscles and discs. Vibration exposure, such as that experienced by truck drivers from , further compounds risk by transmitting mechanical stress to the spine. Psychosocial factors, integrated within the , include , depression, and job dissatisfaction, which amplify pain perception and through central and behavioral pathways. These elements often interact with physical risks, heightening overall susceptibility. Recent epidemiological data indicate that low levels increase the risk of chronic low back pain by approximately 20-30%, underscoring the protective role of regular moderate exercise.

Diagnosis

Medical history and examination

The medical history for low back pain begins with a detailed assessment of the pain's onset, which may be sudden or gradual, and its duration, distinguishing acute (less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks) presentations.[] Clinicians inquire about aggravating and relieving factors, such as mechanical movements that worsen pain or rest that alleviates it, as well as prior episodes to identify patterns of recurrence. Occupational history is essential, evaluating work-related activities like heavy lifting or prolonged sitting that may contribute to symptoms.[] This focused history helps classify the pain as nonspecific, radicular, or indicative of other categories, while screening for potential red flags.[] The starts with inspection of posture and gait to detect abnormalities like or antalgic walking patterns. assesses for paraspinal tenderness or muscle spasms along the spine. is evaluated through forward flexion, extension, and lateral bending, noting limitations or pain provocation. Neurological tests include the straight-leg raise to identify , along with assessment of reflexes (e.g., patellar and Achilles), muscle strength, and sensation in the lower extremities to rule out involvement.[] [] Functional assessment quantifies the impact of low back pain on daily activities using validated tools such as the Roland-Morris Disability Questionnaire, a 24-item self-report measure that evaluates in tasks like or walking.[] This helps gauge severity and guide management planning. Biopsychosocial screening identifies yellow flags—psychosocial factors like fear-avoidance beliefs, negative pain attitudes, or low mood—that may predict chronicity and . Tools such as the Örebro Musculoskeletal Pain Screening Questionnaire are recommended for early detection during history-taking.[] Recent guidelines, including those from 2022 and 2023, emphasize a comprehensive and examination as the initial step in , recommending against routine unless specific concerns arise from these assessments.[] []

Red flag conditions

Red flags in low back pain refer to clinical indicators that suggest potentially serious underlying conditions, such as , , , or , necessitating urgent , , or specialist referral.[] These signs are present in approximately 1% to 5% of low back pain cases in settings but require prompt action to avoid complications.[] Systemic red flags include unexplained , persistent fever or chills, recent infection, intravenous drug use, night pain unrelieved by rest, severe or unrelenting pain not improving with rest, age over 50 or under 18 with new onset, long-term steroid use, immunosuppression, and a personal history of cancer, which may indicate metastatic disease or systemic illness.[] These symptoms warrant immediate assessment, as they raise suspicion for non-mechanical causes like tumors or infections. Neurological red flags encompass progressive motor weakness or numbness in the lower extremities or legs, (numbness in the perineal area), and urinary or bowel retention or incontinence, which are hallmarks of requiring emergency intervention.[] Such findings suggest or nerve root compression and demand rapid referral to prevent permanent neurological damage.[] Patients with these symptoms should seek emergency care. These symptoms, particularly when accompanying low back pain or stiffness in older adults, require immediate medical attention. Traumatic red flags are indicated by recent significant trauma, such as a fall or accident—even minor in older adults or those with —pointing to possible vertebral , which may present as pain or stiffness.[] In these cases, pain or stiffness following injury should prompt for structural damage, even if no is evident. Inflammatory red flags feature morning stiffness lasting more than 1 hour that improves with , often suggesting spondyloarthropathies like .[] This pattern, combined with bilateral involvement, differentiates inflammatory from mechanical and supports referral for rheumatologic assessment.[] Visceral referred pain — When low back pain is right-sided or unilateral, particularly when accompanied by abdominal symptoms, fever, urinary changes, gastrointestinal disturbances, or other systemic signs, clinicians should consider referred pain from visceral sources as a potential serious non-mechanical cause. Examples include appendicitis, right kidney pathology (e.g., kidney stones or infection), gynecological issues in women (e.g., endometriosis), and abdominal aortic aneurysm. These conditions may require urgent evaluation, as they can represent life-threatening or time-sensitive pathology that demands prompt medical assessment to rule out serious complications. Clinicians should obtain or refer patients with red flags indicating severe or progressive neurological deficits or serious underlying conditions, while routine is not recommended for nonspecific low back pain. These criteria emphasize targeted screening to identify the rare but critical subset of cases needing escalation, with no major updates as of 2025.

Diagnostic tests

Diagnostic tests for low back pain primarily involve and evaluations to identify specific underlying causes such as fractures, infections, tumors, or compression, rather than for routine use in nonspecific cases. These tests are guided by clinical suspicion and are not recommended initially for most patients with acute, uncomplicated pain.[] Imaging modalities are selected based on the suspected and presence of red flags. Plain X-rays are useful for assessing bony alignment, fractures, or degenerative changes in the spine, serving as an initial low-cost option when structural abnormalities are suspected.[] Magnetic resonance imaging (MRI) is the gold standard for evaluating structures, including intervertebral discs, spinal cord, and nerve roots, particularly in cases of suspected , herniation, or inflammatory conditions like .[] Computed tomography (CT) provides superior detail for bony structures, such as in or complex fractures, though it involves exposure.[] Laboratory tests help rule out systemic causes like or . (ESR) and C-reactive protein (CRP) are elevated in inflammatory or infectious processes, such as epidural abscess or , and are recommended when these are suspected based on or fever.[] A (CBC) can detect indicative of .[] For suspected malignancy, tumor markers like (PSA) may be ordered if cancer is a concern, though these are not routine.[] Additional specialized tests include (EMG) and nerve conduction studies (NCS) to assess for or by measuring electrical activity in muscles and .[] Bone (bone scan) is sensitive for detecting metastases or occult fractures in the spine when cancer history or unexplained pain raises suspicion.[] Current guidelines, including the 2024 World Federation of Neurosurgical Societies (WFNS) recommendations, advise against routine for nonspecific acute low back pain lasting less than 4-6 weeks without red flags, as it does not improve outcomes and may lead to unnecessary interventions.[] Imaging is reserved for cases with red flags (e.g., progressive neurologic deficits, unexplained ) or persistent symptoms beyond 6 weeks.[] Limitations of these tests include the risk of due to incidental findings, which are common in asymptomatic individuals (e.g., disc abnormalities on MRI in up to 30% of healthy adults), and radiation risks from X-rays and CT scans.[]

Prevention

Lifestyle modifications

Lifestyle modifications play a crucial role in preventing and managing low back pain by addressing modifiable risk factors through daily habit changes. Maintaining a healthy is essential, as excess increases mechanical stress on the spine. Individuals with a BMI greater than 25 kg/m² experience higher rates of chronic low back pain compared to those with normal . Some low-quality evidence suggests that programs may decrease low back pain intensity and in or obese adults. Observational studies indicate that dietary patterns influence chronic low back pain through effects on systemic inflammation. Diets high in refined carbohydrates, added sugars, and energy-dense foods are associated with increased odds of chronic spinal or low back pain, potentially mediated by elevated inflammatory markers such as C-reactive protein (CRP) and interleukin-6 (IL-6). For instance, higher added sugar intake has been linked to up to 49% increased odds of chronic spinal pain, while adherence to energy-dense dietary patterns shows a positive association with chronic low back pain. In contrast, higher consumption of whole grains and fiber-rich foods is associated with a lower likelihood of chronic pain. Reducing intake of refined carbohydrates and added sugars while increasing fiber-rich carbohydrates (such as whole grains, fruits, and vegetables) may therefore help mitigate systemic inflammation and potentially reduce the risk or severity of chronic low back pain. Smoking cessation is another key modification, as use impairs blood flow to spinal discs, leading to reduced oxygenation and accelerated degeneration. Quitting smoking enhances disc and overall spinal health, with evidence from systematic reviews demonstrating improved levels in individuals with degenerative spinal conditions following cessation. This benefit arises from restored vascular function, which supports tissue repair and reduces around the spine. Incorporating activity pacing into daily routines helps mitigate the risks associated with prolonged sedentary behavior. Alternating between sitting and standing positions, along with taking regular breaks during desk-based work, prevents excessive strain on the lower back. Interventions promoting reduced sedentary time, such as using sit-stand desks and activity prompts, have been effective in lowering chronic low back pain incidence. Similarly, optimizing supports spinal recovery; using a supportive that maintains neutral spinal alignment and adopting recommended sleeping positions can help reduce morning pain. These include sleeping on the back with a pillow under the knees to maintain the natural curve of the lower back and relax muscles, and sleeping on the side in the fetal position with a or knee pillow between the knees to support the top leg, prevent it from dropping forward, maintain alignment of the pelvis and spine, and thereby reduce potential twisting that aggravates pain. Sleeping on the stomach should be avoided, as it strains the back and neck by flattening the natural spinal curve and increasing pressure. These positions preserve the natural curve of the lower back, minimizing pressure on discs and muscles. Recent evidence underscores the protective effects of regular within changes. A 2025 prospective study found that walking more than 100 minutes per day was associated with a 23% lower of developing chronic low back pain compared to less than 78 minutes daily, highlighting the value of incorporating moderate daily movement to bolster spinal resilience.

Ergonomic interventions

Ergonomic interventions focus on modifying the physical environment and work practices to minimize mechanical stress on the lower back, thereby reducing the of low back pain in occupational and daily settings. These adjustments aim to promote a neutral spine posture, where the natural S-curve of the spine is maintained, distributing loads evenly across the musculoskeletal system. In workstation setups, adjustable chairs with lumbar support are essential to support the lower back's natural curve, with the seat height set so feet rest flat on the floor and thighs are parallel to it, preventing forward leaning that strains the spine. Monitors should be positioned with the top at or slightly below eye level, approximately an arm's length away, to avoid slouching or excessive flexion that contributes to back tension. Keyboard positioning should allow elbows to bend at about 90 degrees, with forearms parallel to the floor and wrists straight, enabling a relaxed and back posture during prolonged sitting. These configurations, recommended by OSHA, help maintain neutral spine alignment and have been shown to decrease reports of musculoskeletal discomfort, including low back pain, among workers. Proper lifting techniques are critical for manual tasks, where bending at the knees and hips—rather than the waist—while keeping the load close to the body reduces torque on the lumbar spine. Team lifts are advised for objects over 50 pounds to distribute weight and avoid awkward postures, and using mechanical aids like carts or hoists further minimizes risk. NIOSH guidelines emphasize these methods, including the Revised NIOSH Lifting Equation to assess task risks, as they lower the physical demands that lead to low back injuries in high-risk occupations such as warehousing and . For vehicle adaptations, particularly relevant for drivers in transportation roles, lumbar supports in seats promote spinal and reduce static loading on the lower back during extended periods. Studies indicate that prominent lumbar support in automobile seats is associated with decreased low back pain reports among drivers. Anti-vibration seats or cushions attenuate exposure, a known for low back pain; randomized trials in truck drivers show that systems reducing vibration lead to improved low back pain outcomes compared to standard seats. Home ergonomics involve arranging furniture to facilitate safe movements, such as placing frequently used items at waist height to avoid excessive bending or reaching, which can strain the back. When carrying loads, techniques similar to workplace lifting—bending at the knees and keeping objects close to the —prevent undue stress, and using supportive bags or carts for groceries aids in maintaining balance. These practices, aligned with general principles, help mitigate cumulative back strain from household activities. OSHA and NIOSH provide comprehensive guidelines for implementing these interventions, recommending risk assessments and worker training to tailor adjustments to specific job demands. Meta-analyses of ergonomic programs in occupational settings demonstrate significant reductions in work-related musculoskeletal pain, including low back pain, with odds ratios indicating lower prevalence among intervened groups in high-risk jobs. These measures integrate with broader modifications to enhance overall prevention of mechanical low back causes.

Management

Non-pharmacological approaches

Non-pharmacological approaches form the cornerstone of management for low back pain across all durations, as recommended by major clinical guidelines that emphasize their use as first-line interventions to promote recovery and prevent chronicity. The World Health Organization's 2023 guideline for non-surgical management of chronic primary low back pain prioritizes holistic, incorporating education, exercise, and physical therapies, while the ' guidelines endorse these for acute and subacute cases to reduce pain and disability without medications. Approximately 70% of acute low back pain cases resolve within six months with such conservative strategies, highlighting their effectiveness in facilitating natural recovery. For chronic low back pain (lasting more than 12 weeks), management prioritizes non-pharmacological approaches. Patients are encouraged to stay active and avoid prolonged bed rest, as inactivity can worsen stiffness and deconditioning. Engagement in physical therapy, strengthening and stretching exercises (e.g., yoga, pilates, walking, swimming), and low-impact aerobics is recommended. Self-care measures include application of heat or ice packs, maintaining good posture, and weight management to reduce mechanical stress on the spine. For nonspecific chronic low back pain persisting after extensive diagnostic workup and potentially involving central nervous system sensitization, treatments emphasize multidisciplinary approaches, including physical therapy, cognitive behavioral therapy, medications targeting nerve pain, and interventional procedures where appropriate. Exercise therapy is a key component, tailored to the pain's duration and individual needs to enhance strength, flexibility, and endurance. For acute low back pain, low-intensity aerobic activities such as walking or are preferred to maintain mobility without exacerbating symptoms, while strengthening exercises targeting core muscles—like bird-dog, plank variations, planks, or bridges—are introduced gradually to support spinal stability and reduce compensatory tightness in paraspinal muscles. In chronic cases, a more structured program combining core strengthening, (e.g., and hip flexor stretches), and yields moderate-certainty evidence of reduced and improved function compared to no intervention, as shown in a 2021 Cochrane . These interventions should be supervised initially to ensure proper form and progression, with benefits accruing over 8-12 weeks of consistent participation. Specific lower back stretches commonly recommended for pain relief include:
  • Knee-to-chest stretch: Lie on your back, pull one knee to your chest, hold for 20-30 seconds, repeat with the other leg and then both.
  • Cat-Cow stretch: On all fours, alternate arching and rounding your back.
  • Child's pose: Kneel, sit back on heels, reach arms forward, hold.
  • Pelvic tilt: Lie on back, tighten abdominals to flatten back against floor.
  • Piriformis stretch: Cross one ankle over opposite knee, pull thigh toward chest.
These stretches should be performed gently and slowly, with deep breathing. Stop immediately if any movement increases pain. Consult a healthcare provider before starting, especially for persistent pain or in cases of severe symptoms. For low back pain caused by constant forward bending (repetitive flexion), exercises typically focus on gentle stretching, core strengthening, and improving mobility to reduce tension and support the spine. These help counteract tightness from prolonged bending by promoting extension, flexibility, and core support. Recommended exercises include:
  • Knee-to-Chest Stretch: Lie on your back, pull one knee toward your chest while keeping the other foot flat. Hold 5-30 seconds, repeat 2-3 times per leg. Helps relieve lower back tension.
  • Cat-Cow Stretch: On hands and knees, alternate arching (cat) and dipping (cow) your back. Repeat 10-20 times. Improves spinal flexibility and reduces stiffness.
  • Pelvic Tilt: Lie on your back with knees bent, tighten abs to flatten your lower back against the floor, hold 5-10 seconds. Repeat 10-30 times. Strengthens core and stabilizes the spine.
  • Bridge Exercise: Lie on your back, lift hips to form a straight line from knees to shoulders. Hold briefly, repeat 5-30 times. Strengthens glutes and lower back.
  • Hamstring Stretch: Lie on your back, raise one leg and gently straighten it. Hold 5-30 seconds per side. Addresses tightness that contributes to back strain from bending.
Start slowly, avoid pain, and consult a doctor or physical therapist first, especially if pain persists or worsens. Physical therapy techniques specifically targeting paraspinal muscle tightness contributing to disc pain focus on reducing muscle spasm, improving flexibility, strengthening supporting muscles, and relieving pressure on the disc. These techniques should be guided by a licensed physical therapist, often starting with pain-relieving techniques before progressing to strengthening. Aggressive stretching or high-impact activities should be avoided during acute phases. Common evidence-based techniques include:
  • Manual therapy: Soft tissue mobilization, myofascial release, and massage to reduce paraspinal tightness and trigger points.
  • Stretching exercises: Gentle stretches such as knee-to-chest, cat-cow pose, child's pose, and piriformis stretch to lengthen paraspinal and surrounding muscles.
  • Strengthening exercises: Core stabilization (e.g., bird-dog, plank variations) and back extensor strengthening to support the spine and reduce compensatory tightness.
  • Heat therapy: Application of moist heat to relax muscles before stretching or exercise.
  • Postural education and ergonomic training: To prevent ongoing strain.
  • Modalities: Ultrasound or electrical stimulation in some cases for pain relief.
Physical therapy, including and techniques, serves as an effective adjunct to exercise, particularly for short-term symptom relief. , such as or soft tissue mobilization, when added to exercise programs, leads to greater improvements in pain, function, and in the short term (up to 3 months), according to a 2024 . A 2025 study further confirmed that spinal manipulative therapy reduces pain intensity and related comparably to other recommended therapies like and exercise. These approaches are most beneficial when integrated into a multimodal plan, focusing on restoring mobility and muscle balance without reliance on passive treatments alone. In Australia, particularly in Melbourne where many clinics offer these services, physiotherapy, chiropractic, and osteopathy are commonly used and effective non-pharmacological treatments for low back pain. The Low Back Pain Clinical Care Standard recognizes physiotherapists and chiropractors (with tailored quick guides) for managing acute low back pain as part of non-pharmacological care, and includes osteopaths among allied health providers. Research indicates similar outcomes across these three professions for back pain, with no single one superior; choice depends on patient preferences (e.g., physiotherapy for exercise and rehabilitation, chiropractic for spinal adjustments, osteopathy for holistic manual techniques). Education and self-management strategies empower patients to actively manage their condition, emphasizing the importance of staying active and avoiding prolonged . Guidelines consistently advise against exceeding two days, as it can worsen and , with from clinical practice recommendations showing that early return to normal activities accelerates recovery. on posture, activity pacing, and coping techniques—delivered through verbal advice, brochures, or digital tools—improves adherence and long-term outcomes by fostering . Older adults, in whom low back pain frequently relates to degenerative conditions such as osteoarthritis, spinal stenosis, or vertebral fractures, require tailored application of non-pharmacological strategies with added caution due to risks of falls, comorbidities, and impaired healing. Encouraging gentle activities such as short walks helps prevent further stiffness and deconditioning while strictly avoiding prolonged bed rest. Heat therapy, applied for 15-20 minutes using a warm compress or heating pad, promotes muscle relaxation and improved blood flow, with alternation to ice if inflammation is present. Gentle stretches, such as knee-to-chest pulls or seated spinal twists, should be performed only if pain-free and under guidance from a healthcare provider or physical therapist. Good posture should be supported with ergonomic chairs or pillows. Consultation with a healthcare provider is essential before starting any new exercises or treatments in older adults, given higher risks. Prompt medical evaluation is recommended if stiffness is severe, sudden, or accompanied by red flag symptoms such as numbness, weakness, or bowel/bladder dysfunction, which may indicate serious conditions requiring urgent assessment. For acute relief, superficial or and provide symptomatic benefits by reducing muscle tension and . For chronic low back pain, heat therapy is often more effective than ice as it relaxes tight muscles and improves circulation; consider alternating ice and heat or switching to heat after the first 48 hours. Continuous low-level application, such as heat wraps, significantly alleviates pain and enhances function in acute low back pain, outperforming oral analgesics in some trials. For immediate relief of lower back muscle fatigue or acute pain following strenuous exercise such as squats, apply ice packs for the first 48-72 hours to reduce inflammation and numb pain if signs of acute strain are present, then transition to heat packs for 15-20 minutes several times daily. Perform gentle stretching or proper cool-down exercises, such as cat-cow pose, child's pose, or supine knee-to-chest rolls without forcing movements, and consider light self-massage if comfortable. Avoid prolonged rest; engage in light activities such as walking to promote recovery while avoiding aggravating movements like bending or heavy lifting. If the pain is severe or persists, seek medical advice. Similarly, therapy decreases pain intensity in the short term, as supported by systematic reviews, making it suitable for initial episodes when combined with activity advice; for acute low back pain, consider massage or physical therapy if pain persists beyond one or two weeks, as most cases resolve spontaneously in that timeframe per clinical guidelines on early conservative management with escalation if needed. If non-pharmacological approaches prove insufficient after 4-6 weeks, pharmacological options may be considered as adjuncts. Patients should consult a healthcare provider if pain persists, worsens, or is accompanied by red flags such as numbness, weakness, or bowel/bladder issues.

Pharmacological treatments

Pharmacological treatments for low back pain primarily target symptom relief through reduction and control, serving as an adjunct to non-pharmacological interventions when initial approaches prove insufficient. Over-the-counter medications like NSAIDs (e.g., ibuprofen) or acetaminophen are first-line for pain and inflammation; prescription options may include muscle relaxants or antidepressants (e.g., duloxetine) for chronic cases. Guidelines from the recommend initiating drug therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants for acute or subacute nonradicular low back pain, emphasizing their modest benefits in improving and function. For chronic cases, options expand to include certain antidepressants, though overall evidence indicates small to moderate effects across classes, with risks often outweighing benefits for long-term use. Analgesics form the foundation for managing mild to moderate low back pain. Acetaminophen is often considered a first-line option due to its favorable safety profile compared to other analgesics, typically dosed at 500–1,000 mg every 4–6 hours up to 4 g daily, though systematic reviews show no significant pain relief over in acute or chronic settings. NSAIDs, such as ibuprofen (400–800 mg every 6–8 hours, commonly known as Advil) or naproxen (250–500 mg twice daily), address the inflammatory component more effectively, providing moderate-certainty evidence of small pain reductions (approximately 10–15 mm on a 100 mm visual analog scale) in acute low back pain. For most acute back pain and muscle pain, NSAIDs like ibuprofen are typically recommended as a first-line pharmacologic treatment due to their effectiveness against both pain and inflammation. Topical NSAIDs, such as diclofenac gel (commonly known as Voltaren), provide an alternative with lower systemic absorption and reduced gastrointestinal risk compared to oral formulations. However, a 2024 randomized, double-blind, placebo-controlled trial found oral ibuprofen more effective than topical 1% diclofenac for nonradicular acute low back pain, with greater functional improvement (mean Roland-Morris Disability Questionnaire change of 10.1 vs. 6.4 at day 2) and no added benefit from combining them. For acute low back pain from a herniated disc, which often involves radicular components (excluded in the 2024 trial), oral NSAIDs such as ibuprofen or diclofenac are commonly recommended as first-line treatment. Although diclofenac may offer stronger anti-inflammatory effects, evidence does not demonstrate clear superiority over ibuprofen; the choice between oral and topical formulations depends on patient factors such as gastrointestinal risk (topical has fewer systemic effects) and provider recommendation. Common side effects of NSAIDs include gastrointestinal irritation, such as dyspepsia or ulceration, particularly with prolonged use exceeding 1–2 weeks, necessitating co-administration of inhibitors in at-risk patients. Muscle relaxants are indicated for short-term relief of muscle spasms in acute low back pain, with (5–10 mg three times daily) and methocarbamol (Robaxin) being commonly prescribed agents due to their central nervous system-mediated effects. Methocarbamol is a prescription muscle relaxant primarily used to relieve muscle spasms and associated pain, such as in acute back pain. Muscle relaxants like methocarbamol are often added if pain persists or if muscle spasms are a significant component after initial treatment with NSAIDs, but they may cause drowsiness and are generally for short-term use. The choice depends on the specific cause (e.g., spasms vs. inflammation), and they can sometimes be used together with NSAIDs like ibuprofen. Always consult a healthcare provider for personalized recommendations, as overuse of either can lead to side effects. Evidence from overviews of systematic reviews supports a small benefit in pain and function for up to 2 weeks, with around 3–4 for meaningful improvement, but use beyond this duration is discouraged due to . and occur in up to 50% of users, impairing daily activities and increasing fall risk, which limits their suitability for older adults or those operating machinery. Opioids are reserved for severe acute low back pain unresponsive to other therapies, with (50–100 mg every 4–6 hours, up to 400 mg daily) preferred over stronger agents due to its dual mechanism of weak mu-opioid agonism and serotonin-norepinephrine reuptake inhibition. The 2022 CDC guidelines, reaffirmed in 2024 updates, strongly advise against routine use in chronic low back pain owing to risks of dependence, overdose, and minimal long-term functional gains, with showing only short-term pain reductions of 10–20 mm on visual analog scales but no superiority over NSAIDs. Side effects include , , and respiratory depression, contributing to their classification as a last-resort option. Adjuvant medications target neuropathic components in chronic low back pain. , a serotonin-norepinephrine , is recommended at 60 mg daily, with high-quality evidence demonstrating moderate pain relief (about 10–15% greater than ) and improvements in scores after 12 weeks. like (300–1,200 mg three times daily, titrated slowly) or show mixed results, with some trials indicating no significant benefit over for non-specific chronic low back pain, though they may aid in radicular cases; common adverse effects include and in 20–30% of patients. Overall, pharmacological interventions yield modest outcomes, typically reducing pain by 10–20% in responsive patients, underscoring the need for individualized assessment and integration with non-drug strategies.

Interventional and surgical options

Interventional procedures and surgical interventions are reserved for cases of low back pain refractory to conservative management, particularly when structural abnormalities such as , facet joint pathology, disc herniation, or spinal instability contribute to symptoms. These options target specific pain generators and are guided by evidence-based recommendations emphasizing targeted application to minimize risks. Surgery is generally considered a last resort for specific structural issues. According to the American Society of Pain and Neuroscience (ASPN) guidelines, such treatments should follow a diagnostic confirmation process, including imaging and diagnostic blocks where applicable, to ensure appropriate patient selection. Epidural injections are commonly used for associated with disc herniation or , delivering corticosteroids into the to reduce around compressed roots. These injections, typically administered via transforaminal, interlaminar, or caudal approaches, provide short- to medium-term relief in 50-70% of patients, with effects lasting 3-6 months in responsive cases. The ASPN guidelines recommend their targeted use for confirmed by clinical exam and imaging, limiting frequency to 3-4 sessions per year to avoid cumulative exposure. injections and medial branch blocks target zygapophyseal joint-mediated , with diagnostic blocks confirming facet involvement before therapeutic intervention; these yield temporary relief in up to 60% of selected patients, per ASPN recommendations for dual confirmatory blocks prior to . Minimally invasive procedures include (RFA) for facet-mediated axial low back pain and percutaneous disc decompression techniques for contained disc herniations. Cooled or conventional RFA denervates medial branch nerves supplying the facet joints, achieving ≥50% reduction in 50-70% of patients for 6-12 months or longer, with repeat procedures maintaining benefit in over 50% of cases. For disc-related without severe herniation, procedures like the minimally invasive lumbar decompression (MILD) remove hypertrophic ligamentum flavum to alleviate central , offering relief and functional improvement in 60-75% of patients while preserving spinal stability. These interventions are indicated after failure of non-invasive therapies and diagnostic confirmation, with outpatient recovery typical. Surgical options, which are a last resort for specific structural issues, are required in fewer than 10% of low back pain cases and are pursued after 6-12 weeks of unsuccessful conservative treatment or in the presence of progressive neurological deficits. Microdiscectomy addresses symptomatic disc herniation causing , involving removal of extruded disc material to decompress roots; success rates exceed 80% for leg pain relief and functional recovery at one year, with low recurrence in aggressive techniques. For such as degenerative , stabilizes affected segments using instrumentation and bone graft, indicated for persistent pain with radiographic ; outcomes show 50-70% improvement in scores, though back pain relief is more variable than leg symptoms. Recent guidelines stress surgery's role in <5% of chronic cases overall, prioritizing decompression alone over fusion when is mild. Reoperation rates for surgical interventions range from 20-30% within five years, often due to adjacent segment degeneration or incomplete resolution. Common risks include (1-5% incidence, higher in fusions), damage leading to sensory or motor deficits (0.5-2%), and dural tears (up to 5% in discectomies). Clinical practice guidelines advocate shared decision-making, incorporating patient values, risks, and alternatives to optimize outcomes and reduce overuse.

Complementary and alternative therapies

involves the insertion of thin needles into specific points on the body to stimulate sensory nerves and promote pain relief through mechanisms such as endorphin release and modulation of nociceptive pathways. A 2024 umbrella and of systematic reviews found moderate-quality evidence that provides significant pain reduction for chronic low back pain, with standardized mean differences indicating approximately 15-20% improvement in pain intensity compared to sham or no treatment. This effect is particularly noted in chronic nonspecific cases, where outperforms in short- to medium-term outcomes. Chiropractic care primarily employs therapy, a high-velocity, low-amplitude thrust to adjust spinal joints and alleviate musculoskeletal tension. According to a 2024 of clinical practice guidelines, is recommended as an effective first-line treatment for acute low back pain, offering modest improvements in pain and function within the first few weeks. High-quality guidelines from multiple international bodies endorse its use for acute episodes due to low risk and comparable efficacy to other non-drug therapies. In Australia, the Low Back Pain Clinical Care Standard provides tailored resources for chiropractors as part of non-pharmacological care for acute low back pain. Physiotherapy for low back pain typically includes individualized exercise programs, manual techniques such as mobilization, and patient education to enhance mobility, strength, and self-management. The Australian Low Back Pain Clinical Care Standard offers tailored resources for physiotherapists, recognizing their role in non-pharmacological management of acute low back pain. Evidence from clinical trials indicates that physiotherapy provides improvements in pain and function comparable to other manual therapies. Osteopathy employs manual techniques including soft tissue massage, joint mobilization, and holistic approaches to improve overall body function and reduce pain. Osteopaths are recognized among allied health providers in the Australian Low Back Pain Clinical Care Standard for supporting low back pain management. A 2021 systematic review and meta-analysis found that osteopathic interventions improve pain levels and functional status in patients with chronic nonspecific low back pain. Research comparing outcomes across physiotherapy, chiropractic care, and osteopathy for back and neck pain demonstrates similar efficacy, with no single profession shown to be superior. Patient choice often depends on preferences, such as physiotherapy for exercise-based rehabilitation, chiropractic care for spinal adjustments, or osteopathy for holistic manual techniques. In Melbourne, Australia, these services are commonly offered and widely used for treating back pain. Mind-body practices like , , and qigong incorporate gentle postures, breathing exercises, and meditative elements to enhance flexibility, strength, and stress reduction. Randomized controlled trials from 2024 demonstrate that these interventions reduce chronic low back pain intensity by about 25% on average, with greater effects observed in virtual or group-based programs lasting 12 weeks or more. A 2020 narrative review by researchers at Florida Atlantic University synthesized evidence from 32 studies involving 3,484 participants aged 33-73, highlighting strongest support for yoga (particularly with longer or higher-dose interventions), moderate evidence for tai chi (e.g., in acute pain among young males), and limited data for qigong in reducing pain, disability, and psychological distress. A of such trials confirms improvements in pain and , attributing benefits to enhanced and . Cognitive behavioral therapy (CBT) is a complementary approach for chronic low back pain, helping patients develop coping strategies, alter pain perceptions, and improve function and outlook. Certain herbal remedies, such as devil's claw (Harpagophytum procumbens) and white willow bark (Salix alba), exhibit NSAID-like effects due to compounds like harpagoside and . A Cochrane provides moderate evidence for their short-term efficacy in reducing acute and chronic low back pain, with daily doses of 50-100 mg harpagoside from devil's claw or 120-240 mg from white willow bark showing better pain relief than in high-quality trials. However, data remain limited by small sample sizes and short follow-up periods, with potential gastrointestinal side effects noted. Ginger (Zingiber officinale) and turmeric (Curcuma longa, specifically its active compound curcumin) are herbal supplements with anti-inflammatory properties that have been studied for pain relief in conditions such as osteoarthritis, which may overlap with some causes of low back pain. Evidence for their use in low back pain is limited and primarily indirect, derived from studies on general inflammation or related joint conditions. Common dosages from studies include 500 mg of curcumin twice daily (total 1,000 mg), often combined with piperine (from black pepper) to enhance absorption, and 1–2 grams of ginger per day (e.g., as extract or powder). Combining ginger and turmeric may offer synergistic anti-inflammatory effects based on in vitro and some clinical evidence, though no specific combined dosage is established for back pain. There is no standardized or FDA-approved dosage for these supplements in treating low back pain inflammation. Potential benefits should be weighed against limited high-quality evidence specific to low back pain, possible side effects (e.g., gastrointestinal issues), and interactions with medications. Always consult a healthcare provider before use, as these are not substitutes for conventional medical treatment. Magnesium supplementation has been investigated for chronic low back pain, particularly in cases with a neuropathic component. A 2013 double-blinded RCT involving 80 patients found that 2 weeks of intravenous magnesium followed by 4 weeks of oral supplementation significantly reduced pain intensity and improved lumbar mobility at 6 months compared to placebo. However, a 2020 systematic review of 9 RCTs (including this one) concluded that evidence for magnesium's analgesic efficacy in chronic pain, including low back pain, is equivocal due to study heterogeneity, small sample sizes, methodological issues, and inconsistent safety data; no meta-analysis was possible. Observational data suggest a possible association between higher magnesium intake and lower chronic pain risk, but there is no strong support for routine supplementation in chronic low back pain. Despite these findings, complementary and alternative therapies for low back pain exhibit variable across modalities. Many lack standardization, long-term data, or consistent replication, necessitating cautious integration with conventional management to avoid delaying proven interventions.

Prognosis and Outcomes

Natural course

Low back pain, particularly in its acute form, often follows a self-limiting trajectory for the majority of individuals. Acute low back pain, defined as lasting less than six weeks, shows substantial improvement in most cases, with average pain scores halving within the first 6 weeks and continuing to decrease thereafter, though full recovery (no pain or ) occurs in approximately 25-50% of cases by 1 year. This rapid improvement is observed across diverse populations, with pain and associated typically decreasing substantially within the first few weeks. However, not all episodes follow this favorable path, as a subset transitions to subacute or chronic phases. Around 10-40% of acute cases persist beyond , evolving into chronic low back pain that may require ongoing attention, though the exact transition can be modulated by factors such as early care approaches. Initial pain intensity and baseline levels play key roles in this progression, with higher starting values correlating to slower resolution and greater risk of prolongation. Recurrence remains a hallmark of the condition's natural course, affecting a significant proportion of those who initially recover. Between 40% and 70% of individuals experience relapse within one year of the first episode. Longitudinal studies of non-specific low back pain underscore its predominantly self-limiting nature in acute presentations, yet highlight that the chronic variant imposes enduring burdens on , including persistent functional limitations and reduced .

Prognostic factors

Several prognostic factors have been identified that influence the likelihood of low back pain (LBP) transitioning to chronicity or resulting in poor long-term outcomes, including older age, which is associated with slower recovery and higher persistence rates in settings. High baseline , measured by tools like the Roland-Morris Disability Questionnaire, predicts ongoing functional limitations and reduced improvement over time. Psychological distress, particularly fear-avoidance beliefs and depression, significantly elevates the risk of , with systematic reviews highlighting these as frequent contributors to prolonged . In contrast, positive prognostic indicators include early active management, such as prompt initiation of nonpharmacological interventions like exercise within the first 90 days, which correlates with faster resolution and lower chronicity rates compared to delayed care. Strong from family or informal networks is linked to better , reducing the of persistent symptoms through enhanced and adherence to treatment. Additionally, return to work or regular employment serves as a favorable predictor, associated with greater long-term improvements in pain and among patients with LBP. Biomarkers, particularly elevated inflammatory markers such as (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α), have been shown to correlate with pain persistence in nonspecific acute and chronic LBP, indicating an underlying inflammatory component that may hinder recovery. Clinical models like the STarT Back Tool facilitate risk stratification by categorizing patients into low, medium, or high risk groups based on a 9-item assessing physical and factors, enabling tailored interventions to mitigate poor outcomes. Recent evidence from 2025 cohort studies further underscores the role of , demonstrating that low daily walking time (<78 minutes) is associated with a 23% higher risk of developing chronic LBP compared to higher volumes (>100 minutes per day).

Epidemiology

Prevalence and distribution

Low back pain (LBP) is a major issue, with lifetime estimated at 60-80% among adults worldwide. The global point of low back pain is approximately 7.5% (age-standardized), varying by region and definition, while annual incidence in adults is approximately 5-10%. According to the Global Burden of Disease (GBD) Study 2021, around 629 million people were affected by LBP in 2021, making it the leading cause of disability globally, with 267 million new incident cases that year. The reports that in 2020, LBP impacted 619 million individuals, with projections estimating an increase to 843 million cases by 2050 due to and aging; recent analyses as of 2025 confirm these estimates remain current. Geographically, prevalence is notably higher in low- and middle-income countries (LMICs), where rates can reach up to 93% lifetime prevalence, largely attributable to prevalent manual labor and occupational demands. In contrast, age-standardized prevalence rates are often elevated in high-income regions like North America, but the overall burden in LMICs is amplified by limited access to care and higher disability-adjusted life years (DALYs). The GBD data indicate that while global age-standardized prevalence has decreased by about 11% since 1990, the absolute number of cases continues to rise, particularly in regions with rapid socioeconomic transitions. Incidence and prevalence peak between ages 30 and 50, coinciding with peak occupational activity, though the highest number of cases occurs around 50-55 years. Women experience LBP slightly more frequently than men, with global estimates showing about 50% higher prevalence among females. Recent trends suggest stability in age-standardized rates, but the healthcare burden is increasing, exacerbated by post-COVID-19 shifts toward sedentary lifestyles, which have contributed to a surge in reports, including LBP.

Demographic variations

Low back pain exhibits notable variations across demographic groups, influencing its and clinical presentation. In children and adolescents, the condition is relatively uncommon, with rates ranging from 1% to 6% at any given time, often linked to growth-related issues or . increases progressively with age, becoming more common from early adulthood onward and peaking in midlife around 50–55 years, where the highest number of cases occur due to cumulative and occupational exposures. Among older adults, low back pain frequently transitions to chronic forms, driven by degenerative changes such as disc degeneration and , with severe and chronic cases rising steadily after age 60. Gender differences show women experiencing low back pain at approximately 1.5 times the rate of men, based on lifetime data from large-scale studies. This disparity is partly attributed to hormonal fluctuations, particularly during and postpartum periods, where relaxin and other hormones increase laxity, elevating the risk of persistent ; women with prior pregnancy-related low back face even higher odds of recurrence. Occupational factors contribute to marked variations, with manual laborers facing 2–4 times the lifetime of pronounced low back pain compared to those in sedentary roles, owing to heavy lifting, repetitive motions, and awkward postures. For instance, industrial and factory workers report rates exceeding 60%, far surpassing general population estimates. also plays a role, with individuals in lower-income groups showing higher of low back pain due to barriers in accessing preventive care, ergonomic resources, and early treatment. Lower and residence in deprived areas further exacerbate risks, leading to more frequent and disabling episodes. Ethnic and racial variations highlight differential patterns, such as increased incidence of high-impact chronic low back pain among and populations compared to individuals, potentially tied to disparities in healthcare access and occupational demands. In contrast, exhibit the lowest overall prevalence across ethnic groups, while imaging studies indicate lower rates of spinal degeneration in Southeast Asian populations relative to Caucasians.

Historical Context

Early concepts

Early understandings of low back pain in ancient civilizations often intertwined medical observations with rudimentary anatomical knowledge. In , around 1600 BCE, the provided the oldest known surgical treatise, describing cases of spinal injuries, including symptoms like pain and paralysis, though effective treatments were limited to immobilization or observation. Herbal remedies, such as those involving honey and myrrh, were commonly used for pain relief in various conditions. In , (c. 460–370 BCE) provided one of the earliest detailed descriptions of , characterizing it as pain radiating from the hip to the leg, and recommended traction using wooden boards and weights to realign the spine, alongside warm applications and herbal remedies like willow bark poultices containing for pain relief. During the medieval period, European and Islamic medicine largely operated under the humoral theory, which attributed low back pain to imbalances in the body's four humors—, , yellow bile, and black bile—often linked to excess moisture or cold in the lower body. Treatments aimed to restore equilibrium through dietary adjustments, , and purgatives. Islamic scholars advanced these ideas; (Ibn Sina, 980–1037 CE) in his discussed and low back pain as arising from humoral disturbances or compression, advocating conservative measures such as , moderated diet to avoid aggravating foods, and analgesics like for and pain relief. In the 18th and 19th centuries, low back pain was commonly classified as "lumbago," a form of believed to stem from inflammatory or in the spine, influenced by lingering humoral concepts but increasingly tied to mechanical injury or strain. Early surgical interventions emerged, with Victor Horsley performing the first in 1887 to remove a causing compression and pain, marking a shift toward operative approaches despite high risks. Folk remedies persisted across eras, including cupping to draw out "bad humors" from affected areas and to reduce supposed blood excess, both widely used for deep-seated back pain into the early before scientific scrutiny diminished their practice.

Modern developments

The advent of radiographic imaging marked a pivotal advancement in the of low back pain. Wilhelm Conrad Röntgen's discovery of X-rays in 1895 enabled the visualization of skeletal structures, with spine X-rays entering clinical use shortly thereafter to detect fractures and foreign bodies, fundamentally altering the approach to assessing spinal pathology. The development of (MRI) in the further revolutionized diagnostics by providing detailed images without ; the first human MRI scan occurred in 1977, and by the 1980s, MRI became instrumental in evaluating disc herniations and nerve compression in low back pain cases. Evolving clinical guidelines reflected growing evidence against overuse of imaging and toward conservative management. The on Spinal Disorders, in its 1987 report, recommended against routine imaging for uncomplicated low back pain, emphasizing that such tests often yield incidental findings without improving outcomes and may lead to unnecessary interventions. Building on this, the (ACP) guidelines in 2007 advocated a focused history and physical exam to categorize patients, reserving imaging for those with red flags, while prioritizing nonpharmacologic therapies like exercise and as first-line treatments. The ACP updated these in 2017, reinforcing non-drug options—such as superficial heat, , , and —for acute and chronic low back pain, with medications like NSAIDs considered only if benefits outweigh risks. The 1980s introduced the , shifting focus from purely biomedical explanations to integrating psychological and social factors in low back pain. Gordon Waddell's 1987 Volvo Award-winning paper proposed this framework, distinguishing physical pathology from illness behaviors influenced by fear, distress, and socioeconomic elements, which has since guided multidisciplinary care to address disability beyond anatomical issues. Surgical innovations emphasized precision and reduced invasiveness. Microdiscectomy, pioneered independently by M. Gazi Yasargil and Wolfhard Caspar in 1977, utilized the operating microscope for targeted removal of herniated disc material through a small incision, significantly lowering complication rates compared to open and becoming the gold standard for relief. In the 2000s, minimally invasive spine surgery expanded with endoscopic and tubular retractors, enabling procedures like transforaminal lumbar interbody fusion via smaller incisions, which minimized muscle disruption, shortened recovery times, and improved patient satisfaction for conditions such as . Recent guidelines underscore holistic, active approaches to chronic low back pain. The World Health Organization's 2023 guideline for non-surgical management of chronic primary low back pain in adults recommends integrating education, exercise, psychological therapies, and manual therapies like or , while advising against routinely ineffective options such as belt use or . A 2024 review of high-quality clinical practice guidelines highlights consensus on active treatments, including therapeutic exercise and , as core interventions for chronic cases to enhance function and reduce reliance on passive modalities.

Societal and Cultural Aspects

Economic impact

Low back pain imposes a substantial economic burden through direct medical costs, including physician visits, diagnostic imaging, medications, and therapeutic interventions. In the United States, annual direct costs for low back pain are estimated at approximately $100 billion, encompassing expenses related to healthcare services and treatments. Globally, healthcare costs attributable to low back pain totaled about $50.9 billion in recent assessments, with high-income countries bearing over 70% of this economic load. These figures highlight the scale of resource allocation required for managing the condition, particularly in advanced economies where advanced diagnostics and interventions drive expenditures. Indirect costs further amplify the financial impact, primarily through lost productivity and . An estimated 264 million workdays were lost annually worldwide due to low back pain as of , making it a leading cause of and reduced workforce participation. Low back pain is a leading cause of , accounting for nearly 25% of musculoskeletal-related disability claims in systems like the U.S. Department of . The condition's role in the opioid crisis exacerbates these costs; prescription opioid misuse, often initiated for including low back pain, generated an economic burden of $78.5 billion in the U.S. in 2013 alone, including healthcare, lost productivity, and expenses. Projections indicate that the number of people affected by low back pain will increase to 843 million by 2050, further escalating economic and societal burdens, particularly in low- and middle-income countries. The economic burden of low back pain is rising, driven by aging populations in high-income countries that increase demand for care and disability support. This trend is compounded by the , which has added billions in downstream costs related to treatment and overdose management. Cost-effective interventions offer potential mitigation; for instance, early for low back pain yields average 12-month healthcare savings of about $25,621 per patient compared to ($11,151 versus $36,772) and $2,455 compared to injections ($11,151 versus $13,606). Exercise-based therapies, such as interdisciplinary rehabilitation or , have been shown to be cost-effective alternatives to more invasive options, reducing overall societal expenditures while improving outcomes.

Stigma and access to care

Low back pain is frequently stigmatized as a non-serious condition or a sign of laziness, particularly in cases of chronic nonspecific low back pain, where patients experience both subtle and overt stigmatization from healthcare providers, family, and society. This perception contributes to underreporting of pain severity, as individuals fear being viewed as weak or overly dramatic, leading to delayed diagnosis and inadequate management, especially among those with chronic symptoms. Such stigma exacerbates the emotional burden of the condition, reinforcing cycles of isolation and reduced help-seeking behavior. Access to care for low back pain remains uneven, with significant disparities in rural and low-income areas where physical therapists and specialists are scarce; for instance, rural communities in the United States have approximately 40% fewer physical therapists per capita compared to urban areas, limiting rehabilitation options. In low- and middle-income countries (LMICs), the burden is compounded by inadequate healthcare infrastructure, where low back pain affects millions but treatment access is restricted, contributing to high rates of untreated chronic cases and disability. These barriers result in substantial unmet needs, with chronic pain prevalence reaching 33% among adults in LMICs, often without formal intervention. Cultural factors influence pain expression and care-seeking for low back pain, with variations in how discomfort is communicated across groups; for example, cultures emphasizing —such as certain Western or Asian communities—encourage restraint and minimization of symptoms, delaying medical consultation and worsening outcomes. Gender biases further complicate access, as women's reports of low back pain are more likely to be dismissed as psychological or exaggerated compared to men's, leading to undertreatment and prolonged suffering. Efforts to address stigma include public awareness campaigns and guidelines promoting non-stigmatizing care; the World Health Organization's 2023 guidelines on chronic low back pain advocate for messaging to foster understanding and equitable support, emphasizing integrated approaches that reduce misconceptions. campaigns targeting low back pain have proven effective in shifting public and provider beliefs toward evidence-based management, thereby encouraging timely care-seeking and diminishing discriminatory attitudes.

Research Directions

Current evidence gaps

A 2025 systematic review and of placebo-controlled randomized trials on non-surgical and non-interventional treatments for low back pain revealed that only one in 10 such interventions demonstrates , typically providing small effects comparable to or only marginally better than , underscoring the urgent need for higher-quality randomized controlled trials (RCTs) to establish robust for treatment . This scarcity of strong hampers the development of reliable clinical guidelines, as current recommendations often rely on short-term or low-certainty data. Significant uncertainty persists regarding responses to interventions like exercise, where heterogeneity in characteristics leads to variable outcomes, yet predictors of who benefits versus non-responders remain unclear despite efforts to identify motor variability or phenotypic differences. Similarly, long-term outcomes beyond one year are inadequately addressed in most studies, with clinical practice guidelines noting limited high-quality evidence for sustained pain relief or functional improvements from interventions such as exercise or . Pediatric and geriatric populations represent particularly understudied groups in low back pain research, with systematic reviews highlighting substantial evidence gaps in tailored interventions for children and adolescents, where management trials are sparse and often exclude younger participants. In older adults, exclusion from RCTs evaluating management strategies has persisted, limiting understanding of age-specific risks and responses despite higher prevalence of severe chronic low back pain in this demographic. Within the biopsychosocial framework, quantification of psychological contributions to low back pain persistence remains inconsistent, as a prospective study in older adults with chronic LBP found that psychological factors such as catastrophizing and fear-avoidance did not independently predict 12-month outcomes in pain, , or physical function after adjusting for baseline values and other characteristics. These gaps emphasize broader societal needs for research prioritizing diverse populations and integrated models to inform equitable care.

Emerging therapies and trials

In recent years, research into low back pain (LBP) has increasingly focused on innovative pharmacological approaches to address chronic cases, driven by the limitations of traditional analgesics. A phase III of VER-01, a full-spectrum extract, demonstrated significant pain reduction in adults with chronic nonspecific LBP, with a mean difference of -0.6 points on the 11-point numerical rating scale compared to over 12 weeks, alongside improvements in sleep quality and tolerability superior to opioids in a head-to-head comparison. Similarly, a phase II trial at the (UCSF), is evaluating psilocybin-assisted therapy to enhance coping mechanisms for chronic LBP, including potential reductions in pain interference and improvements in emotional regulation following guided sessions, though long-term efficacy remains under evaluation as of 2025. Regenerative medicine has emerged as a promising avenue for treating discogenic LBP, particularly through intradiscal injections aimed at restoring integrity. Phase II trials, such as the BioRestorative Therapies study using autologous mesenchymal s derived from , have shown safety and preliminary efficacy, with participants experiencing an average 3.2-point reduction on the visual analog scale for pain and a 27-point improvement on the Oswestry Disability Index at one year post-injection, without serious adverse events. These interventions target underlying degenerative changes, offering potential for sustained structural repair in moderate-to-advanced disc . Technological advancements are also transforming LBP management, with devices and (AI)-guided gaining traction in clinical trials. Novel spinal cord stimulation systems, including ultra-low-frequency and dorsal horn-targeted restorative neurostimulators, have reported up to 70% of patients achieving at least 50% pain relief in refractory mechanical LBP over 12 months, outperforming conventional medical management in randomized sham-controlled studies. Complementing this, AI-assisted telerehabilitation programs have demonstrated superior outcomes in multimodal exercise protocols, with a 2025 randomized trial showing greater reductions in pain intensity (mean difference -1.5 on the numerical rating scale) and compared to standard physiotherapy after four weeks, by personalizing exercise regimens based on real-time patient data. Behavioral interventions continue to evolve, with stratified care models emphasizing long-term psychological and functional integration. The three-year follow-up of the RESTORE trial, a multicenter randomized controlled study in , confirmed sustained benefits from cognitive functional therapy (CFT), where 60% of participants maintained clinically meaningful reductions in LBP intensity and activity limitations compared to usual care, highlighting the durability of addressing pain-related fears and behaviors. Global research priorities for 2025 underscore a shift toward in LBP and treatment, integrating multimodal data to tailor interventions and address evidence gaps in chronic management. The National Institutes of Health's HEAL Initiative, including a $16.5 million project at the , prioritizes adaptive therapies like precision and biomarker-driven to optimize outcomes for heterogeneous LBP phenotypes. These efforts aim to incorporate emerging therapies into standard care pathways for broader clinical impact.

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