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Best Practice & Research Clinical Rheumatology Vol. 21, No. 1, pp. 77e91, 2007
doi:10.1016/j.berh.2006.08.004 available online at

5 Low back pain (non-specific)
M. Krismer

Professor of Orthopaedic Surgery Department of Orthopaedic Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria

M. van Tulder*


Professor ofHealth Technology Assessment Institute for Research in Extramural Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam Institute of Health Sciences, De Boelelaan 1081, 1081 HV, Vrije Universiteit Amsterdam, The Netherlands

The Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project
Low back pain (LBP) is defined as pain localised between the12th rib and the inferior gluteal folds, with or without leg pain. Most cases are non-specific, but in about 10% of cases a specific cause is identified. Red flags are typical signs or symptoms that are frequently associated with specific LBP. Yellow flags are prognostic factors associated with a more unfavourable and often chronic disabling course of the disease. LBP has a lifetime prevalence of 60e85%.At any one time, about 15% of adults have LBP. LBP poses an economic burden to society, mainly in terms of the large number of work days lost (indirect costs) and less so by direct treatment costs. A substantial proportion of individuals with chronic LBP has been found to have chronic widespread pain. LBP is often associated with other pain manifestations such as headache, abdominal pain and painin different locations of the extremities. Widespread pain is associated with a worse prognosis compared to localised LBP. Treatment targets are reduction of pain and better activity/participation, including prevention of disability as well as maintainance of work capacity. The evidence from selected and appraised guidelines, systematic reviews and major clinical studies was classified into fourlevels, level Ia being the best level with evidence from meta-analysis of randomised controlled trials. Key recommendations (level Ia): fitness programmes and advice to stay active can reduce pain, improve function and can prevent LBP becoming chronic. Simple analgesics, NSAIDs and muscle relaxants can reduce pain and can improve and maintain function. Maintaining physical activity, avoiding rest andmanual therapy can reduce pain and maintain and restore function in acute LBP. Behavioural treatment can prevent LBP becoming chronic. Aerobic fitness and
* Corresponding author. Tel.: þ31 20 5988 178. E-mail address: (M. van Tulder). 1521-6942/$ - see front matter ª 2006 Published by Elsevier Ltd.

78 M. Krismer and M. van Tulder

endurance training, behaviouraltreatment and multi-disciplinary treatment programmes can reduce pain and can improve/maintain function in chronic LBP. Key words: low back pain; non-specific; treatment; guidelines.

INTRODUCTION Low back pain (LBP) is defined as pain localised between the 12th rib and the inferior gluteal folds, with or without leg pain. Most cases are non-specific, but in 5e10% of cases a specific cause is identified.Specific causes of back pain are some degenerative conditions, inflammatory conditions, infective and neoplastic causes, metabolic bone disease, referred pain, psychogenic pain, trauma and congenital disorders. Non-specific LBP is defined as back pain with no known underlying pathology. The term ‘specific low back pain’ is restricted by some health care professionals to destructive diseases such as tumourand infection, as well as to diseases associated with a neurological deficit, such as disc herniation and spinal stenosis. Others use this term in the presence of a localised source of pain when a specific structure of the spine is painful and if a specific diagnosis is available to characterise the cause of the pain. Acute LBP occurs suddenly after a period of a minimum of 6 months without LBP...
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