Management of Acute Low Back Pain in a 26-year-old Hispanic Female, Exams of Nursing

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QUESTIONS AND ANSWERS

iHuman Case Study: Tina Williams, 71Yrs Old Female Cc:

Low Back Pain

TESTED AND CONFIRMED A+ ANSWERS

Tina Williams " Acute Low Back Pain" iHuman

History & Physical Examination

SOAP #4 2

Patient Demographics:

Name: T.H.

Age/race/sex: 26 Hispanic Female

Clinical site: Primary Care clinic; Presents for sick visit.

SUBJECTIVE DATA

Chief Complaints : “My lower back has been hurting for about 2 weeks now”.

History of Present Illness :

Mrs. H is a 26 y/o Hispanic female with a six year history of depression-controlled on Sertraline,

who presents to the clinic today complaining of spontaneous occurring acute low back pain to

lumber region that started about 2 weeks ago after wearing heels to a party. Reports it has been

very difficult to dress lower body and to bend. She reports the pain is constant but has

intermittent intensities of aching and soreness throughout the day. The pain is localized to the

lumber area, described as aching and soreness with no radiation, rated a 5/10 in office today with

3/10 being the lowest amount of pain experienced and 8/10 being the worst pain she has

experienced. Reports the pain is worse in the mornings when getting out of bed after lying down

all night. She hasn’t tried any pharmacological or non-pharmacological therapies. She reports no

heavy lifting, strenuous exercise, current injuries, nor feelings of anxiety or

depression. However, about 5 years ago she was riding her bike, went down a ramp and flipped head first over

the handle bars of the bike. At which time she experienced this same low back pain, went to the ER and had

X-rays that showed some inflammation and swelling. She was then prescribed a muscle relaxant, Ibuprofen,

and physical therapy for 8 weeks, which helped tremendously. At today’s visit, she hopes to find out where

the pain is coming from and what she can do to prevent it from returning.

Past Medical History:

• Depression-active- diagnosed 6 years ago after mom passed in a MVA • Low

back pain-active-diagnosed about 5 years ago after previous back inju

Past Surgical History:

• No surgeries to date

Allergies:

NKA to food, dust, mold, environment, or medications.

Medications:

Sertraline 150 mg by mouth daily for depression

Health Maintenance:

• Influenza Vaccine-October 2017 at CVS.
• All other immunizations are up-to-date including TDaP, MMR, and Varicella.
• Last Pap smear- June 2016 - normal
• Performs MSBE
• Depression screen positive for PHQ2; on meds and see Psychologists regularly.

• CAGE 0/

Personal & Social History:

• Lives alone in a one bedroom apartment.
• Works at a nursing home as a Certified Nursing Assistant 4 days/week. She loves her

job and has a dependable car.

• Denies any smoking, illicit drug abuse, or alcohol misuse.
• Previously did cross fit in high school. However, do to work she hasn’t had much

time to get the amount of exercise she needs.

• Patient is sexually active with only one sex partner, her boyfriend.
• 24 hour diet recall: B- one bowl of Chex cereal; L- a turkey sandwich, chips, and a

diet coke; S-about 1-2 cups of cheese-it crackers and a diet coke; D- Meatloaf,

veggies, mashed potatoes from Boston Market, and a bottled water.

Family History:

Grandparents

Paternal: Paternal grandfather 81, HTN, DM; Paternal grandmother 76 history of DM

and MI.

Maternal: Maternal grandfather died at 82 from MI, maternal grandmother 79,

history of diabetes and arthritis.

Skin Denies dry skin and itching. Denies abnormal lesions or new

nevi/moles

Head Previous head injury, denies any masses, lesions and headache Eyes Denies

any discharge, itchy, blurred vision, vision loss

or vision changes, eye pain or injection.

Ears Denies any itching, fullness, vertigo, ear pain or drainage,

hearing loss or changes in quality of hearing.

Nose/Sinuses Denies epistaxis, PND, maxillary or frontal sinus pain, or changes in

smell

Mouth/Throat Denies sore throat and dysphagia. Denies gum disease, has

all original teeth, last dental exam was in July of this year, sees the

dentist annually.

Neck/Lymph Nodes Denies swollen /painful lymph nodes, denies any neck pain or stiffness.

Breasts Denies masses, pain, or nipple discharge. Does perform regular

SBE.

Thorax/Respirator Denies any SOB, DOE, or wheezing. y

CVS Denies CP, palpitat

ons, denies peripheral edema, Orthopnea GI/Abdomen Denies

dyspepsia, nausea, vomiting, diarrhea, constipation, bloating, hematemesis, hematochezia, or

abdominal pain. No recent c

is consistent with her regula

GU

Musculoskeletal

Neurologic

anges in bowel habits. Last bowel movement was this morning, whic h

bowel habits and was normal.

Denies any pain on urination, frequency, urgency, or vaginal

discharge.

See HPI.

Denies memory loss, numbness, tingling, or burning pains or

weakness.

Endocrine Denies known glucose abnormalities, heat or cold intolerance Psychiatric

Reports a history of depress on but denies any anxiety.

Physical Examination:

OBJECTIVE

sitting on the examination table in moderate distress as evidenced

by arms tensed on elbows as she’s guarding pain. Well

groomed, well developed, AAOx

Skin Warm, moist, no rashes or suspicious moles, +turgor Head/Scalp ATNC, thick black

hair, no dandruff, no lesions/masses.

Eyes External examination without ptosis, strabismus or exophthalmos. Conjunctiva pink.

Rest of exam deferred.

Ears Auricles symmetrical, no lesions or tophi; Rest of exam deferred.

Nose Bilateral nasal turbinates’ pink, moist. Rest of exam deferred.

Sinuses Deferred

Mouth Lips pink, moist mucous membrane, tongue protrudes in midline.

Pharynx/Throat Deferred.

Neck/Lymph nodes Trachea midline with full AROM without pain.

CVS RRR, normal S1, S2, no murmurs, rubs, or extra systole, JVD

Vital Signs/HT/WT T: 98.2F, P: 72 readily palpable, RR: 16, BP 110/64 on right, 110/

on the left SaO2 on RA: 100% HT: 5’8”, WT: 128lbs (toned-

physique, stable with no gains or losses within the last 6 months),

BMI: 19.46, normal for ht. and wt.

General 26 y/o Hispanic female, pleasant appears her stated age

3cm at 30 degrees, no carotid bruits, no cyanosis or vascular lesions. No chest wall

deformity. PMI at 5

th

ICM MCL. Nontender without heaves or thrill. Auscultation of the

abdomen without bruit. Palpation without pulsatile masses

Lungs/Thorax Chest sym

throughout anterior and po

present. Resonance heard o

breath sounds auscultated t

etrical without deformity, respirations even and unlabored

terior lung fields. Palpation without tenderness. Tactile fremitus

n percussion throughout anterior and posterior lung fields. Vesicular

hroughout anterior and posterior peripheral lung fields.

Breasts Deferred

Abdomen Deferred

GU Deferred

Musculoskeletal Mandible moves in midline TMJ palpation without clicks or

tenderness. Neck and cervical spine have no noted deformities or

signs of inflammation. Curvature of cervical, thoracic and lumbar

spine within normal limits. Bony features of shoulders and hips are

of equal height bilaterally and nontender. Posture is slumped and

gait is smooth but guarded. Palpation of spinous processes of C7-L

are palpable, midline, and tender to deep palpation right below L5.

Discomfort noted with lying flat on exam table. Patient can bend to

touch toes but experiences discomfort at about 90 degrees from

the upright position. Although patient can actively perform such

maneuvers as bending her knees to her chest while lying flat, flex,

extend, and rotate the spine there is some mild discomfort and

pain noted throughout the maneuvers.

Extremities/Pulses No edema, erythema or cyanosis to upper or lower extremities.

Pulses 2/4 to bilateral femoral, popliteal, posterior tibial, and dorsalis

pedis pulses.

Neurologic AA O X3. Slumped posture while sitting and walking. Gait steady

and intact. Sensation intact to light, deep, and sharp touch. gait and

balance intact. CN II- XII intact. Memory and

cognition intact for present d past medical history. Psych Appropriate mood and

affect

Evidence Based Assessment/Plan

Clinical Decision Making: 26 y/o Hispanic female presents to the primary care

clinic with a two week history of constant low back pain worse when ambulating and

dressing. The pain is non-radiating and has intermittent intensities of aching and soreness

consistent with acute non-specific low back pain. She has experienced these symptoms

before after a biking accident 5 years ago. Given Mrs. H’s presenting signs and symptoms

there is a need to differentiate between the diagnosis of acute nonspecific low back pain and

low back pain with radiculopathy. Mrs. H is an otherwise healthy young female with a

history of depression controlled on antidepressant. She has no other co-morbidities or health

issues.

CHARACTERISTICS pain might or might not be associated Some physical exam findings of low

OF with significant pathology on magnetic back pain may include the following;

DIFFERENTIA resonance imaging (MRI) and is

L DIAGNOSIS SIGNS

Non-specific Acute AND SYMPTOMS Superficial tenderness over the lumbar

Low Back Pain region to light touch Nonanatomic

Nonspecific or

nonradicular low back Pain areas: in the low back, muscles and tenderness bones, hip,

or leg. pain is not associated

with neurologic Sensory: leg numbness or pins and Exacerbation of pain by applying a few symptoms or signs. In

needles. pounds of pressure with the hands to

general, the pain is the top of the head localized to the spine or Back joint dysfunction or

muscle spasms.

paraspinal regions (or Exacerbation of pain by simulated

both) and does not Slumped gait due to pain on standing rotation or flexion of the spine radiate into the

leg. In upright. www.aafp.org

general, nonspecific low PHYSICAL EXAM FINDINGS Ability to sit up straight from a supine

back pain is not position, but intolerance of the straight- associated with spinal leg-raising test nerve root

compression.

Nonspecific low back Nonanatomic distribution of sensory

Differential Diagnosis:

often a result of simple changes soft tissue disorders such as strain, but it

can also be caused by http://www.clevelandclinicmeded.co serious

medical m disorders arising in the bony spine, parameningeal, or

retroperitoneal regions.

Risk factors:

Smoking, obesity, older age, female gender, physically strenuous work,

sedentary work, a stressful job, job dissatisfaction and psychological

factors such as anxiety or depression.

Diagnosis:

Diagnosis is based on physical exam findings. Routine spine radiographs are

of limited value because they visualize only bony structures.

Guidelines from the

U.S. Agency for Health Care Policy and

Research (AHCPR) indicated value of routine spine radiographs for

acute low back pain in the following settings: acute major trauma,

minor trauma associated with risk of osteoporosis, risk of spinal

infection, pain that does not respond to rest or recumbency,

and history of cancer,

fever, or unexplained

weight loss. They may

also be of value in

assessing spinal

alignment and

rheumatologic

disorders of bone. The

American Academy of

back pain accompanied by spinal nerve root damage is usually associated with with

limited or no treatment, neurologic signs or symptoms and is described below.

described as radiculopathy. There is

usually pathologic evidence of spinal Sciatica — Sciatica refers to the most nerve

root compression by disk or arthritic common symptom of radiculopathy. It spur,

but other intraspinal pathologies may is a pain that occurs when one of the be

present and are often apparent on an five spinal nerve roots, which are

MRI scan of the lumbosacral spine. branches of the sciatic nerve, is

irritated, causing a sharp or burning

Neurology guideline

Risk factors: pain that extends down the back or side

recommends

nonsurgical therapy

before CT and MRI are

used in patients with

uncomplicated acute

low back pain of less

than 7 weeks’ duration.

www.aafp.org

Acute lumbosacral

radiculopathy Low

neurologic

and

Traumatic injury Lumbar sprain or strain of the thigh, usually to the foot or ankle.

Postural strain sitting, standing or walking You may also feel numbness or >2hrs

per day Radiculopathy — A tingling. Occasionally, the sciatica may common

feature of low back pain is also be associated with muscle radiculopathy, which occurs

when a weakness in the leg or the foot. If a disc nerve root is irritated by a

protruding disc is herniated, sciatic pain often increases or arthritis of the spine.

Radiculopathies with coughing, sneezing, or bearing usually cause radiating pain,

numbness, down.

tingling, or muscle weakness in the

specific areas related to the affected nerve A comprehensive physical examination root,

usually the lower leg. Most people of a patient with acute LBP should with these

conditions improve include an in-depth evaluation of the

musculoskeletal systems.

The neurologic

examination should

always include an

evaluation of sensation,

strength, and reflexes in

the lower extremities.

This portion of the

examination allows the

examiner to detect

sensory or motor deficits

that may be consistent

with an associated

radiculopathy or cauda

equina syndrome.

Often, an assessment of

the L5 reflex (medial

hamstrings) is helpful.

Also, in L

radiculopathy,the

presence of weakness in

foot investors should

raise theadditional

suspicion of a peroneal

nerve palsy.

When differentiating

between an L

radiculopathy versus a

femoral neuropathy,

weakness in the hip

adductors in addition to

the quadriceps group

would indicate an

frequent moving or lifting

25 lbs. strength <50%

depression obesity poor

health prior LBP poor

back endurance

Osteoarthritis

Rheumatoid Arthritis

www.aafp.org

Diagnosis:

After the initial

examination, the

diagnosis of lumbar

radiculopathy can be

supported by

electrodiagnosis, MRI,

CT scans, and/or

contrast myelography.

Treatment of lumbar

radiculopathy will vary

depending on the actual

cause of the

radiculopathy. These

treatments can include

the use of back supports,

medication, physical

therapy, steroid injection

in the spine, and even

surgery.

http://www.aanem.org

Neurogenic

claudication

— Neurogenic

claudication is a type of

pain that can occur when

the spinal cord is

compressed due to

narrowing of the spinal

canal from arthritis or

other causes. The pain

runs down the back to

the buttocks, thighs, and

lower legs, often

involving both sides of

the body. This may

cause limping and

weakness in the legs.

Pain usually gets worse

when extending the

lower spine (e.g., when

standing or walking),

and gets better when

flexing the spine by

sitting, stooping, or

leaning forward.

https://www.uptodate.com/contents/low -

back-pain-in-adults

The onset of symptoms in patients with

lumbosacral radiculopathy is often sudden

and includes LBP. Some patients state the

preexisting back pain disappears when the

leg pain begins.

Sitting, coughing, or sneezing may

exacerbate the pain, which travels from

the buttock down to the posterior or

posterolateral leg to the ankle or foot.

Radiculopathy in roots L1-L3 refers pain

to the anterior aspect of the thigh and

typically does not radiate below the knee,

but these levels are affected in only 5% of

all disc herniations.

When obtaining a patient's history, be

alert for any red flags (i.e., indicators of

medical conditions that usually do not

resolve on their own without

management). Such red flags may imply a

more complicated condition that requires

further workup (e.g., tumor, infection).

The presence of fever, weight loss, or

chills requires a L3 radiculopathy. In an

isolated femoral neuropathy, only the

quadriceps group would show weakness.

Provocative maneuvers, such as the

straight-leg raising test or the slump test,

may provide evidence of increased dural

tension, indicating underlying nerve root

pathology.

Attempts at pain centralization through

postural changes (i.e., lumbar extension)

may suggest a discogenic etiology for

pain and may also assist in determining

the success of future treatment strategies.

The musculoskeletal evaluation should

include an assessment of the lower

extremity joints, as pain referral patterns

may be confused with focal peripheral

involvement. For example, a patient with

anterior thigh and knee pain may actually

have a degenerative hip condition rather

than an upper lumbar radiculopathy. By

assessing lower extremity flexibility,

hip rotation, muscular balance, and

ligamentous stability, the evaluating

physician might be alerted to the

patient's predisposition toward an acute

LBP episode.

https://emedicine.medscape.com

No POC labs to review

Diagnosis 1-Guidelines for Treatment for Non-Specific Acute Low Back Pain (most likely dx):

There is general agreement that patients with acute nonspecific spine pain or nonlocalizable

lumbosacral radiculopathy (without neurologic signs or significant neurologic symptoms)

require only conservative medical management. Patients should abstain from heavy lifting or

other activities that aggravate the pain. Bed rest is not helpful and has been shown to delay

recovery. Bed rest may be recommended for the first few days for patients with severe pain with

movement. Recommended medications include nonsteroidal anti-inflammatory drugs such as

ibuprofen or aspirin. If there are complaints of muscle spasm, muscle relaxants such as

cyclobenzaprine may be used in the acute phase of pain. Narcotic analgesia should be avoided,

in general, but it can be prescribed in cases of severe acute pain. A study by Cherkin and

coworkers compared standard physical therapy maneuvers and chiropractic spinal manipulation

for the treatment of acute low back pain and found that both provide small short- term benefits

and improve patient satisfaction.

http://www.clevelandclinicmeded.com

Nonpharmacologic treatment, including superficial heat, massage, acupuncture, or spinal

manipulation, should be used initially for most patients with acute or sub-acute low back pain, as

they will improve over time regardless of treatment. When pharmacologic treatment is desired,

nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants should be used.

Avoid imaging in cases of uncomplicated low back pain (unless there are specific clinical

indications). Medications prescribed today;

• Diclofenac Sodium 50 mg 1 by mouth twice daily for pain for 2 weeks.
• Flexeril (Cyclobenzaprine) 10 mg 1 tab by mouth three times a day as needed for

muscle spasms for 2 weeks. www.aafp.org

Diagnostic test needed:

No further diagnostic test needed at this time. Diagnosis was based on clinical presentation,

history, and physical exam.

Referrals/Consults:

Referral for physical therapy to evaluate and treat for low back pain and spasms.

Patient Education :

Remaining active — many people are afraid that they will hurt their backs further or delay

recovery by remaining active. However, remaining active is one of the best things you can do for

your back. In fact, prolonged bed rest is not recommended. Studies have shown that people with

low back pain recover faster when they remain active. Movement helps to relieve muscle spasms

and prevents loss of muscle strength. Although high-impact activities should be avoided, it is

fine to continue doing regular day-to-day activities and light exercises, such as walking. If

certain activities cause the back to hurt too much, it is fine to stop that activity and try another. If

back pain is severe, bedrest may be necessary for a short period of time, generally no more than

one day. When in bed, the most comfortable position may be to lie on the back with a pillow

behind the knees and the head and shoulders elevated, or to lie on the side with the upper knee

bent and a pillow between the knees.

Heat — using a heating pad can help with low back pain during the first few weeks. It is not

clear if cold packs help as well.

Work — most experts recommend that people with low back pain continue to work so long as it

is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. Some people need

to stay home from work if their occupation does not allow them to sit or stand comfortably.

While standing at work, stepping on a block of wood with one foot (and periodically alternating

the foot on the block) may be helpful.

Pain medications — Take medications on a regular basis for two weeks for it to be effective,

rather than using the medication only when the pain becomes unbearable. If needed, take muscle

relaxant before bedtime. Do not take this medication while driving or operating machinery.

Exercise — a program of exercises can help to increase back flexibility and strengthen the

muscles that support the back. Although starting back exercises or stretching immediately after a

new episode of low back pain might temporarily increase the pain, the exercise may reduce the

total duration of pain and prevent recurrent episodes. Recommended activities include those that

involve strengthening and stretching, such as walking, swimming, use of a stationary bicycle,

and low-impact aerobics. Avoid activities that involve twisting, bending, are high- impact, or

make the back hurt more. Some specific exercises may help strengthen the muscles of the lower

back. People with frequent episodes of low back pain should continue these exercises

indefinitely to prevent new episodes.

Mattress choice – The benefit of a firm mattress in preventing or treating low back pain has not

been proven. In one study, medium-firm mattresses were more likely to improve chronic back

pain compared with firm mattresses https://www.uptodate.com/contents/low-back-pain-in-

adults

Diagnosis 2-Guidelines for Treatment for Acute Lumbosacral Radiculopathy: The initial

treatment of the patient with lumbosacral radiculopathy presenting with sensory symptoms and

pain without significant neurologic deficits is not different from the approach for the patient with

uncomplicated low back pain. However, such patients require observation for possible

worsening of their neurologic status. For patients with acute lumbosacral radiculopathy, the

objectives of treatment are to ameliorate pain (symptomatic treatment) and to address the

specific underlying process (mechanismspecific treatment) if necessary

http://www.clevelandclinicmeded.com

Diagnostic test needed:

If signs and symptoms of radiculopathy, sciatica, or neurogenic claudication exists the patient

may require one or more of test including Spinal Radiography, CT scan, MRI, contrast

myelography, or electrodiagnosis. http://www.aanem.org

Referrals/Consults:

Referral to an orthopedic surgeon or neurosurgeon is recommended under the following

circumstances:

● Increasing neurologic problems (measurable weakness)

● Loss of sensation (e.g., numbness) or bladder and bowel symptoms ●Failure to

improve after four to six weeks of nonsurgical management, with persistent and

severe sciatica and evidence of nerve root involvement

https://www.uptodate.com/contents/low- back-pain-in-adults

Patient Education :

Most people with radiculopathy improve with conservative treatment such as medication and

PT. Surgery is recommended for some people with radiculopathy. They, too, usually improve

after a recovery period. Following treatment, most people are able to work and take part in other

daily activities. Patient education would include education to prevent acute non-specific low

back pain in addition to reducing chances of developing radiculopathy by maintaining good

posture and a healthy weight. Using safe techniques when lifting heavy objects to prevent

injuries to your back. Remembering to lift with your knees. That means you should bend your

knees, not your back. Also asking for help when moving heavy or bulky objects and when doing

repetitive tasks, take frequent breaks. https://www.healthline.com

Prevention :

There are a number of ways to prevent low back pain from returning. Perhaps the most

important are exercise and staying active. Regular exercise that improves cardiovascular fitness

can be combined with specific exercises to strengthen the muscles of the hips and torso. The

abdominal muscles are particularly important in supporting the lower back and preventing back

pain. It is also important to avoid activities that involve repetitive bending or twisting and high-

impact activities that increase stress in the spine.

Bend and lift correctly — People with low back pain should learn the right way to bend and

lift. As an example, lifting should always be done with the knees bent and the abdominal

muscles tightened to avoid straining the weaker muscles in the lower back (p

Take a break — People who sit or stand for long periods should change positions often and use

a chair with appropriate support for the back. An office chair should be readjusted several times

throughout the day to avoid sitting in the same position. Taking brief but frequent breaks to walk

around will also prevent pain due to prolonged sitting or standing. People who stand in place for

long periods can try placing a block of wood on the floor, stepping up and down every few

minutes.

https://www.uptodate.com/contents/low-back-pain-in-adults

Healthcare Maintenance/Recommendations :

Annual Influenza vaccine education provided-Received in October of 2017 Depression

screen-positive- Recommended to continue Sertraline and visits to Psychologists as

scheduled.

CAGE-0/4

STI and STD education

Sex behavioral

counseling

Reinforced recommendations for MSBE

Cervical Cancer screen and HPV education-Recommended continuing routine Pap testing every

3 years.

Diet and exercise education- Recommended to exercise at least 3 days/week; with exercises to

help strengthen the core muscles. Continue eating a healthy diet and stay hydrated during

workouts.

Recommended using a back brace while at work to help with support with lifting and to call for

lifting help instead of trying lift alone.

The USPSTF also recommends high blood pressure, depression, and alcohol misuse screening in

this age group. Screening for HIV, Syphilis, HBV, HCV, and STI screening and behavioral

counseling is also recommended in all sexually active females in this age group. Although, Mrs.

H has a toned physique I think it’s important to counsel her on the importance of daily exercise

and physical activity to help reduce pain and on healthful diet practices such as the DASH diet,

which is high in grains, fruits, vegetables, and low in fat to help prevent future co-morbidities

especially since her family history is so significant for such severe co-morbidities and

mortalities.

www.uspstf.org

Follow-up: Follow up in 2 weeks for evaluation of pain management or as needed if pain

becomes worse or changes in presentation.

References

American Academy of Family Physicians. (2017). Diagnosis and Treatment of Low

Back Pain; Clinical Practice Guidelines. Retrieved from:

http://www.aafp.org/patientcare/clinical- recommendations/all/back-pain.html

American Association of Neuromuscular & Electrodiagnostic Medicine. (2017).

Lumbar Radiculopathy. Retrieved from: http:www.aanem.org/Patients/Disorders/Lumbar-

Radiculopathy

Cleveland Clinic Center for Center for Continuing Education. Published by; Levin,

Kerry. M.D. (2010). Low Back Pain. Retrieved from:

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/lowback-

pain/#top

Healthline. (2017). Radiculopathy (Pinched Nerve). Retrieved from:

https://www.healthline.com/health/radiculopathy#overview1

Scientific Electronic Library Online by Ladeira, Carlos (2011). Evidence based

practice guidelines for management of low back pain: physical therapy implications. Retrieved

from: http://www.scielo.br/pdf/rbfis/v15n3/04.pdf

U.S. Preventive Services Task Force. (2017). Grade A and B

Recommendations. https://www.uspreventiveservicestaskforce.org/Search

UpToDate. (2017). Patient Education. Low Back Pain in Adults (Beyond the

Basics). Retrieved from: https://www.uptodate.com/contents/low-back-pain-

inadultsbeyond-the- basics