Evaluation and Diagnostic Approach

Patient Education and Self-care

Non-pharmacologic and Non-invasive Therapy

Pharmacotherapy

Dietary Supplements

Non-surgical Invasive Therapy

Team Approach

Algorithms

Sidebars

Document Overview

Design and created by Guideline Central in participation with the Veterans Health Administration / Department of Defense.

Diagnosis and Treatment of Low Back Pain

Veterans Health Administration / Department of Defense

Publication Date: Apr 26, 2022

Page Last Updated: May 5, 2026

Strength of Recommendations in GRADE

Strength	Interpretation	Implications for clinicians	Implications for policymakers
Strong for	Almost all informed patients would choose to receive the intervention	Should be accepted by most patients to whom it is offered	Should be adopted as policy
Weak for	Most informed patients would choose the intervention, but a sizable minority would not	Large role for education and shared decision-making	Requires stakeholder engagement and discussion
Weak against	Most informed patients would not choose the intervention, but a small minority would	Large role for education and shared decision-making	Requires stakeholder engagement and discussion
Strong against	Most patients should not receive the intervention	Should not be offered to patients	Should be adopted as policy

Document Overview

Document Title: Diagnosis and Treatment of Low Back Pain (LBP)

Authoring Society: Veterans Health Administration / Department of Defense

Document Publication Date: Apr 26, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: www.healthquality.va.gov/guidelines/Pain/lbp/VADoDLBPCPGFinal508.pdf

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.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Scope: Assessment and Screening, Diagnosis, Management, Prevention, Rehabilitation, Treatment

Diseases/Conditions (MeSH)

D017116 - Low Back Pain

Keywords: Exercise-Based Prevention, degenerative lumbar spinal stenosis, low back pain (LBP), lumbar disc herniation, magnetic resonance imaging (MRI)

Inclusion Criteria: Male, Female, Adolescent, Adult, Older Adult

Health Care Settings: Ambulatory, Laboratory Services, Long Term Care, Operating and Recovery Room, Outpatient

Intended Users: Chiropractor, MRI Technologist, Nurse, Nurse Practitioner, Physical Therapist, Physician, Physician Assistant, Social Worker

Recommendation Development Processes & Methodology

Number of Source Documents: 224

Literature Search Start Date: Saturday, October 1, 2016

Literature Search End Date: Monday, February 1, 2021

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: Yes

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: No

Possible Serious Conditions	Red Flags (e.g., signs, symptoms, history)	Suggested Evaluation^a
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 MRI^b (preferred)
Infection	· Fever · Immunosuppression · IV drug use · Recent infection, indwelling catheters (e.g., central line, Foley)	· MRI^c · 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	· MRI^c · Lumbosacral plainradiography

Possible Other Conditions	Red Flags (e.g., signs, symptoms, history)	Suggested Evaluation^b
Herniated disc	· Radicular back pain (e.g., sciatica) · Lower extremity dysesthesia and/or paresthesia	None
Herniated disc	· Severe/progressive lower extremity neurologic deficits · Symptoms present >1 month	MRI^c
Spinal stenosis	· Radicular back pain (e.g., sciatica) · Lower extremity dysesthesia and/or paresthesia · Neurogenic claudication · Older age	None
Spinal stenosis	· Severe/progressive lower extremity neurologic deficits · Symptoms present >1 month	MRI^c
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

Category	Intervention (listed alphabetically by category)	Low Back Pain Duration
Category	Intervention (listed alphabetically by category)	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
Pharmacologic treatment	NSAIDs	X - Rec 19	X - Rec 19
Other treatment	Multidisciplinary or interdisciplinary program		X - Rec 39

Diagnosis and Treatment of Low Back Pain

Evaluation and Diagnostic Approach

Patient Education and Self-care

Non-pharmacologic and Non-invasive Therapy

Pharmacotherapy

Dietary Supplements

Non-surgical Invasive Therapy

Team Approach

Algorithms

Module A: Initial Evaluation of Low Back Pain

Module B: Management of Low Back Pain

Sidebars

Sidebar 1: Evaluation for Possible Serious Conditions

Sidebar 2: Evaluation for Possible Other Conditions^a

Sidebar 3: Management of Low Back Pain

Strength of Recommendations in GRADE

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Diagnosis and Treatment of Low Back Pain

Evaluation and Diagnostic Approach

Patient Education and Self-care

Non-pharmacologic and Non-invasive Therapy

Pharmacotherapy

Dietary Supplements

Non-surgical Invasive Therapy

Team Approach

Algorithms

Module A: Initial Evaluation of Low Back Pain

Module B: Management of Low Back Pain

Sidebars

Sidebar 1: Evaluation for Possible Serious Conditions

Sidebar 2: Evaluation for Possible Other Conditionsa

Sidebar 3: Management of Low Back Pain

Strength of Recommendations in GRADE

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Sidebar 2: Evaluation for Possible Other Conditions^a