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Low back pain (LBP) is the fifth most common physician visit and affects 60-80% of people throughout their lifetime. Some studies have shown that up to 23% of the world’s adults suffer from chronic low back pain. This population has also shown a one-year recurrence rate ranging from 24% to 80%. Some estimates of lifetime prevalence are as high as 84% in adult populations. A systematic review revealed an annual incidence of adolescent back pain ranging from 11.8% to 33% 11-12% of the population are disabled by back pain.
There are different definitions of low back pain depending on the outcome. According to the European Guidelines for the prevention of low back pain, low back pain is defined as “pain and discomfort in the lower back and above the lower gluteal folds with painful or missing legs. . . . . Another definition according to S.Kinkade similar to European guidelines is that low back pain is “pain that occurs back in the region between the lower ribs and the proximal thigh”. The most common type of back pain is called “nonspecific back pain” is defined as “back pain that is not attributed to a specific known diagnosis”.
Low back pain is generally divided into 3 subtypes: acute subacute and chronic low back pain. This breakdown is based on the duration of back pain. Acute low back pain is low back pain that lasts less than 6 weeks, subacute low back pain between 6 and 12 weeks, chronic low back pain 12 weeks or more. 
Low back pain that persists for more than three months is considered chronic. More than 80% of all healthcare costs can be attributed to chronic LBP. Almost one-third of people seeking treatment for low back pain will experience persistent pain one year after an acute episode action. An estimated seven million adults in the United States are functionally impaired due to chronic low back pain.
A recent study looked at low back pain and long-term antibiotic therapy in a specific population. Inclusion criteria were previous disc herniation >6 months back pain and type 1 modic changes adjacent to previous herniation on MRI scan. The Modic transformation is where edema in the vertebral body. These patients were treated with antibiotics for 100 days and at re-evaluation and 1 year later, there was a statistically significant improvement in their pain ratings. So this could be something to consider in this population. However recent clinical guidelines issued by NICE in the UK Danish Health Authority and American College of Physicians do not mention antibiotics for low back pain. Another guideline issued by the KCE in Belgium in 2017 states that it does not recommend it seasonal antibiotics for pelvic or pelvic pain.
Low Back Pain Examination
The first objective of the physical therapy evaluation of a patient presenting with low back pain is to classify the patient according to the diagnostic tests recommended in the international low back pain guidelines. 15] Serious (such as fracture cancer infection and ankylosing spondylitis) are the specific causes back pain with neuropathic pain (such as radiculopathy caudal equina syndrome) is rare but it is important to investigate these conditions. Severe conditions account for 1-2% of people presenting with low back pain and 5-10% presenting with specific causes of LBP and arthritis insufficient funds. If specific causes of back pain have been ruled out, individuals are said to have nonspecific (or mild or mechanical) back pain.
Nonspecific low back pain accounts for more than 90% of primary care patients , and these are the majority of low back pain patients receiving physical therapy. A physical therapy evaluation is designed to identify possible causes of pain episodes or Increased likelihood of developing persistent pain. These include biological factors (such as weakness and stiffness), psychological factors (such as depression, fear of exercise, and catastrophizing), and social factors (such as the work environment) . Assessment does not focus on identifying anatomy Structures (such as intervertebral discs) as a source of pain may be the case in peripheral joints such as the knee . Previous research and international guidelines suggest that it is not possible or necessary to identify a specific tissue source of pain for effective pain management Mechanical back pain . Therefore, diagnostic imaging is not recommended, especially in the first month. Diagnostic management should only be used if low back pain is unresponsive to recommended regimens and requires a change in management or is more severe Pathology is suspected. [twenty two]
Leg pain is a common accompaniment of low back pain caused by a disorder of the neurological or musculoskeletal structures of the lumbar spine. Distinguishing between different sources of radiating pain to the leg is important for making a proper diagnosis and identifying the underlying pathology. Schaefer  proposed to divide low back pain-related leg pain into four subgroups according to the main pathological mechanism involved. Although there may be considerable overlap between classifications, each group presents a distinct pattern of symptoms and signs. the importance of The division of low back-related leg pain into these four groups is intended to facilitate diagnosis and provide more effective and appropriate treatment:
- Central sensitization with positive symptoms such as hyperalgesia
- Denervation with significant axonal damage shows predominantly negative sensory symptoms and possible loss of movement
- Peripheral nerve sensitization enhances neural trunk mechanical sensitization
- Somatic pain from musculoskeletal structures such as discs or facet joints.
Recently there has been a shift from a pathoanatomical approach to managing patients with back pain. We no longer aim to diagnose the faulty structure, but rather target that specific structure for treatment. Research and international guidelines suggest not possible or necessary Identify specific tissue sources of pain for effective management of mechanical back pain . Instead, a layered approach to managing low back pain has become popular.
Recent guidelinesrecommend counseling and non-pharmacological interventions such as physical therapy interventions including exercises and manual therapy. The ACP currently recommends acupuncture only for the treatment of individuals with back pain. A recent study by Ford et al suggest that individual Physiotherapy for people with LBP using Specific Treatment of Problems of the Spine (STOPS) approach can be highly effective in managing LBP. To guide these treatment plans, a hierarchy of care has been suggested as an appropriate strategy. Hierarchical care and targeting treatment to subgroups of patients based on characteristics. Foster et al suggest that there are 3 different approaches to stratification with good evidence:
In a clinical trial study by Finta et al  titled The effect of diaphragm training on lumbar stabilizer muscles: a new perspective to improve segmental stability for low back pain recent evidence suggested that diaphragm training has an effect in development improve others try spinal stabilizing factors such as the transversus abdominis and spinal multifidus muscles in low back pain .
- Treatments that match patient outcomes such as persistent pain and likelihood of disability (e.g. STarT Back Screening Tool.
- Response to treatment—matching treatment to individuals who will benefit from that treatment (eg, stopping trials based on treatment-based low back pain classification).
- Underlying Mechanisms – Matching treatment to mechanisms driving pain and disability, such as pathological pain mechanisms negative thoughts and behaviors (e.g. cognitive functional approaches ).
Recently, Almeida et al. proposed two approaches according to recent clinical guidelines when considering the management of patients with nonspecific low back pain .
- Traditional approach – stratify patients by duration of symptoms – acute (less than 6 weeks), subacute (6-12 weeks) and chronic (more than 12 weeks) and then use a stepwise approach to treatment starting with simple therapies until Progression to if not more complex treatment Very significant improvement. This approach is recommended by US  and Danish  guidelines.
- Using risk-prediction tools such as the STarT Back Örebro Musculoskeletal Pain Screening Questionnaire and PICKUP to determine optimal treatment options based on their risk of poor clinical outcome, as recommended by UK  and Belgian  guidelines.
Management of Low Back Pain: Adapted from Almeida et al.
The use of these different layering methods varies around the world, and there is overlap between the three different methods. A perfect grouping method would include all three of these methods. These models do not replace clinical reasoning or experience, but they can Guarantees informed exploration in clinical practice in an appropriate setting.
Physiotherapy intervention for mechanical back pain has few contraindications as long as the diagnostic classification is applied to identify the serious cause of back pain in people. Osteoporosis is a contraindication to most manual treatments. Importantly, physical therapists work within a model in which Closely reassess treatment effects to minimize the possibility of increased symptoms or adverse events .
Prevention of Low Back Pain
Prevention also falls into three categories:
- Primary prevention is defined as “specific practices to prevent disease or mental disorders in susceptible individuals or populations. These include health promotion, including mental health; protective measures such as infectious disease control; surveillance and regulation environmental pollutants. Primary prevention is distinguished from secondary and tertiary prevention. “
- Secondary prevention is defined as “prevention of recurrence or exacerbation of established disease. This also includes prevention of complications or sequelae of medication or surgery” 
- Tertiary prevention is “measures aimed at providing appropriate support and rehabilitation services to minimize morbidity and maximize quality of life following long-term illness or injury”. 
The guidelines discuss different possibilities for preventing low back pain. Physical activity is recommended to prevent the consequences of low back pain, such as lack of work and the occurrence of further attacks. Physical exercise is especially useful for training the back extensors and trunk flexors Combine with regular aerobic training. There are no specific exercise frequency or intensity recommendations.  With regard to the back school program, an intensive program is recommended for patients with recurrent and persistent low back pain, but not for low back pain prevention. this Lessons include exercises and educational skills sessions. Education and information alone or based on biomechanical models had only a small impact. Education and information are more effective when combined with other interventions in a therapeutic setting based on a biopsychosocial model influences. Information based on a biopsychosocial model focused on beliefs about low back pain and reducing job losses due to low back pain. This informative attitude had a positive impact on back pain beliefs.  It is important to know that individually customized programs and Interventions can have more outcomes than group interventions.  Lumbar support belts and insoles are not recommended for the prevention of low back pain. Lumbar supports and harnesses have also been shown to have a negative effect on back pain beliefs, so are Not recommended for the prevention of low back pain.  There is no evidence for or against specific mattresses and chairs used for prevention. A medium support mattress may reduce symptoms of existing persistent low back pain.  Ergonomic adjustments to the work environment may be required, and Facilitates an early return to work. 
Exercises For Low Back
Workout program includes a warm-up session with five exercises (full body movement while standing with awareness of posterior pelvic tilt lumbar spine rotation arm movement) known exercises for back extensors abdominal lateral hips trunk rotators posterior hips leg muscles Obliques (such as planks and leg raises) and flexibility exercises for each of the eight exercises. After each type of exercise, the patient should record the level of each exercise for each session during the eight-week period. 
- Casiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK538173/ (last accessed 21.1.2020)
- Balagué F1, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.
- Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group. 2004: 1-53.
- Kinkade S. Evaluation and treatment of acute low back pain. Am Ac of Family Phys. 2007: 1182-1188.
- Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.
- Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.
- Chou R, Qaseem A, Snow V, Casey D, Cross TJ, 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;147:478-491.
- Chou R. Pharmacological Management of Low Back Pain. Drugs [online]. 2010;70 (4):387-402. Available from MEDLINE with FULL TEXT. Accessed April 30, 2011.
- Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic Treatment in Patients with Chronic Low back Pain and Vertebral Bone Edema (Modic Type 1 Changes): A Double-blind Randomized Clinical Controlled Trial of Efficacy. Euro Spine Journal 2013; 22: 607-707
- British Association of Spinal Surgeons. Antibiotic Treatment for Chronic Low Back Pain. http://www.spinesurgeons.ac.uk/patients/antibiotics-back-pain (accessed 11 October 2015)
- National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. London: NICE, 2016.
- Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60-75.
- Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514-530.
- Van Wambeke P, Desomer A, Ailliet L, et al. Summary: Low back pain and radicular pain: assessment and management. KCE report 287Cs. Brussels: Belgian Health Care Knowledge Centre (KCE), 2017.
- Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 2010;19:2075–94
- Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072–80.
- van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 2006;15(Suppl 2):S169–91
- O’Sullivan, P. and Lin, I. Acute low back pain Beyond drug therapies. Pain Management Today, 2014, 1(1):8-14
- Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430–34.
- M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118
- Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
- Hoffmann TC, Del Mar CB, Strong J, et al. Patients’ expectations of acute low back pain management: implications for evidence uptake. BMC Fam Pract 2013; 14: 7
- Axel Schäfer, Toby Hall and Kathy Briffa. Classification of low back-related leg pain—A proposed patho-mechanism-based approach. fckLRManual Therapy, 2009;14(2):222-230
- Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539–50.
- Ford J, Hahne A, Surkitt L, Chan A, Richards M. The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain. Journal of clinical medicine. 2019 Sep;8(9):1334.
- Foster N.E, Hill J.C, O’Sullivan P, Childs J.D, Hancock M.J. Stratified models of care for low back pain. WCPT Congress, Singapore, 2015
- Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Care and Research 2008;59:632-41.
- Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71.
- K Vibe Fersum, P O’Sullivan,2 JS Skouen, A Smith, and A Kvåle1. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul; 17(6): 916–928.
- Helen Clare, Roger Adams, Chris G Maher. A systematic review of efficacy of McKenzie therapy for spinal pain. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 50(4):209-16 · FEBRUARY 2004
- Tom Petersen. Non-specific Low Back Pain: Classification and treatment. Lund University, 2003
- Almeida M, Saragiotto, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275
- National Center of Biotechnology Information [www.ncbi.nlm.nih.gov]. Brussels [cited 2011 Apr 17]. Available from: http://www.ncbi.nlm.nih.gov/mesh/.
- van Poppel MNM , WE. An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace. Occupational Medicine. 2004: p 345-352.
- Van Nieuwenhuyse, P. G. The role of physical workload and pain-related fear in the development of low back pain in young workers: evidence from the BelCoBack Study; results after one year of follow up. Occup Environ Med. 2006: p 45-52.
- Kjaer P, Kongsted A, Ris I, Abbott A, Rasmussen CD, Roos EM, Skou ST, Andersen TE, Hartvigsen J. GLA: D® Back group-based patient education integrated with exercises to support self-management of back pain-development, theories and scientific evidence. BMC musculoskeletal disorders. 2018 Dec 1;19(1):418.
34.↑ Finta R, Nagy E, Bender T. The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain. Journal of pain research. 2018;11:3031.