Back To Search Results

Back Pain

Editor: Matthew Varacallo Updated: 2/20/2023 8:39:56 PM

Back pain is one of the most common causes for patients to seek medical care in both primary care and emergency setting. An estimated 200 billion dollars are spent annually on the management of back pain [1]. It is the most common reason for workman's compensation and lost work hours and productivity. There is a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly, it is mechanical or non-specific. Not all back pain is lumbago or paraspinal muscle hypertonicity. Heuristics are useful, but they are also problematic. If 90 percent of back pain is mechanical, and somewhere between 12 to 33 percent of people experience back pain at any one time, then it is likely to be the primary focus of medical treatment. [1] The mechanical back is both prevalent and with a large incidence. By only focusing on the most common and most dangerous etiologies of back pain, providers are missing a significant portion of cases. Some sources say up the 30 percent of mechanical back pain is sacroiliac joint in origin, yet it is often an afterthought in a differential diagnosis. [2]. Cases of ankylosing spondylitis are missed when providers assume back a patient's back pain is mechanical [3]

Inflammatory disorders, malignancy, pregnancy, trauma, osteoporosis, nerve root compression, radiculopathy, plexopathy, degenerative disc disease, disc herniation, spinal stenosis, sacroiliac joint dysfunction, facet joint injury, and infection are all part of the differential. Distinguishing the signs and symptoms of nociceptive pain (mechanical) from neuropathic pain (radiculopathy) is an essential first step in the diagnosis of back pain. Special tests such as the straight leg raise or Patrick's test can be used to help differentiate the origin of the patient's back pain. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. Back pain is a significant contributor to morbidity and mortality. Chronic back pain is also the most common cause of chronic pain in general. 

The two most important aspects in the management of back pain are the identification of red flags that could be alarming for diagnoses such as malignancy or neurological conditions such as cauda equina syndrome [4]. It is essential to be able to evaluate patients of all ages and understand the unique differences in the presentation in these different populations. Knowing the typical red flags of back pain such as weakness, bowel or bladder incontinence, or pain that awakens patients from sleep in both children and adults can guide the provider to appropriate evaluation and treatment. Most cases of back pain will resolve with time and rest.

Conservative management often includes over-the-counter pain medications such as acetaminophen or NSAIDs. Muscle relaxants, gabapentin, topical analgesics, and opioids all play a role in the management of back pain, on a case-by-case basis [5]. Most cases of back pain are mechanical in origin and respond to activity modification, rest, ice, and heat. Physical therapy and core strengthening exercises also play a role. Different therapy modalities have been used to treat back pain, but the most effective is the McKenzie method [6]. Unfortunately, not all back pain resolves with physical therapy.  If back pain has persisted longer than six weeks duration after an acute injury, x-ray imaging may be warranted. Also, an MRI of the thoracolumbar spine may be necessary to help identify possible disc herniation or spinal stenosis. 

Furthermore, corticosteroid injections, radiofrequency ablative therapy, spinal cord stimulators, kyphoplasty, TENS units, and surgeries such as laminectomy, spinal fusion, or discectomy are possible treatments options as well for refractory cases. Comorbid conditions such as major depressive disorder or opioid use disorder must be addressed and treated to their fullest extent to help minimize the long-term effects of back pain. Separately, obesity plays a critical role in the development of back pain Integrative treatment modalities such as acupuncture, tai chi, and yoga have also been shown to have a moderate effect on the improvement of back pain [7][8]. Limited studies have been done regarding the use of cannabinoids in back pain, but it may be a treatment modality in the future.

Back pain is and likely will continue to be the focus of many providers because of the profound effect it has on patients' well-being. Function becomes impaired, activities of daily living are changed to accommodate back pain, and quality of life suffers. Unlike injuries to almost everywhere else in the body, back pain (and axial skeletal injuries) affects almost every aspect of life. For example, sleeping is disrupted, it is difficult to bend, reach or turn, it is hard to drive or go to work, lifting and exercise become strenuous, anxiety-provoking activity, walking to the bathroom becomes a difficult task, and so on. This article address how to diagnosis back pain through a careful history and physical exam, evaluate back pain with various diagnostic tests, and treat back pain via pharmacological, interventional, surgical, non-pharmacological, and/or alternative treatment modalities.


Earn CME credit as you help guide your clinical decisions.
Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed.


$59 per month


$599 per year

Back pain is a broad topic with many potential etiologies that are broken mainly into five primary categories [9]

  • Mechanical: Most commonly this is due to injury to the spine, intervertebral discs, or soft tissues. Fractures such as spondylolisthesis can be both an acute or chronic process. Lumbago often is labeled as acute back pain or a strain to either the quadratus lumborum muscle or the paraspinal muscles. Disc herniation is a common type of traumatic back pain. Pregnancy is also a mechanical cause of back pain. 
  • Degenerative: Osteoarthritis of the spine includes facet joint osteoarthritis, sacroiliac joint osteoarthritis, spinal stenosis, and degenerative disc disease. Furthermore, osteoporotic compressive fractures are also a degenerative process.
  • Inflammatory: This is caused primarily due to inflammatory (seronegative) spondyloarthropathies such as ankylosing spondylitis. Sacroiliitis is most commonly seen. The pathophysiology of back pain depends on the etiology. Most often, it may be a part of an acute inflammatory process.
  • Oncologic: This is caused by lytic lesions to the spine, cancers of the marrow, or compressive nerve phenomena from adjacent space-occupying lesions. Often presenting as a pathological fracture.
  • Infectious: Infections of the spine, discs, epidural abscesses, or muscular/soft tissue abscesses

It is important to note, however, that many non-back-related disorders may result in pain that patients perceive in the back, such as biliary colic, pneumonia, and obstructive or infectious renal disease. Therefore, it is prudent not to exclude these processes from your differential diagnosis while evaluating the patient.

Back pain is widespread in the adult population. Some studies have shown that up to 23% of the world’s adults suffer from chronic low back pain. This population has also shown a one-year recurrence rate of 24% to 80% [10][11]. Some estimates of lifetime prevalence are as high as 84% in the adult population [12].

However, the prevalence is much less apparent in the pediatric literature. One Scandinavian study demonstrated that the point prevalence of back pain was approximately 1% for 12-year-olds and 5% for 15-year-olds, with a cumulative incidence of 50% by age 18 for females and age 20 for males [13]. An extensive systematic review demonstrated an annual rate of adolescents suffering from back pain of 11.8% to 33% [14].

History and Physical

A thorough history and physical exam are critical in the evaluation of the patient with back pain in both adult and pediatric populations.

The historical characteristics of the pain that require elucidation are very similar for the two populations. The mechanism of injury is often a valuable clue in diagnosis. The intensity and the quality of pain or whether the pain radiates helps narrow the differential. The alleviating and provoking factors of back pain can provide insight. Furthermore, previous treatments are all critical for gathering a thorough history of present illness. It may also be helpful to assess the impact on the patients daily living the pain has caused, such as work/school absenteeism, as useful clues for functional impairment. Past medical and family history (including the history of cancers or inflammatory conditions) and social history (including periods of injection drug use, exercise regimens, periods of exposure to tuberculosis) can also change the most likely working diagnosis. The character of the pain can help differentiate neuropathic pain from nociceptive pain, while the duration of pain helps establish the acute or chronic nature of the pain. Chronic pain is often centralized and has a specific set of signs and symptoms that include allodynia and hyperalgesia. The mechanism of the backs elucidates the likelihood of a herniated disc or acute muscle spasm. The location of the pain may help to decipher between a compression fracture, sacroiliac (SI) joint injury, and degenerative arthritic changes. Exacerbating and relieving factors such as positional changes to pain severity, as well, the effectiveness of various medications can also help narrow the differential diagnosis. Radiation of pain is a useful tool to help assess radicular symptoms. The severity of pain also helps the provider clue in on the effect the illness or injury may have on the patient's quality of life. Furthermore, associated symptoms such as weakness, sensation changes, difficulty with ambulation, bowel or bladder changes, fever, chills, unexplained weight loss, and pain awakening the patient from sleep are all useful questions to rule out for severe pathology. 

The physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the review. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation, and deep tendon reflex) assessments. Several provocative exercises help demonstrate or decrease suspicion of different processes.

A straight leg raise (SLR) can be completed by raising the patient’s leg to 30 to 70 degrees [15]. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. The likelihood ratio (LR) of a straight leg raise is 2, with ave likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for a lumbar disk herniation with LR of 3.5 and NLR of 0.72 [15][16].

One leg hyperextension test/stork test: Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect [17].

Adam test: Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication of scoliosis [17].

There are numerous other examination techniques; however, they have mixed evidence for inter-practitioner reliability and poor sensitivities or specificities.

Red flags features on history or physical exam should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:

Adults Red Flags:

  • Malignancy:
    • History: History of metastatic cancer, unexplained weight loss
    • Physical exam: Focal tenderness to palpation in the setting of risk factors [18]
  • Infection:
    • History: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
    • Physical exam: Fever, wound in the spinal region, localized pain, and tenderness [18]
  • Fracture:
    • History: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years [19]
    • Physical exam: Contusions, abrasions, tenderness to palpation over spinous processes
  • Neurologic:
    • History: Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
    • Physical exam: Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes [18]

Pediatric red flags are the same as adults with a few notable differences:

  • Malignancy:
    • History: age less than four years, nighttime pain [20]
    • Physical exam: Focal tenderness to palpation in the setting of risk factors
  • Infectious:
    • History: age less than four years, nighttime pain, history of tuberculosis exposure [20]
    • Physical exam: Fever, wound in the spinal region, localized pain, and tenderness
  • Inflammatory:
    • History: age less than four years, morning stiffness for greater than 30min, improving with activity or hot showers [21]
    • Physical exam: limited range of motion, localized pain, and tenderness
  • Fracture:
    • History: activities with repetitive lumber hyperextension (sports such as cheerleading, gymnastics, wrestling, or football linemen)
    • Physical exam: Tenderness to palpation over spinous process, positive Stork test


While typically, history and physical exams are sufficient for evaluation of back pain, the presence of red flags requires further investigation. Early imaging in the adult population correlates with worse outcomes and more invasive treatments without a corresponding improvement in outcomes [22][23]. Imaging for adults should be part of the management of symptoms that last longer than six weeks with appropriate conservative management [22]. Protracted pain in children should have imaging; however, the definition of protracted has not been as clearly defined as it is in adults.

Anteroposterior and lateral plain films should be sufficient to evaluate for boney pathology. In contrast, magnetic resonance imaging (MRI) may be necessary to evaluate soft tissue lesions, nerve root/cord compression from a bulging disc, malignancy, and inflammatory conditions of the spine and surrounding tissues [24][25]. Bone scans may demonstrate osteomyelitis, discitis, and stress reactions, but remains inferior to MRI to evaluate these conditions [26]. In adolescents with MRI evidence of herniated disc, one may consider a computed tomogram (CT) to confirm or rule out apophyseal ring separation as this occurs in 5.7% of these patients [27]. For complex cases, such as patients with a history of previous spinal surgery, electromyography (EMG) or nerve conduction studies are needed to help aid in the diagnosis of possible radiculopathy or plexopathy. Empirical treatment with a diagnostic injection is also used in cases of suspected sacroiliac joint injury. 

In addition to imaging, one may consider laboratory evaluation if red flags are present. Rheumatologic assays such as HLA-B27, antinuclear antibody (ANA), rheumatoid factor (RF), and Lyme are typically not helpful [28]. They are unspecific for back pain [29]. Inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be useful tests [30]. Separately, a complete blood count (CBC) and blood cultures may assist in the diagnosis of inflammatory, infectious, or malignant etiologies as well. The addition of lactate dehydrogenase (LDH) and uric acid may assist in diagnosing a condition with rapid marrow turnover such as leukemia [31].

Treatment / Management

There are various treatments for pain based on etiology, age, and chronicity of back pain. The best evidence in adult back pain according to the "Noninvasive treatments for low back pain: current state of the evidence" clinician summary published by the Agency for Healthcare Research and Quality in 2016:

In adults:

For radicular low back pain, nonpharmacologic interventions such as exercise, traction, and spinal manipulation have shown some benefits but have relatively weak levels of evidence to support it. Non-steroidal anti-inflammatory drugs (NSAIDs) have moderate evidence of benefit. However, other pharmacologic interventions, such as diazepam and systemic steroids, do not seem to provide benefits [AHRQ,  2016].

For non-radicular acute or subacute low back pain, acetaminophen appears to have weak evidence of no benefit. However, NSAIDs, heat, and muscle relaxants have moderate evidence for positive gain. Massage has weak evidence that leans toward being advantageous [AHRQ 2016].

For non-radicular chronic low back pain, there is moderate evidence to support physical therapy[AHRQ 2016], particularly utilizing the McKenzie method [32][33]. Acupuncture also has moderate-strength evidence to support its benefit in this population. Tai chi, yoga, psychological techniques (such as biofeedback and progressive relaxation), spinal manipulation, and multidisciplinary rehab all have weak evidence that leans toward benefit [34]. Back schools also have some evidence of benefit [35]. As far as pharmacologic management of chronic low back pain, NSAIDs and duloxetine demonstrate ongoing benefits, while opioids only demonstrate short-term benefits [AHRQ 2016]. Gabapentin is a very commonly used anticonvulsant for chronic pain; however, it has not demonstrated a significant benefit for patients with chronic low back pain [36]. Topiramate is more effective than a placebo [37]. Topical anesthetics such as lidocaine patches and transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo [38][39].

According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year [40]. However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, spinal fusion, or lumbar disk replacement [40][41][42].

In children:

In pediatrics, treatments for pain are less well studied. However, activity modification, physical therapy, and NSAIDs have broad support as first-line therapies [17]. If there is an underlying malicious cause present, the treatment of those underlying disorders is the standard of care. A majority of spondylolysis may be managed conservatively as above, but some will need a referral for surgical intervention [43][44][43]. Persistent symptoms after greater than six months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation [45][46]. In patients with Scheuermann's kyphosis, physical therapy and guided exercise may be sufficient for patients with less than 60 degrees curvature, bracing may be added for patients with curvature less than 70 degrees. Surgical correction may be indicated for patients with greater than 75 degrees curvature, especially if they have failed conservative measures and are skeletally mature [47][48]. Scoliosis of 20 degrees or more during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for surgical referral [49].

Differential Diagnosis

The differential diagnosis for back pain is comprehensive when considering the pediatric population. Below is a review of the more common diagnoses along with history or physical exam features that may increase your index of suspicion. This list is not comprehensive but represents the more likely and more concerning conditions that make up the differential.


  • Lumbosacral muscle strains/sprains
    • Presentation: follows traumatic incident or repetitive overuse, pain worse with movement, better with rest, restricted range of motion, tenderness to palpation of muscles
  • Lumbar spondylosis
    • Presentation: patient typically is greater than 40 years old, pain may be present or radiate from hips, pain with extension or rotation, the neurologic exam is usually normal [50]
  • Disk herniation
    • Presentation: usually involves the L4 to S1 segments, may include paresthesia, sensory change, loss of strength or reflexes depending on severity and nerve root involved [50]
  • Spondylolysis, Spondylolisthesis
    • Presentation: similar to pediatrics, spondylolisthesis may present back pain with radiation to the buttock and posterior thighs, neurologic deficits are usually in the L5 distribution [50]
  • Vertebral compression fracture
    • Presentation: localized back pain worse with flexion, point tenderness on palpation, may be acute or occur insidiously over time, age, chronic steroid use, and osteoporosis are risk factors [51]
  • Spinal stenosis
    • Presentation: back pain, which can be accompanied by sensory loss or weakness in legs relieved with rest (neurologic claudication), neuro exam can be within normal limits or can have progressive loss of sensation, as well as weakness [51]
  • Tumor
    • Presentation: a history of metastatic cancer, unexplained weight loss, focal tenderness to palpation in the setting of risk factors
    • Clinical note: 97% of spinal tumors are metastatic diseases; however, the provider should keep multiple myeloma in the differential [51]
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
    • Presentation: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery, fever, wound in the spinal region, localized pain, and tenderness
    • Clinical note: Granulomatous disease may represent as high as one-third of cases in developing countries [52]
  • Fracture
    • Presentation: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes


  • Tumor
    • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis [53]
    • Clinical note: Osteoid osteoma is the most common tumor that presents with back pain - classically, the pain is promptly relieved with anti-inflammatory drugs such as NSAIDs [54][55][54]
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
    • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis
    • Clinical notes: Epidural abscess should be a consideration with the presence of fever, spinal pain, and neurologic deficits or radicular pain; discitis may present with a patient refusing to walk or crawl [56][57][56]
  • A herniated disk, slipped apophysis
    • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal forward flexion, recent onset scoliosis [58]
  • Spondylolysis, spondylolisthesis, lesion, or injury to the posterior arch
    • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal extension, tight hamstrings [58]
  • Vertebral fracture
    • Presentation: acute pain, other injuries, traumatic mechanism of injury, neurologic loss
  • Muscle strain
    • Presentation: acute pain, muscle tenderness without radiation
  • Scheuermann’s kyphosis
    • Presentation: chronic pain, rigid kyphosis
  • Inflammatory spondyloarthropathies
    • Presentation: chronic pain, morning stiffness lasting greater than 30min, sacroiliac joint tenderness 
  • Psychological Disorder (conversion, somatization disorder)
    • Presentation: normal evaluation but persistent subjective pain
  • Idiopathic Scoliosis:
    • Presentation: positive Adam’s test (for more significant angle curvature), most commonly asymptomatic
    • Clinical note: Of note, no definitive evidence that scoliosis causes pain, but patients with scoliosis have more frequently reported pain; therefore the provider should rule out other causes before attributing pain to scoliosis [58]


Many factors seem to predict worse outcomes for patients who suffer from back pain. Prior episodes of back pain, greater intensity of back pain, and the presence of leg or widespread symptoms are all associated with worse “chronic disabling pain.” Lifestyle activities also seem to play a role, including patients having higher body mass indexes (greater than 25) and smoking contributing to worse outcomes [59]. Depression, catastrophizing, and fear-avoidance behavior all worsen outcomes, including disability rates [60]. There are also underlying social factors that have significant prognostic accuracy [61]. These factors all have significant interplay, such as low educational attainment, having a job that requires significant physical workloads, poor compensation, and poor job satisfaction all negatively impact outcomes [62][63]. Overall, the vast majority of back pain cases improve and do not leave a significant impact on a patient's quality of life or function. 

There is less clear prognostic evidence for pediatrics. However, one valid assumption is that the prognosis largely relies on the underlying etiology of the pain [64]. The pain caused by cancer will likely have a different impact on disability than a muscle strain [65]. Similarities exist in the pediatric population and adults, however. In regards to non-specific back pain, some studies lean toward increasing back pain with behavioral comorbidities [66]. Conduct problems, attention deficit hyperactivity disorder (ADHD), and psychological distress, as well as passive coping strategies, and fear-avoidance behavior [67][68].


Complications are largely determined based on underlying etiology; however, they can mostly subdivide into physical and social complications. Physically, complications can include chronic pain, deformity, and/or neurologic impact either with motor or sensory deficits, or bowel/bladder involvement. Socially, complications are usually measured by disability, decreased gross domestic product, and increased absenteeism. A study in 2015 found that back pain was responsible for 60.1 million years lived with disability worldwide. This data represents the most common cause of disability globally [69]. In the US, low back pain accounts for the most common reason for disability [70]. Due diligence with a thorough history and physical exam, along with a high index of suspicion are what help negate potential adverse outcomes. The global impact of back pain is hard to quantify. Stopping acute pain before it becomes chronic is the ounce of prevention. Sedentary activity leads to worsening obesity, which, in turn, causes more back pain. An effective way to break this cycle is through active patient engagement and motivating patients to work towards recovery.

Deterrence and Patient Education

After a review of the evidence, it would seem that the best patient education that can be provided to prevent back pain is to maintain a healthy body weight with a body mass index (BMI) less than 25, as higher BMI correlates with worse outcomes [59]. Patients of all ages should avoid smoking as it increases rates of back pain in all ages [71][72]. Continuing to engage in physical activity as fear-avoidant behaviors worsen disability. There is strong evidence that intensive patient education lasting for 2.5 hrs discussing activity modification, staying active, and early return to normal activity is more effective for returning to work [73]. There is mixed evidence about whether bookbag weight plays a role in pediatric back pain [74]. Still, despite the unclear evidence, the American Academy of Pediatrics recommends that book bags do not exceed 10 to 20% of the child’s body weight.[AAP 2004]. Furthermore, it is never normal to have sensation changes, weakness, difficulty ambulating, pain awakening from sleep, or bowel or bladder incontinence associated with back pain. These are potential signs and symptoms of more serious injury and require urgent medical evaluation. Fortunately, the vast majority of cases of back pain are self-limited and improve over a few weeks. Furthermore, in cases of persistent back pain, following the acute period (six weeks), imaging may be indicated. Back pain unresponsive to initial conservative management may warrant evaluation by a specialist and may benefit from more invasive treatment modalities such as injections or surgery.

Pearls and Other Issues

There are practice pearls worth remembering in the evaluation and treatment of back pain.

For adults:

  • History and physical exam are sufficient for evaluation of non-traumatic, acute back pain in the absence of red flags - avoid imaging before six weeks in severe back pain in the absence of red flags [75][76][75]
  • NSAIDs, opioids, and topiramate are more effective than placebo in the short-term treatment of nonspecific chronic low back pain [77][78][77]
  • Acetaminophen, antidepressants (except duloxetine), lidocaine patches, and TENS are not consistently more effective than placebo in the treatment of chronic low back pain [79][80]
  • Consider a physical therapy referral for McKenzie method techniques to reduce the risk of recurrence; intensive patient education that includes advice to stay active, avoid aggravating movements, and return to regular activity as soon as possible is effective in patients with nonspecific pain [81][82]

For children:

  • Children with back pain who have no significant physical findings, a short duration of pain, and a history of minor injury can be treated conservatively with no further evaluation [83]
  • Children with back pain, either abnormal physical findings, constant pain, nighttime pain, or radicular pain, should receive further evaluation [83]
  • Anterioposterior and plain lateral films are the first-line radiographic studies
  • Consider laboratory evaluation to accompany your radiographs as malignancy and infection are higher on the differential diagnosis for pediatric patients than adults [68]
  • Tumor and infection needs to be ruled out for back pain in children four years and younger [84]

Enhancing Healthcare Team Outcomes

Back pain affects millions of people and is a leading cause of chronic pain and disability. It also leads to higher costs of healthcare. The first line assessment of back pain comes from the patient's primary care provider. They are essential in the evaluation and treatment of back pain. It helps to identify red flags for urgent treatment and referral, and it aids to minimize unnecessary procedures or opioid prescriptions and is critical in limiting the development of chronic pain.

The patients who develop chronic pain may benefit from seeing a chronic pain specialist for possible medication management and/or interventional procedures. Signs and symptoms of inflammatory arthritis of the lumbar spine should be further evaluated by a rheumatologist. Either severe radiculopathy or rapid neurological changes should be evaluated by a neurosurgeon urgently. Management of comorbid depression is also paramount. Cognitive-behavioral therapists and/or psychiatrists are needed to help co-manage patients with back pain with comorbid mental health disorders. The physical therapist should be involved early in the care and urge the patient to exercise regularly. The dietitian should encourage a healthy diet and body weight maintenance.

Furthermore, a nutritionist or obesity medicine specialist can help with weight loss and is useful for both primary and secondary prevention of back pain. Acupuncturists, osteopathic manipulative medicine specialists,  yoga instructors, or tai chi instructors can all be instrumental in improving function in patients with both acute and chronic low back pain. Pharmacists play an essential role in the care of complex patients with chronic pain; patients may be on multiple opioids and sedatives requiring frequent monitoring. Furthermore, radiologists aid in the diagnosis of various etiologies of back pain, including spinal stenosis and disc herniation.

Back pain, if not treated appropriately, can become chronic and debilitating over time. There is some debate as to the most appropriate treatment for back pain to maximize outcomes. Disease-oriented medicine, not holistic, has proven to have relatively weak outcomes regarding chronic back pain.  Approaching the treatment of pain from an interprofessional approach maximizes the chances of having better results. 

Nursing should assist the clinical team with educating the patient on non-narcotic pain medications and possibly on alternative means of pain control, including yoga, deep breathing, and acupuncture. Clinicians should refrain from empirically prescribing narcotics as they lead to addiction, tolerance, and abuse. In the rare instances when narcotics are specified, both the pharmacist and clinician should work together to avoid long-term prescriptions of controlled drugs.

Bearing in mind the clinical clues which provide worse prognostic outcomes such as underlying mental health disorders, kinesiophobia, obesity, and smoking, it is likely to be helpful to treat the whole patient with an interprofessional team. Screening for some of these comorbidities as a primary care provider may be of assistance if the patient is not responding to conservative therapy. The primary physician can also offer smoking cessation and other lifestyle management counseling to the patient. The interprofessional team should communicate with each other to prevent duplication of treatments and tests, and this also helps deliver the same message to the patient.


The addition of early physical therapy has shown benefit more rapid improvement of health care utilization and opioid use [85] [Level I]. The addition of a provider skilled in cognitive behavioral therapy may assist patients with an underlying mood disorder that can contribute to symptoms as well as the development of coping skills [86] [Level I]. Interventions aimed at lowering the patient's weight may also provide significant back pain relief; however, the evidence is not as compelling [87] [Level IV]. 



Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Archives of internal medicine. 2009 Feb 9:169(3):251-8. doi: 10.1001/archinternmed.2008.543. Epub     [PubMed PMID: 19204216]


Barros G, McGrath L, Gelfenbeyn M. Sacroiliac Joint Dysfunction in Patients With Low Back Pain. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2019 Aug:36(8):370-375     [PubMed PMID: 31456628]


Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert review of neurotherapeutics. 2013 Jan:13(1):99-116. doi: 10.1586/ern.12.148. Epub     [PubMed PMID: 23253394]


Buell KG, Sivasubramaniyam S, Sykes M, Zafar K, Bingham L, Mitra A. Expediting the management of cauda equina syndrome in the emergency department through clinical pathway design. BMJ open quality. 2019:8(4):e000597. doi: 10.1136/bmjoq-2018-000597. Epub 2019 Nov 2     [PubMed PMID: 31799444]

Level 2 (mid-level) evidence


Musich S, Wang SS, Slindee LB, Keown K, Hawkins K, Yeh CS. Using Pain Medication Intensity to Stratify Back Pain Among Older Adults. Pain medicine (Malden, Mass.). 2019 Feb 1:20(2):252-266. doi: 10.1093/pm/pny007. Epub     [PubMed PMID: 29394401]


Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British journal of sports medicine. 2020 Nov:54(21):1279-1287. doi: 10.1136/bjsports-2019-100886. Epub 2019 Oct 30     [PubMed PMID: 31666220]

Level 1 (high-level) evidence


Wei X, Liu B, He L, Yang X, Zhou J, Zhao H, Liu J. Acupuncture therapy for chronic low back pain: protocol of a prospective, multi-center, registry study. BMC musculoskeletal disorders. 2019 Oct 27:20(1):488. doi: 10.1186/s12891-019-2894-4. Epub 2019 Oct 27     [PubMed PMID: 31656194]


Qin J, Zhang Y, Wu L, He Z, Huang J, Tao J, Chen L. Effect of Tai Chi alone or as additional therapy on low back pain: Systematic review and meta-analysis of randomized controlled trials. Medicine. 2019 Sep:98(37):e17099. doi: 10.1097/MD.0000000000017099. Epub     [PubMed PMID: 31517838]

Level 2 (mid-level) evidence


Patrick N, Emanski E, Knaub MA. Acute and chronic low back pain. The Medical clinics of North America. 2014 Jul:98(4):777-89, xii. doi: 10.1016/j.mcna.2014.03.005. Epub     [PubMed PMID: 24994051]


Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet (London, England). 2012 Feb 4:379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6     [PubMed PMID: 21982256]


Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best practice & research. Clinical rheumatology. 2010 Dec:24(6):769-81. doi: 10.1016/j.berh.2010.10.002. Epub     [PubMed PMID: 21665125]


Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. Journal of spinal disorders. 2000 Jun:13(3):205-17     [PubMed PMID: 10872758]

Level 1 (high-level) evidence


Leboeuf-Yde C, Kyvik KO. At what age does low back pain become a common problem? A study of 29,424 individuals aged 12-41 years. Spine. 1998 Jan 15:23(2):228-34     [PubMed PMID: 9474731]


Jeffries LJ, Milanese SF, Grimmer-Somers KA. Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine. 2007 Nov 1:32(23):2630-7     [PubMed PMID: 17978666]

Level 3 (low-level) evidence


Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992 Aug 12:268(6):760-5     [PubMed PMID: 1386391]


M Das J, Nadi M. Lasegue Sign. StatPearls. 2023 Jan:():     [PubMed PMID: 31424883]


Patel DR, Kinsella E. Evaluation and management of lower back pain in young athletes. Translational pediatrics. 2017 Jul:6(3):225-235. doi: 10.21037/tp.2017.06.01. Epub     [PubMed PMID: 28795014]


Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, Macaskill P, Irwig L, van Tulder MW, Koes BW, Maher CG. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.). 2013 Dec 11:347():f7095. doi: 10.1136/bmj.f7095. Epub 2013 Dec 11     [PubMed PMID: 24335669]

Level 1 (high-level) evidence


Casazza BA. Diagnosis and treatment of acute low back pain. American family physician. 2012 Feb 15:85(4):343-50     [PubMed PMID: 22335313]


Feldman DS, Hedden DM, Wright JG. The use of bone scan to investigate back pain in children and adolescents. Journal of pediatric orthopedics. 2000 Nov-Dec:20(6):790-5     [PubMed PMID: 11097256]


Hollingworth P. Back pain in children. British journal of rheumatology. 1996 Oct:35(10):1022-8     [PubMed PMID: 8883446]


Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, Holly L, Hunt CH, Jagadeesan BD, Kennedy TA, O'Toole JE, Perlmutter JS, Policeni B, Rosenow JM, Schroeder JW, Whitehead MT, Cornelius RS, Corey AS. ACR Appropriateness Criteria Low Back Pain. Journal of the American College of Radiology : JACR. 2016 Sep:13(9):1069-78. doi: 10.1016/j.jacr.2016.06.008. Epub 2016 Aug 3     [PubMed PMID: 27496288]


Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, Robinson D, Staiger T, Wessbecher F, Sullivan SD, Kreuter W, Deyo RA. Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4:289(21):2810-8     [PubMed PMID: 12783911]

Level 1 (high-level) evidence


Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. Journal of pediatric orthopedics. 2013 Apr-May:33(3):282-8. doi: 10.1097/BPO.0b013e318287fffb. Epub     [PubMed PMID: 23482264]


Borchers AT, Gershwin ME. Transverse myelitis. Autoimmunity reviews. 2012 Jan:11(3):231-48. doi: 10.1016/j.autrev.2011.05.018. Epub 2011 May 18     [PubMed PMID: 21621005]


Kujala UM, Kinnunen J, Helenius P, Orava S, Taavitsainen M, Karaharju E. Prolonged low-back pain in young athletes: a prospective case series study of findings and prognosis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 1999:8(6):480-4     [PubMed PMID: 10664307]

Level 2 (mid-level) evidence


Wang H, Cheng J, Xiao H, Li C, Zhou Y. Adolescent lumbar disc herniation: experience from a large minimally invasive treatment centre for lumbar degenerative disease in Chongqing, China. Clinical neurology and neurosurgery. 2013 Aug:115(8):1415-9. doi: 10.1016/j.clineuro.2013.01.019. Epub 2013 Feb 16     [PubMed PMID: 23419406]

Level 2 (mid-level) evidence


Gran JT, Husby G. HLA-B27 and spondyloarthropathy: value for early diagnosis? Journal of medical genetics. 1995 Jul:32(7):497-501     [PubMed PMID: 7562959]


Reveille JD. HLA-B27 and the seronegative spondyloarthropathies. The American journal of the medical sciences. 1998 Oct:316(4):239-49     [PubMed PMID: 9766485]


McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children. Pediatrics. 2002 Aug:110(2 Pt 1):354-9     [PubMed PMID: 12165590]


Ejaz AA, Pourafshar N, Mohandas R, Smallwood BA, Johnson RJ, Hsu JW. Uric acid and the prediction models of tumor lysis syndrome in AML. PloS one. 2015:10(3):e0119497. doi: 10.1371/journal.pone.0119497. Epub 2015 Mar 16     [PubMed PMID: 25775138]


Rosedale R, Rastogi R, May S, Chesworth BM, Filice F, Willis S, Howard J, Naudie D, Robbins SM. Efficacy of exercise intervention as determined by the McKenzie System of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy. 2014 Mar:44(3):173-81, A1-6. doi: 10.2519/jospt.2014.4791. Epub 2014 Jan 22     [PubMed PMID: 24450370]

Level 1 (high-level) evidence


Dunsford A, Kumar S, Clarke S. Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain. Journal of multidisciplinary healthcare. 2011:4():393-402. doi: 10.2147/JMDH.S24733. Epub 2011 Nov 1     [PubMed PMID: 22135496]


Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ (Clinical research ed.). 2015 Feb 18:350():h444. doi: 10.1136/bmj.h444. Epub 2015 Feb 18     [PubMed PMID: 25694111]

Level 1 (high-level) evidence


Straube S, Harden M, Schröder H, Arendacka B, Fan X, Moore RA, Friede T. Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research-systematic review and meta-analysis. Pain. 2016 Oct:157(10):2160-2172. doi: 10.1097/j.pain.0000000000000640. Epub     [PubMed PMID: 27257858]

Level 1 (high-level) evidence


Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ, Bhandari M. Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS medicine. 2017 Aug:14(8):e1002369. doi: 10.1371/journal.pmed.1002369. Epub 2017 Aug 15     [PubMed PMID: 28809936]

Level 1 (high-level) evidence


Muehlbacher M, Nickel MK, Kettler C, Tritt K, Lahmann C, Leiberich PK, Nickel C, Krawczyk J, Mitterlehner FO, Rother WK, Loew TH, Kaplan P. Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. The Clinical journal of pain. 2006 Jul-Aug:22(6):526-31     [PubMed PMID: 16788338]

Level 1 (high-level) evidence


Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC musculoskeletal disorders. 2014 Aug 30:15():286. doi: 10.1186/1471-2474-15-286. Epub 2014 Aug 30     [PubMed PMID: 25175885]

Level 1 (high-level) evidence


Buchmuller A, Navez M, Milletre-Bernardin M, Pouplin S, Presles E, Lantéri-Minet M, Tardy B, Laurent B, Camdessanché JP, Lombotens Trial Group. Value of TENS for relief of chronic low back pain with or without radicular pain. European journal of pain (London, England). 2012 May:16(5):656-65. doi: 10.1002/j.1532-2149.2011.00061.x. Epub 2011 Dec 20     [PubMed PMID: 22337531]


Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM, American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May 1:34(10):1066-77. doi: 10.1097/BRS.0b013e3181a1390d. Epub     [PubMed PMID: 19363457]

Level 1 (high-level) evidence


Staal JB, de Bie R, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain. The Cochrane database of systematic reviews. 2008 Jul 16:2008(3):CD001824. doi: 10.1002/14651858.CD001824.pub3. Epub 2008 Jul 16     [PubMed PMID: 18646078]

Level 1 (high-level) evidence


Machado GC, Ferreira PH, Yoo RI, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML. Surgical options for lumbar spinal stenosis. The Cochrane database of systematic reviews. 2016 Nov 1:11(11):CD012421     [PubMed PMID: 27801521]

Level 1 (high-level) evidence


Karatas AF, Dede O, Atanda AA, Holmes L Jr, Rogers K, Gabos P, Shah SA. Comparison of Direct Pars Repair Techniques of Spondylolysis in Pediatric and Adolescent Patients: Pars Compression Screw Versus Pedicle Screw-Rod-Hook. Clinical spine surgery. 2016 Aug:29(7):272-80. doi: 10.1097/BSD.0b013e318277cb7d. Epub     [PubMed PMID: 23075858]


Menga EN, Kebaish KM, Jain A, Carrino JA, Sponseller PD. Clinical results and functional outcomes after direct intralaminar screw repair of spondylolysis. Spine. 2014 Jan 1:39(1):104-10. doi: 10.1097/BRS.0000000000000043. Epub     [PubMed PMID: 24108299]


Helenius I, Lamberg T, Osterman K, Schlenzka D, Yrjönen T, Tervahartiala P, Seitsalo S, Poussa M, Remes V. Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients. Spine. 2005 Feb 1:30(3):336-41     [PubMed PMID: 15682016]


Lundine KM, Lewis SJ, Al-Aubaidi Z, Alman B, Howard AW. Patient outcomes in the operative and nonoperative management of high-grade spondylolisthesis in children. Journal of pediatric orthopedics. 2014 Jul-Aug:34(5):483-9. doi: 10.1097/BPO.0000000000000133. Epub     [PubMed PMID: 24590330]


Tsirikos AI, Jain AK. Scheuermann's kyphosis; current controversies. The Journal of bone and joint surgery. British volume. 2011 Jul:93(7):857-64. doi: 10.1302/0301-620X.93B7.26129. Epub     [PubMed PMID: 21705553]


Lim M, Green DW, Billinghurst JE, Huang RC, Rawlins BA, Widmann RF, Burke SW, Boachie-Adjei O. Scheuermann kyphosis: safe and effective surgical treatment using multisegmental instrumentation. Spine. 2004 Aug 15:29(16):1789-94     [PubMed PMID: 15303023]


Parent S, Newton PO, Wenger DR. Adolescent idiopathic scoliosis: etiology, anatomy, natural history, and bracing. Instructional course lectures. 2005:54():529-36     [PubMed PMID: 15948477]


Will JS, Bury DC, Miller JA. Mechanical Low Back Pain. American family physician. 2018 Oct 1:98(7):421-428     [PubMed PMID: 30252425]


Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M, Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet (London, England). 2018 Jun 9:391(10137):2356-2367. doi: 10.1016/S0140-6736(18)30480-X. Epub 2018 Mar 21     [PubMed PMID: 29573870]


Trecarichi EM, Di Meco E, Mazzotta V, Fantoni M. Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. European review for medical and pharmacological sciences. 2012 Apr:16 Suppl 2():58-72     [PubMed PMID: 22655484]


Slipman CW, Patel RK, Botwin K, Huston C, Zhang L, Lenrow D, Garvan C. Epidemiology of spine tumors presenting to musculoskeletal physiatrists. Archives of physical medicine and rehabilitation. 2003 Apr:84(4):492-5     [PubMed PMID: 12690585]


Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Seminars in arthritis and rheumatism. 1983 Feb:12(3):265-81     [PubMed PMID: 6603021]

Level 3 (low-level) evidence


Azouz EM, Kozlowski K, Marton D, Sprague P, Zerhouni A, Asselah F. Osteoid osteoma and osteoblastoma of the spine in children. Report of 22 cases with brief literature review. Pediatric radiology. 1986:16(1):25-31     [PubMed PMID: 2935775]

Level 3 (low-level) evidence


Kang HM, Choi EH, Lee HJ, Yun KW, Lee CK, Cho TJ, Cheon JE, Lee H. The Etiology, Clinical Presentation and Long-term Outcome of Spondylodiscitis in Children. The Pediatric infectious disease journal. 2016 Apr:35(4):e102-6. doi: 10.1097/INF.0000000000001043. Epub     [PubMed PMID: 26974751]


Spencer SJ, Wilson NI. Childhood discitis in a regional children's hospital. Journal of pediatric orthopedics. Part B. 2012 May:21(3):264-8. doi: 10.1097/BPB.0b013e32834d3e94. Epub     [PubMed PMID: 22015583]


Ramirez N, Johnston CE, Browne RH. The prevalence of back pain in children who have idiopathic scoliosis. The Journal of bone and joint surgery. American volume. 1997 Mar:79(3):364-8     [PubMed PMID: 9070524]


Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7:303(13):1295-302. doi: 10.1001/jama.2010.344. Epub     [PubMed PMID: 20371789]


Hendrick P, Milosavljevic S, Hale L, Hurley DA, McDonough S, Ryan B, Baxter GD. The relationship between physical activity and low back pain outcomes: a systematic review of observational studies. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2011 Mar:20(3):464-74. doi: 10.1007/s00586-010-1616-2. Epub 2010 Nov 4     [PubMed PMID: 21053026]

Level 1 (high-level) evidence


Pinheiro MB, Ferreira ML, Refshauge K, Maher CG, Ordoñana JR, Andrade TB, Tsathas A, Ferreira PH. Symptoms of depression as a prognostic factor for low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2016 Jan 1:16(1):105-16. doi: 10.1016/j.spinee.2015.10.037. Epub 2015 Oct 30     [PubMed PMID: 26523965]

Level 1 (high-level) evidence


Wertli MM, Eugster R, Held U, Steurer J, Kofmehl R, Weiser S. Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2014 Nov 1:14(11):2639-57. doi: 10.1016/j.spinee.2014.03.003. Epub 2014 Mar 7     [PubMed PMID: 24607845]

Level 1 (high-level) evidence


Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2014 May 1:14(5):816-36.e4. doi: 10.1016/j.spinee.2013.09.036. Epub 2013 Oct 18     [PubMed PMID: 24412032]

Level 1 (high-level) evidence


Jones GT, Watson KD, Silman AJ, Symmons DP, Macfarlane GJ. Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics. 2003 Apr:111(4 Pt 1):822-8     [PubMed PMID: 12671119]


Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Psychosocial risks for disability in children with chronic back pain. The journal of pain. 2006 Apr:7(4):244-51     [PubMed PMID: 16618468]


Korovessis P, Repantis T, Baikousis A. Factors affecting low back pain in adolescents. Journal of spinal disorders & techniques. 2010 Dec:23(8):513-20. doi: 10.1097/BSD.0b013e3181bf99c6. Epub     [PubMed PMID: 20075753]


Ramond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, Huez JF. Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Family practice. 2011 Feb:28(1):12-21. doi: 10.1093/fampra/cmq072. Epub 2010 Sep 10     [PubMed PMID: 20833704]

Level 1 (high-level) evidence


Mustard CA, Kalcevich C, Frank JW, Boyle M. Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up. American journal of epidemiology. 2005 Oct 15:162(8):779-86     [PubMed PMID: 16150891]


GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet (London, England). 2016 Oct 8:388(10053):1545-1602. doi: 10.1016/S0140-6736(16)31678-6. Epub     [PubMed PMID: 27733282]

Level 1 (high-level) evidence


US Burden of Disease Collaborators, Mokdad AH, Ballestros K, Echko M, Glenn S, Olsen HE, Mullany E, Lee A, Khan AR, Ahmadi A, Ferrari AJ, Kasaeian A, Werdecker A, Carter A, Zipkin B, Sartorius B, Serdar B, Sykes BL, Troeger C, Fitzmaurice C, Rehm CD, Santomauro D, Kim D, Colombara D, Schwebel DC, Tsoi D, Kolte D, Nsoesie E, Nichols E, Oren E, Charlson FJ, Patton GC, Roth GA, Hosgood HD, Whiteford HA, Kyu H, Erskine HE, Huang H, Martopullo I, Singh JA, Nachega JB, Sanabria JR, Abbas K, Ong K, Tabb K, Krohn KJ, Cornaby L, Degenhardt L, Moses M, Farvid M, Griswold M, Criqui M, Bell M, Nguyen M, Wallin M, Mirarefin M, Qorbani M, Younis M, Fullman N, Liu P, Briant P, Gona P, Havmoller R, Leung R, Kimokoti R, Bazargan-Hejazi S, Hay SI, Yadgir S, Biryukov S, Vollset SE, Alam T, Frank T, Farid T, Miller T, Vos T, Bärnighausen T, Gebrehiwot TT, Yano Y, Al-Aly Z, Mehari A, Handal A, Kandel A, Anderson B, Biroscak B, Mozaffarian D, Dorsey ER, Ding EL, Park EK, Wagner G, Hu G, Chen H, Sunshine JE, Khubchandani J, Leasher J, Leung J, Salomon J, Unutzer J, Cahill L, Cooper L, Horino M, Brauer M, Breitborde N, Hotez P, Topor-Madry R, Soneji S, Stranges S, James S, Amrock S, Jayaraman S, Patel T, Akinyemiju T, Skirbekk V, Kinfu Y, Bhutta Z, Jonas JB, Murray CJL. The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018 Apr 10:319(14):1444-1472. doi: 10.1001/jama.2018.0158. Epub     [PubMed PMID: 29634829]


Hestbaek L, Leboeuf-Yde C, Kyvik KO. Are lifestyle-factors in adolescence predictors for adult low back pain? A cross-sectional and prospective study of young twins. BMC musculoskeletal disorders. 2006 Mar 15:7():27     [PubMed PMID: 16539729]

Level 2 (mid-level) evidence


Leboeuf-Yde C. Smoking and low back pain. A systematic literature review of 41 journal articles reporting 47 epidemiologic studies. Spine. 1999 Jul 15:24(14):1463-70     [PubMed PMID: 10423792]

Level 1 (high-level) evidence


Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. The Cochrane database of systematic reviews. 2008 Jan 23:2008(1):CD004057. doi: 10.1002/14651858.CD004057.pub3. Epub 2008 Jan 23     [PubMed PMID: 18254037]

Level 1 (high-level) evidence


Skaggs DL, Early SD, D'Ambra P, Tolo VT, Kay RM. Back pain and backpacks in school children. Journal of pediatric orthopedics. 2006 May-Jun:26(3):358-63     [PubMed PMID: 16670549]


Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Annals of internal medicine. 2011 Feb 1:154(3):181-9. doi: 10.7326/0003-4819-154-3-201102010-00008. Epub     [PubMed PMID: 21282698]


Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. The Cochrane database of systematic reviews. 2016 Jun 7:2016(6):CD012230. doi: 10.1002/14651858.CD012230. Epub 2016 Jun 7     [PubMed PMID: 27271789]

Level 1 (high-level) evidence


Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine. 2008 Jul 15:33(16):1766-74. doi: 10.1097/BRS.0b013e31817e69d3. Epub     [PubMed PMID: 18580547]


van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for non-specific low back pain. The Cochrane database of systematic reviews. 2003:2003(2):CD004252     [PubMed PMID: 12804507]

Level 1 (high-level) evidence


Urquhart DM, Hoving JL, Assendelft WW, Roland M, van Tulder MW. Antidepressants for non-specific low back pain. The Cochrane database of systematic reviews. 2008 Jan 23:2008(1):CD001703. doi: 10.1002/14651858.CD001703.pub3. Epub 2008 Jan 23     [PubMed PMID: 18253994]

Level 1 (high-level) evidence


Long A, May S, Fung T. The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? The Journal of manual & manipulative therapy. 2008:16(4):248-54     [PubMed PMID: 19771197]

Level 2 (mid-level) evidence


Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms--a systematic review. Manual therapy. 2004 Aug:9(3):134-43     [PubMed PMID: 15245707]

Level 1 (high-level) evidence


Clare HA, Adams R, Maher CG. Reliability of McKenzie classification of patients with cervical or lumbar pain. Journal of manipulative and physiological therapeutics. 2005 Feb:28(2):122-7     [PubMed PMID: 15800512]


Szpalski M, Gunzburg R, Balagué F, Nordin M, Mélot C. A 2-year prospective longitudinal study on low back pain in primary school children. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2002 Oct:11(5):459-64     [PubMed PMID: 12384754]


Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. Journal of pediatric orthopedics. 2006 May-Jun:26(3):353-7     [PubMed PMID: 16670548]


Arnold E, La Barrie J, DaSilva L, Patti M, Goode A, Clewley D. The Effect of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review. Archives of physical medicine and rehabilitation. 2019 Jul:100(7):1324-1338. doi: 10.1016/j.apmr.2018.11.025. Epub 2019 Jan 24     [PubMed PMID: 30684490]

Level 1 (high-level) evidence


Hajihasani A, Rouhani M, Salavati M, Hedayati R, Kahlaee AH. The Influence of Cognitive Behavioral Therapy on Pain, Quality of Life, and Depression in Patients Receiving Physical Therapy for Chronic Low Back Pain: A Systematic Review. PM & R : the journal of injury, function, and rehabilitation. 2019 Feb:11(2):167-176. doi: 10.1016/j.pmrj.2018.09.029. Epub 2019 Feb 11     [PubMed PMID: 30266349]

Level 2 (mid-level) evidence


Roffey DM, Ashdown LC, Dornan HD, Creech MJ, Dagenais S, Dent RM, Wai EK. Pilot evaluation of a multidisciplinary, medically supervised, nonsurgical weight loss program on the severity of low back pain in obese adults. The spine journal : official journal of the North American Spine Society. 2011 Mar:11(3):197-204. doi: 10.1016/j.spinee.2011.01.031. Epub     [PubMed PMID: 21377601]

Level 3 (low-level) evidence


Lam OT, Strenger DM, Chan-Fee M, Pham PT, Preuss RA, Robbins SM. Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis. The Journal of orthopaedic and sports physical therapy. 2018 Jun:48(6):476-490. doi: 10.2519/jospt.2018.7562. Epub 2018 Mar 30     [PubMed PMID: 29602304]

Level 1 (high-level) evidence


Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ, Orthopaedic Section of the American Physical Therapy Association. Low back pain. The Journal of orthopaedic and sports physical therapy. 2012 Apr:42(4):A1-57. doi: 10.2519/jospt.2012.42.4.A1. Epub 2012 Mar 30     [PubMed PMID: 22466247]


Holtermann A, Clausen T, Jørgensen MB, Aust B, Mortensen OS, Burdorf A, Fallentin N, Andersen LL. Does rare use of assistive devices during patient handling increase the risk of low back pain? A prospective cohort study among female healthcare workers. International archives of occupational and environmental health. 2015 Apr:88(3):335-42. doi: 10.1007/s00420-014-0963-4. Epub 2014 Jul 23     [PubMed PMID: 25053444]