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| :''See also [[back pain]]''
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| {{Infobox_Disease |
| | {{Low back pain}} |
| Name = {{PAGENAME}} |
| | '''For patient information on Acute low back pain, click [[Acute low back pain (patient information)|here]]''' |
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| Caption = |
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| DiseasesDB = |
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| ICD10 = {{ICD10|M|54|4|m|50}}-{{ICD10|M|54|5|m|50}} |
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| ICD9 = {{ICD9|724.2}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 003108|
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| eMedicineSubj = pmr|
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| eMedicineTopic = 73|
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| MeshID = D017116 |
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| }}
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| {{Search infobox}}
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| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}} | | '''For patient information on Chronic low back pain, click [[Chronic low back pain (patient information)|here]]''' |
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| {{Editor Join}}
| | '''Editor-In-Chief:''' [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}} |
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| '''Low back pain''' is a common musculoskeletal disorder which affects the lumbar segment of the spine. It can be either [[Acute (medical)|acute]], subacute or [[Chronic (medicine)|chronic]] in its clinical presentation. Typically, the symptoms of low back pain do show significant improvement within two to three months from its onset. In a significant number of individuals, low back pain tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion of sufferers this condition can become chronic. Population studies show that back pain affects most adults at some stage in their life and accounts for more sick leave and disability than any other single medical condition. | |
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| An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue like [[muscle]]s, [[ligament]]s and [[tendon]]s. With a serious accident or due to osteoporosis or other causes of weakened vertebral bones, vertebral fractures in the lumbar spine may also occur. 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 at the bottom of the lumbar spine, called sacroiliac joint dysfunction.
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| Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. Physical causes may include [[osteoarthritis]], [[rheumatoid arthritis]], [[degenerative disc disease|degeneration of the discs]] between the [[vertebrae]], or a [[spinal disc herniation]], a vertebral fracture (such as from [[osteoporosis]]), or rarely, a tumor (including [[cancer]]) or infection. The cause may also be psychological or emotional or due to other non-anatomical factors.
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| ==Normal Anatomy and Function==
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| The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord — the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations. Stacked on top of one another are more than 30 bones — the vertebrae — that form the spinal column, also known as the spine. Each of these bones contains a roundish hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage. Small nerves (“roots”) enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.
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| Starting at the top, the spine has four regions:
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| * the seven cervical or neck vertebrae (labeled C1–C7),
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| * the 12 thoracic or upper back vertebrae (labeled T1–T12),
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| * the five lumbar vertebrae (labeled L1–L5), which we know as the lower back, and
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| * the sacrum and coccyx, a group of bones fused together at the base of the spine.
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| The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.
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| ==Pathophysiology==
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| As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.
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| Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results.
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| Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.
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| Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition. People with diabetes may have severe back pain or pain radiating down the leg related to neuropathy. People with these symptoms should contact a doctor immediately to help prevent permanent damage.
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| ==Risk Factors==
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| Nearly everyone has low back pain sometime. Men and women are equally affected. It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary life styles with too little (sometimes punctuated by too much) exercise. The risk of experiencing low back pain from disc disease or spinal degeneration increases with age.
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| Low back pain unrelated to injury or other known cause is unusual in pre-teen children. However, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. The U.S. Consumer Product Safety Commission estimates that more than 13,260 injuries related to backpacks were treated at doctors’ offices, clinics, and emergency rooms in the year 2000. To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, visit their locker or desk between classes to lighten loads or replace books, or purchase a backpack or airline tote on wheels.
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| ==Associated Conditions==
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| Conditions that may cause low back pain and require treatment by a physician or other health specialist include:
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| Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, lumbar portion of the spinal column.
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| A much more serious complication of a ruptured disc is cauda equina syndrome, which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated. | |
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| Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the leg due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, metastatic disease, or degeneration of the sciatic nerve root.
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| Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
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| Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
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| Osteoporosis is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine and hips results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis. Caucasian women of northern European heritage are at the highest risk of developing the condition.
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| Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
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| Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple “tender points,” particularly in the neck, spine, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
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| Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).
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| | {{SK}} Lumbar pain; low back pain/Swelling; lower back pain |
| | == [[Low back pain overview|Overview]] == |
| | == [[Low back pain pathophysiology|Pathophysiology]] == |
| | == [[Low back pain causes|Causes]] == |
| | == [[Low back pain differential diagnosis|Differentiating Low back pain from other Diseases]] == |
| | == [[Low back pain epidemiology and demographics|Epidemiology and Demographics]] == |
| | == [[Low back pain risk factors|Risk Factors]] == |
| | == [[Low back pain natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| ==Diagnosis== | | ==Diagnosis== |
| | [[Low back pain history and symptoms|History and Symptoms]] | [[Low back pain physical examination|Physical Examination]] | [[Low back pain laboratory findings|Laboratory Findings]] | [[Low back pain x ray|X Ray]] | [[Low back pain CT|CT]] | [[Low back pain MRI|MRI]] | [[Low back pain ultrasound|Ultrasound]] | [[Low back pain other imaging findings|Other Imaging Findings]] | [[Thermography|Musculoskeletal Thermography]] | [[Low back pain other diagnostic studies|Other Diagnostic Studies]] |
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| A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.
| | ==Treatment== |
| | | [[Low back pain conservative management|Conservative Management]] | [[Low back pain surgery|Surgery]] | [[Low back pain primary prevention|Primary Prevention]] | [[Low back pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Low back pain future or investigational therapies|Future or Investigational Therapies]] |
| A variety of diagnostic methods are available to confirm the cause of low back pain:
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| X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any vertebral misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.
| | ==Case Studies== |
| | | [[Low back pain case study one|Case #1]] |
| Discography involves the injection of a special contrast dye into a spinal disc thought to be causing low back pain. The dye outlines the damaged areas on x-rays taken following the injection. This procedure is often suggested for patients who are considering lumbar surgery or whose pain has not responded to conventional treatments. Myelograms also enhance the diagnostic imaging of an x-ray. In this procedure, the contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray.
| | ==Related Chapters== |
| | | * [[Back pain|Back Pain]] |
| Computerized tomography (CT) is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of low back pain. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures of the back. This diagnostic exam is generally conducted at an imaging center or hospital.
| | * [[Upper back pain|Upper Back Pain]] |
| | | * [[Chronic pain|Chronic Pain]] |
| Magnetic resonance imaging (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
| | * [[Spinal disc herniation|Spinal Disc Herniation]] |
| | | * [[Degenerative disc disease|Degenerative Disc Disease]] |
| Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.
| | * [[Coccydynia|Coccydynia (Coccyx Pain, Tailbone Pain)]] |
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| Bone scans are used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
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| Thermography involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of nerve root compression.
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| Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
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| ==Differential Diagnosis of Causes of {{PAGENAME}}== | |
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| Possible causes of low back pain: <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| * Mechanical:
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| ** Apophyseal osteoarthritis
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| ** Diffuse Idiopathic Skeletal Hyperostosis
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| ** [[Degenerative disc disease|Degenerative Discs]]
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| ** [[Scheuermann's disease|Scheuermann's kyphosis]]
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| ** [[Spinal disc herniation]] (slipped disc)
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| ** [[Spinal stenosis]]
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| ** [[Spondylolisthesis]] and other congenital abnormalities
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| ** Fractures
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| ** Non-specific muscular or ligamentous strains or sprains
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| ** Leg Length Difference
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| ** Restricted hip motion
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| ** Misaligned pelvis - pelvic obliquity, anteversion or retroversion
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| * Inflammatory:
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| ** Seronegative spondylarthritides (e.g. [[ankylosing spondylitis]])
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| ** [[Rheumatoid arthritis]]
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| ** Infection - epidural abscess or osteomyelitis
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| * [[Neoplastic]]:
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| ** [[Bone tumor]]s (primary or [[metastatic]])
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| ** Intradural Spinal tumors
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| * [[Metabolic]]:
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| ** [[osteoporosis|Osteoporotic]] fractures
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| ** [[Osteomalacia]]
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| ** [[Ochronosis]]
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| ** [[Chondrocalcinosis]]
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| * [[Paget's disease of bone|Paget's disease]]
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| * [[Referred pain]]:
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| ** Pelvic/abdominal disease
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| ** Posture
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| * [[clinical depression|Depression]]
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| * oxygen deprivation
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| ==Treatments==
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| The course of treatment for low back pain will usually be dictated by the clinical [[diagnosis]] of the underlying cause of the [[Pain and nociception|pain]].
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| ===Conservative treatment=== | |
| For the vast majority of patients, low back pain can be treated with non-surgical care. For those with acute, short-term back pain, certain home remedies<ref>{{cite web |url=http://www.back.com/articles-back_pain_relief.html |title=Acute back pain. Causes and treatment options. |accessdate=2007-09-26 |format= |work=}}</ref> may be effective.
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| [http://clinicalevidence.com/ ClinicalEvidence.com] has systematically reviewed [[randomized controlled trials]] published through April, 2004 and concluded: | |
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| ====Treatments likely to be beneficial====
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| * Advice to stay active.<ref name="pmid16973062">{{cite journal |author=Koes B, van Tulder M |title=Low back pain (acute) |journal=Clinical evidence |volume= |issue=15 |pages=1619–33 |year=2006 |pmid=16973062 |doi=|url=http://clinicalevidence.bmj.com/ceweb/conditions/msd/1102/1102.jsp}}</ref>
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| * [[Analgesic]]s (pain medications), such as [[NSAIDs]] or [[acetaminophen]].<ref name="pmid16973062"/><ref name="pmid16973063">{{cite journal |author=van Tulder M, Koes B |title=Low back pain (chronic) |journal=Clinical evidence |volume= |issue=15 |pages=1634–53 |year=2006 |pmid=16973063 |doi=|url=http://clinicalevidence.bmj.com/ceweb/conditions/msd/1116/1116.jsp}}</ref>
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| * [[Spinal manipulation]] for acute<ref name="pmid16973062"/> or chronic<ref name="pmid16973063"/> pain. A [[clinical prediction rule]] can guide who is most likely to respond to manipulation.<ref name="pmid15611489">{{cite journal |author=Childs JD, Fritz JM, Flynn TW, ''et al'' |title=A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study |journal=Ann. Intern. Med. |volume=141 |issue=12 |pages=920-8 |year=2004 |pmid=15611489 |doi=}} [http://www.annals.org/cgi/content/full/141/12/920/T1 Summary of the rule]</ref> | |
| * [[Muscle relaxant]]s for acute<ref name="pmid16973062"/> or chronic<ref name="pmid16973063"/> pain.
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| * [[Antidepressant]]s for chronic low back pain.<ref name="pmid16973063"/> | |
| * Exercise for chronic pain.<ref name="pmid16973063"/>
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| * Intensive multidisciplinary treatment programs may help subacute<ref name="pmid16973062"/> or chronic<ref name="pmid16973063"/> low back pain.
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| * Behavioral therapy<ref name="pmid16973063"/>
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| * [[Acupuncture]] may help chronic pain<ref name="pmid16973063"/>; however, a more recent [[randomized controlled trial]] suggested significant difference between real and sham acupuncture.<ref name="pmid17893311">{{cite journal |author=Haake M, Müller HH, Schade-Brittinger C, ''et al'' |title=German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups |journal=Arch. Intern. Med. |volume=167 |issue=17 |pages=1892–8 |year=2007 |pmid=17893311 |doi=10.1001/archinte.167.17.1892}}</ref>
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| ====Other treatments====
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| Additional treatments have been more recently reviewed by the [[Cochrane Collaboration]]:
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| * [[Massage]] therapy may benefit some patients (PMID 12076429) | |
| * Ice and/or heat application (or moist heat) has uncertain benefit (PMID 16437495).
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| Individual [[randomized controlled trials]], thus interpretation may be subject to publication bias, also confounded by absence of double blinding have shown benefit for:
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| * Viniyoga (PMID 16365466), Iyengar (PMID 15836974), and Hatha yoga (PMID 15055095 - small trial).
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| * Correcting leg length difference may help (PMID 16271551). To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.
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| * [[Muscle Energy Technique]] (MET) may help (PMID 14524509 - small study)
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| Other treatments that were not reviewed are
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| * Education and attitude adjustment (TMS)
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| * Increasing internal hip rotation
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| * Increase internal hip rotation with stretching or connective tissue massage
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| Because of variations in clinical study methodology, a review of clinical studies in any one area is not necessarily conclusive.
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| For any one condition, it may be necessary to try a variety of treatments in order to find the best one (or combination) to best manage the pain. In almost all cases, [[physical therapy]] and/or a regular [[exercise]] program that includes stretching, strengthening and low impact cardio conditioning will be part of the treatment and rehabilitation program.
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| The role of [[narcotic]]s for ''chronic'' low back pain is uncertain.<ref name="pmid17636781">{{cite journal |author=Deshpande A, Furlan A, Mailis-Gagnon A, Atlas S, Turk D |title=Opioids for chronic low-back pain |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD004959 |year=2007 |pmid=17636781 |doi=10.1002/14651858.CD004959.pub3}}</ref>
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| ===Surgery===
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| Lumbar surgery is 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 lumbar disc herniation, spinal abscess or cauda equina syndrome. Other possible indications for surgery include:
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| * Severe [[Degenerative disc disease]]
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| * [[Spinal stenosis]]
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| * [[Spondylolisthesis]] | |
| * [[Scoliosis]]
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| * [[Compression fracture]]
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| * Spinal instability
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| * Spinal [[trauma]]
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| * Spinal [[malignancy]] ([[cancer]])
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| * Spinal [[hematoma]]
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| 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.
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| ==References==
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| {{Reflist|2}}
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| ==See also==
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| * [[Back pain]]
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| * [[Upper back pain]]
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| * [[Chronic pain]]
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| * Lumbar disc herniation
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| * [[Degenerative disc disease]]
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| * [[Coccydynia| Coccydynia (coccyx pain, tailbone pain)]] | |
| * [[Sciatica]] | | * [[Sciatica]] |
| * Failed back syndrome | | * [[Failed back syndrome|Failed Back Syndrome]] |
| * [[Bertolotti's syndrome]] | | * [[Bertolotti's syndrome|Bertolotti's Syndrome]] |
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| ==External links==
| | {{Diseases of the musculoskeletal system and connective tissue}} |
| * [http://www.vertibax.co.uk Non-Invasive Lower Back Pain Relief]
| | [[zh:下背痛]] |
| * [http://back-pain-health.com/Lower_Back_Pain.html Lower Back Pain Prevention]
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| * [http://www.spine-health.com Back Pain, Neck Pain, Low Back Pain]
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| * [http://www.spine-health.com/topics/cd/stress/str01.html Stress related back pain]
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| * [http://www.ascent-oxford.kramesonline.com/HealthSheets/AlphaList.pg?Letter=b Low Back Pain - Information for Patients]
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| * [http://www.emedicine.com/pmr/topic242.htm Coccydynia (coccyx pain, tailbone pain) at eMedicine]
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| * [http://www.spineuniverse.com/displayarticle.php/article44.html Low Back Pain Resource Center - SpineUniverse]
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| * [http://www.spine-health.com Back pain and neck pain information for patients]
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| * [http://www.emedicine.com/pmr/topic242.htm Tailbone pain (coccyx pain, coccydynia) article at eMedicine]
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| * [http://lumbago.keuf.net Lumbago forum (in French)]
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| * [http://www.davmarpad.com/Back_Pain_Information_Web.htm Back Pain Information Web]
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