II. Definitions
- See Low Back Pain
- Chronic Low Back Pain
- Low Back Pain persisting >12 weeks
III. Epidemiology
- Chronic Low Back Pain represents a small subsegment of Low Back Pain (<5%)
- Most patients with Low Back Pain will have Musculoskeletal Low Back Pain (95% will resolve within 6 weeks)
- Frequent, severe Low Back PainPrevalence occurs in 8% or 11.8 of 145 Million Employed Adults (U.S., 2015)
- Ages 18-29: 5.9% (1.99 Million)
- Ages 30-44: 7.9% (3.74 Million)
- Ages 45-64: 9.7% (5.52 Million)
- Age >65: 8.7% (0.63 Million)
- CDC Low Back Pain
- Chronic Low Back Pain Prevalence
- U.S.: 13% (severe in 30% of this subset with Chronic Low Back Pain)
- Worldwide: 23%
IV. Risk Factors
- More intense Low Back Pain
- Consistently symptomatic Acute Low Back Pain at 4 weeks
- Obesity
- Major Depression
- Anxiety Disorder
- Poor coping skills
- Smoking
- High intensity physical labor
V. History
- See Low Back Pain History
- See Serious Low Back Symptoms (Low Back Pain Red Flags)
- See Thoracolumbar Trauma
- Careful history and examination is the most important evaluation measure in Low Back Pain
VI. Exam
- Back should be exposed (e.g. in gown) to allow for adequate palpation and visualization
- See Lumbar Spine Anatomy
- Low Back Exam
-
Neurologic Exam
- See Sensory Exam
- See Reflex Exam
- See Motor Exam
- Active Knee Extension (L4)
- Walk on heels (L5)
- Walk on toes (S1)
- Clonus (suggests Upper Motor Neuron involvement)
VII. Differential Diagnosis
VIII. Labs
- Not routinely indicated
- Consider lab testing in suspected cancer, infection or inflammatory disorders
IX. Imaging
- See Low Back Imaging
- See Low Back Pain Red Flags
- Imaging is typically indicated in Chronic Low Back Pain
- Contrast with Acute Low Back Pain, in which imaging is limited to Low Back Pain Red Flags and Trauma
- Avoid catastrophizing imaging findings
- Imaging often demonstrates asymptomatic changes unrelated to the patients symptoms and signs
- Describing imaging as normal with age related changes benefits patient outcomes
- Better treatment efficacy and higher resulting function
- Rajasekaran (2021) Eur Spine J 30(7): 2069-81 [PubMed]
X. Diagnostics: Electromyogram (EMG)
- Not recommended if radiculopathy is obvious from exam
- Indications: Radiculopathy, Neuropathy, Myelopathy, Myopathy
- Persistent symptoms >6 weeks AND
- Suspected nerve root dysfunction with neuromuscular deficit
- Radicular Pain
- Muscle Weakness
- Sensory Loss
- Muscle atrophy
XI. Management
XII. Prevention
- See Low Back Rehabilitation
- Prevent the transition from Acute Low Back Pain to Chronic Low Back Pain
- Regular Exercise
- Protective factor in the prevention of Chronic Low Back Pain
XIII. Prognosis
- Risk of progression from Acute Low Back Pain to Chronic Low Back Pain
- PICKUP Score
- Orebro Musculoskeletal Pain Screening Questionnaire
- STarT Back Calculator
- Psychosocal red flags associated with delayed improvement
- Belief that pain and activity are harmful
- Worker Compensation claims or prolonged Sick Leave
- Depressed Mood
- Social isolation, social withdrawal, or lack of social support
- Exaggerated illness response
- Overprotective family
- References
XIV. Resources
- Keele STarT Back Approach (YouTube) for patients at risk of progressing to Chronic Low Back Pain
- Bob and Brad's Back Pain Playlist (YouTube)
XV. References
- Cali and Bond (2022) Crit Dec Emerg Med 36(7): 4-11
- Arce (2001) Am Fam Physician 64(4):631-8 [PubMed]
- Atlas (2001) J Gen Intern Med 16:123 [PubMed]
- Bratton (1999) Am Fam Physician 60(8):2299-306 [PubMed]
- Bueff (1996) Prim Care 23:345-64 [PubMed]
- Jarvik (2002) Ann Intern Med 137:586-97 [PubMed]
- Joines (2001) J Gen Intern Med 16:14-23 [PubMed]
- Maharty (2024) Am Fam Physician 109(3): 233-44 [PubMed]
- Patel (2000) Am Fam Physician 61(6):1779-86 [PubMed]
- Rose-Innes (1998) Geriatrics 53:26-40 [PubMed]
- Swenson (1999) Neurol Clin 17:43-63 [PubMed]
- Will (2018) Am Fam Physician 98(7):421-8 [PubMed]