Skeletal-muscle (non-specific) low back pain: clinical guidelines

Applies toadults2023 editionM54.5

Clinical Guidelines of the Russian Ministry of Health, adults. 2023 edition, ICD-10 codes: M54.5.

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Brief for Practice

WhiteCoat Pro editorial summary of the clinical guideline text, 2023 edition. Each point links to the original section — consult it before prescribing.

The guideline focuses on non-specific musculoskeletal pain between the 12th pair of ribs and the gluteal folds after excluding radiculopathy, lumbar spinal stenosis, and specific causes. Key clinical practices include identifying "red flags," avoiding routine imaging for typical acute pain, maintaining activity, and prioritizing non-pharmacological treatment methods.

Key points

Musculoskeletal LBP is diagnosed only after ruling out specific causes, radiculopathy, and lumbar spinal stenosis. → in the text
Typical pain occurs after exertion, an awkward movement, or prolonged uncomfortable positioning, worsens with movement and eases at rest; paresis, sensory disturbances, reflex changes, and pelvic organ dysfunction must be absent. → in the text
The prognosis for acute and subacute pain is generally favorable: intensity decreases significantly within 1–3 weeks, and in about 90% of cases, pain completely resolves within 6 weeks. → in the text
In the absence of "red flags" in a patient aged 18–50 with typical acute pain lasting less than 4 weeks, radiography, CT, and MRI are not performed. If there is no positive progress after 4 weeks, imaging is performed. → in the text
It is important to explain the benign nature of the condition to the patient, maintain physical, social, and professional activity, and avoid bed rest. In cases of high-intensity pain, bed rest is permissible, but for no longer than 1–2 days. → in the text
NSAIDs are recommended for acute, subacute LBP and exacerbation of chronic pain; they are prescribed at an effective dose for the minimum duration without combining them with each other. Oral forms are preferred; treatment should ideally be limited to 10–14 days. → in the text
For chronic LBP, regular physical therapy and psychological methods, including cognitive behavioral therapy and mindfulness therapy, are particularly important and should be combined. → in the text

Diagnostics

Assess pain intensity upon presentation and dynamically using the VAS, NRS, or VDS (Level of Evidence: 3, Grade of Recommendation: B). → in the text
Use a brief questionnaire to identify "red flags": age under 18 or over 50, recent trauma, history of malignancy, infectious or systemic inflammatory disease, prolonged glucocorticoid use, immunosuppressive state, HIV infection, substance abuse, fever, weight loss, and progressive non-mechanical pain. → in the text
Additionally, ask about pain radiation to the chest, perineum, rectum, abdomen, or vagina, as well as the relationship of pain with defecation and urination. → in the text
Conduct a somatic examination: assess for fever, weight loss, and skin changes, perform lung auscultation, abdominal palpation, and lymph node palpation to screen for fracture, tumor, infection, or somatic disease (Level of Evidence: 5, Grade of Recommendation: C). → in the text
Perform a brief neurological examination: check strength, sensation, knee, Achilles, and plantar reflexes, and nerve root tension signs. The Lasegue sign is evaluated with straight leg raise at 30–70°; pain occurring past 70° elevation is not considered pathological by itself. → in the text
The diagnosis of musculoskeletal LBP is established if signs of a specific disease, radiculopathy, or lumbar spinal stenosis are not detected (Level of Evidence: 5, Grade of Recommendation: C). To assess the severity of impaired functions, disease dynamics, and treatment efficacy, the Oswestry Disability Index or Roland-Morris Questionnaire is used (Level of Evidence: 3, Grade of Recommendation: B). → in the text
Laboratory tests are not ordered in the absence of signs indicating a specific cause (Level of Evidence: 5, Grade of Recommendation: C). → in the text

Treatment

Inform the patient about the favorable prognosis, encourage maintaining physical, social, and professional activity, and avoid prescribing prolonged bed rest. If forced to lie down due to severe pain, limit it to 1–2 days (Level of Evidence: 5, Grade of Recommendation: C). → in the text
In acute, subacute LBP or exacerbation of chronic pain, prescribe NSAIDs at an effective dose for the minimum necessary duration (Level of Evidence: 1, Grade of Recommendation: A). NSAIDs should not be combined; oral forms are preferred, and treatment duration should ideally be limited to 10–14 days. → in the text
In patients at risk for gastrointestinal complications, select NSAIDs with a lower gastrointestinal risk — meloxicam, nimesulide, aceclofenac, celecoxib, or etoricoxib — at low doses for a short course and/or use gastroprotection. NSAIDs are contraindicated in erosive and ulcerative gastrointestinal lesions, especially in the acute phase, severe hepatic and renal impairment, hypersensitivity, pregnancy, and severe heart failure. → in the text
Central muscle relaxants are used in acute pain to reduce painful muscle hypertonus (tolperisone, tizanidine, cyclobenzaprine; Level of Evidence: 1, Grade of Recommendation: B). They can be added to NSAIDs to enhance analgesia (Level of Evidence: 2, Grade of Recommendation: B), but muscle relaxants are not combined with each other, and sedative effects must be taken into account. → in the text
Paracetamol is not used as monotherapy: its efficacy for pain and function has not been proven (Level of Evidence: 1, Grade of Recommendation: B). It can be used when NSAIDs are contraindicated or cause adverse events, or added to NSAIDs in the absence of contraindications (Level of Evidence: 5, Grade of Recommendation: C). → in the text
For chronic LBP, amitriptyline or duloxetine is used (Level of Evidence: 2, Grade of Recommendation: A). Antidepressants are recommended if a comorbid depressive disorder is identified. Opioids are not recommended; tramadol or tapentadol are acceptable for managing intolerable high-intensity pain if it cannot be relieved otherwise (Level of Evidence: 1, Grade of Recommendation: A). → in the text
Physical therapy is indicated for acute pain if well tolerated (Level of Evidence: 2, Grade of Recommendation: A), and for subacute and chronic pain to reduce pain and improve function (Level of Evidence: 2, Grade of Recommendation: B). Sudden movements, excessive loads, and exercises involving significant flexion, extension, or rotation that exacerbate pain should be avoided. → in the text
For chronic pain, use cognitive behavioral therapy and mindfulness therapy in combination with physical therapy (Level of Evidence: 1, Grade of Recommendation: A). Additionally, superficial heat for acute pain, massage, manual therapy, reflexology, and pulsed low-frequency electromagnetic field therapy may be used. Braces, supportive belts, and traction are not recommended (Level of Evidence: 5, Grade of Recommendation: C). → in the text

When to refer and how to monitor

Planned hospitalization is indicated when outpatient conservative therapy fails. → in the text
Emergency hospitalization is required for suspected cauda equina compression syndrome, spinal fracture, spinal or spinal cord tumor, or inflammatory spinal disease. → in the text
An urgent neurosurgical consultation is required if cauda equina root compression is suspected. → in the text
Patients with subacute or chronic pain and prominent psychological or social factors should ideally be managed in a specialized multidisciplinary pain center. → in the text

Frequently asked questions

When are MRI or CT indicated for low back pain?

In the presence of "red flags," lack of improvement in acute pain after 4 weeks, as well as in subacute and chronic LBP. For typical acute pain lasting less than 4 weeks without signs of a dangerous disease in patients aged 18–50, imaging is not performed. → in the text

What signs require an urgent search for a specific cause?

These include pelvic dysfunction, leg paresis, and perineal anesthesia, as well as fever, recent infection, history of malignancy, weight loss, pain at rest or at night, recent trauma, and marked or progressive leg weakness during walking. → in the text

Is bed rest permissible in acute LBP?

Prolonged bed rest worsens the clinical course and prognosis. In cases of high-intensity pain, lying down for 1–2 days is acceptable, but only as a means to reduce pain, not as a treatment method; overall, activity should be maintained. → in the text

What medications are recommended for pain relief?

NSAIDs are recommended for acute, subacute pain, and exacerbations of chronic LBP (Level of Evidence: 1, Grade of Recommendation: A). They are prescribed at an effective dose for the minimum duration without combining them; the specific drug is chosen taking into account contraindications and risk factors. → in the text

Is surgery necessary for non-specific pain and disc herniation?

Disc herniation removal and other disc interventions are not recommended in musculoskeletal LBP: advantages over conservative treatment have not been proven, and the risk of adverse events exists (Level of Evidence: 5, Grade of Recommendation: C). → in the text

Status: Applied · approved by the Scientific and Practical Council of the Russian Ministry of Health
Database ID: 778, edition 1 (ID 778_1)
Publication date: December 7, 2023
Age category: adults
ICD-10 codes: M54.5
Specialties: Palliative care and pain management
Developers: Interregional Public Organization "Pain Study Society"
Official text: Russian Ministry of Health Rubricator — 778_1

List of Abbreviations

LBP – low back pain

VAS – visual analogue scale

VRS – verbal rating scale

HIV – human immunodeficiency virus

GCs – glucocorticoids

GI – gastrointestinal tract

SIJ – sacroiliac joint

CBT – cognitive behavioral therapy

CT – computed tomography

ICD-10 – International Classification of Diseases, 10th Revision

MRI – magnetic resonance imaging

NSAIDs – non-steroidal anti-inflammatory and antirheumatic drugs

PET – positron emission tomography

LCE – level of confidence of evidence

GRS – grade of recommendation strength

ZJ – zygapophyseal (facet) joint

NRS – numerical rating scale (for pain)

Terms and Definitions

Low back pain (LBP, synonyms: lower back pain, lumbar pain, lumbalgia, vertebrogenic lower back pain) is pain localized between the twelfth pair of ribs and the gluteal folds.

Acute LBP is low back pain lasting not more than 4 weeks.

Subacute LBP is low back pain lasting from 5 to 12 weeks.

Chronic LBP is low back pain lasting 12 weeks or more.

Lumboischias (sciatica) is a pain syndrome in the lumbar region radiating to the leg. This term primarily refers to musculoskeletal pain syndromes, i.e., conditions where the sources of pain can be muscles, joints, and ligaments, but not spinal nerve roots.

Musculoskeletal (nonspecific) LBP is low back pain caused by damage to elements of the musculoskeletal system and not associated with radiculopathy, lumbar stenosis, or specific causes (spinal fracture, infectious, systemic inflammatory, or oncological diseases).

Radiculopathy is damage to spinal nerve root(s) due to their compression, manifested by pain and/or sensory disturbances in the corresponding dermatomes, weakness in the corresponding myotomes (indicator muscles), and decreased or absent reflexes.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Low back pain (LBP) is pain localized between the twelfth pair of ribs and the gluteal folds [1-6].

LBP is regarded as musculoskeletal (nonspecific) pain if spinal nerve root damage (radiculopathy) and lumbar stenosis are not detected, and there are no specific causes of pain (vertebral fracture, tumor, infection, spondyloarthritis, or other diseases) [4-6].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The most common anatomical sources of musculoskeletal LBP are back muscles, their tendons and ligaments, facet joints (FJs), sacroiliac joints (SIJs), and the intervertebral disc [4-7]. In many cases, the exact source of pain in LBP cannot be established. Furthermore, it has not been proven that its precise identification improves treatment and disease outcomes [4-7]. Osteochondrosis represents a natural process of degeneration (aging) of spinal structures, is observed to varying degrees in all people, significantly increases with age, and is not regarded as the cause of musculoskeletal LBP [4].

Risk factors for the development of musculoskeletal LBP include heavy physical labor, frequent trunk bending, heavy lifting, as well as a sedentary lifestyle and vibration exposure. Individuals whose work or physical activities involve heavy lifting or "twisting" loads inappropriate for the spine (loaders, gymnasts, tennis players, skiers, mechanics, etc.) are at risk. At the same time, the factor of frequently repeated, constant, and even minor trauma to the joint-ligamentous apparatus and muscles during awkward movements or heavy lifting is of great importance. People who are forced to stay in prolonged static tension or a prolonged sitting position (professional drivers, office workers) are also at risk [4-10].

Chronification of LBP is associated not only with the degree of damage to muscles, ligaments, FJs, SIJs, and discs, but also with psychological and social factors, which include anxiety and depressive disorders, job dissatisfaction, family problems, the patient's misconception of pain with an inadequate subjective exaggeration of the real danger of the disease (catastrophizing), hypochondriacal personality type, decreased activity (professional, social, domestic, physical), and the search for and availability of financial compensation ("rentier" attitude towards the illness) [2,11].

1.3 Epidemiology of the Disease or Condition

LBP is one of the most frequent reasons for seeking medical attention [4,5]. Approximately 6–9% of the population consult for this reason within a year [12]. Worldwide, 632 million people suffer from LBP [13]. According to a survey conducted in Moscow polyclinics, out of 1,300 patients, 24.9% consulted in connection with LBP. Moreover, over the past year, LBP bothered more than half (52.9%) of the respondents [14]. This category of patients is most frequently encountered at the outpatient appointment of a neurologist and general practitioner [15].

LBP ranks first among all non-communicable diseases in terms of the number of years of life lost due to chronic deterioration of health [16-17]. Nonspecific (musculoskeletal) pain represents the most frequent (90-95%) cause of acute LBP [4-10].

1.4 Features of Coding the Disease or Condition

In ICD-10, musculoskeletal (nonspecific) LBP corresponds to category M54.5 – low back pain [1].

1.5 Classification of the disease or condition

Musculoskeletal pain is classified by duration (Table 1).

Table 1. Musculoskeletal (nonspecific) low back pain

Musculoskeletal (nonspecific) low back pain	Pain duration
Acute	Up to 4 weeks
Subacute	From 4 to 12 weeks
Chronic	12 weeks and more

1.6 Clinical presentation of the disease or condition

Musculoskeletal LBP is characterized by its appearance after physical exertion, an awkward movement, or prolonged stay in an uncomfortable position [10]. The pain is usually aching in nature, varies in intensity, increases with movement in the lumbar spine, certain postures, and walking, and subsides at rest. Radiation of pain to the abdomen, perineum, or genitals is not typical. During neurological examination, there are no signs of radiculopathy and other neurological diseases (paresis, loss or reduction of reflexes, sensory disorders, pelvic disorders, etc.).

The assumption of musculoskeletal LBP is based on complaints and inquiry about the nature of the patient's pain, medical history, somatic and neurological examinations, ruling out a so-called "specific" disease (see below), discogenic radiculopathy, and lumbar stenosis [10].

Acute and subacute musculoskeletal LBP has a favorable prognosis; it significantly decreases in intensity within 1-3 weeks and in most cases completely regresses within several weeks (in 90% of cases – up to 6 weeks) [10,18-20]; the majority of working patients return to work within a month [21]. Acute musculoskeletal LBP regresses with the use of various treatment methods as well as without them, which indicates its naturally favorable prognosis [20-23].

Recurrences of acute LBP are observed within a year in 1 out of 3 patients, while in 1 out of 5 patients, the exacerbation significantly impairs daily activity [24]. The chronic course of LBP is promoted by prolonged (more than 3-5 days) bed rest, excessive restriction of physical activity, "pain-prone" personality type, emotional disorders (depression, anxiety disorder), symptom aggravation, or a "rentier" attitude towards the illness [2,4,7,9]. It has been shown that patients who underwent radiography, computed tomography, or magnetic resonance imaging of the spine and were informed about the presence of spinal pathological changes, such as intervertebral disc herniations, have a worse recovery prognosis than those individuals who did not undergo instrumental examinations [25]. This confirms the importance of psychological factors in the course of nonspecific LBP.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria. Diagnosis of LBP is indicated for all patients when its presence is suspected. The diagnosis of musculoskeletal LBP is based on collecting the patient's complaints and medical history, somatic and brief neurological examinations, performed inter alia to rule out radiculopathy and specific causes of pain that require referral to an appropriate specialist for further examination and treatment.

2.1 Complaints and Anamnesis

When collecting complaints and medical history in patients with LBP, it is recommended to use a brief questionnaire to identify signs of so-called "specific" causes of the disease in order to select further management tactics for the patient (Table 2) (LE – 5, GRR-C) [6-8; 26-28].

Table 2. Questionnaire to identify signs of a specific disease ("red flags")

Age	Younger than 18 and older than 50 years
Medical history	Recent back trauma; Malignant neoplasm (even in case of radical tumor removal); Current infectious or systemic inflammatory disease; Prolonged use of GCs; Drug addiction, HIV infection, immunosuppressive state; Unexplained weight loss, fever.
Character and localization of pain	Progressive pain over time that is not relieved at rest ("non-mechanical" pain); Radiation of pain to the chest, perineum, rectum, abdomen, or vagina; Association of pain with defecation and urination.

Age

Younger than 18 and older than 50 years

Medical history

Recent back trauma;

Malignant neoplasm (even in case of radical tumor removal);

Current infectious or systemic inflammatory disease;

Prolonged use of GCs;

Drug addiction, HIV infection, immunosuppressive state;

Unexplained weight loss, fever.

Character and localization of pain

Progressive pain over time that is not relieved at rest ("non-mechanical" pain);

Radiation of pain to the chest, perineum, rectum, abdomen, or vagina;

Association of pain with defecation and urination.

If a patient with non-specific low back pain presents with red flags, an additional examination is recommended (somatic and brief neurological examination, neuroimaging) (LeveL of Evidence (LoE) - 5, Grade of Recommendation (GoR) - C) [6-8; 26-28] to search for specific causes of the disease.

To assess the severity of the condition and the effectiveness of treatment in patients with chronic low back pain, it is recommended to evaluate pain intensity both at presentation and dynamically (LoE - 3, GoR - B). Standardized scales can be used for this purpose: the visual analogue scale (VAS), numerical rating scale (NRS), verbal rating scale (VRS) [29,30] (Appendix G1).

Comments. The proposed form for collecting complaints and anamnesis complies with the guidelines of various countries on the management of patients with non-specific low back pain [5,6,31-33].

2.2 Physical Examination

A somatic examination is recommended for all patients to rule out a specific cause of back pain. It aims to detect signs of vertebral fractures, malignant neoplasms, infectious processes, and somatic diseases that may manifest as non-specific low back pain, and includes checking for fever, weight loss, skin changes, lung auscultation, abdominal and lymph node palpation (LoE - 5, GoR - C) [4-10].

A neurological examination in patients with non-specific low back pain is recommended to rule out spinal cord and nerve root lesions. During a neurological examination, it is important to identify paresis, sensory disturbances, changes in knee, Achilles, and plantar reflexes (LoE - 5, GoR - C) [4-10]. It is necessary to check for nerve root tension signs (Lasègue, Wassermann, Matzkewitsch). The appearance or significant intensification of pain when raising the straight leg at an angle of 30° to 70° in a supine patient (Lasègue's sign), followed by its disappearance or reduction when the leg is bent at the knee joint, is characteristic of L5 and S1 radiculopathy. If pain occurs when raising the leg at an angle of 30° to 70°, dorsiflexion of the foot usually increases the pain in discogenic radiculopathy. If pain occurs when raising the leg more than 70°, this is not regarded as pathology (observed in the majority of healthy individuals). Discogenic radiculopathy is characterized by the appearance (intensification) of pain on the affected side when raising the "healthy" leg (crossed Lasègue's sign), but this is a less sensitive test. The appearance or significant intensification of pain upon hip extension (Wassermann's sign) or when flexing the leg at the knee joint in a prone patient (Matzkewitsch's sign) are characteristic of L2, L3, or L4 radiculopathy [6-8;34-36].

To identify potential causes of non-specific low back pain, it is recommended to assess appearance (physiological curves, scoliosis, muscle tension) and range of motion in the lumbar spine (flexion, extension, side bending), and to determine the relationship between movements and pain. Palpation of the spinous processes, facet joints, sacroiliac joints, and special diagnostic tests to detect facet joint or sacroiliac joint lesions or signs of discogenic pain are recommended [6,7]. Neuro-orthopedic and manual examination is recommended and in some cases makes it possible to establish the cause (facet joint, sacroiliac joint, or muscle lesion, disc pathology) of non-specific low back pain [7] (LoE - 5, GoR - C); it is performed primarily in specialized centers.

The diagnosis of musculoskeletal non-specific low back pain should be based on the patient's complaints, anamnesis data, somatic and brief neurological examination. The leading role belongs to the exclusion of a specific cause of pain, in the presence of which a referral to a relevant specialist for further examination and treatment is recommended (Table 3) (LoE - 5, GoR - C) [4-10].

Table 3. Possible causes of pain and medical tactics in the presence of red flags

Red flags	Possible causes of pain	Management strategy
History of malignant neoplasm, unexplained weight loss, age over 50 years, onset or intensification of pain at rest, at night	Malignant neoplasm	MRI or CT of the spine (one segment), in some cases – whole-body bone scintigraphy, whole-body PET-CT of bones, consultation with an oncologist
Fever, recent infectious disease, parenteral drug use	Infectious involvement of vertebrae or discs	Radiography of the lumbosacral spine, spine radiography with functional tests, MRI or CT of the spine (one segment), consultation with a phthisiatrician, infectious disease physician
Pelvic disorders, lower limb paresis, perineal anesthesia	Cauda equina syndrome	MRI or CT of the spine (one segment), urgent neurosurgeon consultation
Presence of signs of osteoporosis, GC use, age over 50 years, recent back trauma	Vertebral compression fracture	Radiography of the lumbar and sacral spine, spine radiography with functional tests, MRI or CT of the spine (one segment), ultrasound densitometry, lumbar spine X-ray densitometry, rheumatologist consultation
Morning stiffness, young age, awakening in the second half of the night due to pain, improvement after physical exercise and NSAID intake	Ankylosing spondylitis (Bekhterev's disease)	Radiography of the lumbosacral spine, spine radiography with functional tests, rheumatologist consultation
Presence of a pulsating mass in the abdominal cavity	Abdominal aortic aneurysm	Complex ultrasound of abdominal organs. CT of abdominal organs, surgeon consultation
Pronounced or progressive weakness in the legs when walking (in the absence of neuromuscular disease)	Disc herniation and (or) lumbar stenosis	MRI or CT of the spine (one segment), neurosurgeon consultation

Diagnosis of musculoskeletal non-specific low back pain is recommended if: 1) complaints, anamnesis, and examination data (Tables 2, 3) reveal no warning signs regarding specific causes of back pain; 2) no signs of spinal nerve root compression (radiculopathy) or lumbar stenosis are detected (LoE - 5, GoR - C) [4-10].

To assess the severity of impaired functions, disease dynamics, and the effectiveness of ongoing treatment in musculoskeletal non-specific low back pain, the use of the Oswestry or Roland-Morris questionnaires is recommended (LoE - 3, GoR - B) (Appendix G2 and G3) [37].

Comments. The proposed examination algorithm complies with the guidelines of various countries on the management of patients with non-specific low back pain [5,6,31-33].

2.3 Laboratory Diagnostics

In non-specific low back pain, there are no changes associated with this condition in the complete blood count, general biochemical blood test, routine urinalysis, as well as in other laboratory tests.

In non-specific low back pain, laboratory tests are not recommended unless there are signs of a specific cause of non-specific low back pain (vertebral fracture, infectious, systemic inflammatory, oncological, or other disease) [4-10] (LoE - 5, GoR - C).

2.4 Instrumental Diagnostics

In non-specific low back pain, CT and MRI may reveal disc herniations and other spinal changes, but it has not been proven that their detection is of substantial clinical significance, affects patient management, and the disease prognosis [6,7,25]. The informative value of various methods (radiography of the lumbosacral spine, spinal CT (one region), spinal MRI (one region)) has also not been proven regarding the diagnosis of facet joint, sacroiliac joint, muscle, and ligament lesions of the lumbar spine [6,7,25].

If a patient with non-specific low back pain has red flags (Tables 2, 3), instrumental examinations are recommended (radiography of the lumbosacral spine, radiography of the spine with functional tests, spinal CT (one region) or spinal MRI (one region)) (LoE - 5, GoR - C) [4-10, 27, 32-34].

In a typical clinical presentation of acute (less than 4 weeks) musculoskeletal non-specific low back pain (absence of signs of "dangerous" diseases, red flags) in patients aged 18-50 years, instrumental examination methods (radiography of the lumbosacral spine, radiography of the spine with functional tests, spinal CT or MRI (one region)) are not recommended (LoE - 5, GoR - C) [4-10, 27, 32-34].

In the absence of positive dynamics of acute non-specific low back pain during treatment for 4 weeks, it is recommended to perform instrumental examination methods - radiography of the lumbosacral spine, radiography of the spine with functional tests, spinal CT or MRI (one region) (LoE - 5, GoR - C) [5,6,38,39].

Patients with subacute and chronic non-specific low back pain are recommended instrumental examinations: radiography of the lumbosacral spine, radiography of the spine with functional tests, spinal CT or MRI (one region) (LoE - 5, GoR - C), because prolonged pain increases the likelihood of a specific nature of the disease [5,6,38,39]. Radiography of the lumbosacral spine allows the detection of congenital anomalies and deformations, vertebral fractures, spondylolisthesis, inflammatory diseases (spondylitis), primary and metastatic tumors, as well as other changes. CT or MRI detects intervertebral disc herniations, determines their size and localization, and also reveals lumbar canal stenosis, spinal cord or cauda equina tumor, and other changes. The choice of method for a particular patient is determined by the clinical situation and the need to rule out certain diseases.

Comments. Performing radiography, CT, or MRI in patients with acute non-specific low back pain who do not have red flags does not improve the disease prognosis, does not affect the development of complications and chronification of the process, but unjustifiably increases the cost of treatment, patient anxiety, and the frequency of neurosurgical interventions. When pain lasts for more than a month (subacute or chronic pain), the probability of a specific disease increases, and it is necessary to determine the causes of pain (muscle, facet joint, disc, or sacroiliac joint lesion), therefore instrumental examinations are indicated.

2.5 Other Procedures

Comments. There are no diagnostic methods other than clinical ones that allow diagnosing non-specific low back pain. To rule out specific causes of pain, various diagnostic methods can be used depending on the suspected condition. Assessment of psychological and social factors of pain, in addition to standard somatic, orthopedic, and neurological examination, significantly improves the disease prognosis and optimizes medical tactics.

In patients with subacute and chronic non-specific low back pain, assessment of psychological and social factors of pain is recommended (LEL – 5, GOR - C), because if present, effective psychological therapy methods can be used [4,6,7,9]. The presence of psychological and social factors in the development of non-specific low back pain justifies providing care to patients in specialized (multidisciplinary) pain centers, where these factors are identified and addressed using various therapeutic methods [4-7,9].

Comments. In real clinical practice, psychological and social aspects are assessed relatively rarely. They are predominantly identified in multidisciplinary pain centers, which are not yet sufficiently developed in our country.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Non-pharmacological treatments are of paramount importance in the management of patients with non-specific low back pain, because the prognosis is favorable even with the natural course of the disease, and the use of pharmacological treatments carries a certain risk of complications. Non-pharmacological methods include informing the patient with low back pain about the favorable prognosis and the importance of maintaining physical, social, and professional activity; for subacute and chronic low back pain, exercise therapy and psychological therapy methods are used [4-10].

3.1 Conservative Treatment

It is recommended to inform patients with acute non-specific low back pain about the benign nature of the disease and the likelihood of a rapid (2-3 weeks) recovery if doctor's recommendations are followed, the necessity to maintain physical, social, and professional activity, and to avoid bed rest. Informing the patient about the favorable prognosis of musculoskeletal low back pain and maintaining physical activity prevents pain catastrophizing and promotes rapid recovery. Prolonged reduction of professional, social, and daily activity worsens the prognosis and course of musculoskeletal low back pain [4-10, 31-33] (LEL – 5, GOR - C).

In cases where patients are forced to stay in bed due to intense pain, the duration of bed rest should not exceed 1-2 days; longer bed rest worsens the course of the disease. It is recommended to explain to the patient that short-term bed rest is acceptable for high-intensity pain (LEL – 5, GOR - C), but this is a way to reduce pain rather than a treatment method [5,6,31-33].

3.1.1 Pharmacotherapy

Nonsteroidal anti-inflammatory and antirheumatic drugs (NSAIDs); ATC code: M01A (drugs with analgesic, anti-inflammatory, and antipyretic effects) are recommended in patients with acute, subacute, or exacerbation of chronic non-specific low back pain (LEL – 1, GOR - A), as they relieve pain and improve patients' functional activity [40-42]. NSAIDs should be prescribed at effective doses for the minimum necessary number of days to reduce the risk of adverse effects [41-44]. Currently, no reliable superiority of any single NSAID over others has been established regarding the relief of non-specific low back pain [40-44]. The use of oral NSAIDs is preferable, as parenteral administration has no efficacy advantages but is significantly inferior in safety [40-44]. In acute high-intensity pain, short-term use of the combination drug diclofenac + orphenadrine is possible [45-48].

Comments. When choosing an NSAID, it is necessary to take into account the presence and nature of risk factors for adverse events, comorbid conditions, and drug-drug interactions. NSAIDs should not be combined with each other or used long-term (it is advisable to limit treatment to 10–14 days), which significantly reduces the risk of gastrointestinal, cardiovascular, and other system complications. NSAIDs are contraindicated in erosive and ulcerative gastrointestinal lesions, especially in the acute phase, severe hepatic and renal impairment, individual hypersensitivity, pregnancy, and severe heart failure. In patients at risk for gastrointestinal complications, it is recommended to use NSAIDs with a minimal risk of such complications (meloxicam, nimesulide, aceclofenac, and coxibs [celecoxib, etoricoxib]) [49-53] at low doses for a short duration, and/or consider gastroprotection to prevent such complications [44]. When choosing a specific NSAID, consult the product labeling for the presence of the relevant indication and the absence of contraindications.

Paracetamol** (other analgesics and antipyretics, ATC code: N02B) is not recommended for patients with musculoskeletal low back pain as monotherapy (LEL – 1, GOR - B), because its efficacy in reducing pain and improving patients' functional status has not been proven [31-33,54,55].

Paracetamol** for low back pain is recommended in cases where NSAIDs are contraindicated or have led to adverse events, as well as in combination with NSAIDs to enhance the effect, if there are no contraindications to its use (LEL – 5, GOR - C) [31-33,54,55].

Comments. Recommendations on prescribing paracetamol** for musculoskeletal low back pain are contradictory. If the patient has no contraindications to NSAIDs, but expresses a desire to take paracetamol**, the patient should be informed about the potential ineffectiveness of paracetamol** in relieving pain and improving functional activity.

Centrally acting muscle relaxants (ATC code: M03BX; tolperisone, tizanidine**, cyclobenzaprine) are recommended for patients with acute musculoskeletal low back pain to reduce painful muscle hypertonus (LE – 1, GR – B), and they are simultaneously effective in treating pain [56-59].

The addition of a centrally acting muscle relaxant to an NSAID is recommended to enhance the analgesic effect of NSAIDs in patients with acute low back pain [59-61] (LE – 2, GR – B). Currently, the superiority of any single muscle relaxant over others for reducing back pain has not been established [56-59].

Comments. Centrally acting muscle relaxants should not be combined with each other; the potential sedative effect of muscle relaxants must be taken into account.

Opioids (ATC code: N02A)** are not recommended for patients with musculoskeletal low back pain (LE – 2, GR – B), as they provide only a short-term analgesic effect, do not improve functional activity, and can cause drug dependence [62, 63].

Nevertheless, certain opioids, for example, tramadol**, tapentadol**, are recommended for relief of intolerable high-intensity pain when it is impossible to do so by other means (LE – 1, GR – A) [64].

Glucocorticoids (glucocorticoids, ATC code: H02AB)** orally, intramuscularly, or intravenously are not recommended for patients with musculoskeletal low back pain (LE – 2, GR – B), because they only briefly reduce pain and can cause serious adverse events [31,32,42,65].

B vitamins (vitamin B1 in combination with vitamins B6 and/or B12, ATC code: A11DB) are recommended in addition to NSAIDs for acute non-specific low back pain (LE – 1, GR – A), because there is evidence of an enhanced analgesic effect when combining B vitamins with NSAIDs [66-70].

Antidepressants (non-selective monoamine reuptake inhibitors: amitriptyline**, ATC code: N06AA; duloxetine N06AX21) are recommended in patients with chronic musculoskeletal low back pain (LE – 2, GR – A), because they are capable of exerting an analgesic effect [71-73, 116-118]. The use of antidepressants is recommended if a comorbid depressive disorder is identified.

Comments. The use of antidepressants (duloxetine and non-selective monoamine reuptake inhibitors) remains one of the viable methods for treating chronic non-specific low back pain in combination with exercise therapy and cognitive behavioral therapy (CBT) [31, 32, 74].

3.1.2 Non-pharmacological treatment

In acute musculoskeletal low back pain, spinal therapeutic exercise (regular physical exercises performed under the recommendation and supervision of a specialist) is recommended, provided the patient tolerates it well (LoE – 2, GoR - A); however, performing it during an exacerbation leads to only a slight reduction in pain, and exercises (significant flexion, extension, or trunk rotation) that may provoke increased pain should be avoided [10,75,76]. As a rule, therapeutic exercise sessions are recommended for patients after pain reduction in order to prevent recurrent exacerbations.

For patients with subacute or chronic musculoskeletal low back pain, spinal therapeutic exercise is recommended (LoE – 2, GoR - B), because its superiority (compared to no exercise or other treatment methods) in reducing pain and improving patients' functional activity has been demonstrated [76,77]. Starting physical exercise as early as possible in a patient with low back pain may accelerate pain relief and reduce the risk of chronification [78]. In chronic musculoskeletal low back pain, spinal therapeutic exercise is regarded as the most effective treatment method [5,6,31-33]. Currently, there is no convincing evidence of the superiority of any specific therapeutic exercise method or set of exercises; regularity, avoidance of sudden movements, and avoidance of excessive loads capable of triggering pain exacerbation are of primary importance.

Comments. Outdoor physical exercises (aerobic therapeutic exercise) recommended by a specialist have a slight advantage. There is no evidence of the superiority of individual therapeutic exercise sessions over group sessions.

Spinal manual therapy is an option for patients with acute musculoskeletal low back pain and is recommended for subacute and chronic musculoskeletal low back pain (LoE – 1, GoR - B); it can reduce pain and improve the patient's functional status (in subacute and chronic low back pain, manual therapy has a more significant impact on the patient's functional status) [79-81]. The use of manual therapy in combination with therapeutic exercise and psychological methods increases its effectiveness [31,81]. When performing manual therapy in patients with low back pain, it is necessary to consider the possibility of worsening or emergence of musculoskeletal pain from other sources. The risk of complications from lumbar manipulations is relatively low [81].

Comments. Manual therapy remains one of the most frequently used treatment methods for low back pain in the Russian Federation; many patients report pain reduction and improvement in functional status after manual therapy sessions [3,82-86].

Psychological methods of therapy, including CBT and mindfulness therapy (clinical and psychological adaptation, clinical and psychological counseling, clinical and psychological correction, clinical and psychological training), are recommended for patients with chronic non-specific low back pain (LoE – 1, GoR - A) as they reduce pain and improve patients' functional status [87-90]. Psychological therapy methods form the basis of multidisciplinary management of patients with chronic non-specific low back pain [75]. Psychological methods of treatment should be combined with therapeutic exercise [31]. In chronic low back pain, psychological methods are regarded as the most effective in the guidelines of experts from various countries [5,6,31-34]. CBT aims to change the patient's perceptions of the disease, chronic pain, its course and prognosis, as well as their behavior. Cognitive therapy includes analyzing the patient's perceptions of pain, the ability to control it, and modifying thoughts, sensations, and beliefs. In many cases, it is important to explain to the patient that increased pain is a normal reaction to increased activity, which will not cause disease progression, but will instead contribute to muscle training and subsequent pain reduction. Behavioral therapy aims to modify the "pain" lifestyle and increase physical and social activity; the patient's close relatives and family members should also participate in this process. A gradual increase in physical activity under medical supervision is recommended, which helps convince the patient that pain is not dangerous and even decreases with repeated exercises and a gradual increase in loads.

Comments. Psychological methods are used predominantly in specialized pain centers and have not yet become widespread in our country. Psychological methods are most justified when the patient has misconceptions about the disease, its prognosis, and physical activity.

Patients with acute musculoskeletal low back pain are recommended superficial heat (a shawl, a warm belt) applied to the lumbar region (LoE – 1, GoR - B), as heat can reduce pain intensity [31,91].

Reflexology is recommended for patients with acute and subacute musculoskeletal low back pain (LoE – 2, GoR - B), because some studies have noted a reduction in pain after reflexology sessions [92-94]. Reflexology is recommended as an adjunctive treatment method for chronic low back pain (LoE – 1, GoR - A); some studies have noted pain reduction following reflexology [95,96]. Reflexology is not associated with serious adverse events [95-97].

Lumbosacral spinal massage, lumbosacral region massage, and segmental lumbosacral massage are recommended for patients with musculoskeletal low back pain (LoE – 1, GoR - A) because some studies have noted a decrease in pain intensity after massage [98].

Comments. Massage remains one of the most common treatment methods for low back pain in our country, and many patients attribute a significant improvement in their condition to massage. Massage is noted as a potential therapy method in the guidelines of experts from various countries [31,32].

Therapeutic taping is recommended as an adjunctive therapy for low back pain (LoE – 5, GoR - C), although currently there is no convincing evidence of the efficacy of this method [7,9,99].

Comments. In recent years, therapeutic taping has been becoming one of the popular methods for treating low back pain in our country. Many patients attribute an improvement in their condition to its application.

Physiotherapeutic treatment methods. The effectiveness of pulsed low-frequency electromagnetic field therapy in musculoskeletal low back pain has been noted; this method is recommended as part of combination therapy to reduce pain intensity and improve impaired functions (LoE – 2, GoR - B) [101-104].

Comments. Physiotherapeutic methods remain a common way to treat low back pain in our country. Many patients attribute a significant improvement in their condition to these procedures. Physiotherapeutic treatment is not regarded as effective in the guidelines of experts from a number of countries [5,6,30-31, 77,100].

Wearing corsets, braces, belts, and other special orthopedic devices that fix the lumbosacral spine, as well as traction, is not recommended for patients with non-specific musculoskeletal low back pain (LoE – 5, GoR - C), as these methods do not relieve pain or improve patients' functional activity [77].

Comments. Wearing corsets, braces, belts, and other special orthopedic devices, as well as traction, are not recommended by experts from a number of countries for managing patients with low back pain [5,6,31-33]. Wearing corsets, braces, belts, and other special devices may be recommended if there are indications for orthopedic correction, regardless of the presence of musculoskeletal low back pain.

3.2. Surgical treatment

Surgical treatment is discussed in chronic low back pain only if conservative therapy fails.

Surgical treatment in the form of intervertebral disc herniation removal or other disc interventions is not recommended for musculoskeletal low back pain (LoE – 5, GoR - C), as it has no advantages over conservative therapy and is associated with the risk of adverse events [4-10].

3.3. Other treatment

Intra- and periarticular administration of medications (local anesthetics and GCs) in the area of the facet joints and sacroiliac joints is recommended for subacute and chronic non-specific low back pain (LoE – 3, GoR - C), because this approach can reduce pain and slightly improve patients' functional status [105-108].

Intra- and periarticular administration of medications (local anesthetics and GCs) in the area of the facet joints and sacroiliac joints is advisable in combination with other therapy methods (therapeutic exercise, psychological methods). Pain reduction (following medication administration) allows the patient to engage in therapeutic exercise more actively [4,6,7].

Comments. Intra- and periarticular administration of drugs (local anesthetics and glucocorticoids) in the region of the zygapophysial joints and sacroiliac joints is recommended by some experts in the management of patients with low back pain [108], but is not noted as an effective method by experts in a number of countries [31–33]. The use of radiographic or ultrasound guidance and compliance with established patient safety standards during drug administration is recommended [109].

Radiofrequency denervation of the zygapophysial joints or sacroiliac joints is recommended for patients with chronic musculoskeletal low back pain (Level of Evidence – 1, Grade of Recommendation – B) when a positive effect from diagnostic blockade (with local anesthetics and glucocorticoids) has been achieved [7, 31, 105]. Radiofrequency denervation is indicated only for those patients who demonstrate a significant effect (50–70% pain reduction or more) from the diagnostic blockade with local anesthetics [31].

Comments. Radiofrequency denervation is noted as an effective method in guidelines from various countries for the management of patients with low back pain [5, 6, 31–32].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Recommended for all patients with chronic low back pain. Rehabilitation may include therapeutic exercise for spinal disorders, manual therapy for spinal disorders, psychological methods, and pulsed low-frequency electromagnetic field therapy (see section "Non-pharmacological treatments").

Sanatorium-resort treatment is recommended for patients with chronic low back pain and may include therapeutic mineral baths and pelotherapy (mud therapy) (Level of Evidence – 2, Grade of Recommendation – C), because these methods are effective in the comprehensive treatment of chronic back pain. They are contraindicated in concomitant oncological diseases, impaired blood coagulation, cardiovascular diseases with severe functional disorders, and benign neoplasms prone to growth [110–112].

5. Prevention and Dispensary Observation

To prevent exacerbations, patients with low back pain are advised to avoid excessive physical exertion (heavy lifting, carrying a heavy bag in one hand, etc.), prolonged static loads (prolonged sitting, staying in an uncomfortable position, etc.), and hypothermia (Level of Evidence – 5, Grade of Recommendation – C), because excessive exertion and hypothermia are highlighted as risk factors for the development of low back pain [30–31, 113].

Comments. These provisions are highlighted in the guidelines of various countries for the management of patients with low back pain [5, 6].

To prevent exacerbations, patients with low back pain are recommended to regularly engage in therapeutic exercises for spinal disorders, therapeutic swimming in a pool, and terrain cure (walking therapy) (Level of Evidence – 5, Grade of Recommendation – C), because these types of treatment have been proven effective as methods for preventing low back pain [30–31, 113].

Comments. These provisions are highlighted in the guidelines of a number of countries for the management of patients with low back pain [5, 6].

6. Organization of Medical Care

Indications for planned hospitalization:

1) lack of response to conservative outpatient therapy;

Indications for emergency hospitalization:

1) suspected cauda equina compression syndrome;

2) suspected spinal fracture;

3) suspected spinal or spinal cord tumor;

4) suspected inflammatory spinal disease.

Indications for patient discharge from the hospital:

1) reduction in pain intensity according to the VAS or NRS;

2) reduction in the degree of functional impairment according to the Roland-Morris or Oswestry questionnaire.

7. Additional Information

Obesity, smoking, depression, anxiety, pain catastrophizing, and sleep disorders are modifiable risk factors for the onset of chronic pain. Timely identification of these factors in patients with acute low back pain and addressing them is recommended to improve the recovery prognosis and prevent subsequent exacerbations (Level of Evidence – 4, Grade of Recommendation – C) [114–115, 119–123].

Criteria for Evaluating the Quality of Medical Care

№	Quality criteria	Performance evaluation
1.	When collecting complaints and anamnesis in patients with low back pain, it is recommended to use a short questionnaire to identify signs of so-called "specific" causes of the disease in order to choose further treatment tactics	Yes/No
2.	Assessment of pain intensity using the VAS, VRS, or NRS was performed at the time of presentation and dynamically	Yes/No
3.	A somatic examination was performed to check for "specific" causes of back pain	Yes/No
4.	A clinical examination was performed with a brief assessment of neurological status and tension tests	Yes/No
5.	If the patient with low back pain has "red flags", instrumental examinations were performed (radiography of the lumbar and sacral spine, spine radiography with functional tests, CT or MRI of the spine [one region])	Yes/No
6.	The patient was informed about the benign nature of musculoskeletal (non-specific) back pain and the likelihood of a quick recovery	Yes/No
7.	Methods for preventing exacerbations of musculoskeletal (non-specific) back pain were recommended	Yes/No

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Appendix A1. Working Group Composition

1.	Alexander V. Amelin	Professor at the Department of Neurology, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health; Head of the Laboratory of Neurophysiology and Pharmacology of Pain, V. A. Waldman Institute of Pharmacology; Member of the Presidium of the Russian Pain Society; Doctor of Medical Sciences, Professor (Saint Petersburg).
2.	Leila R. Akhmadeeva	Professor at the Department of Neurology, Bashkir State Medical University; Doctor of Medical Sciences, Professor (Ufa).
3.	Evgeny E. Achkasov	Head of the Department of Physical Therapy and Sports Medicine; Professor at the Department of Hospital Surgery No. 1, Sechenov First Moscow State Medical University (Sechenov University) of the Russian Ministry of Health; Doctor of Medical Sciences, Professor (Moscow).
4.	Evgeny R. Barantsevich	Head of the Department of Neurology and Manual Medicine, Pavlov First Saint Petersburg State Medical University; Doctor of Medical Sciences, Professor (Saint Petersburg).
5.	Alexander E. Barulin	Head of the Department of Neurology, Psychiatry, Manual Medicine and Medical Rehabilitation, Institute of Professional Education, Volgograd State Medical University of the Russian Ministry of Health; Doctor of Medical Sciences, Professor (Volgograd).
6.	Maxim A. Bakhtadze	Leading Research Fellow, Laboratory of Fundamental and Applied Problems of Pain, Research Institute of General Pathology and Pathophysiology; Assistant Professor, Department of Neurology, Neurosurgery, and Medical Genetics, Faculty of General Medicine, Pirogov Russian National Research Medical University of the Ministry of Health of Russia, PhD (Moscow).
7.	Anna N. Belova	Head of the Department of Medical Rehabilitation, Privolzhsky Research Medical University of the Russian Ministry of Health; Honored Doctor of the Russian Federation; Doctor of Medical Sciences, Professor (Nizhny Novgorod).
8.	Galina N. Belskaya	Head of the Multidisciplinary Clinical and Diagnostic Center, Research Center of Neurology; Honored Doctor of the Russian Federation; Doctor of Medical Sciences, Professor (Moscow).
9.	Vera N. Blokhina	Assistant Professor at the Department of Neurology, Institute of Advanced Training, Pirogov National Medical Research Center; Candidate of Medical Sciences (Moscow).
10.	Vladimir G. Bychenko	Head of the Department of Diagnostic Radiology, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health; Candidate of Medical Sciences (Moscow).
11.	Vasilyev Sergey Amurabievich	Head of the Neurosurgery Department, Petrovsky National Research Centre of Surgery, Associate Professor of the Department of Neurosurgery and Neuroresuscitation, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia, MD (Moscow).
12.	Veronika A. Golovacheva	Assistant Professor, Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, PhD (Moscow)
13.	Oleg S. Davydov	Leading Researcher at the Laboratory of Fundamental and Applied Problems of Pain, Research Institute of General Pathology and Pathophysiology; Member of the Presidium of the Russian Pain Society; Candidate of Medical Sciences (Moscow).
14.	Grigory Yu. Evzikov	Professor, Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Professor, MD (Moscow)
15.	Oleg I. Zagorulko	Head of the Clinic for the Study and Treatment of Pain, Petrovsky National Research Centre of Surgery; Member of the Presidium of the Russian Pain Society; Doctor of Medical Sciences (Moscow).
16.	Emil D. Isagulyan	Senior Researcher at the Department of Functional Neurosurgery, Burdenko National Medical Research Center of Neurosurgery of the Russian Ministry of Health; President of the National Neuromodulation Association in the Russian Federation; Candidate of Medical Sciences (Moscow).
17.	Aleksey I. Isaykin	Associate Professor, Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Associate Professor, PhD (Moscow)
18.	Dmitry A. Iskra	Professor at the Department of Nervous System Diseases, Kirov Military Medical Academy; Head of the North-Western Pain Society; Doctor of Medical Sciences, Professor (Saint Petersburg).
19.	Pavel P. Kalinsky	Professor at the Institute of Clinical Neurology and Rehabilitation Medicine, Pacific State Medical University of the Russian Ministry of Health; Member of the Presidium of the Russian Pain Society; Honored Doctor of the Russian Federation; Doctor of Medical Sciences, Professor (Vladivostok).
20.	Andrey E. Karateev	Head of the Laboratory of Pain Pathophysiology and Polymorphism of Musculoskeletal Diseases, Nasonova Research Institute of Rheumatology; Member of the Presidium of the Russian Pain Society; Doctor of Medical Sciences (Moscow).
21.	Mikhail L. Kukushkin	Head of the Laboratory of Fundamental and Applied Problems of Pain, Research Institute of General Pathology and Pathophysiology; Head of the Russian Pain Society; Doctor of Medical Sciences, Professor (Moscow).
22.	Olga V. Kurushina	Head of the Department of Neurology, Neurosurgery and Medical Genetics, Volgograd State Medical University of the Russian Ministry of Health; Doctor of Medical Sciences, Professor (Volgograd).
23.	Lyudmila A. Medvedeva	Chief Researcher at the Clinic for the Study and Treatment of Pain, Petrovsky National Research Centre of Surgery; Member of the Presidium of the Russian Pain Society; Doctor of Medical Sciences (Moscow).
24.	Vladimir A. Parfenov	Head of the Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Member of the Presidium of the Russian Society for the Study of Pain, Professor, MD (Moscow)
25.	Andrey P. Rachin	Deputy Director for Scientific Activities at the National Medical Research Center for Rehabilitation and Balneology of the Russian Ministry of Health, Board Member of the All-Russian Society of Neurologists, Professor, MD (Moscow)
26.	Habirov Farit Ahatovich	Head of the Department of Neurology at Kazan State Medical Academy — a branch of the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Presidium Member of the Russian Society for the Study of Pain, Honored Scientist of the Republic of Tatarstan, Professor, MD (Kazan)
27.	Churyukanov Maxim Valerievich	Associate Professor, Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia; Senior Research Fellow, Pain Clinic, Petrovsky National Research Centre of Surgery; Member of the Presidium of the Russian Society for the Study of Pain, Associate Professor, PhD (Moscow)
28.	Shirokov Vasily Afonasievich	Professor, Department of Nervous Diseases with a Course in Neurosurgery and Manual Therapy, Ural State Medical University of the Russian Ministry of Health, Member of the Presidium of the Russian Society for the Study of Pain, Professor, MD (Yekaterinburg)
29.	Yakupov Eduard Zakirzyanovich	Head of the Department of Neurology, Neurosurgery, and Medical Genetics, Kazan State Medical University of the Russian Ministry of Health, Honored Physician of the Republic of Tatarstan, Professor, MD (Kazan)
30.	Yakhno Nikolai Nikolayevich	President of the Russian Society for the Study of Pain, Academician of the Russian Academy of Sciences, Professor of the Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Professor, MD (Moscow).

Conflict of interest: none declared.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

Anesthesiologists-intensivists
Manual therapy physicians
Neurologists
General practitioners (family physicians)
Osteopaths
Exercise therapy physicians
Medical rehabilitation physicians
Rheumatologists
Reflexotherapists
Internists
General practitioners / district physicians
Trauma and orthopedic surgeons
Physiotherapists
Physical and rehabilitation medicine physicians
Neurosurgeons

Methods used for evidence collection/selection:

Search in electronic databases.

Description of methods used for evidence collection/selection:

The evidence base for the recommendations consists of publications included in the Cochrane Library, EMBASE, and MEDLINE databases. The search depth was 10 years.

Methods used to assess the quality and strength of evidence:

Expert consensus;

Significance assessment according to tables P1, P2, and P3.

Table P1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

LoE	Definition
1	Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis
2	Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis
3	Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies
4	Non-comparative studies, case report
5	Only justification of mechanism of action or expert opinion is available

Table P2. Levels of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

LoE	Definition
1	Systematic review of randomized controlled trials with meta-analysis
2	Individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis
3	Non-randomized comparative studies, including cohort studies
4	Non-comparative studies, case reports or case series, case-control studies
5	Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available

Table P3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

GoR	Definition
A	Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent)
C	Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent)
C	Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent)

Consultation and peer review:

The preliminary version was posted for broad discussion on the website of the Russian Society for the Study of Pain (www.painrussia.ru) to give the widest possible range of individuals the opportunity to participate in discussing and improving the guidelines.

Working Group:

For the final revision and quality control, the recommendations were re-evaluated by the members of the working group, who concluded that all comments and feedback from the experts had been taken into account and the risk of bias in the development of the recommendations was minimized.

Procedure for updating clinical guidelines:

The mechanism for updating clinical guidelines provides for their systematic revision at least once every 2 years.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

- Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care"

- CG400. Chronic pain syndrome (CPS) in adult patients requiring palliative medical care.

These clinical guidelines were developed taking into account the following methodological materials and interdisciplinary specialist consensuses:

- Nasonov E.L., Yakhno N.N., Karateev A.E., et al. General principles for the treatment of musculoskeletal pain: an interdisciplinary consensus. Scientific and Practical Rheumatology. 2016;54(3):247-265.

- Karateev A.E., Nasonov E.L., Ivashkin V.T., et al. Rational use of nonsteroidal anti-inflammatory drugs. Clinical guidelines. Scientific and Practical Rheumatology. 2018; 56: 1-29.

- Davydov O.S., Yakhno N.N., Kukushkin M.L., Churyukanov M.V., et al. Neuropathic pain. Clinical guidelines for diagnosis and treatment. Russian Journal of Pain. 2018. No. 4 (57). P. 5-41.

These clinical guidelines have been developed taking into account the indications for use, contraindications, routes of administration, and dosages of medicinal products in accordance with the instructions for use of medicinal products contained in the State Register of Medicinal Drugs – www.grls.rosminzdrav.ru

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Causes of back pain

Low back pain is caused by excessive physical and static exertion, and hypothermia. A significant factor is constant and often minor trauma to the articular-ligamentous apparatus and muscles during awkward movements and lifting heavy loads. Musculoskeletal back pain can be caused by disorders of the spinal joints, muscles, and ligaments. Disc herniations, even when present, are not necessarily the cause of back pain. Osteoarthritis (osteochondrosis) is a natural process of degeneration (aging) of spinal structures, observed to varying degrees in all people, increasing significantly with age, and cannot be considered as a mandatory cause of back pain.

Chronic low back pain is caused not only by musculoskeletal factors, but also by psychological and social factors: misconceptions about pain and inadequate catastrophizing of the actual danger of the disease, decreased professional, social, domestic, and physical activity (pain behavior), increased anxiety and low mood; job dissatisfaction, and marital problems.

Examination

A consultation with a specialist (general practitioner, family physician, neurologist, rheumatologist) makes it possible to establish the correct diagnosis and is comparable in informational value to instrumental diagnostic methods. Based on the collection of complaints, medical history, and examination, the specialist rules out serious ("red flag") causes of back pain, which are relatively rare (about 1% of cases). In most cases, laboratory and instrumental diagnostic methods are not required; they are prescribed when a "dangerous" disease is suspected. Performing radiography, computed tomography, or magnetic resonance imaging for low back pain does not improve the prognosis of the disease, nor does it affect the course of the disease or the development of complications. In cases where changes are detected (disc herniations and other findings), patient anxiety often arises, up to the phenomenon of "catastrophizing" and "pain behavior".

Prognosis

Musculoskeletal low back pain has a favorable prognosis; it decreases in intensity within 1–3 weeks and in most cases completely regresses within several weeks (in 90% of cases – up to 6 weeks). The pain usually resolves even without treatment, indicating its naturally favorable prognosis. In cases where the pain is associated with an intervertebral disc herniation, it resolves due to the natural reduction in the size of the disc herniation and the associated aseptic (non-infectious) inflammatory changes.

Treatment

Non-pharmacological therapies are of paramount importance. It is very important to maintain daily activity as much as possible, as this promotes faster recovery. Conversely, bed rest slows down recovery. For intense pain, a short period of bed rest (1–2 days) can be observed, but this is a way to reduce pain, rather than a treatment method.

For prolonged back pain (more than 4 weeks), therapeutic exercise for spinal disorders is effective – regular physical exercises performed under the recommendation and supervision of a specialist. It is very important to learn the correct technique for performing certain movements (e.g., lifting objects from the floor) and exercises to optimize muscle condition, as recommended by physical therapy (rehabilitation) physicians. A consultation with a physician or psychologist regarding the causes of the disease, its prognosis, and the appropriateness of daily activity also helps; psychotherapeutic treatment methods, back muscle massage, and manual therapy can be effective.

To reduce pain, the physician may prescribe over-the-counter pain relievers. If the effect proves insufficient, they can be supplemented with stronger (prescription) medications.

For musculoskeletal pain, surgical treatment (disc herniation removal or other disc interventions) is not recommended because its efficacy has not been proven, and there is a risk of complications.

Prevention

To prevent musculoskeletal low back pain, it is recommended to avoid excessive physical exertion (lifting heavy loads, carrying a heavy bag in one hand, etc.) and prolonged static loads (prolonged sitting, staying in an awkward position), as well as hypothermia. Regular physical therapy exercises, swimming, and walking are recommended.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Pain intensity assessment scales

Russian name: visual analog scale (VAS), numeric rating scale (NRS), verbal rating scale (VRS)

Original name: Visual Analog Scale, Numeric Rating Scale, Verbal Rating Scale

Source:

A.Williamson, B. Hoggart: Pain: a review of three commonly used pain rating scales. Journal of Clinical Nursing. 14:798-804 2005.

Pain: A guide for students and physicians: textbook / edited by Academician of the Russian Academy of Medical Sciences N.N. Yakhno. – Moscow: MEDpress-inform, 2010. – 304 p.

Type – scale

Purpose: assessment of pain intensity

Explanation: The VAS is a 10 cm (100 mm) line on which the patient is asked to make a mark corresponding to the intensity of pain experienced at the moment (or over a certain period, e.g., the last week), with the patient choosing between "no pain" and "unbearable pain". Then, the distance between the start of the scale ("no pain") and the patient's mark is measured with a ruler, and centimeters are then converted into points (1 cm = 10 mm = 1 point).

The NRS is similar to the VAS and is a modification of it. The patient marks one of 11 (sometimes a gradation from 0 to 10 is used) points on the scale corresponding to the current intensity of their pain.

The VRS consists of adjectives describing pain, arranged in order of increasing intensity. Sometimes a scale containing both adjectives and numerical designations is used (0 – "no pain", 1 – "mild", 2 – "moderate", 3 – "severe", 4 – "very severe", 5 – "unbearable"). The algorithm of use is the same as for the VAS.

Appendix G1 - G... Rating scales, questionnaires — Musculoskeletal (non-specific) low back pain

Appendix G 2. Oswestry Disability Index

Russian title: Oswestry Questionnaire

Original title: The Oswestry low back pain disability questionnaire.

Sources:

Fairbank J.C., Couper J., Davies J.B., et al. The Oswestry low back pain disability questionnaire // Physiotherapy. 1980. Vol. 66. P. 271–273.

Bakhtadze M.A., Bolotov D.A., Kuzminov K.O. Low back pain disability index (Oswestry questionnaire): assessment of reliability and validity of the Russian version. Manualnaya Terapiya, 2016.-N 4.-P.24-33.

Cherepanov V.A. The Russian version of the Oswestry questionnaire: cultural adaptation and validity. Hirurgia Pozvonochnika 2009;(3):93–98.

Type – questionnaire

Purpose: Assessment of the degree of functional impairment (disability) in chronic lower back pain

This questionnaire is designed to obtain information on how back or leg pain has affected your daily life
Please answer every section and mark in each section only one box which applies to you.
We understand that you may consider that two statements in any one section relate to you, but please just mark the box that most closely describes your problem.
Section 1. Pain intensity.
I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.
Section 2. Personal care (washing, dressing, etc.)
I can look after myself normally without extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need daily help in most aspects of self-care.
I do not get dressed, wash with difficulty and stay in bed.
Section 3. Lifting.
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on a table.
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
Section 4. Walking.
Pain does not prevent me from walking any distance.
Pain prevents me from walking more than 1 km.
Pain prevents me from walking more than 500 meters.
Pain prevents me from walking more than 100 meters.
I can only walk using a cane, crutches, or a walker.
I am in bed most of the time and have to crawl to the toilet.
Section 5. Sitting.
I can sit in any chair as long as I like.
I can only sit in my favorite chair as long as I like.
Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than 30 minutes.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
Section 6. Standing.
I can stand as long as I want without significant pain.
I can stand as long as I want with some pain.
Pain prevents me from standing for more than 1 hour.
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
Section 7. Sleeping.
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
Because of pain, I sleep less than 6 hours.
Because of pain, I sleep less than 4 hours.
Because of pain, I sleep less than 2 hours.
Pain prevents me from sleeping at all.
Section 8. Sex life.
My sex life is normal and causes no significant pain.
My sex life is normal, but causes some pain.
My sex life is nearly normal, but very painful.
My sex life is severely restricted by pain.
Because of pain, I am nearly devoid of a sex life.
Pain deprives me of any sex life.
Section 9. Social life.
My social life is normal and causes no significant pain.
My social life is normal, but increases the degree of pain.
Pain has no significant effect on my social life, but it limits my more energetic activities, e.g., sports, etc.
Because of my pain, my activity is limited; I go out less often than usual.
Pain has restricted my social life to the home.
I have no social life because of pain.
Section 10. Traveling.
I can travel anywhere without pain.
I can travel anywhere with some pain.
Pain is bad, but I can manage journeys over two hours.
Pain restricts me to journeys of less than 1 hour.
Pain restricts me to short journeys of under 30 minutes.
Pain restricts me to journeys necessary to receive treatment (e.g., doctor or hospital).

Explanation: The Oswestry questionnaire consists of 10 sections. In each section, the first answer is the minimum score (0), and subsequent answers are 1, 2, 3, 4, and 5 points, respectively. When all 10 sections are completed, the Oswestry index is calculated as follows: sum of scores / 50 (maximum possible score) × 100 =. If one of the sections is not filled out or cannot be assessed (e.g., sex life), the Oswestry index is calculated as follows: sum of scores / 45 (maximum possible score) × 100 =. The higher the index, the more significant the disability. The questionnaire can also be used to assess the patient's condition dynamically, for example, during therapy.

Appendix G 3. Roland-Morris Questionnaire

Russian title: Roland-Morris Questionnaire

Original title: Roland-Morris Disability Questionnaire, RDQ

Sources:

Roland M.O., Morris R.W. A study of the natural history of back pain. Part 1: Development of a reliable and sensitive measure of disability in low back pain //Spine. – 1983. – Vol. 8. – P. 141–144.

Tarakanov A.A., Efremov V.V. Instrumental validation of the "Low Back Pain and Disability (Roland-Morris)" questionnaire. Russian Journal of Pain: 2 (56); 2018. pp. 96-97.

Type – questionnaire

Purpose: assessment of the impact of lower back pain on disability.

Check only those statements that describe your condition today.

	Because of my back, I stay at home most of the time.
	I change position frequently to try and get my back comfortable.
	Because of my back, I walk more slowly than usual.
	Because of my back, I am not doing any jobs that I usually do around the house.
	Because of my back, I use a handrail to get upstairs.
	Because of my back, I lie down to rest more often.
	Because of my back, I have to hold on to something to get out of an easy chair.
	Because of my back, I try to get other people to do things for me.
	Because of my back, I get dressed more slowly than usual.
	Because of my back, I can only stand for short periods of time.
	Because of my back, I try not to bend or kneel down.
	Because of my back, it is painful to get out of a chair.
	My back is painful almost all the time.
	Because of my back, I find it difficult to turn over in bed.
	Because of my back pain, I am not enjoying my food as much as usual.
	Because of my back pain, I have trouble putting on socks (stockings).
	Because of my back, I can only walk a short distance.
	I sleep less well because of my back.
	Because of my back pain, I have to get dressed with help from someone else.
	Because of my back, I sit down almost all day.
	Because of my back, I avoid heavy housework.
	Because of my back pain, I am more irritable and short-tempered with other people than usual.
	Because of my back, I walk up stairs slower than usual.
	Because of my back, I lie in bed almost all day.

Explanation: The Roland-Morris Disability Questionnaire consists of 24 items answered by the patient. The total number of items checked by the patient is calculated, so the possible result ranges from 0 to 24. The higher the number of checked items, the more pronounced the patient's disability. To monitor treatment dynamics, the questionnaire can be refilled, and the number of items showing improvement can be converted into a percentage.

Scales and calculators from this guideline

VAS for Pain (Visual Analog Scale)Assessment of pain intensity using a 10-point visual analog scale Oswestry Disability Index (ODI)Low back pain disability index Roland–Morris Disability Questionnaire (RDQ)Impact of lower back pain on daily functioning: 24 statements

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