Diagnosis and Treatment of Low Back Pain
Publication Date: April 26, 2022
Last Updated: May 10, 2022
Evaluation and Diagnostic Approach
For patients with low back pain, we recommend the history and physical examination include evaluation for progressive or otherwise serious neurologic deficits and other red flags (e.g., signs, symptoms, history) associated with serious underlying pathology (e.g., malignancy, fracture, infection). (Strong for)
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For patients with low back pain, we recommend diagnostic imaging and appropriate laboratory testing when neurologic deficits are progressive or otherwise serious or when other red flags (e.g., signs, symptoms, history) are present. (Strong for)
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For patients with acute low back pain, without focal neurologic deficits or other red flags (e.g., signs, symptoms, history), we recommend against routinely obtaining imaging studies or performing invasive diagnostic tests. (Strong against)
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For patients with low back pain, we suggest assessing psychosocial factors and using predictive screening instruments (e.g., STarT Back and The Orebro Musculoskeletal Pain Screening Questionnaire) to inform treatment planning. (Weak for)
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For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against specific physical exam maneuvers to assist in the diagnosis of facet or sacroiliac joint pain, or a lumbar/lumbo-sacral radiculopathy. (Neither for or against)
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Patient Education and Self-care
For patients with low back pain, there is insufficient evidence to recommend for or against pain neuroscience education, clinician-directed education with patient-led goal setting, or back school. (Neither for or against)
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For the self-management of low back pain, there is insufficient evidence to recommend for or against technology-based modalities. (Neither for or against)
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Non-pharmacologic and Non-invasive Therapy
For patients with chronic low back pain, we suggest cognitive behavioral therapy. (Weak for)
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For patients with low back pain, we suggest a structured clinician-directed exercise program (e.g., aerobic, aquatic, mechanical diagnosis and therapy, mobility, motor control, Pilates, strengthening exercises, structured walking program, tai chi). (Weak for)
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For patients with chronic low back pain, we suggest spinal mobilization/manipulation. (Weak for)
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For patients with acute low back pain, there is insufficient evidence to recommend for or against spinal mobilization/manipulation. (Neither for or against)
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For patients with chronic low back pain, there is insufficient evidence to recommend for or against mindfulness-based stress reduction. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against lumbar supports. (Neither for or against)
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For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against mechanical lumbar traction. (Neither for or against)
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For patients with chronic low back pain, there is insufficient evidence to recommend for or against auricular acupressure. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against yoga or qi gong. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against cupping, laser therapy, transcutaneous electrical nerve stimulation, and ultrasound. (Neither for or against)
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Pharmacotherapy
For patients with chronic low back pain, we suggest duloxetine. (Weak for)
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For patients with low back pain, we suggest nonsteroidal anti-inflammatory drugs. (Weak for)
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For patients with low back pain, with or without radicular symptoms, there is insufficient evidence to recommend for or against gabapentin or pregabalin. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against tricyclic antidepressants. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against topical preparations. (Neither for or against)
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For patients with acute low back pain, there is insufficient evidence to recommend for or against a non-benzodiazepine muscle relaxant for short-term use. (Neither for or against)
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For patients with chronic low back pain, we suggest against offering a non-benzodiazepine muscle relaxant. (Weak against)
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For patients with low back pain, we suggest against acetaminophen. (Weak against)
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For patients with low back pain, we suggest against monoclonal antibodies. (Weak against)
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For patients with chronic low back pain, we suggest against opioids. For patients who are already using long-term opioids, see the VA/DoD CPG for the Use of Opioids in the Management of Chronic Pain. (Weak against)
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For patients with low back pain, with or without radicular symptoms, we suggest against systemic corticosteroids (oral or intramuscular injection). (Weak against)
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For patients with low back pain, we recommend against benzodiazepines. (Strong against)
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Dietary Supplements
For patients with low back pain, there is insufficient evidence to recommend for or against any specific diet or nutritional, herbal, or homeopathic supplements (e.g., anti-inflammatory diet, turmeric, vitamin D), cannabis, or cannabinoids. (Neither for or against)
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Non-surgical Invasive Therapy
For patients with chronic low back pain, we suggest lumbar medial branch and/or sacral lateral branch radiofrequency ablation. (Weak for)
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For patients with low back pain, there is insufficient evidence to recommend for or against sacroiliac joint injections. (Neither for or against)
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For patients with low back pain, we suggest against the injection of corticosteroids for intra-articular facet joint injections and therapeutic medial branch blocks with steroid. (Weak against)
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For patients with chronic low back pain, we suggest acupuncture. (Weak for)
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For patients with acute low back pain, there is insufficient evidence to recommend for or against acupuncture. (Neither for or against)
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For patients with low back pain, there is insufficient evidence to recommend for or against ortho-biologics (e.g., platelet-rich plasma, stem cells). (Neither for or against)
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For patients with low back pain, with radicular symptoms, there is insufficient evidence to recommend for or against epidural steroid injections. (Neither for or against)
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For patients with low back pain, we suggest against spinal cord stimulation. (Weak against)
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Team Approach
For patients with chronic low back pain, we suggest a multidisciplinary or interdisciplinary program. These programs should include at least one physical component and at least one other component of the biopsychosocial model (psychological, social, and/or occupational) used in an explicitly coordinated manner. (Weak for)
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Algorithms
Module A: Initial Evaluation of Low Back Pain
Module B: Management of Low Back Pain
Sidebars
Sidebar 1: Evaluation for Possible Serious Conditions
| Possible Serious Conditions | Red Flags (e.g., signs, symptoms, history) | Suggested Evaluationa |
| Cauda equina syndrome or conus medullaris syndrome | · Urinary retention · Urinary or fecal incontinence · Saddle anesthesia · Changes in rectal tone · Severe/progressive lower extremity neurologic deficits |
· Emergent MRIb (preferred) |
| Infection | · Fever · Immunosuppression · IV drug use · Recent infection, indwelling catheters (e.g., central line, Foley) |
· MRIc · ESR and/or CRP |
| Fracture | · History of osteoporosis · Chronic use of corticosteroids · Older age (≥75 years old) · Recent trauma · Younger patients at risk for stress fracture (e.g., overuse) |
· Lumbosacral plainradiography · For inconclusive results, advancedimaging as indicated |
| Cancer | · History of cancer with new onset of LBP · Unexplained weight loss · Failure of LBP to improve after 1 month · Age >50 years · Multiple risk factors present |
· MRIc · Lumbosacral plainradiography |
a Consider specialty consultation
b MRI, except where contraindicated (e.g., patients with pacemakers), otherwise CT or CT myelogram
c MRI without and with contrast, except where contraindicated (e.g., renal insufficiency)
b MRI, except where contraindicated (e.g., patients with pacemakers), otherwise CT or CT myelogram
c MRI without and with contrast, except where contraindicated (e.g., renal insufficiency)
Sidebar 2: Evaluation for Possible Other Conditionsa
| Possible Other Conditions | Red Flags (e.g., signs, symptoms, history) | Suggested Evaluationb |
| Herniated disc | · Radicular back pain (e.g., sciatica) · Lower extremity dysesthesia and/or paresthesia |
None |
| · Severe/progressive lower extremity neurologic deficits · Symptoms present >1 month |
MRIc | |
| Spinal stenosis | · Radicular back pain (e.g., sciatica) · Lower extremity dysesthesia and/or paresthesia · Neurogenic claudication · Older age |
None |
| · Severe/progressive lower extremity neurologic deficits · Symptoms present >1 month |
MRIc | |
| Inflammatory LBP | · Morning stiffness · Improvement with exercise · Alternating buttock pain · Awakening due to LBP during the second part of the night(early morning awakening) · Younger age |
Radiography of pelvis, SI joint, and spine area of interest |
a These conditions usually do not require urgent diagnostic evaluation
b Consider specialty consultation
c Some patients may have contraindications to MRI, contrast usually not required
b Consider specialty consultation
c Some patients may have contraindications to MRI, contrast usually not required
Sidebar 3: Management of Low Back Pain
| Category | Intervention (listed alphabetically by category) | Low Back Pain Duration | |
| Acute <4 Weeks | Subacute or Chronic ≥ 4 Weeks | ||
| Self-care | Advice to remain active | X | X |
| Non-pharmacologic treatment | Acupuncture | X - Rec 34 | |
| CBT and/or MBSR | X - Rec 8 and 12 | ||
| Clinician-directed exercise program | X - Rec 9 | ||
| Spinal mobilization/manipulation | X - Rec 10 | ||
| Pharmacologic treatment | Duloxetine | X - Rec 18 | |
| NSAIDs | X - Rec 19 | X - Rec 19 | |
| Other treatment | Multidisciplinary or interdisciplinary program | X - Rec 39 | |
Recommendation Grading
Overview
Title
Diagnosis and Treatment of Low Back Pain (LBP)
Authoring Organization
Publication Month/Year
April 26, 2022
Last Updated Month/Year
February 12, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Laboratory services, Long term care, Outpatient, Operating and recovery room
Intended Users
Chiropractor, mri technologist, physical therapist, social worker, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention, Rehabilitation
Diseases/Conditions (MeSH)
D017116 - Low Back Pain
Keywords
magnetic resonance imaging (MRI), Exercise-Based Prevention, lumbar disc herniation, degenerative lumbar spinal stenosis, low back pain (LBP)
Source Citation
Pangarkar SS, Kang DG, Sandbrink F, Bevevino A, Tillisch K, Konitzer L, Sall J. VA/DoD Clinical Practice Guideline: Diagnosis and Treatment of Low Back Pain. J Gen Intern Med. 2019 Nov;34(11):2620-2629. doi: 10.1007/s11606-019-05086-4. Epub 2019 Sep 16. PMID: 31529375; PMCID: PMC6848394.
Methodology
Number of Source Documents
224
Literature Search Start Date
October 1, 2016
Literature Search End Date
February 1, 2021