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GENERAL CONSIDERATIONS

Low back pain (LBP), discomfort, tension, or stiffness below the costal margin and above the inferior gluteal folds, is one of the most common conditions encountered in primary care as an acute self-limited problem, second only to the common cold. LBP has an annual incidence of 5%, and a lifetime prevalence of 60−90%. It is the leading cause of disability in the United States for adults aged <45 years, is a leading cause of non−battle injury air evacuation from recent military deployments, and is responsible for one-third of workers’ compensation costs and accounts for direct and indirect of nearly $90 billion per year. At any given time 1% of the US population is chronically disabled and another 1% temporarily disabled as a result of back pain. Numerous studies report a favorable natural history for acute and subacute LBP, with <90% of patients regaining function within 6−12 weeks with or without physician intervention. Recent evidence suggests that about one in five acute LBP patients will have persistent back pain resulting in limitations in activity at 1 year. Approximately 85% of back pain has no readily identifiable cause, and up to one-third of all patients will develop chronic low back pain. This chapter reviews a detailed evidence-based approach to the assessment, diagnosis, and management of the adult patient with acute, subacute, and chronic LBP.

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PREVENTION

Low back pain is a heavy medical and financial burden to not only the patients who are experiencing the ailment but also society. The US Preventive Services Task Force produced a recommendation statement on primary care interventions to prevent low back pain in adults stating that currently there is insufficient evidence to support or rebuke the routine use of exercise to prevent low back pain. However, regular physical activity has been shown to be beneficial in the treatment and the limitation of recurrent episodes of chronic low back pain. Lumbar supports (back belts) and shoe inserts (orthotics) have not been found effective in the prevention of low back pain. Worksite interventions, including education on lifting techniques, have been shown to have some short-term effects, on decreasing lost time from work for patients with back pain.

Risk factor modifications may be the only way to truly prevent LBP. These risk factors can be classified as individual, psychosocial, occupational, and anatomic. Table 25-1 lists the prominent risk factors for LBP.

Table 25–1.Risk Factors associated with LBP

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