Low Back Pain

Importance: Low back pain is defined as pain localized below the costal margin and above the inferior gluteal fold, with or without leg pain. Low back pain affects approximately 619 million people worldwide and is the leading cause of years lived with disability worldwide. Observations: Approximately 90% of patients presenting for care with low back pain have nonspecific low back pain, which is defined as low back pain that is not associated with specific spinal disorders (such as lumbar radiculopathy, lumbar spinal stenosis, vertebral fracture, axial spondyloarthritis, infection, or malignancy). Low back pain is classified as acute if the duration is shorter than 6 weeks, subacute if the duration is 6 to 12 weeks, and chronic when the duration is longer than 12 weeks. The age-standardized prevalence of low back pain is higher in females (9330 per 100 000) than in males (5520 per 100 000). The prevalence of low back pain increases with age, peaking at approximately 85 years. Risk factors for low back pain include obesity, depressive symptoms, occupational exposures (eg, heavy lifting), tobacco use, chronic disease (eg, diabetes), and previous low back pain. Acute nonspecific low back pain is usually self-limited, and approximately 72% of individuals recover by 12 months. Prognosis is less favorable for chronic nonspecific low back pain, but 42% of patients recover within 12 months. Initial management of patients with low back pain of any duration includes reassurance that serious underlying disease is unlikely, discussion about the expected time course of recovery, and the recommendation to remain physically active. Patients should be encouraged to continue their usual activities (including work), avoid prolonged rest, and be advised to self-manage their condition, which consists of symptom-relief strategies (such as heat application) and activity pacing (maintaining or gradually increasing usual activities and work). For patients with acute nonspecific low back pain, first-line therapies include heat application, spinal manipulation, massage, and acupuncture (typically provided by physical therapists, chiropractors, acupuncturists, and massage therapists) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; such as ibuprofen) and skeletal muscle relaxants (such as cyclobenzaprine). For chronic nonspecific low back pain, first-line therapies include exercise of any type, psychological therapies (eg, cognitive behavioral therapy), or combined multidisciplinary approaches (such as pain management programs and integrated exercise and psychological care) along with spinal manipulation, massage, and acupuncture. NSAIDs should be considered as second-line therapy for chronic nonspecific low back pain. Conclusions and Relevance: Low back pain is a leading cause of disability worldwide. Acute nonspecific low back pain is often self-limited, whereas chronic nonspecific low back pain has a less favorable prognosis. For patients with acute nonspecific low back pain, first-line treatments include selected nonpharmacological therapies and medications (such as NSAIDs and skeletal muscle relaxants). For patients with chronic nonspecific low back pain, first-line treatment consists of exercise, psychological therapies (such as cognitive behavioral therapy), and combined multidisciplinary care.