Nonsurgical Management of Chronic Low Back Pain

Article information

J Korean Med Assoc. 2007;50(6):507-522
Publication date (electronic) : 2007 June 30
doi : https://doi.org/10.5124/jkma.2007.50.6.507
Department of Neurosurgery, Korea University College of Medicine, Korea. jypark@kumc.or.kr

Abstract

Chronic low back pain (CLBP), defined as low back pain persisting more than 3 months, develops in about 5~7% of those who experience low back pain anytime during the lifetime. It is associated with not only substantial functional disability in each patient, but also a great socioeconomic burden. The etiology of CLBP is usually multifactorial. Also, known risk factors related to the development of CLBP are diverse, including age, sex, genetic factors, environment, previous trauma, dissatisfaction from work, etc. The more common causes of CLBP encounteredin clinical settings are disorders related to intervertebral disc, spinal stenosis, spondylolisthesis, compression fracture related to osteoporosis, pain originating from zygapophysial, and sacroiliac joints. Less common but other important causes include metastatic lesions, infection, and myofacial pain syndromes. Here, an evidence-based literature review on nonsurgical management of CLBP is presented with a special attention focused on various therapeutic approaches based on etiologic processes and clinical presentations. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain, but do not usually play a role in CLBP. Tricyclic antidepressants play a role in CLBP with its analgesic effect and sleep improvement. Tramadol, a centrally acting analgesic, also provides effects on moderate to severe CLBP but careful considerations, as with opioids, are necessary to prevent side effects and should be prescribed in refractory patients. Exercise therapy has strong evidence in the management of CLBP. Moderately strong evidence supports the use of manipulation in acute back pain but not in CLBP. Evidence for epidural steroid is strong for short-term relief of CLBP and is moderate to strong for long-term relief, especially with radicular pain, when performed transforaminally. Medial branch block (MBB) has moderate effects on facet-related pain and mechanical LBP, and the radiofrequency medial branch neurotomy has strong evidence of long-term effects when done properly in patients responsive to MBB. The use of facet injections, orthoses, traction, magnets, prolotherapy, trigger point injection, or acupuncture in the management of CLBP, unlike in acute LBP, is not supported by evidence for the long-term effectiveness. Sacroiliac joint injections are not indicated in the routine management of low back pain but show moderate effects in selected patients with CLBP. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation. For primary care providers and for those who specialize pain management, every effort should be made to contemplate all possible factors that might have played roles in generating the chronic pain and inform the patients of the natural course of various problems causing CLBP. Also, whatever management is chosen, the decision should be based upon the clinical presentation that closely correlates with definitive findings from studies best available whenever possible to provide the best treatment possible, not only to relieve the pain but also to provide functional capability to return previous social status as well as to prevent further development of disability and chronicity with refractory pain syndromes.

References

1. Weinstein JN. Anatomy and neurophysiologic mechanisms of spinal pain. The adult spine 1991. 1st edth ed. New York: Raven Press;
2. Wyke BD. The neurology of low back pain. The lumbar spine and bak pain 1980. 2nd edth ed. Kent: Pitman Medical;
3. Andersson GBJ. Epidemiological features of chronic low back pain. Lancet 1999. 354581–585.
4. von Korff M, Saunders K. The course of back pain in primary care. Spine 1996. 212833–2837.
5. van den Hoogen HJ, Koes BW, van Eijk JT, Bouter LM, Deville W. On the course of low back pain in general practice: A one year follow up study. Ann Rheum Dis 1998. 5713–19.
6. Wahlgren DR, Atkinson JH, Epping-Jordan JE. One-year follow-up of first onset low back pain. Pain 1997. 73213–221.
7. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997. 222128–2156.
8. Bogduk N, Barnsley L. Backpain and neck pain: an evidence-based up date. Pain 1999-an Updated review 1999. Seattle: IASP Press; 371–377.
9. Edmond SL, Felson DT. Prevalence of back symptoms in elders. J Rheumatol 2000. 27220–225.
10. Frymoyer JW. Backpain and scitica. N Engl J Med 1988. 38291–300.
11. March LM, Brnabic AJ, Skinner JC, Schwarz JM, Finnegan T, Druce J, Brooks PM. Musculoskeletal disability among elderly people in the community. Med J Aust 1998. 168439–442.
12. Goel V, Young JB, Patterson CJ. Infective discitis as an uncommon but important cause of back pain in older people. Ageing 2000. 5454–456.
13. Van Tulder MW, Waddell G. In : Nachemson AL, Jonsson E, eds. Conservative treatment of acute and subacute low back pain. Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis, and Treatment 2000. Philadelphia, PA: Lippincott Williams & Wilkins; 241–269.
14. Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine 1980. 5117–125.
15. Jayson MI. Why does acute back pain become chronic? Spine 1997. 221053–1056.
16. Papageorgiou AC, Croft PR, Ferry S, Jayson MI, Silman AJ. Estimating the prevalence of low back pain in the general population: Evidence from the South Manchester Back Pain Survey. Spine 1995. 201889–1894.
17. Roland M, Dixon M. Randomized controlled trial of an education booklet for patients presenting with back pain in general practice. J R Coll Gen Pract 1989. 39244–246.
18. Cherkin DC, Deyo RA, Street JH, Hunt M, Barlow W. Pitfalls of patient education: Limited success of a program for back pain in primary care. Spine 1996. 21345–355.
19. Linton SJ, van Tulder MW. Preventive interventions for back and neck pain. Spine 2001. 26778–787.
20. Hodselmans AP, Jaegers SM, Goeken LN. Short-term outcomes of a back school program for chronic low back pain. Arch Phys Med Rehabil 2001. 821099–1105.
21. Lonn JH, Glomsrod B, Soukup MG, Bo K, Larsen S. Active back school: Prophylactic management for low back pain: A randomized, controlled, 1-year follow-up study. Spine 1999. 24865–871.
22. Malanga GA, Nadler SF. Nonoperative treatment of low back pain. Mayo Clin Proc 1999. 741135–1148.
23. Schnitzer TJ, Gray WL, Paster RZ, Kamin M. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol 2000. 27772–778.
24. Jamison RN, Raymond SA, Slawsby EA, Nedeljkovic SS, Katz NP. Opioid therapy for chronic noncancer back pain: A randomized prospective study. Spine 1998. 232591–2600.
25. Keitel W, Frerick H, Kuhn U, Schmidt U, Kuhlmann M, Bredehorst A. Capsicum pain plaster in chronic non-specific low back pain. Arzneimittelforschung 2001. 51896–903.
26. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of non-steroidal anti-inflammatory drugs for low back pain: A systematic review of randomised clinical trials. Ann Rheum Dis 1997. 56214–233.
27. van Tulder MW, Koes BW, Assendelft WJ, Bouter LM, Daams J, van der Laan JR. Acute low back pain: Activity, NSAID's and muscle relaxants effective; bedrest and targeted exercise not effective; results of systematic reviews. Dutch Ned Tijdschr Geneeskd 2000. 1441484–1489. [Dutch].
28. Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Medication use for low back pain in primary care. Spine 1998. 23607–614.
29. Beebe FA, Barkin RL, Barkin S. A clinical and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions. Am J Ther 2005. 12151–171.
30. Malanga GA, Nadler SF, Lipetz JS. Pharmacologic treatment of low back pain. Phys Med Rehabil STAR 1999. 13531–549.
31. Bigos SJ, Bowyer OR, Braen GR, et al. Clinical Practice Guideline 14, AHCPR Publication No. 95-0642. Acute Low Back Problems in Adults 1994. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services;
32. Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review. Clin J Pain 1997. 13116–137.
33. McQuay HJ, Tramer M, Nye BA, Carroll D, Wiffen PJ, Moore RA. A systematic review of antidepressants in neuropathic pain. Pain 1996. 68217–227.
34. Alcoff J, Jones E, Rust P, Newman R. Controlled trial of imipramine for chronic low back pain. J Fam Pract 1982. 14841–846.
35. Goodkin K, Gullion CM, Agras WS. A randomized, double-blind, placebo-controlled trial of traxodone hydrochloride in chronic low back pain syndrome. J Clin Psychopharmacol 1990. 10269–278.
36. Pheasant H, Bursk A, Goldfarb J, Azen SP, Weiss JN, Borelli L. Amitriptyline and chronic low-back pain: A randomized double-blind crossover study. Spine 1983. 8552–557.
37. Harman K, Pivik RT, D'Eon JL, Wilson KG, Swenson JR, Matsunaga L. Sleep in depressed and nondepressed participants with chronic low back pain: Electroencephalog-raphic and behaviour findings. Sleep 2002. 25775–783.
38. Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of bed rest for acute low back pain and sciatica. Spine 2000. 252932–2939.
39. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. Br J Gen Pract 1997. 47647–652.
40. Koes BW, van den Hoogen HMM. Efficacy of bed rest and orthoses of low-back pain: A review of randomized clinical trials. Eur J Phys Med Rehabil 1994. 486–93.
41. Atlas SJ, Volinn E. Classics from the spine literature revisited: A randomized trial of 2 versus 7 days of recommended bed rest for acute low back pain. Spine 1997. 222331–2337.
42. Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of advice to stay active as a single treatment for low back pain and sciatica. Spine 2002. 271736–1741.
43. Rozenberg S, Delval C, Rezvani Y. Bed rest or normal activity for patients with acute low back pain: A randomized controlled trial. Spine 2002. 271487–1493.
44. Malmivaara A, Hakkinen U, Aro T. The treatment of acute low back pain: Bed rest, exercises, or ordinary activity? N Engl J Med 1995. 332351–355.
45. Nordin M, Campello M. Physical therapy: Exercises and the modalities. When, what, and why? Neurol Clin 1999. 1775–89.
46. Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders: A meta-analysis. Pain 1995. 6385–91.
47. Nadler SF, Steiner OJ, Erasala GN. Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine 2002. 271012–1017.
48. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003. 138898–906.
49. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000. 252784–2796.
50. Faas A, van Eijk JT, Chavannes AW, Gubbels JW. A randomized trial of exercise therapy in patients with acute low back pain: Efficacy on sickness absence. Spine 1995. 20941–947.
51. Casazza BA, Young JL, Herring SA. The role of exercise in the prevention and management of acute low back pain. Occup Med 1998. 1347–60.
52. Anshel MH, Russell KG. Effect of aerobic strength training on pain tolerance, pain appraisal and mood of unfit males as a function of pain location. J Sports Sci 1994. 12535–547.
53. Frost H, Lamb SE, Klaber Moffett JA, Fairbank JC, Moser JS. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain 1998. 75273–279.
54. Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: Exercise therapy for nonspecific low back pain. Ann Intern Med 2005. 142765–775.
55. Gaber TA, McGlashan KA, Love S, Jenner JR, Crisp AJ. Bone density in chronic low back pain: A pilot study. Clin Rehabil 2002. 16867–870.
56. Collacott EA, Zimmerman JT, White DW, Rindone JP. Bipolar permanent magnets for the treatment of chronic low back pain. JAMA 2000. 2831322–1325.
57. Carey TS, Evans A, Hadler N, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine 1995. 20312–317.
58. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM. Spinal manipulation for low back pain: An updated systematic review of randomized clinical trials. Spine 1996. 212860–2871.
59. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med 1999. 3411426–1431.
60. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain: A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003. 138871–881.
61. Brown A, Angus D, Chen S. Costs and Outcomes of Chiropractic Treatment for Low Back Pain 2005. Ottawa, Ontario: Canadian Coordinating Office for Health Technology Assessment; 1–76.
62. van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, Bouter LM. The efficacy of traction for back and neck pain: A systematic, blinded review of randomized clinical trial methods. Phys Ther 1995. 7593–104.
63. Harte AA, Baxter GD, Gracey JH. The efficacy of traction for back pain: A systematic review of randomized controlled trials. Arch Phys Med Rehabil 2003. 841542–1553.
64. Beurskens AJ, de Vet HC, Koke AJ. Efficacy of traction for non-specific low back pain: 12-week and 6-month results of a randomized clinical trial. Spine 1997. 222756–2762.
65. Sherry E, Kitchener P, Smart R. A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain. Neurol Res 2001. 23780–784.
66. Byrod G, Otani K, Brisby H, Rydevik B, Olmarker K. Methylprednisolone reduces the early vascular permeability increase in spinal nerve roots induced by epidural nucleus pulposus application. J Orthop Res 2000. 18983–987.
67. Devor M, Govrin-Lippmann R, Raber P. Corticosteroids suppress ectopic neural discharges originating in experimental neuromas. Pain 1985. 22127–137.
68. Lee HM, Weinstein JN, Meller ST, Hayashi N, Spratt KF, Gebhart GF. The role of steroids and their effects on phospholipase A2: An animal model of radiculopathy. Spine 1998. 231191–1196.
69. Bogduk N, Crhistophidis N, Cherry D. Epidural Use of Steroids in The Management of Back Pain: Report of Working Party on Epidural Use of Steroids in the Management of Back Pain 1994. Canberra, Australia: National Health and Medical Research Council; 1–76.
70. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: A systematic review of randomized clinical trials. Pain 1995. 63279–288.
71. Koes BW, Scholten RJPM, Mens JMA, Bouter LM. Epidural steroid injections for low back pain and sciatica: An updated systematic review of randomized clinical trials. Pain Digest 1999. 9241–247.
72. McQuay HJ, Moore RA, Eccleston C, Morley S, Williams AC. Systematic review of outpatient services for chronic pain control. Health Technol Assess 1997. 1i–iv. 1–135.
73. Nelemans PJ, deBie RA, deVet HC, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Spine 2001. 26501–515.
74. Manchikanti L, Heavner JE, Racz GB. Methods for evidence synthesis in interventional pain management. Pain Physician 2003. 689–111.
75. Ward A, Watson J, Wood P, Dunne C, Kerr D. Glucocorticoid epidural for sciatica: Metabolic and endocrine sequelae. Rheumatology 2002. 4168–71.
76. Lee HS, Lee JB, Kim SD, Lim DJ, Park JY. Useful Tips for Safe and Successful Transforaminal Dorsal Root Ganglion and Epidural Blocks for Lumbar Disc Disorder. The Kor Pain Res Soc 2006. 1683–92.
77. Park JY, Lee CI, Kim SD, Kim SH, Lim DJ, Suh JK. Effect of Transforaminal Dorsal Root Ganglion and Epidural Block in Herniated Lumbar Disc Disease: Results from Minimum of 6-Month Follow-up. Kor J Spine 2005. 1113–120.
78. Choi SJ, Bae SR, Suh SW, Kim SD, Kim SH, Park JY. Study on Complications of Transforaminal Lumbar Epidural Block. Kor J Spine 2004. 165–69.
79. Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA 1933. 1011773–1777.
80. Yamashita T, Cavanaugh JM, Ozaktay AC, Avramov AI, Getchell TV, King AI. Mechanosensitive afferent units in the lumbar facet joint. J Bone Joint Surg 1990. 72A865–870.
81. Jackson RP. The facet syndrome, myth or reality? Clin Orthop 1992. 279110–121.
82. Zdeblick TA. The treatment of degenerative lumbar disorders. A critical review of the literature. Spine 1995. 20S126–S137.
83. Yang KH, King AI. Mechanism of facet load transmission as a hypothesis for low back pain. Spine 1984. 9557–565.
84. Adams MA, Hutton WC. Effect of posture on the role of the apophyseal joints resisting intervertebral compressive force. J Bone Joint Surg 1980. 62B358–362.
85. Schwarzer AC, April CN, Derby R, Fortin J, King G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994. 191132–1137.
86. Lippitt AB. The facet joint and its role in spine pain management with facet joint injection. Spine 1984. 9746–750.
87. Carrera GF. Lumbar facet joint injection in low back pain and sciatica. Radiology 1985. 10816–820.
88. Silvers HR. Lumbar percutaneous facet rhizotomy. Spine 1990. 1536–40.
89. Sluijter ME, Mehta M. In : Lipton S, Miles J, eds. Treatment of chronic back and neck pain by percutaneous thermal lesions. Modern Methods of Treatment, Vol. 3, Persistent Pain 1981. London: Academic Press; 141–179.
90. Gallagher J, Petriccione di Va PL, Wedely JR, et al. Radiofrequency facet joint denervation in the treatment of low back pain: a prospective controlled double-blind study to assess its efficacy. Pain Clinic 2006. 9981–83.
91. Park J, Park JY, Kim SD, Lim DJ, Kim SH, Chung HS. Long term results from pereutaneous radiofrequency neurotomy on posterior primary ramus in patients with chronic low back pain. Acta Neurochirurgica 2006. 99S. 81–83.
92. Jh H, Ha SK, Kim SH, Lim DJ, Park JY, Suh JK, Suh . Prognostic Factors of Percutaneous Radiofrequency Neurotomy on the Posterior Primary Ramus. J Kor Neurosurg Soc 2003. 3351–55.
93. Holm I, Friis A, Brox JI, Gunderson R, Steen H. Minimal influence of facet joint anesthesia on isokinetic muscle performance in patients with chronic degenerative low back disorders. Spine 2000. 252091–2094.
94. Carette S, Marcoux S, Truchon R. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med 1991. 3251002–1007.
95. Manchikanti L, Pampati V, Fellows B, Bakhit CE. The diagnostic validity and therapeutic value of lumbar facet joint nerve blocks with or without adjuvant agents. Curr Rev Pain 2000. 4337–344.
96. Park JY, Cho TH, Lee HK. A role of percutaneous radiofrequency neurotomy of posteior primary ramus in management of chronic low back pain In : 35th Meeting of Canadian Congress of Neurological Science; June 13-17, 2000; Ottawa, Canada.
97. Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M. Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine 2001. 261411–1416.
98. Manchikanti L, Staats PS, Singh V. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2003. 63–81.
99. Niemistö L, Kalso E, Malmivaara A, Seitsalo S, Hurri H. Radiofrequency denervation for neck and back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2003. 281877–1888.
100. Kraus H, Fischer AA. Diagnosis and treatment of myofascial pain. Mt Sinai J Med 1991. 58235–239.
101. Johnson EW, Braddom R, Watson R. Electromyographic abnormalities after intramuscular injections. Arch Phys Med Rehabil 1971. 52250–252.
102. Dreyfuss P, Dryer S, Griffin J, Hoffman J, Walsh H. Positive sacroiliac screening tests in asymptomatic adults. Spine 1994. 191138–1143.
103. Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique. I: Asymptomatic volunteers. Spine 1994. 191475–1482.
104. Dreyfuss P, Dreyer SJ, Cole A, Mayo K. Sacroiliac joint pain. J Am Acad Orthop Surg 2004. 12255–265.
105. Forst SL, Wheeler MT, Fortin JD, Wilensky JA. The sacroiliac joint anatomy, physiology and clinical significance. Pain Physician 2006. 961–67.
106. Daqenais S, Haldeman S, Wooley JR. Intrligamentous injection of sclerosing solutions (prolotheraphy) for spinal pain: a critical review of the literature. Spine J 2005. 5310–328.
107. Million R, Nilsen KH, Jayson MI, Baker RD. Evaluation of low back pain and assessment of lumbar corsets with and without back supports. Ann Rheum Dis 1981. 40449–454.
108. Walsh NE, Schwartz RK. The influence of prophylactic orthoses on abdominal strength and low back injury in the workplace. Am J Phys Med Rehabil 1990. 69245–250.
109. van Poppel MN, Koes BW, Smid T, Bouter LM. A systematic review of controlled clinical trials on the prevention of back pain in industry. Occup Environ Med 1997. 54841–847.
110. van Poppel MN, Koes BW, van der Ploeg T, Smid T, Bouter LM. Lumbar supports and education for the prevention of low back pain in industry: A randomized controlled trial. JAMA 1998. 2791789–1794.
111. Reyna JR, Leggett SH, Kenney K, Holmes B, Mooney V. The effect of lumbar belts on isolated lumbar muscle: Strength and dynamic capacity. Spine 1995. 2068–73.
112. Woodhouse ML, McCoy RW, Redondo DR, Shall LM. Effects of back support on intra-abdominal pressure and lumbar kinetics during heavy lifting. Hum Factors 1995. 37582–590.
113. Khadilkar A, Milne S, Brosseau L, Wells G, Teqwell P, Robinson Y, Shea B, Saquinur M. Transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a systemic review. Spine 2005. 302657–2666.
114. Ernst E, White AR. Acupuncture for back pain: A meta-analysis of randomized controlled trials. Arch Intern Med 1998. 1582235–2241.
115. Weidenhammer W, Linde K, Strenq A, Hoppe A, Melchart D. Acupuncture for chronic low back pain in routine care: a multicenter observational study. Clin J Pain 2007. 23128–135.
116. Chu J, Yuen KF, Wang BH, Chan RC, Schwartz I, Neuhauser D. Electrical twitch-obtaining intramuscular stimulation in lower back pain: a pilot study. Am J Phys Med Rehabil 2004. 83104.
117. Linton SJ. In : Nachemson AL, Jonsson E, eds. Utility of cognitive-behavioral psychological treatments. Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis, and Treatment 2000. Philadelphia, PA: Lippincott Williams & Wilkins; 361–382.
118. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of pshchological interventions for chronic low back pain. Health Psychol 2007. 261–9.
119. Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab J, Leid R. Effectiveneee and cost-effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain. J Rehumatol 2006. 332519–2526.
120. Huge V, Schloderer U, Steinberger M, Wuenschmann B, Schops P, Beyer A, Azad SC. Impact of a functional restoration program on pain and health-related quality of life in patients with chronic low back pain. Pain Med 2006. 7501–508.
121. Ostelo RW, van Tulder MW, Vlaeyen JW, Linton SJ, Morley SJ, Assendelft WJ. Behavioural treatment for chronic low back pain. Cochrane Database Syst Rev 2005. 25CD002014.

Article information Continued

Table 1

Red flag signs of low back pain

Table 1