Low back pain

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Low back pain
190px
The five vertebrae in the lumbar region of the back are the largest and strongest in the spinal column.
ICD-10 M54.4-M54.5
ICD-9 724.2
MedlinePlus 003108
eMedicine pmr/73
MeSH D017116

Low back pain (or lumbago) is a common musculoskeletal disorder affecting 80% of people at some point in their lives. It accounts for more sick leave and disability than any other medical condition.[1] It can be either acute, subacute or chronic in duration. Most often, the symptoms of low back pain show significant improvement within a few weeks from onset with conservative measures.

Classification

One method of classifying lower back pain is by the duration of symptoms: acute (less than 4 weeks), sub acute (4–12 weeks), chronic (more than 12 weeks).

Cause

Most cases of lower back pain are due to benign musculoskeletal problems and are referred to as non specific low back pain. They are generally believed to be due to a sprain or strain in the muscles of the back and the soft tissues,[2] especially if the pain arose suddenly during physical load to the back, and the pain is lateral to the spine. The rate of serious causes is less than 1%.[3] The full differential diagnosis includes many other less common conditions.

Pathophysiology

File:Illu vertebral column.jpg
The lumbar region in regards to the rest of the spine.

The lumbar region (or lower back region) is made up of five vertebrae (L1-L5). In between these vertebrae lie fibrocartilage discs (intervertebral discs), which act as cushions, preventing the vertebrae from rubbing together while at the same time protecting the spinal cord. Nerves stem from the spinal cord through foramina within the vertebrae, providing muscles with sensations and motor associated messages. Stability of the spine is provided through ligaments and muscles of the back, lower back and abdomen. Small joints which prevent, as well as direct, motion of the spine are called facet joints (zygapophysial joints).[4]

The lumbar region is the area of the spine that is also the source of most movement and flexibility, and is the support structure for much of a person's body weight.[5] Both factors often contribute to the onset of back pain, but the causes of lower back pain are varied. Most cases are believed to be due to a sprain or strain in the muscles and soft tissues of the back.[2] Overactivity of the muscles of the back can lead to an injured or torn ligament in the back which in turn leads to pain. An injury can also occur to one of the intervertebral discs (disc tear, disc herniation). As the body ages, the spine does as well. Due to aging, discs begin to diminish and shrink in size, resulting in vertebrae and facet joints rubbing against one another. Ligament and joint functionality also diminishes as one ages, leading to spondylolisthesis, which causes the vertebrae to move much more than they should. Pain is also generated through spinal stenosis, sciatica and scoliosis. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia). Others may have pain from their sacroiliac joint, where the spinal column attaches to the pelvis, called sacroiliac joint dysfunction. Physical causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, an infection or tumor.

In the vast majority of cases no noteworthy or serious cause is ever identified. Usually the pain resolves on its own after a few weeks. Intensive testing for a physical cause without waiting for the pain to recede is not prudent because any problems identified may be irrelevant and misleading.[6]

Diagnostic approach

Acute back pain is defined as pain less than 6 weeks while chronic back pain is defined as pain that has been present for over three months. The intermediate time period is known as sub acute back pain.[7] Determination of the underlying cause is usually made through a combination of a medical history, physical examination, and, when necessary, diagnostic testing, such as an x-ray, CT scan, or MRI.

Imaging

From 1994 to 2006, MRI scans of the lumbar region increased by 307%.[8] Imaging rates and surgery rates are directly related. Where imaging rates are highest in the country, surgery rates are the highest.[9] The American College of Physicians as well as the American Pain Society both highly advise against consistent imaging in patients who deal with nonspecific low back pain.[10] However, the use of MRI and CT scans is recommended when a patient deals with consistent leg and back pain.[10] There is no relation between MRI/CT scans and positive patient outcomes.[11]

X-ray

X-rays are useful in determining deformities in one's bones. They can provide one with the most obvious causes of low back pain due to bone fractures or changes in bone due to aging.

Bone density test

Osteoporosis does not cause low back pain; however, bone fractures may occur due to osteoporosis, resulting in low back pain.

X-rays and CT scans are not required in lower back pain except in the cases where "red flags" (listed below) are present.[12] If the pain is of a long duration X-rays may increase patient satisfaction.[13]

Red flags

  • Milder trauma if age is greater than 50 years
  • Unexplained weight loss
  • Unexplained fever
  • Intravenous drug use
  • Osteoporosis
  • Chronic corticosteroid use
  • Age greater than 70 years
  • Focal neurological deficit
  • Duration greater than 6 weeks[14]

Prevention

Low back pain is common and there are several methods of prevention. Although exercise show conflicting results in treatment of acute episodes, it is effective in preventing recurrences.[15] Proper lifting technique may also be important.[16]

A number of studies were conducted about the relationship between the spine and nicotine. Cigarette smoking is a factor that inversely affects the success and proper healing of spinal fusion surgery. In patients who underwent cervical fusion, a smokers rate of nonunion was much greater than a nonsmoker.[17] Smoke and nicotine cause the spine to age faster than normal. Smoking also reduces blood flow to the lower spine and causes the spinal discs to degenerate.[18]

Management

Conservative

For the vast majority of people, low back pain can be treated conservatively. A number of recommendations which may help alleviate symptoms include:[19] applying heat or cold,[20][21] physical therapy,[22] and continued activity within the limits of the pain with bed rest being discouraged.[23] Firm mattresses are less likely to lead to improvement when compared with a medium-firm mattress.[24]

Acute back pain

Medications

Short term use of pain and antiinflammatory medications, such as NSAIDs or acetaminophen can help with the symptoms of lower back pain.[25][26] However, these medications are not without risk and for persistent pain a health care practitioner should be consulted. Muscle relaxants for acute[25] and chronic[26] pain have some benefit, however, there are concerns with side effects, and their routine use is discouraged.[27] Muscle relaxants are more effective in relieving pain and spasms when they are used in combination with NSAIDs.[28]

Activity

Staying as physically active as possible is recommended by most guidelines. Bed rest is discouraged as not being helpful.[25][29] Even when the pain is severe, some activity is still preferable to prolonged sitting or lying down, as long as it does not involve movements such as heavy lifting that would further strain the back.[6] Structured exercise in acute low back pain, however, leads to neither improvement nor harm.[30]

Spinal manipulation

Most reviews and guidelines have found that spinal manipulation (SM) therapy for low back pain of unknown cause is of no benefit beyond standard conservative management.[31][32] A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,[33]. The Swedish guideline for low back pain in 2002 does not recommend considering SM therapy for acute low back pain in patients needing additional help, possibly because the guideline's recommendations were based on a higher evidence level.[31] A 2008 review found that SM is similar to other forms of conventional care.[34] A 2007 literature synthesis, however, found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain.[35] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review[36] stated that SM or mobilization is no more or less effective than other standard interventions for back pain.[37] A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.[38]. However, the American College of Physicians and the American pain Society still recommend spinal manipulation when other conservative forms of treatment for lower back pain have failed.[39]

Chronic back pain

Low back pain is more likely to be persistent among people who previously required time off from work because of low back pain, those who expect passive treatments to help, those who believe that back pain is harmful or disabling or fear that any movement whatever will increase their pain, and people who have depression or anxiety.[6] A systematic review (2010) published as part of the Rational Clinical Examination Series in the Journal of the American Medical Association reviews the factors that predict disability from back pain.[40] The data quantified that patients with back pain who have poor coping behaviors or who fear activity are about 2.5 times as likely to have poor outcomes at 1 year.

The following measures have been found to be effective for chronic non-specific back pain :

  • Exercise appears to be slightly effective for chronic low back pain.[41] The Schroth method, a specialized physical exercise therapy for scoliosis, kyphosis, spondylolisthesis, and related spinal disorders, has been shown to reduce severity and frequency of back pain in adults with scoliosis.[42]

Prolotherapy, facet joint injections, and intradiscal steroid injections have not been found to be effective.[57] Epidural corticosteroid injections are said to supply the patient with temporary relief of sciatica. However studies show that they do not decrease the rate of ensuing operations.[58] Therapeutic massage is proven to be effective for chronic back pain.[59] Traditional Chinese Medical acupuncture was proven to be relatively ineffective for chronic back pain.[59]

Surgery

Surgery may be indicated when conservative treatment is not effective in reducing pain or when the patient develops progressive and functionally limiting neurologic symptoms such as leg weakness, bladder or bowel incontinence, which can be seen with severe central lumbar disc herniation causing cauda equina syndrome or spinal abscess.[citation needed] Spinal fusion has been shown not to improve outcomes in those with simple chronic low back pain.[60]

The most common types of low back surgery include microdiscectomy, discectomy, laminectomy, foraminotomy, or spinal fusion. Another less invasive surgical technique consists of an implantation of a spinal cord stimulator and typically is used for symptoms of chronic radiculopathy (sciatica). Lumbar artificial disc replacement is a newer surgical technique for treatment of degenerative disc disease, as are a variety of surgical procedures aimed at preserving motion in the spine. According to studies, benefits of spinal surgery are limited when dealing with degenerative discs.[61]

A medical review in March 2009 found the following: Four randomised clinic trials showed that the benefits of spinal surgery are limited when treating degenerative discs with spinal pain (no sciatica). Between 1990 and 2001 there was a 220% increase in spinal surgery, despite the fact that during that period there were no changes, clarifications, or improvements in the indications for surgery or new evidence of improved effectiveness of spinal surgery. The review also found that higher spinal surgery rates are sometimes associated with worse outcomes and that the best surgical outcomes occurred where surgery rates were lower. It also found that use of surgical implants increased the risk of nerve injury, blood loss, overall complications, operating times and repeat surgery while it only slightly improved solid bone fusion rates. There was no added improvement in pain levels or function.[62]

Spinal fusion

The logic behind spinal fusion is that by fusing two vertebrae together, they will act and function as a solid bone. Since lumbar pain may be caused by excessive motion of the vertebra the goal of spinal fusion surgery is to eliminate that extra motion in between the vertebrae, alleviating pain. If scoliosis or degenerative discs is the problem, the spinal fusion process may be recommended. There are several different ways of performing the spinal fusion procedure; however, none are proven to reduce pain better than the others.[22]

Some or no benefit

Additional treatments have been more recently reviewed by the Cochrane Collaboration:

  • Heat application may have a modest benefit. The evidence for cold therapy is limited.[64]
  • Correcting leg length difference may help by inserting a heel lift or building up the shoe.[67]
  • The role of narcotics for chronic low back pain is uncertain.[68]
  • A 2008 review found antidepressants ineffective in the treatment of chronic back pain[69] even though some previous studies did find them helpful.[26]

Prognosis

Most patients with acute lower back pain recover completely over a few weeks regardless of treatments.[71][72] With the usual lumbar muscle strain or sprain as the cause, over 90% of patients are completely recovered within one month.[73] Although an episode of lower back pain may settle quickly, recurrence rates are about 50% in the following 12 months. About 2% of the population with low back pain are temporarily or chronically disabled by their form of low back pain. 41% of adults aged between 26 and 44 years reported having back pain in the previous 6 months. Most had occasional episodes of pain that lasted a few days, was mild or moderate in intensity, and did not limit activities. Although a high percentage of individuals have persistent lower back pain, 75% of them self-manage their problem and a few become significantly disabled by low back pain. In the United States, the costs of low back pain range between $38 and $50 billion a year and there are 300,000 operations annually. Along with neck operations, back operations are the 3rd most common form of surgery in the United States.[74]

Epidemiology

Over a life time 80% of people have lower back pain,[72] with 26% of American adults reporting pain of at least one day in duration every three months.[75]

In pregnancy

50-70% of all pregnant women experience back pain.[76]

As one gets farther along in the pregnancy, due to the additional weight of the baby, one’s center of gravity will shift forward causing one’s posture to change. This change in posture leads to increasing lower back pain.[77][78]

The increase in hormones during pregnancy is in preparation for birth. This increase of hormones softens the ligaments in the pelvic area and loosens joints. This change in ligaments and joints may alter the support in which one’s back is normally used to.[79][80]

See also

References

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  1. ↑ "Lower Back Pain Fact Sheet. nih.gov". Retrieved 2008-06-16. 
  2. ↑ 2.0 2.1 irishhealth.com > Lumbago Retrieved on Dec 25, 2009
  3. ↑ Lua error in package.lua at line 80: module 'Module:Citation/CS1/Suggestions' not found.
  4. ↑ Floyd, R., & Thompson, Clem. (2008). Manual of structural kinesiology. New York, NY: McGraw-Hill Humanities/Social Sciences/Languages.
  5. ↑ "Basic Spine Anatomy". Retrieved 2010-04-23. 
  6. ↑ 6.0 6.1 6.2 6.3 Atlas SJ (2010). "Nonpharmacological treatment for low back pain". Journal of Musculoskeletal Medicine. 27 (1). 
  7. ↑ Bogduk M (2003). "Management of chronic low back pain". Medical Journal of Australia. 180 (2): 79–83. PMID 14723591. 
  8. ↑ Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22: 62–8.
  9. ↑ Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003; 28: 616–20.
  10. ↑ 10.0 10.1 Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478–91.
  11. ↑ Gilbert F, Grant A, Gillan M, et al. Scottish Back Trial Group. Low back pain: influence of early MR imaging or CT on treatment and outcome—multicenter randomized trial. Radiology. 2004;231:343-51. [PMID: 15031430]
  12. ↑ "Imaging strategies for low-back pain: systematic review and meta-analysis : The Lancet". 
  13. ↑ "BestBets: Early radiography in acute lower back pain". 
  14. ↑ "www.acr.org". 
  15. ↑ Choi BK, Verbeek JH, Tam WW, Jiang JY (2010). "Exercises for prevention of recurrences of low-back pain". Cochrane Database Syst Rev (1): CD006555. doi:10.1002/14651858.CD006555.pub2. PMID 20091596. 
  16. ↑ Delavier, Frédéric. Strength training anatomy. Human Kinetics Publishers, 2006. Print.}
  17. ↑ http://www.spineuniverse.com/wellness/cigarette-smoking-its-impact-spinal-fusions
  18. ↑ Mayo Clinic (2008). Back pain guide [on-line].
  19. ↑ "Clinical Evidence: The international source of the best available evidence for effective health care". (registration and log-in required)
  20. ↑ French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006:CD004750. [PMID: 16437495]
  21. ↑ "Heat or Cold Packs for Neck and Back Strain: A Randomized Controlled Trial of Efficacy. Gregory Garra. 2010; Academic Emergency Medicine - Wiley InterScience". 
  22. ↑ 22.0 22.1 http://orthoinfo.aaos.org/topic.cfm?topic=A00311
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  24. ↑ Kovacs FM, Abraira V, Peña A, Martín-Rodríguez JG, Sánchez-Vera M, Ferrer E, et al. Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet. 2003;362:1599-604. [PMID: 14630439]
  25. ↑ 25.0 25.1 25.2 25.3 Koes B, van Tulder M (2006). "Low back pain (acute)". Clinical evidence (15): 1619–33. PMID 16973062. 
  26. ↑ 26.0 26.1 26.2 26.3 26.4 26.5 van Tulder M, Koes B (2006). "Low back pain (chronic)". Clinical evidence (15): 1634–53. PMID 16973063. 
  27. ↑ "BestBets: Muscle relaxants for acute low back pain". 
  28. ↑ Malanga GA, Dunn KR. Low back pain management: approaches to treatment. J Musculoskel Med. 2010;27:305-315.
  29. ↑ Hagen KB, Hilde G, Jamtvedt G, Winnem M (2004). "Bed rest for acute low-back pain and sciatica". Cochrane Database Syst Rev (4): CD001254. doi:10.1002/14651858.CD001254.pub2. PMID 15495012. 
  30. ↑ Choi BK, Verbeek JH, Tam WW, Jiang JY (2010). "Exercises for prevention of recurrences of low-back pain". Cochrane Database Syst Rev (1): CD006555. doi:10.1002/14651858.CD006555.pub2. PMID 20091596. 
  31. ↑ 31.0 31.1 Murphy AYMT, van Teijlingen ER, Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948. 
  32. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  33. ↑ Chou R, Qaseem A, Snow V; et al. (October 2, 2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–91. PMID 17909209. 
  34. ↑ Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469. 
  35. ↑ Meeker W, Branson R, Bronfort G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13. 
  36. ↑ Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  37. ↑ Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782 Freely accessible. PMID 16574972. Lay summary – BBC News (2006-03-22). 
  38. ↑ Dagenais S, Mayer J, Wooley JR, Haldeman S (2008). "Evidence-informed management of chronic low back pain with medicine-assisted manipulation". Spine J. 8 (1): 142–9. doi:10.1016/j.spinee.2007.09.010. PMID 18164462. 
  39. ↑ http://www.medicalnewstoday.com/articles/84989.php
  40. ↑ Will This Patient Develop Persistent Disabling Low Back Pain? Roger Chou, MD; Paul Shekelle, MD, PhD JAMA. 2010;303(13):1295-1302. PMID: 20371789
  41. ↑ Hayden JA, van Tulder MW, Malmivaara A, Koes BW (2005). "Exercise therapy for treatment of non-specific low back pain". Cochrane Database Syst Rev (3): CD000335. doi:10.1002/14651858.CD000335.pub2. PMID 16034851. 
  42. ↑ Weiss HR, Scoliosis-related pain in adults: Treatment influences. Eur J Phys Med Rehabil 1993; 3(3):91-94.
  43. ↑ King SA (July 1, 2008). "Update on Treatment of Low Back Pain: Part 2". Psychiatric Times. 25 (8). 
  44. ↑ Haake M, Müller HH, Schade-Brittinger C; et al. (2007). "German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups". Arch. Intern. Med. 167 (17): 1892–8. doi:10.1001/archinte.167.17.1892. PMID 17893311. 
  45. ↑ Paul Little et al.,Randomised controlled trial of Alexander technique (AT) lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain, British Medical Journal, August 19, 2008.
  46. ↑ "BestBets: Are back schools effective in the management of chronic simple low back pain?". 
  47. ↑ Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies * Willem J.J. Assendelft, * Sally C. Morton, * Emily I. Yu, * Marika J. Suttorp, * and Paul G. Shekelle Ann Intern Med June 3, 2003 138:871-881
  48. ↑ Luciana AC Machado, Chris G Maher, Rob D Herbert, Helen Clare and James H McAuley. The effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial. BMC Medicine, 8:10, doi:10.1186/1741-7015-8-10, 2010 here online
  49. ↑ Audrey Long et al.: Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008, Volume 60, Number 4 here online
  50. ↑ Manca A, Dumville JC, Torgerson DJ, Klaber Moffett JA, Mooney MP, Jackson DA, Eaton S ; Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost-effectiveness analysis. Rheumatology; 46:1495-15010, 2007 pdf
  51. ↑ Schenk R, Jozefczyk, Kopf A ; A randomised trial comparing interventions in patients with lumbar posterior derangement. J Man & Manip Ther; 11:95-102, 2003
  52. ↑ Machado LAC, de Souza MvS, Ferreira PH, Ferreira ML ; The McKenzie Method for low back pain. A systematic review of the literature with a meta-analysis approach Spine; 31:E254-E262, 2006
  53. ↑ Long A, Donelson R, Fung T.: Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004; 29, 2593-2602 here online
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  60. ↑ "BestBets: Spinal fusion in chronic back pain". 
  61. ↑ Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 2007; 32: 816–23.
  62. ↑ "Overtreating chronic back pain: time to back off? Deyo.A et.al, Journal of the American Board of Family Medicine, March 2009". 
  63. ↑ Furlan AD, Brosseau L, Imamura M, Irvin E (2002). "Massage for low back pain". Cochrane database of systematic reviews (Online) (2): CD001929. doi:10.1002/14651858.CD001929. PMID 12076429. 
  64. ↑ French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ (2006). "Superficial heat or cold for low back pain". Cochrane database of systematic reviews (Online) (1): CD004750. doi:10.1002/14651858.CD004750.pub2. PMID 16437495. 
  65. ↑ Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA (2005). "Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial". Ann. Intern. Med. 143 (12): 849–56. PMID 16365466. 
  66. ↑ Williams KA, Petronis J, Smith D; et al. (2005). "Effect of Iyengar yoga therapy for chronic low back pain". Pain. 115 (1-2): 107–17. doi:10.1016/j.pain.2005.02.016. PMID 15836974. 
  67. ↑ Defrin R, Ben Benyamin S, Aldubi RD, Pick CG (2005). "Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain". Archives of physical medicine and rehabilitation. 86 (11): 2075–80. doi:10.1016/j.apmr.2005.06.012. PMID 16271551. 
  68. ↑ Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D (2007). "Opioids for chronic low-back pain". Cochrane database of systematic reviews (Online) (3): CD004959. doi:10.1002/14651858.CD004959.pub3. PMID 17636781. 
  69. ↑ Urquhart DM, Hoving JL, Assendelft WW, Roland M, van Tulder MW (2008). "Antidepressants for non-specific low back pain". Cochrane Database Syst Rev (1): CD001703. doi:10.1002/14651858.CD001703.pub3. PMID 18253994. 
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  73. ↑ about.com > Low Back Strain. Muscle strain of the lumbar spine By Jonathan Cluett, M.D. Updated January 10, 2010
  74. ↑ ACSM's resources for clinical exercise physiology: musculoskeletal, neuromuscular, neoplastic, immunologic and hematologic conditions. (2009). Philadelphia, PA: Amer College of Sports.
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  76. ↑ Danforth Obstetrics and Gynecology Ninth Ed. Scott, James. Gibbs, et al, Ch. 1
  77. ↑ Williams’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 8
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  79. ↑ http://www.americanpregnancy.org/pregnancyhealth/backpain.html
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