WEEK 8 SOAP NOTE

Family Medicine 10: 45-year-old male with low back pain User: hyunsoo Ellis Email: [email protected] Date: May 26, 2020 11:23PM

Learning Objectives

The student should be able to:

Discuss the differential diagnosis for low back pain. Develop physical exam skills in evaluating low back pain. Develop the skills in diagnosis and treatment of low back pain. Recognize red flags for possible serious causes of low back pain. List the indications for imaging studies for low back pain. Propose appropriate treatment for back pain. Discuss the management of refractory back pain with consultation and surgical intervention.

Knowledge

Low Back Pain Prevalence, Cost, & Duration

Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves in two to four weeks.

Common Causes of Back Pain

Musculoskeletal (MSK) and Non-MSK Causes of Back Pain

MSK Causes

Axial: Degenerative disc disease Facet arthritis Sacroiliitis Ankylosing spondylitis Discitis Paraspinal muscular issues SI dysfunction

Radicular: Disc prolapse Spinal stenosis

Trauma: Lumbar strain Compression fracture

Non-MSK Causes

Neoplastic: Lymphoma/leukemia Metastatic disease Multiple myeloma Osteosarcoma

Inflammatory: Rheumatoid Arthritis

Visceral: Endometriosis Prostatitis Renal lithiasis

Infection: Discitis

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Herpes zoster Osteomyelitis Pyelonephritis Spinal or epidural abscess

Vascular: Aortic aneurysm

Endocrine: Hyperparathyroidism Osteomalacia Osteoporotic vertebral fracture Paget disease

Gastrointestinal: Pancreatitis Peptic ulcer disease Cholecystitis

Gynecological: Endometriosis Pelvic inflammatory disease

Most Common Causes of Back Pain

There are three major categories of back pain: mechanical, visceral, and non-mechanical. Mechanical

97% of back pain no primary inflammatory or neoplastic cause

Visceral

2% of back pain no primary involvement of the spine, usually from internal organs

Non-mechanical

1% of back pain other

The three most common causes of back pain are all mechanical: 1. lumbar strain/sprain - 70% 2. age-related degenerative joint changes in the discs and facets - 10%. 3. herniated disc - 4% Acute sciatica is lower back pain with radiculopathy below the knee and symptoms lasting up to six weeks. Sciatica is a common and costly problem, caused by a variety of conditions: disc herniation, lumbar spinal stenosis, facet joint osteoarthritis or other arthropathies, spinal cord infection or tumor, or spondylolisthesis. Less common causes of mechanical back pain:

osteoporotic fracture - 4% spinal stenosis - 3%

Uncommon causes of back pain: Pyelonephritis, a visceral cause, accounts for 0.4% of back pain.

Risk Factors for Low Back Pain

Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs Deconditioning Sub-optimal lifting and carrying habits Repetitive bending and lifting Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta Obesity Prolonged use of steroids Intravenous drug use Education status: low education is associated with prolonged illness Psycho-social factors: anxiety, depression, stressors in life Occupation: Job dissatisfaction, increased manual demands, and compensation claims

Red Flags For Serious Illness or Neurologic Impairment with Back Pain

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Fever Unexplained weight loss Pain at night Bowel or bladder incontinence Urinary retention Neurologic symptoms Saddle anesthesia Trauma

Anatomy of Mechanical Lower Back Pain

Mechanical lower back pain generally involves one or more of the following: 1. bones of the spine 2. muscles and ligaments surrounding the spine 3. nerves (the nerves entering and exiting the spinal cord or problems with the cord itself)

Symptoms of Disc Herniation

When disc herniation is suspected, a very important historical point is the position of comfort or worsening of symptoms. Classically, disc herniation is associated with exacerbation when sitting or bending; and relief while lying or standing. Other symptoms of disc herniation include:

increased pain with coughing and sneezing pain radiating down the leg and sometimes the foot paresthesias muscle weakness, such as foot drop

Red Flags for Serious Underlying Causes of Back Pain

While the majority of back pain has a benign course and resolves within a month, a small number of cases are associated with serious underlying pathology. Timely treatment of these conditions is important to avoid serious consequences. Indications for early diagnostic testing such as x-rays and other imaging and referral are patients with progressive neurological deficits, patients not responding to conservative treatment, and patients with red flags signaling serious medical conditions such as fracture, cancer, infection, and cauda equina syndrome. Knowing this would also help guide the evaluation and treatment of the back pain. While the worst pain a patient has ever had is concerning and needs to be addressed, it is not by itself indicative of a more serious condition. Numbness can be part of cauda equina, but is also common with a simple disc herniation, therefore by itself it is not a red flag. Red Flags by Serious Condition

Cancer

1. History of cancer 2. Unexplained weight loss >10 kg within 6 months 3. Age over 50 years or under 17 years old 4. Failure to improve with therapy 5. Pain persists for more than 4 to 6 weeks 6. Night pain or pain at rest

Infection

1. Persistent fever (temperature over 100.4 F) 2. History of intravenous drug abuse 3. Recent bacterial infection, particularly bacteremia (UTI, cellulitis, pneumonia, pelvic inflammatory disease) 4. Immunocompromised states (chronic steroid use, diabetes, HIV, taking chemotherapeutic or biologic medications)

Cauda Equina Syndrome

1. Urinary incontinence or retention 2. Saddle anesthesia 3. Anal sphincter tone decreased or fecal incontinence 4. Bilateral lower extremity weakness or numbness 5. Progressive neurologic deficits

Significant Herniated Nucleus Pulposus

1. Major muscle weakness (strength 3 of 5 or less) 2. Foot drop

Vertebral Fracture

1. Prolonged use of corticosteroids 2. Mild trauma over age 50 years 3. Age greater than 70 years 4. History of osteoporosis

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5. Recent significant trauma at any age (car accident, fall from substantial height) 6. Previous vertebral fracture

Acute Low Back Pain Prognosis

Most cases of low back pain are acute in onset and resolution, with 90% resolving within one month and only 5% remain disabled longer than three months. For patients who are out of work greater than six months, there is only 50% chance of them returning to work; this drops to almost zero chance if greater than two years. Patients who are older (>45) and patients who have psychosocial stress take longer to recover. Recurrence rate for back pain is high at 35 to 75%.

Clinical Skills

Recommended Low Back Pain History

1. History of present illness.

What is the location of the pain? Is it upper, middle or lower back? Left or right side? What is the duration of the pain or how long ago did it start? Is it getting worse or better? Does the pain radiate? Pain that radiates below the knee- more consistent with sciatica; pain around the buttock- more consistent with lumbar strain. What is the severity of the pain? Use a pain scale of 1 to 10 to make the severity somewhat more objective. Intensity of the pain. What is the quality of the pain? Is it achy, or sharp, or dull, or throbbing? Is the pain constant or intermittent? If intermittent, how often does it occur? Is it present at night or at rest? Are there associated symptoms (such as fever, weight loss, weakness, numbness, tingling)? Are there aggravating or alleviating factors? Aggravating circumstances (active vs. passive motion, day vs. night). Valsalva can increase pain from a herniated disk. Alleviating circumstances (medication, positioning-sitting, lying, standing). What has the patient tried to relieve the problem (what worked, what didn't). Any history of similar problems?

2. Pertinent past history. Recent illnesses, history of recent trauma or injury, patient's occupation, previous history of back injury, history of back surgery, cancer, or DM. (Fatigue is a nonspecific finding which may not help you to narrow your differential diagnosis.) 3. Review of systems. In order to narrow your differential diagnosis for the patient's problem, a review of systems, focused on pertinent positives and negatives is important.

Neurologic symptoms: saddle anesthesia, lower extremity numbness, tingling, muscle weakness particularly in the lower extremities, fecal incontinence Urinary symptoms: urinary incontinence, urinary retention, hesitancy, frequency, dysuria Gastrointestinal symptoms: nausea, vomiting, hematemesis, hematochezia, constipation, diarrhea, acid reflux symptoms Constitutional symptoms: fever, unexplained weight loss

4. Current medications and allergies

Approach to the Physical Exam for Back Pain

Perform the back exam systematically in sequential order with the patient: 1. Standing 2. Sitting 3. Supine

Physical Exam for Back Pain - Standing

Throughout the whole exam make certain to note how your patient is sitting, standing, and walking in general, asking yourself, "What is his degree of impairment?" and "How uncomfortable is he?" I. Inspection: Look at posture, contour and symmetry. Also inspect overlying skin to check for any lesions or abnormalities.

Check for lordosis Check for kyphosis Check for scoliosis

Slight scoliosis may be more easily visualized during lumbar flexion. This is performed by having the patient stand with their feet and hands together, like they are about to dive off a diving board, bending forward toward their toes. Look out across the back to see if the shoulders are level. II. Palpation: Check for any tenderness, tightness, rope-like tension, or inflammation in the paraspinous muscles or tenderness

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over bony prominences. This procedure checks for muscle spasm, vertebral fracture, or infection. III. Range of Motion (ROM):

Lumbar Flexion (normal is 90 degrees): This is the best measure of spine mobility. Restriction and pain during flexion are suggestive of herniation, osteoarthritis, or muscle spasm. Lumbar Extension (normal is 15 degrees): Pain with extension is suggestive of degenerative disease or spinal stenosis. Lateral motion (normal is 45 degrees): Most patients should be able to touch the proximal fibular head of the knee. Pain on the same side as bending is suggestive of bone pathology, such as osteoarthritis or neural compression. Pain on the opposite side of bending is suggestive of a muscle strain. Range of motion may be varied due to the patient's age and body habitus

IV. Gait: Ask the patient to walk on heels and toes. Expect normal gait, even with disc herniation. Difficulty with heel walk is associated with L5 disc herniation Difficulty with toe walk is associated with S1 disc herniation

V. Stoop Test: Have the patient go from a standing to squatting position. In patients with central spinal stenosis, squatting will reduce the pain. However, asking the patient to run is not part of a back exam and may cause discomfort to the patient who is already in pain.

Physical Exam for Back Pain - Seated Position

Overview of the Neurologic Exam

Deep Tendon Reflexes

Grading Reflexes: 0 No evidence of contraction 1+ Decreased, but still present (hyporeflexic) 2+ Normal 3+ Increased (hyper-reflexic) 4+ Clonus: Repetitive shortening of the muscle after a single stimulation Decreased patella reflex implies nerve impingement at the L3-L4 level. Decreased Achilles reflex implies nerve impingement of S1 levels. Hyper-reflexia is a sign of upper-motor neuron syndrome associated with spinal cord compression. Muscle Strength

Rating Scale: 0/5 No movement 1/5 Barest flicker of movement of the muscle, though not enough to move the structure to which it's attached. 2/5 Voluntary movement, which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface. 3/5 Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied. 4/5 Voluntary movement capable of overcoming "some" resistance 5/5 Normal strength i. Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you push down on his thigh ii. Hip Abduction (L 4, 5, S1): Ask the patient to push his legs apart while you push them together iii. Hip Adduction (L 2, 3, 4): Ask the patient to push his legs together while you push them apart iv. Knee Extension (L 2, 3, 4): Ask the patient to extend their knee while you push it down. v. Knee Flexion (L 5, S1, S2): Ask the patient to flex his knee while you push against it. vi. Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up while you push it down. vii. Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot down while you push it up. Decreased strength implies nerve impingement of the associated nerve in parenthesis. Sensation

Test for sharp and light touch along dermatomal distribution, great toe (L5), lateral malleolus, and posteriolateral foot (S1) Nerve Root Impingement Syndromes

Nerve Root Reflex Pin-Prick Sensation

Motor Examination Functional Test

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L3 Patellar tendon reflex Lateral thigh and medial femoral condyle Extend quadriceps Squat down and rise

L4 Patellar tendonreflex Medial leg and medial ankle Dorsiflex ankle Walk on heels

L5 Medial hamstring Lateral leg and dorsum of foot Dorsiflex great toe Walk on heels

S1 Achilles tendonreflex Posterior calf, Sole of foot, and lateral ankle Stand on toes

Walk on toes (plantarflex ankle)

Check for costovertebral angle (CVA) tenderness , a sign suggesting pyelonephritis. Modified version of the straight leg raise (SLR) test

While continuing to talk to the patient, raise each leg by extending the knee from 90 degrees to straight. If the pain is due to structural disease, the patient will instinctively exhibit the "tripod sign" by leaning backward and supporting himself with his outstretched arms on the exam table. (The unmodified version of the straight leg raise (SLR) test is done in the next section of the exam with the patient supine.) Neurological exam

Check reflexes, muscle strength, and sensation of the lower extremities. Focus on the L4, L5, and S1 nerve roots because most neuropathic back pain is due to impingement of these. Therefore, check the patellar reflex (L2-4) and Achilles reflex (S1). Check muscle strength for hip flexion, abduction, and adduction; knee extension and flexion; as well as ankle dorsiflexion and plantar flexion. Also, test for sharp and light touch along the dermatomal distribution of the great toe (L5), lateral malleolus and posterolateral foot (S1).

Physical Exam for Back Pain - Supine

I. Abdominal Exam

Auscultation: Check for abdominal bruit, looking for abdominal aortic aneurysm. Palpation: Check for abdominal tenderness (on all patients, not just female patients), pelvic tenderness (pelvic inflammatory disease), pulsatile mass, unequal femoral/brachial pulses (abdominal aortic aneurysm), or any general tenderness indicating visceral pathology.

II. Rectal Exam

To be done only on patients with red flags or alarm symptoms, which we will discuss later! Check for masses, bleeding, or abnormal rectal tone. Bleeding or rectal mass can be signs of cancer with metastasis to the spine causing back pain. Decreased tone can indicate disc herniation and/or cauda equina syndrome.

III. Passive Straight Leg Raise (SLR or Lasegue's sign) The normal leg can be raised 80 degrees. If a patient only raises their leg <80 degrees, they have tight hamstrings or a sciatic nerve problem. To differentiate between tight hamstrings and a sciatic nerve problem, raise the leg to the point of pain, lower slightly, then dorsiflex the foot. If there is no pain with dorsiflexion, the patient's hamstrings are tight. The test is positive if pain radiates down the posterior/lateral thigh past the knee. This radiation indicates stretching of the nerve roots (specifically S1 or L5) over a herniated disc. This pain will most likely occur between 40 and 70 degrees.

IV. Crossed Leg Raise: asymptomatic leg is raised Test is positive if pain is increased in the contralateral leg; this correlates with the degree of disc herniation. Such results imply a large central herniation. Cross SLR test is much less sensitive (0.25) but is highly specific (about 0.90). Thus, a negative test is nonspecific, but a positive test is virtually diagnostic of disc herniation. V. FABER Test : Flexion, Abduction, and External Rotation

The Faber test looks for pathology of the hip joint or sacrum (sacroiliac pain from sacroiliitis). The test is performed by flexing the hip and placing the foot of the tested leg on the opposite knee. Pressure is then placed on the tested knee while stabilizing the opposite hip. The test is positive if there is pain at the hip or sacral joint or if the leg cannot lower to the point of being parallel to the opposite leg from pathology of the hip, sacrum or sacroiliac joint.

The FABER test should be done on all patients suspected of having sacroiliac pain, not just in the older adult patients. Sacroiliitis can occur in the young population as well. VI. Muscle Atrophy: of quadriceps and calf muscles.

Management

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Conservative Therapy for Acute Low Back Pain

Conservative therapy for acute low back pain includes: Pharmacologic therapy: Aspirin/NSAID and/or muscle relaxants Local therapy: Local therapy (heat/cold). Learn more about local therapy here. Activity: Advice to stay active or sending patient to physical therapy may help prevent recurrence.

Pharmacologic therapy: The first line medications for the treatment of LBP are non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and muscle relaxants. A systematic review of randomized controlled studies found strong evidence that NSAIDs and muscle relaxant are helpful in the treatment of LBP. The various NSAIDs and muscle relaxants are equally effective, while some muscle relaxants are more sedating. There is conflicting evidence about the superiority of NSAIDs to acetaminophen. There is little evidence regarding the benefits of opioid use in LBP, and there is significant concern about the risk of the development of addiction. Occasionally, when pain cannot be controlled in other ways or when there are contraindications to other options, opioids are prescribed. Such prescriptions should be time-limited. No studies support the use of oral steroids in patients with LBP. Learn more about activity here and here. Strict bed rest has not been shown to be beneficial. Patients should be encouraged to resume normal activities as soon as they are able to. Referral to a surgeon or advanced imaging, such as MRI/CT scans, should be entertained if back pain is not better in four to six weeks or if progression of neurologic deficits is demonstrated. The "Choosing Wisely" campaign in family medicine has good patient resource material to explain the recommendation to wait for imaging.

Effectiveness of Physical Therapy for Acute Back Pain

There is some data to show that tailored physical therapy is slightly more effective for acute back pain compared to patients who just stay active. At four weeks, patients who received physical therapy had 10-point improvement in a 100-point disability score compared to the control group. There is great variation in physical therapy because various interventions (exercises, traction, massage) and different modalities (heat, ice, ultrasound) may be used. There is also evidence that spinal manipulation is safe and can help in the short term.

Low Back Pain Treatment After Adequate Trial of Conservative Therapy

If a patient has been in pain for five weeks with progression of neurological deficit (such as absent reflex at the ankles) and poor pain control, it is reasonable to refer him to a spine surgeon for surgical consultation. If the patient doesn't have any red flags, continuation of conservative treatment is also an option. However, if the patient has already been getting PT, more PT is not likely to help. There is some evidence that acupuncture can be helpful in low back pain. The benefit of epidural injections of glucocorticoids is uncertain in this case. The clinical benefits in randomized trials are minimal, and a recent study compared with sham injection and oral gabapentin showed no benefit of epidural steroid injections at three months. Despite the weak evidence, this intervention is still frequently recommended so as to avoid surgery.

Studies

Indications for Studies to Evaluate Low Back Pain

Laboratory tests generally are not needed in the evaluation of acute low back pain. CBC

CBC, sedimentation rate (ESR), and C-reactive protein (CRP) should be ordered if tumor or infection is suspected. X-ray

Agency for Health Care Policy and Research (AHCPR) guidelines for x-ray: History of trauma Strenuous lifting in patient with osteoporosis Prolonged steroid use Osteoporosis Age <20 and >70 History of cancer Fever/chills/weight loss Pain worse when supine or severe at night Spinal fracture, tumor, or infection

The American College of Radiology (ACR) has appropriateness criteria for imaging for various conditions. View the ones for low back pain (.pdf). Lumbar spine film

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Lumbar spine films are commonly used, but lack specificity and have a high rate of false-positive findings. Patients with symptoms and pathology may have an apparently benign x-ray and asymptomatic patients may have abnormal x-rays. MRI

An MRI is indicated if the following are present: Worsening or unremitting neurologic deficit or radiculopathy Progressive major motor weakness Cauda equina compression (sudden bowel/bladder disturbance) Suspected systemic disorder (metastatic or infectious disease) Failed six weeks of conservative care

However, 75% of herniated discs improve with six weeks of conservative therapy. MRI testing is not associated with clinical benefit in randomized trials. Early MRI is not associated with improved outcomes in patients with acute back pain or radiculopathy (Level 2/mid-level evidence). If surgery is being considered, some physicians recommend, in the absence of red flags, to obtain an imaging study after one month of symptoms. Electrodiagnostics-Electromyography

Electrodiagnostics-Electromyography (EMG) and nerve conduction studies can be used in the evaluation of patients with radicular pain and lumbar spinal stenosis. Electrodiagnostic tests are useful to confirm the existence of radiculopathy (level of nerve involvement) and to exclude the presence of other peripheral nerve disorders. Electrodiagnostic tests are time sensitive because nerve root abnormalities may not be reliably detectable until three weeks after the onset of symptoms. They are particularly useful as an adjunct to clinical evaluation and imaging in the following two clinical scenarios: physical examination does not correlate with imaging studies; and to clarify the functional significance of an imaging abnormality.

Assessment of Acute Back Pain

In the absence of red flags or findings suggestive of systemic disease, diagnostic testing, especially imaging, is not indicated until after four to six weeks of conservative treatment. Ordering tests too early is not only cost ineffective, but can also cause harm to the patient. Spine x-rays expose patients to radiation. This is particularly concerning in younger women because the radiation exposure to the ovaries in a single plain radiograph of the lumbar spine is equal to getting a daily chest x-ray (CXR) for more than a year. CT scans expose patients to contrast materials that have renal toxicity, and even higher doses of radiation. Routine imaging of the back using CT or MRI is not associated with improved outcomes, and may identify abnormalities that are unrelated to the patient's back pain. This can cause anxiety and could lead to more testing and possibly unnecessary intervention. Algorithm for assessment of acute back pain.

Clinical Reasoning

Differential for Low Back Pain

Lumbar strain

The most common cause of acute low back pain in adults Typically has an acute or sub-acute onset after an injury or precipitating activity (e.g., moving furniture) Pain is typically worse in the paraspinal muscles lateral to the spine and may be bilateral or unilateral Pain may radiate down one or another leg Pain is worse after periods of immobility and with particular movements (depending on where the strain is)

Disc herniation May have acute or sub-acute presentation May be precipitated by a sudden injury Pain is often worse when the hips are flexed, as in sitting Location of pain depends on the level of the herniation

Degenerative arthritis

Increasingly common with advancing age If an osteophyte impinges a nerve root, can cause radicular symptoms in that nerve’s distribution Has a more insidious onset

Spinal stenosis

Caused by central deformity compressing the cord, such as by central disc herniation, spondylolisthesis, osteophyte, or mass Hallmark symptom is pain radiating to the legs (bilateral more common than unilateral) that is brought on by walking or standing (sometimes called pseudoclaudication) Sitting relieves the symptoms

Spinal fracture Not likely without history of trauma.

Bony point-tenderness in a patient with low back pain should prompt an x-ray to rule out fracture

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Cauda equina syndrome

Should always be considered due to the seriousness of the consequences.

Occurs when a large mass effect (such as an acute disc herniation or a tumor) compresses the cauda equina, causing pain radiating down the leg and can be accompanied by weakness and numbness of the leg.

True emergency. Decompression should be performed within 72 hours to avoid permanent neurologic deficits.

Low on the differential if the patient denies problem with bowel or bladder control.

Pyelonephritis Unlikely with lack of fever and urinary symptoms.

Malignancy

Important consideration. A very serious, although uncommon, cause of back pain.

Unlikely without a history of cancer.

Back pain due to malignancy is localized to the affected bones , it is a dull, throbbing pain that progresses slowly, and it increases with recumbency or cough .

More commonly seen in patients over 50 .

Ankylosing spondylitis

Chronic, painful, inflammatory arthritis primarily affecting the spine and sacroiliac joints, causing eventual fusion of the spine.

Often seen in patients 15-40 years old, associated with morning stiffness and achiness over the sacroiliac joint and lumbar spine.

Spondylolisthesis

Anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.

Can occur at any age.

Causes aching back and posterior thigh discomfort that increases with activity or bending .

Prostatitis

Can cause referred LBP in men.

(Pelvic inflammatory disease and endometriosis in women can cause referred LBP).

Expect to find evidence of infection in the history.

Pancreatitis Pancreatitis and other gastrointestinal diseases such as cholecystitis and ulcers can cause LBP via visceral pain.

Usually associated with other abdominal symptoms.

References

Arce D, Sass P, Abul-Khoudoud H. Recognizing spinal cord emergencies. Am Fam Physician. 2001 Aug 15;64(4):631-8.

Bigos S, Bowyer O, Braen G, Brown K, Deyo R A, Haldeman S., et al. Acute Low Back Problems in Adults. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Clinical Practice Guideline No. 14. Report No. 95-0642. December, 1994.

Browning R, Jackson J, O'Malley P. Cyclobenzaprine and Back Pain: A Meta-analysis. Archives of Internal Medicine. July 9, 2001;161:1613-1620.

Casazza BA. Diagnosis and Treatment of Acute Low Back Pain Am Fam Physician 2012;85(4):343-350. Accessed Nov. 5, 2019.

Casazza BA. Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012 Feb 15;85(4):343-50.

Casazza, B. Diagnosis and Treatment of Acute Low Back Pain. Am Fam Physician. 2012 Feb 15;85(4):343-350. Accessed August 30, 2019.

Chou R, Qaseem A, Snow V, Casey D, Cross J T Jr., Shekelle P, Owens P. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society." Annals of Internal Medicine. 2007;147:478-491.

Cohen SP, Hanling S, Bicket MC, White RL, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ. 2015 Apr 16;350:h1748. doi: 10.1136/bmj.h1748.

Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.

Deyo RA, Deihl AK. Lumbar spine films in primary care: Current Use and Effects of Selective Ordering Criteria. Journal of General Internal Medicine. 1986;1:20-5.

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Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;(1):CD004057.

French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006 Jan 25;(1). http://www.ncbi.nlm.nih.gov/pubmed/16437495. Accessed Nov. 6, 2019.

Fritz, JM, Delitto A, Erhard RE. Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain: A Randomized Clinical Trial. Spine. July 1, 2003;28(13):1355-1486, E245-E264.

Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4.

Hagen K B, Hilde G, Jamtvedt G, Winnem M. Bedrest for Acute Low-Back Pain and Sciatica. Cochrane Database System. Revised 2004; (4):CD001254.

Hedron, et. al. Common Questions About Chronic Low Back Pain. Am Fam Physician. 2015;91(10):708-714.

Humphreys SC, Eck JC, Hodges SD. Neuroimaging in low back pain. Am Fam Physician. 2002 Jun 1;65(11):2299-306. Accessed Nov. 5, 2019.

Jarvik JG, Deyo, RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Annals of Internal Medicine. October, 2002;137(7):586-97.

Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007 Apr 15;75(8):1181-8.

Machado LA, de Souza MS, Ferreira PH, Ferreira ML. The McKenzie Method for Low Back Pain: A Systematic Review of the Literature with a Meta-Analysis Approach. Spine. 2006 Apr 20;31(9):E254-62.

Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute Low Back Pain: Systematic Review of its Prognosis. British Medical Journal. August 9, 2003;327(7410): 323.

Petering, Ryan C. MD and Webb, Charles, DO. Treatment Options for Low Back Pain in Athletes. Sports Health. Nov 2011; 3(6): 550- 555. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445234/. Accessed Nov. 6, 2019.

Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharmacological treatment for chronic pain: A systematic review. Comparative effectiveness review no. 209. Publication no. 18-EHC013-EF, Agency for Healthcare Research and Quality; Department of Health and Human Services, Portland, OR 2018.

Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD001824. DOI: 10.1002/14651858.CD001824.pub3.

Thorson D, Campbell R, Massey M, Mueller B, et al. Institute for Clinical Systems Improvement. Low Back Pain, Adult Acute and Subacute. Updated March, 2018. https://www.icsi.org/wp-content/uploads/2019/08/March-2018-LBP-Interactive2.pdf. Accessed Nov 1, 2019.

Toward Optimized Practice. Guideline for the evidence-informed primary care management of low back pain. Edmonton (AB): Toward Optimized Practice; 2009 Mar 2.

van Tulder M W, Scholten R Jr., Koes B W, Deyo R A. Nonsteroidal Anti-Inflammatory Drugs for Low Back Pain. Cochrane Database Syst Rev. 2007 Jul 18;(2):CD000396.

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