Tina Williams " AcuteLow
Back Pain" iHuman
History & Physical Examination
SOAP #4 2
Patient Demographics:
Name: T.H.
Age/race/sex: 26 Hispanic
... [Show More] Female
Clinical site: Primary Care clinic; Presents for sick visit.
SUBJECTIVE DATA
Chief Complaints : “My lower back has been hurting for about 2 weeks now”.
History of Present Illness :
Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline,
who presents to the clinic today complaining of spontaneous occurring acute low back pain to
lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has
been very difficult to dress lower body and to bend. She reports the pain is constant but has
intermittent intensities of aching and soreness throughout the day. The pain is localized to the
lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today
with 3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has
experienced. Reports the pain is worse in the mornings when getting out of bed after lying
down all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She
reports no heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or
depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped
head first over the handle bars of the bike. At which time she experienced this same low back
pain, went to the ER and had X-rays that showed some inflammation and swelling. She was
then prescribed a muscle relaxant, Ibuprofen, and physical therapy for 8 weeks, which helped
tremendously. At today’s visit, she hopes to find out where the pain is coming from and what
she can do to prevent it from returning.
Past Medical History:
• Depression-active- diagnosed 6 years ago after mom passed in a MVA
• Low back pain-active-diagnosed about 5 years ago after previous back injury.
Past Surgical History:
• No surgeries to date
Allergies:
NKA to food, dust, mold, environment, or medications.
Medications:
Sertraline 150 mg by mouth daily for depression
Health Maintenance:
• Influenza Vaccine-October 2017 at CVS.
• All other immunizations are up-to-date including TDaP, MMR, and Varicella.
• Last Pap smear- June 2016-normal
• Performs MSBE
• Depression screen positive for PHQ2; on meds and see Psychologists regularly.
• CAGE 0/4
Personal & Social History:
• Lives alone in a one bedroom apartment.
• Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her job
and has a dependable car.
• Denies any smoking, illicit drug abuse, or alcohol misuse.
• Previously did cross fit in high school. However, do to work she hasn’t had much time to
get the amount of exercise she needs.
• Patient is sexually active with only one sex partner, her boyfriend.
• 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a diet
coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf, veggies,
mashed potatoes from Boston Market, and a bottled water.
Family History:
Denies any fever, chills, night sweats, weight loss or weight
gain in the past year.
General
Grandparents
Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM
and MI.
Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79, history
of diabetes and arthritis.
Parents
Father: Father 59, history of HTN, Diabetes, Depression, and Stroke. Mother:
Mother 52, died in a MVA.
Siblings
Siblings: Only child.
Children
Children: No children.
Review of Systems:
SOAP #4 4
Skin Denies dry skin and itching. Denies abnormal lesions or new
nevi/moles
Head Previous head injury, denies any masses, lesions and headache
Eyes Denies any discharge, itchy, blurred vision, vision loss or
vision changes, eye pain or injection.
Ears Denies any itching, fullness, vertigo, ear pain or drainage,
hearing loss or changes in quality of hearing.
Nose/Sinuses Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in
smell
Mouth/Throat Denies sore throat and dysphagia. Denies gum disease, has
all original teeth, last dental exam was in July of this year, sees the
dentist annually.
Neck/Lymph Nodes Denies swollen /painful lymph nodes, denies any neck pain or
stiffness.
Breasts Denies masses, pain, or nipple discharge. Does perform regular
SBE.
Thorax/Respirator Denies any SOB, DOE, or wheezing.
y
CVS Denies CP, palpitations, denies peripheral edema, Orthopnea GI/Abdomen Denies
dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or
abdominal pain. No recent changes in bowel habits. Last bowel movement was this morning,
which is consistent with her regular bowel habits and was normal.
GU Denies any pain on urination, frequency, urgency, or vaginal
discharge.
Musculoskeletal See HPI.
Neurologic Denies memory loss, numbness, tingling, or burning pains or
weakness.
Endocrine Denies known glucose abnormalities, heat or cold intolerance Psychiatric
Reports a history of depression but denies any anxiety.
Physical Examination:
OBJECTIVE
Vital Signs/HT/WT T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right,
110/68 on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-
physique, stable with no gains or losses within the last 6 months),
BMI: 19.46, normal for ht. and wt.
General 26 y/o Hispanic female, pleasant appears her stated age
sitting on the examination table in moderate distress as evidenced
by arms tensed on elbows as she’s guarding pain. Well groomed,
well developed, AAOx3
Skin Warm, moist, no rashes or suspicious moles, +turgor Head/Scalp ATNC, thick black
hair, no dandruff, no lesions/masses.
Eyes External examination without ptosis, strabismus or
Neck/Lymph nodes Trachea midline with full AROM without pain.
exophthalmos. Conjunctiva pink. Rest of exam deferred.
Ears Auricles symmetrical, no lesions or tophi; Rest of exam
deferred.
Nose
Sinuses
Bilateral nasal turbinates’ pink, moist. Rest of exam deferred.
Deferred
Mouth Lips pink, moist mucous membrane, tongue protrudes in
midline.
Pharynx/Throat Deferred.
CVS RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD
Lungs/Thorax
3cm at 30 degrees, no carotid bruits, no cyanosis or vascular
lesions. No chest wall deformity. PMI at 5th ICM MCL. Nontender
without heaves or thrill. Auscultation of the abdomen without
bruit. Palpation without pulsatile masses
Chest symmetrical without deformity, respirations even and
unlabored throughout anterior and posterior lung fields. Palpation
without tenderness. Tactile fremitus present. Resonance heard on
percussion throughout anterior and posterior lung fields. Vesicular
breath sounds auscultated throughout anterior and posterior
peripheral lung fields.
Breasts Deferred
Abdomen Deferred
GU Deferred
Musculoskeletal Mandible moves in midline TMJ palpation without clicks or
tenderness. Neck and cervical spine have no noted deformities or
signs of inflammation. Curvature of cervical, thoracic and lumbar
spine within normal limits. Bony features of shoulders and hips are
of equal height bilaterally and nontender. Posture is slumped and
gait is smooth but guarded. Palpation of spinous processes of C7-L5
are palpable, midline, and tender to deep palpation right below L5.
Discomfort noted with lying flat on exam table. Patient can bend to
touch toes but experiences discomfort at about 90 degrees from
the upright position. Although patient can actively perform such
maneuvers as bending her knees to her chest while lying flat, flex,
extend, and rotate the spine there is some mild discomfort and
pain noted throughout the maneuvers.
Extremities/Pulses No edema, erythema or cyanosis to upper or lower extremities.
Pulses 2/4 to bilateral femoral, popliteal, posterior tibial, and
dorsalis pedis pulses.
Neurologic AA O X3. Slumped posture while sitting and walking. Gait steady
and intact. Sensation intact to light, deep, and sharp touch. gait and
balance intact. CN II- XII intact. Memory and
cognition intact for present and past medical history.
Psych Appropriate mood and affect
Evidence Based Assessment/Plan
Clinical Decision Making: 26 y/o Hispanic female presents to the primary care clinic
with a two week history of constant low back pain worse when ambulating and dressing. The
pain is non-radiating and has intermittent intensities of aching and soreness consistent with
acute non-specific low back pain. She has experienced these symptoms before after a biking
accident 5 years ago. Given Mrs. H’s presenting signs and symptoms there is a need to
differentiate between the diagnosis of acute nonspecific low back pain and low back pain with
radiculopathy. Mrs. H is an otherwise healthy young female with a history of depression
controlled on antidepressant. She has no other co-morbidities or health issues.
CHARACTERISTICS
OF DIFFERENTIAL
DIAGNOSIS
pain might or might not be associated
with significant pathology on magnetic
resonance imaging (MRI) and is SIGNS
Some physical exam findings of low
back pain may include the following;
Non-specific Acute AND SYMPTOMS
Pain areas: in the low back, muscles and
bones, hip, or leg.
Sensory: leg numbness or pins and
needles.
Back joint dysfunction or muscle spasms.
Slumped gait due to pain on standing
upright. www.aafp.org
PHYSICAL EXAM FINDINGS
Superficial tenderness over the lumbar
Low Back Pain
Nonspecific or
nonradicular low back
region to light touch Nonanatomic
tenderness
pain is not associated
with neurologic Exacerbation of pain by applying a few
symptoms or signs. In pounds of pressure with the hands to
general, the pain is
localized to the spine or
the top of the head
paraspinal regions (or
both) and does not
Exacerbation of pain by simulated
rotation or flexion of the spine
radiate into the leg. In
general, nonspecific low
back pain is not
associated with spinal
nerve root compression.
Ability to sit up straight from a supine
position, but intolerance of the straight-
leg-raising test
Nonspecific low back Nonanatomic distribution of sensory
Differential Diagnosis:
often a result of simple changes soft tissue disorders such as strain, but it
can also be caused by http://www.clevelandclinicmeded.co
serious medical m disorders arising in the
bony spine, parameningeal, or retroperitoneal regions.
Risk factors:
Smoking, obesity, older age, female gender, physically strenuous work,
sedentary work, a stressful job, job dissatisfaction and psychological
factors such as anxiety or depression.
Diagnosis:
Diagnosis is based on physical exam findings. Routine spine radiographs
are of limited value because they visualize only bony structures.
Guidelines from the
U.S. Agency for Health Care Policy and
Research (AHCPR) indicated value of routine spine radiographs for
acute low back pain in the following settings: acute major trauma,
minor trauma associated with risk of osteoporosis, risk of spinal
infection, pain that does not respond to rest or recumbency, and
history of cancer,
fever, or unexplained
weight loss. They may
also be of value in
assessing spinal
alignment and
rheumatologic disorders
of bone. The American
Academy of Neurology
guideline recommends
nonsurgical therapy
before CT and MRI are
used in patients with
uncomplicated acute
low back pain of less
than 7 weeks’ duration.
www.aafp.org
Acute lumbosacral
radiculopathy Low back
pain accompanied by
spinal nerve root
damage is usually associated with
neurologic signs or symptoms and is
described as radiculopathy. There is
usually pathologic evidence of spinal
nerve root compression by disk or arthritic
spur, but other intraspinal pathologies
may be present and are often apparent on
an MRI scan of the lumbosacral spine.
Risk factors:
Traumatic injury Lumbar sprain or strain
Postural strain sitting, standing or walking
>2hrs per day Radiculopathy — A
common feature of low back pain is
radiculopathy, which occurs when a
nerve root is irritated by a protruding disc
or arthritis of the spine. Radiculopathies
usually cause radiating pain, numbness,
tingling, or muscle weakness in the
specific areas related to the affected
nerve root, usually the lower leg. Most
people with these conditions improve
with limited or no treatment,
described below.
Sciatica — Sciatica refers to the most
common symptom of radiculopathy. It
is a pain that occurs when one of the
five spinal nerve roots, which are
branches of the sciatic nerve, is
irritated, causing a sharp or burning
pain that extends down the back or
side of the thigh, usually to the foot or
ankle. You may also feel numbness or
tingling. Occasionally, the sciatica may
also be associated with muscle
weakness in the leg or the foot. If a disc
is herniated, sciatic pain often increases
with coughing, sneezing, or bearing
down.
A comprehensive physical examination
of a patient with acute LBP should
include an in-depth evaluation of the
neurologic and
musculoskeletal systems.
The neurologic
examination should
always include an
evaluation of sensation,
strength, and reflexes in
the lower extremities.
This portion of the
examination allows the
examiner to detect
sensory or motor deficits
that may be consistent
with an associated
radiculopathy or cauda
equina syndrome.
Often, an assessment of
the L5 reflex (medial
hamstrings) is helpful.
Also, in L5 radiculopathy,
the presence of
weakness in foot
investors should raise the
additional suspicion of a
peroneal nerve palsy.
When differentiating
between an L3
radiculopathy versus a
femoral neuropathy,
weakness in the hip
adductors in addition to
the quadriceps group
would indicate an
frequent moving or lifting
>25 lbs. strength <50%
depression obesity poor
health prior LBP poor
back endurance
Osteoarthritis
Rheumatoid Arthritis
www.aafp.org Diagnosis:
After the initial
examination, the
diagnosis of lumbar
radiculopathy can be
supported by
electrodiagnosis, MRI,
CT scans, and/or
contrast myelography.
Treatment of lumbar
radiculopathy will vary
depending on the actual
cause of the
radiculopathy. These
treatments can include
the use of back
supports, medication,
physical therapy, steroid
injection in the spine,
and even surgery.
http://www.aanem.org
Neurogenic claudication
— Neurogenic
claudication is a type of
pain that can occur
when the spinal cord is
compressed due to
narrowing of the spinal
canal from arthritis or
other causes. The pain
runs down the back to
the buttocks, thighs, and
lower legs, often
involving both sides of
the body. This may
cause limping and
weakness in the legs.
Pain usually gets worse
when extending the
lower spine (e.g., when
standing or walking),
and gets better when
flexing the spine by
sitting, stooping, or
leaning forward.
https://www.uptodate.com/contents/low
-back-pain-in-adults
The onset of symptoms in patients with
lumbosacral radiculopathy is often sudden
and includes LBP. Some patients state the
preexisting back pain disappears when the
leg pain begins.
Sitting, coughing, or sneezing may
exacerbate the pain, which travels from
the buttock down to the posterior or
posterolateral leg to the ankle or foot.
Radiculopathy in roots L1-L3 refers pain to
the anterior aspect of the thigh and
typically does not radiate below the knee,
but these levels are affected in only 5% of
all disc herniations.
When obtaining a patient's history, be
alert for any red flags (i.e., indicators of
medical conditions that usually do not
resolve on their own without
management). Such red flags may imply a
more complicated condition that requires
further workup (e.g., tumor, infection).
The presence of fever, weight loss, or
chills requires a L3 radiculopathy. In an
isolated femoral neuropathy, only the
quadriceps group would show weakness.
Provocative maneuvers, such as the
straight-leg raising test or the slump test,
may provide evidence of increased dural
tension, indicating underlying nerve root
pathology.
Attempts at pain centralization through
postural changes (i.e., lumbar extension)
may suggest a discogenic etiology for pain
and may also assist in determining the
success of future treatment strategies.
The musculoskeletal evaluation should
include an assessment of the lower
extremity joints, as pain referral
patterns may be confused with focal
peripheral involvement. For example, a
patient with anterior thigh and knee
pain may actually have a degenerative
hip condition rather than an upper
lumbar radiculopathy. By assessing
lower extremity flexibility, hip rotation,
muscular balance, and ligamentous
stability, the evaluating physician might
be alerted to the patient's
predisposition toward an acute LBP
episode.
https://emedicine.medscape.com
No POC labs to review
Diagnosis 1-Guidelines for Treatment for Non-Specific Acute Low Back Pain (most likely dx):
There is general agreement that patients with acute nonspecific spine pain or nonlocalizable
lumbosacral radiculopathy (without neurologic signs or significant neurologic symptoms)
require only conservative medical management. Patients should abstain from heavy lifting or
other activities that aggravate the pain. Bed rest is not helpful and has been shown to delay
recovery. Bed rest may be recommended for the first few days for patients with severe pain
with movement. Recommended medications include nonsteroidal anti-inflammatory drugs
such as ibuprofen or aspirin. If there are complaints of muscle spasm, muscle relaxants such as
cyclobenzaprine may be used in the acute phase of pain. Narcotic analgesia should be avoided,
in general, but it can be prescribed in cases of severe acute pain. A study by Cherkin and
coworkers compared standard physical therapy maneuvers and chiropractic spinal
manipulation for the treatment of acute low back pain and found that both provide small short-
term benefits and improve patient satisfaction.
http://www.clevelandclinicmeded.com
Nonpharmacologic treatment, including superficial heat, massage, acupuncture, or spinal
manipulation, should be used initially for most patients with acute or sub-acute low back pain,
as they will improve over time regardless of treatment. When pharmacologic treatment is
desired, nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants should be
used. Avoid imaging in cases of uncomplicated low back pain (unless there are specific clinical
indications). Medications prescribed today;
• Diclofenac Sodium 50 mg 1 by mouth twice daily for pain for 2 weeks.
• Flexeril (Cyclobenzaprine) 10 mg 1 tab by mouth three times a day as needed for muscle
spasms for 2 weeks.
www.aafp.org
Diagnostic test needed:
No further diagnostic test needed at this time. Diagnosis was based on clinical presentation,
history, and physical exam.
Referrals/Consults:
Referral for physical therapy to evaluate and treat for low back pain and spasms.
Patient Education :
Remaining active — many people are afraid that they will hurt their backs further or delay
recovery by remaining active. However, remaining active is one of the best things you can do
for your back. In fact, prolonged bed rest is not recommended. Studies have shown that people
with low back pain recover faster when they remain active. Movement helps to relieve muscle
spasms and prevents loss of muscle strength. Although high-impact activities should be
avoided, it is fine to continue doing regular day-to-day activities and light exercises, such as
walking. If certain activities cause the back to hurt too much, it is fine to stop that activity and
try another.
If back pain is severe, bedrest may be necessary for a short period of time, generally no more
than one day. When in bed, the most comfortable position may be to lie on the back with a
pillow behind the knees and the head and shoulders elevated, or to lie on the side with the
upper knee bent and a pillow between the knees.
Heat — using a heating pad can help with low back pain during the first few weeks. It is not
clear if cold packs help as well.
Work — most experts recommend that people with low back pain continue to work so long as
it is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. Some people
need to stay home from work if their occupation does not allow them to sit or stand
comfortably. While standing at work, stepping on a block of wood with one foot (and
periodically alternating the foot on the block) may be helpful.
Pain medications — Take medications on a regular basis for two weeks for it to be effective,
rather than using the medication only when the pain becomes unbearable. If needed, take
muscle relaxant before bedtime. Do not take this medication while driving or operating
machinery.
Exercise — a program of exercises can help to increase back flexibility and strengthen the
muscles that support the back. Although starting back exercises or stretching immediately after
a new episode of low back pain might temporarily increase the pain, the exercise may reduce
the total duration of pain and prevent recurrent episodes. Recommended activities include
those that involve strengthening and stretching, such as walking, swimming, use of a stationary
bicycle, and low-impact aerobics. Avoid activities that involve twisting, bending, are high-
impact, or make the back hurt more. Some specific exercises may help strengthen the muscles
of the lower back. People with frequent episodes of low back pain should continue these
exercises indefinitely to prevent new episodes.
Mattress choice – The benefit of a firm mattress in preventing or treating low back pain has not
been proven. In one study, medium-firm mattresses were more likely to improve chronic back
pain compared with firm mattresses https://www.uptodate.com/contents/low-back-pain-in-
adults
Diagnosis 2-Guidelines for Treatment for Acute Lumbosacral Radiculopathy: The initial
treatment of the patient with lumbosacral radiculopathy presenting with sensory symptoms
and pain without significant neurologic deficits is not different from the approach for the
patient with uncomplicated low back pain. However, such patients require observation for
possible worsening of their neurologic status. For patients with acute lumbosacral
radiculopathy, the objectives of treatment are to ameliorate pain (symptomatic treatment)
and to address the specific underlying process (mechanismspecific treatment) if necessary
http://www.clevelandclinicmeded.com
Diagnostic test needed:
If signs and symptoms of radiculopathy, sciatica, or neurogenic claudication exists the
patient may require one or more of test including Spinal Radiography, CT scan, MRI, contrast
myelography, or electrodiagnosis. http://www.aanem.org
Referrals/Consults:
Referral to an orthopedic surgeon or neurosurgeon is recommended under the following
circumstances:
● Increasing neurologic problems (measurable weakness)
● Loss of sensation (e.g., numbness) or bladder and bowel symptoms ●Failure to
improve after four to six weeks of nonsurgical management, with persistent and severe
sciatica and evidence of nerve root involvement https://www.uptodate.com/contents/low-
back-pain-in-adults
Patient Education :
Most people with radiculopathy improve with conservative treatment such as medication and
PT. Surgery is recommended for some people with radiculopathy. They, too, usually improve
after a recovery period. Following treatment, most people are able to work and take part in
other daily activities. Patient education would include education to prevent acute non-specific
low back pain in addition to reducing chances of developing radiculopathy by maintaining good
posture and a healthy weight. Using safe techniques when lifting heavy objects to prevent
injuries to your back. Remembering to lift with your knees. That means you should bend your
knees, not your back. Also asking for help when moving heavy or bulky objects and when doing
repetitive tasks, take frequent breaks. https://www.healthline.com
Prevention :
There are a number of ways to prevent low back pain from returning. Perhaps the most
important are exercise and staying active. Regular exercise that improves cardiovascular fitness
can be combined with specific exercises to strengthen the muscles of the hips and torso. The
abdominal muscles are particularly important in supporting the lower back and preventing back
pain. It is also important to avoid activities that involve repetitive bending or twisting and high-
impact activities that increase stress in the spine.
Bend and lift correctly — People with low back pain should learn the right way to bend and lift.
As an example, lifting should always be done with the knees bent and the abdominal muscles
tightened to avoid straining the weaker muscles in the lower back (p
Take a break — People who sit or stand for long periods should change positions often and use
a chair with appropriate support for the back. An office chair should be readjusted several
times throughout the day to avoid sitting in the same position. Taking brief but frequent breaks
to walk around will also prevent pain due to prolonged sitting or standing. People who stand in
place for long periods can try placing a block of wood on the floor, stepping up and down every
few minutes.
https://www.uptodate.com/contents/low-back-pain-in-adults
Healthcare Maintenance/Recommendations :
Annual Influenza vaccine education provided-Received in October of 2017 Depression
screen-positive- Recommended to continue Sertraline and visits to Psychologists as
scheduled.
CAGE-0/4
STI and STD education
Sex behavioral counseling
Reinforced recommendations for MSBE
Cervical Cancer screen and HPV education-Recommended continuing routine Pap testing every
3 years.
Diet and exercise education- Recommended to exercise at least 3 days/week; with exercises to
help strengthen the core muscles. Continue eating a healthy diet and stay hydrated during
workouts.
Recommended using a back brace while at work to help with support with lifting and to call for
lifting help instead of trying lift alone.
The USPSTF also recommends high blood pressure, depression, and alcohol misuse screening in
this age group. Screening for HIV, Syphilis, HBV, HCV, and STI screening and behavioral
counseling is also recommended in all sexually active females in this age group. Although, Mrs.
H has a toned physique I think it’s important to counsel her on the importance of daily exercise
and physical activity to help reduce pain and on healthful diet practices such as the DASH diet,
which is high in grains, fruits, vegetables, and low in fat to help prevent future co-morbidities
especially since her family history is so significant for such severe co-morbidities and
mortalities.
www.uspstf.org
Follow-up: Follow up in 2 weeks for evaluation of pain management or as needed if pain
becomes worse or changes in presentation.
References
American Academy of Family Physicians. (2017). Diagnosis and Treatment of Low Back
Pain; Clinical Practice Guidelines. Retrieved from: http://www.aafp.org/patient-care/clinical-
recommendations/all/back-pain.html
American Association of Neuromuscular & Electrodiagnostic Medicine. (2017).
Lumbar Radiculopathy. Retrieved from: http:www.aanem.org/Patients/Disorders/Lumbar-
Radiculopathy
Cleveland Clinic Center for Center for Continuing Education. Published by; Levin, Kerry.
M.D. (2010). Low Back Pain. Retrieved from:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/lowback-
pain/#top
Healthline. (2017). Radiculopathy (Pinched Nerve). Retrieved from:
https://www.healthline.com/health/radiculopathy#overview1
Scientific Electronic Library Online by Ladeira, Carlos (2011). Evidence based practice
guidelines for management of low back pain: physical therapy implications. Retrieved from:
http://www.scielo.br/pdf/rbfis/v15n3/04.pdf
U.S. Preventive Services Task Force. (2017). Grade A and B Recommendations.
https://www.uspreventiveservicestaskforce.org/Search
UpToDate. (2017). Patient Education. Low Back Pain in Adults (Beyond the Basics).
Retrieved from: https://www.uptodate.com/contents/low-back-pain-in-adultsbeyond-the-
basics [Show Less]