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Recommend
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Option
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Recommend against
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History and Physical Exam
34 studies
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Basic history (B).
History of cancer/infection (B). Red Flags
Cauda equina syndrome (C). Red Flags
History of significant trauma (C). Red Flags
Psychosocial history (C).
Focused neurological exam (B).
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Pain drawing and
Visual Analog Scale (D).
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14 studies
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Patient education about back problems (B).
Back school in occupational settings (C).
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Back school in non-occupational settings(C).
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23 studies
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Acetaminophen (C).
NSAIDs (B).
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Muscle relaxants(C).
Opioids, short course(C).
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Opioids used >2 wks (C).
Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).
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42 studies
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Manipulation during first month of low back pain without radiculopathy (B).
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Manipulation for patients with radiculopathy(C).
Manipulation questionable for patients with symptoms >1 month (C).
Self-application heat/cold to back (D)
Shoe insoles(C).
Corset for prevention
in occupational setting(C).
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Manipulation for patients with undiagnosed neurologic deficits (D).
Prolonged course of manipulation (D).
Traction (B).
Transcutaneous Nerve Stimulation TENS (C).
Biofeedback (C).
Shoe lifts (D).
Corset for treatment (D).
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26 studies
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Epidural steroid injections for radicular pain to avoid surgery( C).
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Epidural injections for back pain without radiculopathy (D).
Trigger point injections (C).
Ligamentous injections (C).
Facet joint injections (C).
Needle acupuncture (D).
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Bed Rest 4 studies
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Bed rest of 2-4 days for severe radiculopathy (D).
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Bed rest > 4 days (B).
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20 studies
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Temporary reduction of activities that increase mechanical stress on spine as necessary (D).
Gradual return to normal activities ASAP (B).
If limited - Low-stress aerobic exercise(C).
Conditioning exercises for trunk
muscles after 2 weeks of limitation (C).
Exercise quotas(C).
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Back specific exercise machines (D).
Therapeutic stretching of back muscles (D).
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Detect
14 studies
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BP not improving after 1 month: ? Bone scan (C).
Radiculopathy? Needle EMG and H-reflex tests to clarify nerve root compromise(C).
? SEP to assess spinal stenosis (C).
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EMG for clinically obvious radiculopathy (D).
Surface EMG and F-wave tests (C).
Thermography (C).
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18 studies
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When Red Flags for fracture present(C).
When Red Flags for cancer or infection present(C).
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Routine use in first month of symptoms in absence of "RED FLAGS "(B).
Routine oblique views (B).
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18 studies
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? MRI test of choice for patients with prior back surgery (D).
Criteria for imaging tests (B).
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Myelography or CT-Myelography for preoperative planning (D).
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Use of imaging test before one month in absence of "Red Flags"(B).
Discography or CT-discography (C).
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14 studies
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Discuss possible surgical options with patients with persistent and severe sciatica and clinical evidence of nerve root compromise after 1 month of conservative therapy (B).
Standard discectomy and micro-discectomy of similar efficacy in treatment of herniated disc (B).
Chymopapain, after ruling out allergic sensitivity, acceptable but less efficacious than discectomy for herniated disc(C).
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Disc surgery for back pain alone, no "Red Flags," and no nerve root compression (D).
Percutaneous discectomy, less efficacious than chymopapain (C).
Surgery for spinal stenosis within the first 3 months of symptoms (D).
Stenosis surgery by imaging tests rather than Cauda equina syndrome or neuroclaudication (D).
Fusion without motion & stenosis fracture, dislocation, tumor or infection complications(C).*
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Non-physical
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Social, economic, and non-physical factors can alter patients response to symptoms or care (D).*
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Before extensive Evaluations or Treatment Programs, explore patient expectations & non-physical factors (D).
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