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Am Fam Physician. 2023;107(4):435-437

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Because no treatments for low back pain are clearly superior, patients should be engaged in shared decision-making about whether to consider nonpharmacologic, pharmacologic, or watchful waiting approaches to managing acute or chronic low back pain.

• Cognitive behavior therapy modestly improves pain and function in chronic low back pain.

• Although medications have limited benefit in low back pain, NSAIDs and duloxetine have the strongest evidence for benefit.

• Acetaminophen does not improve pain or function in low back pain compared with placebo.

From the AFP Editors

Low back pain is one of the most frequently experienced medical conditions, affecting 84% of adults in the United States at some point. Nearly 40% of adults will have experienced this type of pain within a three-month period. Low back pain is the leading cause of disability worldwide. The U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) have published guidelines on the diagnosis and treatment of low back pain.

Evaluation of Low Back Pain

Because low back pain is common, the initial evaluation focuses on identifying patients with serious underlying conditions. Red flags (Table 1) are the most reliable indicators of serious or progressive neurologic deficits and serious conditions that warrant immediate imaging.

The physical examination has limited use in evaluating back pain. The numerous special tests for nerve root compression, including the straight leg raise, Bragard, Fajersztajn, Sicard, passive neck flexion, and slump tests, have limited accuracy. Similarly, the Mekhail, Patrick, and thigh thrust tests do not reliably identify a sacroiliac source of pain.

FindingSuggested condition
New urinary retentionCauda equina
Saddle sensation disturbanceCauda equina
Bladder fullnessCauda equina
Abnormal neurologic examinationSerious or progressive neurologic deficit
Fever or other signsInfection
Hemoglobin < 10 g per dL (100 g per L)Cancer, epidural hematoma
History of intravenous drug use and previous infectionEpidural abscess (LR+ = 14)
Indwelling vascular catheterEpidural abscess (LR+ = 16)
Recent spine fractureEpidural abscess (LR+ = 10)
Trauma and neurologic deficitVertebral fracture (LR+ = 31)
History of cancer and clinical suspicion of cancerCancer (LR+ = 28)
Older than 75 years and recent trauma, osteoporosis, pain ≥ 7 out of 10, or thoracic painVertebral fracture: if more than one finding in an older patient, risk of fracture is at least 42%

Unless there are focal neurologic deficits or red flags, imaging does not improve outcomes. Obtaining early magnetic resonance imaging for low back pain increases the probability of surgery by 13 times. Early imaging is also associated with increased opioid use, higher cost of care, higher pain scores, and more work absence.

Approach to Care

Because there is no single treatment that is clearly effective, low back pain care is based on a patient-centered, holistic approach based on comorbidities. Because care is commonly self-directed, success depends on the communication between physician and patient. The limited evidence for many of the common treatments emphasizes the importance of shared decision-making.

Noninvasive Treatments


Cognitive Behavior Therapy. Cognitive behavior therapy leads to small improvements in pain and functional status in patients with chronic low back pain after four to 12 visits. This type of therapy often uses relaxation, behavioral activation, and exposure to improve quality of life and reduce the functional impact of pain.

Mindfulness-based Stress Reduction. Mindfulness-based stress reduction does not appear as helpful, with similar pain and functional outcomes vs. usual care. Another systematic review of very low-quality evidence suggests mindfulness-based interventions may be as effective as cognitive behavior therapy at reducing pain intensity.


Many types of clinician-directed, structured exercise programs improve pain, disability, and function in patients with low back pain. Beneficial exercise programs include aerobic exercise, aquatic exercise, mechanical diagnosis and therapy, mobility, motor control, Pilates, strength training, structured walking programs, and tai chi. Nearly every activity is beneficial.

Yoga and qi gong do not consistently improve outcomes over other types of activity. Yoga does not improve disability, quality of life, or pain more than physical therapy or strength training. The benefits of qi gong are less certain.

Lumbar supports and mechanical traction do not improve pain or function.


Although demonstrated to be beneficial in patients with chronic low back pain, there is not enough research to support a recommendation for or against spinal manipulation and mobilization for patients with acute low back pain.

Acupuncture appears to be effective for chronic low back pain, with reduced pain up to one year but no benefit at two years. Acupuncture has not been adequately studied in acute low back pain. Cupping, laser therapy, transcutaneous electrical nerve stimulation, and ultrasound therapy do not improve pain or disability in low back pain.

Medications for Low Back Pain


Duloxetine. In patients with chronic low back pain, one additional patient will experience at least a 30% reduction in pain with duloxetine (Cymbalta) compared with patients who receive placebo (number needed to treat = 9; 95% CI, 6 to 16). However, many patients will not find a clinically relevant decrease in pain with treatment. Discontinuation is common with duloxetine because of adverse effects including nausea, insomnia, dry mouth, constipation, and fatigue.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs). In patients with chronic low back pain, treatment with NSAIDs reduces pain by at least 30% compared with placebo, with a number needed to treat of 6 over four to 12 weeks. Studies of NSAIDs used for more than 12 weeks show results that are equivalent to placebo. Adverse events are similar between NSAIDs and placebo for up to 12 weeks.


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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at

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