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Recommendations for diagnosing and treating low back pain call for a conservative, step-by-step approach

Although low back pain rarely indicates a serious disorder, it is a major cause of disability and cost. In the workplace, low back pain accounts for one-third of workers' compensation costs, with an average cost of $8,000 per claim. Most patients with acute low back pain improve within a month, but 6 to 10 percent of patients develop chronic or recurrent symptoms.

According to a 1994 guideline on acute low back pain, there were insufficient reliable data on which to base treatment recommendations. National guidelines for chronic low back pain management have been published in other countries, but not in the United States, note Steven J. Atlas, M.D., M.P.H., and Rachel A. Nardin, M.D., of Harvard Medical School, in a recent article.

With support from the Agency for Healthcare Research and Quality (HS06344, HS08194, and HS09804), Drs. Atlas and Nardin incorporated findings from recent studies to develop an evidence-based approach to the evaluation and treatment of low back pain. They point out that a patient's history and physical examination usually provide clues to the uncommon but potentially serious causes of low back pain, such as cancer, and identify patients at risk for prolonged recovery. Diagnostic testing should not be a routine part of the initial evaluation but should be used selectively based on the patient's history, examination, and initial response to treatment.

For patients without significant neurological impairment, initial treatments should include activity modification, nonnarcotic analgesics, and education. Patients whose symptoms do not improve over 2 to 4 weeks, should be referred for physical treatments. Several therapeutic options of limited or unproven benefit are available for patients with radicular pain (back-related radiating leg pain, such as the sharp burning pain of sciatica) or chronic low back pain. Patients with radicular pain and little or no neurological symptoms (such as leg weakness, numbness, or tingling) should receive conservative treatment. Elective surgery is appropriate for those with nerve root compression (usually patients with radiating pain below the knee and neurological symptoms) who are unresponsive to conservative therapy.

See "Evaluation and treatment of low back pain: An evidence-based approach to clinical care," by Drs. Atlas and Nardin, in the March 2003 Muscle & Nerve 27, pp. 265-284.

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