The US Department of Health and Human Services
AHCPR Clinical Practice Guideline
Number 14
Acute Low Back Problems in Adults
Stanley J. Bigos, MD (Panel Chair)
Panel Members
Rev. O. Richard Bowyer Margareta Nordin, RPT, DrSci
G. Richard Braen, MD Bernice D. Owen, PhD, RN
Kathleen Brown, PhD, RN Malcolm H. Pope, DrMedSc, PhD
Richard Deyo, MD, MPH Richard K. Schwartz, MS, OTR, FSR
Scott Haldeman, DC, MD, PhD Donald H. Stewart, Jr., MD
John L. Hart, DO Jeff Susman, MD
Ernest W. Johnson, MD John J. Triano, MA, DC
Robert Keller, MD Lucius C. Tripp, MD, MPH, FACPM
Daniel Kido, MD, FACR Dennis C. Turk, PhD
Matthew H. Liang, MD, Clark Watts, MD, JD
Roger M. Nelson, PT, PhD MPH James N. Weinstein, DO
U.S. Department of Health and Human Services
Public Health Service
Agency for Health Care Policy and Research
Rockville, Maryland
AHCPR Publication No. 95-0642
December 1994
This document is in the public domain and may be used and reprinted without special permission. AHCPR will appreciate citation of the source, and the suggested format is provided below:
Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
Guideline Development and Use
Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care. This guideline was developed by an independent multidisciplinary panel of private-sector clinicians and other experts convened by the Agency for Health Care Policy and Research (AHCPR). The panel employed explicit, science-based methods and expert clinical judgment to develop specific statements on acute low back problems in adults.
Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review and field review were undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice. The panel's recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants.
The guideline reflects the state of knowledge, current at the time of publication. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done.
We believe that the AHCPR-assisted clinical guidelines will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in this Clinical Practice Guideline. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances presented by individual patients.
Clifton R. Gaus, ScD
Administrator
Agency for Health Care Policy and Research
Publication of this guideline does not necessarily represent endorsement by the U.S. Department of Health and Human Services.
Abstract
Findings and recommendations on the assessment and treatment of adults with acute low back problems (activity limitations due to symptoms in the low back and/or back-related leg symptoms of less than 3 months' duration) are presented in this clinical practice guideline. The following are the principal conclusions of this guideline:
- The initial assessment of patients with acute low back problems focuses on the detection of "
Red Flags" (indicators of potentially serious spinal pathology or other nonspinal pathology).
- In the absence of red flags, imaging studies and further testing of patients are not usually helpful during the first 4 weeks of low back symptoms.
- Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation.
- While some activity modification may be necessary during the acute phase, bed rest >4 days is not helpful and may further debilitate the patient.
- Low-stress aerobic activities can be safely started in the first 2 weeks of symptoms to help avoid debilitation; exercises to condition trunk muscles are commonly delayed at least 2 weeks.
- Patients recovering from acute low back problems are encouraged to return to work or their normal daily activities as soon as possible.
- If low back symptoms persist, further evaluation may be indicated.
- Patients with sciatica may recover more slowly, but further evaluation can also be safely delayed.
- Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery.
- With or without surgery, 80 percent of patients with sciatica recover eventually.
- Nonphysical factors (such as psychological or socioeconomic problems) may be addressed in the context of discussing reasonable expectations for recovery.
Panel Members
Stanley J. Bigos, MD, Chair
University of Washington
Seattle, Washington
Orthopedic Surgeon
Reverend O. Richard Bowyer
Fairmont State College
Fairmont, West Virginia
Consumer Representative
G. Richard Braen, MD
University of New York
Buffalo, New York
Emergency Medicine Physician
Kathleen Brown, PhD, RN
University of Alabama
Birmingham, Alabama
Occupational Health Nurse
Richard Deyo, MD, MPH
University of Washington
Seattle, Washington
General Internist
Scott Haldeman, DC, MD, PhD
University of California at Irvine
Santa Ana, California
Neurologist/Chiropractor
John L. Hart, DO
Still Regional Medical Center
Columbia, Missouri
Physiatrist
Ernest W. Johnson, MD
Ohio State University
Columbia, Ohio
Physiatrist
Robert Keller, MD
Maine Medical Assessment Foundation
Belfast, Maine
Orthopedic Surgeon
Daniel Kido, MD, FACR
Washington University Medical Center
St. Louis, Missouri
Radiologist
Matthew H. Liang, MD, MPH
Harvard Medical School
Boston, Massachusetts
Rheumatologist
Roger M. Nelson, PT, PhD
Thomas Jefferson University College of Allied Health Sciences
Philadelphia, Pennsylvania
Physical Therapist
Margareta Nordin, RPT, DrSci
Hospital for Joint Diseases
New York, New York
Physical Therapist/Orthopedic Researcher
Bernice D. Owen, PhD, RN
University of Wisconsin
Madison, Wisconsin
Community Health Nurse
Malcolm H. Pope, DrMedSc, PhD
University of Vermont
Burlington, Vermont
Orthopedic Researcher
Richard K. Schwartz, MS, OTR, FSR
San Antonio, Texas
Occupational Therapist
Donald H. Stewart, Jr., MD
Arlington, Virginia
Neurosurgeon
Jeff Susman, MD
University of Nebraska Medical Center
Omaha, Nebraska
Family Physician
John J. Triano, MA, DC
Texas Back Institute
Plano, Texas
Chiropractor
Lucius C. Tripp, MD, MPH, FACPM
General Motors-Henry Ford Hospital Rehabilitation Center
Warren, Michigan
Neurosurgeon/Occupational Medicine Specialist
Dennis C. Turk, PhD
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Psychologist
Clark Watts, MD, JD
University of Texas Health Sciences Center
San Antonio, Texas
Neurosurgeon
James N. Weinstein, DO
University of Iowa Hospitals
Iowa City, Iowa
Orthopedic Surgeon
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