Trauma 2011; 13: 5764

The diagnosis and management of commonnon-specific back pain a clinical reviewGrahame Brown

The assessment and management of common non-specific back pain that isassociated with considerable personal morbidity and cost to society is reviewed andset in a bio-psycho-social context.

Key words: non-specific back pain; bio-psycho-social

Introduction

Most of us appreciate the difficulties of people whosuffer back pain because up to 80% of us willexperience it at sometime in our life. In any group ofpeople the point prevalence is estimated to bebetween 15% and 30% (CSAG, 1994). Althoughmost episodes of back pain get better naturally, it isnot uncommon for people to experience anotherepisode within a year (Croft et al., 1998). Back pain isone of the commonest reasons for people consultingtheir GP and taking time off work. For others,attending an Accident & Emergency departmentwhen they are distressed with back pain might betheir first encounter with a health care professionalfor the problem. Misconceptions surrounding backpain and activity or exercise, often inadvertentlyreinforced by clinicians, are a major contributoryfactor for the increasing prevalence of back painrelated disability in industrialised countries.Throughout the world, published guidelines basedon research evidence demonstrate a genuine consen-sus over management (Waddell and Burton, 2000;Koes et al., 2001; Chou et al., 2007; NICE, 2009).Clinicians who work in primary care and occupa-tional health should nowbe aware of these guidelines.

If the back pain is not the presenting problem, it maybe an associated co-morbid clinical problem in manymedical specialties. This review is aimed at cliniciansin secondary care and in the specialty training gradeswho may not be familiar with changes in themanagement of these problems.

Different kinds of back pain

For the most part of the twentieth century, theproblem of back pain was viewed from a predom-inantly bio-medical model of injury to spinal struc-tures. In this model, emphasis is on looking for thepathological lesion that causes back pain which inturn is likely to generate inappropriate investiga-tions and treatment and contribute to the persis-tence of symptoms (CSAG, 1994; Hadler, 1999).Waddell (1998) has called the dominance of amedical model for the enigma of human back pain atwentieth century health care disaster.Back pain frequently starts for no apparent reason

or after an every day activity, and recovery (or lackof it) is also frustratingly unpredictable. Only a smallproportion (55%) of people with back pain have adiagnosable condition from a bio-medical and his-topathological perspective (such as vertebral col-lapse due to osteoporosis) and very few (51%) have aserious medical problem (CSAG, 1994).So the vast majority of people have no specific

diagnosis or medical reason for their back pain.It is often said that most peoples back painresolves within 68 weeks, and only 1520% goon to develop persistent and disabling back pain.Given the number of us that can expect to

Orthopaedic, Musculoskeletal, Sports & Exercise Physician,The Royal Orthopaedic Hospital NHS Foundation Trust,Birmingham, UK.

Address for correspondence: Dr Grahame Brown,Orthopaedic, Musculoskeletal, Sports & Exercise Physician,The Royal Orthopaedic Hospital NHS Foundation Trust,Birmingham, B31 2AP, UK.E-mail: grahamebrown50@hotmail.com

The Author(s), 2011. Reprints and permissions:http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/1460408610385758

experience the problem at least sometime in our life,this is a massive cost in terms of personal morbidity,health care, work loss and incapacity benefits.However, the neat division into acute back painthat resolves quickly and completely and persistentpain that does not is too simplistic and misleading.Many people have a long term and episodicproblem, characterised by periods of relativelylittle or no pain interspersed with acute episodesof disabling pain. Many people continue to experi-ence considerable pain and disability but stopconsulting their GP (Croft et al., 1998). The highrate of resolution of acute back pain is moreperceived than actual. Whether the problem isacute, chronic, or acute relapses of a chroniccondition makes little fundamental difference tothe advice and care people need and should receive.Management should depend on whether people arelikely to be able to help themselves effectively byfollowing simple, appropriate advice, or are dis-tressed, fearful, struggling to cope and have, or atrisk of developing, a long-term disabling problem.

How is it diagnosed?

The triage system has been developed in mostindustrialised countries to help identify those whohave features (mostly in the history) thatmight predictpossible serious pathology (the red flags) (Box 1).

The second triage is those who have nerve root pain,and the third is common (non-specific) back pain.The management of possible serious pathology thatincludes infection, fracture, osteoporosis, inflamma-tory arthropathy or tumour, and the management ofnerve root pain, is not covered in this review.Non-specific back pain is defined as symptoms

without a clear specific histopathological cause.The symptoms are generated on a spectrum ofdysfunctions including movements of the joints,strain on the ligaments and discs and dysfunctionsin the neuromuscular system. The physiology of painsignalling in these non-specific disorders is on aspectrum from entirely nociceptive throughto neurogenic (also termed neuropathic) withprobably most patients having a mixture of both.Thephysiologyof pain signalling andperception is anexceptionally complex process and although knowl-edge is incomplete, neurophysiological research overthe past few decades have helped us to understandbetter the plasticity of the pain sensory systemand thegating of pain signals that is thought to occurmostlywithin the dorsal horn of the spinal cord.At least 90% of patients will have non-specific

back pain. Many health care professionals will usedifferent labels in an attempt to classify this veryheterogeneous group of patients. For example,general practitioners may use lumbago, osteopathsmay use dysfunctions, physiotherapists hyperexten-sion or derangements, chiropractors subluxations.Surgeons favour degenerative disc disease. However,at present no reliable and valid classification systemexists for most cases of non-specific back pain.

How useful is imaging?

Anomalies commonly seen on X-ray and magneticresonance imaging, such as narrow joint spaces,grade 1(up to 25% slippage) spondylolisthesis,degenerative discs, disc bulges, cracks, protrusionsand herniations, and the occurrence of non-specificback pain are generally poorly associated (Jensenet al., 1994; van Tulder et al., 1997; Kjaer et al.,2005). There is, however, a stronger associationbetween Modic changes (bone oedema in vertebrae,only seen on magnetic resonance imaging) andpersistent non-specific low back pain (Kjaer et al.,2005; Albert and Manniche, 2007; Jensen et al.,2008). It is important that clinicians do not make

Box 1 Red flag conditions indicating possible underlying

spinal pathology or nerve root problems

Red Flags

Onset age520 or4 55 years Non-mechanical pain (unrelated to time or activity) Previous history of carcinoma, steroids, HIV Feeling unwell, weight loss Widespread neurological symptoms Structural spinal deformity Loss of bladder or bowel control Thoracic pain Major traumaIndicators for nerve root problems

Unilateral leg pain4 low back pain Radiates to foot or toes Numbness or paraesthesia in same distribution Straight leg raising test induces more leg pain Localised neurology (limited to one nerve root)

58 G Brown

Trauma 2011; 13: 5764

potentially false assumptions and diagnoses basedon imaging findings because this may lead to thepatient learning unhelpful and negative healthbeliefs or being offered unnecessary invasive treat-ment. Current guidelines advise that imaging shouldbe reserved for those patients with red flags or nerveroot pain. Imaging can be helpful for the patientwith non-specific back pain who is experiencingpersistent disease related anxiety that cannot bealleviated by examination and explanation, pro-vided the clinician makes it clear beforehandprecisely what imaging can and cannot do. Basicblood count, inflammatory markers and biochem-istry also have an important role to play if theclinician is uncertain about possible seriouspathology.

Management of non-specificback pain

There has been an exponential growth over the last50 years in certified back pain disability, occurringdespite huge improvements in working environ-ments. There is clear epidemiological evidence thatcultural changes have led to a greater awareness ofmore minor back symptoms and willingness toreport them (Croft, 2000; Palmer et al., 2000). In thesame period, the number of treatments availableand the number of treatment sessions delivered havealso risen exponentially and are indicative of thefailure of the attempt to fit the symptom of backpain into the model of disease and pathology(CSAG, 1994; Waddell, 1998).What is said to the patient and how it is said will

have far more impact on the clinical outcome thanwhat is done to the patient (Burton et al., 1999;Roland et al., 2002). People experiencing back painwithout an identifiable medical problem need toreceive clear, accurate and realistic information thatpromotes recovery. Additionally, those at risk ofdeveloping a chronic problem must be identifiedand monitored closely. It is very easy for busyclinicians and therapists to be (or perceived as)dismissive of peoples problems. Recent onset ofback pain must be acknowledged as being verypainful, debilitating and worrying, but people needto be reassured their condition is very unlikely toindicate a serious underlying disorder or lead tolong-term disability. Advice and management

perceived as uninterested, dismissive or lackingconviction can be misinterpreted by the distressedperson and be counter-productive.Although it may seem counter-intuitive to some-

one who experiences pain when they move, encour-aging people to stay active is the single mosteffective measure in preventing the development ofpersistent disabling problems (Hagen et al., 2005).Advice to avoid activities or take time off work isalmost always unhelpful and increases the chance oflong-term disability (Waddell and Burton 2000;NICE, 2009). Following an acute episode, peoplemight take things easier for a few days to letthe pain settle, but even during this time they mustbe advised and encouraged to move gently and beactive. An over cautious attitude to pain by thehealth professional can easily be transferred topatients and reinforce inappropriate health beliefsand behaviours (Bishop and Foster, 2005).Reducing the likelihood of an acute episode of

back pain becoming persistent is a key aim ofmanagement, because while only a relatively smallpercentage of people have disabling, chronic backpain they are responsible for 80% of back painhealth care use and expenditure.The main reasons for someone with acute pain

going on to develop chronic, disabling problems arepsychological, behavioural and social and havebeen termed the yellow flags (Kendall et al.,1997) (Box 2). These are very strong predictors ofchronic and disabling problems and must beacknowledged and addressed where possible for asuccessful outcome (Linton, 2000; Pincus et al.,2002).

Box 2 Yellow flags; risk factors for developing and or

maintaining long-term pain and disability

Belief that pain and activity is harmful Belief that pain will persist Sickness, avoidant and excessive safety behaviours

(like extended rest, guarded movements)

Low or negative moods, anger, distress, social withdrawal Treatment that does not fit with best practice Claims and compensation for pain-related disability Problems with work, sickness absence, low job satisfaction Overprotective family or lack of support Placing responsibility on others to get them better

(external locus of control)

Common non-specific back pain 59

Trauma 2011; 13: 5764

Acknowledge that back pain is not just amechanical problemEmpathetic exploration of psychological and socialfactors can be helpful in understanding what mightcontribute to peoples problems, but risks beingmisconstrued as dismissing their problems as all inthe mind. However, a sensitive explanation of howanxiety, depression, exhaustion, insufficient restor-ative sleep, negative life events and over or underactivity can act as a pain volume control via thepain gate system is often extremely helpful andfrequently patients recognise in themselves.

Too little activity or too much?Many people avoid activities that cause pain in thebelief that they cause harm (fear-avoidance). Suchbeliefs are understandable, but this leads to thembecoming less and less active and more and moredisabled and dependant. This results in muscleweakness and physical de-conditioning and moredistress, and hence more pain. Conversely, otherpeople do too much at once (for example aprolonged bout of gardening) to get it over anddone with, or spend long periods in a poor workingenvironment and with undesirable posture. Thesebehaviours are sometimes combined in a sequenceof booms and busts. Once identified, teachingpacing of activity with skills to assist relaxation(for example active relaxation through breathingcontrol, sometimes called Yoga breathing) helps toprovide more control over pain.

Support return to activity and exercisePeople with long standing pain and failed manage-ment are often highly resistant to the notion thatexercise and activity are beneficial. In fact, exerciseis very beneficial for people with chronic pain, eventhose who do not think it will help them (Moffettet al., 1999). Exercise frequently involves someinitial discomfort, and many people need support,reassurance and encouragement at this stage.Graded or paced exercise, in which activity levelsare initially low and progressively increased towardsclearly identified functional goals, is more appro-priate than traditional advice to let pain be yourguide. Supervised exercise, either by a physiother-apist or fitness instructor, is probably more effective

than unsupervised general exercise, but any exer-cise/physical activity is far better than none.

How effective are commonlyavailable treatments?

More than 1000 randomised controlled trials havebeen published evaluating all types of conservative,complementary and surgical treatments for backpain in primary and secondary care. In manyWestern countries, clinical guidelines have beenissued for the management of acute back pain.In general, recommendations are similar acrossguidelines. Box 3 summarises the main recommen-dations for diagnosis and treatment for acute lowback pain from 11 countries. For chronic (variabledefinition but generally symptoms persisting longerthan 12 months) low back pain, far fewer guidelinesare available. Box 4 shows the recommendationsfrom the European clinical guidelines for chroniclow back pain. The UK guidelines published byNICE (2009) for the management of non-specificlow back pain of between 6 weeks and 12 monthsduration is summarised in Box 5.

What is the role of invasiveprocedures in non-specific back pain?

van Tulder et al. (2006) published an evidence-basedreview summarising the efficacy of surgery and

Box 3 Summary of recommendations of 11 national clinical

guidelines for acute low back pain (adapted from Koes et al.,2001)

Diagnosis

Diagnostic triage (non-specific back pain, nerve rootpain, specific pathology)

History taking and physical examination to exclude redflags and neurological screening

Consider psychosocial factors if there is no improvement X-rays are not useful for non-specific back painTreatment

Reassure patients (favourable prognosis) Advise patients to stay active Prescribe medication if necessary, preferably at fixed

intervals

Discourage bed rest Consider spinal manipulation for pain relief Do not advise back-specific exercises

60 G Brown

Trauma 2011; 13: 5764

other invasive interventions for back pain andsciatica. A number of interventions, includingfacet joint, epidural, trigger point, and sclerosinginjections, have not clearly been shown to beeffective. Such treatments can be very effective incarefully selected individual cases but the causes ofnon-specific back pain, and factors that might serveto perpetuate the symptoms and disability aremultifactorial. Identifying sub groups of patientswho may benefit from these interventions is thechallenge for clinicians and research. In clinicalpractice, when these interventions are used theyshould ideally be combined with other rehabilitationstrategies, such as graded physical activity andcognitive behavioural management. The UK NICEguidelines (2009) for the management of non-specific low back pain of between 6 weeks and12 months duration go so far as to advise thatinjections of therapeutic substances should not beoffered.Surgical micro-discectomy may be considered for

selected patients with nerve root pain due to lumbardisc prolapse who have not responded to conserva-tive management (van Tulder et al., 2006). The roleof surgical fusion surgery for chronic low back pain

is under debate, summarised by Gibson (2007).Recent randomised clinical trials comparing fusionsurgery with conservative treatment showed con-flicting results (Fritzell et al., 2001; Brox et al., 2003;Fairbank et al., 2005). Recommendations thatfusion surgery should be applied in carefullyselected patients are difficult to follow because noclear and validated criteria exist to identify thosepatients in advance.

Recent developments

Little and colleagues (2008) designed and imple-mented a randomised control trial of Alexanderlessons and technique for patients with chronic and

Box 5 Summary of the United Kingdom NICE guidelines for

the management of persistent non-specific low back pain of

between 6 weeks and 12 months duration (adapted from NICE,

2009)

Assessment

X-rays should not be used in non-specific low back pain MRI should only be considered for suspicion of red flags,

malignancy, sepsis, fracture, cauda equina syndrome,

inflammatory disease or in the context of referral for

opinion on spinal fusion.

Initial treatment recommendations

Education Maintain active lifestyle Oral analgesia including a tri-cyclic antidepressant Consider a course of manual therapy or acupuncture of up

to 12 weeks

Structured exercise programmes

In patients not suitable for manual treatment Patient choice Individual no better than group but group more cost

effective

Combined physical and psychological programmes

High intensity of more than 40 hours intervention should bemade available to patients with a high level of disability,

with psychosocial distress or after one or more previous

treatments

Surgery

Should be reserved for a small group of selected individualswho fail to respond to a combined physical and

psychological treatment programme.

Box 4 Recommendations in the European clinical guidelines

for diagnosis and treatment of chronic low back pain (adaptedfrom Airaksinen et al., 2006)

Diagnosis

Diagnostic triage (non-specific back pain, nerve root pain,specific pathology

Assessment of prognostic factors (yellow flags) Imaging is recommended only if specific pathological cause

is strongly suspected

Magnetic resonance imaging is best option for radicularsymptoms, discitis, or neoplasm

Plain radiographs are best option for structural deformitiesTreatment

Recommended Cognitive behavioural therapy, supervisedexercise therapy, brief educational interventions and

multidisciplinary (biopsychosocial) treatment

To be considered Back schools and short courses ofmanipulation and mobilisation, tricyclic antidepressants

(for example, amitriptyline)

Not recommended passive treatments (for example,ultrasound and short wave), gabapentine. Invasive

treatments are in general not recommended in chronic

low back pain.

Common non-specific back pain 61

Trauma 2011; 13: 5764

recurrent back pain and demonstrated long-term(over 12 months) benefit. Lessons in the Alexandertechnique offer an individualised approach todevelop skills that help people recognise, under-stand, and avoid poor habits affecting postural toneand neuromuscular coordination.Stirling et al. (2001) showed an association

between sciatica and propionibacterium acnes. Thepossible association between Modic changes onmagnetic resonance imaging and chronic back painhas recently been tested in an uncontrolled pilotstudy: the clinical effect of 90 days of antibiotictreatment was large in a group of 29 patientssuffering chronic low back who had Modic changeson imaging following a disc herniation and who hadnot responded to previous active conservativetreatment (Albert et al., 2008).Prolotherapy treatment has been advocated for a

variety of soft tissue conditions, including non-specific low back pain (Ongley et al., 1987; Kleinand Eck, 1997). The procedure was initially used fortreatment of spinal pain in the 1930s. Conclusionsdrawn about the effectiveness of the treatment frompublished trials have been mixed (Yellend et al.,2004). The reasons might be a result of themethodology of the studies and the application ofthe treatment in these studies for a very diverseheterogeneous group of chronic low back painpatients. As with other interventions, the challengeis identifying sub-groups of patients who will mostlikely benefit. The sacroiliac joint is a source of painin the lower back and buttocks and thigh in about15% of the population (Dreyfuss et al., 2004), andthere is evidence that dysfunction of this joint could,similar to herniated lumbar discs, produce painalong the same distribution as the sciatic nerve(Fortin et al., 1994, 2003). A recent prospectivestudy of 25 patients identified as having pain anddysfunction in excess of 6 months arising from thesacroiliac joint and who had not responded to activephysical therapy were given three prolotherapytreatments to the posterior sacroiliac ligaments.Clinical scores all improved significantly in thosefollowed up at 3, 12 and 24 months (Cusi et al.,2010). Chakraverty and Dias (2004) showed similarresults when prolotherapy was offered to a carefullyselected group of patients whose pain was thoughtto be arising from the sacroiliac joint.Detecting relevant subgroups of patients

with non-specific low back pain has been

highlighted as a priority area for research, as thiscould enable better secondary prevention throughthe targeting of prognostic indicators (the yellowflags) for persistent, disabling symptoms. A briefnine-question screening tool (STarT) that coversreferred leg pain, comorbid pain, disability, bother-someness, catastrophising, fear, anxiety and depres-sion looks very promising, and easy to use, in aclinical setting (Hill et al., 2008).

Conclusion

The causes of non-specific back pain are multi-factorial and consequently management must bemulti-modal. Over recent years, there has been aparadigm shift in the assessment and managementof these problems away from a purely medicalmodel towards a bio-psycho-social model. Keymessages to give to patients with non specific backpain is summarised in Box 6. Box 7 provides a guideto some important messages for clinicians workingwith patients who present with these problems.Neurophysiological advances are helping us tounderstand how pain can persist in the absence oftissue injury and under the influence of belief,emotional, social and cultural factors. It is muchmore important to know what sort of a patient has adisease than what sort of a disease a patient hasquoted Sir William Osler (18491919); in the light ofemerging evidence for the management of low backpain clinicians would be wise to remember this.

Declaration of interest

Dr Brown works within a multidisciplinary, sec-ondary care, clinical team. He offers interventionsto selected patients with persistent non-specific backpain, which include deep dry needling (medicalacupuncture), osteopathic manual treatment, tri-cyclic antidepressant medication, physical, postural(Alexander) and relaxation (Yoga) exercises andgraded physical aerobic exercise and prolotherapy.He integrates brief psychological and behaviouraltreatment strategies into consultations and treat-ment sessions. He runs educational workshops opento all health care professionals on psychologicalapproaches to pain management and has publisheda book (2009) called How to liberate yourself from

62 G Brown

Trauma 2011; 13: 5764

pain, a practical help for sufferers. He works withoccupational health professionals and employers toadvise on occupational rehabilitation and jobretention, He has not been involved with thepromulgation of any of the published guidelinesreferred to in the article.

References

Airaksinen O, Brox JI, Cedrashi C et al. 2006. On behalfof the COST B13 Working Group on Guidelines forChronic Low Back Pain. European guidelines forthe management of chronic non-specific low backpain. Eur Spine J 15: 192300.

Albert HB, Manniche C. 2007. Modic changes followinglumbar disc herniation. Eur Spine J 16: 97782.

Albert HB, Manniche C, Sorensen JS, Deleuran BW.2008. Antibiotic treatment in patients with low backpain associated with Modic changes Type 1 (boneoedema): a pilot study. Br J Sports Med 42: 96973.

Bishop A, Foster N. 2005. Do physical therapists in theUnited Kingdom recognize psychosocial factors inpatients with acute low back pain? Spine 30:131622.

Brox JI, Sorenson R, Friis A et al. 2003. Randomisedclinical trial of lumbar instrumented fusion andcognitive intervention and exercises in patients withchronic low back pain and degeneration. Spine 28:191321.

Burton AK, Waddell G, Tillotson KM, Summerton N.1999. Information and advice to patients with backpain can have a positive effect. A randomisedcontrolled trial of a novel educational booklet inprimary care. Spine 24: 248491.

Chakraverty R, Dias R. 2004. Audit of conservativemanagement of chronic low back pain in a second-ary care setting - Part 1: facet joint and sacroiliacjoint interventions. Acupunct Med 22: 20713.

Chou R, Qaseem A, Vincenza S et al. 2007. Diagnosisand treatment of low back pain: a joint clinicalpractice guideline from the American College ofPhysicians and the American Pain Society. Ann IntMed 147: 47891.

Croft P. 2000. Is life becoming more of a pain? Peoplemay be getting more willing to report pain. BMJ320: 15523.

Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E,Silman AJ. 1998. Outcome of low back pain ingeneral practice: a prospective study. BMJ 316:13569.

CSAG. 1994. Clinical Standards Advisory Group reporton back pain. London: HMSO.

Cusi M, Saunders J, Hungerford B, Wisbey-Roth T,Lucas P, Wilson S. 2010. The use of prolotherapy inthe sacroiliac joint. Br J Sports Med 44: 1004.

Dreyfuss P, Dreyer SJ, Cole A et al. 2004. Sacroiliacjoint pain. J Am Acad Orthop Surg 12: 25565.

Fairbank J, Frost H, Wilson-Macdonald J, Yu L-M,Barker K, Collins R. 2005. for the Spine StabilisationTrial Group. The MRC spine stabilisation trial: arandomised controlled trial to compare surgicalstabilisation of the lumbar spine with an intensive

Summary

Box 6 Key messages to give to patients with non-specific

back pain

Back pain rarely represents serious pathology Diagnosis can be difficult but this does not prevent

effective treatment

Acute back problems usually improve naturally, but oftenincompletely and may recur, this is normal

Imaging is rarely helpful unless specific pathology issuspected or surgery contemplated

Physical activity and exercise does not cause damage Most common back pain can be explained on the basis

of disturbed physiological function

Prolonged rest and time off work delays recovery andmakes the development of disabling back pain more likely

Treatment interventions can help to alleviate symptomsbut complete abolition of pain is unlikely

If a treatment given by a healthcare professional is notmaking a difference by six treatments it is not

working: reassess

Find an enjoyable physical activity or formal exercise anddo it regularly, little and often is a good formula

Discomfort following activity is not a sign of treatmentfailure

Balance activity with rest

Box 7 Key messages for clinicians working with patients with

non-specific back pain

Listen carefully to the patient Carefully observe the patients behaviour Attend not only to what is said but also to how it is said Attempt to understand how the patient feels Offer encouragement to disclose fears and feelings Offer reassurance that you accept the reality of the pain Correct misunderstandings or miscommunications about

the consultation

Offer appropriate challenges to unhelpful thoughts andbiases (such as catastrophising)

Understand the patients general social and economiccircumstances

Use terms like learning to manage pain or taking backcontrol rather than psychological treatment

Common non-specific back pain 63

Trauma 2011; 13: 5764

rehabilitation programme for patients with chroniclow back pain. BMJ 330: 12339.

Fortin JD, April CN, Ponthieux B et al. 1994. Sacroiliacjoint: pain referral maps upon applying a newinjection/arthrography technique. Part II: clinicalevaluation. Spine 19: 14839.

Fortin JD, Vilensky JA, Merkel GJ. 2003. Can thesacroiliac joint cause sciatica? Pain Physician 6:26971.

Fritzell P, Hagg O, Wessberg P, Nordwall A. 2001. TheSwedish Lumbar Spine Study Group. 2001 Volvoaward winner in Clinical studies: Lumbar fusionversus nonsurgical treatment for chronic low backpain. Spine 26: 252134.

Gibson JNA. 2007. Surgery for disc disease. BMJ 335:949.

Hadler NM. 1999. Occupational musculoskeletal disor-ders, 2nd edn. Philadelphia: Lippincott Williamsand Wilkins.

Hagen KB, Jamtvedt G, Hilde G, Winnen MF. 2005. Theupdated Cochrane review of bed rest for low backpain and sciatica. Spine 30: 5426.

Hill JC, Dunn KM, Lewis M et al. 2008. A primary careback pain screening tool: identifying patientsubgroups for initial treatment. Arthritis Rheum59: 110.

Jensen MC, Brant-Zawadzki MN, Obuchowski N,Modic MT, Malkasian D, Ross JS. 1994. Magneticresonance imaging of the lumbar spine in peoplewithout back pain. N Engl J Med 331: 6973.

Jensen TS, Karppinen J, Sorenson JS, Niinimaki J,Leboeuf-Yde C. 2008. Prevalence of vertebral end-plate signal (Modic) changes and their associationwith non-specific low back pain. Eur Spine J 17:140722.

Kendall NAS, Linton SJ, Main CJ. 1997. Guide toassessing psychosocial yellow flags in acute low backpain: risk factors for long term disability and workloss. Wellington, NZ: Accident Rehabilitation andCompensation Insurance Corporation of NewZealand and the National Health Committee.

Kjaer PT, Leboeuf-Yde C, Korsholm L, Sorenson JS,Bendix T. 2005. Magnetic resonance imaging andlow back pain in adults; a diagnostic imaging studyof 40 year old men and women. Spine 30: 117380.

Klein RG, Eck B. 1997. Prolotherapy: an alterna-tive approach to managing low back pain.J Musculoskeletal Med 14: 4549.

Koes BW. 2005. Surgery versus intensive rehabilitationprogrammes for chronic low back pain: spinalfusion surgery has only modest, if any, effects.BMJ 330: 12201.

Koes BW, van Tulder MW, Ostelo R, Burton AK,Waddell G. 2001. Clinical guidelines for the man-agement of low back pain in primary care: aninternational comparison. Spine 26: 250413.

Linton SJ. 2000. A review of psychological risk factorsin back and neck pain. Spine 25: 114856.

Little P, Lewith G, Webley F, Evans M et al. 2008.Randomised controlled trial of Alexander techniquelessons, exercise, and massage (ATEAM) forchronic and recurrent back pain. BMJ 337: 43841.

Moffett JK, Torgerson D, Bell-Dyer S et al. 1999.Randomised controlled trial of exercise for low backpain: clinical outcomes, costs, and preferences. BMJ319: 27983.

NICE. 2009. National Institute for Health and ClinicalExcellence. Low back pain: early management ofpersistent non-specific low back pain. (Clinical guide-line 88) www.nice.uk/CG88.

Ongley MJ, Klein RG, Dorman TA et al. 1987. A newapproach to the treatment of chronic low back pain.Lancet 1436.

Palmer KT, Walsh K, Bendall H, Cooper C, Coggan D.2000. Back pain in Britain: comparison of twoprevalence surveys at an interval of 10 years. BMJ320: 15779.

Pincus T, Burton AK, Vogel S, Field AP. 2002. Asystematic review of psychological factors as pre-dictors of chronicity/disability in prospectivecohorts of low back pain. Spine 27: E10920.

Roland M, Waddell G, Klaber-Moffett J, Burton AK,Main CJ. 2002. The Back Book: the best way to dealwith back pain; get back active, 2nd edn. Norwich:The Stationary Office.

Stirling A, Worthington T, Rafiq M et al. 2001.Association between sciatica andPropionibacterium acnes. Lancet 357: 20245.

van Tulder MW, Assendelft WJ, Koes BW, Bouter LM.1997. Spinal radiographic findings and non-specificlow back pain. A systematic review of observationalstudies. Spine 22: 42734.

van Tulder MW, Koes B, Seitsalo S, Malmivaara A.2006. Outcome of invasive treatment modalities onback pain and sciatica: an evidence-based review.Eur Spine J 15: S8292.

Waddell G. 1998. The back pain revolution. Edingburgh:Churchill Livingstone.

Waddell G, Burton K. 2000. Occupational Health guide-lines for the management of low back pain at work.Evidence review and recommendations. London:Faculty of Occupational Medicine.

Yelland MJ, Del Mar C. Pirozzo S, Schoene ML, VercoeP. 2004. Prolotherapy injections for chronic lowback pain. Cochrane Database.

64 G Brown

Trauma 2011; 13: 5764

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.