Medscape.com, the medical information website I have mentioned many times, just published a very practical essay on Low Back Pain. The article was concise, but comprehensive and contained facts that give perspective to the breadth of the problem.
The author of the article was from Australia, but that had no influence on its content. Instead, she presented a lot of information from various groups whose members (physicians) treat low back pain every day. These organizations’ data and guidelines were quoted to emphasize a fact or a procedure. These organizations are listed below:
The American College of Physicians (ACP)
The National Institute for Health and Care Excellence (NICE)—a British Organization
Haute Autorite’ de Sante’ (HAS)—a French Organization
The American Academy of Family Physicians (AAFP)
The World Health Organization (WHO)—an international organization
Each of these organizations has offered data and guidelines that guide physicians in the diagnosis and treatment of low back pain. They don’t always agree on similar topics, but their positions are all backed by scientific data and are evidence based.
Low back pain is the “leading cause of disability worldwide.” It affects “40% of adults and in 9 out of 10 cases, no specific cause can be identified.” One in four US workers report having low back pain, and during our lifetime, we have a 40% chance of having it. In 2020, an estimated 619 million people worldwide had low back pain.
In less than 10% of cases, the cause is a specific spinal disorder. For example, problems such as a herniated disc, lumbar spinal stenosis, a vertebral fracture, or the cauda equine syndrome (a surgical emergency) aren’t as common as we think.
Low back pain can be acute, subacute, or chronic based on duration of symptoms:
Acute—symptoms last 6 weeks or less
Subacute—symptoms last 6-12 weeks
Chronic—symptoms last more than 12 weeks
Adults are more likely to have low back pain (LBP) if they are obese, depressed, or have a job that requires heavy lifting, frequent bending, or using your hands above your head. Smokers, diabetics, and asthmatics are at higher risk.
Ninety percent of low back pain sufferers have no identifiable cause and are thus classed as having non-specific LBP. There are numerous vague, or unexplainable factors that have been implicated in causing LBP. These are biological factors like muscle, joint, or ligament dysfunction, psychological factors like anxiety, depression, or negative beliefs about pain, social and occupational factors like dangerous living conditions, all of which lead to limitations in daily activities. But in nearly a third of cases, no triggering event is identifiable.
Less than 1% of cases of LBP are caused by vertebral fractures, inflammatory spondyloarthritis, infections, tumors, or vascular problems. A lot of time and money are spent looking for these rare causes, but they are not often found. Cauda equina syndrome is one such problem. Occurring in 0.1% of cases, it is a true surgical emergency that causes urinary retention or incontinence, anesthesia of the anal and buttock areas, and loss of movement in the legs.
The article identifies several “red flags” which are indicators of serious problems that cause LBP. They are usually problems in the past medical history that point to specific causes of LBP. Examples are a history cancer, fall or trauma, osteoporosis, or prolonged use of corticosteroids. These give the doctor clues as to what might be causing the pain.
Routine X-rays are not recommended nor are CT or MRI, unless exam findings are present that indicate specific problems. Degenerative changes are commonly seen on adult images, yet they may not be the cause of LBP. In this situation, clinical judgement and experience must guide the physician’s decision to blame symptoms on what images show.
Low back pain can last for months, but most cases improve in 6 weeks. Continuing physical activity is the first rule of treatment. Avoid bed rest. It weakens muscles, stiffens joints, and prolongs recovery. Activity is enhanced by physical therapy from the onset of problems. French
practitioners limit medications and encourage early resumption of daily activities and return to work. The ACP lists spinal manipulation as first-line treatment, but others prefer a supervised exercise program, ie. PT.
Preferred medications are NSAID’s like ibuprofen and naproxen, and “centrally-acting muscle relaxants” like Flexeril or Zanaflex. Tylenol is ok, but less effective than NSAID’s. Opioids and corticosteroids are not recommended. The AAFP advises against tramadol.
The ACP, NICE, and the WHO all agree that primary treatment includes exercise, physical activity, and physical therapy. Plus they recommend “psychological interventions,” specifically cognitive behavioral therapy. These are associated with statistically significant reduction in pain intensity. Patients with significant functional limitations or an inadequate response to first-line treatment are good candidates for combined PT, OT, and behavioral rehabilitation.
Spinal manipulation, acupuncture, traction, ultrasound, back braces, and electrical nerve stimulation all have proponents who use them in specific cases, but these are also discouraged by skeptics. Evidence of effectiveness is lacking in most of these treatments. Invasive treatments like spinal injections, radiofrequency denervations, spinal cord stimulation, and spinal surgery are limited to specific situations and are not used in routine LBP.
To summarize treatment, LBP patients have non-specific pain that should be treated with physical activity, physical therapy, NSAID’s, muscle relaxants, and early return to work. Multiple other treatments are available, but are used only if indicated for the specific situation. “With or without treatment approximately 72% of patients [with acute low back pain] recover within 12 months after onset of symptoms. In chronic low back pain, this percentage falls to 42% underscoring the importance of early and appropriate management.”
Reference: Lefevre-Colau M-M, Why More Testing May Backfire in Low Back Pain. medscape.com 2026 September 23.
