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Recommend Option Recommend against
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History and physical Pain drawing and visual
exam 34 studies Basic history (B). analog scale (D).
History of cancer/
infection (B).
Signs/symptoms of
cauda equina
syndrome (C).
History of significant
trauma (C).
Psychosocial history
(C).
Straight leg raising
text (B).
Focused neurological
exam (B).
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Patient education 14 Patient education Back school in
studies about low back nonoccupational settings
symptoms (B). (C).
Back school in
occupational
settings (C).
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Medication Acetaminophen (C). Muscle relaxants (C). Opioids used >2wks (C).
23 studies NSAIDs (B). Opioids, short course (C). Phenylbutazone (C).
Oral steroids (C).
Colchicine (B).
Antidepressants (C).
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Physical treatment Manipulation of low Manipulation for patients Manipulation for patients
methods 42 methods back during first with radiculopathy (C). with undiagnosed
month of symptoms (B). Manipulation for patients neurologic deficits
with symptoms >1 month (D).
(C). Prolonged course of
Self-application of heat manipulation (D).
or cold to low back. Traction (B).
Shoe insoles (C). TENS (C).
Corset for prevention in Biofeedback (C).
occupational setting Shoe lifts (D).
(C). Corset for treatment (D).
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Injections Epidural steroid Epidural injections for
26 studies injections for radicular back pain without
pain to avoid surgery (C). radiculopathy (D).
Trigger point injections
(C).
Ligamentous injections
(C).
Facet joint injections
(C).
Needle acupuncture (D).
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Bed rest Bed rest of 2-4 days for Bed rest >4 days (B).
4 studies severe radiulopathy (D).
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Activities and Temporary avoidance of Back-specific exercise
exercise 20 studies activities that machines (D).
increase mechanical Therapeutic stretching of
stress on spine back muscles (D).
(D).
Gradual return to
normal activities
(B).
Low-stress aerobic
exercise (C).
Conditioning exercises
for trunk mescles
after 2 weeks (C).
Exercise quotas (C).
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Detection of If no improvement EMG for clinically obvious
physiologic after 1 month, radiculopathy (D).
abnormalities 14 consider: Surface EMG and F-wave
studies Bone scan (C). tests (C).
Needle EMG and H- Thermography (C).
reflex tests to
clarify nerve root
dysfunction (C).
SEP to assess spinal
stenosis (C).
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X-rays of L-S spine 18 When red flags for Routine use in first month
studies fracture present (C). of symptoms in absence of
When red flags for red flags (B).
cancer or infection Routine oblique views (B).
present (C).
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Imaging 18 studies CT or MRI when cauda Myelography or CT- Use of imaging test before
equina, tumor, myleography for one month in absence red
infection, or preoperative planning (D). flags (B).
fracture stongly Discography or CT-
suspected (C). discography (C).
MRI text of choice for
patients with prior
back surgery (D).
Assure quality
criteria for
imaging tests (B).
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Surgical Discuss surgical Disc surgery in patients
considerations 14 options with with back pain alone,
studies patients with no red flags, and no
persistent and nerve root compression
severe sciatica and (D).
clinical evidence Percutaneous discectomy
of nerve root less efficacious than
compromise after 1 chymopapain (C).
month of Surgery for spinal
conservative stenosis within the
therapy (B). first 3 months of
Standard discectomy symptoms (D).
and microdiscectomy Stenosis surgery when
of similar efficacy justified by imaging
in treatment of test rather than
herniated disc (B). patient's functional
Chymopapain, used status (D).
after ruling out Spinal fusion during the
allergic first 3 months of
sensitivity, symptoms in the absence
acceptable but less of fracture,
efficacious than dislocation,
discectomy to treat complications of tumor
herniated disc (C). or infection (C).
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Psychosocial factors Social, economic, and Referral for extensive
psychological factors evaluation/treatment prior
can alter patient to exploring patient
response to symptoms expectations or
and treatment (D). psychosocial factors (D).
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