Low back pain conservative management

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Low back pain Microchapters





Differentiating Low back pain from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis


History and Symptoms

Physical Examination

Laboratory Findings

X Ray




Other Imaging Findings

Other Diagnostic Studies


Conservative Management


Primary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Conservative Management

For the vast majority of patients, low back pain can be treated with non-surgical care. For those with acute, short-term back pain, certain home remedies[1] may be effective.

Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals.[2]

Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles.[3][4] Bed rest should be avoided. A 1996 Finnish study found that persons who continued their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs. Patients should resume activities as soon as possible. At night or during rest, patients should lie on one side, with a pillow between the knees (some doctors suggest resting on the back and putting a pillow beneath the knees).

Massage therapy

According to a systematic review of randomized controlled trials by the Cochrane Collaboration, massage therapy, compared to inactive controls, over the short-term significantly reduced pain (SMD=0.75; large) and improved function (SMD=0.72; large).[5] However, the Cochrane concluded "very little confidence that massage is an effective treatment".

Mckenzie Method

The Mckenzie Method has been shown to be a modestly effective therapy for adults with chronic low back pain. A 2011 summary of 4 studies showed consistent significant improvement in pain and function although only one study had a large enough population to demonstrate effect sizes on pain and functional outcomes, 0.50 and 0.39 respectively.[6]


According to a systematic review of randomized controlled trials by the Cochrane Collaboration, Pilates, compared to minimal intervention, reduced pain and improves disability. Pain was reduced in both short term (<3 months) - (MD -14.05, 95% CI -18.91 to -9.19), and intermediate term (3-12 months) - (MD -10.54, 95% CI -18.46 to -2.62). Disability was improved in both the short term - (MD -7.95, 95% CI -13.23 to -2.67, and intermediate term (MD -11.17, 95% CI -18.41 to -3.92). The authors conclude "there is low to moderate quality evidence that Pilates is more effective than minimal intervention for pain and disability. When Pilates was compared with other exercises we found a small effect for function at intermediate-term follow-up. Thus, while there is some evidence for the effectiveness of Pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercises. The decision to use Pilates for low back pain may be based on the patient's or care provider's preferences, and costs."[7]

The benefit of pilates was confirmed in a more recent randomized controlled trial.[8]

Spinal manipulation

Spinal manipulation is literally a "hands-on" approach in which professionally licensed specialists (doctors of chiropractic care) use leverage and a series of exercises to adjust spinal structures and restore back mobility[4] or chronic[3] pain. A clinical prediction rule can guide who is most likely to respond to manipulation.[9]

Tai Chi

Tai Chi is supported by a randomized control trial to be effective for the treatment of chronic low back pain.[10] The trial offered a 10 week tai chi program versus a control group with no activity. Tai Chi was shown to have a clinically significant effect on Pain Disability Index, Roland-Morris Disability Questionnaire, Quebec Back Pain Disability Scale, Patient-Specific Functional Scale, and global perceived effect. Pain was shown to specifically be reduced 1 point on a 10 point scale when comparing mean pain baseline to mean pain after 10 week tai chi trial.


  • Disability as measured by the Roland-Morris Disability Questionnaire (RMDQ) was reduced at 3 months according to a randomized controlled trial of chronic or recurrent low back pain[11].
  • Another multicentered randomized control trial suggests that the 12 week yoga programs are also a cost effective intervention for low back pain.[12]
  • Additional studies have been done of Viniyoga (PMID 16365466), Iyengar (PMID 15836974), and Hatha yoga (PMID 15055095 - small trial).

Other therapies

When back pain does not respond to more conventional approaches, patients may consider the following options:

  • Acupuncture[3] involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.[13]
  • Biofeedback is used to treat many acute pain problems, most notably back pain and headache. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature (by controlling local blood flow patterns). The patient can then learn to effect a change in his or her response to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.(PMID 12076429)
  • Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, proliferative agents (Prolotherapy) or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to increased functional impairment.
  • Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.
  • Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).
  • Correcting leg length difference may help (PMID 16271551). To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.
  • Muscle Energy Technique (MET) may help (PMID 14524509 - small study)

Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.

Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty. Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief. In kyphoplasty, prior to injecting the epoxy, a special balloon is inserted and gently inflated to restore height to the bone and reduce spinal deformity.


Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.

  • Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen)[4][3], are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
  • Muscle relaxants for acute[4] or chronic[3] pain.
  • Anticonvulsants— drugs primarily used to treat seizures— may be useful in treating certain types of nerve pain and may also be prescribed with analgesics.
  • Some antidepressants, particularly tricyclic antidepressants such as amitriptyline and desipramine, have been shown to relieve pain (independent of their effect on depression) and assist with sleep. Antidepressants alter levels of brain chemicals to elevate mood and dull pain signals. Many of the new antidepressants, such as the selective serotonin reuptake inhibitors, are being studied for their effectiveness in pain relief.[3]
  • Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute and chronic back pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and even increasing pain.[14]

Inflammation reduction

An unregistered randomized controlled trial with conflict of interest found an improvement after diet changes for inflammation[15].

On the other hand, prylotherapy has been posed to reduce back pain by creating inflammation[16].


  1. "Acute back pain. Causes and treatment options". Retrieved 2007-09-26.
  2. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ (2006). "Superficial heat or cold for low back pain". Cochrane Database Syst Rev (1): CD004750. doi:10.1002/14651858.CD004750.pub2. PMID 16437495.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 van Tulder M, Koes B (2006). "Low back pain (chronic)". Clinical evidence (15): 1634–53. PMID 16973063.
  4. 4.0 4.1 4.2 4.3 Koes B, van Tulder M (2006). "Low back pain (acute)". Clinical evidence (15): 1619–33. PMID 16973062.
  5. Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M (2015). "Massage for low-back pain". Cochrane Database Syst Rev. 9: CD001929. doi:10.1002/14651858.CD001929.pub3. PMID 26329399.
  6. Dunsford A, Kumar S, Clarke S (2011). "Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain". J Multidiscip Healthc. 4: 393–402. doi:10.2147/JMDH.S24733. PMC 3215349. PMID 22135496.
  7. Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo RW, Cabral CM; et al. (2015). "Pilates for low back pain". Cochrane Database Syst Rev. 7: CD010265. doi:10.1002/14651858.CD010265.pub2. PMID 26133923.
  8. Valenza MC, Rodríguez-Torres J, Cabrera-Martos I, Díaz-Pelegrina A, Aguilar-Ferrándiz ME, Castellote-Caballero Y (2016). "Results of a Pilates exercise program in patients with chronic non-specific low back pain: A randomized controlled trial". Clin Rehabil. doi:10.1177/0269215516651978. PMID 27260764.
  9. Childs JD, Fritz JM, Flynn TW; et al. (2004). "A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study". Ann. Intern. Med. 141 (12): 920–8. PMID 15611489. Summary of the rule
  10. Hall AM, Maher CG, Lam P, Ferreira M, Latimer J (2011). "Tai chi exercise for treatment of pain and disability in people with persistent low back pain: a randomized controlled trial". Arthritis Care Res (Hoboken). 63 (11): 1576–83. doi:10.1002/acr.20594. PMID 22034119.
  11. Tilbrook HE, Cox H, Hewitt CE, Kang'ombe AR, Chuang LH, Jayakody S; et al. (2011). "Yoga for chronic low back pain: a randomized trial". Ann Intern Med. 155 (9): 569–78. doi:10.7326/0003-4819-155-9-201111010-00003. PMID 22041945.
  12. Chuang LH, Soares MO, Tilbrook H, Cox H, Hewitt CE, Aplin J; et al. (2012). "A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation". Spine (Phila Pa 1976). 37 (18): 1593–601. doi:10.1097/BRS.0b013e3182545937. PMID 22433499.
  13. Haake M, Müller HH, Schade-Brittinger C; et al. (2007). "German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups". Arch. Intern. Med. 167 (17): 1892–8. doi:10.1001/archinte.167.17.1892. PMID 17893311.
  14. Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D (2007). "Opioids for chronic low-back pain". Cochrane database of systematic reviews (Online) (3): CD004959. doi:10.1002/14651858.CD004959.pub3. PMID 17636781.
  15. Shell WE, Pavlik S, Roth B, Silver M, Breitstein ML, May L; et al. (2016). "Reduction in Pain and Inflammation Associated With Chronic Low Back Pain With the Use of the Medical Food Theramine". Am J Ther. 23 (6): e1353–e1362. doi:10.1097/MJT.0000000000000068. PMC 5102273. PMID 25237981.
  16. Dagenais S, Yelland MJ, Del Mar C, Schoene ML (2007). "Prolotherapy injections for chronic low-back pain". Cochrane Database Syst Rev (2): CD004059. doi:10.1002/14651858.CD004059.pub3. PMC 6986690 Check |pmc= value (help). PMID 17443537.

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